By Tricia Dixon-Thomas, MSN, RN
Can your patients tell the difference when they interact with your direct employee versus someone from an agency? Does your staff feel a difference? Do your metrics show a variance based on who provides a service? Whether support or direct care staff, outsourced services must follow your policies and procedures and be held to the same high standards as the rest of your team.
Historically, ambulatory surgery centers have contracted with both support staff and direct care providers, whereas hospitals have relied more on contractors for nonclinical roles like IT and billing. However, staffing shortages and other organizational goals have caused a shift in hiring practices, with more hospitals leaning towards contracting with telemedicine providers, anesthesiology services and more.
Either way, subcontractors represent you, and therefore your commitment to compliance, operational efficiency, and quality care. Poor service from contractors can lead to delays, rework, or compliance issues. Mismanaged contracted services (e.g., instrument processing, billing errors, or inadequate documentation of anesthesia services) increase legal and reputational risks. Periodically evaluating your contracted services is a risk management necessity as well as an accreditation requirement.
ACHC standards for contractors cover the same basic principles, regardless of the healthcare setting:
• The governing body must oversee services provided by a third party and ensure these services are provided safely and effectively.
• Contractor services must be included in the organization’s Quality Assurance and Performance Improvement (QAPI) Program.
• Contracts must be reviewed annually.
What to watch for
When evaluating a contracted service, set clear expectations. The contract should specify the services to be delivered, the methods to be used, and the expected level of quality. For direct care services, staffing agencies should provide evidence of competencies and how they were assessed. But this does not mean your hospital or ASC can omit orientation to your own policies and procedures, nor does it absolve your organization from completing relevant due diligence – including credentialing and privileging for provider roles.
Even if the contracted service is required to provide relevant metrics, collect your own data. Check whether the services are provided within the agreed upon time frames, whether they impact patient satisfaction surveys, and if the contracted personnel adhere to your policies and procedures. Communicate corrective actions according to the contract’s provisions.
Developing quality indicators
To embed contracted services within your QAPI Program, establish specific quality indicators. Examples of commonly used metrics that can be applied to contracted services include:
Anesthesia Services
• Patient safety outcomes (e.g., adverse reactions, post-anesthesia complications)
• Timeliness of anesthesia administration and recovery
• Compliance with ASA (American Society of Anesthesiologists) guidelines
• Patient satisfaction scores related to pain management
Sterilization and Infection Control Services
• Sterility failure rates (e.g., positive biological indicator tests)
• Compliance with CDC & OSHA guidelines
• Turnaround time for sterilized instruments
• Hand hygiene compliance of contracted personnel
Medical Equipment Maintenance and Repair
• Percentage of equipment failures during procedures
• Response time for urgent repairs
• Preventive maintenance compliance rate
• Documentation of equipment testing and calibration
Medical Billing & Revenue Cycle Management
• Claim denial rate due to billing errors
• Turnaround time for claims submission
• Accuracy of coding and compliance with CMS regulations
• Patient billing complaints and resolution times
Housekeeping & Environmental Services
• Frequency of compliance audits (e.g., surface disinfection, temperature, humidity, and air pressure logs)
• Incidence of hospital-acquired infections (HAIs)
• Completion rates of daily cleaning checklists
• Inspection results from regulatory agencies
Laboratory & Pathology Services
• Turnaround time for test results
• Accuracy of test results (error rates)
• Compliance with CLIA (Clinical Laboratory Improvement Amendments) standards
• Patient safety incidents related to lab errors
Waste Management & Biohazard Disposal
• Compliance with EPA & OSHA regulations
• Proper segregation of medical waste
• Incidents of improper disposal
• Staff training compliance on waste handling
IT & Electronic Medical Records (EMR) Services
• System uptime percentage
• Data breach or cybersecurity incidents
• Resolution time for user-reported issues
• HIPAA compliance for data security
Security & Facility Management Services
• Incident reports related to unauthorized access
• Staff and patient satisfaction with security presence
• Response time for security concerns
• Adherence to emergency preparedness protocols
What you stand to gain
Using quality indicators to review contract services contributes to regulatory compliance, but that’s not all. Tracking quality metrics identifies trends, addresses deficiencies, and improves workflows. Setting clear, measurable benchmarks (e.g., infection rates, equipment maintenance logs, billing accuracy) holds contractors accountable for their services and performance. When you evaluate performance, your organization gets the best value for your money. Thorough and thoughtful analysis of the data produces meaningful results that only serve to make your organization better.
Read the fine print
While some contracts are considered “evergreen,” reviewing them periodically (the ACHC Standard requires annual review) is important to ensure they continue to meet the organization’s needs. If an existing contract does not meet your needs, make revisions during the next review.
– Tricia Dixon-Thomas, MSN, RN is a Clinical Review Specialist for the ASC and OBS Accreditation Programs at Accreditation Commission for Healthcare (ACHC) with more than 20 years of experience in ASCs. She is passionate about teaching and mentoring the next generation of outstanding managers and directors in the outpatient surgical environment.
