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Quality & Perf. H.C.

Quality and Performance Improvement in Healthcare

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