HITT 2343 Test #3 Chapters 13-18

this is the forming stage, in which team members tend to be very polite as they get to know one another. This also is a time in which the team members assess one another's strengths and weaknesses.

Cautious Affiliation

grants approval for a healthcare organization to provide services to a specific group of beneficiaries.

Certification

are usually conferred by a national professional organization dedicated to a specific area of healthcare practice.

Certifications

includes provisions for health information in the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed 2009 requires that healthcare organizations and providers make significant investments in information systems that have "meaningful use." The objective of this concept is to focus the attention of healthcare organizations and providers on the attributes of healthcare information systems that will make the greatest positive impact on the care the organizations and clinicians provide to their patients, resideents, and clients.

American Recovery and Reinvestment Act (ARRA)

can make an important contribution to the improvement of performance in healthcare organizations. It is so important that the Joint Commission and CMS have place renewed emphasis on it by required that accredited and participating organizations, respectively, participate in national benchmarking activities through the cores measures projects and patient satisfaction surveying. In turn, the organizations have access to data from these measures databases. The organization then can compare its performance with the performance of similar organizations. The comparison can assure the organization that it is performing up to industry standards or help the organization identify opportunities for improvement. The JC and CMS have identified several sets of core measures - sets of patient care characteristics that reflect the quality of care an organization can provide for significant diagnoses.

Benchmarking

conducts a variety of quality initiatives targeting hospitals, physicians offices, nursing homes, home health agencies, and end-stage renal disease facilities. Physicians and other eligible professionals can participate in the Physician Quality Reporting Initiative (RQRI), the Hospital Inpatient Quality Reporting Program, and the electronic health record (EHR) meaningful use incentive program.

CMS

are performed to fulfill legal or licensure requirements.

Compulsory reviews

the Joint Commission categories its performance measures into accountability and nonaccountability measures. This approach places more emphasis on an organization's performance on accountability measures which are quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement: - Research: some strong evidence exists demonstrating that compliance with a given process of care improves health outcomes (either directly or by reducing risk of adverse outcomes). - Proximity: the process being measured is closely connected to the outcome it impacts; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs. - Accuracy: the measure accuracy assesses whether the evidence-based process has actually been provided. That is, the measure should be capable of judging whether the process has been delivered with sufficient effectiveness to make improved outcomes likely... - Adverse effects: the measure construct is designed to minimize or eliminate unintended adverse effects.

Accountability measures

is the act of granting approval to a healthcare organization that has demonstrated satisfactory quality of service.

Accreditation

Accreditation reviews by CARF are usually scheduled in advance. Most CARF-accredited organizations undergo a site visit every three years. The CARF survey team commonly includes three members, although additional members may be added for special purposes unique to the applying organization. Typically, the team is made up of professionals from other CARF-accredited organizations. CARF accreditation site visit begins with an opening conference and requires that the opening conference be accessible to all communities of interest in the organization.

Accreditation of Psychiatric and Rehabilitative Care Facilities: CARF

developed by the accreditation agency that serve as the basis for comparative assessment during the review or survey process and confirm the quality of the services that healthcare organizations provide. The Joint Commission is an example of an accreditation agency.

Accreditation standards

permission given by the healthcare organization to practice in a specific area of specialty within that organization..

Clinical privileges

is stage four of project management, the new system or process is used by the customer. This is the phase in which the project shifts to become an integrated part of organizational operations.

Closure

this is the performing stage, where a group of individuals begins to collaborate as a team. Team members come to understand group norms, and communication becomes more efficient and effective. In highly effective teams, there is less conversation and more action. Individuals take pride in the results produced by the team.

Collaborative teamwork

this is the storming stage, in which conflicts emerge. Without effective leadership and the ability to resolve conflicts, it is difficult for teams to get past this stage. They will either stay in conflict or revert to a phony politeness. Regardless of how they react, the productivity of the team is limited during the stage.

Competitiveness

is the process of meeting a prescribed set of standards or regulations to maintain active accreditation, licensure, or certification status.

Compliance

every healthcare organization that provides services to Medicare and Medicaid beneficiaries must demonstrate compliance with the CMS Conditions of Participation. The compliance process is known as certification, and it is usually carried out by state departments of health. The Conditions of Participation for healthcare facilities cover issues related to medical necessity, level of care, and quality of care. CMS also contracts with nongovernmental agencies across the country to monitor the care provided by independent healthcare practitioners.

Conditions of Participation

includes obtaining, verifying, and assessing qualifications of a licensed healthcare practitioner.

Credentialing process

are the recognition by healthcare organizations of previous professional practice responsibilities and experiences commonly accorded to licensed independent practitioners.

Credentials

monitoring data for boards of directors

Dashboard

in healthcare organizations, this falls into one of three categories: - patient-specific which pertains to the care services provided to each patient - aggregated which summarizes the experiences of many patients regarding a set of aspects of their care - comparative which uses aggregate data to describe the experiences of unique types of patients with one or more aspects of their care.

Data collection

is uniformly defined by four stages of progression; cautious affiliation, competitiveness, harmonious cohesiveness, and collaborative teamwork.

Models of team development

designation for data storage, either copied or collected. As these repositories become more common in healthcare information systems implementations, they will provide healthcare professionals involved in PI activities with timely data and information that can be used continuously to monitor the quality of many different aspects of the care they provide.

Data repositories

examples are registered nurses, licensed practical nurses, physical therapists, chaplains, and social services staff.

Direct caregivers

is the second part of the CARF accreditation. The document review examines policies and procedures, administrative rules and regulations, administrative records, human resources records, and the case records of patients.

Document review

provides fair treatment through a hearing process that is generally outlined in the healthcare organization's medical staff bylaws. The procedure stipulates the means by which the physician's application and supporting materials will be reviewed by an impartial panel to ensure objective assessment.

Due process

is defined as how well an organization's leaders plan, direct, integrate, and coordinate services, and how they well they create a culture that focuses on continual performance improvement (PI) while maintaining a balanced budget and fiscal viability in the market.

Effective leadership

a natural or man-made event that significantly disrupts the environment of care; that significantly disrupts care, treatment, and services; or that result in sudden, significantly changed, or increased demands for the organization's services.

Emergency

describes the management of space, supplies, staff, and security and describes the following processes in detail: - assignment of authority for notifying staff, notifying and communicating with external authorities, communicating with patients and their families, and communicating with the community when emergency response measures are initiated. - setup of command center and identification of individuals to serve in the incident command structure - assignment of staff to cover all essential functions the EOP is practiced twice a year in response to either an actual disaster or a planned drill.

Emergency operations plan (EOP)

once the project is completed, execution (implementation) begins. This is where installation of the equipment or construction begins, and any policy or procedure manuals should be prepared for distribution. Specifications developed int he design (planning) phase should be finalized. Any new systems or processes should be tested for performance. Execution has milestones that need to be achieved. 1. define the critical success criteria for each phase. 2. organize the work on a weekly and monthly basis 3. make the project calendar public 4. standardize status reporting for the entire organization. 5. manage resource conflicts

Execution

Joint Commission surveyors summarize their findings and explain any deficiencies identified during the site visit.

Exit conference

analytical tools used to illustrate the sequence of activities in a complex process

Flow chart

an effective tool for planning and tracking the implementation of a project. A recent development in healthcare project management is the use of the project management methodology for planning and tracking inpatient care. Dr. Kaufman points out that each hospital admission is a one-time event and is a project that can be managed in four stages: clinical assessment, planning, scheduling, and tracking.

Gantt charts

most members of healthcare boards of directors are appointed from the community at large. It is unlikely that the directors will have specific knowledge of healthcare operations or organizations when they are first appointed. Even after serving for several years, most directors will not have expertise in clinical processes. Therefore, it is important that the individuals leading PI activities in healthcare organizations know how to optimally manage the board of director's PI oversight responsibility.

Governance of a healthcare organization

it is important to note the privacy responsibilities that the HIPAA Act places on this type of information when collateral disclosures are allowed to occur outside of formal PI structures in an organiztion. There may also be data-gathering situations in which protected health information (PHI) form patient, resident, or client health records is specifically matched with other data from marketing or satisfaction surveys that would require the special protection of HIPAA to be exercised. Organizational privacy officers may need to be consulted by PI teams to be sure PHI is used, stored, and disclosed appropriately to meet the requirements of federal and state laws and regulations. The privacy officers may also be of assistance in treating PI data as appropriate to their status as research versus quality improvement information.

HIPAA

this is the norming stage, in which team members learn to communicate and collaborate. They become more focused on the task at hand. Members begin to feel as though they are a contributing part of the team. They also begin to establish rules of engagement with one another.

Harmonious cohesiveness

sets forth guidelines and requirements in five areas: - Chemical labeling provision - Safety data sheet (SDSs) - Hazard determination provision - Written implementation program - Employee training

Hazard Communication Standard

the Joint Commission further requires organizations to conduct an annual analysis to identify potential hazards, threats, and adverse events and then assess their impact on the care, treatment, and services that must be sustained during an emergency.

Hazard vulnerability analysis (HVA)

Organizations are required by US department of labor, Occupational Safety and Health Administration (OSHA) to have a written hazards communication program and to educate and train staff about the unique hazards in the workplace.

Hazardous materials and waste management plan

HCQIA of 1986 is a federal statute designed to make the peer review process more effective by reducing the feara of legal liability on the part of participants. This statute confers immunity from civil liability for damages under federal and state laws to the following individuals and entities for actions taken for peer review bodies: - the professional body itself - any person acting as a member of or staff to the professional review body - any person under a contract or other formal agreement with the professional review body - any person who participates in or assists the professional review body with respect to the action This statute also provides protection from liability for individuals who provide information to professional review bodies during the medical staff appointment and reappointment process, including physicians and members of hospitals, medical schools, and insurance companies.

Health Care Quality Improvement Act (HCQIA)

examples are clinical support professionals from the pharmacy, laboratory, housekeeping, dietary, and so on.

Indirect caregivers

the information management chapter of the accreditation standards was developed during the mid-1990's to focus healthcare organization on the importance of information systems issues in the provision of high-quality patient care. Any healthcare organization that uses accreditation as a component of its PI program must ensure that it meets these standards. Even healthcare organizations that do not seek Joint Commission accreditation as a component of their PI programs would be wise to consider the standards in developing PI systems and procedures. The Joint Commission information management standards focuses on information systems issues, not on information systems. Information management standards address areas in which information resources management contributes to high-quality and improved patient care. These standards require the Joint Commission accredited healthcare organization to plan for, and organize their information resources, and ensure the confidentiality, privacy, security, and integrity of the information is maintained.

Information Management Standards

allow organizations to store reports, presentations, profiles, and graphics interpreted and developed from stores of data for reuse in subsequent organizational activities.

Information warehouses

initiation phase begins with the determination that a gap exists between organization performance and expected outcomes. The leadership then identifies an opportunity for improvement and assesses the feasibility of the project.

Initiation

new staff members should not work independently until they have completed orientation and demonstrated competence. This type of training and orientation may include having the new employee shadow a seasoned employee for a specified period of time, complete a self directed study course, or attend classroom instruction and then demonstrate his or her competence by performing a particular job skill a set number of times for a certified trainer.

Job shadowing

the Joint Commission uses the following five categories to report its decisions on accreditation: - Accreditation: the organization is in compliance with all applicable standards at the time of the on-site survey or has successfully addressed all RFIs in an Evidence of Standards and Compliance (ESC) within 45 or 60 days following the posting of the Accreditation Survey Findings Report and does not meet any other rules for other accreditation decisions. - Accreditation with follow-up survey: the organization is not in compliance with specific standards and requires a follow-up survey within 30 days to 4 months. The organization must address the identified problem areas in an evidence of compliance report that details what the organization has changed to bring itself into compliance with the standards. - Contingent accreditation: the organization did not meet all the Joint Commission's standard at the time of the on-site survey and had a level of standards noncompliance and RFIs in excess of the published levels for that year. Although organizations that receive contingent accreditation may appeal, they must also remedy the noncompliance to the satisfaction of the Commission and, in most cases, are subject to a follow-up survey in 30 days to show resolution of the issues that led to this decision. - Preliminary denial of accreditation: the organization is in significant noncompliance with the Joint Commission standards in multiple performance areas, with RFIs in excess of the published levels for that year. This accreditation decision is subject to appeal, and the organization has the opportunity to present additional information or evidence of compliance prior to accreditation denial. The accreditation decision on appeal also may result in decisions other than accreditation other than accreditation denied. - Denial of accreditation: all available appeal procedures have been exhausted, and the organization has been denied accreditation.

Joint Commission 5 Categories on Accreditation

mobilizes employer purchasing power to promote healthcare safety, quality, and customer value and recognize improvements with rewards. Leapfrog is a voluntary program that works with employer members to encourage transparency and easy access to healthcare information as well as rewards for hospitals that have a proven record of high-quality care. Participating hospitals can take part in Leapfrog's public reporting initiatives, which provide quality benchmarks for both healthcare providers and employer purchasers.

Leapfrog

are individuals permitted by law and the organization to provide patient care services without direction or supervision, within the scope of their license and individually granted clinical privileges.

Licensed independent practioners

are conferred by state regulatory agencies.

Licenses

is a state's act of granting a healthcare organization or an individual healthcare practitioner permission to provide services of a defined scope in a limited geographical area.

Licensure

goals of the medical equipment management program are to provide safe and reliable equipment to patients, train care providers in the safe and effective use of the equipment, and ensure that the equipment is maintained by qualified individuals. The plan provides provisions for the following: - outline how equipment is selected and acquired - establish criteria for including equipment, regardless of ownership, on the facility inventory list. - define time frames for inspecting, testing, and maintaining the equipment in the inventory - defines how equipment and medical device recall will handled. - provides for reporting incidents in which a medical device may have caused death, serious injury, or illness to any patient, as required by the Safe Medical Devices Act of 1990. - identifies processes to respond to equipment malfunction or failure - specifies cleaning and infection control procedures for receiving and handling equipment between patients.

Medical equipment management plan

NCQA began accrediting managed care organizations in 1991. Since then, the NCQA's activities have been broadened to include accreditation of managed behavioral health organizations and credentials verification for physician organizations. As a private, not for profit, the NCQA is dedicated to improving the quality of healthcare by assessing and reporting on the nation's managed care plans. Its efforts are focused on the development of performance management in key areas such as member satisfaction, quality of care, access, and service. It uses HEDIS to accomplish these assessments of managed healthcare plans.

National Committee for Quality Assurance

a system that provides guidelines for common functions and terminology to support clear communication and effective collaboration in an emergency situation, has evolved to include standardization or a total program approach for disaster and emergency management and business continuity programs in the private and public sectors.

National Incident Management System (NIMS)

healthcare organizations are required by law to query NPDB for information on applicants requesting clinical priviledges. Prior to May, 2013, there were two separate operating data banks; the NPDB and the Healthcare Integrity and Protection Data Bank (HIPDB). Legislation was passed that consolidated the operations of both data banks into one, the NPDB.

National Practitioner Data Bank (NPDB)

are more suitable for secondary uses, such as exploration or learning within individual health care organizations, and are good advice in terms of appropriate patient care. Going forward, only accountability measures will be evaluated statistically and reported on the Quality Check website for use in rating an organization against national experience or against other similar organizations.

Nonaccountability measures

is based on the premise that employees who may be exposed to hazardous chemicals in the workplace have a right to know about the hazards and how to protect themselves. For that reason, the Communication Standard is sometimes referred to as the Worker Right to Know Legislation, as more often just as the Right to Know Law.

OSHA

a meeting conducted at the beginning of the accreditation site visit during which the surveyors outline the schedule of activities and list any individuals whom they would like to interview, is an important opportunity for the organization to set the tone for the survey process.

Opening conference

which is training for the use of fire extinguishers, stands for: P - pull pin A - aim nozzle S - squeeze handle S - sweep from side to side

PASS

if a more quantitative approach is required, the program evaluation and review technique (PERT) may be used. It depicts a network of activities, represented by arrows. This is called the critical path method (CPM). The most helpful element of PERT is that it identifies those critical activities that must be completed on time in order for the entire project to meet its final deadline.

PERT charts

review by like professionals, or peers, established according to an organization's medical staff bylaws, organizational policy and procedure, or the requirements of state law. The peer review system allows medical professionals to candidly critique and criticize the work of their colleagues without the fear of reprisal.

Peer review

defines the responsibilites of the job and the qualifications need to fulfill those responsibilites.

Position descrition

begins the formal communication between the human resources staff and the department or service area initiating the recruitment process. A detailed position requisition provides human resources staff with the information needed to advertise the open position, including the position title, qualifications, and experience required, work schedule, and salary.

Position requisitions

focuses on a way of delivering services that leads to a certain outcome. A scientific or experiential basis must exist for believing that the process, when executed appropriately as designed, will increase the probability of achieving a desired outcome.

Process measure

the length of time a project will take over its entire life cycle varies depending on the scope and size of the project. The life cycle of a project is composed of several phases; the number of phases and their definitions vary depending on who is outlining the phases and the industry involved. Most projects have between four and six phases.

Project Life Cycle

agencies that review patient records to ensure that the care provided by practitioners meets the federal standards for medical necessity, level of care, and quality of care.

Quality Improvement Organizations (QIOs)

the federal government is ramping up efforts to further tie healthcare reimbursement to quality of care through initiatives like value-based purchasing and accountable care organizations, quality measurement organizations are gaining more national prominence. Many organizations develop, endorse, implement, and promote performance measures. Trying to decipher and understand the interplay of organizations involved with quality measures can be challenging.

Quality Measurement Organizations

an easy method to train staff, RACE stands for: R - rescue anyone in immediate danger of the fire A - activate alarms C - confine fires (close doors and windows) E - extinguish fires using PASS and prepare to evacuate patients

RACE

a process where the organization can reassess each staff member's ability to meet the performance expectations and competencies described in their job description. The performance appraisal process should be specific to the staff member's assigned responsibilities and assessed competencies. The employee and manager should work together to develop new performance goals and to modify or enhance performance standards.

Reappraisal/Reappointment

states that the patient record should be detailed enough so the patient can be identified, as well as support the care provided to include diagnosis, treatments, care results, and staff communication.

Record of care standards

analysis of a sentinel event from all aspects (human, procedural, machinery, and material_) to identify how each contributed to the occurrence of the event and to develop new systems that will prevent recurrence.

Root cause analysis

strategic planning may include a process in which the leaders complete an assessment of the organization's Strengths, Weaknesses, Opportunities, and Threats. Finds from SWOT analyses are used to validate the mission of the organization as a whole and determine the direction the organization is going as a business entity during the coming year.

SWOT analysis

major component of the safety management plan is a fire prevention plan that is based on appropriate design and construction of the building, fire detection, alarm and extinguishment systems, and training to provide for appropraite safety for all components.

Safety management plan

is designed to manage the physical and personal securities of the patients served, staff, and individuals coming to the organization as well as the security of the building, equipment, supplies, and information. It is reflective of the security risk assessment conducted annually. The security management program and security policies describe procedures to manage door access, visiting hours, and after-hours access to the facility; security in parking areas, such as suspicious vehicles; high-risk patients, such as victims of crime or patients in police custody; high-profile patients or visitors; weapons in the facilities; suspicious individuals and disruptive visitors; manpower alerts, and the issuing of trespass notices, to name a few.

Security management plan

an in-person review conducted by an accreditation survey team, every three years; however, with the Joint Commission's move to unannounced facilities a more continuous, efficient accreditation process.

Site visit

One or more individuals in an organization sponsors a project. Sponsorship by top leadership, therefore, must be characterized by commitment and clear articulation of expectations.

Sponsorship

facilitates the use of data by multiple individuals and multiple teams. Sharing can decrease the time and cost of PI activities for the organization. To accomplish sharing ability, organizations should carefully consider the most appropriate kind of information technology support.

Standardization

contains the organization's overall mission, vision, and goals, is developed by the organization's senior leaders and board of directors, whom the public holds accountable for the quality of the organization's products and services.

Strategic plan

is conducted using a set of standard questions that are asked of all job applicants, the purpose of which is to gather comparative data.

Structured interview

composition of the Joint Commission survey team will vary depending on the size of the organization. It may include a physician, an administrator, a registered nurse, and other master's level clinicians. Representatives from state licensing agencies who have arranged to join the survey for their own examination of the organization for licensing and CMS validation purposes may bring physician, nurse, pharmacist, nutritionist, or life safety surveyors. Beginning in 2005, most survey teams included an expert in environment of care and life safety issues. The Joint Commission surveyors have many years of experience practicing in the healthcare industry.

Survey team

team members should be selected by identifying individuals who possess a variety of skills and experience.

Team member selection

uses general questions from which other questions are developed over the course of the conversation. The purpose of this type of interview is to prompt the interviewee to speak openly.

Unstructured interview

This standardization has required healthcare organizations to reevalutate their emergency operations plans (EOPs) and the Joint Commission to redefine standards that address six critical areas of emergency management with a focus that includes linkage to community resources. When a healthcare organization has a sound understanding of their response to these six critical areas of emergency management, they have developed an all hazards approach that supports a level of preparedness sufficient to address a range of emergencies, regardless of the cause. The six critical areas of emergency management are (communications; resources and assets; safety and security; staff responsibilities; utilities management; and patient, clinical, and support activities).

Total program approach/All hazards approach

permits assessment of operational systems and processes in relation to the actual experiences of selected patients currently under the organization's care. Tracer methodology analyzes an organization's systems, with particular attention to identified priority focus areas, by following individual patients through the organization's healthcare process in the sequence experienced by its patients. Patients are selected on the basis of the current census of patients that the organization identifies as typical of its case mix. As cases are examined in related to the actual care processes, the surveyor may identify performance issues or trends in one or more steps of the process of in the interfaces between processes. Patients on subsequent days may be selected on the basis of issues raised.

Tracer methodology

is designed to ensure that utilities systems throughout the EOC are planned and maintained safely and comfortably; that utililties are delivered without interruption; and that mechanical systems operate safely, accurately, and reliably. A good utilities management program helps organization minimize the risk of hospital-acquired illnesses that may be transmitted through the utility systems.

Utilities management program

are conducted at the request of the healthcare facility seeking accreditation or certification.

Voluntary reviews

the term used for the assumption by the Centers for Medicare and Medicaid Services (CMS) that an organization meets the Medicare and Medicaid Conditions of Participation as a result of prior accreditation by the Accreditation Association for Ambulatory (AAAHC), the American Osteopathic Association (AOA), the Commission on Accreditation of Rehabilitation Facilities (CARF), or the Joint Commission.

deemed status