[Editor's Note: This is the second of a potential several articles on the Gila Regional Board of Trustees meeting on March 20, 2024. It begins the reports and updates.]

By Mary Alice Murphy

At the Gila Regional Medical Center Board of Trustees meeting on March 20, 2024, Chief Executive Officer Robert Whitaker presented board education. He noted the conditions of participation surround "our being accredited by CMS (Centers for Medicare and Medicaid) as a health-care provider. So what are our conditions of participation? They involve health and safety guidelines that we share by improving quality and participation. In order for us to seek payment from the federal government, we must meet these conditions of participation. There is a 306-page manual for this. It's called the State Operations Manual.

"We're a critical access hospital, so it is Appendix W where the protocols, procedures and guidelines for critical access hospitals are. Know that each condition has a standard that must be met, and each standard will have a interpretive guideline as well as survey procedures. We have to be in compliance with local, state and federal laws. They will look at the agreements that a critical hospital must have, such as transfer agreements. They survey emergency services. For our cost report year, the average length of stay for all our services must be 96 hours or less."

He said a separate surveyor will look at the physical environment, including emergency preparedness, physical structure, staffing and staff responsibilities, clinical records, surgical services and special requirements.

"Who certifies that these conditions are met?" Whitaker asked and answered. "CMS certifies them during unannounced compliance audits. We had an unannounced survey in 2023. Joint Commission is the one we contract with and they survey us once every three years. There are other things that happen in between the unannounced surveys. It's isn't like we can sit back and relax. These surveys can be done by a state agency, typically the state department of health or by a CMS accredited organization. The Joint Commission is by far the largest accreditation organization. For evaluations, every three years the Joint Commission comes and does the unannounced survey. Usually they are here for two to three days to make sure we are a safe environment for health care. Carolyn St. Charles [of Health Tech] comes here to regularly to do mock surveys to make sure we meet the conditions, and to always be ready for a survey. The quality committee, the safety committee and other hospital and staff committees are always working to make sure we provide quality care in a safe environment."

He noted that Gila Regional is fully accredited by CMS as a critical access health-care organization. In addition to these surveys, there are other surveys to makes sure the hospital provides safe and quality health care. One is CAP, which surveys the lab. The hospital lab is accredited by CAP. There is also a compliance team for the rural health clinic. A separate organization, the Compliance Team, surveyed the rural health clinic and certified it. He said a couple of other surveys take place, but don't necessarily impact the federal payments from CMS. He said they are all accredited, including radiology and the Level 4 Trauma Center. Future accreditations are on the radar and include stroke, cardiology and orthopedic.

"It's all to make sure we have good processes, good protocols in place to provide good quality of care," Whitaker said. "I give a lot of credit to Ron (Green, chief nursing officer, Carolyn, Denise (Baird, risk compliance) and Ramon (Wilson, chief quality officer) and our clinical and quality teams."

He said surveyors will always find something and there are different levels of what they find. "The ones they found last time were standard levels of efficiency, and we put together a plan of action to correct them. We submit it, the Joint Commission accepts it. For a higher level finding, they will come back within 60 days to make sure it has been corrected."

Board member Pat McIntire said the surveys are "highly anxiety-provoking for staff when the surveyors show up."

Whitaker said the surveyors do interviews as well as looking a charts and records. "We practice that to help alleviate the anxiety."

That ended his report.

The next report will come from the chief nursing officer.
To read the prior article, visit https://www.grantcountybeat.com/news/news-articles/83696-grmc-held-board-of-trustees-meeting-032024