Quality and Performance Improvement in Healthcare
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
|
|
||||
|---|---|---|---|---|---|
| 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
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
emilydouglas
Popular Medical sets