hpm final 12.14.22

Benefits of Effective Teams

Teams that are empowered to be innovative and rewarded for performance: Improve coordination and quality of care, Use of health care services more efficiently Increase job satisfaction among team members Increase patient satisfaction Increase productivity

Ethics and Social Responsibility

What is your moral responsibility in marketing as a health care manager? Inducing the use of unhealthy products? Influencing children or vulnerable populations? Ensuring well-being of patients or society? Avoiding conflicts of interest?

roll out & implementation

board approval/ endorsement operating plan marketing plan facilities plan capital plan

Situational Assessment

misson vison values organizational assessments - organizational volume forecast - financial condition - strategic performance - core capabilities

The matrix model recognizes that a strict functional structure may limit the organization's flexibility to carry out the work, and that the expertise of other disciplines is needed on a continuous basis.

true

Terms in health insurance

Risk pooling Forms of payment Fee-for-service Prepayment Cost sharing Copayments Deductibles Coinsurance Policy limitations Maximum out-of-pocket expenditure Lifetime limits Types of benefits Comprehensive Basic/major medical Catastrophic coverage Disease-specific MediGap Long-term care

Kotter's 8 Step Change Model

-Creating a sense of urgency -Building a guiding coalition -Providing a clear vision of success -Communicating the vision -Empowering others to act -Create short-term wins -Use success to foster the next steps -Institutionalize the new behavior (changes)

Motivation: The Concept

According to Webster's New Collegiate Dictionary: Motive: "something (a need or desire) that causes a person to act." Motivate: "to provide with a motive." Motivation: "the act or process of motivating." What are rewards? What are incentives? Who motivates employees? Is everybody motivated?

Key Changes in the Evolution of the Health Insurance Industry

Advent of comprehensive health services and benefits. Increased role of the public and private sectors in health care coverage Health insurance as an employee benefit Changes in reimbursement for care provided Shift from fee-for-service to managed care The continual rise in the cost of health care

Health Information Systems (HIS) Defined

All pieces of computer systems, including: -Software -Hardware -Operating systems -End-user devices connecting systems •Networks: the electronic connectivity between system, people, and organizations •Data that systems -Create -Capture through the use of software -These become the building blocks for all functions and applications.

Employee engagement is best described as:

Employee motivation and commitment to the organization.

Leadership vs Management

Are leaders and managers the same people? Health care has a special need for both Leader focus is more external to organization There is crossover into various areas.

Managerial Competencies

Assuring patient-centered practices Staffing personnel Controlling resources Supervising the services provided Overseeing adherence to regulations Counseling/developing employees Managing operations

Conflict Management for Teams

Bargaining Voting Problem solving Research Third-party mediation

Current Research in Health Care Management

Best practices of managers: employee engagement, staff acquisition and development, staff frontline empowerment, and leadership alignment and development. Leader behaviors: leader decision making, and creating a culture of caring Speed and conviction of decision making, gaining input from stakeholders, focusing on the long term, delivering results Huddling for patient safety and quality; empowering staff to take action; engaging with employees through rewards, recognition, and idea solicitation for improvement; and aligning staff personal values with organizational mission

Classifying Costs: Frequently Utilized Methods

By behavior Fixed costs Variable costs By traceability Direct costs Indirect costs Full costs By decision-making capability Controllable costs Uncontrollable costs

Which of the following competencies involves the ability to critically analyze and solve complex problems?

Conceptual

Management competencies

Conceptual Skills Those skills that involve the ability to critically analyze and solve complex problems Examples: A manager conducts an analysis of the best way to provide a service A manager determines a strategy to reduce patient complaints regarding food service Competencies: Technical Skills Those skills that reflect expertise or ability to perform a specific work task Examples: A manager develops and implements a new incentive compensation program for staff A manager designs and implements modifications to a computer-based staffing model Competencies: Interpersonal Skills Those skills that enable a manager to communicate with and work well with other individuals, regardless of whether they are peers, supervisors, or subordinates Examples: A manager counsels an employee whose performance is below expectationA manger communicates to subordinates the desired performance level for a service for the next fiscal year

Conflict Management

Conflict management de-escalates emotional tension and re-establishes team or organizational goals using effective communication, problem-solving abilities, and good negotiating skills. Higher performing teams were more likely to: Focus on the content of interpersonal interactions rather than delivery style Explicitly discuss reasons behind any decisions reached in accepting and distributing work assignments Assign work to members who have the relevant task expertise rather than assigning by other common means such as volunteering, default, or convenience Anticipate the need for conflict resolution and develop strategies that apply to all group members

Ongoing Medicare Program Concerns

Continuing expansions of benefits Access to Medicare participating physicians and providers Continuing increases in program spending Program solvency Reducing costs while increasing quality

Cost Allocation

Cost allocation involves the determination of the total cost of producing a health care service Purpose is to: Ensure the proper allocation of costs to services and departments Allocate costs from non-revenue-producing departments into revenue-producing departments Separate costs at the unit-of-service level to allow managers to measure changes in intensity and case mix, and to identify inefficient functions Set accurate pricing for services provided

Health Insurance Coverage Statistics, 2017

Coverage by: •Employment-based private health insurance: 56.0% •Direct purchase private health insurance: 16.0% •Medicaid: 17.2% •Medicare: 19.3% •Military health care: 4.8% Note that categories are not mutually

Eligibility for Medicare

Coverage is provided to: Elderly citizens older than 65 years of age Permanently disabled younger adults Individuals with end-stage renal disease (ESRD) Terminally ill patients in the end of life 58.4 million people were enrolled as of 2017*

Management innovation refers to improving which of the following?

Decision-making, Management thinking, How operational activities get accomplished All of these are correct

Managing Budgets

Definition: The process of turning the objectives of the organization into a plan for earning revenues and controlling expenditures. Involves all managers. Major types of budgets: Master budget: income statement, balance sheet, and statement of cash flows Operating budget, or cash budget: annual budget that is a forecast of cash inflows, outflows, and net lending or borrowing needs. Expense budget Revenue budget Capital budget: plan for expenditures for long-term assets whose useful life is more than 1 year.

Direct vs Non-Direct Care

Direct care settings: provide care directly to a patient, resident, or client who seeks services from the organization Non-direct care settings: not directly involved in providing care to persons needing health services; support the care of individuals through products and service made available to direct care settings Traditional non-direct care settings: not directly involved in providing care to persons needing health services; but still paid mostly through insurance billing Alternative non-direct care settings include companies focused on population health and consumer products; very rarely paid through insurance billing

Tax Status of Healthcare Organizations

For-profit, investor-owned Serve private interests and pay taxes. Goal is to maximize profits for the owner(s). Provides services which the community is willing to pay for Not-for-profit Serve public interests and are tax-exempt Goal is to provide community benefit and optimal patient care (including the indigent). Types: business-oriented (private), private not-for-profit, and government-owned Must also turn a profit for sustainability

Tuckman's Stages

Forming: getting oriented to the team goals and each other, finding out what the tasks are, and who they will be working with Storming: intragroup conflict, attempts at dominance, passive-aggressive behavior, along with information withholding and other forms of resistance to team tasks and goals Norming: expectations and roles become codified, either formally or informally Performing: peace breaks out and team members actually begin the work at hand, have open dialogue with one another, and share information to accomplish the team's goals Adjourning: team members have worked together over a long period of time, have developed respect for one another, like each other as individuals and the team as a whole, and become sad that they are disbanding

Major Objectives of Financial Management

Generate a reasonable net income. Ensure proper cost allocation. Set prices for services. Facilitate relationships and manage contracts with third party payers. Record and analyze cost information. Prepare, audit, and disseminate the organization's financial reports. Ensure that payroll is covered and that suppliers are paid. Protect the organization's tax status. Respond to government regulators, external auditors, accrediting agencies, and quality consultants. Control financial risk to the organization. Invest in long-term capital assets.

Financial Governance: In Order of Responsibility

Governing Body, or Board of Directors/Trustees Chief Executive Officer (CEO) Chief Financial Officer (CFO) Controller Treasurer Internal auditor All managers in the health care organization

Innovation and Change Management

Health care organizations cannot remain static! Environmental forces require adaptation. Achieving and sustaining high performance (outcomes or results) requires making improvements to organizational structure and processes. Two types of innovation: management innovation and operational innovation (Hamel, 2007). Change management: organizational change is a structured management approach to improving the organization and its performance, and is based on knowledge of performance gaps (Thompson, 2010).

Intrinsic Rewards: Intangibles

Healthy relationships: feeling a sense of connection Meaningful vs. meaningless work Competence Choice and participation in decision making Progress: accountability, meeting milestones

Ensuring High Performance

High-performance organizations are results-oriented. One framework has pillars of excellence for the specific goals of the organization: people (employees, patients and physicians), service, quality, finance, and growth (Studer, 2003). Another framework speaks of "champions" and the "championship process" measures of performance. Governance and strategic management, clinical quality, customer satisfaction, clinical organization (caregivers), financial planning, planning and marketing, information services, human resources, and plant and supplies (Griffith, 2000) Stakeholders, including insurers, state and federal governments, and consumer advocacy groups, are expecting, and in many cases demanding, acceptable levels of performance in health care organizations. Want to make sure that services are provided in a safe, convenient, low-cost, and high-quality environment

Effective change management requires that managers:

Identify performance gaps by routinely assessing operational activities and performance

Master Budget

Includes all financial information for the organization Comprised of income statement, balance sheet, and statement of cash flows Typically prepared for the upcoming fiscal year Prepared by Finance Department with input from all departments

What is Financial Management?

It is the process of: Providing oversight of the health care organization's financial operations Planning the organization's long-term financial direction (both internal and external) Increasing the organization's revenues and decreasing expenses to improve income

Leadership Competencies

Leaders have a different set of competencies Establishing mission Setting vision/direction for the organization Motivating stakeholders (includes employees) Being an effective spokesperson Determining strategies for future Transforming the organization Networking

Change Management

Lewin's basic change model -Change in three steps (CATS) •Unfreeze •Change •Freeze -Understanding the forces driving and resisting change •Force field analysis

Hierarchy and Control

Management positions exist at lower levels, middle-management levels, and at upper levels, i.e., senior management. Hierarchy of management means that authority, or power, is delegated downward in the organization, and that lower-level managers have less authority than higher-level managers, whose scope of responsibility is much greater. Vertical Structure Size and complexity of the specific health services organization will dictate the particular structure. Larger organizations—such as large community hospitals, hospital systems, and academic medical centers—will likely have deep vertical structures reflecting varying levels of administrative control for the organization. Matrix Structure These include team-based models and service line management models. The matrix model recognizes: that a strict functional structure may limit the organization's flexibility to carry out the work; and that the expertise of other disciplines is needed on a continuous basis. Team: functional staff, such as nursing and rehabilitation personnel, are assigned to a specific program, such as geriatrics, and report for programmatic purposes to the program director of geriatrics. Service Line: manager heads a specific clinical service line (e.g., cardiology) with accountability for staffing, resource acquisition, budget, and financial control.

Health Care Policy

Managers must be knowledgeable about health policy matters under consideration at the state and federal levels that affect organizations and health care delivery. Often, organizations have designated staff to monitor this—but managers must stay current or lose opportunities. Professional organizations such as ACHE, MGMA, and HFMA help with this.

Strategic Planning and Strategy Development

Managers play a key role in determining the future of the organization through the strategic planning process. Strategic planning is the process of identifying a desired future state for an organization and a means to achieve it. Manager's role is critical: Has unique knowledge of patient needs, services and industry trends specific to their area of responsibility Can be an advocate for his or her department or function, in terms of setting organizational goals, strategies, and implementation plans Plays a key role in determining implementation plans with realistic input on staffing, resources, and accountability In the population health and consumer industry, managers heavily influence collaboration efforts.

Marketing Management

Marketing management is the art and science of selecting target markets, creating, communicating, and delivering value to selected customers in a manner that is both sustainable and differentiated from the competition.

Marketing Plan

Marketing plan is a written document that serves to guide marketing initiatives across the organization. Part of the broader strategic plan that has a long-term horizon Contains specific tactical marketing activities that are more short-term in nature

The external domain of health care management includes which of the following?

Medicare/Medicaid

Which of the following leadership development activities addresses learning and personal growth of aspiring leaders as assisted by senior managers?

Mentoring

What is the relationship of organizational mission, values, and vision?

Mission shapes values, which shape vision

Organizational Culture, Values, Mission and Vision

Organizational culture is known as the beliefs, attitudes and behaviors that are shared among organizational members Values: principles that organization believes in that guide activities Mission: the organization's purpose Vision: a desired future state describing what the HSO will be recognized and known for

Extrinsic Rewards: Tangibles

Money Benefits Flexible schedules Job responsibilities Promotions Status changes Supervision Praise/feedback Good boss Strong leader Inspirational people Nurturing organizational culture

History of Major Pieces of Health Insurance Legislation

National Health Insurance Discussed in 1930s Seen as socialized medicine Not enacted Medicare and Medicaid enacted in 1965 Children's Health Insurance Program (CHIP) legislated in 1997 Patient Protection and Affordable Care Act passed in 2010

Networks

Networks can be categorized as intranets, which are internal to an organization, or extranets, which are external and allow users to share information •Networks also can be characterized as -Local area networks (LANs) -Wireless LANs (WLANs) -Wide area networks (WANs) -Wireless WANs (WWANs) -Storage area networks (SANs) •The Internet is a well-known WAN (Balgrosky, 2015, p .81).

Organizational vs. Consumer Buying Behavior

Organizational behavior concentrates on business buyers (for-profit or nonprofit). Example: employers purchasing health care insurance for employees Consumer behavior refers to the influences on purchase decision-making of consumers' acquisition of goods, services, time, and ideas. Example: person choosing a cosmetic surgeon

Talent Management

Recruitment, retention, training, and development of highly skilled employees Human resources is critical to health care organizations. Health care organizations compete with each other for the brightest and the best talent. Managers look for and keep the talent!

Ensuring a Positive Patient Experience

Organizations have increasingly recognized that service quality—customer service—is required. With the shift to value-based performance, Medicare and commercial insurers are now paying for care on the basis of clinical quality and patient perceptions of care and customer service. The patient experience is defined as "the sum of all interactions, shaped by an organization's culture, that influence patient perceptions across the continuum of care" (Beryl Institute, 2018). To ensure a positive patient experience, a manager needs to: Understand the organizational processes of providing care and support services, and the interactions of the patient with the organization Understand the needs and expectations of patients Focus on and improve the physical environment of care, which promotes access, comfort, and convenience

Which function refers to the setting of reporting and responsibility relationships within a manager's unit?

Organizing

Medicare "Parts"

Part A: Hospital Insurance (HI) Part B: Supplemental Medical Insurance (SMI) Part C: Medicare Advantage Plans (MAs) Part D: Prescription Drug Benefit

Stark Law

Physician Self-Referral Laws •Law developed to prohibit physicians from referring their patients to providers in which they have a financial interest •If a physician discovers a violation after the fact, physician is subject to potential criminal liability if the error is not disclosed. •Violation of Stark is always also a violation of both Anti-Kickback and False Claims Acts. •Examples include: -Paying a physician for a referral -A hospital offering rental space for a physician below fair market value -A physician who receives benefits not given to other doctors or staff •Prosecutors may impose personal or criminal responsibility on officers and board members of for-profit providers who know, but fail to disclose to the government, that the provider is not entitled to those received Medicare payments.

Management functions

Planning This function requires the manager to set a direction and determine what needs to be accomplished. It means setting priorities and determining performance targets Organizing The overall design of the organization or the specific division, unit, or service for which the manager is responsible. Further, it means designating reporting relationships and intentional patterns of interaction. Determining positions, teamwork assignments, and distribution of authority and responsibility are critical components of this function. Staffing Acquiring and retaining human resources Developing and maintaining the workforce through various strategies and tactics Controlling and Directing Controlling: monitoring staff activities and performance, and taking the appropriate actions for corrective action to increase performance Directing: initiating action in the organization through effective leadership and motivation of, and communication with, subordinates Decision Making This function is critical to all of the aforementioned management functions and means making effective decisions based on the consideration of benefits and the drawbacks of alternatives.

Pros and Cons of Virtual Teams

Pros: less interpersonal conflict, reduced travel, and increased access to diverse employees and talents regardless of geography Cons: communication challenges, intellectual property issues, need for careful selection of team members, work hours may not be limited to normal work week, problems with determining who the supervisor is when there are HR issues

Strategic Planning Process

SWOT analysis Strategy identification and selection Strategy tactical plans Rollout and implementation Monitoring and control Feedback

Segmentation, Target Market, and Positioning

Segmentation: dividing the total market into groups or segments that have relatively similar needs for products and services and results in a target market. Positioning: various techniques used to differentiate offerings and establish the brand image in the mind of the target market.

Focus of Management

Self management: the individual manager must be able to effectively manage himself or herself, as well as time, information, space, and materials, being responsive and following through with peers, supervisors, and clients. Maintaining a positive attitude and high motivation; developing and applying appropriate skills and competencies. Unit/Team Management The expertise of the manager at this level involves managing others in terms of effectively completing the work through task interdependence. Includes assigning work tasks, review and modification of assignments, monitoring and review of individual performance, and carrying out the management functions described previously Organizational Management Managers must work together as part of the larger organization to ensure organizational-wide performance and organizational viability. Success of the organization depends upon the success of its individual parts, and effective collaboration is needed to ensure that this occurs.

Reimbursements by The Uninsured

Self-pay patients are billed for full charges. No contractual rate to reduce costs to patients Has resulted in the rise of personal bankruptcies, due to inability to pay such large sums of money Uncompensated care: Two major types Bad debt: no payment received for billed services; written off by the organization; can result in damage to patient's credit score. Charity care: organization provides care, knowing the patient will be unable to pay

Causes of Growth in Medicare Spending

Shift from acute to chronic care Growth in hospital expenditures Fee-for-service reimbursement Growth in pharmaceutical costs Advances in medical technology Increased payments to health plans Increased payments to rural health providers Rising medical malpractice premiums

Paying for Care

Sources of payments: Out-of-pocket payments: 10.6% Private health insurance: 33.7% Public funding, including Medicare, Medicaid, the State Children's Health Insurance Program: 51.1% Investments: 4.7%

EMRAM & O-EMRAM Models

Stages 0-1: very basic automation of individual areas Stages 2: ability to start bringing disparate data together Stages 3-6: implementation of advanced clinical systems Stage 7: ability to share or exchange data with external entities

Types of Leaders

Strategic: defines purpose and vision and aligns people, processes, and values (internal and external focus) Network: connects people across disciplines, organizational departments, and regions (more external focus) Operational: has functional oversight responsibilities (more internal focus)

Health care managers influence which of the following in the population health and consumer industry?

Strategy, medical care, collaboration, growth

Definition of Management

The process, comprised of social and technical functions and activities, occurring within organizations for the purpose of accomplishing predetermined objectives through human and other resources Managers work through others to accomplish organizational goals.

Marketing Promotions

Traditional channels Paid media: television, radio, billboards, mailings Digital channels Owned media: websites, blogs, patient portals, podcasts Earned media: recognition by customers via social media postings, retweets

chapter 4- organizational behavior & management thinking: people skills

thinking skills: critical thinking reasoning problem solving decision making mental flexibility socio-emotional skills: interpersonal relations teamwork empathy self-awarness self-discipline

Capital Budgets

​​Basic questions that need to be answered: Does this asset at least pay for itself? Does the asset add value to the organization? Types of items included in capital budgets: Land acquisition Facility construction, acquisition, renovation Routine capital equipment used in clinical areas Information technology infrastructure & upgrades Acquisition of staff physicians (human capital) Wish list submitted to managers and proposals submitted by managers to Finance Department. Methods (decision rules) utilized to make capital budgeting decisions Accept/reject Capital rationing: those selected have highest profitability index Non-criteria-based: safety valve allowing purchase "no matter what" Approval by administration and Governing Body

Other Concerns Relating to Health Insurance

​​Choice of provider Access to care Restrictions on care Moral hazard Pre-existing conditions Buy-downs Coordination of benefits

PHI

​​Individually identifiable health information (IIHI) relates to: •the individual's past, present, or future physical or mental health or condition; •the provision of health care to the individual, or, •the past, present, or future payment for the provision of health care to the individual; and, •that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual.

HIPAA

​​•1996: Health Insurance Portability and Accountability Act (HIPPA) established, among other things: -standardization of data, and -regulations on its privacy. •Heightened attention to measures to protect personally identifiable health information (PHI)

Systems in Health Care

​​•Standard office applications such as word processing, spreadsheet management, and e-mail and other administrative tools to enable collaboration •Budget systems to manage expenses and income •Cost accounting systems to model the profit (or loss) of key services/products •Enterprise resource planning (ERP) systems, which include human resource, payroll, accounts payable, materials management, and general ledger functions •Time and attendance, staffing and scheduling, and productivity systems to manage a diverse exempt and nonexempt, and in many health care organizations a 24/7, 365-days-a-year workforce •Marketing systems including customer relationship management (CRM) and typically the organization's website, Facebook and other social media accounts •For those health care entities that are nonprofit, fund-raising systems that play a key role in identifying and managing the contributions of donors

Additional Areas

•E-health: electronic data transfer •mHealth: mobile technologies for health-related activities (look at your phone—there is probably a health app on it!) •Telemedicine & Telehealth: practicing at a distant site •Health informatics, analytics, & big data: aggregating, analyzing, and sharing data trends will inform research and policy.

EMR or EHR?

•Electronic health record (EHR) broader term than EMR •Refers to total health of patient, including immunizations, allergies, medications, etc. •Data in EHR accessible to many, including patient and other health providers.

Continuous Process Improvement

•"A structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations" •Based on process part of Donabedian's definition •TQM/CQI's five dimensions -Process focus -Customer focus -Data-based decision making -Employee empowerment -Organization-wide scope •FOCUS-PDCA

Continuous Process Improvement

•"A structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations" •Based on process part of Donabedian's definition •TQM/CQI's five dimensions -Process focus -Customer focus -Data-based decision making -Employee empowerment -Organization-wide scope •FOCUS-PDCA

Six Sigma

•"Data-driven quality methodology that seeks to eliminate variation from a process" -Six Sigma Performance: <3.4 defects per 1M opportunities •Large HR component -Quality training and personnel -Leadership •DMAIC

The Electronic Medical Record (EMR)

•1991, Institute of Medicine (IOM) concluded computer-based patient record to be an essential technology •2000, IOM report, To Err is Human, emphasized further need to increase the safety of patient care through automation •Clinicians have responded to call for safer care, adoption of EMRs has accelerated •Now we are in the era of optimization.

Management Responsibility to Compliance & Internal Controls

•According to the American Institute of Certified Public Accountants (AICPA), "internal control is a process effected by an entity's board of directors, management, and other personnel designed to provide reasonable assurance regarding the achievement of objectives in the following categories: reliability of financial reporting, effectiveness and efficiency of operations, and compliance with applicable laws and regulations." •Compliance programs are now the responsibility of the board, management and other internal personnel. •The responsibility clearly rests in the hands of management. The AICPA lists five interrelated components of internal control: 1.Control environment sets the tone of an organization. It is the foundation for all other components of internal control, providing discipline and structure. 2.Risk assessment is the entity's identification and analysis of relevant risks to achievement of its objectives, forming a basis for determining how the risks should be managed. 3.Control activities are the policies and procedures to help ensure that management directives are carried out. 4.Information and communication are the identification, capture, and exchange of information in a form and time frame that enable people to carry out their responsibilities. 5.Monitoring is a process that assesses the quality of internal control performances over time.

Importance of Medicaid

•Accounts for 35% of safety-net hospital revenues •Provides 40% of health center revenues •Covers one-fourth of all behavioral health care spending nationally •Pays for nearly 50% of all births in the U.S. •Covers 50% of the costs of long-term care and support of the disabled and elderly

What is EMR?

•An EMR is a computer application that includes: -Clinical data repository -Clinical decision support -Controlled medical vocabulary -Physician order entry -Pharmacy and clinical documentation •Used across inpatient and outpatient areas •Used by all practitioners to document, monitor, and manage health care delivery •Legal record of care for a patient during their encounter at a health services organization (HSO)

Hospital EMR Adoption

•As of Q4 2017, 73% of all U.S. hospitals progressed past stage 4. •Only 6.4% (351) of over 5,487 hospitals have progressed to stage 7. •Slow progress due to: -High cost of systems -Slow development of data standards -User unfriendliness of systems -Patient lack of trust in the ability of the industry to hold their information secure

Some Basic Legal Concepts

•Civil vs criminal laws •Criminal law: a wrong against society as a whole, even if a particular individual is harmed •Civil law: wrongs against a person or organization, either by contract violations or by wrongful acts (torts) •Malpractice can be either civil or criminal •Contract law: four necessary key elements must be met in order for a contract to exist

Uses of Performance Appraisals

•Compare absolute and relative performance of staff •Determine a plan for improving performance for those employees in need of improvement •Determine what additional training and development activities are needed to improve employee performance •Use the findings to clarify employee's interests and desires •Document performance in those cases where termination or re-assignment is necessary •Determine adjustments to compensation based on performance •Determine promotional or other advancement opportunities for the employee

HIT Impact on the Manager

•Complex and quickly evolving work environment •Effective managers must use technology themselves and understand well enough to manage effectiveness of their employees use. •Dependency will create new norms around computer competencies, processes during "downtimes," etc.

Beginning of Meaningful Use

•Concept of "meaningful use" criteria for EHRs focused on achieving five health outcomes policy priorities: 1.Improve quality, safety, and efficiency, and reduce health disparities 2.Engage patients and families in their health 3.Improve care coordination 4.Improve population and public health 5.Ensure adequate privacy and security of patient health information

Barriers to Adoption & Optimization

•Cost to deploy and sustain •Major changes to clinical workflow •Annual maintenance costs •Complex use interface and experience •Interoperability issues •Lack of business education •Lack of change management

cultural proficiency

•Cultural proficiency (as an individual and an organization): -The ability and willingness to respond respectfully and effectively to people of all cultures, classes, races, ages, sexual orientation, ethnic backgrounds, and religions in a manner that values all -Also referred to as: •Cultural intelligence •Cultural competence •Cultural conditioning •Cultural sensitivity •Cultural congruence

DMAIC

•Define: delimit scope of work and time frames for completion •Measure: create and apply measures and metrics •Analyze: assess and flowchart the process •Improve: specify the steps to be taken to meet goals •Control: assure permanence of the improvements

Malpractice

•Defined as negligence or carelessness of a professional person •Under civil law = simple carelessness •Under criminal law = "reckless disregard for the safety of another" •Of concern for health care organizations, to protect patients and the organization itself •Very difficult to prove •Costly and time consuming •All health care professionals need to be aware of malpractice issues. •Numerous protections and checks exist •Need to address in proactive manner

Utilization of the Health Care System by the Uninsured

•Delay seeking care or forgo care altogether, thereby increasing their chances of: -Preventable health problems -Disability -Premature death •Utilize the most expensive access point to the health care system—hospital emergency departments—to obtain care •Do not have a primary care physician

Examples of Health Disparities

•Diabetes -Prevalence: •11.9% in U.S. population •18% in those of Mexican origin •Infant mortality -Infant deaths per 1,000 live births per CDC •4.8 among Whites •11.7 among Blacks •HIV and AIDS -8x rate among Blacks for HIV and 10x rate for AIDS as compared to Whites

summary

•Disproportionate burden of illness and injury among underserved populations •U.S. population and the patient population are becoming more ethnically and racially diverse: will the health care workforce follow suit? •Health care organizations must reflect and support the communities they serve with best practices in cultural proficiency.

The Emergency Medical Treatment and Active Labor Act (EMTALA)

•Enacted in 1986 to prevent patient dumping. •Also known as the "Anti-Dumping Act" •Used to prevent an emergency room from refusing treatment or transferring a patient to another facility because of the patient's inability to pay for treatment. •Mandates a medical screening exam be given to any patient who presents to a provider of emergent or urgent care. •The patient must be treated and discharged or admitted as a patient and transferred from the ER. •To avoid violations, providers should: -Require all clinical, administrative, and contact staff to review and understand the EMTALA requirements and to document this training -Ensure that all patients who have an emergent admission and either refuse or withdraw treatment are offered a medical screening and treatment before they leave the hospital. Refusal of treatment should be documented (informed consent). -Ensure that the ER staff understands all rules regarding transfer of patients to another facility -Enforce the requirement that prevents staff from asking financial and accounting information before the medical screening and stabilizing treatment provided

Federal Response

•Establishment of the Notice of Privacy Practice (NOPP) •While influential on the development and enhancement of HIT, didn't have any immediate impact to increase adoption and reduce other barriers •By 2009, adoption continued to be very slow. •Rising health care costs led the Obama administration to intervene. •Legislation: American Recovery and Reinvestment Act (ARRA) •ARRA includes Health Information Technology (HITECH) Act to increase adoption through use incentives for hospitals and physicians (among other care providers).

History of Laws Relating to Fraud and Abuse

•False Claims Act •Anti-Kickback Statute •Stark Law: Physician Self-Referral •Social Security Act: includes Exclusion Statute and the Civil Monetary Penalties Law •Antitrust laws: Sherman Antitrust Act, the Clayton Act, and the Federal Trade Commission Act •The Emergency Medical Treatment and Active Labor Act (EMTALA)

FOCUS

•Find: identify process problem •Organize: put together a team to work on process •Clarify: use techniques to clarify the problem -Geographic mapping -Flowcharting •Understand: measure and collect data to •Select: identify process improvements for implementation

HIPAA in 2018

•Fines for breaches range from $100 to $50,000 per violation, with a cap of $1.5 million. •HIPAA breaches with criminal intent have penalties up to $250,000 and 10 years' imprisonment.

What is fraud and abuse?

•Fraud is an intentional act of deception. •Abuse consists of improper acts that may be unintentional, but are not consistent with standard practices. •The more common forms are: -False claims -Duplicate billing -Up-coding -Kickbacks for referrals

Benefits of Cultural Proficiency

•Good business practice -Improved patient and provider satisfaction -Climate of inclusion •Good workforce management -Effective communications between staff and patients -Decreased turnover -Enrich the future talent pool -Decreased lawsuits •Ethical and moral imperative •Decreased economic burden on society

Conclusion

•HIT impact of health care/manager increasing •Costs have risen, quality has not kept pace •While many barriers, optimization of clinical systems is increasing •There are models to help, EMRAM & O-EMRAM

Historical Uses of Information Technology

•Health care settings include hospitals, physician practices, nursing homes, home health care, insurance companies •Mainly used for administrative support •To support regulatory requirements such as those defined by JCAHO, CMS, and CAP •Opportunity to reduce costs and increase patient safety and treatment effectiveness has encouraged use in more clinical settings.

Current Research in Human Resources Management

•High-performance work systems and best practices: staff engagement, staff acquisition and development, staff empowerment in decision making, and leadership alignment and development •Involvement of senior human resources professionals in organizational strategic planning •Predictive analytics: large, internal datasets on employee skills, capabilities, and business performance help identify employee needs, ways to better deploy staff, factors affecting employee engagement, and ways to reduce turnover •Link between Human Resource capabilities and quality of patient care (Khatri, Gupta, & Varma, 2017)

Definition

•Human Resources Management (HRM): -Addresses the need to ensure that qualified and motivated personnel are available to staff the business units operated by the health service organization (Hernandez et al., 1998)

Antitrust Issues

•Implemented to protect from the negative effects of monopolies. Three Acts form the basis of the Antitrust law: -Sherman Act: Section 1 prohibits all conspiracies or agreements that restrain trade. -Clayton Act: Section 7 prohibits mergers and acquisitions that may substantially lessen competition "in any line of commerce...in any section of the country." -The Federal Trade Commission (FTC) Act: Section 5 prohibits unfair methods of competition. •The Department of Justice (DOJ) and FTC revised the Statements of Antitrust Enforcement Policy in Health Care in 1996. •Intended to ensure that policies did not interfere with activities that reduce health care costs

Anti-Kickback Act vs Stark Law

•In contrast to the Anti-Kickback Act, Stark Law describes prohibited conduct explicitly. •Unlike the Anti-Kickback Act, Stark Law is a strict liability statute that does not require proof of intent, nor does it have regulatory safe harbors that give rise to gray areas.

Elements of a Contract

•In order for a contract to be binding, it must include all of the following: 1. The agreement must made between two or more parties. 2. Both parties must be competent to consent. •Competency must be in terms of both age and mental capacity. 3. Agreement must be for something of value. 4. The agreement must be lawful.

Health Insurance Total Cost of Premiums, 2018

•Individual Coverage -$6,896: All plans -$6,869: HMOs -$7,149: PPOs -$7,048: POSs -$6,459: HDHP/SO ​​•Family Coverage -$19,616: All plans -$19,445: HMOs -$20,324: PPOs -$19,216: POSs -$18,602: HDHP/SO

provider rights

•Providers have the right to: •Be treated with fairness and dignity by their employers •Be protected from sexual or other types of harassment, including racist comments, •Generally be able to excuse themselves from patient care with which they disagree (although this is under litigation at present)

Definition of Quality

•Institute of Medicine -"degree to which health services for individuals or populations increase the likelihood of desired health outcomes and are consistent with the current professional knowledge" •Donabedian conception of quality as: -Structure: quality personnel and facilities -Process: quality processes both in management and production of health care -Outcomes: quality resulting from the application of structural and process variables •Donabedian's four parts -Technical management -Interpersonal relationships -Amenities of care -Ethical principles guiding care •Two quality questions -Are the right things done? (effectiveness) -Are things done right? (efficiency)

Definition of Quality

•Institute of Medicine -"degree to which health services for individuals or populations increase the likelihood of desired health outcomes and are consistent with the current professional knowledge" •Donabedian conception of quality as: -Structure: quality personnel and facilities -Process: quality processes both in management and production of health care -Outcomes: quality resulting from the application of structural and process variables •Donabedian's four parts -Technical management -Interpersonal relationships -Amenities of care -Ethical principles guiding care •Two quality questions -Are the right things done? (effectiveness) -Are things done right? (efficiency)

Potential Confounders

•Interoperability •Optimizing existing vs. replacing EHRs •Data integrity •Promoting patient safety •Cybersecurity •Cloud-based Systems and Bring Your Own Device (BYOD) •Passive and active use of the EHR

Change Management

•Lewin's basic change model -Change in three steps (CATS) •Unfreeze •Change •Freeze -Understanding the forces driving and resisting change •Force field analysis

Characteristics of the Uninsured, 2017

•Most of the uninsured were between 19 and 64 years old •25% were 26-34 years old •20% were aged 34-44 •Over 50% were male •4 in 10 were non-Hispanic white •Other races made up the majority of the remaining uninsured folks •14% were younger than 19 years of age •1.4% were age 65 or older •Most of the uninsured had a high school education or less •The uninsured were disproportionately more likely to live in poverty •1 in 3 worked in a service occupation

Physician EMR Adoption

•Most patient care in the U.S. occurs in the physician offices. •Of all care settings - they have the LEAST amount of automation due to the previously defined barriers to adoption. •98.6% hospitals have "some" form of an EMR; 67.9% of physician practices have EMR. •Larger practices with more staff adopt more quickly due to more resources. Exceptions are growing where adoption and use leading to better outcomes has begun

PHI Breach Notification & Enforcement

•Must consider the following factors: -Nature and extent of PHI involved -To whom the PHI may have been disclosed -Whether that PHI was actually acquired or viewed -The extent to which the risk to the PHI has been mitigated (for example, assurances from recipient that information has been destroyed or will not be further used or disclosed) (APA Practice Organization, 2013).

Negligence

•Must have the following four elements: 1. Negligent party must have a duty toward the harmed party 2. Breach of duty must have occurred 3. Proof of injury or damages • These do not have to be monetary 4. Proof of causation

Patient Responsibilities

•Patient responsibilities include; •Understand and consent to care •Ask relevant questions of their care providers •Provide accurate information (including insurance information, medications, etc.) •Comply with doctor's directives and prescriptions

Sources of Ethics

•Personal/Individual •Family upbringing •Religion •Communities (ethnic, residential, national) •Professions (with codes, traditions, practices) •Organizational •Public/Private •For profit/nonprofit •Religious/nonsectarian •Theoretical (moral philosophies) -Examples: •Utilitarianism, Deontology, Natural Law, Hybrid philosophies (i.e., Rawls) •Bioethic

Examples: Bioethical Concerns

•Physician-patient relationship •Allocation of scare resources •Genetics •Transplantation •Beginning- and end-of-life care •Human subjects of biomedical & behavioral research

PDCA

•Plan: create an implementation plan for taking the process to the next level •Do: implement and test the new process •Check: evaluate the measures used and assess outcomes •Act: assure continuation of newly implemented process, if successful, or redo the process, if not successful

Problems with EHRs

•Poor design •Poor usability •Time-consuming data entry •Interference with face-to-face patient care •Inefficient and less fulfilling work content •Lack of interoperability

Future of Health Information Technology (HIT)

•Portability: EMR in your pocket. •There's an app for that! •Virtual health care: be "seen" without need for physical exam •Future uses of technology in health care include: -Patients wearing computers to regulate and/or monitor (smart vests) -Embedded microchips •Systems improvements for complex information

Provider Responsibilities

•Primary responsibility/duty is to avoid harming patients and improve patient situation. •Notion of "duty" is critical - flows from: •Provider's training •Professional oath •Existence of a relationship (contractual or implied) •Health care organizations' responsibilities are informed by federal and state laws, including EMTALA (Emergency Medical Treatment and Active Labor Act) of 1985 -Requires that hospitals participating in Medicare provide screening examinations and treatment in their emergency departments unless they can prove that a patient requested a transfer and/or that hospital cannot provide the necessary care for the patient's condition -Not exclusive to hospitals, but there is debate about what type of organizations EMTALA applies to. ​​•Fiduciary duty: people or organizations have an obligation to those who have placed their trust in them. -Health care organization, Board of Trustees, and staff are in a position of relative power to patient. •Health care organizations also have responsibility towards employees and attending staff to be treated fairly and with dignity. •Individual providers responsibilities involve abiding by requirements of their licenses and living up to standards of their professions, including: - Protecting patient information - Providing best quality of care - Serving as advocates for their patients - Up-to-date training - Reporting unethical behavior

Evolution of the Automation of Health Care

•Repetitive workloads lend themselves to automation: -Filling prescriptions -Resulting laboratory tests -Completing radiology images •Initial automation was in each clinical area and not "hooked" together or integrated. •Primary caregivers did not use computers as part of their daily routines. •Systems too cumbersome and time consuming •Medical devices are more sophisticated •Robotic use has increased, e.g., pharmacy robots that fill prescriptions. •Unification of medical devices and information systems •Systems more prevalent in the clinical setting •Health care managers will need to use these new systems in their daily routine.

Business Associate Agreements

•Requirements of the law are extended to include all groups that hospitals or other covered entities do business with, as well as to the subcontractors with whom those associates do business. •Contracts with business associates and sub-contractors must address HIPAA requirements.

Central Principles/Ethical Concepts

•Respect for persons -Autonomy, truth-telling, confidentiality, fidelity •Beneficence •Nonmaleficence (do no harm) •Justice -Philosophical -Issue of fairness

Solutions?

•Scribes: people trained in medical terminology and pathophysiology who make notes on EHR while physician speaks with the patient •Better training and more intuitive systems: difficulty using EHR decreases productivity, increasing provider frustration with hassle factor

Medicaid Program Characteristics: Funding

•Second-largest social health insurance program •Jointly funded by federal and state governments -Federal share = 50-77% of costs -State share = 23-50% of costs •"Bare bones" programs •"Rich" programs: offer extensive expanded eligibility and benefits •Program expansion was a major provision of the ACA, with 100% federal funding through 2016 and 90% through 2020 •Enrollment now at approximately 76 million people

Medicaid Program Characteristics: Benefits

•Services mandated by federal legislation: -Inpatient hospital stays -Outpatient hospital services -Physician services -Lab and x-ray -Nursing facilities -Home health services -EPSDT •Services added at a state's discretion: -Dental care -Mental health care -Drug and alcohol treatment -Rehabilitation -Preventive care -Prescription drugs -Prostheses

Meaningful Use vs. EMRAM

•Stages of Meaningful Use -Stage 1, 2011-2012: data capture and sharing -Stage 2, 2014: advance clinical processes -Stage 3, 2016: improve outcomes •EMRAM vs. Meaningful Use Stage 4 = Stage 1 Stage 6 = Stage 2 Stage 7 = Stage 3 •Physicians push back and resistance •AMA/AHA call for changing adoption time frames •Issues remain unresolved

Impact of the ACA on the Uninsured

•States that expanded Medicaid had an uninsured rate of 6.5% in 2017. •States that did not expand their Medicaid programs had a 12.2% uninsured rate. •Those covered have included young adults younger than age 26, who could stay on their parents' insurance policies. •28.5 million people were still uninsured in 2017.

HR Includes Activities That Are

•Strategic -Compete for labor and want to have an adequate supply and the proper mix of high quality staff -HSO staff ("talent") should be viewed as a "strategic asset" to gain competitive advantage -Organizational performance depends on individual performance •Administrative -There are a number of administrative functions and action steps carried out in support of the human resources of the HSO to ensure high levels of performance. Employees as Drivers of Performance

False Claims Act

•The False Claims Act (FCA) was enacted in 1863 as the federal government's primary civil remedy against fraudulent claims for payment. •In 1986, the first major amendments were added to the FCA. •Removed the requirement that there be specific intent to defraud the federal government •Government need only show that the claim submitted is false and submitted knowingly. -The US Supreme Court ruled in 2000 that government-owned health care providers were exempt from damage under the FCA. This acts as a shield for them. •Added the qui tam provision: a private citizen also known as a "whistle blower" or a "relator" can bring suit against fraudulent parties, on behalf of federal government, in exchange for share of the recovered funds •Between 1986 and 2017, the federal government recovered more than $56 billion under the FCA. •In 2017 alone, $3.7 billion was recovered under the FCA.

Corporate Compliance Programs

•The HHS OIG strongly recommends the adoption of a corporate compliance plan, as it helps limit the risk of compliance errors and limits the liability of management and directors. •An effective program can also limit liability under the Federal Sentencing Guidelines. •Most importantly, an effective corporate compliance plan gives employees the guidelines necessary to follow the laws and allows management to know that the laws are being followed. •The OIG has published a list of essential elements of an effective compliance program.

Introduction

•The fundamental principle underlying health care regulation is the social contract between the general public and health care professionals. •Each regulation was developed in response to bad actors exploiting the health care system. •The landscape of regulation is always shifting to keep up with clever bad actors that find new and innovative ways to cheat the system. •Agencies at federal, state, and local levels create rules to protect the public and promote health, including the following: -Centers for Medicare and Medicaid Services -Food and Drug Administration -Health Resources and Services Administration -Centers for Disease Control and Prevention -Indian Health Service -National Institutes of Health -Office of the Secretary of Health -Public Health Service -Substance Abuse and Mental Health Services Administration -Office of Civil Rights •Main focus here on federal regulations. •State and local governments often have parallel laws and agency regulations. •Three federal agencies do most of enforcement: -The Department of Justice -The Department of Health and Human Services, Office of Inspector General -Centers for Medicare and Medicaid Services •Processes for fighting regulatory noncompliance: -Recovery Audit Contractors find and recover improper Medicare payments. -Health Care Fraud Prevention and Enforcement Action Team (HEAT) is collaboration among agencies. -Affordable Care Act (2010) provides additional funding to fight fraud and abuse. •Focus now is on prevention, rather than trying to detect it and punish after the fact.

Anti-Kickback Statute

•This is the law of choice for federal enforcement authorities. •Imposes criminal liability for the knowing and willful payment, solicitation, or receipt of remuneration in return for referring an individual to a person for, or in return for purchasing, leasing, ordering, arranging for, or recommending the purchase, lease, or order of items or services reimbursable by the federal health care program •HHS OIG has issued narrow regulatory "safe harbors" that the OIG deems harmless and as such, "shall not be treated as criminal offense ... and shall not be used as a basis for exclusion" from the federal health care programs. Activities outside of these safe harbors are not necessarily illegal, but it is often unclear at what point conduct crosses the line between a legitimate practice and a violation of the Anti-Kickback Act. ​​•Legislation has broadened the Act's reach to encompass ALL federal health care programs •Penalties include: -Criminal penalties: up to $25,000 fine per claim plus 5-year prison term -Civil penalties: up to $74,792 (in 2017) per kickback plus three times the amount of the kickback -Exclusion from participation in federal health care programs

tort law

•Tort law plays an important role in the delivery of health services. •Types of tort law relevant to health care -Negligence: generally unintentional •Commission or omission -Intentional torts: deliberate act •Assault and battery •False imprisonment, etc. -Infliction of mental distress

From Meaningful Use to MIPS

•Under MU, providers expected to progress through three stages of development, over the following 5 period: •2011-2012, Stage 1: data capture and sharing •2014, Stage 2: advance clinical processes •2016, Stage 3: improved outcomes (HealthIT, 2015). •Merit-Based Incentive Program (MIPS) •Process evolved from defining goals of utilizing EHRs to optimizing EHRs •MIPS has four pillars that are weighted -Quality (50%) -Advancing care information (25%) -Improvement activities (15%) -Cost (10%)

Why is Quality Important?

•Underuse: failure to provide a service whose benefit is greater than its risk -54.9% of patients receive recommended care •Overuse: use of service when risk outweighs its benefits -Uncritical use of antibiotics, especially in consumer products •Misuse: risk service is provided badly reducing benefit to patient

Why is Quality Important?

•Underuse: failure to provide a service whose benefit is greater than its risk -54.9% of patients receive recommended care •Overuse: use of service when risk outweighs its benefits -Uncritical use of antibiotics, especially in consumer products •Misuse: risk service is provided badly reducing benefit to patient -Medical errors, medication errors

Definitions

•Vulnerable populations: groups of people not well integrated into the health care system. •Medically Underserved Areas and Populations (MUA/Ps): identify geographic areas and populations with a lack of access to primary care services (HRSA, 2016). •Medically Underserved Areas (MUAs) have a shortage of primary care health services for residents within a geographic area (HRSA, 2016). •Medically Underserved Populations (MUPs) are specific sub-groups of people living in a defined geographic area with a shortage of primary care health services (HRSA, 2016). •Health disparities: "differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States" (NIH, 2010b, para.1). •Priority populations (for research): women; children; racial and ethnic minorities; the elderly; low-income, inner-city, and rural people; and those with special health care needs, such as those who have disabilities, need chronic care, or need end-of-life health care. •Health inequities: avoidable inequalities in health between groups of people within countries and between countries. These inequities arise from inequalities within and between societies. Social and economic conditions and their effects on people's lives determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs (World Health Organization, 2008).

Cultural Proficiency Initiatives

•Workforce diversity and career development •Supportive leadership and culture •Appropriate human resources policies •Assessment on individual and organizational levels •Education and training •Multilingual services and support materials: CLAS •Evaluation and research: data analytics •Eliminate structural barriers •Community outreach and engagement •Public policies