QUANTIFYING AND REPAYING OVERPAYMENTS PURSUANT TO SECTION
III.H (REPORTING) WHEN APPROPRIATE.
(VIII)
ENSURING THAT EACH FOCUS ARRANGEMENT IS SET FORTH IN WRITING AND
SIGNED BY TENET AND THE OTHER PARTIES TO THE FOCUS ARRANGEMENT; PROVIDED THAT
FOCUS ARRANGEMENTS CONSTITUTING NON-CONTRACTUAL TRANSACTIONS SUBJECT TO 42
C.F.R. § 411.357(K) ARE NOT REQUIRED TO BE IN WRITING BUT ARE REQUIRED TO BE
TRACKED IN THE FOCUS ARRANGEMENTS DATABASE.
(IX)
INCLUDING IN EACH WRITTEN AGREEMENT REFLECTING A FOCUS
ARRANGEMENT A REQUIREMENT THAT ALL INDIVIDUALS WHO MEET THE DEFINITION OF
COVERED PERSONS SHALL COMPLY WITH TENET'S COMPLIANCE PROGRAM AND TENET'S
POLICIES AND PROCEDURES RELATED TO THE ANTI-KICKBACK STATUTE AND THE STARK LAW;
AND
(X)
INCLUDING IN EACH WRITTEN AGREEMENT A CERTIFICATION BY THE
PARTIES TO THE FOCUS ARRANGEMENT THAT THE PARTIES SHALL NOT VIOLATE THE
ANTI-KICKBACK STATUTE AND THE STARK LAW.
C.
CLINICAL QUALITY.
THESE POLICIES AND PROCEDURES SHALL BE
DESIGNED TO PROMOTE THE DELIVERY OF PATIENT CARE ITEMS OR SERVICES AT TENET
HOSPITALS THAT MEET PROFESSIONALLY RECOGNIZED STANDARDS OF HEALTH CARE AND ARE
REASONABLE AND APPROPRIATE TO THE NEEDS OF FEDERAL HEALTH CARE PROGRAM
BENEFICIARIES.
THESE POLICIES AND PROCEDURES SHALL INCLUDE THE FOLLOWING:
(I)
ENSURING THE APPROPRIATE DOCUMENTATION OF MEDICAL RECORDS;
(II)
MEASURING, ANALYZING, AND TRACKING QUALITY INDICATORS, INCLUDING
ADVERSE PATIENT EVENTS, AND OTHER ASPECTS OF PERFORMANCE THAT RELATE TO
PROCESSES OF CARE, HOSPITAL SERVICES, AND OPERATIONS;
(III)
INCORPORATING QUALITY INDICATOR DATA, INCLUDING PATIENT CARE DATA
AND OTHER RELEVANT DATA TO MONITOR THE EFFECTIVENESS AND SAFETY OF SERVICES AND
QUALITY OF CARE AND TO IDENTIFY OPPORTUNITIES FOR IMPROVEMENT AND CHANGES THAT
WILL LEAD TO IMPROVEMENT;
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(IV)
SETTING PRIORITIES FOR PERFORMANCE IMPROVEMENT ACTIVITIES THAT (1)
FOCUS ON HIGH RISK, HIGH-VOLUME, OR PROBLEM-PRONE AREAS; (2) CONSIDER THE
INCIDENCE, PREVALENCE, AND SEVERITY OF PROBLEMS IN THOSE AREAS; AND (3) AFFECT
HEALTH OUTCOMES, PATIENT SAFETY, AND QUALITY OF CARE;
(V)
TRACKING MEDICAL ERRORS AND ADVERSE PATIENT EVENTS, ANALYZING
THEIR CAUSES, AND IMPLEMENTING PREVENTIVE ACTIONS AND MECHANISM THAT INCLUDE
FEEDBACK AND LEARNING THROUGHOUT TENET;
(VI)
CONDUCTING QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT
PROJECTS, INCLUDING PERIODIC CLINICAL QUALITY AUDITS OF TENET HOSPITALS;
(VII)
COLLECTING AND REPORTING QUALITY ASSESSMENT AND PERFORMANCE
IMPROVEMENT DATA TO RELEVANT DATA REGISTRIES;
(VIII)
PERIODICALLY REPORTING QUALITY ASSESSMENT AND PERFORMANCE
IMPROVEMENT DATA TO THE BOARD COMMITTEE;
(IX)
COLLECTING, VERIFYING, AND ASSESSING CURRENT LICENSURE,
EDUCATION, RELEVANT TRAINING, EXPERIENCE, ABILITY AND CURRENT COMPETENCE TO
PERFORM REQUESTED PRIVILEGES;
(X)
MONITORING PRACTITIONERS WITH CURRENT PRIVILEGES BY THE REVIEW OF
CLINICAL PRACTICE PATTERNS, ONGOING CASE REVIEW, PROCTORING, AND DISCUSSION WITH
OTHER INDIVIDUALS INVOLVED IN THE CARE OF PATIENTS;
(XI)
IMPLEMENTING AND MONITORING MEDICAL STAFF PEER REVIEW IN ALL
TENET HOSPITALS;
(XII)
INCORPORATING CLINICAL QUALITY METRICS ON THE BALANCED SCORECARD
FOR SENIOR MANAGEMENT; AND
(XIII)
IMPLEMENTING EFFECTIVE RESPONSES WHEN CLINICAL QUALITY PROBLEMS
ARE DISCOVERED.
D.
PERFORMANCE STANDARDS AND INCENTIVES.
THESE POLICIES AND
PROCEDURES SHALL ADDRESS PERFORMANCE STANDARDS FOR TENET CORPORATE MANAGEMENT.
THESE POLICIES AND PROCEDURES SHALL INCLUDE THE FOLLOWING:
(I)
CLINICAL QUALITY MEASURES;
(II)
COMPLIANCE PROGRAM EFFECTIVENESS MEASURES; AND
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(III)
COMPENSATION AND INCENTIVE AWARDS DIRECTLY LINKED TO CLINICAL
QUALITY MEASURES