Health Information Management Technology: An applied Approach 4th ed. Chapter 10 – Content

discharge abstract system
relevant coded data abstracted from the patient’s medical records and placed in database
What is the key to improvement
measurement – the key to improvement lay in the measurement of the important characteristics of their practice
performance
the execution of an activity or pattern of behavior; the application of inherent or learned capabilities to complete a process according to prescribed specifications or standards.
How is performance measured?
Using one or more performance indicators. Ex: performance can be measured against financial indicators, such as the average cost per laboratory test, or productivity indicators, such as the number of patients seen per physician per day. What is IMPORTANT is to measure the aspects of performance that really reflect quality and that point conclusively to the aspects of performance that require improvement.
Performance Improvement (PI)
process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations. aka Continous quality improvement CQI and total quality management TQM.
What is the key feature of performance improvement in today’s healthcare organizations?
it is a continuous cycle of measurement, analysis, monitoring, planning, designing, and evaluating. Performance monitoring is data driven.
Identifying areas to monitor
includes important organizational functions, particularly those that are high-risk, high-volume, or problem-prone. Outcomes of care, customer feedback and the requirements of regulatory agencies are additional areas that organizations consider when prioritizing performance measures.
Performance improvement process
1 Identify performance measures
2 Measure performance
3. Analyze and compare internal/external data
4. Identify improvement opportunity
5. Perform ongoing monitoring
Identification of performance measures:
for each service, process, or outcome determined important to track.
performance measure
is a quantitative tool (rate, ratio, index, percentage) that provides an indication of an organization’s performance in relation to a specific process or outcome.
Performance Measurement System required by the Joint Commission for use in accreditation processes
the sum total of performance measures selected as applicable to a healthcare organization.
Outcome required to be continuously monitored by hospitals:
monthly delinquent health record rate. To determine rate: # of incomplete health records that exceed the medical staff-established time frame for record completion/Average monthly discharges
The Joint Commission – delinquent health records:
will cite the healthcare organization with a requirement for improvement if the total average health record delinquency exceeds 50 percent of the average monthly discharges in any one quarter.
Donabedian proposed 3 types of quality indicators
1 Structure indicators: measure the attributes of the setting, such as number and qualifications of the staff, adequacy of equipment and facilities, and adequacy of organizational policies and procedures.
2 Process indicators: measures the actions by which services are provided, the things people or devices do, from conducting appropriate tests, to making a diagnosis, to actually carrying out a treatment.
3 Outcome indicators: measure the actual results of care for patients and populations, including patient and family satisfaction.
External customers
those people outside the organization for whom it provides services: patients, physicians, and third-party payers.
Internal customers
employees
Dashboards and scorecards
tool that present metrics from a variety of quality aspects in one concise report such as: infection rates, financial quality, volume, and patient satisfaction.
What is the primary focus of PI efforts?
the customers
Which of the following provide process measure metrics in a precise format?
Dashboard
The focus of performance improvement should be on:
Customers
Fifty percent of our HIM staff have a nationally recognized credential. This is an example of what type of indicator?
Structured
True or False: Performance monitoring is outcomes driven
False
True or False: Performance improvement is something that is done periodically
False
True or False: An outcome indicator measures results of care provided to the patient
True
Fundamental Principles of Continuous Performance Improvement: (9)
1. The structure of a system determines its performance. Therefore, problems are more often within systems than within individual people.
2. All systems demonstrate variation. Some variation occurs because of common causes and some because of special causes.
3.Improvements rely on the collection and analysis of data that increase knowledge.
4. PI requires the commitment and support of top administration
5. PI works best when leaders and employees know and share the organization’s mission, vision, and values
6. PI efforts take time and require a big investment in people
7. Excellent teamwork is essential
8. Communication must be open, honest, and multidirectional
9. Success must be celebrated to encourage more success.
The problem is usually?
the system. problems in patient care and other areas of the healthcare organization are usually symptoms of shortcomings inherent in a system or a process.
Variations within the system: common-cause variation
ex: when a nurse takes a patient’s blood pressure, she may believe that she is performing the procedure in exactly the same way every time, but she will get slightly different readings each time.
Variations caused outside the system: special-cause variation
If the special cause produces a negative effect, we will want to identify the special cause and eliminate it. If a positive effect we will reinforce it. ex: before blood pressure test, patient is upset about phone call resulting in his blood pressure being too high
Data must support PI activities and decisions:
best method for obtaining timely, accurate, and relevant data.
Nothing can happen or improve without:
effective communication
benchmark
a systematic comparison of one organization’s measured characteristics with those of another similar organization or with regional or national standards.
checksheet
a data collection tool that records and compiles observations or occurrences. Has a list of activities, or issues, or categories on one side and a place to check on the other when they have been observed.
data abstracts
frequently used in healthcare, either paper based or computer based facts taken from the patients records..
time ladders
support the collection of data that must be oriented by time.
Run chart
displays data points over a period of time to provide information about performance. Measured points of a process are plotted on a graph at regular time intervals to help team members see whether there are substantial changes in the numbers over time.
Statistical process chart
very much like a run chart except that it has lines drawn at the top and bottom. The upper line represents the upper control limit (UCL) and the lower line represents the lower control limit (LCL)
stable
predictable and within the bounds of probability
Which tool is used to display performance data over time?
Run Chart
The nosocomial infection rate for our hospital is 0.2% while the rate at a similar hospital across town is 0.3%. This is an example of:
Benchmark
The type of variation that is caused by factors outside a system is called:
special-cause variation
True or False: Goals should be measurable
True
True or False: Effective communication is the responsibility of administration only.
False
True or False: A checksheet is used to record and complete observations and occurrences
True
Team based performance improvement processes – success depends on 7 elements:
1 establishing ground rules
2 Stating the team’s purpose or mission
3 Identifying customers and their requirements
4 Documenting current processes and identifying barriers
5 Collecting and analyzing data
6 Identifying possible solutions by brainstorming or using other PI techniques
7 Making recommendations for changes in the process
Establishing ground rules (5)
1 to arrive on time for meetings
2 To complete and present the results of assignments from the previous meeting
3. to respect the opinions of all team members
4 to listen to other team members’ points of view without criticism
5 to abide by decisions made by the team
Mission
Team must state it’s mission – Why has it been formed?
Identifying customers/requirements
internal and external customers and their requirements – then modify process to meet the requirements
Document current processes and identifying barriers
-What is the current process?
-Where are the start and end points of the process?
-What are the barriers to the process?
Collecting current process data
Create a flow chart of the current process – Flowcharts help all the team members understand the process in the same way. Will identify redundancies and complex and problematic areas.
Brainstorm Problem areas
technique used to generate a large number of creative ideas from a group. Thinking out of the box for original ideas. Technique can be structured or unstructured
Cause and effect diagram aka fishbone diagram
common quality improvement tools used for risk management purposes. Problem is placed in a box on the right side of diagram, a horizontal line is drawn and diagonal lines resembling ribs are added to connect the boxes above and below the main horizontal line (or backbone) Each box contains a different category. eX: People, materials, equipment, methods. Usually 4 categories. Brainstorming the root causes for each category. Purpose is to permit the team to explore, identify, and graphically display all of the root causes of a problem.
Force-field analysis
another tool used to visually display data generated through brainstorming. Draw a large T (cross) shape on a board. The word drivers is written above the crossbar on the left and barriers is written above the crossbar on the right. Team members brainstorm the reasons or factors that would encourage a change for improvement and those that might create barriers. After completion can work on ways to enforce drivers and eliniminate barriers. May also need to undertake the following:
-Research any regulatory requirements related to the current process
-Benchmark the organization’s current process against performance standards and/or nationally recognized standards
-Conduct a survey to gather customer input on their needs and expectations
analyzing process data
by use of bar graphs, histograms, scatter diagrams, pareto chart,
bar graph aka bar chart
used to display discrete categories, such as the gender of respondents or the type of health insurance respondents have. – groups
histogram
used to display frequencies of responses – much easier way to summarize and analyze data than using a table made up of numbers – is a bar graph of categories, ie patient wait times 0-5, 6-10, etc
scatter diagrams –
used to plot the points for two continuous variables that may be related to each other in some way. Ex One might want to look at whether age and blood pressure are related.
Pareto chart
ranking of various categories visually displayed. Based on Pareto principle: 20 percent of a problem’s sources are responsible for 80 percent of its actual effects. by concentrating on the vital few sources, the team can eliminate a large number of undesirable results
Process Redesign
After reviewing data, policies, procedures, interviews, etc it is decision time. either leaving the situation as it is with minor adjustments or to develop major restructuring of the process to make it meet customers’ expectations. If restructuring is required include the next 5 steps:
1 Incorporate findings or changes identified in the research phase of the improvement process
2 If necessary, collect focused data from the prioritized problem areas to further clarify process failure or variation
3. Create a flowchart of the redesigned process
4 Develop policies and procedures that support the redesigned process
5 Educate involved staff about the new process.
Brainstorming for solutions!
4 basic ground rules for creative solution brainstorming
1 Welcome all ideas – no judgments, no wrong ideas or ridiculous proposals
2 Be creative in contributions – think out side the box! every point of view is valuable. Far fetched ideas may trigger more practical ones and/or present valid solutions
3 Attempt to contribute a large quantity of ideas in a short amount of time. 5 – 15 minutes at most
4. Piggyback on one another’s ideas – add or build on the ideas of others to create combinations, improvements or variations. In all cases a member’s own words are used to record the ideas.
To reduce to a set that is manageable and effective for the problem, use a grouping technique
Affinity grouping
allows the team to organize similar ideas into logical groupings. Write the ideas on sticky notes and arrange them on a table or on a board. Without talking to each other, each team member is asked to walk around the table or board, look at the ideas, and place them in natural groupings that seem related or connected to each other. The goal is to have the team become comfortable with the arrangement. Finally each group is labeled with a category
Nominal Group Technique
process used to develop agreement about an issue or an idea that the team considers most important. Each member ranks ideas according to importance. eX: if 6 ideas, the most important would be given #6, next most #5, etc. Then each is totaled, providing a agreed ranking for the group as a whole.
Recommendations for process change
the PI team is responsible for putting the outcome of its work in a report format, along with recommendations for improving the process. Beyond the data provided and analyzed, the recommendations should take into account anything that might have an impact on the organization, such as:
-Utilization of staff
-Effect on the budget
-Change in productivity
-Effects on customer requirements
Staff members adapt to change more readily when:
They have been a part of the decision
Which of the following documents the current process?
Flowchart
What technique would be the best to display rankings?
Pareto chart
true or false: Affinity grouping helps to determine what issue is the most important.
False
true or false: Establishing ground rules and identifying customers and their requirements are part of team-based performance improvement processes
True
true or false: Brainstorming tries to identify a large number of ideas in a short amount of time.
True
What type of leadership helps to increase employee motivation and empowerment?
Shared leadership because every employee is a vital part. Shared leadership framework is essential for implementing PI
Name some suggested framework to develop and encourage shared leadership
Governing Board of Directors (GBOD), Quality Management board (QMB) and Quality management liaison group (QMLG)
Governing Board of Directors (GBOD)
has overall responsibility and accountability for the successful operation of the organization’s quality and PI activities and should include membership form the communities of interest. Regular review current status of quality and PI initiatives and approve all strategic decisions and organization all expenditures of resources concerning them.
Quality management board (QMB)
has responsibility for the PI program across all subunits of the organization and should include membership from top administration, medical staff officers, top quality management staff. Should be facilitating all proposals for quality and PI initiatives, making recommendations to the governing board regarding strategic quality direction. Monitor the progress of all initiatives, providing assistance and advisement as necessary to keep initiatives moving along to completion.
Quality management liaison group (QMLG)
responsibility for disseminating information about the organization’s quality and PI initiatives throughout the middle management of the organization, for educating managers regarding their roles and the roles of their organizational units in quality and PI initiatives and for developing cross-functional coordination and communication across organizational units in order to accomplish quality and PI initiatives. Also responsible for maintaining the organization in continuous readiness for accreditation and/or licensure survey
Quality Management Department
Responsibilities:
-Helping departments or groups of departments with similar issues to identify potential quality problems
-Assisting determination of the best methods for studying potential problems (for ex: survey, chart review, or interview with staff)
-Participating in regular meetings across the organization, as appropriate, and training organization members on quality and performance improvement methodology, tools, and techniques.
-tracks progress on specific quality studies; distributes study results and recommendations to the appropriate bodies (departments, committees, administration, board of directors or trustees); facilitates implementation of educational or structural changes that flow from the recommendations;p and ensures that follow-up studies are performed in a timely manner.
Who has the ultimate responsibility for ensuring the quality of the medical care provided by the organization?
in hospitals and healthcare organizations, the board of directors has ultimate responsibility. Also responsible for fiscal stability. staff training is critical to success and orientation should include training in quality management.
Standards of Organizational Quality in Healthcare AKA standards of quality, standards of care, quality of care standards, performance standards, accreditation standards, and practice standards
A standard is a written description of the expected features, characteristics, or outcomes of a healthcare-related service. Generally based on a minimum level of performance. Standards represent the level of performance expected of every healthcare provider and/or providing organizations. 4 types of standards are relevant within the context of clinical quality assessment:
4 types of standards
– Clinical practice guidelines and clinical protocols: Detailed step-by-step guides used by healthcare practitioners to make knowledge-based clinical decisions directly related to patient care.
-Accreditation standards: Predefined statements of the criteria against which the performance of participating healthcare organizations will be assessed during the voluntary accreditation process
-Government regulations:Detailed descriptions of the compulsory requirements for participation in the federal Medicare and Medicaid programs
-Licensure requirements: Detailed descriptions of the criteria healthcare organizations must fulfill in order to obtain and maintain state licenses to provide specific healthcare services
Clinical Practice Guidelines and Protocols
Agency for Healthcare Research and Quality (AHRQ) is an agency within the Dept of Health and Human Services (HHS), their mission is to improve the quality, safety, efficiency, and effectiveness of healthcare for all
Americans.Clinical practice guidelines are developed with the goal of standardizing clinical decision making. Clinical protocols are treatment recommendations that are often based on guidelines – generally accepted procedures with clinical steps explicitly recommended by an authoritative body, such as the medical staff.
Accreditation Standards
all base accreditation on a data collection and submission process followed by a comprehensive survey process. Survey involves measurement of a healthcare facility’s performance in comparison to preestablished accreditation standards. Most standards are provided to participating healthcare organizations in the form of manuals, such as the Joint Commission’s Comprehensive Accreditation Manual for Hospitals.
The Joint Commission
it is the largest healthcare standards-setting body in the world. 2003 – 2004 the commission began issuing and scoring healthcare organizations on compliance with specific national patient safety goals (NPSGs)
Outcome measures
document the results of care for individual patients as well as for specific types of patients grouped by diagnostic category.
Tracer Methodology
consists of following (tracing) at the time of on-site survey a few patients through their entire stay at the hospital in order to identify quality and patient safety issues that might indicate quality problems and/or patterns of less than optimum care. – TJC states: tracer methodology is an evaluation method in which surveyors select a patient, resident, or client and use that individual’s record as a roadmap to move through an organization to assess and evaluate the organization’s compliance with selected standards and the organizations systems of providing care and services.
Other voluntary accreditation organizations
-National Committee on Quality Assurance – focuses on its accreditation activities on health plans and outpatient provider organizations, and
– the Commission on the Accreditation or Rehabilitation Facilities which focuses on long-term andmental health rehabilitation facilities.
Government Regulations and Licensure Requirements
Various federal, state, and local governments review the quality of services provided in healthcare organizations. Government regulations and licensure requirement are compulsory rather than voluntary
Medicare Conditions of Participation
Healthcare providers must comply with federal regulations known as the Conditions of Participation and are distributed by CMS.
Health Care Quality Improvement Program(HCQIP)
instituted by CMS and peer review organizations (PROs) working under contract with CMS. HCQIP’s approach (mission) to improving the health of Medicare beneficiaries involves the analysis of patterns of care to promote changes in the healthcare delivery system. CMS changed the name of PROs to (2002) Quality Improvement Organizations (QIOs). CMS and QIOs collaborate with practitioners, beneficiaries, providers, plans, and other purchasers of healthcare services to achieve the following goals:
-Develop quality indicators that are firmly based in science
-Identify opportunities for healthcare improvements through careful measurement of patterns of care.
– Communicate with professional and provider communities about patterns of care
– Intervene to foster quality improvement through system improvements
– Conduct follow-up studies to evaluate success and redirect efforts
State and local Licensure Requirements
Every state government has required licensure of hospitals and other types of healthcare organizaions since the early 20th century. Some city and county governments regulate healthcare facilities that operate within local boundaries. They provide a defined scope of operation. To maintain status, they must comply with the state regulations and/or county, city. Healthcare facilities that lose their licenses, are no longer allowed to operate in the state.
QIOs use peer review, data analysis, and other tools to:
Evaluate whether or not a healthcare facility is meeting standards for accreditation and licensing.
Shared leadership means:
Employees are participants in the performance improvement program
The NPSG scores organizations on areas that:
commonly lead to patient injury
true or false: Accreditation standards were developed to standardize clinical decision making.
false
true or false: The Conditions of Participation are used to monitor hospitals and other healthcare organizations in becoming licensed by the state
False
true or false: The mission of AHRQ is to improve quality, safety, efficiency, and effectiveness for all Americans
True
Utilization Management (UM)
is composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care. Whether the services are determined to be appropriate is based on the patient’s diagnosis, the site of care, the length of stay (LOS), and other clinical factors.
3 important functions of utilization management
-Utilization review
-case management
-discharge planning
Utilization Review(UR)
the process of determining whether the medical care provided to a specific patient is necessary. UR can be performed prospectively, before care is provided; concurrently, while care is being provided; or retrospectively, after the episode of care is complete.
Screening Criteria
UR is based on pre-established screening criteria for inpatient care. Intensity-of-service screening criteria determine whether the patient’s needed services could be fulfilled most efficiently in an inpatient hospital setting or safely provided on an outpatient basis. Severity of illness screening criteria determine whether the patient’s level of physical impairment requires inpatient care.
timing
UR is usually performed before the patient is admitted for inpatient care or at the time of admission. Most health insurance and managed care plans require preadmission certification at or before admission to a hospital.
Precertification
is the process of collecting information to be used for advance eligibility verification, determination of insurance coverage, communication with the physician and/or insured, and initiation of preservice discharge planning and specialized programs such as disease or case management.
Preadmission Utilization Review
is conducted to determine whether the planned service (intensity of service) or the patient’s condition (severity of illness) warrants care in an inpatient setting. The purpose of preadmission (or prospective utilization review) is to identify patients who do not qualify for inpatient benefits before they are actually admitted. In this way, patients can be referred to the appropriate healthcare setting in a timely manner. UR also can be conducted at the time of admission to a hospital through its emergency department. The purpose of admission utilization review is the same as the purpose of preadmission UR, that is, to identify patients who do not require inpatient care an d to direct them to the appropriate healthcare provider.
Continued Stay Utilization Review
conducted to determine whether the patient continues to require inpatient care. The purpose is to ensure that the patient’s LOS is not being unnecessarily prolonged and that the hospital’s resources are being used efficiently.
Discharge utilization review
is performed to determine whether the patient meets discharge screening criteria and no longer requires services available only in an acute care setting.
Retrospective utilization Review
is conducted after the patient has been discharged. It examines the medical necessity of the services provided to the patient. It may be conducted by a peer review org or a hospital committee. The purpose is to evaluate quality issues, cost issues, and LOS factors, as well as the appropriateness of the patient’s admission and the utilization of hospital resources.
Utilization Review Process
most hospitals follow a 2 step UR process, Nonphysician staff members perform the initial review using information provided by the admitting physician(s) compared to the predetermined screening criteria for inpatient admission or continued inpatient stay. If the screening criteria is not met they will ask the physician for more information or alternatively, they may refer the case to a member of the medical staff for peer review.
Case management
is the ongoing review of clinical care to ensure the necessity and effectiveness of the services being provided to the patient. It is conducted concurrently with the patient’s stay and is performed by clinical professionals (usually registered nurses) employed by acute care hospitals. The primary role of the case manager is to coordinate and facilitate care.
4 goals of case management
-To coordinate multidisciplinary and/or multisetting patient care
-to ensure positive outcomes of care
-to manage the patient’s LOS in the acute care facility
-to ensure that the healthcare organization’s resources are used efficiently.
Discharge planning
Purpose of discharge planning is to ensure that patients are released from acute care hospitals when they no longer need inpatient care sand that if services at a lower level of care are necessary, the patient is referred to that level. Discharge planning ensures that the patient can leave the hospital safely and receive the follow-up medical and nursing care he or she needs.
Risk management
can be defined as any occurrence or circumstance that might result in a loss. Losses include any damage to an entity’s person, property, or rights, including physical injury, cognitive injury, emotional injury, wrongful death, and financial loss. Can be defined as a set of policies , processes, and procedures that identify potential operational and financial losses, prevent losses whenever possible and lessen the effects of losses that cannot be prevented. The purpose of the risk management program should be to link risk management functions to the related processes of quality assessment and performance improvement. The aims of the program are to 1. help provide high-quality patient care while also enhancing a safe environment for patients, employees, and visitors and 2. minimize financial loss by reducing risk through prevention and evaluation
3 basic functions of risk management
1 risk identification and analysis
2. Loss prevention and reduction
3. claims management
Risk Identification and Analysis
Role of risk manager is to collect and analyze information on actual losses and potential risks and to design systems that lessen potential losses in the future.
Sources of Risk management information include (9)
-Incident reports (sometimes called occurrence reports or occurrence screens)
-Current and past liability claims against the organization
-Performance improvement reports
-Internal inspections of the organization’s physical plant and medical equipment
– Reviews conducted by the organization’s insurance carriers
– Survey reports from state and local licensing agencies
– Survey reports from accreditation organizations
-Reports of complaints from patients, visitors, medical staff, and employees
-Results of patient satisfaction surveys
An Incident/occurrence report
is a structured tool used to collect data and information about any event not consistent with routine operational procedures. The documentation of these events is undertaken to identify Potentially compensable events. Incident/occurrence reports are prepared to help healthcare facilities identify and correct problem areas and prepare for legal defense. They are considered extremely confidential documents that are never filed in the patient record and should not be photocopied or prepared in duplicate.
Loss prevention and Reduction
risk mgr responsible for developing systems to prevent injuries and other losses within the organization. Education also is an invaluable tool in risk management and sometimes is the only activity required to prevent potential safety problems.
Claims management
the process of managing the legal and administrative aspects of the healthcare organization’s response to injury claims.
4 general steps in claims management process
1. Reporting of claims: written or formal legal notification – risk mgr notifies the proper authority:administration, vendor or corporate counsel. Risk mgr also reports and investigates potentially compensable events for which no claims have been filed.
2. Initial Investigation of claims: gathers all info of relevant claim or the potentially compensable event, interviews and copies of witness statements, etc.
3. Protection of primary and secondary health records: After completion of records upon discharge, they should be kept in a lock storage place.
4. Negotiation of settlements: Risk mgr, insurance rep, admin, and or legal counsel decide whether to offer a monetary settlement.
Patient Advocacy Programs
a patient rep (aka ombudsperson) responds personally to complaints from patients and their families. Patient reps are trained to handle minor complaints and to seek remedies on behalf of patients. Also trained to recognize serious problems that need to be forwarded to performance improvement and/or risk management personnel.
Ombudsperson model
According to the healthcare ombudsperson model, all parties benefit because the ombudsperson:
-Intervenes at the earliest possible opportunity at the lowest possible level
-Maintains informality, confidentiality, and independence
-Resolves potentially compensable events through timely communication
-Is a professional trained in communicating adverse outcomes and mediation skills
– Has the time built into his or her job to spend with patients and providers
– Is sanctioned by top leadership to move fluidly horizontally and vertically within the existing organizational structure
Regulatory and Accreditation Requirements for Risk Management In Acute Care Hospitals
Anything that undermines patient safety is a risk issue. According to (JC) all hospital activities must be evaluated as to the potential risk to the patient or to the organization. Leadership is responsible for ensuring adequate resources for patient safety.
Sentinel Events
The Joint commission requires healthcare organizations to conduct in-depth investigations of occurrences that resulted – or could have resulted – in life-threatening injuries to patients, medical staff, visitors, or employees. The JC uses the term: sentinel Events for such occurrences.
It describes an occurrence with an undesirable outcome usually occurring only once. It points to serious issues involved in care processes that must be resolved in order not to suffer the occurrence again.
According to the Joint Commission a Sentinel Event is:
-An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
– An outcome of such magnitude that each event requires an investigation and response.
examples: medical errors, explosions, and fires and acts of violence
A group of processes that determine the appropriateness of medical services is:
Utilization management
A patient has been discharged prior to an administrative utilization review being conducted. Which of the following should be performed?
Retrospective utilization review
A patient fell out of bed. What should be done?
Complete an incidence occurrence report
A patient is dissatisfied with his or her care. Who should the patient contact at the hospital?
Patient representative/advocate
A woman dies in labor and delivery. The Joint Commission would call this type of outcome an:
Sentinel event
Recent Clinical Quality Management Initiatives
Stemming from the IOM 1999 and 2001 reports on the quality of healthcare in America, a consensus developed around the need to use information technology as both a methodology and a pathway for managing and improving healthcare quality. Attempts to link clinical quality to reimbursement for health services. Recent pay for performance initiatives by the federal government, the Joint Commission, and private payers are rewarding organizations for quality outcomes in hopes of this will encourage healthcare providers to invest in technology that will improve patient care and safety. CMS has become an advocate for pay for performance within the Medicare program. Federal legislation in 2005 allows for the voluntary reporting of medical errors, serious adverse events,and their underlying causes.
Accountable Care Organization (ACO)
is a network of doctors and hospitals that shares responsibility for providing care to patients. An ACO would agree to manage all of the healthcare needs of a minimum of 5000 Medicare beneficiaries for at least three years. The proposed rules also include strong protections to ensure patients do not have their care choices limited by an ACO.
To share in savings, ACOs would meet quality standards in five key areas:
1 Care coordination
2 Patient/caregiver care experiences
3 Patient safety
4 Preventive health
5. At risk population/frail elderly health
Six Sigma
is practiced widely in business sectors outside healthcare, and this philosophy is gaining acceptance in the healthcare industry. – Uses statistics for measuring variation in a process with the intent of producing error-free results. Sigma refers to the standard deviation used in descriptive statistics to determine how much an event or observation varies from the estimated average of the population sample.