Health Quality & Info Management

CARF Survey Process

-Opening Conference -Document Review -Interviews with program staff and patients -Exit interview with organization leaders

The Joint Commission Survey Process

-Opening Conference -Tailor onsite activities -Visit of Patient care settings -Conduct leadership interviews -Review of system tracers deficienies -exit conference

Accreditation of Psychiatric and Rehabilitate Care:CARF

-Three surveyors -Flexible survey process -Tailored to patient care services and community of interest of the organization

Basic elements of negligence or malpractice

-duty to use due care -breach of duty -damages -causation

Business life cycle

1. acquire data 2. clean the data 3. analyze the data 4. identify problems and opportunities 5. API

Legislation that addresses disabilities?

ADA: the American Disabilities Act of 1990

Legislation that addresses wages and hours?

EEOA: the Equal Employment Opportunity Act of 1972

Legislation that addresses medical leave?

FMLA: the Family Medical Leave Act of 1993

great risk

Failure to meet expected performance standards creates

Certification

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

tort of negligence

In healthcare, them most common tort is_________also referred to as malpractice

Healthcare organization are required by law to query what to obtain information on applicants requesting clinical privileges.

National Practitioner Data Bank (NPDB)

Legislation that addresses safe working conditions?

OSHA: the Occupational Safety and Health Act of 1970

Compulsory Reviews

Performed to fulfill legal or licensure requirements

Structured Interview

Structuredis conducted using a set of standard questions that are asked of all job applicants to gather comparative data

Licensure

The act of granting a healthcare organization or an individual healthcare provider permission to provide services of a defined scope in a limited geographical area.

Accreditation

The act of granting approval to a healthcare organization

Who is responsible for Disclosing Adverse Events to the Patient and Family?

The doctor

Tort Law

a wrongful act committed against a person or a piece of property

Information warehouses

allow organizations to store reports, presentations, profiles, and graphics interpreted and developed from stores of data for reuse

information warehouses

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

Information Governance (IG)

an organization -wide framework for managing information through-out its lifecycle and supporting the organization strategy , operations, regulatory , legal, risk, and environmental requirements

Credentials

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

peer review committee

can review specific incident through occurrence report and sentinel event

Voluntary Reviews

conducted at the request of the healthcare facility seeking accreditation

causation

connection between breach of duty and the damage evidence that the failure to exercise due care, or breach, caused the damage

PI models are based on?

continuous monitoring and assessment of performance measures

The process by which facts are gathered

data collection

Breach of Duty

did the physician exercise a standard or care that a reasonably prudent physician would have exercised under those same circumstances

Most organizations define their clinical staffing needs into what two categories?

direct and indirect caregivers

Peer review protection

discussion, deliberations, records and proceedings of medical staff committees having responsibility for the evaluation and improvement of quality shall be kept confidential and shall not be subject to disclosure outside of them medical staff process

Accountability measures

ensure quality patient outcomes

immunity from liability

federal health care quality improvement act (HCQIA) of 1986 - designed to make the peer review process more effective by reducing the fear of legal liability on the part of participants

what tools are used show trends overtime, find meaningful information, and better organize data

flowcharts, fishbones, diagrams and dashboards

Comparative performance data

internal and external benchmarking, the joint commission core measures

Licensed independent practitioner

is any individual permitted by law to provide healthcare services without direction or supervision, within the scope of the individual's license as conferred by state regulatory agencies and consistent with individually granted clinical privileges.

Compliance

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

Intranet-based communication technologies

keep everyone in the organization apprised of the current status of PI projects

PI initiative

one purpose is to develop the best possible clinical practices.

Clinical Privileges

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

Credentialing process

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

Data repository

provide PI activities with timely data and information that can be used to continuously monitor the quality of care

Malpractice

providers or hospitals are sued for being careless and thereby causing an injury to the patient

Due Process

provides for fair treatment through a hearing procedure that is generally outlined in the healthcare organization's medical staff by laws.

Information resources management professionals

recognize the important resources already developed within the organization

What kind of interviews can be held to screen applicants?

structured, unstructured and stress

Business intelligence (BI)

the end product or goal of knowledge management as part of an organization information governance adoption model of analytics competency.

Data Governance (DG)

the sub-domain of IG that provides for the design and execution of data needs planning and data quality assurance in concert with the strategic information needs of organization.

How many data collection tools are there?

three

non accountability measures

used for secondary measures (exploration, learning from other healthcare organizations, and setting terms for patient care

Unstructured Interview

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 freely. Ex: Tell us about your previous position.

Stress Interview

uses specific questions to determine how the interviewee responds under pressure. Ex: If an attorney came to your nursing unit and wanted to review her client's health record, what would you do?

Examples of administrative data

which users entered data, which access terminal was used, and the date and time of entry

What are the three data collection tools?

· Patient Specific- pertains to the care services provided to each patient · Aggregated- Summarizes the experiences of many patients regarding a set of aspects of their care · Comparative- Uses aggregate data to describe the experiences of unique types of patients with one or more aspects of their care.

accountability measures

· Research-strong scientific evidence exists demonstrating that compliance with a given process of care improves health outcomes · Proximity- the process 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 accurately assesses whether the evidence- based process has been provided Adverse effects- The measure construct is designed to minimize or eliminate unintended adverse effects

The Joint Commission Accreditation

• Composition of survey team varies depending on the size of the organization o Physician o Administrator o Registered nurse o Other masters-level clinicians o State licensing agency representative o Expert in environment of care and life safety issues o Length of the survey process also depends of the size of the organization (approximately three days)

Meeting Multiple Standards and Regulations

• Continuously review organization operating policies and procedures to make sure they reflect ongoing changes to accreditation standards and federal and state regulations • The most stringent standard or regulation on each aspect of care should be identified and policies and procedures based on that standard or regulation

Surviving the Survey Process

• Preparation for accreditation and licensure processes cannot be accomplished a few weeks before the organization is due for review. • A solid accreditation and licensure infrastructure must be built and maintained so that the organization is ready for an inspection at any time. • Some are scheduled, others are unannounced. CMS accepts accreditation by organizations with deeming authority in granting what it calls deemed status • Surveyors want to be assured that the facility's leadership and staff o Can successfully execute organizational policies and procedures o Are continuously monitoring and improving performance in the organization and that those improvements are tied to the organization's strategic plan • No standard review process o Voluntary processes are more flexible and tailored to the organization o Governmental processes tend to be more bureaucratic

Long-Term Care Survey Process

• Public notice of survey on door of facility and all nursing stations • Examination of facility operations o Resident's council members interviewed o Ancillary departments are visited o Nursing units o Resident records reviewed • Closing meeting with administrators and director of nursing to summarize findings

What are the standard setting bodies?

• The Joint Commission • DNV-GL Healthcare Accreditation • Commission on Accreditation of Rehabilitation Facilities (CARF) • American Osteopathic Association (AOA) • National Committee for Quality Assurance (NCQA) • Accreditation Association for Ambulatory Health Care (AAAHC) • CMS Conditions of Participation • State Licensure

Conditions of Participation

• Unannounced surveys • Survey team drops in on an annual basis or in response to complaints from patients or employees • Surveyors usually from state department of health, however one to two Medicare officials from the regional office may be present • Process similar to state licensure surveys

The Joint Commission Accreditation

• Unannounced surveys • Surveyors will come with knowledge of the organization o Midpoint assessment action plan o Any consumer complaints o Previous accreditation data o Core measure data

Certification and Licensure of Long-Term Care Facilities

• Usually unscheduled reviews • Two surveyors who come from nursing, pharmacy, dietetic, or clinical laboratory background • Look for evidence of three trigger issues o Excessive percentage of patients suffering from dehydration o Decubitus ulcers in low-risk residents o Fecal impaction • "Trigger" issues are based on the facility quality indicator profile