Q&A: Monitoring contracted services

Accreditation Insider, May 15, 2012

Want to receive articles like this one in your inbox? Subscribe to Accreditation Insider!

Q: What is expected of me when it comes to monitoring the performance improvement of contracted services?

A: Although not new, a focus of the Leadership standard will be on external clinical contract services provided to the organization. CMS and The Joint Commission expect organizations to have oversight for their external contractors to ensure the quality of care, treatment, and services they provide. In a nutshell, leadership must establish and put in writing (can be an addendum to the contract) the performance expectations for the services provided. The hospital has to monitor the performance and the contracted service has to improve when expectations are not met. This puts more of a burden on the organization to establish performance measures and monitor results. It may mean termination of the contracted services if improvement is not seen.

LD.04.03.09 outlines very clearly the expectations to meet this standard, so follow closely as you assess your current processes to ensure compliance.

It is a good idea to establish a multidisciplinary team to identify which external contracts fall into the category of providing care, treatments, and services to patients. The team should include, at a minimum, representatives from human resources, legal, and the accreditation coordinator. Examples of external contractors may fall into the category of external clinical contracts are security guards, mobile imaging, food services, reference labs, and cleaning services.

Once the contracts have been identified, develop a log that includes the contract names, the services provided, the hospital-defined performance measures, how often the measures will be assessed and reported, and the person responsible at the hospital.

Editor’s Note: Do you have a question about clarifying RFIs, policy management, or survey-prep for our experts? E-mail your queries to Jaclyn Beck at and receive one-on-one advice from our experienced advisory board. Submit a question and our credible sources will provide you with a timely answer.

Want to receive articles like this one in your inbox? Subscribe to Accreditation Insider!

Most Popular