quality chapters 15, 16, & 17

Health Insurance Portability and Accountability Act

HIPAA

The make-up of a survey team

A group of individuals sent by an accrediting agency to review a healthcare organization for accreditation purposes, to discuss any issues of concerns. The composition of a 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.

10) This private, not-for-profit organization is committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs: A. Commission on Accreditation of Rehabilitation Facilities B. American Osteopathic Association C. National Committee for Quality Assurance D. The Joint Commission

A. Commission on Accreditation of Rehabilitation Facilities

Private or public agencies contracted by CMS to undertake examination and evaluation of the quality of healthcare rendered to beneficiaries of federal healthcare programs are referred to as _____. A. QIOs B. HMOs C. PPOs D. ACOs

A. QIOs

Which type of data collection pertains to the care services provided to each patient? A. patient-specific B. aggregated C. comparative D. detailed

A. patient-specific

*american osteopathic association* -accredits osteopathic hospitals

AOA

summarizes the experiences of many patients regarding a set of aspects of their care

Aggregated

Which of the following is the process of meeting a prescribed set of standards or regulations to maintain active accreditation, licensure, or certification status? A. performance improvement B. compliance C. document review D. deemed status

B. Compliance

Which type of data collection summarizes the experience of many patients regarding a set of aspects of their care? A. patient-specific B. aggregated C. comparative D. detailed

B. aggregrated

Data found on sites such as Hospital Compare use aggregated data to describe the experiences of unique types of patients with one or more aspects of their care. What is this data collection called? A. patient-specific B. aggregated C. comparative D. detailed Reset Selection

C. Comparative

This organization accredits managed care organizations, managed behavioral health organizations, and credentials verification for physician organizations: A. Commission on Accreditation of Rehabilitation Facilities B. American Osteopathic Association C. National Committee for Quality Assurance D. The Joint Commission

C. National Committee for Quality Assurance

Oversight process by like professionals established according to an organization ?s medical staff bylaws, organizational policy and procedure, or the requirements of state law that allows the candid critique of colleagues without fear of reprisal is called _____. A. process review B. credentialing C. peer review D. compulsory review

C. Peer review

The act of granting approval for a healthcare organization to provide services to a specific group of beneficiaries is called _____. A. accreditation B. licensure C. certification D. approval

C. certification

Conditions of Participation to receiving funding through the medicare and medicaid programs.

COP

This private, not-for-profit organization is committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs

Commission on Accreditation of Rehabilitation Facilities

Uses aggregated data to describe the experiences of unique types of patients with one or more aspects of their care.

Comparative

This type of healthcare organization review is performed to fulfill legal or licensure requirements:

Compulsory Review

are performed to fulfill legal or licensure requirements

Compulsory review

Every Organization that provides services to Medicare & Medicaid beneficiaries must demonstrate its compliance with this set of standards.

Conditions of Participation

The organization has been responsible for accrediting healthcare organization since the mid-1950s and determines whether the healthcare organization is continually monitoring and improving the quality of care it provides. a. commission on accreditation of rehabilitation facilities b. American osteopathic association c. national committee for quality assurance d. joint commission on accreditation of healthcare organizations

D

he document in which the leadership of a healthcare organization identifies the organization's overall mission, vision, and goals to help set the long-term direction of the organization as a business entity is called: a. operational plan b. organizational plan c. safety plan d. strategic plan

D

Community Hospital of the West has recently been accredited by the Joint Commission for a full three-year period. Based on its accreditation status, CMS assumes that the Community Hospital of the West meets the Conditions of Participation. The reason CMS makes this assumption is because the Joint Commission has been granted _____. A. performance improvement B. compliance C. document review D. deemed status

D deemed status

Which of the following is NOT an organization currently collecting data on quality of healthcare? A. AHRQ (Agency for Healthcare Research and Quality) B. CMS (Center of Medicare and Medicaid Services) C. IOM (Institute of Medicine) D. AMCAS (American Medical College Application Service)

D. AMCAS (American Medical College Application Service)

During a recent Joint Commission survey, one of the survey team members asked a nurse in the ICU about her patient. The surveyor asked the nurse about the medications that the patient was on and also asked for the nurse to explain how those medications were ordered and received from the pharmacy. After the nurse explained this process, the surveyor then went to the pharmacy and asked the pharmacist to explain his role in the medication process for this specific patient. The surveyor is utilizing what process? A. medication reconciliation B. document review C. drug diversion D. tracer methodology

D. Tracer methodology

A report developed by a PI team on the occurrence of methicillin-resistant Staphylococcus aureus infection in a neonatal intensive care unit was subsequently used by the perinatal morbidity and mortality committee in a monthly review of infant morbidity. Access to this report was possible because it was housed in the organization's _____. A. computer hard drive B. comparative performance data C. PI database D. information warehouse

D. information warehouse

as part of the ARA, this act requires that healthcare organizations and providers make significant investments in information systems to have a positive impact on the care they provide

HITECH

Which of the following is NOT an organization currently collecting data on quality of healthcare? AHRQ CMS TJC HL7

HL7

This organization has been responsible for accrediting healthcare organizations since the middle 1950's and determines whether the organization is continually monitoring and improving the quality of care they provide

Joint Commission on Accreditation of Healthcare Organizations

The hospitals plans managing information The hospital protects the privacy of health information The hospital maintains the security and integrity of health information

Joint commission information management standards examples

The act of granting a healthcare organization or an individual healthcare practitioner permission to provide services of a defined scope in a limited geographical area is called _____. accreditation licensure certification approval

Licensure

is a states 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

This organization accredits managed care organizations, managed behavioral health organizations, and credentials verification for physician organizations.

National Committee for Quality Assurance (NCQA)

are data repositories, but they cannot be accessed as easily as computer-based repositories.

Paper base records

Quality Improvement Organization; retrospectively review patients records to ensure that the care provided by practitioners meets the federal standards for medical necessity, level of care, and quality of care.

QIO

A _______________is contracted by CMS to examine and evaluate the quality of healthcare rendered to beneficiaries of federal healthcare programs

QIO (Quality Improvement Organization)

are contracted to federal government to use medical peer review, data analysis, and other tools to identify patterns of care and outcomes that need improvement and then to work cooperatively with facilities and individual physicians to improve care.

Quality Improvement Organization

Strategic planning may include SWOT analysis process in which the leaders complete an assessment of the organizations Strengths, Weaknesses, Opportunities, and Threats. SWOT analysis findings 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

The senior leadership and board of directors are meeting to determine the key priorities for community Hospital for the year ahead. during this time they also used a SWOT analysis to validate the mission. The resulting document of this session is called?

Strategic Planning

on information systems issues, not on information systems. The systems implemented may be computer-based or paper-based.

The Joint Commission information management Standards Focus

is a document in which the leadership of a healthcare organization identifies the organizations overall mission, vision, and goals to help set the long-term direction of the organization as a business entity. Leaderships are responsible for ensuring that a process is in process is in place to measure, assess, and improve the hospitals governance, management, clinical, and support functions. Strategic planning process occurs annually prior to the start of the fiscal year and coincides with organization-wide plan/program reviews and the budgeting process

Strategic Planning Process

These standards require the Joint Commission- accredited healthcare organization to plan for and organize their information is maintained. These standards instruct the healthcare organization to collect and analyze appropriate data to monitor and improve processes within organizations.

The Joint Commission information management Standards intent

What is the role of the governing board of directors?

They oversee and are responsible for the safety and quality or care patients receives within a organization

True or false? Paper-based records are data repositories, but they cannot be accessed as easily as computer-based repositories.

True

This type of healthcare organization review is conducted at the request of the healthcare facility seeking accreditation _____. voluntary review complimentary review vocational review compulsory review

Voluntary review

This group has ultimate responsibility for maintaining the quality and safety of patient care provided by its healthcare organization a.board of directors b. executive team c. nursing leadership d. state board licensure

a

every organization that provides services to medicare and medicaid beneficiaries must demonstrate its compliance with this set of standards a. conditions of participation b. JCAHO accreditation c. CARF accreditation d. NCQA accreditation

a

The act of granting approval to an organization that has demonstrated satisfactory quality of service is A. accreditation B. licensure C. certification D. approval

a. accreditation

a large database that stores every data element collected within a healthcare organization and is used for PI activities is called a/an....? a. data repository b. information warehouse c. comparative performance data d. PI database

a. data repository

What are the 5 categories of accreditation decisions made by The Joint Commission?

accreditated accreditation with follow up survey contingent accreditation preliminary denial of accreditation denial of accreditation

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

accreditation

An accrediting agency's published rules, which serve as the basis for comparative assessment during the review or survey process is called _____. accreditation guides accreditation policies accreditation standards accreditation controls

accreditation standards

grants approval for a healthcare organization to provide services to a specific group of beneficiaries. Ex. healthcare organizations must meet the federal Conditions of Participation to receive funding through the medicare and medicaid programs.

certification

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

compliance

The regular presentation of concise, appropriately displayed monitoring data for hospital board of directors that provides minute to minute data in a organized, comparative format that maximizes the use of the board's time and assists its members in accomplishing oversight activities is called?

dashboard

is an open-structure database that is not dedicated to the software of a particular vendor or data supplier, in which data from diverse sources are stored so that an integrated, multidisciplinary view of the data can be achieved.

data repository

CMS accepts accreditation by organizations with deeming authority in granting what is called?

deemed status

Before the on-site survey team leaves the healthcare facility they meet with the organization's leadership team and provide a report of their findings. This meeting is called _____. preliminary report exit conference closing meeting convening authority

exit conference

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

information warehouse

Governance of a healthcare organization is comprised of the board of directors and the ___. administration nursing administration medical staff leaders employed staff

medical staff leaders

What are the three standing committees of the medical staff and what are their responsibilities?

medical staff, nursing units, and administrative areas related to that specialty these committees are organized to review specific aspects of patient care services, such as ethical issues that may come up during the course of patient care

pertains to the care services provided to each patient

patient-specific

Oversight process like professionals established according to an organization's medical staff bylaws, organizational policy and procedure, or the requirements of state law that allows the candid critique of colleagues without fear of reprisal is called?

peer review

that permits assessment of operational systems and processes in relation to the actual experiences of selected patients currently under the organizations care. This analyzes an organizations 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.

tracer methodology

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

voluntary review