Recommendations for improving transitions of care (7) | o IMPROVE COMMUNICATION during transitions between providers, patients, and caregivers
o IMPLEMENT EMRs that include standardized medication reconciliation elements
o ESTABLISH POINTS OF ACCOUNTABILITY for sending and receiving care, particularly for hospitals and nursing home providers
o INCREASE USE OF CARE MANAGEMENT and professional care coordination
o EXPAND ROLE OF PHARMACIST in transitions of care
o IMPLEMENT PAYMENT SYSTEMS that align incentives and include performance measures to encourage better transitions
o DEVELOP PERFORMANCE MEASURES to encourage better transitions of care |
Recommendations for improving transitions of care (7) | o IMPROVE COMMUNICATION during transitions between providers, patients, and caregivers
o IMPLEMENT EMRs that include standardized medication reconciliation elements
o ESTABLISH POINTS OF ACCOUNTABILITY for sending and receiving care, particularly for hospitals and nursing home providers
o INCREASE USE OF CARE MANAGEMENT and professional care coordination
o EXPAND ROLE OF PHARMACIST in transitions of care
o IMPLEMENT PAYMENT SYSTEMS that align incentives and include performance measures to encourage better transitions
o DEVELOP PERFORMANCE MEASURES to encourage better transitions of care |
Recommendations for improving transitions of care (7) | o IMPROVE COMMUNICATION during transitions between providers, patients, and caregivers
o IMPLEMENT EMRs that include standardized medication reconciliation elements
o ESTABLISH POINTS OF ACCOUNTABILITY for sending and receiving care, particularly for hospitals and nursing home providers
o INCREASE USE OF CARE MANAGEMENT and professional care coordination
o EXPAND ROLE OF PHARMACIST in transitions of care
o IMPLEMENT PAYMENT SYSTEMS that align incentives and include performance measures to encourage better transitions
o DEVELOP PERFORMANCE MEASURES to encourage better transitions of care |
Recommendations for improving transitions of care (7) | o IMPROVE COMMUNICATION during transitions between providers, patients, and caregivers
o IMPLEMENT EMRs that include standardized medication reconciliation elements
o ESTABLISH POINTS OF ACCOUNTABILITY for sending and receiving care, particularly for hospitals and nursing home providers
o INCREASE USE OF CARE MANAGEMENT and professional care coordination
o EXPAND ROLE OF PHARMACIST in transitions of care
o IMPLEMENT PAYMENT SYSTEMS that align incentives and include performance measures to encourage better transitions
o DEVELOP PERFORMANCE MEASURES to encourage better transitions of care |
Recommendations for improving transitions of care (7) | o IMPROVE COMMUNICATION during transitions between providers, patients, and caregivers
o IMPLEMENT EMRs that include standardized medication reconciliation elements
o ESTABLISH POINTS OF ACCOUNTABILITY for sending and receiving care, particularly for hospitals and nursing home providers
o INCREASE USE OF CARE MANAGEMENT and professional care coordination
o EXPAND ROLE OF PHARMACIST in transitions of care
o IMPLEMENT PAYMENT SYSTEMS that align incentives and include performance measures to encourage better transitions
o DEVELOP PERFORMANCE MEASURES to encourage better transitions of care |
NA | NA |
Recommendations for improving transitions of care (7) | o IMPROVE COMMUNICATION during transitions between providers, patients, and caregivers
o IMPLEMENT EMRs that include standardized medication reconciliation elements
o ESTABLISH POINTS OF ACCOUNTABILITY for sending and receiving care, particularly for hospitals and nursing home providers
o INCREASE USE OF CARE MANAGEMENT and professional care coordination
o EXPAND ROLE OF PHARMACIST in transitions of care
o IMPLEMENT PAYMENT SYSTEMS that align incentives and include performance measures to encourage better transitions
o DEVELOP PERFORMANCE MEASURES to encourage better transitions of care |
What is the Board of Directors role in Quality? | 1. Set policy
2. Financial and strategic direction
3. Quality of Care
4. Goals and objectives
(Should establish quality priorities ALONG with management and medical staff) |
Which of these is the BOD's role in Quality?
Set policy
Financial and strategic direction
Implementing Strategies
Quality of Care
Collecting quality measure indicators
Goals and objectives | • Set policy
• Financial and strategic direction
• Quality of Care
• Goals and objectives |
What is the role of leadership? | Develop vision and align subsystems to cope with change |
What is the role of management? | Plan and budget to cope with change |
Mission | Organization’s purpose or reason for existence; why are we here?
• Builds org direction
Ex) ACS’s Mission is to save lives, celebrate lives, and lead the fight for a world without cancer. |
Vision | Organization’s statement of its goals for the future (It LOOKS with VISION into the FUTURE)
• Guides org direction
• Core values help direct vision |
Core values | Define organization’s attitudes and helps direct vision
Ex) ACS’s core values are Integrity, Compassion, Courage, Determination, Diversity. |
Goals | Board, general statements specifying a purpose or desired outcome
• May be more abstract than objectives
• One goal can have several objectives
• SMART goals: Specific, Measurable, Actionable, Relevant, Timebound |
Objectives | Specific statements that detail how goal(s) will be achieved through specific and measurable actions; Relatively narrow and concrete |
Voice of the Customer (VOC) | A process conducted at the start of any new product, process or service design initiative to understand better the customer’s wants and needs |
4 aspects of VOC | o Customer needs
o Hierarchical structure
o Priorities
o Customer perceptions and performance |
How do you construct VOC research? | 1. Identify customers of a process output
2. Develop a list of questions to ask customers about the process and their needs
3. Refine the list to use with the process review and improvement |
Goals of strategic planning (6) | • Create a framework for operations
• Create a fit with external environment
• Establish process for coping with change and renewal
• Foster anticipation, innovation, and excellence
• Facilitate consistent decision making
• Create an organizational focus |
Hoshin Planning | A Japanese term that means policy deployment
• One approach for integration in a quality, safety, and performance improvement system
• Used to ensure that the vision set forth by top management is being translated into planning objectives and actions that both management and employees will take to accomplish long-term organizational strategic goals |
Balanced Scorecard | Views organization from multiple perspectives• 4 perspectives of measurement |
Population Health | Outcomes for a group of individuals |
Population Health Management (PHM) | Improving health within and across populations of patients who have/are at risk for chronic disease
• Cornerstone of value-driven healthcare
• Value defined as outcomes achieved for cost expended
• Involves gaining understanding of clinical and social determinants of health of population/subpopulation and associated risks
• Enables appropriate allocation of resources for greatest benefit to entire population |
Transitions of Care | Occurs when a patient moves from one healthcare provider or setting to another
EXAMPLES:
- Sharing patient hx and vitals during transfer from nursing home to hospital
- Hospital sharing pt. information on hospital stay with home health service |
Recommendations for improving transitions of care (7) | o IMPROVE COMMUNICATION during transitions between providers, patients, and caregivers
o IMPLEMENT EMRs that include standardized medication reconciliation elements
o ESTABLISH POINTS OF ACCOUNTABILITY for sending and receiving care, particularly for hospitals and nursing home providers
o INCREASE USE OF CARE MANAGEMENT and professional care coordination
o EXPAND ROLE OF PHARMACIST in transitions of care
o IMPLEMENT PAYMENT SYSTEMS that align incentives and include performance measures to encourage better transitions
o DEVELOP PERFORMANCE MEASURES to encourage better transitions of care |
Handoffs | Real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care
EXAMPLES:
- Sharing vital signs and care with the care providers on the next shift
- Sharing patient hx when transferring to a new unit |
What information should handoffs include? | o Patient history
o Health rhythm
o Infections
o Complications
o Need for restraints |
Name 5 people frequently involved in care transitions | Patient
Family/caregiver
Nurses
Social workers
Case managers
Pharmacists
Physicians
Other providers |
Episode of care | All the care a patient receives during treatment for a specific illness, condition, or medical event
EXAMPLES:
- Cardiac specialist called in to provide consultation on cardiac issues with a surgical patient
- Provide patient information to a dietician consulted about patient who is losing weight after a procedure |
Managed healthcare | System of healthcare delivery to manage cost, quality, and access to healthcare |
Name the 7 types of reimbursement | Fee-for-service: Providers receive payment for each service provided
Traditional Retrospective Payment: Pays providers after services have been provided
Managed Care Reimbursement: Third Party payers manage cost of healthcare and episodes of care
Episode of Care Reimbursement: Providers receive one lump sum for all services related to a condition/disease
Capitation: Third party payer reimburses providers a fixed per capita amount for a period (PMPM or Per Member Per Month)
Prospective Payment: Payment rates established in advance for a specified time period; pre-determined rates based on average levels of resource use (DRGs)
Pay for Performance: Provides bonus to health care providers if they meet or exceed agreed upon quality or performance measures |
Fee-for-Service | Providers receive payment for each service provided |
Traditional Retrospective Payment | Pays providers after services have been provided |
Managed Care Reimbursement | Third Party payers manage cost of healthcare and episodes of care |
Episode of Care Reimbursement | Providers receive one lump sum for all services related to a condition/disease |
Capitation | Third party payer reimburses providers a fixed per capita amount for a period (PMPM or Per Member Per Month) |
Prospective Payment | Payment rates established in advance for a specified time period; pre-determined rates based on average levels of resource use (DRGs) |
Pay for Performance | Payment rates established in advance for a specified time period; pre-determined rates based on average levels of resource use (DRGs) |
Patient Protection and Affordable Care Act (PPACA) Goals (3) | o Give more individuals access to affordable, quality health insurance
o Reduce the growth in health care spending in the country
o Expand affordability, quality, and availability of private and public health insurance though consumer protections, regulations, subsidies, taxes, insurance exchanges, and other reforms |
Types of Provider Networks (3) | Health Maintenance Organization (HMO)
Preferred Provider Organization (PPO)
Exclusive Provider Organization (EPO) |
Health Maintenance Organization (HMO) | o Members need to receive most or all care from network provider
o Select PCP responsible for managing and coordinating all healthcare
o PCP provides referrals to network specialists or laboratory or radiology test
o Members pay for using providers outside the network |
Preferred Provider Organization | o Health plan contracts with a network of preferred providers from which to choose
o Do not need to select PCP
o Do not need referrals to see other network providers
o Only responsible for annual deductible and copay for visit
o Pay higher amount if using providers out of network |
Exclusive Provider Organization | o Network of individual medical care providers or groups of medical care providers who have entered into a written agreement with an insurer to provide health insurance to subscribers
o Must receive care exclusively from healthcare providers with EPO contracts of EPO won’t pay
o Services limited to medically necessary or preventive care |
Purpose of Credentialing physicians | • Encompasses practitioners, privileges, place
• Provides protection from
- Incompetent or unlicensed professionals or orgs
- Liability claims |
Required credentialing elements | 1. Current licensure or certification
2. Specific relevant training
3. Peer or faculty recommendation
- Medical/clinical knowledge
- Technical/clinical skills
- Clinical judgement
- Interpersonal and communication skills
- Professionalism
4. Evidence of physical ability to perform requested privilege |
Privileges and types of privileges (5) | Defines what a practitioner can do in a specific healthcare org and reflect their training, experience, and qualifications
1. Provisional
2. Active
3. Consulting
4. Temporary
5. Emergency |
Provisional privileges | Enables someone to practice as a health care provider, with certain restrictions imposed.
- Applies to individuals who do not meet the requirements for full credentialing. |
Active privileges | Granted based on education, training, experience, and recommendation of the Credentialing Committee/Medical Staff to the governing body.
- Privileges periodically reviewed
- Have to work within the scope of their privilege criteria |
Consulting privileges | Privileges may be granted to medical staff members who may respond to requests from attending physicians or department chairs for consultations in their area of specific clinical expertise. |
Temporary privileges | May be granted when an applicant is awaiting review and approval by the medical executive committee (MEC) and the governing body to fulfill important patient care, treatment, or service needs.
o Last no longer than 120 days
o Must be granted by the hospital CEO |
Emergency privileges | Granted during disasters to volunteer Licensed Independent Practitioners (LIPs) when the Emergency Operations Plan has been activated in response to a disaster and the hospital is unable to meet immediate patient needs. |
Credentialing Process | 1. Application
2. Primary Source Verification
3. Privileges Selected
4. Department Head Review
5. Credentialing Committee Review
6. Medical Executive Committee Review
7. Governing Board Review and Approval |
Focused Professional Practice Evaluation (FPPE) | Time-limited process for organization to evaluate and confirm current competence for initially requested privileges.
Purpose: demonstrate competency in delivering safe, effective care
- Provides a method for establishing a monitoring plan specific to a requested privilege and determining the duration of performance monitoring
Occur at 3 times:
- At time of initial appointment to medical staff
- At time of new privileges
- Provider-specific issues affecting provision of safe, effective patient care |
Ongoing Professional Practice Evaluation (OPPE) | Purpose: To demonstrate ongoing competency in delivering safe, effective care
- Used to determine whether to continue, limit, or revoke existing privileges
Like a report card to help practitioner improve patient care
Compares performance to criteria to identify opportunities for improvement |
The Joint Commission | Improves safety of care using accreditation and certification as risk reduction activities |
National Committee for Quality Assurance (NCQOA) | Dedicated to improving healthcare quality and driving improvement through the healthcare system |
Det Norske Veritas (DNV) GL - Healthcare | Accreditation program CMS-approved to accredit hospitals and critical access hospitals and acquire ISO 9001 certification by 4th year; risk management and TA |
International Organization for Standardization (ISO) | Developer of voluntary international standards for products, services, and good practice |
Accredidation Association of Ambulatory Health Care (AAAHC) | Exclusive focus on ambulatory healthcare |