At the 18th Annual Ambulatory Surgery Centers Conference in Chicago on Oct. 28, Sandra Jones, FHFMA, LHRM, CASC, owner, Ambulatory Strategies, Inc., and an executive vice president with ASD Management, discussed key strategies for meeting CMS' governing body documentation requirements (CMS Appendix L).
Ms. Jones began by discussing the importance of having an up-to-date operating agreement, which lists who constitutes the governing body and how often they will meet. She also mentioned the importance of keeping detailed board meeting agendas and minutes, as these may be reviewed by a CMS surveyor to determine if the governing body is indeed providing direct oversight for all ASC activities. "The only evidence the surveyors have, except for what they see in your facility, is in your minutes," she said.
She warned attendees that oversight of quality assessment and performance improvement (QAPI) is a common area boards fall short, as physicians can tend to be most concerned with financial issues. As a result, administrators must push the governing board to know and approve all quality improvement efforts and document this has occurred in the minutes. While the governing body can delegate responsibilities, such as infection control and risk management efforts, delegation must be documented in writing through a signed appointment letter or job description with a date that matches the date listed for the item on the governing body's minutes, said Ms. Jones. Even after delegation though, the governing body must help establish QAPI priorities and stay aware of the status of efforts.
Another common area of deficiency is credentialing/privileging. Here common errors include late reappointment, out-of-date verifications and lack of full peer-review in the credentialing process, said Ms. Jones. Governing bodies must also approve outside service agreements, such as radiology and pathology service agreements.
Ms. Jones closed the session by providing examples of what ASCs shouldn't do in their minutes. First, unspecific minutes or minutes that do not explicitly state the board reviewed a QAPI plan could be problematic, even if the plan is attached to the minutes. Thomas Stalling, JD, a partner with McGuireWoods' Richmond office, who joined Ms. Jones for the session, provided a second rule of thumb: Avoid treating minutes as a transcript as it could lead to trouble down the line. Instead, state the issue was discussed and the outcome of the motion. He also recommended surgery center leaders discuss any sensitive issues with legal counsel before the meeting to get advice on how to discuss and document the issues.
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Ms. Jones began by discussing the importance of having an up-to-date operating agreement, which lists who constitutes the governing body and how often they will meet. She also mentioned the importance of keeping detailed board meeting agendas and minutes, as these may be reviewed by a CMS surveyor to determine if the governing body is indeed providing direct oversight for all ASC activities. "The only evidence the surveyors have, except for what they see in your facility, is in your minutes," she said.
She warned attendees that oversight of quality assessment and performance improvement (QAPI) is a common area boards fall short, as physicians can tend to be most concerned with financial issues. As a result, administrators must push the governing board to know and approve all quality improvement efforts and document this has occurred in the minutes. While the governing body can delegate responsibilities, such as infection control and risk management efforts, delegation must be documented in writing through a signed appointment letter or job description with a date that matches the date listed for the item on the governing body's minutes, said Ms. Jones. Even after delegation though, the governing body must help establish QAPI priorities and stay aware of the status of efforts.
Another common area of deficiency is credentialing/privileging. Here common errors include late reappointment, out-of-date verifications and lack of full peer-review in the credentialing process, said Ms. Jones. Governing bodies must also approve outside service agreements, such as radiology and pathology service agreements.
Ms. Jones closed the session by providing examples of what ASCs shouldn't do in their minutes. First, unspecific minutes or minutes that do not explicitly state the board reviewed a QAPI plan could be problematic, even if the plan is attached to the minutes. Thomas Stalling, JD, a partner with McGuireWoods' Richmond office, who joined Ms. Jones for the session, provided a second rule of thumb: Avoid treating minutes as a transcript as it could lead to trouble down the line. Instead, state the issue was discussed and the outcome of the motion. He also recommended surgery center leaders discuss any sensitive issues with legal counsel before the meeting to get advice on how to discuss and document the issues.
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