Don’t overlook COPs during mock surveys

Patient tracers should include COP requirements

In light of a recent Government Accounting Office report that found that the Joint Commission on Accreditation of Healthcare Organizations failed to detect deficiencies in the Medicare Conditions of Participation (COPs) during surveys, quality managers need to take extra care to ensure their organizations are compliant with, says Patrice L. Spath, BA, RHIT, a health care quality specialist with Brown-Spath & Associates in Forest Grove, OR.

"Be aware of the current COPs for hospitals, and make sure you are in compliance," she warns. "The COPs include some regulations that are not fully or specifically addressed by the Joint Commission standards."

For example, the Centers for Medicare & Medicaid Services (CMS)’ Patients Rights Regu-lations require that hospitals provide written information to each patient regarding his or her right to make decisions about medical care, whereas the Joint Commission standard RI.2.20 states that patients must receive information about their rights but does not specify that it must be in writing.

While the Joint Commission standards contain many of the CMS regulations, there also are some new elements or slight differences in interpretation, says Spath. (Information about the current Medic-are COPs can be found on-line at www.cms.hhs. gov/cop.)

If you are doing patient tracers to identify problem areas in your organization, the tracers should include requirements unique to the COPs as well as the JCAHO standards, Spath advises.

The tracer method of identifying system and process faults in the delivery of patient care can be used to assess compliance with any externally or internally defined standards and is not unique to the Joint Commission standards, Spath notes. "If you’ve got a checklist of things you are looking for during a tracer, you can add anything to that checklist, not just the JCAHO elements of performance."

For example, while tracing the care provided to a patient admitted through the emergency department, you could check to see if the patient received written information about his or her rights, which is a CMS requirement, while also checking for compliance with Joint Commission standards.

The tracer process, if completed on a sufficient sample of patients, also could be used to gather data to measure the effectiveness of improvement actions, Spath says. "There’s no limit to what information can be gathered using the tracer methodology."