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Quality & Perf. H.C.
Quality and Performance Improvement in Healthcare
| Question | Answer |
|---|---|
| The act of granting approval to a healthcare organization | Accreditation |
| The act of granting a healthcare organization or an individual healthcare provider permission to provide services of a defined scope in a limited geographical area | Licensure |
| Grants approval for a healthcare organization to provide services to a specific group of beneficiaries | Certification |
| Performed to fulfill legal or licensure requirements | Compulsory Review |
| Conducted at the request of the healthcare facility seeking accreditation | Voluntary Review |
| Name 3 organizations that conduct surveys to healthcare organizations. | JCAHO, CMS, CARF, AOA, NCQA, AAAHC... |
| JCAHO Accreditation : The organization has complied with all performance standards | Accredited |
| JCAHO Accreditation : The organization has not demonstrated compliance with all standards during a full survey | Provisionally Accredited |
| JCAHO Accreditation : An organization that receives this decision did not meet the standards at the time of the onsite survey | Conditionally Accredited |
| JCAHO Accreditation : Assigned to organizations that were in significant noncompliance with standards in multiple performance areas | Preliminary Denial of Accreditation |
| JCAHO Accreditation : This results when all available appeal procedures have been exhausted and the organization has been denied accreditation | Accreditation Denied |
| Unannounced surveys; team drops in on an annual basis or in response to complaints from patients/employees; Surveyors usually from state department of health, however one to two Medicare officials from the regional office may be present | CMS Conditions of Participation |
| Why is data collection so important? | It is important for performance improvement; to monitor the quality of care and measure performance improvement, and make changes where need be. |
| What are the three types of data collection? | Patient-specific, Aggregated, & Comparative |
| What are some techniques/tools used to change data into knowledge? | QI toolbox techniques (charts, graphs, etc.), compiling information for statistical analysis, standard reporting formats, benchmarking |
| JCAHO ___ ___ Standards: .1—The [healthcare organization] plans for managing information 2.1—Privacy, security, and integrity of data and information are maintained | Information Management |
| JCAHO ____ _____ Standards: 2.2—The [healthcare organization] effectively manages the collection of health information and retrieves, disseminates,transmits health information in usable formats | Information Management |
| JCAHO ___ ___ Standards:.3—Knowledge-based information resources are available, current, and authoritative. | Information Management |
| JCAHO ___ ___ Standards: IM.4—The organization maintains accurate health information. | Information Management |
| JCAHO ___ ___ Standards: 01.01.01 The [HC org.] maintains complete & accurate medical records. 01.02.01 Entries in the medical record are authenticated | Record of Care, Treatment and Services Standards |
| JCAHO ___ ___ Standards: 01.03.01 Documentation in the medical records is entered in a timely manner, including time frames for completion of all components. | Record of Care, Treatment and Services Standards |
| JCAHO ___ ___ Standards: 01.04.01 The [healthcare organization] audits its medical records. 01.05.01 The [healthcare organization] retains its medical records | Record of Care, Treatment and Services Standards |
| JCAHO ___ ___ Standards: 02.01.XX The medical record contains information that reflects the patient’s care, treatment, and services. | Record of Care, Treatment and Services Standards |
| JCAHO ___ ___ Standards: 02.03.07 Qualified staff receive and record verbal orders. 02.04.01 The hospital documents the patient’s discharge information. | Record of Care, Treatment and Services Standards |
| What are some reasons for medication safety plans? | Patient safety, cost to hospitals due to patient LOS costing possibly millions per year |
| MMS : Step One - Maintain and annually review formulary; Indications for when a medication is to be used; The medications effectiveness; Risks associated with the medication Cost | Select and Procure Medications |
| MMS: Step Two - Double-locked storage of controlled substances; Stored under conditions suitable for product stability; Use of patient’s own medications; Inspecting all medication storage areas | Properly and Safely Store of Medications |
| MMS:Step 3-Policies & procedures must specify the required elements of how orders are written or communicated; Not acceptable to use abbreviations when ordering or communicating medication orders; Acceptable use of Verbal orders; “Read-back” requirement | Order (Prescribe) and Transcribe Medications |
| MMS, Step 4: Pharmacist must review each prescription or medication order for appropriateness. Prevent following errors: Prescribing, Administrating, Pharmacy, Discharge. | Prepare and Dispense Medications |
| MMS Step 5: Five Rights-Patient, drug, dose, route, time. Use at least two patient identifiers before medication administration. | Administer Medications |
| MMS Step 6: Monitored according to the clinical needs of the patient and addresses the patient’s responses to the prescribed medication and actual or potential medication-related problems; Gathering the patient’s own perceptions about side effects. | Monitoring the Effects of Medications on Patients |
| MMS Step 7: Identify and analyze medical error, medication errors and near misses; Pharmacy and therapeutics committee; Medication-safety committee. | Evaluating the Medication Management System |
| Year that the Massachusetts General Hospital set limitations on clinical practice in the first granting of clinical privileges | 1837 |
| Year that Massachusetts General established the first disease/procedure index by classifying patient disposition | 1853 |
| Year that ACS established the Hospital Standardization program | 1917 |
| Year that the Hill-Burton Act established funding to build new hospitals | 1946 |
| Year that the Joint Commission was formed | 1952 |
| Public Law 89-97 establishes Medicare and Medicaid | 1965 |
| Local peer review organizations were formed in this year | 1972 |
| JCAH became JCAHO in this year | 1990s |
| JCAHO implemented the National Patient Safety Goals in this year | 2003 |
| JCAHO begins to show up unannounced, conducting surveys using tracer methodology | 2005 |
| QA | Quality Assurance |
| TQM | Total Quality Management |
| QI | Quality Improvement |
| CQI | Continuous Quality Improvement |
| QM | Quality Management |
| PI | Performance Improvement |
| A quantitative tool that provides an indication of an organization's performance in relation to a specified process or outcome | Performance measures |
| Comparing your organization's performance to similar organizations | Benchmarking |
| They set an organization's expectations, develop plans, and hire employees to implement procedures to assess and improve the quality of important functions | Board of Directors |
| The board's understanding of the quality assessment & improvement system; adequate reporting to the board by staff; the board's oversight & approval of the process to ensure the controlled competence by staff;the board's questioning of info are all what? | Elements that affect the board's ability to carry out PI responsibilities |
| Ethics, Credentials, Pharmacy and Therapeutics, Utilization & Documentation Standards, Environment Safety, and Departmental are all what? | Standing committees of the medical staff with PI accountability |
| Communication of mission, vision, and values; PI training at new hire orientation; and supplemental training annually are all a part of what kind of education? | Performance Improvement Education |
| To determine whether the org.'s approach is planned, systematic, and organization-wide | Reason PI Programs are Evaluated |
| To determine whether org.'s approach to activities are carried out collaboratively | Reason PI Programs are Evaluated |
| To determine whether the org.'s approach needs redesign in the light of changes in the strategic plan or organizational objectives | Reason PI Programs are Evaluated |
| To determine whether the program was effective in the improvement of overall organizational performance | Reason PI Programs are Evaluated |
| Clinical PI that has affected patient care, treatment, and services. EX: Medication management, patient rights, infectious disease mngmnt, etc. | Patient-Focused Improvements |
| Focus is nonclinical and may deal with systems such as environment of care issues, staff development needs, leadership dev. goals. EX: Re-engineering the admitting process, reducing staff injuries, reducing suspense days on unbilled accounts, etc. | Organizational Improvements |
| Measurements & results related to important systems, processes, and outcomes that are monitored on an ongoing basis. EX: Measurements required by JCAHO, staffing effectiveness, disease-specific monitoring, med use, customer satisfaction, etc. | Ongoing Measurements |
| Internal/external comparative database used to assess outcomes or determine areas for improvement. JCAHO's Core Measures on pt care | Comparative Summary Measurements |
Created by:
emilydouglas
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