Final Exam SG
standing committees for medical staff
Ethics, Credentials, Pharmacy and Therapeutics, Utilization and Documentation Standards, Environmental Safety, Departmental
Certification
Grants approval for an organization to provide services to a specific group of beneficiaries
Phases of Project Developmen
Initiation, planning, execution, closure
Elements of prescription label
Legal document that must contain patients name, address and age (if significant), Prescriber's name, address & id, Date, Name/amount of drug, Dosage, route, Directions for taking, Permission for additional quantities
Critical path
Longest time it would take to finish a project, used for project planning and tracking
Licensed
Permission to provide services of a defined scope in a limited geographic area
Data used for?
Process Improvement
6 Elements of Healthcare (IOM)
STEPEE (safe, timely, efficient, patient centered, effective, equitable)
Sentinel Event Reporting
Submit root cause analysis within 45 days of becoming aware of the event; Grace period of 30 days; accreditation status is changed to provisional; not done with in 60 days after due date, accreditation status is changed to conditional; After 90 days, denial of accreditation
adverse event
a negative consequence of care that results in unintended injury or illness that may or may not have been preventable
trends of line charts
a run of points going up or down
shifts of line charts
a sudden shift in a different direction
Ordinal
aka called ranked data, it expresses the comparative evaluation of various characteristics or entities and relative assignment of each, to a class according to set of criteria. (Examples: likert scales; best displayed on bar or pie charts)
Denial of Accreditation
all available appeal procedures have been exhausted and the org is denied accreditation
Sentinel Event
an unexpected occurrence involving death, serious physical injury, psychological injury or the risk there of (loss of limb or function)
Root-Cause Analysis
analysis of a sentinel event from all aspects to identify how each contributed to the event sustained in a healthcare facility
Force-field analysis
analysis of forces in favor of change and forces that resist change as they work against each other
measures of access (HEDIS)
at least one visit to provider in 3 years
Mean
average
Histogram
bar chart for continuous data
Pareto chart
bar chart that displays data in descending frequency w/ line
conclude post-discharge planning
case manager conveys information on the patient's course of treatment to the clinicians that will continue the patients care
perform care planning at the time of admission
case manager reviews all information gathered by clinicians assigned to confirm patient meets admission criteria; critical pathway is assigned
qualitative analysis
categorical usually
Rapid Cycle Testing/Improvement
changes made and tested in 3 months rather than normal 8-12
Bar Chart
compare relative size of data
measures of financial performance (HEDIS)
cost per member plus dependents
Discrete
count; numerical values that represent whole numbers (best displayed in bar graphs
measure of membership (HEDIS)
coverage cancellation as indicator of dissatisfaction
Severity of Illness
criterion based on patient's condition used to screen patients for appropriate care setting
Intensity of Service
criterion consisting primarily of monitoring and diagnostic assessments, that must be met in order to quality a patient for inpatient admission (above severity of illness)
Initiation
determination of gap b/w org performance and expected outcomes; then they identify opportunities for improvement; includes defining objectives/scope, group selection, vision and mission statement
National Patient Safety Goals
developed by the joint commission; all institutes participating in accreditation must promote and train their staff members who provide care to adherence of the NPSGs
4 basic elements of negligence/malpractice
duty of use due care; breach of duty; damages; causation
Peer Review
evaluation of work by others in same field
pivot table
flexible means to organize and filter data
Tracer Methodology
follows patients through their path of care at an organization to assess compliance standards
Spaghetti Diagram
for flow
scatter diagram
helps find correlations
measures of utilization (HEDIS)
high-occurrence, high-cost and DRGs; frequency of procedures, etc.
Planning
identification of final system requirements/criteria that set standards for measuring success; includes: identification of task and length, schedule and cost elements, perform tasks, track progress, develop training/implementation plan
Data Collection Objectives
identify purpose of data management activity (monitoring at regular intervals, one time study or investigation over limited time period); identify appropriate data sources; identify most important measures to collect; design common sense collection strategy (gives complete, accurate and timely information)
measures of quality (HEDIS)
immunizations, screening tests
Nominal
Categorical; Includes values assigned to name-specific categories (usually displayed on bar or pie charts)
Breach of Duty
in malpractice action, the issue is whether a physician exercised a standard of care that a reasonably prudent physician would have exercised under those circumstances; failure to exercise due care
in what phase are teams formed for project development?
initiation stage
Execution
installation of equipment/construction + policies/procedure manuals prepared for distribution; includes presenting recommendations to leadership, executing implementation plan, training, tracking/monitoring, project revision
ORYX Initiative
joint commission initiative in 1997; it was mandated by the joint commission and CMS to require healthcare organizations to collect performance data on high risk procedures and occurrences (pneumonia measures, heart failure, etc) so they can review and compare data trends and patterns to help improve patient care processes
Number of defects for 6 Sigma
less than 3.4 per million
control chart
line chart with upper and lower limits
Formulary
list of drugs approved for use in a healthcare org; selection of items to be included in a formulary is based on object eval of their relative therapeutic merits, safety, and cost; if accredited by the JC, then maintain the formulary for a medications continued safety and efficacy
National Practitioner Databank
maintains reports on medical malpractice settlements, clinical privilege actions, and professional society membership actions against licensed healthcare providers
Median
middle number impacted by skew whole set is taken into account
Causation
must be a connection between the breach of duty and the damage - evidence that the failure to exercise due care or breach caused the damage
Why collect data
needed to identify and address QI issue
Harmonious Cohesiveness
norming stages where they all begin to communicate and collaborate
absolute frequency
number of times a value appears in a data set
quantitative
numeric
Contingent Accreditation
org didn't meet all of JC standards @ time of on-site survey and had a standard of noncompliance higher than published levels of that year; they can appeal the accreditation
JC - Accredited
org is in compliance w/ standards @ time of on-site surveyor addressed all RFIs within 45 or 60 days
Accreditation with Follow up survey
org is not compliant with specific standards and requires follow-up survey within 30 days to 6 months; org must address problem areas
Cautious Affiliation
overly polite team members as they get to know each other
Damages
patient must show that actual harm or damage occurred
relative frequency
percentage of time a value appears in a data set
Radar Chart
performance measures for time interval w/ performance expectations
conduct discharge planning
performs final discharge planning and continued care post discharge
review the progress of care
periodic review of the patient's progress
pre-admission care planning
physician contacts a healthcare org to schedule an episode of care service; case manager reviews projected patient needs w/ physician; admission criteria established
Case Management
pre-admission, admission, review, discharge
Kaizen Blitz
process improvement in a workshop environment
Medication Reconciliation
process of identifying the most accurate list of all medications a patient is currently taking and then comparing the list against the physician's admission/transfer/ discharge orders at each transition point along the patient's continuum of care
Closure
project becomes part of organization operations; includes final report, celebration of success, and continual improvement
physician profile
provides credentialing committee w/ significant data about specific physicians scheduled for reappointment to the medical staff
Uses of HEDIS
quality measure, access measure, membership measure, utilization measure, financial performance measure, longterm care MDS
Rights to patients
right patient, right medication, right dose/ time, right route, and right to refuse
Incident Report
risk manager's principle tool for capturing the facts about potentially compensable events
Line chart
shows progress of process over time
Pie chart
shows relationship of part to whole
Preliminary Denial of Accreditation
significant noncompliance w/ JC standards in multiple areas and RFIs higher than published levels; they can appeal
This quality improvement methodology uses statistics for measuring variation in a process with the intent of producing error-free results?
six sigma
standard deviation
spread of values (most often +/- 2)
Failure Mode and Effect Analysis (FMEA)
technique that promotes systems thinking; includes defining high risk processes using flow charts; proactive tool to analyze potential problems when introducing new systems or equipment; identifies most important areas for process improvement
validity
the extent to which an empirical measure accurately reflects the meaning of the concept under consideration
what is done when a specific drug that a patient need sis not on the formulary?
the patient will very likely have more out-of-pocket costs in order to be able to the medication their doctor recommends
Consideration of data collection
time and cost
Drug Diversion
transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for illicit use
skewing
very high/low values distort calculated means
Accreditation
voluntary validation of achieving set standards- required to see CMS patients
Competitiveness
where conflict emerges and leader needs to help them thru it
Collaborative Teamwork
where they are effectively collaborating and users and group norms
reliability
whether a particular technique applied repeatedly to the same object yields the same results each time
cycling in line charts
zig zag pattern of up and down movement
what agencies are lab services regulated by?
CDC and CLIA (clincal laboratory improvement amendments)
Order for force-field analysis
1. Define the problem 2. Define the change objective 3. Identify driving forces 4. Identify restraining forces 5. Develop comprehensive change strategy
Reappointment of Medical Staff
2 years
JC Rec for Population size
<30 = 100% 30-150 = 30 cases 151-595 = 20% >596 = 120/20%
Duty to Use Due Care
A relationship must have been established between the parties in which one party has an obligation, or duty, to act as a reasonably prudent person would act toward the other. This duty exists in a physician's relationship with his or her patients. Using due care is acting as a reasonably prudent person would act under a given set of circumstances.
Deemed Status
Accreditation by one organization is equal to accreditation by another (JC accreditation = Medicare Accreditation)
Continuous
Assume an infinite number of possible values in measurements that have decimal values as possibilities (best displayed in histograms or line charts)
infection control
The process of preventing the spread of communicable disease in compliance w/ applicable legal requirements is performed in this quality management function
