In the past, when CMS conducted a survey and unfavorable findings led to a determination of Immediate Jeopardy, healthcare organizations had very little choice and very little time to correct the deficiencies. For some healthcare organizations, failure to provide an acceptable corrective action plan following multiple citations of Immediate Jeopardy or repeated surveys with Immediate Jeopardy findings resulted in Medicare terminating the hospital's contract.
The Systems Improvement Agreement (SIA) is a legal contract between a healthcare institution and the CMS to aid compliance with the Conditions of Participation (CoPs) in federal programs. Medicare healthcare organizations can request to enter an SIA with CMS when faced with the loss of Medicare participation.
This contract between the hospital/healthcare organization and CMS binds the organization to engage in a series of improvement activities to address multiple deficiencies in compliance with the CoPs with the assistance of a third-party monitor/consultant approved in advance by the CMS Regional Office. The agreement grants the organization additional time to make sustainable improvements in complex quality, cultural, policy, and procedural deficiencies.
After completing this activity, the participant should be able to:
- Discuss how to implement the SIA as a measure to recover when a hospital/healthcare organization is at risk of being placed on a Medicare termination track following deficient Medicare surveys.
- Identify the steps required in a SIA.
- Describe how a successful SIA may look.
This activity is relevant to all hospital staff, medical staff, volunteers, and contracted staff, particularly those who are responsible for life safety-related activities, including safety officers and committees, department managers and supervisors, performance improvement (PI) staff, training and education staff, and risk managers.
Executive Director, Government Regulations and Advisory Services
Joint Commission Resources
This presenter does not have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity. This presenter has also attested that her discussion will not include any unapproved or off-label use of products.
The Joint Commission is accredited by the Accreditation Council for Continuing Medical Education (ACCME-AMA PRA Category 1 ™), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.
Note: No ACPE credit was provided for this program.
The Joint Commission is provider approved by the California Board of Registered Nursing, provider number CEP 6381, for 1 contact hour.
The Joint Commission is authorized to award 1.0 contact hour of pre-approved ACHE Qualified Education credit for this program toward advancement or recertification in the American College of Healthcare Executives. Participants in this program wishing to have the continuing education hours applied toward ACHE Qualified Education credit should indicate their attendance when submitting application to the American College of Healthcare Executives for advancement or recertification.
This activity has been approved by the National Association for Healthcare Quality (NAHQ) for 1.0 Certified Professional Healthcare Quality (CPHQ) credit.
The Joint Commission Enterprise has been accredited as an Authorized Provider by the International Association for Continuing Education and Training (IACET).
This education offering qualifies for 1.0 Certified Joint Commission Professional (CJCP) credit hours towards CJCP recertification. In order to obtain CJCP credit hours, an individual must first be certified before they start acquiring CJCP credit hours. CJCP credit hours will not be retroactive.
Full attendance at every session is a prerequisite for receiving full continuing education credits. If a participant needs to leave early, his or her continuing education credits will be reduced.
Successful completion of this CE activity includes the following:
- View the presentation and read the accompanying Resource Guide.
- Complete the online Evaluation Form and Post Test.
- A CE certificate/statement of credit can be printed online following successful completion of the Post Test and the Evaluation Form