CMS Changes Conditions of Participation (CoP) for Anesthesia Services Part 3 of 4

Part III: Responsibilities of the Anesthesia Department

While many hospitals view Anesthesia Services as primarily a Medical Staff department, like Surgery or Gynecology, the CMS Conditions of Participation view it as similar to departments like Radiology, Food and Nutrition, and Rehabilitation Services. The emphasis lies in the provision of services rather than the positioning or reporting responsibilities set forth on an organizational chart. The Anesthesia Services department provides anesthesia, sedation, and analgesia as defined earlier. Staffing includes anesthesia providers, along with technicians or support staff members who assist in the management of the department. As a department of the hospital, Anesthesia Services has similar responsibilities for meeting the needs of patients, and improving care through the QA/PI process. Additional responsibilities are specified in the regulations.

Responsibilities of Anesthesia Director

The regulations require the Medical Staff to establish criteria for the qualifications of the Director of Anesthesia Services. The Director of Anesthesia department is responsible for:

  • Developing policies and procedures governing the provision of all categories of Anesthesia Services, including under what circumstances an MD or DO who is not an anesthesiologist, a dentist, oral surgeon or podiatrist is permitted to administer anesthesia
  • Defining the minimum qualifications for each category of practitioner who is permitted to provide anesthesia services
  • Integrating Anesthesia Services into the QA/PI program of the hospital

Required Policies and Procedures

The goal for delivery of anesthesia services, centers around consistent use of resources to meet patient needs. Policies outline these expectations, and at minimum, hospitals must address:

  • How Anesthesia Services needs will be met at all locations
  • Clearly defined pre-anesthesia and post-anesthesia responsibilities
  • Delivery of anesthesia services consistent with recognized standards—well designed policies would likely include:
    • Patient consent
    • Infection control measures
    • Safety practices in anesthetizing areas
    • Protocol for supporting life functions (cardiac, respiratory and hyperthermia emergencies)
    • Reporting requirements (errors, incidents)
    • Documentation requirements (both in the medical record and other sources such as narcotic logs)
    • Equipment requirements (monitoring, inspection and maintenance)

Tips for Compliance

To comply with this section of the regulations, changes in policies and practices may be necessary. Begin by assuring that the following items have been established in policy or practice:

  • Assure that Medical Staff documents clearly spell out the required items for privileging physicians and others practitioners for the types of anesthesia and complexity of procedures.
  • Review policies to assure that each item noted in the Conditions of Participation can be found. 
  • Conduct an internal review of all sedation and anesthesia locations to assure consistent standards among all locations. 

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