Did You Know?

If your organization is like many others, contracted services are a vital part of the patient care you provide. That can include support services or staff providing direct care.

Regardless of how you see the multiple parts of your organization, you must be aware that patients’ views of your care and services include everything about your organization. Patients do not distinguish between what you provide directly or what you provide through a contracted service. To your patients, it all is reflective of you.

With that in mind, paying attention to each of your contracted services is essential, and that’s also a requirement in Accreditation Commission for Health Care (ACHC) Office-Based Surgery (OBS) Standards.

Although multiple ACHC Standards or required elements specifically call out contracts, one standard is overriding:

01.02.01 Contract Services: When services are provided through a contract, the governing body must ensure that these services are provided in a safe and effective manner.

Each contract must be specific to the purpose of the services, but there are components to consider for all when you’re linking the contract to the quality of services. Having a framework for what you want outlined in the contract to monitor the quality of services will help ensure consistency across contracts. Be sure to identify actionable items for ensuring your expectations are met, and always specify the remedial steps to be taken if the expectations are not met.

If review of quality relies on information supplied by the contracted service, building the specific requirements into the final contract will reduce confusion about what you expect to receive. For example, your basic framework may provide for:

• The type of data or information required.
• The format of information provided.
• The schedule for information to be provided to you.
• The remedial actions to take if data is missing or incomplete.

Your organization also should be collecting its own data on the contracted service, even if you are expecting data to be provided. For example:

• Are the services provided within the contracted timeframes (e.g., weekly, monthly, in a timely manner when needed episodically)?
• Are the services negatively reflected in patient satisfaction surveys?
• Do contracted personnel follow your policies and procedures?
• If the contracted service is required to provide information, does it?

Once you have information, it must be evaluated through your quality program. If corrective actions are necessary, those actions must be communicated according to the contract provisions.

Some contracts are considered “evergreen,” but all contracts need periodic review to ensure they continue to meet the needs of the organization. If an existing contract is not supporting your efforts to monitor quality, take the opportunity to update the contract at the next review.

Note: This information is intended to assist you in meeting the ACHC standards and is not meant to provide legal advice for contracts.

ACHC is here to help. For access to the most recent Office-Based Surgery Accreditation Standards Manuals, contact your Account Advisor or email us at customerservice@achc.org.