CMS SOM App. A, Tag A-1693

appropriateness of services and treatment provided by the medical staff.

Interpretive Guidelines §482.62(b)(2)

Services and treatment prescribed to patients must be in accordance with appropriate and

acceptable standards of practice. The clinical director must show evidence of direct

involvement in monitoring and evaluating the quality and appropriateness of all clinical

services and treatment. Oversight and involvement may include:

• Participating in the credentialing and privileging process which includes

recommendations to the governing body,

• Ongoing review of medical staff performance,

• Reviewing clinical outcomes,

• Being involved in peer review process, and

• Collaborating with other disciplines to identify and discuss issues related to the

medical staff.

Additionally, oversight and monitoring may include:

• Attending clinical rounds with the medical staff,

• Performing medical record reviews, and

• Observing the provision of care by medical staff.

The clinical director and hospital’s governing body must approve policies and

procedures that establish a system for overseeing and evaluating the quality of the

clinical services provided by the medical staff. Policies include the process, criteria and

frequency for evaluating the medical staff performance in providing clinical services.

Evaluations should take place at regular intervals specified in the hospital’s policy.

Additionally, in states that allow psychologists and other licensed practitioners to have

admitting privileges, it is still the responsibility of the clinical director to oversee the

quality of the patient’s treatment. In cases where someone other than a psychiatrist

admits a patient, §482.60 requires a physician to be responsible for the patient’s care.

There are a variety ways for monitoring and improving the quality of care provided

within the psychiatric hospital. In accordance with 42 CFR §482.21, the hospital's

Governing Body must ensure that the quality assessment and performance improvement

(QAPI) program reflects the complexity of the hospital's organization and services. The

director of psychiatric services should choose specific indicators related to improved

health outcomes and the prevention and reduction of medical errors to be included in the

overall QAPI program.

Survey Procedures §482.62 (b)(2)

• Interview the clinical director and ask him/her to describe their role and

involvement in the credentialing and privileging process.

• Ask the clinical director to describe the process for ongoing review of the

medical staff.

• What mechanisms are used to monitor and evaluate the work of the medical

staff?

• Is there evidence that the clinical director spends sufficient time at the

hospital monitoring the provision of care by the medical staff?

• Interview the clinical director to determine how he/she addresses problems or

concerns related to the psychiatric services. Interview staff and patients to

determine the effectiveness of clinical director’s interventions.

• Review medical staff meeting minutes and/or Governing Body meeting

minutes to verify the clinical director’s involvement in oversight and

evaluation of the medical staff.

• Review the mechanisms utilized, as reported by the clinical director, to ensure

the quality and appropriateness of psychiatric services and treatment are

monitored.