What are our responsibilities related to services provided by our contracted organization?

Any examples are for illustrative purposes only.

Leaders must oversee contracted services to make sure that they are provided safely and effectively. The only contractual agreements subject to the requirements at Standard LD.04.03.09 are those for the provision of care, treatment, and services provided to the hospital's (organization's) patients. This standard does not apply to contracted services that are not directly related to patient care, treatment, or services. The EPs do not prescribe the methods for evaluating contracted services; leaders are expected to select the best methods for their hospital (organization) to oversee the quality and safety of services provided through contractual agreement.

Examples of sources of information that may be used for evaluating contracted services include the following:

• Review of information about the contractor's Joint Commission accreditation or certification status.
• Direct observation of the provision of care.
• Audit of documentation, including medical records.
• Review of incident reports.
• Review of periodic reports submitted by the individual or hospital providing services under contractual agreement.
• Collection of data that address the efficacy of the contracted service.
• Review of performance reports based on indicators required in the contractual agreement.
• Input from staff and patients.
• Review of patient satisfaction studies.
• Review of results of risk management activities

In the event that contracted services do not meet expectations, leaders take steps to improve care, treatment, and services. In some cases, it may be best to work with the contractor to make improvements, whereas in other cases it may be best to renegotiate or terminate the contractual relationship. When the leaders anticipate the renegotiation or termination of a contractual agreement, planning needs to occur so that the continuity of care, treatment, and services is not disrupted.