CMS pilots discharge planning, quality surveys

Tools created to go with infection control survey

The Centers for Medicare & Medicaid Services (CMS) has started pilot testing of two more survey tools to go with the infection control pilot it began testing last year. The new tools are for hospital activities related to quality assessment and performance improvement (QAPI) and discharge planning and are already being used by state survey agencies, according to a CMS spokesperson who asked to remain anonymous.

The spokesperson says that they will be used separately during the pilot phase and that CMS is seeking feedback from surveyors and hospitals about the worksheets under consideration. Which hospitals are chosen for the pilot tests is, itself, being tested, says the spokesperson. CMS will look at readmissions data and use the knowledge of hospitals accrued by the state surveyors in past surveys. So a hospital that has higher risk-adjusted, all-cause readmission rates, or a hospital that a surveyor has found issues with previously is more likely to encounter the pilot test. Hospitals that don’t meet the criteria of the tools won’t be cited during the pilot phase.

Testing is due to be completed in a few months, and then revisions to the tools will be incorporated. The spokesperson says there is no word on when a final tool will be ready for surveyors. The infection control tool, in use for more than a year, has already had some tweaks due to comments from users, but there is no word on when it will be put into use officially, either. It has been praised by infection control professionals.

The new tools still need some work, though. “There is no instruction manual that goes with the tools,” says Patrice Spath, RHIT, a quality consultant at Brown-Spath & Associates in Forest Grove, OR. “So a lot of the questions asked are very subjective. There is nothing here that defines the terms.” For example, in the discharge planning tool, question 4.2 asks: Can hospital staff demonstrate that the hospital’s criteria and screening process for a discharge planning evaluation were correctly applied? “But is that verbal demonstration? Written in the record? They don’t tell you, and your assumption of what qualifies as ‘demonstrate’ may be different from the surveyor’s.”

Another discharge planning question Spath thinks needs clarification is 4.6, related to evaluating the post-discharge needs of the patient in the environment from which the patient was admitted to the hospital. “Not all patients go from the hospital back to the place they came from,” she says. “You might have a patient admitted from home, but going to a skilled nursing facility. Why would you need a home assessment then?”

In general, Spath says that many of the questions are similar to what you would expect from Joint Commission surveys, so incorporating these pilot tools into your current tracers could help you determine if you are meeting both Joint Commission and CMS requirements. But beware that things will change in the pilot tools. “Use this as a guidepost,” she says. “It could be useful to understanding the CMS requirements and knowing what may be a focus in a survey. These are the things that will probably have a high priority when a surveyor comes.”

In the QAPI survey, Spath says many of the questions have a “flavor” similar to Meaningful Use Stage 1 requirements, and she wonders if the Government Accountability Office will incorporate those questions into the audits they do for Meaningful Use. For example, question 3.1: Can the hospital provide evidence that each quality indicator selected is related to improved health outcomes? (e.g., based on QIO, guidelines from a nationally recognized organization, hospital-specific evidence, peer-reviewed research, etc.). “I could say yes to that, but will anyone be showing up to check on that?”

She also thinks that some of the questions are difficult to interpret, and that some organizations could be cited, even accused of fraud, simply because the questions are difficult to understand. “I may think I’m doing something, I may think that I meet the requirements related to following specific data specifications, but am simply unclear on what the question really means.” This is, of course, why a pilot survey is done, and Spath thinks that comments on confusing areas will be helpful to CMS.

At the very least, look at the surveys, she says. Follow the news as the pilot progresses and changes are made to the tools. They can be a useful way to know how you are doing and to ascertain the areas that are of interest to CMS and the state surveyors.

All three of the CMS surveys are available at:

For more information on this topic, contact Patrice Spath, RHIT, Principle, Brown-Spath & Associates, Forest Grove, OR. Email: