CCT Core Conditions of Participation

VHA Office of Telehealth Services

Telehealth Programs Core Conditions of Participation

Overview

This document contains the Core Conditions of Participation (COP) for VHA Telehealth programs. These Conditions of Participation reflect program processes (clinical, business, and technical) that are essential to the safe and effective provision of care. These standards are required for all telehealth programs operating within VHA. The VHA Office of Telehealth Services adopts a uniform process and COP tools to facilitate the development, approval, and designation of telehealth programs. This designation process requires a combined review of: self assessments of compliance with the Conditions of Participation at the network, facility and program levels for each VISN, interviews with key staff members at all levels of the network, relevant data and documentation, and use of tracer methodology where appropriate.

In addition to these core Conditions of Participation that apply to all Telehealth programs, there are additional modality -specific Conditions of Participation that assess the Home Telehealth (HT) program, the Clinical Video Telehealth (CVT) program, and the Store and Forward Telehealth (SFT) program that must also be met by a VISN.A telehealth ‘program’, verified by COPs, is a system of standards and procedures that are in place and integrated into existing clinical services to deliver safe and effective clinical care using Telehealth technologies.

To implement Telehealth programs within any facility or program unit, a VISN must adopt policies and procedures that ensure implementation of these Conditions of Participation (both core and modality -specific) and then achieve, receive, and sustain designation status via periodic reviews (about every two years) conducted by VHA Office of Telehealth Services. This designation process is essential for any model or application of Telehealth that uses the VHA Telehealth DSS codes and receives workload credit, regardless of organizational alignment or funding source.

For ease of reading, the Conditions of Participation have been numbered with an indication of the type of program process (clinical, business, and technical), where implementation will be reviewed or evaluated (VISN or program level). For example:

1 T C (V) is a Telehealth Program Core Condition of Participation # 1, a clinical process assessed at the VISN level

Additionally, the Office of Telehealth Services staff have noted the Joint Commission standards’ chapters that are related to the VHA Office of Telehealth Services’ Conditions of Participation with “cross walk” abbreviations:

RI = Rights and Responsibilities of the Individual EC = Management of Environment of Care

PC= Provision of Care, Treatment and Services HR = Management of Human Resources

RC= Record of Care, Treatment and Services IM = Management of Information

MM= Medication Management MS= Medical Staff

I

New standards are highlighted in blue

C = Infection Prevention and Control NPSG= National Patient Safety Goals

PI = Improving Organization Performance NR= Nursing LD = Leadership

#	Condition of Participation	Demonstrated By:	Rating:	Comments:
1 T C (V, P)	Telehealth programs are integrated into the clinical practice and operational routines of each clinic, facility or health care system. (PC)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
2 T B (P)	The Telehealth program establishes systematic processes to proactively identify patients by access risk and clinical need, and to direct patients to appropriate care and service using Telehealth modalities. (PC)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
3T B (P)	The Telehealth program uses a systematic marketing plan to encourage involvement of providers and other clinical staff, leadership staff, Veterans and other stakeholders in Telehealth programs. (LD)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
4 T C (P)	The Telehealth program maintains a written statement of the program’s Mission and Scope of Services which is available to each Veteran (either written or by acknowledgement) utilizing Telehealth services (RI)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
5 T C (P)	The Telehealth program ensures assessment of the veteran, and the family as applicable, their willingness, choice, and ability to participate in or decline the Telehealth program without an adverse effect to their continued access to health care services (RI)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
6 T C (P)	The Telehealth program ensures veterans are informed about the use of Telehealth and informed consent is secured as appropriate or required by all clinical, research, or security system processes, including informed consent for group encounters. (RI)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
7 T C (P)	The Telehealth program defines the clinical activities and documentation required for all Telehealth encounters with patients (PC, RC)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
8 T C (P)	Telehealth encounters with Veterans are conducted utilizing processes and practices to preserve confidentiality, privacy and information security (RI)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
9 T C (P)	The Telehealth program ensures care and/or services provided are based on clinical practice guidelines, national protocols and pathways, and other accepted clinical practices (PC)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
10 T C (P)	The Telehealth program establishes and maintains a mechanism for the management of urgent mental health or medical issues (PC)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
11 T C (P)	The Telehealth program demonstrates clinical collaboration with other programs such as PACT, HBPC, SCI, and other specialty care initiatives. (PC, LD)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
12 T B (V, P)	Both the VISN and facilities establish the core requirements of the Telehealth Program. This includes guiding processes, principles, and policies for the development, operations, staffing roles/responsibilities and oversight.. Strategic plans for sustainment and expansion of Telehealth programs are developed based on clinical and business needs assessment across all sites in the Network (LD)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
13 T B (P)	Each facility or health care system maintains an Organizational Chart delineating the lines of authority for Telehealth programs (LD)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
14 T B (V)	There is a designated VISN Telehealth Lead who has a defined role that includes collaboration with Clinical Champions, program development and oversight (LD)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
15 T B (P)	There are designated Facility Telehealth Coordinators (FTC) who have defined roles that include collaboration with Clinical Champions, program development and oversight (LD)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
16 T B (V) (P)	The VISN Lead and FTC identify and engage Clinical Champions across all Telehealth programs in the network. This collaboration is demonstrated by the Clinical Champion’s participation and service as an advisor and expert to enhance information sharing and provide leadership in the development and use of national operations manuals, and other Telehealth guidance documents s	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
17 T B (V)	The VISN develops a cadre of Telehealth experts utilizing OTS national training centers’ Preceptor Programs to provide expertise and education to staff. (LD HR)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
18 T B (P)	Each facility/health care system ensures that there are adequate patient site support resources (including staffing, equipment, etc) to ensure effective and efficient services utilizing Telehealth modalities. (PC HR LD)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
19 T B (P)	The Telehealth program ensures there is adequate physical space that allows for clinical efficiency, patient privacy and information security for Telehealth operations (RI)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
20 T T (P)	The Telehealth program ensures there is adequate technical support for clinicians to ensure clinical efficiency and effectiveness. This might include: help desk functions, user manuals and troubleshooting guides. (PC IM)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
21 T B (V)	The VISN leadership establishes clear expectations for communications and dissemination of information by the designated network Telehealth Lead(s) and FTC regarding local, network, national, and Office of Telehealth Services initiatives. (LD)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
22 T B (V, P)	The VISN requires and monitors core clinical, business, and satisfaction quality and performance indicators for all Telehealth programs and develops appropriate process improvement action plans to optimize Veteran care. (PI)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
23 T B (P)	The Telehealth program utilizes both local and VISN Quality Management processes to report clinical and business quality indicators to providers, leadership staff, and other stakeholders (PI)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
24 T B (P)	The Telehealth program ensures that program staff, to include FTC and TCT, have educational backgrounds, experience, and documented orientation, training and competencies, consistent with the program’s mission, goals and objectives, and the positions’ Functional Statement/ Position Description. Training and competency related to equipment usage and set up, troubleshooting and use of software and data must be include ed.(HR)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
25 T B (P)	The Telehealth program establishes a mechanism for resolving any complaints and grievances that is integrated with the local process (RI, NPSG))	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
26 T B (P)	The Telehealth program contributes information to Office of Telehealth Services and VHA databases as required (IM)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
27 T B (P)	The Telehealth program utilizes and monitors designated VHA workload reporting and data management systems for Telehealth (PI)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
28 T B (V, P)	Both the VISN and the Telehealth program performs a systematic audit of Telehealth workload reporting systems, processes and data at least quarterly and develops appropriate process improvement plans to correct any deficiencies.	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
29 T B (V)	The VISN provides oversight and guidance to assure each facility’s Telehealth programs comply with VHA Directives, Handbooks and other guidance related to Credentialing and Privileging (LD)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
30 T T (V)	The VISN assures Telehealth programs utilize processes for acquisition of nationally approved Telehealth technologies and equipment (LD)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
31 T T (V)	The VISN provides oversight and guidance to ensure that all technologies and softwareselected for use in Telehealth programs comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and related VHA Directives and guidance. (RI)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
32 T T (V)	The VISN in collaboration with IT ensures that adequate connectivity and band width capacity are consistently available and monitored in order to guarantee a satisfactory Telehealth clinical experience.(PC IM)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
33 T T (V,P)	The VISN and the Telehealth program maintain an emergency plan and implement strategies to minimize the risks of disruption of care due to environmental and technology emergencies in accordance with OTS guidance. The Telehealth emergency plans must interface with local and VISN emergency planning processes and include a communication cascade to all Telehealth staff.(EC)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
34 T T (P)	The Telehealth program consistently tracks, trends and reports equipment and/or vendor problems through facility, network and OTS processes Including the Quality Improvement Report (QIR) process	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
3 5 T T (P)	The Telehealth program maintains a systematic equipment maintenance and infection control program for Telehealth technologies, including equipment risk assessment by SPD. (IC, NPSG )	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
3 6 T T (P)	The program has a mechanism in place to follow up on any patient safety alerts related to Telehealth technologies	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
37 T B (P)	If Residents are utilized to provide Telehealth services, Residency Supervision guidelines must be adhered to in accordance with VHA policy: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1289	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable
38 T C (P)	The Telehealth program adheres to the OTS guidance for utilization of Video in patient’s homes including use of approved technologies. (LD)	Document Review (List documents) Staff Interview Direct Observation	Met Provisionally Met /In process (explain) Not Met Not Applicable

“These documents, records, and other information contained herein, are confidential and privileged under the provisions of 38 U.S.C. 5705, and its implementing regulations. This material shall not be disclosed to anyone without authorization as provided for by that law or its regulations.   The statute provides for fines up to $20,000 for unauthorized disclosures.”

Page 9 of 9

December 2011