CMS Broadens Scope Of Hospital Condition Of Participation For Quality Assessment/Performance Improvement Activities

In a move sure to increase survey headaches for hospitals, CMS has adopted a revised version of its COP on quality assurance. The new rule is effective March 25, 2003. Although JCAHO-accredited hospitals already must comply with a set of performance improvement standards, through the revised rule CMS will have a more direct role in monitoring hospital QA/PI systems. CMS states in the preamble that hospitals will be expected to demonstrate, "with objective data, that improvements have taken place in actual care outcomes, processes of care, patient satisfaction levels, hospital operations, or other performance indicators." CMS also states its intent to require hospitals to participate in multi-hospital performance measurement systems once standardized data collection tools have been developed; public reporting of hospital-specific performance measures is expected to result from such systems. See the Final Rule at 68 Fed. Reg. 3435 (Jan. 24, 2003).

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