site visit criteria

Medicare Provider Enrollment – Site Verification

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Medicare Provider Enrollment News

CMS contracts with a third party to provide site visit services as an integral part of the Medicare Provider Enrollment process. The National Sive Visit Contractor (NSVC) will conduct site visits for all providers and suppliers except for Durable Medical Equipment (DMEPOS) which will continue to be inspected by the National Supplier Clearinghouse. MSM Security Services, LLC has the national site visit contract. MSM, or one of its subcontractors, will conduct a site verification and screening process according to Medicare guidelines to prevent questionable providers and suppliers from enrolling in the Medicare program. When an inspector shows up, he or she will have valid ID and a letter of authorization to begin the inspection. You may not copy or retain the ID or letter of authorization. You may contact MSM at any point if you have questions at 855-220-1074.

The site verification may be as quick as verifying your business location, or an inspector may physically show up to tour your clinic. The process ensures that providers aren’t able to Enroll as participating Medicare providers without an appropriate service location.

You may see full details in section 10.6.20 of the Medicare Program Integrity Manual .

Call nCred today at (423) 443-4525 to discuss your Medicare Provider Enrollment needs. We work with all specialties and have extensive experience processing Medicare applications.

From the Medicare Program Integrity Manual:

10.6.20 – Screening: On-site Inspections and Site Verifications (Rev. 11949; Issued: 04-13-23; Effective: 04-21-23; Implementation: 06-19-23)

The contractor shall review section 10.3 of this chapter for special instructions regarding site visits. In the event of a conflict, those instructions take precedence over those in this section 10.6.20.

A. DMEPOS Suppliers and IDTFs

The scope of site visits of DMEPOS suppliers and IDTFs shall continue to be conducted in accordance with existing CMS instructions and guidance. (For purposes of this section 10.6.20, the term “contractor” refers to the Medicare Administrative Contractor; the term “SVC” refers to the site visit contractor.)

B. Provider and Supplier Types Other Than DMEPOS Suppliers and IDTFs

For provider/supplier types other than DMEPOS suppliers and IDTFs – that must undergo a site visit pursuant to this section 10.6.20 and § 424.518, the SVC will perform such visits consistent with the procedures in this section 10.6.20. This includes all of the following:

(1) Documenting the date and time of the visit, and including the name of the individual attempting the visit.

(2) Photographing the provider/supplier’s business for inclusion in the provider/supplier’s file. All photographs will be date/time stamped.

(3) Fully documenting observations made at the facility, which could include facts such as (a) the facility was vacant and free of all furniture, (b) a notice of eviction or similar documentation is posted at the facility, and (c) the space is now occupied by another company.

(4) Writing a report of the findings regarding each site verification.

(5) Including a signed site visit report stating the facts and verifying the completion of the site verification.

In terms of the extent of the visit, the SVC will determine whether the following criteria are met: (i) the facility is open; (ii) personnel are at the facility; (iii) customers are at the facility (if applicable to that provider or supplier type); and (iv) the facility appears to be operational. This will require the site visitor(s) to enter the provider/supplier’s practice location/site rather than simply conducting an external review. If any of the four elements ((i) through (iv)) listed above are not met, the contractor will, as applicable – and using the procedures outlined in this chapter and in existing CMS instructions – deny the provider’s enrollment application pursuant to § 424.530(a)(5)(i) or (ii) or revoke the provider’s Medicare billing privileges under § 424.535(a)(5)(i) or (ii).

C. Operational Status

When conducting a site verification to determine whether a practice location is operational, the SVC shall make every effort to limit its verification to an external review of the location. If the SVC cannot determine whether the location is operational based on this external review, it shall conduct an unobtrusive site verification by limiting its encounter with provider or supplier personnel or medical patients.

The contractor must review and evaluate the site visit results received from the SVC prior to making a final determination. If it is determined (during the review and evaluation process) that the location is non-operational based on the site visit results but there is reason to proceed with the enrollment, the contractor shall provide the appropriate justification in the comment section of the Validation Checklist in PECOS. (For example, a second site visit determined the location to be operational; the provider only renders services in patient’s homes; etc.).

If the contractor is unsure of how to proceed based on its evaluation of the site visit results, it shall contact its PEOG BFL and copy its contracting officer’s representative (COR).

Site verifications should be done Monday through Friday (excluding holidays) during their posted business hours. If there are no hours posted, the site verification should occur between 9 a.m. and 5 p.m. If, during the first attempt, there are obvious signs that the facility is no longer operational, no second attempt is required. If, on the first attempt, the facility is closed but there are no obvious indications that the facility is non-operational, a second attempt on a different day during the posted hours of operation should be made.

E. Documentation

As indicated previously, when conducting site verifications to determine whether a practice location is operational, the SVC shall:

(i) Document the date and time of the attempted visit and include the name of the individual attempting the visit.

(ii) As appropriate, photograph the provider/supplier’s business for inclusion in the provider/supplier’s file on an as-needed basis. All photographs should be date/time stamped.

(iii) Fully document all observations made at the facility (e.g., the facility was vacant and free of all furniture, a notice of eviction or similar documentation was posted at the facility, the space is now occupied by another company, etc.).

(iv) Write a report of its findings regarding each site verification.

F. Determination

(In the event an instruction in this subsection F is inconsistent with guidance in section 10.6.6, 10.4.7 et seq., or 10.4.8, the latter three sections of instructions shall take precedence.)

If a provider/supplier is determined not to be operational or in compliance with the regulatory requirements for its provider/supplier type, the contractor shall revoke the provider/supplier’s Medicare billing privileges – unless the provider/supplier has submitted a change of information request that notified the contractor of a change in practice location. Within 7 calendar days of CMS or the contractor determining that the provider/supplier is not operational, the contractor shall update PECOS or the applicable claims processing system (if the provider/supplier does not have an enrollment record in PECOS) to revoke Medicare billing privileges and issue a revocation notice to the provider/supplier. The contractor shall afford the provider/supplier applicable appeal rights in the revocation notification letter.

For non-operational status revocations , the contractor shall use either 42 CFR § 424.535(a)(5)(i) or 42 CFR § 424.535(a)(5)(ii) as the legal basis for revocation. Consistent with 42 CFR § 424.535(g), the date of revocation is the date on which CMS or the contractor determines that the provider/supplier is no longer operational. The contractor shall establish a 2-year reenrollment bar for providers/suppliers that are not operational.

For regulatory non-compliance revocations , the contractor shall use 42 CFR § 424.535(a)(1) as the legal basis for revocation. Consistent with 42 CFR § 424.535(g), the date of revocation is the date on which CMS or the contractor determines that the provider/supplier is no longer in compliance with regulatory provisions for its provider/supplier type. The contractor shall establish a 2-year enrollment bar for providers/suppliers that are not in compliance with provisions for their provider/supplier type.

G. Multiple Site Visits

Notwithstanding any other instruction to the contrary in this chapter, the contractor shall not order a site visit if the specific location to be visited has already undergone a successful site visit within the last 12 months and the applicable provider/supplier is in an approved status.

Consider the following illustrations:

Example 1 – A single-site home health agency (HHA) undergoes a revalidation site visit on February 1. The HHA submits a change of information request on July 1 to add a branch location. The contractor shall order this site visit because the visit will occur at a location (i.e., the branch location) different from the main location (i.e., the location that underwent the February 1 revalidation visit).

Example 2 – A DMEPOS supplier undergoes a revalidation site visit on April 1. It submits an initial Form CMS-855S application on May 1 to enroll a second location. The new location shall undergo a site visit because: (1) it is different from the first (revalidated) location; and (2) it is/will be separately enrolled from the first location.

Example 3 – A physical therapy (PT) group has three locations – X, Y, and Z. As part of a revalidation, the contractor elects to order a site visit of Location Y rather than X or Z. The visit was performed on June 1. On October 4, the group submits a Form CMS-855B to report a change of ownership, thus requiring a site visit under this chapter. However, the contractor shall not order a visit for Location Y because this site has been visited within the past 12 months. Location X or Location Z must instead be visited.

Example 4 – An IDTF undergoes an initial enrollment site visit on July 1. On September 24, it submits a Form CMS-855B application to change its practice location; this mandates a site visit under this chapter. The site visit shall be performed even though the initial visit took place within the past 12 months. This is because the second visit will be of the new location, whereas the first visit was of the old location.

H. Certified Providers/Suppliers – Address Validation Error

Notwithstanding any other instruction to the contrary in this chapter, the contractor need not order a site visit for a certified provider/supplier prior to making a recommendation to the state if an address validation error is received in PECOS. The contractor shall override the error message and notate in the referral package that the address was unverifiable. This avoids multiple site visits being performed (that is, pre-enrollment, survey, and post enrollment).

Credentialing Resources

CAQH – UPD Provider Login
Centers for Medicare and Medicaid Services
Medicare Provider Enrollment Center
NPI Registry
PECOS Enrollment Checklists

Site Visit Guidelines

Table of Contents

Introduction Composition of the Team Role of the Coordinator Preparing for the Visit The Site Visit After the Visit Accreditation Process

Introduction An on-site visit by a team of qualified peer reviewers is a critical part of the procedure used by the Council in the accreditation of undergraduate and graduate environmental health science and protection programs. We thank you for agreeing to serve on a site visit team and trust that the following will enhance the quality of that effort.

The accreditation decision is the responsibility of the entire voting membership of the Council. However, Council members rely on the site visit team for an objective assessment of how well the school or program meets the criteria for accreditation.

Individuals selected for service on a site visit team, particularly first-time visitors, often have questions about what is expected of them. The following guidelines are intended to provide answers to the common concerns raised by site visitors. The overriding advice, of course, is to use common sense. Individuals are selected for site visitation teams because they have the professional respect of their peers. The good judgment and sense of fair play that contribute to that professional respect will serve the visitor well throughout the accreditation site visit. Table of Contents

Composition of the Team Teams are composed of at least two members, an academician and a practitioner.

Members are selected for the particular perspective they can contribute to the team, as well as geographical considerations related to the site under review. Team members will not be selected from the same state as the program under review. Consideration will be given to selected team members familiar with the general region of the program under review, and not so distant as to present an unreasonable travel expense. Each team member will meet the minimum qualifications required for membership on the Council. One member will be identified as site visit coordinator; this member will have previous experience with accreditation site visits. Making arrangements for site visits is the responsibility of the Vice-Chair for Undergraduate or Graduate Programs, as appropriate.

The Academician is expected to have special knowledge about environmental health science and protection education and training, as well as the broader related educational concerns. This individual should be skilled in assessing such programmatic elements as institutional governance, programmatic relationships within the larger university, methods of financing, linkages between knowledge and skill development and the institutional milieu.

The Environmental Health Practitioner may or may not have detailed knowledge about educational institutions, but he or she will always be able to contribute the essential element--the relevance of the instructional programs to the world of environmental health science and protection practice. The practitioner should be in a good position to assess the appropriateness of the program=s service activities to the community and the professional. He or she should be in a position to assess whether or not the educational thrust of the program is satisfactorily translated into knowledge and skills normally expected of entry-level environmental health employees. Table of Contents

Role of Coordinator The coordinator for the site visit is the key agent in assuring that the site visit is effective and fulfills its intent. The coordinator's responsibilities include:

Confirming the site visit schedule and dates with the institution and the other team member prior to the visit.
Clearing travel and housing arrangements with the other team member(s) and the institution in order to assure the integrity of the site visit schedule.
Coordinating the site visit activities while at the site.
Directing the preparation of the team's site visit report for submission to the Council at their next regular meeting. No later than four weeks after the site visit, a copy of the team's draft report will be submitted to the institution's Program Director for review (for substantive errors only) before the final report is prepared. The report will address the team's observations relative to the strengths and weaknesses of the institution with respect to the accreditation guidelines and to institutional plans or proposals for strengthening the program where need is identified. It will also contain recommendations of the review team.
Ensuring that the Council Secretary receive all documents that will be retained in Council permanent files.
Meeting with the Council and presenting the team findings at the next regular Council meeting.

Preparing for the Visit It is essential that all team members come to the visit well prepared. Preparation must include thorough reading of all self-study materials, and consideration of concerns and questions of other Council members (not on the site visit team) reviewing self-study materials.

A conflict of interest form must be signed prior to the visit. Individuals should decline from serving on a site visit if they have a conflict of interest, or if prior associations could lead to a perception of a conflict of interest. Because clues to potential conflicts may only emerge through a review of the program self-study, early reading of that document is important.

In reviewing the self-study materials (and during the site visit), it is particularly important to look for such things as, although not limited to, the following: (These are not listed in any order of priority.)

Administrative Placement in the Organizational Structure of the Educational Institution. Administrative placement has important influence on program status within the institution, and also the status of the Program Director/Coordinator, budgetary allocations, policy determinations, etc.

Academic Ranking of the Program Director/Coordinator and Instructors, and Administrative Titles. A Program Director/Coordinator must have a faculty appointment. It is important that the Program faculty are actively involved in the educational process.

Adequacy of the Curriculum. Courses included in the curriculum must meet the Council's guidelines. Additional required courses should be reasonable and pertinent, and contribute to the overall quality of the program. Prerequisite courses should be clearly stated. Cooperation should be evident among other departments offering courses for students in environmental health science and protection. Opportunities for electives chosen by the students should be examined.

Adequacy of the Budget to Meet the Program's Needs. This determination should include consideration of the budget preparation and approval process, and what the program budget includes. Faculty workload should also be examined.

Student Internship Experiences. Internships should be examined to determine if they provide appropriate experiences for the students. Methods of evaluation of students, and of sites, should be explored. Student satisfaction with their experiences should be evaluated.

Physical Facilities and Equipment. Classroom and laboratory space should be examined to determine if available space is adequate. Similarly, equipment needed for course instruction should be assessed with regard to adequacy.

Review of Student Performance. Records of graduates should be examined to determine if they are meeting stated criteria for graduation. Student input should be obtained regarding their perception of the adequacy of their program. Information should be obtained on the success of graduates finding appropriate employment or opportunities for graduate education. Table of Contents

The Site Visit Most colleges and universities enjoy a high level of autonomy over their internal organization and programming. While there are various norms and patterns which academic institutions generally observe, each one becomes highly individualized with respect to how they satisfy these norms and standards. Where they locate programs, how they fund and administer programs, how they package courses and allocate instructional responsibilities, and how they provide for the programmatic infra-structure will vary from school to school. Likewise, the accreditation criteria represent a norm or pattern for structuring and administering an accreditable environmental health science and protection program. There are many variables as to how this may be accomplished. The task of a site visitor is to determine how well the school is satisfying the minimum criteria, to identify where their strengths lie, and to explore how they plan to strengthen their weaknesses. These observations will be shared with the school during the exit interview.

Following are some suggestions which may be useful during the site visit.

Be a gracious guest. Remember that you are an invited guest and that you represent the profession of environmental health science and protection as a select observer.
Cooperate as a team. Draw on each others strengths and avoid public confusion over interpretations of accreditation criteria. Take advantage of opportunities when apart from school representatives to seek accord on points of concern and to resolve misunderstandings.
Be attentive. Your job is to solicit information that will validate the school's self-study. Time is precious and discussions will be pointed and intense. Your attentiveness will reflect the importance of the site visit.
Carry your share of responsibilities in questioning various school constituents. The burden of responsibility is heavy and intense during a site visit, and it should be shared if the best outcome is to be achieved.
Be an active participant in the decision-making process. Generally, consensus can be obtained for decisions regarding individual criteria, but should there be unresolved disagreement, this should be shared in a report to the Council.
Do not be combative in your style of questioning, but be inquisitive. It is absolutely necessary to ask the hard questions, but do so in a polite and respective manner.
Do not pursue your own ideological or pedagogical preferences unnecessarily. Remember, there are many ways to accomplish the same ends. Be open minded and remember that the school is being evaluated on how well it meets its own mission. Your task is to look for the results.
Do not be effusive in your praise of the school or the manner in which it carries out its programs. Recognize strengths but avoid encouraging unrealistic expectations.
Avoid discussion which questions the Council's criteria if at all possible. These have been developed over a long period of study and are the basis upon which the review will be judged. Any concerns you may have can be shared later with the Council.
Avoid excessive comparisons with your own school or program. While it is sometimes useful to draw upon your schools programming and operation as a point of reference for discussion of how this school addresses the same area of responsibility, it is never appropriate to hold your school up as a model to be pursued. The school being reviewed should be assessed upon how effectively its procedures accomplish the intended purposes set forth in the self-study.
Be as helpful to the school as possible. Site visitors sometimes face the dilemma of being placed in the role of a consultant, as well as an evaluator. The Council believes that the entire accreditation process should be helpful to the school, including the site visit. Caution should be exercised, however, to avoid conflict with the major objective of verifying the self-study document, and assessing compliance with the accreditation criteria. Consultation-type activities should not be pursued to the point of compromising the team's ability to exercise independent and honest judgments.
Attempt to assess progress in meeting earlier recommendations included in the previous accreditation report. It is important to recognize progress where it is found, and of equal importance to cite failure to comply.
Prepare complete notes of your observations while on site. These notes will become the basis for the exit interview, where they can be double checked to assure that there is no misunderstanding or substantive error. These notes become the basis for the site visit coordinator's preparation of a report.
Do not divulge to the school the team's specific recommendation regarding accreditation. The team's recommendation is not presented during the exit interview nor should it be contained in the written report. This will be conveyed by the coordinator of the site visit at the time the decision is made. Pre-mature disclosure could compromise or embarrass the Council, particularly should subsequent knowledge significantly alter the fact upon which the report or decision is based. Under the rules of due process, the school will have an opportunity to review the site report and respond to the Council. They may submit additional information of substantive nature relating to subsequent actions which may alter the basis of the site team recommendations, and thus, persuade the Council to a different course of action than that recommended by the team. The Council relies heavily upon the site visit team for its major assessment, but the team's role will always remain advisory to the Council.
Provide accurate feedback to the school during the exit interview. Summarize the team's findings succinctly. The content should be straight forward but with sufficient detail so that the school will know exactly what to expect in the written report.
Do not allow the exit interview to be used for debating the issues raised by the team. This is a time for reporting the team's findings. There will be ample opportunity for the school to respond to the team's findings and conclusions after the school receives the written report.
Sample Site Visit Itinerary - Suggested Schedule for Site Visit Team Conferences and Approximate Time Needed First Day 1. Responsible administrative personnel 1 hour 2. Curriculum Director 2 hours 3. President, Provost, Dean or other (a protocol visit) 1/2 hour 4. Faculty members in Environmental Health Science and Protection and related courses 3 hours 5. Tour of facilities and campus 1 hour Second Day 1. Environmental health science and protection class or laboratory in session 1/2 hour 2. Review of student and program records 1 hour 3. Student and alumni interviews 1 & 1/2 hour 4. Public/private environmental health science and protection practitioners 1 hour 5. Survey team private conference 2 hours 6. Final conference with administrative personnel 1 hour 7. Exit interview 1 hour

After the Visit The site team's report, in draft form, should be sent to the Program Director by the team Coordinator within four weeks of the visit. Guidelines for this report are provided in a separate document.

The Program will have an opportunity to review the report, and suggest appropriate corrections of fact. Upon return to the Coordinator, appropriate changes will be made and the document distributed to the entire Council, site visit team and the Program Director. The Program is invited to respond to the report, and must have a representative present at the Council meeting when the report will be reviewed.

Each site visit team member should submit an expense reimbursement voucher form to the Program Director of the program seeking accreditation, they should follow the guidelines set by the program and should expect reimbursement within four weeks. The Council greatly appreciates the contribution of the site review team to the accreditation process. The Councilors rely on the team for major input to the accreditation decision, including their involvement during the final hearings on the application. The continued interest and commitment of the team members to the accreditation process is important to both the school involved and the Council if a well informed decision is to be made. Table of Contents

Declaration of No Conflict of Interest Site Visitors are required to decline participation in a site visit team when any of the following actual or potential conflicts of interest exist:

Individual has a current or previous affiliation with the institution under consideration, including as an administrator, faculty, staff, employee, appointee, or as a current or former candidate for any of the previously mentioned positions.
Individual is an employee of or is in some way affiliated with an institution or program in geographic proximity of or in direct competition with the program/institution under consideration.
Individual currently serves or previously served (during the past three years) as a consultant to the institution/program under consideration.
Individual is or was a student of or is a graduate of the institution under consideration.
Individual has a member of his/her immediate family with a relationship to the program/institution.
Individuals selected for a site visit team will notify the Council within 10 days of actual or potential conflicts of interest with that program/institution so that substitutions can be made in the composition of the team.

Should unforeseen conflicts develop during the site visit or before the final decision is made on the accreditation of the particular program, an individual is required to notify the Chair of the Council.

Signature of site visitor: Printed name of site visitor: Printed name of College or University under review: Date:

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Institute of Medicine (US) Committee to Design a Strategy for Quality Review and Assurance in Medicare; Lohr KN, editor. Medicare: A Strategy for Quality Assurance: VOLUME II Sources and Methods. Washington (DC): National Academies Press (US); 1990.

Medicare: A Strategy for Quality Assurance: VOLUME II Sources and Methods.

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4 Site Visits

Molla S. Donaldson and Kathleen N. Lohr

The site visits occupied a central place in fact-finding for this study. The Institute of Medicine (IOM) study committee comprised individuals whose diverse backgrounds and experience provided breadth to the committee's deliberations. Because of this diversity and the range of settings and issues included in the legislative charges, the committee chose to devote a substantial amount of time to site visits; the committee members believed such activities would provide a collective understanding of the variety of methods, concerns, and viewpoints of groups with roles in quality assurance. Site visits of this kind are often carried out in IOM projects precisely to bring committee members to some common understanding of the issues under study.

The committee members emphasized the educational objectives of the site visits. The principal goals were as follows: (1) to increase their understanding of the strengths and limitations of methods of quality assessment and assurance from the point of view of those involved in them; (2) to come to appreciate the kinds of problems that are (or are not) identified by such techniques; (3) to learn more about the types of quality assurance interventions that are implemented by various quality assurance programs around the country; and (4) to use this information in generating recommendations for the Medicare program. The committee did not, therefore, try to evaluate the soundness or effectiveness of any organization's quality assurance program.

The remainder of this chapter describes the site visit process and documents the main groups, organizations, and facilities visited. It also discusses major issues raised during the visits and gives examples of the types of quality-of-care problems that health care providers identify through their quality assessment systems or that they consider basic health care systems issues.

Site Visit Schedule And Planning

IOM staff began site visit planning in mid-1988. They selected locations that included different regions of the country as well as organizations that conduct quality assurance activities and those that are the object of external quality assurance. For instance, a Medicare Peer Review Organization (PRO) and providers such as hospitals, risk-contract health maintenance organizations (HMOs), and practicing physicians were all included.

In addition, the staff and committee believed it important to visit large urban, small community, and rural settings and to see a range of facilities, for instance large and small institutions and academic and nonacademic settings. They also believed it important to visit groups with ''exemplary'' quality assurance programs and those struggling to implement programs. To tap community perceptions, staff planned site visits to include representatives of consumer and local community groups. Finally, special meetings were also arranged with experts in quality assurance, ethics, geriatrics, and related issues.

Early in the study, members of the study committee and this study's technical advisory panel were asked to recommend organizations and contacts. The staff first contacted possible site visit locations and visitees by telephone and then sent a confirming letter that outlined the objectives of the site visit (see Appendix A ). Staff also determined potential dates for all major site visits and the dates on which committee members could be available and then assigned individuals to specific site visits. Some effort was made to have committee members visit cities and states outside their own location. When committee members could not remain for an entire site visit, they were asked to participate at least partially in more than one visit.

The nine major site visits took place between October, 1988, and March, 1989. Each lasted about 3 days and included two or more committee members and two IOM staff members. During April and May, 1989, several 1 day site visits were made. Tables 4.1 and 4.2 identify the states and cities visited and list the major organizations visited and main meetings conducted.

TABLE 4.1. States and Cities Visited on Major (Multi-day, Multi-city) Site Visits to Major Organizations, and Meetings with Participants from Several Organizations.

States and Cities Visited on Major (Multi-day, Multi-city) Site Visits to Major Organizations, and Meetings with Participants from Several Organizations.

Single City Site Visits.

Visits To Organizations

During the site visits to organizations such as hospitals, hospital associations, HMOs, home health agencies (HHAs), and Medicare PROs, the committee generally used the "Guide for Site Visitors" ( Appendix B ). Individual committee members and staff were, however, also guided by their own interests and those of the group being visited.

Each site visit included an introduction of participants and an overview of the study objectives presented by a committee member. Generally, the formal site visits then included an overview of quality assurance concerns and activities from the site visitees and a broad discussion of issues in defining and measuring quality. When appropriate, the work of Medicare PROs and concerns directly related to care of the elderly were discussed. Organizations were asked to identify important quality problems faced by the elderly, the kinds of quality problems identified by their quality assessment programs, and the strategies used to correct those problems. During some visits, the participants broke into smaller groups for more informal discussions.

All site visits included meetings organized around specific themes or groups representing various views of health care delivery. A highly selective listing includes:

physicians in office practice (Minnesota, Virginia, and Texas);
HMO representatives (Minnesota, Texas, California, and Massachusetts);
hospital administrators and medical directors (Washington, including representatives from Idaho);
HHAs (Washington);
geriatric experts (Pennsylvania and Washington);
rural health care (Washington and Texas);
data base development and retirement benefits (Illinois);
community and minority health concerns (New York and Georgia);
ethical aspects of quality assurance (Virginia).

In several instances, committee members and IOM staff met with experts in a particular area of quality assurance, health services research, nursing quality assurance, or geriatrics. Although all of the meetings concentrated on quality assurance for Medicare, each brought forward somewhat different views.

Documentation

After the site visits, each IOM staff member and some committee members prepared lengthy trip reports based on written and tape-recorded observations. Materials gathered at the site visit or forwarded to the study committee later were logged and filed. A study consultant cataloged this material for later reference and use (particularly for Chapter 6 of this volume). At the committee meetings following the site visits, time was allotted for committee members and staff to report on their observations at the site visits and to compare their findings.

Topics discussed during the site visits can be divided into two major classes: issues of concern to study committee members and staff or to site visitees (some of which were couched as "recommendations" or "messages" to the Health Care Financing Administration); and quality-of-care problems identified by the quality assurance programs of those organizations and facilities that had such programs. These issues are briefly summarized here.

Among the subjects raised fairly consistently across the site visits were the following:

general health care issues including special health care needs of the elderly;
benefits and reimbursement issues in the Medicare program;
environmental issues such as shortages of nurses and other health care professionals and of community-based long-term-care beds;
consumer education and participation in health care decisions;
setting-related topics of health care delivery and quality assessment and assurance that focused on particular difficulties or circumstances of ambulatory care settings, home health care, teaching hospitals, and small and rural hospitals;
internal health care organization issues such as leadership, systems of health care delivery, and accountability for quality;
quality assessment methods, including data issues, guidelines, and outcomes assessment;
quality assurance methods, including concerns about duplication of efforts, the value of education and feedback of quality-of-care information, disclosure, dealing with very poor practitioners, legal issues in peer review, and improving average practice;
the Medicare PRO program.

Because of the salience of the PRO program to the core issues of this study, the site visits allotted considerable time to hear the views of PROs and of the health care institutions subject to PRO review. Among the more contentious topics were the overall focus of the PRO program, case-finding techniques (e.g., usefulness of generic screens), the need for flexibility in responding to local or special problems, the strengths and weaknesses of "peer review," problems with sanctions and other corrective actions and the need for more innovative interventions, the "paper burden" of providing medical records, and rules regarding review. Many site visitees noted both beneficial effects (which some believed is a "sentinel'' effect for their own organization-based programs) and the perverse effects of PRO review on health care providers. These issues are also discussed in Chapter 8 of this volume.

Problems Of Quality And Quality Assurance

The organizations and facilities we visited identified many different types of problems. Some problems were classified as the most important problem for Medicare, some as the most important problem at the institution, and some simply as examples of problems found by the quality assurance program of the facility. Although some problems are narrowly clinical, the majority can and should be seen as problems of "systems," rather than of individual providers. The emphasis on systems problems, rather than on problems attributed to individual practitioners, was an important finding from the site visits.

Problems Reported By Pros And Other External Regulatory Bodies

Generic screens.

The first set of problems were those identified by the inpatient generic screens 1 that PROs use in their retrospective review of hospital charts. 2 PROs reported that the screens frequently flagged the following problems:

abnormal results of diagnostic services that are not addressed and resolved or where the record does not explain why they are unresolved;
care resulting in serious or life-threatening complications that were not related to admitting signs and symptoms, generally involving the neurological, endocrine, cardiovascular, renal, and respiratory systems;
medical instability at discharge;
nosocomial infections (specifically, temperature elevation greater than 2 degrees more than 72 hours after admission and indications of infection following an invasive procedure);
trauma suffered in the hospital (specifically, hospital-acquired decubitus ulcer).

One PRO downplayed the value of generic screens in identifying quality problems. Instead it noted that the best yield of quality problems came from review of cost outliers, readmissions, some beneficiary complaints, and some calls and reports from physicians and fiscal intermediaries.

Problems Reported By Hospitals

The comments from one hospital illustrate a widely held belief about the types of quality problems found in hospitals: "Eighty percent of problems are system problems, not medical diagnosis and management problems." These system problems include timely receipt of laboratory test reports, X-ray films and interpretations, and reports of consults; delayed or missing medical records as patients are transferred from site to site or even cared for within a site was also a significant issue. One hospital noted that their procedures for "intake and admissions" and for ''communication and information transfer" all needed improving. One unusual issue was timeliness of autopsies. Hospital staff could not find the charts necessary to do the daily mortality review of the deceased patients because records were being held in the pathology department pending autopsy.

Several hospitals raised poor documentation as a particular problem. Among the specific examples were lack of documentation of reasons for sinus surgery and lack of documentation of preoperative status. More generally, poor documentation in medical records and information flow were mentioned by site visit participants.

Other system-oriented clinical problems reported by hospitals were the following: infiltrates of intravenous lines; problems with central line catheters; aspiration pneumonia; unplanned transfers to the intensive care unit (ICU); nosocomial infections and patient falls (both of which are PRO generic screens); and lack of informed consent. Long waiting times to go from the emergency room to the ICU or hospital bed were cited at one facility.

Diagnosis-specific problems included phlebitis in stroke patients and dementia-related problems (e.g., excessive use of medications, poor use of occupational therapy). Problems linked to surgery were complications of coronary artery bypass graft (which was traced to length of intubation), hematomas after cardiac catheterization, and post-anesthesia headaches. One institution mentioned that generic screens had helped them discover that a particular type of spinal anesthesia was resulting in slower patient recovery.

Inappropriate use of drugs and medications always figures high in quality problems. Cases in point included inappropriate use of coumadin, misuse of antibiotics, and prolonged use of prophylactic antibiotics both before and after surgery. Falls related to medications were reported by at least one hospital.

Blood transfusions and general overuse of blood products are other traditional quality problems that were noted by more than one hospital. In some cases, the blood usage problem was confined to a single department (e.g., orthopedic surgery) rather than present across the facility.

Infection is a common problem. Among the examples cited were penicillin-resistant organisms and an increase in postoperative pneumonia rates (which, in the reporting institution, was attributable to lack of training of inhalation therapists). One hospital's ambulatory review program found readmissions for hospital-acquired wound infection to be a problem, which was traced to inadequate discharge planning and instruction about wound care. Another hospital reported a high incidence of wound infections after open-heart surgery; the source of the problem was eventually tracked to the blood-clotting tanks, which were filled by ice buckets that had a small amount of old water left in the bottom of them.

Only rarely were technical skills mentioned as an important problem. One hospital mentioned skills needed for gastrointestinal procedures. Another mentioned poor placement of feeding tubes, for which a new policy prohibiting blind passage of feeding tubes was developed. A third cited an emergency room physician who missed some fractures on x-ray. One hospital noted an unacceptably high complication rate for retrograde cannulated sphincterotomies, which prompted them to discontinue the procedure.

Overutilization of procedures was mentioned more than once. Sometimes this issue was couched as ''indications for" admission to the hospital (instead of a more appropriate setting) or for a certain procedure such as cataract surgery. At one facility, site visit participants stated that providers for the elderly (1) prescribed too many medications, (2) initiated more aggressive therapy than appropriate, and (3) failed to recognize that quality of life may be more important than length of life. Finally, one respondent cited "overuse" generally and claimed that the "PROs don't see it.''

Site visit participants occasionally mentioned problems that can affect patient satisfaction. These included excessive waiting times (e.g., in hospital outpatient facilities) and problems of access (e.g., reaching the institution by telephone).

External "environmental" problems were also raised. In one hospital, use of the APACHE database helped it to identify increased morbidity that was linked to a decreasing nurse to patient ratio in its ICU, presumably a reflection of a broader problem with a shortage of nurses. The nursing shortage was cited by other hospitals as a significant limitation on quality of care. Another facility noted morale problems from a low ratio of support personnel. Aging physical plants and lack of funds to undertake the needed capital improvements came up more than once, as did access to and the quality of care in nursing homes.

Finally, some institutions noted limitations of quality assurance itself. For example, programs often do not know how to address problems of overutilization. Further, institutions find it difficult to convince physicians of the value of, and need for, quality assurance and to obtain their willing participation in quality assurance activities.

Problems Reported By Hmos

Prepaid group practices were as likely to report problems with ambulatory care as with inpatient care. With respect to ambulatory care, underuse of preventive services (vaccination, cancer screening) was often noted. A low rate of vaccination for pneumococcal pneumonia among elderly patients (17 percent) was aggressively tackled by one HMO visited. Poor compliance with Pap smear screening guidelines was an issue at another site; poor follow-up for Pap smears and positive fecal occult blood tests was noted at another. Issues related to both diagnosis and ongoing care of common conditions were prominent; for instance, the timeliness of cancer diagnosis and management of hypertension. Failure to follow-up abnormal tests was also cited as a problem. Finally, underuse of mental health services was noted by one large system, as illustrated by the appearance in the emergency room of patients in need of psychiatric admission who had not had prior outpatient mental health care.

Other potential quality problems cited were unscheduled return visits to the emergency room (within 48 to 72 hours) and unexpected or problematic admissions to the hospital. As with hospitals, overuse and misuse of drugs and medications were cited as significant quality problems. One example was overcoagulation of patients with transient ischemic attacks. Other issues were polypharmacy (the use of many medications that have potentially conflicting effects, or the use of multiple medications in the same class), use of outdated medications, and psychotropic drug use.

Patient dissatisfaction arose from problems with telephone contacts, waiting times, and, perhaps most importantly, the patient-physician relationship. Lack of coordination of care was also raised (one example being polypharmacy); little or no case management, appropriate post-hospital care, and follow-up are all seen as manifestations of this problem. Patient complaints noted by the HMOs visited included those relating to benefits, access, and referrals to specialists.

Failure of system integration and documentation surfaced as issues for several HMOs. Examples included accuracy of demographic data, presence and accuracy of discharge summaries, and general problems of record-keeping. One provider mentioned lack of documentation of earlier breast examinations as a an obstacle to appropriate breast cancer screening, diagnosis, and care.

Problems Reported By Physicians For Office-Based Practice

Inadequate patient follow-up, particularly of abnormal diagnostic findings, was an issue in fee-for-service outpatient care as it was for prepaid group practice. Poor compliance with preventive care guidelines (in one case, influenza immunizations; in another, breast cancer screening) was also noted as a problem in office-based practice.

As in every other setting, record-keeping and documentation is a concern. One respondent noted that medical records are not built around a standardized database. Another noted that formal hospital discharge summaries are not in the office chart; that is, the office medical record has no formal place to identify dates of, reasons for, and other clinical information about hospitalizations, especially hospitalizations generated by different physicians.

Office-based physicians face some patient-generated problems that they believe are a cause of poor quality. Among the examples cited were patient requests for abusable, addictive drugs and, more generally, difficulty in getting families to agree to "less technology."

Problems Reported By Hhas

HHAs face some problems that differ in degree or kind from those encountered in more traditional settings. One is lack of coordination of services and continuity of care. The many caregivers involved may give conflicting advice to patients (or their families) and yet overlook some aspects of care altogether. Another problem is the discharge of patients from teaching hospitals, when no physician assumes responsibility as liaison to the HHA staff. This is a significant problem when care plans have to be changed, because there is no responsible physician to approve the changes. Conversely, some HHAs evidently find that with case management, their patients are not always sure if "my doctor" is in charge or knows what is happening to the patient.

As with hospitals, staffing can be a problem, especially in regard to registered nurses and therapists, and the availability of full-time staff may be severely limited. One HHA claimed that aides have basic problems reading and writing, which makes documentation problematic.

Some HHAs noted general "gaps in treatment" as a quality issue. The only diagnosis-specific problem mentioned concerned the teaching of cardiopulmonary rehabilitation to patients.

Concluding Remarks

The site visits were central to the information-gathering portion of this study. They gave committee members an unparalleled opportunity to learn about a wide range of quality problems and to hear opinions about quality assurance and similar topics directly from health care providers and practitioners; from community, business, and elderly interest groups; and from quality assurance experts across the entire country. This staying-in-touch with the real world was considered imperative for a study that could easily have become quite academic.

The locales and institutions visited represented a very broad set of viewpoints and expertise in health care delivery and in quality assurance. The documents and reports provided during and after the site visits demonstrated forcefully the breadth of quality problems that can be identified by good quality assessment and surveillance programs and the many different, often idiosyncratic, approaches that are taken to solve these problems. The variety of issues and problems mentioned in this chapter underscores this immense diversity, adding to the perception that inflexible and centrally directed quality assurance will not be able to identify, let alone properly address, these deficiencies in quality of care.

This chapter has not documented the different ways that our site visit participants dealt with the quality-of-care problems they identify or encounter. These quality assurance methods, which are discussed more fully in Chapter 6 of this volume, are as diverse as the problems they are intended to overcome. It became quite clear that there is much ferment about, experimentation with, and lingering hostility to quality assessment and assurance. Notwithstanding the latter, the interest in this study and the responsiveness of those visited are hard to overstate. The contributions of the site visit participants to our understanding of the many difficulties and opportunities facing a quality assurance effort were very great indeed.

Appendix A. Confirmation Letter Regarding Site Visit

Institute Of Medicine

National Academy Of Sciences

2101 Constitution Avenue Washington. D.C. 20418

Dear ______:

I am writing to follow-up our conversation about the Institute of Medicine Study to Design a Strategy for Quality Review and Assurance in Medicare and to confirm the date and time of our visit to______ on Tuesday, January 31, 1989 at 3:00 - 5:30 p.m. Each site visit team includes Committee and IOM staff members. I am enclosing a brief description of each member of the site visit team to ______

The study is being conducted in response to a request from the United States Congress and will result in a report to Congress early in 1990; it is funded by the Health Care Financing Administration. I enclose a description and an update of study activities for your further information. You will also find enclosed a brochure on the Institute of Medicine.

The study is under the direction of an IOM committee of experts that is chaired by Steven A. Schroeder, MD, who is Chief of the Division of General Internal Medicine and a member of the Institute for Health Policy Studies at the University of California, San Francisco. A list of the other members of the Committee is included on the back of the blue descriptive sheet.

One of the study activities is a series of ten site visits to a number of cities throughout the country; included in the site visits will be provider institutions and associations, PROs, public sector agencies, and the like. The purpose of the visits is to provide Committee and staff members with a more thorough first-hand understanding in the following areas:

the varieties of approaches that exist today for measuring and assuring the quality of health care to the elderly;

the barriers experienced by health care facilities in developing effective quality assurance (QA) programs, and the solutions they may have devised to overcome those obstacles;

the experience of groups responsible for QA activities (e.g., regulatory agencies, Medicare PROs) and of providers and practitioners who are the targets of such activities (e.g., hospitals, health maintenance organizations, ambulatory care centers, home health agencies, private practice physicians) in terms of (1) the effectiveness of these QA or regulatory programs and (2) the direct and indirect monetary or other costs of such programs;

promising initiatives related to quality assurance that are planned or under way (whether or not they are specifically related to the Medicare program); and finally,

the nature and extent of possible problems in the quality of health care delivered to the elderly today.

In short, the intention expressed by the Committee in undertaking these site visits is to gain a "real-world" understanding of what challenges exist in the quality-of-care area, what is being done to meet those challenges, and how well they are being met—beyond what can be learned from published reports. The Committee is also especially interested in hearing your recommendations for increasing the effectiveness of quality assurance strategies for the Medicare program and for health care delivery more broadly.

To achieve our goals for these site visits means that we need to have a frank and open exchange between your group and our site visit team; we need also to hear from people in your organization who have "front line experience" in the quality assurance area. The purpose of the site visits is educational, not evaluative, and the final report will not identify information by individual sites. Please be assured that all information shared will be treated with strict confidentiality.

We believe that it would be helpful to us if the site visitors could meet with a group of no more than 6-8 individuals, including, for instance, a Member of the Board of Trustees or Directors, the Medical Director, the Chairman of the QA Committee, the QA Coordinator, and perhaps the director of your Medical Records or Data Processing Department; it might also be very informative for us to meet with some clinicians on your staff (physicians, nurses, discharge planners and the like) who may have a special perspective on quality review and assurance activities within the institution. We would be particularly interested in learning more about your risk management program and how it may function to improve quality of care.

In discussing their objectives for the site visit Committee members have expressed their strong preference for the site visit to include the following components;

A brief introduction to the IOM study by one of the Committee members.

A relatively brief (20 - 30 minutes) overview of your quality assurance program (in this regard, we would be pleased to receive ahead of time any background materials).

How you know when you might have a clinical quality problem,
How you analyze the cause(s) of a problem and determine if it is an occasional error or a pattern,
What kinds of interventions you use to resolve the problem,
How you know whether what you are doing has an impact,
The burdens and costs of the program,
The overall impact of the program in the organization, and
Your views about what would enable the internal quality assessment/ quality assurance process to be more effective.
The overall impact of external programs in terms of both intended and unintended effects, and
The burdens and costs of responding to external review and regulatory requirements, and your views about how the process could be made more effective.
The nature and extent of current and emerging problems in the quality of health care delivered to the elderly today,
Whether any problems you identify tend to be concentrated in a relatively small fraction of providers, practitioners, or special groups of elderly or are more diffusely spread among the provider community or elderly population,
Whether quality problems you see are primarily those of overuse, underuse, or misuse of services,
Promising quality assurance initiatives.

During the remaining time the Committee may want to divide into two groups to meet with no more than 1-3 people in each group who are very familiar with the operations of the quality assurance program and could discuss the QA program from a "front-lines" perspective. Perhaps you could help identify for us (at the time of the visit) those individuals you think would be most appropriate for the two groups to meet with.

Again, we would very much appreciate receiving ahead of time any available background materials describing your organization and QA program so that we may be better prepared for the visit. It would be particularly useful if you could provide us at the time of the visit with an estimate of the annual cost of your QA activities (direct costs for personnel, data processing, etc., for both internal review and in response to external requests). Also, might we have copies of any quality indicators, screens, guidelines, and clinical protocols that are currently in use? These would be of great interest to the Committee and staff for use as background materials in preparing the final report. No materials will be quoted or duplicated outside the Committee.

On behalf of the Study Committee and the Institute of Medicine, I would like to thank you for sharing your time and allowing us to visit. We are certainly looking forward to our visit. I or someone from our staff will call your office before the visit for any specific location directions. If you should have any questions I can be reached at 202/334-2165.

Molla S. Donaldson, M.S.

Associate Study Director

Enclosures:

Study description

IOM Brochure

Description of site visitors

Appendix B. Guide For Site Visitors Strategies For Quality Review And Assurance In Medicare

Site visitors should meet for at least a half hour every morning to plan strategy.

The site visit team should try to meet for an hour at the end of each day and definitely before the departure of team members for a general debriefing.
Consider taping these debriefings. Try to cover at least the following major points: problem identification and verification, interventions, restudy, costs and burdens, and three important three quality problems identified by sites with an internal QA program and members' general observations.

TEAM CAPTAIN RESPONSIBILITIES

The Team Captain (assigned in rotation) should plan to introduce the study, its purposes, and the team members. Suggested points to cover:

Introduction

What the IOM is (part of NAS—independent, nonfederal, private, nonprofit, research)

Who commissioned the study (US Congress)

Composition of Committee (about 1/2 physicians, health experts, chosen for their own expertise not special interests)

Due date (Jan. 1990)

Assumptions or lack thereof (not starting with assumption about HCFA, PROs, etc.)

Medicare (not Medicaid) study

Educational purpose

Focus is truly on quality not cost containment

Settings hospitals, free-standing clinics, MD offices, and HMOs, HHAs

Other activities of study public hearings, written testimony, focus groups, commissioned papers, site visits

Confidentiality of quality information

Invite them to speak not only for organization, also as individuals

Desire for materials now or later—follow-up

Introduction of those present

How you would like visit to be organized (large/small groups)

Keep questioning on track.

Keep track of time for splitting into smaller groups and for departure.

RECOMMENDATIONS TO ALL SITE VISITORS:

Seek specific examples, and ask if we can follow-up, be provided with materials, etc.

GENERAL TOPICS OF INTEREST

Mandate from Congress:

Definitions of quality of care;

The role of structure, process and outcome;

Prototype criteria and standards;

Adequacy and focus of current methods for assessment and assurance;

Evaluate current research on methodologies, needed research;

Adequacy and range of methods for assurance;

Review mechanisms for promoting, coordinating supervising at the national level;

Criteria for establishing priorities in allocation of funds and personnel

Conditions of participation (hospitals)

Tories of interest:

Definition of "quality of health care"

Level of quality of care now provided to the elderly?

—differ by the type of care, setting of care, or other factors?
—differ for different groups within the elderly population?

Major existing or emerging problems? the major strengths?

Is quality of health care adequately monitored or assessed today? (too extensive, adequate, or too little)

Responsible agencies, institutions, associations, or individuals?

Coordination

—among local, state, and federal agencies?
—among private accrediting and review organizations? and
—between the public and private sectors?

What kinds of activities are the most effective and what are the least effective in improving quality of health care?

—conducting
—priorities for needed research

Medicare benefits and access

Effect of gaps in Medicare coverage (benefits) on quality

Effect of Medicare reimbursement on quality

Special characteristics of the Medicare population

—effect on quality

Access barriers

—that exist
—that they have overcome
Health Care Facilities With Internal Quality Assurance Programs:

The following is the pool of questions suggested by the Committee.

** (asterisks) mark those questions emphasized at the Committee meeting.

Problem Identification

** How do you identify a potential problem?

** What kinds of problems can your QA system identify, and what kinds can it not identify? For instance; overuse, underuse, a single practitioner or service with a pattern of poor care, bad outcomes, misdiagnosis, missed diagnosis, rates of occurrences, case finding, fragmentation in care by setting, service, or dept.

What data do you use to monitor quality? How do you adjust for confounders such as severity? How do you assure the quality of the data itself?

What data (if any) do you collect that is unique for the Medicare patients? Are there data elements you collect beyond what is required for HCFA?

Does your data system allow you to respond to current HCFA requests for data? For HMOs: Can you provide, for instance, no-pay bills?

Problem Verification

** How do you verify a problem found in retrospective review as a real quality problem? Do you use peer groups, expert opinion, other methods? How do you select a given problem (among a number) for review—set priorities among ''competing'' problems?

** To what extent do you focus on the occasional error as compared to a pattern of bad care?

** What is the yield of real quality problems compared to potential problems that fail "screens" or other methods of first level problem identification?

** What are three important quality problems you have found recently? (frequency, potential harm to patient) If answer does not include clinical problems, guide questioning to this.

** Are problems concentrated in a relatively small fraction of practitioners or are they more diffuse?

** Are the quality problems, in general, related to overuse, underuse or misuse of services?

Interventions/Assurance

What do you do if a practitioner or facility is identified as providing sub-standard care?

—education, feedback, privileging, jawboning by Chairman
—anything different if identified internally or externally?

How useful and effective are these interventions?

How many (and what kind of) different methods for assurance have you tried?

What changes have occurred in response to the Patrick case—has peer review been "chilled?" What are the disincentives? Have doctors backed off from making hard decisions?

Impact Of Interventions/ Restudy

** How do you know that your interventions have had an impact?

—What has been changed as a result of this process?

** Please take one quality problem you have identified in the last year and walk us through the steps in identifying it, verifying it, identifying and implementing changes, and reevaluating the problem or impact? Press for specific answers.

—Who has been told about the information—Board of Trustees, medical staff, nursing, etc.?
—What methods of information sharing are used?

** What would improve the effectiveness of your efforts?

—for instance, better measurement tools? expanded financing? greater support from management, providers, or patients? greater integration of quality assurance into the organization's other activities? or other factors?

Costs and Burdens (For Internal And External Review)

** What is the effect of your internal QA program on the institution, medical staff? What is the effect of the external QA review on the institution, medical staff?

How much burden does the quality assessment system place on providers? Have you identified ways to reduce the burden? Have you identified ways to reduce the burden but haven't been able to implement them because of regulatory restrictions?

For HMOs: What has been your experience with PRO (or QRO) review of care (e.g., the "13 conditions?") and with hospitals and PROs for review of acute hospital care?

How much of your time is spent on quality assessment in comparison to utilization review? Has this changed recently? What is your opinion of the distribution?

What do you estimate is the cost of your assessment and assurance activities—for instance, dollars spent per case reviewed, or percentage of your total annual budget spent on quality-related activities?

What is the local environment for health care quality issues? For instance, does the press or a business coalition affect your internal activities?

How does your QA system affect other actors within the health care system (e.g., physicians)?

As a subject of external quality assessment and assurance activities (PRO review, licensure, accreditation, etc.)

What kinds of problems and benefits do you experience with those efforts?
What do you believe would improve the effectiveness of those efforts?

How many (and what kind of) different methods for quality assessment have you tried? How do they compare for yield, cost, validity, and ability to identify true quality problems?

Advocacy/ Shared Decision Making

Is there a well-defined role for "patient advocates" in your organization? If so, what are their responsibilities? To whom do they report? What are institutional/organizational objectives of the patient advocacy process? What methods do you use for grievance resolution?

What are the established mechanisms for promoting and targeting provider education—both clinical education and education about the review process?

What are the established mechanisms for promoting, targeting, and monitoring the effectiveness of patient education and participation in decision making?

Is outcome information routinely collected following major medical or surgical procedures or following diagnostic studies? If so, what kinds of outcomes are ascertained? At what point in time?

Is patient satisfaction specifically addressed? Is this information regularly made available to providers? To patients?

Describe any requirements and review mechanisms regarding informed consent.

How does the organization influence providers' decisions about indications for procedures, special care, or hospital admission and length of stay?

How do you (your institution) make decisions about patient care when a particular service is scarce (e.g., ICU beds)?

Are there any mechanisms designed specifically to blunt volume-driven, fee-for-service incentives, or capitation-based disincentives, to perform procedures or render care?

Are decisions to perform or forego major therapeutic interventions reviewed? If so, how are procedures and specific cases selected for such review?

1. The six major categories of PRO generic screens are as follows: (1) adequacy of discharge planning; (2) medical stability of the patient at discharge—for instance, signs such as blood pressure, temperature, pulse, or purulent drainage of postoperative wounds at the time of discharge that would indicate that the patient was not stable—as well as abnormal results of diagnostic tests that were evidently not addressed during the hospital stay; (3) certain unexpected deaths; (4) nosocomial (hospital-acquired) infections; (5) unscheduled return to surgery; and (6) trauma suffered in the hospital, for example, falls, certain life-threatening events, and hospital-acquired decubitus ulcer. See Chapter 8 for more details.

2. At the time of the site visits, very few PROs were involved in "intervening care" review of home health agencies or skilled nursing facilities. One that was reported that an important failed quality screen for skilled nursing home care was "signs and symptoms not reported to physician within four hours from the time detected."

3. One PRO offered the following example. A 92-year-old woman was admitted to the hospital in septic shock, but the facility was unable to find a responsible physician for almost 3 hours, as her usual physician was on vacation. She subsequently died. The PRO took the case through to possible sanctioning.

4. One PRO, for instance, reported that a rural hospital stocked tissue plasminogen activator (tPA) but had no protocol available for its use. The PRO gave them one.

Cite this Page Institute of Medicine (US) Committee to Design a Strategy for Quality Review and Assurance in Medicare; Lohr KN, editor. Medicare: A Strategy for Quality Assurance: VOLUME II Sources and Methods. Washington (DC): National Academies Press (US); 1990. 4, Site Visits.
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Dashpivot article – How to write a Site Visit Report for construction

How to write a site visit report for construction

What should be in a construction site visit report.

A site visit report for construction is essential in capturing the progress, challenges, and conditions observed on a construction site. Here's a breakdown of what should typically be included in a site visit report report:

Project Reference: The construction project name and reference ID.
Location: The exact address or co-ordinates of the construction site.
Date of Site Visit: The specific date(s) when the visit was recorded.
Prepared By: The name of the individual or team responsible for the report.
Project Overview: A brief description of the construction project and its significance.
Purpose of Visit: The main objectives or reasons for the site visit.
Names, titles, and affiliations of all individuals present during the site visit, including site supervisors, engineers, contractors, stakeholders, etc.
Planned activities, areas inspected, and topics discussed during the visit.
Construction Progress: Status of ongoing construction activities, milestones achieved, and work remaining.
Equipment & Material Status: Condition and availability of machinery, tools, and materials.
Safety Observations: Notes on safety measures in place, potential hazards observed, and any safety incidents that may have occurred.
Quality of Work: Observations related to the quality and standards of the construction work.
Team Dynamics: Interactions among the construction team, including any challenges or bottlenecks in workflows.
Highlights: Significant accomplishments or milestones achieved since the last visit/report.
Issues/Challenges: Problems, delays, or potential risks observed during the visit.
Actionable suggestions or solutions based on the observations and findings. This might include fixes, interventions, or changes in procedures.
Relevant photos from the site visit that showcase progress, challenges, or specific areas of interest. Ensure that photos are labeled or captioned appropriately with timestamps, geotagging and markup.
A brief recap of the main observations, emphasizing the overall status and health of the construction project.
Details about planned interventions, further visits, or any immediate actions required based on the report's observations.

How do you plan for a construction site visit report?

Planning a construction site visit report is crucial to ensure the visit is effective and that the subsequent report is comprehensive and valuable. Here's a systematic approach to planning a construction site visit report:

Determine the main reason for the site visit. Is it a routine check, a response to a reported issue, or to monitor a specific phase of the project?
Familiarize yourself with the status and findings from prior reports to understand the project's progression and to identify any outstanding issues.
Outline what you intend to inspect and the issues you aim to address.
Allocate time for specific activities, such as meetings with the site manager, inspecting particular areas, or reviewing certain processes.
Inform them about your visit, discussing your agenda and objectives.
Request any specific materials, equipment, or personnel you might need during the visit.
Gather project plans, previous site visit reports, safety protocols, and any other relevant documentation that will help guide your visit.
Ensure you have the necessary personal protective equipment, such as a helmet, safety shoes, high-visibility vest, and any other site-specific safety gear.
Carry tools for documentation: notebook, camera (if allowed), voice recorder, and measuring tools, if necessary.
Determine whom you need to meet, such as the site supervisor, safety officer, project manager, or specific workers. Ensure they are available during your visit.
Familiarize yourself with the site's safety protocols.
Ensure you are informed about potential hazards and the safety measures in place.
Set aside time to discuss findings, concerns, or clarifications with the on-site team. It's beneficial to address issues or misconceptions immediately.
Set Report Deadlines:
Determine when your report will be written and by when it needs to be distributed to stakeholders. Setting a deadline will ensure timely follow-ups and actions.

How often should you run site visit reports?

Here's a general guideline for determining the frequency of site visit reports:

Large-Scale Projects: Bigger projects such as skyscrapers or major infrastructure projects might warrant weekly or even more frequent reports, especially during critical phases.
Medium-Scale Projects: Residential complexes, mid-sized commercial buildings, or similar constructions may require bi-weekly to monthly reports.
Small-Scale Projects: Smaller projects, like home renovations, might need bi-monthly or even quarterly reports unless there are significant changes or issues.
Initiation and Mobilization: Frequent reports can ensure the project's initial stages align with plans and guidelines.
Critical Construction Phases: During essential stages, such as foundation laying or the installation of primary structures, more frequent reporting may be needed.
Completion or Finishing Phase: As the project nears completion, visits might focus on ensuring the quality of finishing touches and adherence to project specs.
Conducting site visits upon the achievement of significant project milestones can confirm progress and alignment with project goals.
Some stakeholders or investors might have mandatory frequencies for site visits as part of their oversight or contractual obligations.
If previous visits or reports highlight certain risks, problems, or deviations from the plan, it can be necessary to increase the frequency of visits to monitor corrective measures and developments closely.
Unpredictable events such as severe weather conditions, labor strikes, or supply chain disruptions might require unscheduled visits to assess impacts and adjustments.
Some projects might be under mandates from local or federal agencies, requiring specific site visit and report frequencies, especially if there are environmental or community concerns.
In the wake of safety incidents or if particular high-risk activities are underway, increased visit frequency can reinforce safety measures and ensure compliance with safety standards.

What should a completed site visit report look like?

After you've written your construction site visit report, it should look along the lines of the example below.

Use this free Construction Site Visit Report template for your next project

Use a standardised construction site visit report.

Make it easy for your team to write construction site visit reports by using a standardised site visit report template .

The digital construction site visit report comes standardised with all the fields and sections to run site visit reports smoothly with all the information. you need, first time.

Customise the site visit report with any extra information you need to capture on site to show the progress on the project.

Distribute your digital construction site visit report for your team on mobile or tablet so they can write it on site and sync it back to the office when it's completed.

Build automated processes for your construction site visit reports

Make it easy for your team to request, write and sign off on construction site visit reports by using a dedicated site visit report app .

Create automated workflows with automatic notifications for when someone needs to write a report, or give signoff approval.

Share completed site visit reports quickly and easily as PDF or CSV with brand colours and logo for a professional construction site visit report.

Take and attach photos directly on site from your phone with automatic timestamps, geotagging, markup and smart tags for a well documented construction site visit report.

Site diary template

Complete and organise your daily diaries more efficiently.

Meeting Minutes template

Capture, record and organise those meeting minutes.

Progress Claim template

Streamline and automate the progress claim process to get paid faster and look more professional.

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Administrative Site Visit and Verification Program

USCIS started the Administrative Site Visit and Verification Program in July 2009 as an additional way to verify information in certain visa petitions. Under this program, immigration officers in the Fraud Detection and National Security Directorate (FDNS) make unannounced site visits to collect information as part of a compliance review.

What is a compliance review?

Immigration officers conduct compliance reviews to ensure that petitioners (employers) and beneficiaries (job applicant or other potential employee) follow the terms and conditions of their petitions. This process includes reviewing the petition and supporting documents, researching information in public records and government systems, and, where possible, interviewing the petitioner and beneficiary through unannounced site visits.

Participating in a site visit is voluntary, but strongly encouraged

Participation in the compliance review process is voluntary. FDNS immigration officers will end a site visit if a petitioner or beneficiary expresses an unwillingness to participate. When this happens, the FDNS immigration officer will complete the compliance review by using all available information and will document the circumstances of around ending the site visit.

Types of petitions subject to site visits

As of fiscal year 2019, FDNS conducts compliance-review site visits on petitions for:

Special immigrant religious workers petitions (before and after adjudication);
H-1B nonimmigrant temporary visas (after adjudication);
L-1 nonimmigrant intracompany transferee executive or manager visas (after adjudication); and
EB-5 immigrant investor program visas (before adjudication)

How USCIS chooses site visits

FDNS randomly selects petitioners for site visits after USCIS adjudicates their petitions.

Immigration officer tasks

Officers record their observations on a Compliance Review Report. Officers occasionally conduct multiple site visits if they need more information to complete a compliance review. At the site visit, the officer will:

Verify the information, including supporting documents, submitted with the petition;
Verify that the petitioning organization exists;
Review public records and information on the petitioning organization;
Conduct unannounced site visits to where the beneficiary works;
Take photographs;
Review documents;
Interview personnel to confirm the beneficiary’s work location, physical workspace, hours, salary and duties; and
Speak with the beneficiary.

How employers should prepare for a potential site visit

Before a site visit : Employers should be prepared to present any information originally submitted with the petition. The immigration officer may also may ask for more information relevant to the petition.

During the site visit : Employers should immediately provide all readily available documents and information that the immigration officer requests.

After the site visit : Employers should provide all additional information that USCIS requests in any follow-up communication.

Why some employers receive repeated site visits

Employers might receive more than one site visit if they petition for more than one beneficiary. Each compliance review focuses on one petition and beneficiary. FDNS will randomly select such employers for multiple site visits.

What happens after a site visit?

Because FDNS immigration officers are not adjudicators, they do not make decisions on petitions or applications for immigration benefits. USCIS will review an officer’s Compliance Review Report for any indicators of fraud or noncompliance, and, FDNS may refer the case to U.S. Immigration and Customs Enforcement for criminal investigation.

Bureaus and Offices
Contact HRSA
Site Visit Protocols and Guides
Health Center Program Site Visit Protocol

Health Center Program Site Visit Protocol: Examples of Credentialing and Privileging Documentation

NOTE: The Site Visit Protocol (SVP) is the tool for assessing compliance with Health Center Program requirements during Operational Site Visits (OSVs). Use this resource along with the SVP to prepare for OSVs.

Examples of Credentialing Documentation

Examples of privileging documentation.

This resource applies to the SVP Clinical Staffing section and addresses the credentialing and privileging of all current clinical staff. This resource can be used during the site visit when reviewing credentialing and privileging files. Health centers may also use this resource to prepare for a site visit and ensure their credentialing and privileging files are complete.

This resource provides common examples of credentialing and privileging documentation that may demonstrate compliance with credentialing and privileging requirements. The examples are NOT exhaustive, and health centers may have other documentation that demonstrates compliance. HRSA encourages health centers and site visit reviewers to use this resource along with the SVP and the Compliance Manual.

Note the following when using this resource:

Clinical staff include all staff who provide clinical services (for example, medical services, dental services, behavioral health services).
Examples of LIPs include: physician, dentist, physician assistant, nurse practitioner, clinical psychologist.
Examples of OLCPs 1 include: registered nurse, licensed practical nurse, certified medical assistant, phlebotomist, respiratory therapist, licensed or certified behavioral health support staff.
Examples of other clinical staff include: medical assistants, peer navigators, or community health workers in states, territories or jurisdictions that do not require licensure or certification.
The health center chooses the timeframe for recurring credentialing and renewal of privileges (for example, every 2 years).
The health center chooses what specific credentialing activities apply to “other clinical staff.” For example, if your state does not certify medical assistants, you would verify their training instead of licensure.
A health center that does not employ “other clinical staff” would not need to include them in its operating procedures or make that type of provider file available for review.

1 States may have different scope of practice and licensure and certification requirements that affect how the providers (for example, pharmacists or registered dietitians) are categorized as LIPs or OLCPs.

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Therapeutic Goods (Guidelines for Multi-Site Licences) Instrument 2020

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Annexure A: Project site vist checklist
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Site Inspection Checklist Template in Word, Pages, PDF, Google Docs
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COMMENTS

Site Visit Protocols and Guides
June 2024. Health Center Program Site Visit Protocol (SVP) The Site Visit Protocol is a tool to assist the Health Resources and Services Administration (HRSA) perform its oversight of health centers. The SVP includes a standard and transparent methodology that aligns with the Health Center Program Compliance Manual.
Health Center Program Site Visit Protocol
The Site Visit Protocol (SVP) is a guide to the operational site visits (OSVs) we conduct at health centers. It includes what we look for and how we assess compliance. It aligns with the Health Center Program Compliance Manual. Changes made to the SVP. In 2023, we improved the format of the SVP and made it easier to read.
PDF Health Center Program Site Visit Protocol
HRSA develops and shares a site visit report with the health center within 45 days after the site visit. The report conveys the site visit findings and final compliance determinations. In circumstances where HRSA determines that a health center has failed to demonstrate compliance with one or more of the Health Center Program requirements, HRSA ...
2021 and 2022 Site Visit Protocol: Summary of Updates
The Health Resources and Services Administration (HRSA) implemented the Health Center Program Site Visit Protocol (SVP) for all Operational Site Visits (OSVs) and look-alike (LAL) initial designation (ID) site visits in January 2018. The SVP is the tool used to assess compliance with Health Center Program requirements. The SVP provides HRSA with information necessary to perform its oversight ...
PDF Site Visitor Handbook
The Site Visitor Handbook addresses: the roles and responsibilities of site visitors, the PHAB information system (e-PHAB), site visitor training, the site visit, documentation review and assessment, the development of the Site Visit Report, the review of Action Plans, and evaluation responsibilities.
PDF Public Health Accreditation Board Site Visitor Guide
As a site visitor of health departments on behalf of the Public Health Accreditation Board (PHAB), I will: be present, attentive, and participatory in all training, team meetings, site visit activities, and site visit interviews; arrive on time for training, conference calls, and meetings, and not leave early;
PDF CO HCBS Final Rule Settings Site Visit Checklist
particular setting. Criteria to be assessed (and validated) during the site visit are listed in the far left-hand column. The second column requires the site visit team to verify the statement by checking one of three boxes - True; False; or N/A to this setting. The "True" option should be checked if the site visit team believes, based on a
PDF NAEYC Accreditation Site Visit Protocol
the site visit hiatus may be reassigned to a different assessor. Pre-Visit Protocol and Procedures An assessor will contact each assigned program before their site visit, to collect additional information relevant to scheduling the visit. There are four steps in the assessor's pre-visit scheduling process for Accreditation Visits: 1.
PDF Class Observation Tool: All Ages NAEYC Site Visit
if no infants are observed being placed to sleep. During the Orientation Meeting at the beginning of the Site Visit, the assessor will ask if any enrolled infants younger than 12 months have a physician's authorization to b. placed to sleep in any position other than back. If so, documentation must be shown to t.
PDF HTN-Planning and Conducting Site Visits
It lists Agency requirements for programmatic site visits, identifies practical steps and effective practices for planning and conducting a site visit, and recommends follow-up actions once a site visit has taken place. This How-To Note is intended as a resource for Missions and Washington Operating Units (OUs).
Medicare Site Visits during Provider Enrollment
Call nCred today at (423) 443-4525 to discuss your Medicare Provider Enrollment needs. We work with all specialties and have extensive experience processing Medicare applications. From the Medicare Program Integrity Manual: 10.6.20 - Screening: On-site Inspections and Site Verifications (Rev. 11949; Issued: 04-13-23; Effective: 04-21-23 ...
PDF Florida Site Visit Framework
Effective Date: November 2021 Rule 6A-5.066, F.A.C. FSVF-2021. Notes 1. Reviewers on how review area scores are determined: 2. constraining Constraining criteria team will. 3. The guidance provided a preponderance of evidence nce and will check all the criteria for inadequate before considering higher judgment.
Site Visit
A site visit is required for a Sponsoring Institution or program on Probationary Accreditation or Recognition prior to the next review and accreditation or recognition status decision. Review or Recognition Committees may request a site visit to review complaint allegations and determine the disposition of a complaint.
FTCA Site Visit Protocol
FTCA site visit process. Once scheduled, the health center can expect the team to conduct document reviews. After the site visit begins, staff and board interviews and facility tours will be conducted. FTCA site visits last 2.5 days. All details are discussed before the site visit during the pre-site visit call.
Site Visit Guidelines
After the Visit. The site team's report, in draft form, should be sent to the Program Director by the team Coordinator within four weeks of the visit. Guidelines for this report are provided in a separate document. The Program will have an opportunity to review the report, and suggest appropriate corrections of fact.
Everything You Should Put on Your Site Visit Checklist
Your site visit checklist should cover specifics about the site itself, event-day logistics, A/V availability, storage, and timing. Having this information in advance will help you to either plan your program accordingly or give you some lead time to find vendors offering those services. The bottom line: you can work around anything as long as ...
PDF Preparing for Desk Reviews and Site Visits Guide Sheet
Site visits occur at the recipient's office or program. location or can be done virtually, if there are scheduling or traveling issues. Site visits are intended to review the capacity, performance, and compliance of the recipient. Site visits allow the awarding agency. procedures, audit compliance records, and internal controls.
Site Visits
I am writing to follow-up our conversation about the Institute of Medicine Study to Design a Strategy for Quality Review and Assurance in Medicare and to confirm the date and time of our visit to______ on Tuesday, January 31, 1989 at 3:00 - 5:30 p.m. Each site visit team includes Committee and IOM staff members.
How to write a site visit report for construction
Here's a breakdown of what should typically be included in a site visit report report: Project Reference: The construction project name and reference ID. Location: The exact address or co-ordinates of the construction site. Date of Site Visit: The specific date (s) when the visit was recorded. Prepared By: The name of the individual or team ...
Administrative Site Visit and Verification Program
USCIS started the Administrative Site Visit and Verification Program in July 2009 as an additional way to verify information in certain visa petitions. Under this program, immigration officers in the Fraud Detection and National Security Directorate (FDNS) make unannounced site visits to collect information as part of a compliance review.
Health Center Program Site Visit Protocol: Examples of Credentialing
Health centers may also use this resource to prepare for a site visit and ensure their credentialing and privileging files are complete. This resource provides common examples of credentialing and privileging documentation that may demonstrate compliance with credentialing and privileging requirements.
PDF SITE VISIT AND REMOT E AUDIT REQUIREMENTS AND PROCEDURES
4.1.1 | The VVB shall determine whether a physical site visit is mandatory as per the minimum physical site visit requirements. 4.1.2 | The VVB shall determine whether or not a remote audit is viable for an audit instance of a given project where a physical audit is not mandatory.
2017 Site Visit Manual
Day 1 of the site visit begins with a one-hour meeting with the applicant at the applicant's headquarters, during which the Team Leader makes introductory remarks and introduces the Site Visit Team members. The Team Leader presents a brief overview of the Baldrige Award and site visit process and procedures.
Therapeutic Goods (Guidelines for Multi-Site Licences) Instrument 2020
The Department of Health and Aged Care acknowledges First Nations peoples as the Traditional Owners of Country throughout Australia, and their continuing connection to land, sea and community.