Final Exam SG

standing committees for medical staff

Ethics, Credentials, Pharmacy and Therapeutics, Utilization and Documentation Standards, Environmental Safety, Departmental

Certification

Grants approval for an organization to provide services to a specific group of beneficiaries

Phases of Project Developmen

Initiation, planning, execution, closure

Elements of prescription label

Legal document that must contain patients name, address and age (if significant), Prescriber's name, address & id, Date, Name/amount of drug, Dosage, route, Directions for taking, Permission for additional quantities

Critical path

Longest time it would take to finish a project, used for project planning and tracking

Licensed

Permission to provide services of a defined scope in a limited geographic area

Data used for?

Process Improvement

6 Elements of Healthcare (IOM)

STEPEE (safe, timely, efficient, patient centered, effective, equitable)

Sentinel Event Reporting

Submit root cause analysis within 45 days of becoming aware of the event; Grace period of 30 days; accreditation status is changed to provisional; not done with in 60 days after due date, accreditation status is changed to conditional; After 90 days, denial of accreditation

adverse event

a negative consequence of care that results in unintended injury or illness that may or may not have been preventable

trends of line charts

a run of points going up or down

shifts of line charts

a sudden shift in a different direction

Ordinal

aka called ranked data, it expresses the comparative evaluation of various characteristics or entities and relative assignment of each, to a class according to set of criteria. (Examples: likert scales; best displayed on bar or pie charts)

Denial of Accreditation

all available appeal procedures have been exhausted and the org is denied accreditation

Sentinel Event

an unexpected occurrence involving death, serious physical injury, psychological injury or the risk there of (loss of limb or function)

Root-Cause Analysis

analysis of a sentinel event from all aspects to identify how each contributed to the event sustained in a healthcare facility

Force-field analysis

analysis of forces in favor of change and forces that resist change as they work against each other

measures of access (HEDIS)

at least one visit to provider in 3 years

Mean

average

Histogram

bar chart for continuous data

Pareto chart

bar chart that displays data in descending frequency w/ line

conclude post-discharge planning

case manager conveys information on the patient's course of treatment to the clinicians that will continue the patients care

perform care planning at the time of admission

case manager reviews all information gathered by clinicians assigned to confirm patient meets admission criteria; critical pathway is assigned

qualitative analysis

categorical usually

Rapid Cycle Testing/Improvement

changes made and tested in 3 months rather than normal 8-12

Bar Chart

compare relative size of data

measures of financial performance (HEDIS)

cost per member plus dependents

Discrete

count; numerical values that represent whole numbers (best displayed in bar graphs

measure of membership (HEDIS)

coverage cancellation as indicator of dissatisfaction

Severity of Illness

criterion based on patient's condition used to screen patients for appropriate care setting

Intensity of Service

criterion consisting primarily of monitoring and diagnostic assessments, that must be met in order to quality a patient for inpatient admission (above severity of illness)

Initiation

determination of gap b/w org performance and expected outcomes; then they identify opportunities for improvement; includes defining objectives/scope, group selection, vision and mission statement

National Patient Safety Goals

developed by the joint commission; all institutes participating in accreditation must promote and train their staff members who provide care to adherence of the NPSGs

4 basic elements of negligence/malpractice

duty of use due care; breach of duty; damages; causation

Peer Review

evaluation of work by others in same field

pivot table

flexible means to organize and filter data

Tracer Methodology

follows patients through their path of care at an organization to assess compliance standards

Spaghetti Diagram

for flow

scatter diagram

helps find correlations

measures of utilization (HEDIS)

high-occurrence, high-cost and DRGs; frequency of procedures, etc.

Planning

identification of final system requirements/criteria that set standards for measuring success; includes: identification of task and length, schedule and cost elements, perform tasks, track progress, develop training/implementation plan

Data Collection Objectives

identify purpose of data management activity (monitoring at regular intervals, one time study or investigation over limited time period); identify appropriate data sources; identify most important measures to collect; design common sense collection strategy (gives complete, accurate and timely information)

measures of quality (HEDIS)

immunizations, screening tests

Nominal

Categorical; Includes values assigned to name-specific categories (usually displayed on bar or pie charts)

Breach of Duty

in malpractice action, the issue is whether a physician exercised a standard of care that a reasonably prudent physician would have exercised under those circumstances; failure to exercise due care

in what phase are teams formed for project development?

initiation stage

Execution

installation of equipment/construction + policies/procedure manuals prepared for distribution; includes presenting recommendations to leadership, executing implementation plan, training, tracking/monitoring, project revision

ORYX Initiative

joint commission initiative in 1997; it was mandated by the joint commission and CMS to require healthcare organizations to collect performance data on high risk procedures and occurrences (pneumonia measures, heart failure, etc) so they can review and compare data trends and patterns to help improve patient care processes

Number of defects for 6 Sigma

less than 3.4 per million

control chart

line chart with upper and lower limits

Formulary

list of drugs approved for use in a healthcare org; selection of items to be included in a formulary is based on object eval of their relative therapeutic merits, safety, and cost; if accredited by the JC, then maintain the formulary for a medications continued safety and efficacy

National Practitioner Databank

maintains reports on medical malpractice settlements, clinical privilege actions, and professional society membership actions against licensed healthcare providers

Median

middle number impacted by skew whole set is taken into account

Causation

must be a connection between the breach of duty and the damage - evidence that the failure to exercise due care or breach caused the damage

Why collect data

needed to identify and address QI issue

Harmonious Cohesiveness

norming stages where they all begin to communicate and collaborate

absolute frequency

number of times a value appears in a data set

quantitative

numeric

Contingent Accreditation

org didn't meet all of JC standards @ time of on-site survey and had a standard of noncompliance higher than published levels of that year; they can appeal the accreditation

JC - Accredited

org is in compliance w/ standards @ time of on-site surveyor addressed all RFIs within 45 or 60 days

Accreditation with Follow up survey

org is not compliant with specific standards and requires follow-up survey within 30 days to 6 months; org must address problem areas

Cautious Affiliation

overly polite team members as they get to know each other

Damages

patient must show that actual harm or damage occurred

relative frequency

percentage of time a value appears in a data set

Radar Chart

performance measures for time interval w/ performance expectations

conduct discharge planning

performs final discharge planning and continued care post discharge

review the progress of care

periodic review of the patient's progress

pre-admission care planning

physician contacts a healthcare org to schedule an episode of care service; case manager reviews projected patient needs w/ physician; admission criteria established

Case Management

pre-admission, admission, review, discharge

Kaizen Blitz

process improvement in a workshop environment

Medication Reconciliation

process of identifying the most accurate list of all medications a patient is currently taking and then comparing the list against the physician's admission/transfer/ discharge orders at each transition point along the patient's continuum of care

Closure

project becomes part of organization operations; includes final report, celebration of success, and continual improvement

physician profile

provides credentialing committee w/ significant data about specific physicians scheduled for reappointment to the medical staff

Uses of HEDIS

quality measure, access measure, membership measure, utilization measure, financial performance measure, longterm care MDS

Rights to patients

right patient, right medication, right dose/ time, right route, and right to refuse

Incident Report

risk manager's principle tool for capturing the facts about potentially compensable events

Line chart

shows progress of process over time

Pie chart

shows relationship of part to whole

Preliminary Denial of Accreditation

significant noncompliance w/ JC standards in multiple areas and RFIs higher than published levels; they can appeal

This quality improvement methodology uses statistics for measuring variation in a process with the intent of producing error-free results?

six sigma

standard deviation

spread of values (most often +/- 2)

Failure Mode and Effect Analysis (FMEA)

technique that promotes systems thinking; includes defining high risk processes using flow charts; proactive tool to analyze potential problems when introducing new systems or equipment; identifies most important areas for process improvement

validity

the extent to which an empirical measure accurately reflects the meaning of the concept under consideration

what is done when a specific drug that a patient need sis not on the formulary?

the patient will very likely have more out-of-pocket costs in order to be able to the medication their doctor recommends

Consideration of data collection

time and cost

Drug Diversion

transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for illicit use

skewing

very high/low values distort calculated means

Accreditation

voluntary validation of achieving set standards- required to see CMS patients

Competitiveness

where conflict emerges and leader needs to help them thru it

Collaborative Teamwork

where they are effectively collaborating and users and group norms

reliability

whether a particular technique applied repeatedly to the same object yields the same results each time

cycling in line charts

zig zag pattern of up and down movement

what agencies are lab services regulated by?

CDC and CLIA (clincal laboratory improvement amendments)

Order for force-field analysis

1. Define the problem 2. Define the change objective 3. Identify driving forces 4. Identify restraining forces 5. Develop comprehensive change strategy

Reappointment of Medical Staff

2 years

JC Rec for Population size

<30 = 100% 30-150 = 30 cases 151-595 = 20% >596 = 120/20%

Duty to Use Due Care

A relationship must have been established between the parties in which one party has an obligation, or duty, to act as a reasonably prudent person would act toward the other. This duty exists in a physician's relationship with his or her patients. Using due care is acting as a reasonably prudent person would act under a given set of circumstances.

Deemed Status

Accreditation by one organization is equal to accreditation by another (JC accreditation = Medicare Accreditation)

Continuous

Assume an infinite number of possible values in measurements that have decimal values as possibilities (best displayed in histograms or line charts)

infection control

The process of preventing the spread of communicable disease in compliance w/ applicable legal requirements is performed in this quality management function