2023 Compliatric Webinar Series - Unveiling the Blueprint_ The Components of a Comprehensive Gap Analysis for Federally Qualified Health Centers.pptx.pdf
Federally Qualified Health Centers (FQHCs) play a crucial role in delivering quality care to underserved communities. Understanding and addressing the gaps in compliance, services and patient care is essential for continuous improvement and sustainability.
The goal of this webinar is to provide health center staff, administrators, and stakeholders with the necessary insight to conduct comprehensive assessments, identify gaps and implement effective strategies for improvement. This webinar will discuss the essential components of a comprehensive gap analysis and is designed to:
• Explore methodologies to pinpoint gaps.
• Explain the process for conducting thorough assessments utilizing key performance indicators.
• Identify strategies and best practices for the creation of action plans.
• Ensure alignment with HRSA Health Center Program Requirements.
• Emphasize the importance of patient feedback to foster a culture of patient centered care.
Who Should Attend:
Health center leadership, quality improvement staff, compliance officers, clinical staff and anyone interested in optimizing operations and services within an FQHC.
3 Strategies for Maximizing Service Line Efficiency, Quality and ProfitabilityWellbe
Maximizing service line efficiency, quality and profitability is a hot topic, particularly with rising patient care demands, changing reimbursement models, and estimated physician shortfalls. This webinar takes a look at three solutions beginning in the operating room and expanding to the entire patient care journey.
1st solution: A unique clinical and operational service model focused on the specialization of qualified, reimbursable clinical labor to optimize surgeon involvement and reduce OR costs.
2nd solution: Taking a holistic view of the service line through the patient care journey to produce a value stream map to understand the current state. Assisting staff with comparing this current state to the ideal future state, comparing national benchmarks and clinical best practices helps your staff innovate and co-create an individualized plan to get your service line to a higher level.
3rd solution: Utilizing dashboard metrics of the critical to success factors, to sustain and improve your service line.
As a participant, you will be able to:
• Identify key operational and clinical indicators of orthopedic service line efficiency
• Describe how Surgical First Assists can add value in the OR
• List the steps in developing and/or evaluating or building an orthopedic service line
• Describe how metrics/dashboards assist in sustaining change and improvement of orthopedic service line
About the Speaker:
Miki Patterson, PHD ONP, Senior Director of Orthopedics in Intelligent CareDesign at Intralign
Dr. Patterson is a certified orthopedic nurse practitioner and brings over 25 years of clinical experience in healthcare, consulting, direct advanced orthopedic patient care, teaching, NIH level, qualitative and quantitative research and publishing. She is a past president of the National Association of Orthopedic Nurses (NAON) and continues to be nationally recognized for leadership and advancing orthopedic care.
Presentation by Rich Pollack, VP and Chief Information Officer, VCU Health, at the marcus evans National Healthcare CIO Summit held in Pasadena, CA March 13-14 2017
Patient Satisfaction Surveys are one of the easiest ways for Community Health Centers to evaluate the quality of care being provided, as well as the needs of the patient population. The distribution of Patient Satisfaction Surveys provides a system for collecting and reporting data and can often be the driver of operational transformation. Faced with a lack of resources and low rates of survey completion, Community Health Centers may question how to maximize the value of implementing a process for collecting data. This webinar will address the following:
• Strategies for Developing Patient Satisfaction Surveys
• Strategies for Implementing Patient Satisfaction Surveys
• HRSA Requirements for Patient Satisfaction Surveys
• Best Practices on how to Use and Report Survey Results
Watch the Webinar Here: https://compliatric.com/continuous-compliance-chapters-18-20/
Compliatric is excited to continue their “Continuous Compliance” Webinar Series based on the existing Health Center Compliance Manual and the most recently updated Site Visit Protocol. Each month, program requirements are reviewed to assist health centers in understanding the various elements and ensuring continuing compliance. Participants will be able to use these webinars to increase their knowledge of the requirements, and go one step further and utilize the program requirements to improve operational excellence.
This month’s webinar will focus on the following chapters:
Chapter 18: Program Monitoring
Chapter 20: Board Composition
Webinar attendee takeaways will include:
· An understanding of the program requirements, which includes updates to the Site Visit Protocol
· Maintaining continuous compliance – not only based on a site visit
· Improving operational excellence for your Community Health Center
As Operational Site Visits (OSVs) resume virtually, it is important for Community Health Centers to maintain continuous compliance. Compliatric is excited to continue their “Compliance Webinar Series” where each month, program requirements are reviewed to assist health centers in understanding various elements. Participants will be able to utilize these webinars to increase their knowledge of the requirements, and also take compliance to the next level.
3 Strategies for Maximizing Service Line Efficiency, Quality and ProfitabilityWellbe
Maximizing service line efficiency, quality and profitability is a hot topic, particularly with rising patient care demands, changing reimbursement models, and estimated physician shortfalls. This webinar takes a look at three solutions beginning in the operating room and expanding to the entire patient care journey.
1st solution: A unique clinical and operational service model focused on the specialization of qualified, reimbursable clinical labor to optimize surgeon involvement and reduce OR costs.
2nd solution: Taking a holistic view of the service line through the patient care journey to produce a value stream map to understand the current state. Assisting staff with comparing this current state to the ideal future state, comparing national benchmarks and clinical best practices helps your staff innovate and co-create an individualized plan to get your service line to a higher level.
3rd solution: Utilizing dashboard metrics of the critical to success factors, to sustain and improve your service line.
As a participant, you will be able to:
• Identify key operational and clinical indicators of orthopedic service line efficiency
• Describe how Surgical First Assists can add value in the OR
• List the steps in developing and/or evaluating or building an orthopedic service line
• Describe how metrics/dashboards assist in sustaining change and improvement of orthopedic service line
About the Speaker:
Miki Patterson, PHD ONP, Senior Director of Orthopedics in Intelligent CareDesign at Intralign
Dr. Patterson is a certified orthopedic nurse practitioner and brings over 25 years of clinical experience in healthcare, consulting, direct advanced orthopedic patient care, teaching, NIH level, qualitative and quantitative research and publishing. She is a past president of the National Association of Orthopedic Nurses (NAON) and continues to be nationally recognized for leadership and advancing orthopedic care.
Presentation by Rich Pollack, VP and Chief Information Officer, VCU Health, at the marcus evans National Healthcare CIO Summit held in Pasadena, CA March 13-14 2017
Patient Satisfaction Surveys are one of the easiest ways for Community Health Centers to evaluate the quality of care being provided, as well as the needs of the patient population. The distribution of Patient Satisfaction Surveys provides a system for collecting and reporting data and can often be the driver of operational transformation. Faced with a lack of resources and low rates of survey completion, Community Health Centers may question how to maximize the value of implementing a process for collecting data. This webinar will address the following:
• Strategies for Developing Patient Satisfaction Surveys
• Strategies for Implementing Patient Satisfaction Surveys
• HRSA Requirements for Patient Satisfaction Surveys
• Best Practices on how to Use and Report Survey Results
Watch the Webinar Here: https://compliatric.com/continuous-compliance-chapters-18-20/
Compliatric is excited to continue their “Continuous Compliance” Webinar Series based on the existing Health Center Compliance Manual and the most recently updated Site Visit Protocol. Each month, program requirements are reviewed to assist health centers in understanding the various elements and ensuring continuing compliance. Participants will be able to use these webinars to increase their knowledge of the requirements, and go one step further and utilize the program requirements to improve operational excellence.
This month’s webinar will focus on the following chapters:
Chapter 18: Program Monitoring
Chapter 20: Board Composition
Webinar attendee takeaways will include:
· An understanding of the program requirements, which includes updates to the Site Visit Protocol
· Maintaining continuous compliance – not only based on a site visit
· Improving operational excellence for your Community Health Center
As Operational Site Visits (OSVs) resume virtually, it is important for Community Health Centers to maintain continuous compliance. Compliatric is excited to continue their “Compliance Webinar Series” where each month, program requirements are reviewed to assist health centers in understanding various elements. Participants will be able to utilize these webinars to increase their knowledge of the requirements, and also take compliance to the next level.
The Road To Hospital Quality Accreditation: What’s In It For Us? Is It Even Worth The Expense?” Lecture to Master in Hospital Administration students of the University of the Philippines College of Public Health on August 16, 2013.
View the webinar here! https://attendee.gotowebinar.com/register/5202296824695860825?source=web
Federally Qualified Health Centers (FQHCs) play a crucial role in delivering high-quality healthcare to a wide variety of populations. Implementing effective Quality Improvement/Quality Assurance (QI/QA) Programs is essential for not only meeting federal and state regulatory requirements, but also for maintaining and improving the standard of care offered by FQHCs. This webinar is designed to provide the basics for establishing a QI/QA Program and is specifically tailored for FQHCs.
Key topics covered in this webinar include the following:
• The Health Resources and Services Administration (HRSA) Health Center Program Requirements for QI/QA.
• The basic foundation of high performing QI/QA Programs.
• Key Points to remember when developing a QI/QA Program.
Who Should Attend:
• FQHC administrators, QI Coordinators, Clinical Directors and anyone involved in QI activities within the health center.
North highland himss_hardwiringclinicalfinancialperformance_041315North Highland
North Highland's Ricardo Martinez and Donna Houlne's presentation on "Hardwiring Clinical and Financial Performance Through Patient-Centered, Physician-Directed Transformation"
As Operational Site Visits (OSVs) continue virtually, it is important for Community Health Centers to maintain continuous compliance. Compliatric is excited to continue their “Compliance Webinar Series” where each month, program requirements are reviewed to assist health centers in understanding various elements. Participants will be able to utilize these webinars to increase their knowledge of the requirements, and also take compliance to the next level.
This month’s webinar will focus on the following chapters:
Chapter 18: Program Monitoring and Data Reporting Systems
Chapter 20: Board Composition
Webinar attendee takeaways will include:
· Understanding the requirements and why they are important
· Methods to maintain continuous compliance (without addressing it last minute or only during an OSV)
· How to use the requirement in everyday practice to improve your Community Health Center
REPORT: How healthcare systems are optimizing their workforceMichele Ertl-Rosner
Healthcare industry survey and research showcase the most effective workforce management initiatives and key success factors. Features customer success stories focused on patient centered care and staffing.
Streamlining Your Medical Practice for Profitability and SuccessConventus
Conventus webinar video providing key success strategies and tactics for improving productivity, profitability, and patient care. The one-hour video features host Susan Lieberman of Conventus and Stevie Davidson of Health Informatics Consulting.
Join Compliatric and Molly Evans, Partner, Feldesman Leifer LLP, for this informative session in which the following will be discussed:
Adverse Patient Event Risk Management under The Health Center Federal Tort Claims Act (FTCA) Program
- Overview of the FTCA Program for Health Centers
- Requirements for adverse patient event risk management
Protection under The Patient Safety and Quality Improvement Act (PSQIA)
- Overview of PSQIA
- Definition and scope of Patient Safety Work Product (PSWP)
- How PSQIA protects adverse event information
- The role of Patient Safety Organizations (PSOs)
The Separation of Information Discovery Protection vs. Information Storage Methodology
- Clarifying how PSQIA protection applies regardless of storage medium
- Best practices in documentation regardless of medium
Additional Methods of Protecting Documents from Legal Discovery
- Attorney-client privilege: Definition and application
- Best practices for maintaining confidentiality and privilege
View the Webinar Here: https://attendee.gotowebinar.com/register/5632544520046643551?source=ss
With OSVs now being on-site, join us for an overview of the OSV process and bring your OSV questions for the panel discussion. This Q&A webinar will feature three OSV reviewers: Fiscal, Clinical and Admin/Governance who will answer participant questions. The goal of this interactive session is to focus on YOU being able to ask questions of the panel of experts!
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The Road To Hospital Quality Accreditation: What’s In It For Us? Is It Even Worth The Expense?” Lecture to Master in Hospital Administration students of the University of the Philippines College of Public Health on August 16, 2013.
View the webinar here! https://attendee.gotowebinar.com/register/5202296824695860825?source=web
Federally Qualified Health Centers (FQHCs) play a crucial role in delivering high-quality healthcare to a wide variety of populations. Implementing effective Quality Improvement/Quality Assurance (QI/QA) Programs is essential for not only meeting federal and state regulatory requirements, but also for maintaining and improving the standard of care offered by FQHCs. This webinar is designed to provide the basics for establishing a QI/QA Program and is specifically tailored for FQHCs.
Key topics covered in this webinar include the following:
• The Health Resources and Services Administration (HRSA) Health Center Program Requirements for QI/QA.
• The basic foundation of high performing QI/QA Programs.
• Key Points to remember when developing a QI/QA Program.
Who Should Attend:
• FQHC administrators, QI Coordinators, Clinical Directors and anyone involved in QI activities within the health center.
North highland himss_hardwiringclinicalfinancialperformance_041315North Highland
North Highland's Ricardo Martinez and Donna Houlne's presentation on "Hardwiring Clinical and Financial Performance Through Patient-Centered, Physician-Directed Transformation"
As Operational Site Visits (OSVs) continue virtually, it is important for Community Health Centers to maintain continuous compliance. Compliatric is excited to continue their “Compliance Webinar Series” where each month, program requirements are reviewed to assist health centers in understanding various elements. Participants will be able to utilize these webinars to increase their knowledge of the requirements, and also take compliance to the next level.
This month’s webinar will focus on the following chapters:
Chapter 18: Program Monitoring and Data Reporting Systems
Chapter 20: Board Composition
Webinar attendee takeaways will include:
· Understanding the requirements and why they are important
· Methods to maintain continuous compliance (without addressing it last minute or only during an OSV)
· How to use the requirement in everyday practice to improve your Community Health Center
REPORT: How healthcare systems are optimizing their workforceMichele Ertl-Rosner
Healthcare industry survey and research showcase the most effective workforce management initiatives and key success factors. Features customer success stories focused on patient centered care and staffing.
Streamlining Your Medical Practice for Profitability and SuccessConventus
Conventus webinar video providing key success strategies and tactics for improving productivity, profitability, and patient care. The one-hour video features host Susan Lieberman of Conventus and Stevie Davidson of Health Informatics Consulting.
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Join Compliatric and Molly Evans, Partner, Feldesman Leifer LLP, for this informative session in which the following will be discussed:
Adverse Patient Event Risk Management under The Health Center Federal Tort Claims Act (FTCA) Program
- Overview of the FTCA Program for Health Centers
- Requirements for adverse patient event risk management
Protection under The Patient Safety and Quality Improvement Act (PSQIA)
- Overview of PSQIA
- Definition and scope of Patient Safety Work Product (PSWP)
- How PSQIA protects adverse event information
- The role of Patient Safety Organizations (PSOs)
The Separation of Information Discovery Protection vs. Information Storage Methodology
- Clarifying how PSQIA protection applies regardless of storage medium
- Best practices in documentation regardless of medium
Additional Methods of Protecting Documents from Legal Discovery
- Attorney-client privilege: Definition and application
- Best practices for maintaining confidentiality and privilege
View the Webinar Here: https://attendee.gotowebinar.com/register/5632544520046643551?source=ss
With OSVs now being on-site, join us for an overview of the OSV process and bring your OSV questions for the panel discussion. This Q&A webinar will feature three OSV reviewers: Fiscal, Clinical and Admin/Governance who will answer participant questions. The goal of this interactive session is to focus on YOU being able to ask questions of the panel of experts!
Webinar Available Here! https://attendee.gotowebinar.com/register/3127765771891588950?source=slideshare
Join us for this informative presentation which will cover the following:
1) HRSA Minimum Requirements - We will discuss all minimum requirements as defined in the Site Visit Protocol
2) Contract components that should be included - Sample agreements will be reviewed along with a discussion regarding the necessary components to make a successful agreement: Dos and Don'ts of what to include and what should not be included
3) Best Practices - We will discuss how to develop a process/procedure that not only meets, but far exceeds, the minimum HRSA Requirements and makes administering contracts a manageable process while maintaining proper oversight over the agreements
This webinar will cover key takeaways from the OIG’s recent General Compliance Program Guidance (GCPG) and share current trends and actionable practices Compliance professionals can implement in their programs. The presentation will cover ideas on promoting Compliance effectiveness by implementing analytics, adapting to the evolving AI landscape, and addressing cultural and behavioral considerations.
This webinar will cover key takeaways from the OIG’s recent General Compliance Program Guidance (GCPG) and share current trends and actionable practices Compliance professionals can implement in their programs. The presentation will cover ideas on promoting Compliance effectiveness by implementing analytics, adapting to the evolving AI landscape, and addressing cultural and behavioral considerations.
A Needs Assessment is used by Community Health Centers to identify the needs of the communities they serve. It helps health centers understand specific health challenges, demographics and social economic factors that impact the patient population. This webinar will identify why needs assessments are important, the HRSA program requirements needed for compliance, and identify best practices for developing a needs assessment.
As we ring in the new year, Operational Site Visits (OSVs) continue to be a method that HRSA uses to assess compliance. With OSVs being on-site, join us on January 10th for an overview of the OSV process and bring your OSV questions for the panel discussion. This Q&A webinar will feature three OSV reviewers: Fiscal, Clinical and Admin/Governance who will answer participant questions. The goal of this interactive session is to focus on YOU being able to ask questions of the panel of experts!
Are you a new FQHC? Or new to an FQHC? Wondering what FTCA coverage is all about? How do you prepare to be ready to apply for coverage?
Get answers to these questions and more in this introductory webinar that will benefit everyone
Federally Qualified Health Centers must provide all required primary, preventive and enabling health services, in addition to additional health services, as appropriate and necessary. This can be managed either directly through health center employees and volunteers, or through formal written contracts and formal written referral arrangements.
It is important for health centers to understand that contracts and formal written referral arrangements are not just a piece of paper and not only come with requirements, but also responsibilities on the part of both the health center and the contracted/referral provider(s).
This webinar will address the following:
• HRSA required clinical language for Column II contracts and Column III formal written referral arrangements
• The responsibilities of the health center and the contracted/referral provider
• A high-level review of the clinical chapters associated with Column II and Column III contracts
• Case studies demonstrating gaps in care creating areas of significant risk
• Best Practices to ensure appropriate continuity and quality of care
Watch the webinar Here! https://attendee.gotowebinar.com/register/6554905029175830624?source=web
Join us for this informative session on, "Making the most out of the Sliding Fee Program", which will be an in-depth discussion of all aspects of the SF Program and how to apply this program effectively and efficiently to your patients.
The following items will be discussed:
- HRSA Requirements for implementation of the program
- Purpose/Structure – Including recommended Policies/Procedures
- Eligible Participants in the program
- Required services that are subject to the program
- Effective utilization of Multiple sliding fee scales
- Front Desk Improved efficiencies relating to the sliding fee program
Watch the Webinar Here: https://compliatric.com/developing-a-strong-board-ceo-relationship/
Building and maintaining a strong, healthy relationship between a CEO and the Board of Directors in a health center is a heavy lift and an obligation to the success of the organization and the communities we serve. Asking questions such as, “What are the biggest challenges or barriers to achieving a strong relationship?”, “Does the size of the organization make a difference?” and, “What do board members need to know all the time?” We will focus on understanding and differentiating roles and responsibilities, leadership, and trust, honesty and being humble, that are critical to the foundation of your organizations. We will provide tips, suggestions and resources for opportunities to promote committed alignment with your organization’s goals.
Watch the Webinar Here: https://compliatric.com/overview-of-carf-accreditation/
CARF accreditation is a process that helps health and human service providers improve the quality of their services and meet internationally recognized standards. CARF accredits programs in a variety of settings, including hospitals, rehabilitation centers, substance abuse treatment centers, and home health agencies.
CARF accreditation is a valuable asset for health and human service providers. It signals to consumers, payers, and regulators that a provider is committed to quality and continuous improvement. CARF accreditation can also help providers attract and retain top talent, and it can give them a competitive edge in the marketplace.
In this webinar, Michael Johnson, Senior Managing Director of Behavioral Health will provide an overview of accreditation and the value for organizations.
Watch the Webinar Here: https://compliatric.com/are-you-ready-for-an-osha-inspection/
Join us for this informative presentation which will provide attendees with practical information to prepare for, and respond to, an OSHA Notice of Alleged Violation, or an on-site OSHA inspection.
Watch the Webinar Here! https://compliatric.com/good-faith-estimates-dont-let-the-no-surprises-act-surprise-you/
Following the enactment of the No Surprises Act and the prohibition against balance billing, this session will focus on your responsibilities as providers regarding notices for patients and the regulations and best practices surrounding Good Faith Estimates (GFE).
Watch the Webinar Here! https://compliatric.com/your-accreditation-journey-challenges-along-the-way/
In Part 2 of the Accreditation Guru/Compliatric webinar series, Jennifer and Peggy will present some of the pitfalls/challenges organizations face during the accreditation process. Whether your organization is preparing for initial accreditation, renewal, or in maintenance mode, we will provide tips and strategies on how to avoid these pitfalls.
Join Compliatric and Accreditation Guru’s Founder and CEO, Jennifer Flowers, MBA, and Director of Behavioral Health, Peggy Lavin, LCSW for this informative session!
Watch the Webinar Here! https://compliatric.com/how-to-tackle-the-crucial-task-of-training-for-an-active-shooter-event/
Active shooter events are on the rise, and leaders are increasingly tasked with ways to effectively and safely train hospital and healthcare workers on how to respond. Join us for this informative session in which Paul Sarnese will discuss the methodology of how to tackle the crucial task of training staff members and conducting active shooter exercises.
Watch the Webinar Here!
https://compliatric.com/your-accreditation-journey/
No matter your location on the accreditation road (just starting, maintaining compliance or preparing for re-accreditation), this two part series of 60 minute webinars will help you prepare for a successful journey. The first webinar (July 25) will provide tips, ideas and information designed to give you a clear picture of the accreditation process and to determine the best path forward for your organization. The second webinar (August 15 - more details to follow) will discuss some of the challenging aspects and standards of accreditation. Both webinars will be structured for a lively Q&A!
Join Compliatric and Accreditation Guru’s Founder and CEO, Jennifer Flowers, MBA, and Director of Behavioral Health, Peggy Lavin, LCSW for this informative session!
Watch the Webinar Here! https://compliatric.com/developing-a-pathway-for-promotion-leadership-opportunities-within-your-organization/
Join us for this informative session where we will explore the importance of looking internally within your organizations for ways to create enthusiasm, and opportunities to create pathways for learning and leadership. Asking questions such as, "Are our entry level job descriptions robust and do we have the right people filling those jobs?" and, "What are our blind spots for identifying leadership?". We will focus on optimizing internal recruitment, reducing turnover, and stabilizing those entry level positions that are critical to the foundation of your organizations. We will provide real world examples from rural FQHCs in hard-to-recruit areas as well as suggestions and resources for opportunities to promote engaged and committed personnel to your organizations.
Watch the Webinar here! https://compliatric.com/real-time-strategic-planning-for-your-health-center/
Our presenters will demonstrate how they use David La Piana’s “Real-Time Strategic Planning in a Rapid Response World” to help health centers and other nonprofits be nimble in their approach to strategic planning.
By identifying, understanding, and acting on challenges and opportunities as they arise, an organization can become dynamic and quickly take advantage of market changes. Through the development of a Strategy Screen, the board can remain focused on organizational strategy, leaving programmatic and operational strategy to the CEO and staff. The result in an ongoing strategic planning process that does not “sit on a shelf”.
Watch the Webinar Here! https://compliatric.com/emergency-disaster-preparedness-basics/
Disasters are often unexpected and strike fast. Emergency situations can be challenging even in the best of circumstances.
In this webinar, you will learn the basics of disaster preparedness and best practices for implementation within your care settings.
We will cover:
- The regulations governing emergency preparedness
- Evacuation of patients/clients and staff
- How to build an Emergency Operations Plan
- The "All Hazards" approach to disaster planning
- Disaster policies, training, and testing programs
- Analysis of testing outcomes
- Roles of staff
- Emergency services
- Subsistence needs
- Evacuations
- Creating a disaster communications plan
- Covid and other "Public Health Emergencies"
- Release of patient/client health information during a disaster
- Triage, transportation, and receiving facilities
Within the world of healthcare, disasters can be mentally traumatic and physically devastating. Adequate preparation can mean the difference between life and death for the populations within our care.
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The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
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Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
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Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
2023 Compliatric Webinar Series - Unveiling the Blueprint_ The Components of a Comprehensive Gap Analysis for Federally Qualified Health Centers.pptx.pdf
1. www.compliantfqhc.com
Unveiling the Blueprint: The Components of a
Comprehensive Gap Analysis for a Community
Health Center
COMPLIATRIC WEBINAR SERIES
Michelle Layton BSN, MBA
Infidium Healthcare Solutions
Jennifer Genua-McDaniel, BA (Hons), CHCEF
Genua Consulting, LLC
2. Disclaimers
⚫ This presentation is not endorsed by Management Strategists
Consulting Group (MSCG).
⚫ This presentation is not endorsed by Health Resources Services
Administration (HRSA) or the Bureau of Primary Health Care
(BPHC).
⚫ Not employed by MSCG or BPHC.
⚫ Independent Consultants who are contracted to conduct
Operational SiteVisits (OSV), provide Technical Assistance and
assist health centers with interim leadership and OSV preparation.
⚫ This information should not be considered legal advice.
Confidentiality Notice: This document is confidential and contains proprietary information and intellectual property
of Infidium Healthcare Solutions and Genua Consulting. Neither this document nor any of the information contained
herein may be reproduced or disclosed under any circumstances without the express written permission of the
aforementioned parties.
3. Agenda
⚫ Understanding a Gap Analysis
◦ Definition/Purpose
◦ Benefits and Outcomes
⚫ Key Components of a Gap Analysis
◦ Current Health Center Assessment
◦ Identification of Objectives
◦ Analysis of Gaps
◦ Strategies for Addressing Gaps
◦ Monitoring and Evaluation
⚫ Case Study
⚫ General Considerations
4. Definition and Purpose
Definition
A gap analysis is a process used to assess the differences between
the current state of healthcare services provided by the health
center and the desired or optimal state
Purpose
The purpose of a gap analysis is to do the following:
◦ Compare best practices and regulatory requirements currently in place
at a health center
◦ Determine the gaps between the health center’s current practices and
identified best practices and regulatory requirements
◦ Identify new practices that will be implemented by the health center
5. Benefits and Outcomes
⚫ Identification of gaps in service offerings and/or delivery
⚫ Enhancement of service delivery
⚫ Adherence to compliance and regulatory requirements
⚫ Optimization of resource allocation
⚫ Enhancement of quality improvement
⚫ Contributes to strategic planning efforts
6. What Does HRSA Say?...
⚫ Health Center SiteVisit Protocol (SVP)
◦ Chapter 5 (Clinical Staffing)
◦ Chapter 11 (Key Management Staff)
8. Current Health Center Assessment
Understanding the
history of the Health
Center
History and challenges
Transitions within the organization
Reviewing past and
current data
Organizational structure
Interview staff (confidential discussions)
Review clinical and financial information
•Financial packets, Clinical quality packets,
patient satisfaction, Operational
benchmarks
Evaluating staff
capabilities, resources
and infrastructure
Provide additional training for staff to
complete tasks
What supplies/equipment are needed for
successful clinical workflows?
9. Set Clear Objectives of the Analysis
• Reviewing the mission/vision to align with the Health
Center’s objectives
• Is the strategic plan reasonable?
• What is the goal of the analysis?
• Improve areas of opportunity
• Restructure the organization
Defining clear and measurable goals
• Identify benchmarks and targets for improvement
• Is there an “investment” to meet benchmarks?
• Follow through to make improvements
Setting priorities based on identified
gaps/opportunities for improvement
10. Analyzing Gaps
• Spending time in each health center
department
• Sitting in the waiting room
• Evaluating workflows
Comparison of data
provided during the
initial assessment to
determine whether it
is reflective of what
the health center is
doing
• Identifying “bottlenecks”
• Not closing chart =not able to
bill=outstanding A/R
• Providers unable to see patients because of
credentialing/privileging challenges
Identifying specific
areas of
opportunities
11. Strategies for Addressing Gaps
Identify gaps within different departments being
analyzed
• Administration, Finance, Clinical
• Correlation between departments may be identified
• Identify if resources need to be allocated differently
• Ex. Match employee skillset with health center roles
Implement best practices to improve workflows
• Identify if other health center’s best practices can be implemented
• Remember- “ratios” of workforce are unique to each health center
12. Monitoring and Evaluation of
Implementation of Best Practices
Develop key
performance indicators
Ex. Increase patient visits, explore
adding staff, identify potential
revenue
Regular monitoring of
changes
Report as a quality improvement
project
Not all identified changes may be
implemented right away
Keep staff informed
Celebrate successes!!
14. Gap Analysis Case Study
Current Health Center Assessment
⚫ FQHC with 150
employees
⚫ Many lines of business
◦ Ryan White
◦ Title X
◦ Foundation/Fundraising
◦ Housing
⚫ Clinical Lines:
◦ Medical
◦ Behavioral Health
⚫ Providers work an 8-hour
day
⚫ Behavioral Health
◦ 5 patients per day
⚫ Medical (mix of physicians
and mid-levels)
◦ 10 patients per day
15. Gap Analysis Case Study
Current Health Center Assessment
⚫ Data Collection Process:
◦ Review current organizational structure
◦ Interview staff within various departments
◦ Interview with billing company
◦ Review financial statements
◦ Review clinical reporting structure
◦ Review and evaluation of staffing profile/productivity
◦ Interview clinical leadership, clinical staff and front
desk staff
◦ Interactive participation in clinical workflows
16. Gap Analysis Case Study
Analysis of Gaps (Admin/Fiscal)
• New leadership team
• CEO had 10 direct reports
• CFO/COO did not want to give up operational control of COO tasks; COO role was
not being completed
• Outsourced billing to a billing company but no dedicated staff at the health center to
work denials/other billing issues
• Front desk not collecting nominal fee (sliding fee) or co-pays
• HR Department had 1.0 FTE (General Counsel). General Counsel completing all HR
functions
• Credentialing was being completed by Director of Program for the Health Center
• Director of Program for the Health Center did not have a dedicated Medical Director,
Quality Director
17. Gap Analysis Case Study
Analysis of Gaps (Clinical)
Lacking a Deputy Director, Quality
Coordinator/Manager, Clinic Manager
Front Desk Staff lacking necessary skillset and
customer service skills
Interim Medical Director in need of additional
mentorship
Significant silos between Primary Care Services and
Behavioral Health
Lack of Psychiatric Provider with Prescriptive
Privileges
Scheduling templates allow for primary care
appointment times well above industry standards
18. Gap Analysis Case Study
Analysis of Gaps (Clinical)
Clinical support staff to provider ratio is below industry standards
No shows significantly impact productivity for Behavioral Health
HIV prevention services not provided at the Primary Care Site and
service hours reduced due to the COVID-19 Pandemic
Clinical Support Staff not working to the upper limits of their scope
Inefficient clinical workflows
Lack of Quality Improvement Program
Provider productivity and HRSA compliance significantly impacted by
all of the above
19. Gap Analysis Case Study
Strategies for Addressing Gaps (Admin/Fiscal)
⚫ CFO/COO position requires two separate people
⚫ Add COO (1.0 FTE) role to oversee all the Director of
Programs including the Health Center
⚫ Recommended training and technical assistance to CFO
on health centers and fiscal responsibilities
⚫ Recommended front desk training on customer service
and collecting nominal fees/revenues
◦ Have a dotted line from front desk to CFO and COO
and/or Director of Program (Health Center)
20. Gap Analysis Case Study
Strategies for Addressing Gaps (Admin/Fiscal)
⚫ Recommended 1.0 FTE additional billing staff that is
dedicated to the health center
● Medical Group Management Association (MGMA)
standard- 2.7** billing staff per physician (average)
**This ratio is dependent on various factors**
⚫ Add 2.0 FTE within the HR Department (total of 3.0
including General Counsel)
● Focus on credentialing of staff
● Work with Director of Programs (Health Center) for
privileging component
● Onboarding of staff, personnel issues
● Overall HR compliance issues
21. Gap Analysis Case Study
Strategies for Addressing Gaps (Clinical)
⚫ Determine if vacancies can be filled internally. If not, focus on
recruitment
⚫ Revise scheduling templates for Primary Care Services to align with
industry standard best practices
◦ New Patient Appointment – 30 minutes
◦ Follow-Up Appointments – 15 to 20 minutes
◦ Procedures – 30 minutes (dependent on procedure)
⚫ Validate all clinical support staff are working at the upper limits of
their scope
⚫ Standardize clinical workflows to streamline efficiencies
◦ Where do patients wait for and obtain lab services?
22. Gap Analysis Case Study
Strategies for Addressing Gaps (Clinical)
⚫ Increase the clinical support staff to provider ratio to 1.25:1 or
1.50:1 to align with industry standards
*Dependent on the appointment length and scope of service being provided
⚫ Increase productivity expectations to reflect the following MGMA
and NACHC benchmarks:
◦ MD/DO – 20 patients per day
◦ FNP/PA – 16 patients per day
*Dependent on staffing profile, allocation of clinical space, patient panel. Will
require addressing gaps in scheduling templates, skillset of clinical support staff,
evaluation of clinical support staff to provider ratios and clinical workflows
23. Gap Analysis Case Study
Strategies for Addressing Gaps (Clinical)
⚫ Recruit a 1.0 FTE Psychiatric Nurse Practitioner to provide medication
management, reduce wait times for external Psychiatry and reduce
no-shows for Behavioral Health
⚫ Imbed a 1.0 FTE Behavioral Health Therapist into Primary Care Services to
facilitate warm hand-offs
⚫ Implement an integrated Behavioral Health Model of Care and train staff on
fundamentals
⚫ Integrate HIV prevention services into the Primary Care Services location
to ensure access to care
⚫ Develop a Quality Improvement/Assurance Program that aligns the HRSA
Requirements (Chapter 10, HRSA Health Center Compliance Manual and
25. Considerations…
• Increasing patients seen
• Not leaving “money” on the table
• Investing in staff to diversify workflows
Adding non-revenue staff may mean:
• Are health center specific
• Dependent on FTEs, provider specialty, number of exam
rooms
• Types of patients seen (ex. quick visits versus chronic
visits)
Best practice ratios:
26. Considerations…
• Alleviates anxiety
• Encourages transparency
• Discourages misuse of the
process
Explain the
process to staff
• Provides credibility with staff
• Set reasonable goals
• Evaluate on a continuous basis
Follow through on
recommendations
27. Resources
⚫ HRSA Health Center Program Compliance Manual
◦ HRSA Compliance Manual
⚫ Health Center Program SiteVisit Protocol
◦ HRSA SiteVisit Protocol
⚫ MGMA Benchmarking Success:The Essential Guide for
Medical Practice Management, 2nd
edition
◦ MGMA.com
28. Resources
⚫ What is the Right Billing Staff to Provider ration for a
physician practice?
◦ RTACPA.com
◦ This article has calculations based on FTE’s
⚫ Gap Analysis Facilitator’s Guide
◦ AHRQ.gov
⚫ Health Equity Gap Analysis Tool
◦ Quality Improvement Collaborative