Related Documents:  None

Comments:   General policy regarding contracted services

T o provide essential services in a safe, efficient, consistent and competent manner by all individuals providing care through contractual arrangements by providing a process of verifying compliance with regulatory standards applicable to services provided by contractual arrangement, and to assure appropriate communication across departments and services as it relates to contracted services.

1. All contractual arrangements are reviewed and approved by hospital counsel before being signed by the appropriate individuals.
2. The original signed contract for services provided through a contractual arrangement, is maintained in Administration, and copies are shared with the appropriate department manager, and accounting.
3. All individuals who provide a service through contractual arrangement on hospital premises, complete a general hospital orientation, as well as a department specific orientation. The appropriate documentation is completed for these activities as with any hospital employee.
4. The documentation for each individual providing care through a contractual arrangement shall include the following:
1. Written job description for each individual
2. Evidence of competency, including age-specific competency for each individual
3. Performance evaluation or appraisal tool for each individual
4. Applicable licensure, certification or registration

A copy of the above documentation should be retained by the department manager, and the original documents are forwarded to and maintained by the Personnel Department.

5. The appropriate department manager is responsible for evaluating the service provided. Depending on the contractual arrangement, this can be accomplished by the contracted service submitting a performance improvement report, or by inclusion of performance measures relating to the contracted service in the departmental performance improvement activities.

A copy of the report is forwarded to the Quality Assurance Department on a quarterly basis with the department’s performance improvement report and the department manager will provide a report to the Utilization Review/Quality Assurance/Risk Management Committee along with the scheduled department performance improvement report.

When the contracted individual is the also the department manager, he/she will be responsible for assuming this responsibility.

6. Policies and procedures that relate to, or that are developed by a contracted service, should be adopted to the specific needs of our facility and should follow the format and appropriate approval mechanism and signatures as established by our facility.

New Contractual Arrangements

7. Prior to finalizing any arrangement for services with outside vendors, organizations, individuals, or companies, consideration should be given to the following:
1. Evidence of compliance with applicable regulatory standards should be requested and reviewed
2. The company should be advised of internal requirements as established by this hospital policy
3. Department directors and/or managers should participate in selection outside sources for needed services
4. The contract should be reviewed by legal counsel
5. Sources of essential patient care services provided outside the hospital should be approved by the medical staff
8. The Quality Assurance Department should be notified of all new contracted services by the responsible Department Manager.

Current Contractual Arrangements

9. A list of all current contractual arrangements will be forwarded to the Quality Assurance Department annually with the annual performance improvement evaluations.

10. The department manager will request an annual update of the required documentation as outlined above, and will review the documents and verify appropriateness. Upon verification, the documents will then be forwarded to the Personnel Department. Every effort should be made to update the documents by April 15 each year. In addition, any licensure should be kept current during the course of the year, based on expiration dates.