EL PASO COUNTY HOSPITALPOLICY: L-23

DISTRICT POLICYEFFECTIVE DATE: 09/09

LAST REVISION DATE: 024/136

MANAGEMENT OF CONTRACTED SERVICES

POLICY

UniversityMedicalCenter of El Paso (UMC-El Paso) will provide oversight to ensure that care, treatment and services provided to UMC-El Paso patients through contractual agreement are provided safely and effectively.

This policy does not apply to contracts for consultation or referrals.

RESPONSIBLE

Board of Managers

Care Management

Legal Unit

Medical Executive Committee

Medical Staff Improvement Committee

Manager of Physician Contracting

POLICY REFERENCES

L-20 Contract Management and Legal Review

L-21 Physician/Referral Source Contract Policy, Contract Certification Packet and Payment Checklist

MS-113Telemedicine Credentialing

DEFINITIONS

Contract – a formal agreement for care, treatment, or services with any organization, agency, or individual that specifies the services, personnel, products, or space provided by, to, or on behalf of the organization and specifies the consideration to be expended in exchange.

Contracted Services - services for patient care, treatment or other patient services provided through a written agreement with another organization, agency, or individual. The agreement specifies the services or personnel to be provided on behalf of the applicant organization and the fees to provide these services or personnel. Contracted services include contracts for physician services and non-physician services.

Leaders – members of the Board of Managers, Medical Executive Committee, President and CEO (CEO), Senior Leadership and Directors.

PROCEDURE

  1. Contracted Services Inventory
  1. The Manager of Physician Contracting maintains an inventory of contracted patient care services.
  1. All contracts will comply with Policy L-20, Contract Management and Legal Review, and Policy L-21, Physician/Referral Source ContractPolicy, Contract Certification Packet and Payment Checklist, Policy MS-113, Telemedicine Credentialing, as applicable.
  1. Leaders will have an opportunity to provide advice about the sources of clinical services to be provided through contractual agreement.
  1. Contracts for patient care services, including an evaluation of performance, will be presented to the Medical Executive Committee for advice at least twice yearly.

2. Contracts for patient care services, including an evaluation of performance, will be presented to the Board of Managers at least annually.

3. The Responsible Individual (see Policy L-20, Contract Management and Legal Review) and/or applicable Director shall monitor all contracted services with respect to the on-going performance, and shall initiate appropriate action to correct any deficiencies, including termination of the contract if necessary.

4. The Manager of Physician Contracting shall monitor all contracted services to ensure that the performance monitoring and appropriate corrective actions are completed in accordance with this policy.

  1. To ensure that care, treatment and services provided through contractual agreement are provided safely and effectively, UMC-El Paso shall implement the following measures as appropriate:
  1. Contractual agreements will contain requirements for performance that reflect basic principles of risk reduction, safety, staff competence and performance improvement.

Requirements may include, but are not limited to:

  1. review of information about the contractor’s Joint Commission status
  2. direct observation of the provision of care
  3. audit of documentation including documentation that all contractor staff are properly licensed, privileged and credentialed
  4. review of incident reports
  5. review of periodic reports submitted by the individual or organization providing services under the contract
  6. collection of data that addresses the quality of the contracted service
  7. review of performance reports based on indicators in the contractual agreement
  8. input from staff and patients
  9. review of patient satisfaction studies
  10. review of results of risk management activities
  11. UMC-El Paso performance improvement indicators as recommended by the Care Management Department and Performance Improvement Committees.
  1. A written description of the expectations will be provided either as part of the written agreement or in addition to it.
  1. A requirement that the provider fully cooperate upon the termination of the agreement, in order to effectuate a smooth transition of services in a manner that does not negatively impact patient care.
  1. Physicians and allied health professionals providing services through a contractual agreement must be credentialed and privileged by UMC-El Paso in accordance with Policy MS-113, Telemedicine Credentialing, except for:

a.direct care through a telemedicine link

  1. interpretive services through a telemedicine link
  2. off-site services provided by a Joint Commission-accredited contractor
  1. The Responsible Individual (see Policy L-20, Contract Management and Legal Review) or designee will be responsible for evaluating/reviewing performance statistics (see Section C.1 above) at least twice during each rolling twelve month period.
  1. such evaluations/reviews will be reported to the Manager of Physician Contracting, Medical Staff Improvement Committee and the Medical Executive Committee semi-annually.
  1. such evaluations/reviews will be reported to the Board of Managers annually.
  1. If contracted services do not meet expectations, the RI and appropriate Director are responsible to take appropriate corrective action which may include but are not limited to:
  1. increasing monitoring of the contracted services
  2. providing consultation or training to the contractor
  3. developing a corrective action plan
  4. renegotiating contractual terms
  5. applying defined penalties
  6. terminating the contract

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El Paso County Hospital District Date

Policy and Procedure Committee

Chairperson

______

President and Chief Executive Officer Date

______

Chief of Medical StaffDate

______

Board of Managers ChairpersonDate

Review/Revision History:

P&P
Committee / Legal Review / Administrative Team / Medical Executive Committee / Board of
Managers
09/09 / 09/09 / 03/16 / 10/09 / 09/09
01/13 / 12/12 / 01/13 / 02/13
03/16 / 01/16

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