This document discusses quality management in healthcare. It defines key terms like quality and quality management. It describes historical perspectives on quality such as pioneers in infection control and the establishment of Medicare and Medicaid. It discusses drivers of quality like accreditation, regulatory requirements, and value-based care. It also outlines tools and processes used for quality management, such as ongoing quality measure reviews, the plan-do-check-act cycle, and tracer methodology. Finally, it discusses assessing outcomes, systematic processes to improve performance, and professional roles in healthcare quality.
Presentation designed to explain Business Associates the basics of HIPAA and real-life examples of cases that failed to implement and follow HIPAA requirements on a timely basis.
How to Ensure your Healthcare Organisation is IG compliantProofreading4all
Information Governance is an important part of ongoing CQC assessment. IG should be built-in to the daily working routine of your business, follow these simple tips to make sure that IG does not let you down during your next CQC inspection ...
ControlCases discusses the following:
– Healthcare compliance in general
– What is HIPAA
– What is HITRUST
– How do they relate?
– Advantages of being HITRUST certified
Presentation designed to explain Business Associates the basics of HIPAA and real-life examples of cases that failed to implement and follow HIPAA requirements on a timely basis.
How to Ensure your Healthcare Organisation is IG compliantProofreading4all
Information Governance is an important part of ongoing CQC assessment. IG should be built-in to the daily working routine of your business, follow these simple tips to make sure that IG does not let you down during your next CQC inspection ...
ControlCases discusses the following:
– Healthcare compliance in general
– What is HIPAA
– What is HITRUST
– How do they relate?
– Advantages of being HITRUST certified
A brief introduction to hipaa compliancePrince George
As you can imagine, complying with federal regulations around privacy and healthcare data is no small task. This presentation is to help you wade through what you need to know about HIPAA compliance as it relates to your application and what steps you’ll need to take to ensure you don’t end up in violation of the law.
There is plenty to research about HIPAA guidelines. This presentation is not meant to be comprehensive, but rather give you a framework and reference to help you understand the major portions of the law.
A PowerPoint presentation addressing HIPAA overview and definitions, the Privacy Rule, access to medical records, including mental health and psychotherapy notes, and patient amendments or corrections to medical records.
The HIPAA Security Rule - An overview and preview for 2014, from Summit Security Group. Summit Security Group is a business partner to Resource One, managed IT services provider for over 15 years to small and mid-sized businesses in the Portland Metro and Southwest Washington area.
Organizations in the healthcare industry are under immense pressure to improve quality, reduce complexity, increase efficiency and better manage medical expenses. The HITRUST Common Security Framework: A way to protect electronic health information.
The HITRUST Common Security Framework (CSF) was developed to address the myriad of security, privacy and regulatory challenges facing healthcare organizations and their sub-service providers. By including federal and state regulations, standards and frameworks, and incorporating a risk-based approach, the CSF assists organizations address these challenges through a comprehensive framework of prescriptive and scalable security control.
Topics covered in clude:
• A background and overview of the CSF program
• Understanding and leveraging the CSF
• Standards and regulations mapping
• Implementing the CSF
• Third party certification
• The benefits and challenges
Hitrust: Navigating to 2017, Your Map to HITRUST CertificationSchellman & Company
Organizations in the healthcare industry are under immense pressure to improve quality, reduce complexity, increase efficiency and better manage medical expenses.
The HITRUST Common Security Framework (CSF) was developed to address the myriad of security, privacy and regulatory challenges facing healthcare organizations and their sub-service providers. By including federal and state regulations, standards and frameworks, and incorporating a risk-based approach, the CSF assists organizations address these challenges through a comprehensive framework of prescriptive and scalable security control.
Enterprise Health Clouds Disrupt Traditional
Healthcare Information Technology Vendors
The enterprise health cloud market is growing rapidly because
healthcare companies are realizing that digital transformation is very critical to survive and thrive in the 21st Century.
Enterprise health cloud vendors (such as Salesforce, Microsoft, IBM etc.) have cloud platform offerings that combine traditional "software" with security, compliance & governance, predictive, exploratory analytics, collaboration and decision-making (AI) capabilities all for a monthly subscription with $0 investment any hardware or software.
Vendors that can integrate systems of record (multiple "SSOT" - Single Source of Truth), cross-platform inter-operative capability and even cognitive capabilities. Such platform offer access to a thriving developer communities where members can post questions, problems and have it resolved quickly without any formal support. True digital transformation is closer than ever before in Healthcare.
Training innovations information governance slideshare 2015Patrick Doyle
What you will learn in this training:
Principles of Information Governance and their application to health and social care organisations
Accessing Information Governance resources including national legislation, guidance and local policies & procedures
Health and social care organisations’ responsibilities
Protection of an individual’s confidentiality and the Caldicott Principles
How to practice and promote a confidential service
Principles of ensuring and maintaining good client records
Recognising / responding to Freedom of Information requests
Keeping Information Secure
HIPAA Training: Privacy Review and Audit Survival Guidebenefitexpress
HIPAA Privacy Overview for Employers. Review a helpful checklist of requirements an employer must adopt to stay compliant with HIPAA and to survive an audit by Health and Human Services (HHS).
The HIPAA Security Rule: Yes, It's Your ProblemSecurityMetrics
An overview of the HIPAA Security Rule for office managers, receptionists, doctors, physicians, and IT professionals. Need to get HIPAA compliant?
Learn more here: www.securitymetrics.com/sm/pub/hipaa/overview
ACOs and CINs — Where Did They Start, How Have They Evolved, and Where Are Th...Health Catalyst
As the types and structures of Accountable Care Organizations (ACOs) and Clinically Integrated Networks (CINs) continue to evolve, organizations moving into value-based care face an ever-changing landscape. Alternative payment model arrangements have driven provider organizations to hone in on specific tactics to meet their contractual and strategic objectives.
Please join Health Catalyst Senior Vice President Dr. Amy Flaster and Population Health Management Consultant Jonas Varnum as they discuss the evolution of the ACO and CIN models, what new tools ACOs employ today to promote success, and lessons learned from organizations that have succeeded in alternative payment models. They will dive deep into lessons learned in addition to providing a primer on what has always been and continues to be vitally important to success in value based care. Specifics they will cover include:
- Approaches to simplify quality metric reporting
- Enhanced methodology that zeroes in on identifying high-value opportunities to improve patient populations
- Key tips to expand your business with new contracts
Dr. Flaster and Mr. Varnum’s combined experience make them uniquely qualified to guide you in your ACO or CIN journey. Dr. Flaster comes from a clinical background where she worked as Associate Medical Director at Partners HealthCare - one of the largest ACOs in the country. Mr. Varnum is a professional services strategy leader with demonstrated expertise delivering payment model transformation and helping providers and payers to strategically adjust their operations.
A brief introduction to hipaa compliancePrince George
As you can imagine, complying with federal regulations around privacy and healthcare data is no small task. This presentation is to help you wade through what you need to know about HIPAA compliance as it relates to your application and what steps you’ll need to take to ensure you don’t end up in violation of the law.
There is plenty to research about HIPAA guidelines. This presentation is not meant to be comprehensive, but rather give you a framework and reference to help you understand the major portions of the law.
A PowerPoint presentation addressing HIPAA overview and definitions, the Privacy Rule, access to medical records, including mental health and psychotherapy notes, and patient amendments or corrections to medical records.
The HIPAA Security Rule - An overview and preview for 2014, from Summit Security Group. Summit Security Group is a business partner to Resource One, managed IT services provider for over 15 years to small and mid-sized businesses in the Portland Metro and Southwest Washington area.
Organizations in the healthcare industry are under immense pressure to improve quality, reduce complexity, increase efficiency and better manage medical expenses. The HITRUST Common Security Framework: A way to protect electronic health information.
The HITRUST Common Security Framework (CSF) was developed to address the myriad of security, privacy and regulatory challenges facing healthcare organizations and their sub-service providers. By including federal and state regulations, standards and frameworks, and incorporating a risk-based approach, the CSF assists organizations address these challenges through a comprehensive framework of prescriptive and scalable security control.
Topics covered in clude:
• A background and overview of the CSF program
• Understanding and leveraging the CSF
• Standards and regulations mapping
• Implementing the CSF
• Third party certification
• The benefits and challenges
Hitrust: Navigating to 2017, Your Map to HITRUST CertificationSchellman & Company
Organizations in the healthcare industry are under immense pressure to improve quality, reduce complexity, increase efficiency and better manage medical expenses.
The HITRUST Common Security Framework (CSF) was developed to address the myriad of security, privacy and regulatory challenges facing healthcare organizations and their sub-service providers. By including federal and state regulations, standards and frameworks, and incorporating a risk-based approach, the CSF assists organizations address these challenges through a comprehensive framework of prescriptive and scalable security control.
Enterprise Health Clouds Disrupt Traditional
Healthcare Information Technology Vendors
The enterprise health cloud market is growing rapidly because
healthcare companies are realizing that digital transformation is very critical to survive and thrive in the 21st Century.
Enterprise health cloud vendors (such as Salesforce, Microsoft, IBM etc.) have cloud platform offerings that combine traditional "software" with security, compliance & governance, predictive, exploratory analytics, collaboration and decision-making (AI) capabilities all for a monthly subscription with $0 investment any hardware or software.
Vendors that can integrate systems of record (multiple "SSOT" - Single Source of Truth), cross-platform inter-operative capability and even cognitive capabilities. Such platform offer access to a thriving developer communities where members can post questions, problems and have it resolved quickly without any formal support. True digital transformation is closer than ever before in Healthcare.
Training innovations information governance slideshare 2015Patrick Doyle
What you will learn in this training:
Principles of Information Governance and their application to health and social care organisations
Accessing Information Governance resources including national legislation, guidance and local policies & procedures
Health and social care organisations’ responsibilities
Protection of an individual’s confidentiality and the Caldicott Principles
How to practice and promote a confidential service
Principles of ensuring and maintaining good client records
Recognising / responding to Freedom of Information requests
Keeping Information Secure
HIPAA Training: Privacy Review and Audit Survival Guidebenefitexpress
HIPAA Privacy Overview for Employers. Review a helpful checklist of requirements an employer must adopt to stay compliant with HIPAA and to survive an audit by Health and Human Services (HHS).
The HIPAA Security Rule: Yes, It's Your ProblemSecurityMetrics
An overview of the HIPAA Security Rule for office managers, receptionists, doctors, physicians, and IT professionals. Need to get HIPAA compliant?
Learn more here: www.securitymetrics.com/sm/pub/hipaa/overview
ACOs and CINs — Where Did They Start, How Have They Evolved, and Where Are Th...Health Catalyst
As the types and structures of Accountable Care Organizations (ACOs) and Clinically Integrated Networks (CINs) continue to evolve, organizations moving into value-based care face an ever-changing landscape. Alternative payment model arrangements have driven provider organizations to hone in on specific tactics to meet their contractual and strategic objectives.
Please join Health Catalyst Senior Vice President Dr. Amy Flaster and Population Health Management Consultant Jonas Varnum as they discuss the evolution of the ACO and CIN models, what new tools ACOs employ today to promote success, and lessons learned from organizations that have succeeded in alternative payment models. They will dive deep into lessons learned in addition to providing a primer on what has always been and continues to be vitally important to success in value based care. Specifics they will cover include:
- Approaches to simplify quality metric reporting
- Enhanced methodology that zeroes in on identifying high-value opportunities to improve patient populations
- Key tips to expand your business with new contracts
Dr. Flaster and Mr. Varnum’s combined experience make them uniquely qualified to guide you in your ACO or CIN journey. Dr. Flaster comes from a clinical background where she worked as Associate Medical Director at Partners HealthCare - one of the largest ACOs in the country. Mr. Varnum is a professional services strategy leader with demonstrated expertise delivering payment model transformation and helping providers and payers to strategically adjust their operations.
Network physicians, hospitals, and other care continuum providers work collaboratively in active clinical process improvement programs across service lines and specialties to define, establish, implement, monitor, evaluate and periodically update the processes of:
- Evidence-based medicine
- Beneficiary engagement
- Care coordination
- Conservation of healthcare resources
- Clinical data reporting
Implementing CMS Hospital QAPI Guidelines for 2024Conference Panel
Explore the significance of Quality Assessment and Performance Improvement (QAPI) programs in Medicare-certified hospitals, focusing on the updated CMS standards and interpretive guidelines. Learn about essential requirements, assessment areas, and hospital leadership's role in ensuring compliance and enhancing patient safety.
Title: Understanding CMS Hospital QAPI Standards and Guidelines: Key Elements for Implementation and Compliance
Description: Explore the significance of Quality Assessment and Performance Improvement (QAPI) programs in Medicare-certified hospitals, focusing on the updated CMS standards and interpretive guidelines. Learn about essential requirements, areas of assessment, and the role of hospital leadership in ensuring compliance and enhancing patient safety.
Quality Assessment and Performance Improvement (QAPI) Conditions of Participation deficiencies rank among the top three cited issues for Medicare-certified hospitals, highlighting the critical need for robust QAPI programs. CMS emphasizes the pivotal role of well-designed and maintained QAPI initiatives in enhancing patient care quality, reducing medical errors, and fostering a safer healthcare environment.
Register,
https://conferencepanel.com/conference/cms-hospital-qapi-standards-2024
What You Need to Know from HCCA's 2019 Compliance InstituteMD Ranger, Inc.
In this presentation, we cover coming changes to Stark Law, turning your hospital's board of directors into compliance advocates, tracking time for medical directors and more!
Clinical Integration: The Foundation for Accountable Care - Presentation delivered by Keynote Speaker Marvin O’Quinn, Senior Executive Vice President and Chief Operating Officer, Dignity Health at the National Healthcare CXO Summit held in Las Vegas Oct 19-21, 2014.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Safalta Digital marketing institute in Noida, provide complete applications that encompass a huge range of virtual advertising and marketing additives, which includes search engine optimization, virtual communication advertising, pay-per-click on marketing, content material advertising, internet analytics, and greater. These university courses are designed for students who possess a comprehensive understanding of virtual marketing strategies and attributes.Safalta Digital Marketing Institute in Noida is a first choice for young individuals or students who are looking to start their careers in the field of digital advertising. The institute gives specialized courses designed and certification.
for beginners, providing thorough training in areas such as SEO, digital communication marketing, and PPC training in Noida. After finishing the program, students receive the certifications recognised by top different universitie, setting a strong foundation for a successful career in digital marketing.
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Normal Labour/ Stages of Labour/ Mechanism of LabourWasim Ak
Normal labor is also termed spontaneous labor, defined as the natural physiological process through which the fetus, placenta, and membranes are expelled from the uterus through the birth canal at term (37 to 42 weeks
In the healthcare industry, various terminology is used to describe quality and performance. Sometimes various terms are used interchangeably (although incorrect to do so), so it is important to have an understanding of terms related to quality, quality management, total quality management, and performance improvement to appreciate their differences.
Within healthcare organizations, quality management is a shared responsibility among everyone. While a quality department is part of the organizational structure of healthcare organizations, the department does not work in a silo to assess, measure, and evaluate the quality of care provided to patients.
An effective quality management effort will include complementary focus on performance improvement. Without also focusing on performance improvement, understanding quality (or lack thereof) would be somewhat a moot point if identified deficiencies and opportunities for improvement were not followed up with actions to improve deficiencies.
Before clinicians scientifically understood the risks that infections posed to patients, clinical care – including surgical procedures – did not apply infection control techniques to reduce the risk of infections. Identifying that infections could be prevented was a big step forward in improving patient safety in healthcare. Three early patient safety pioneers were Joseph Lister, Ignaz Sammelweis, and Florence Nightingale.
Lister = 18th century physician; specialized in surgery. Implemented earliest examples of infection control processes into surgery such as placing anti-infective agents into surgical incisions/wounds and on dressings. Also identified the need to sterilize instruments.
Sammelweis = earliest to champion hand washing in clinical care settings
Nightingale = applied understanding of clinical practice and statistical analysis to identify that unsanitary conditions in healthcare facilities led to negative outcomes and increased mortality.
Prior to the Darling case, legal liability was not a concern for hospitals or other healthcare institutions when medical errors occurred and harmed patients. Prior to Darling, if a patient was harmed, only the physician could be liable; the Darling case set a new legal precedent in which hospitals as an organization could also be liable, along with physicians, when patients were harmed.
Patient broke leg playing football and went to the hospital. A series of errors during his hospitalization occurred, including poor communication among the care team, oversight of an infection that developed inside his cast, and providers directing medical care who weren’t qualified to do so. By the time the hospital realized the leg was infected, the damage to the leg was so extensive, the hospital was unable to treat the patient and had to transfer him to an academic medical center to provide specialized care. The academic medical center was unable to restore the leg and the leg required amputation. The patient sued hospital and even though it went through several levels of appeal, won a judgment against the hospital. From this point forward, hospitals could be held legally liable for medical errors occurring within their organization (and liability no longer resided solely with physicians or other health professionals).
Medicare covers those 65 and older, as well as select instances of disability and medical conditions; Medicaid provides insurance coverage to low income individuals/families.
Conditions for Coverage and Conditions of Participation are baseline health and safety standards that must be met by healthcare organizations that treat Medicare and Medicaid patients. CMS maintains the CfCs and CoPs online.
Patient advocacy groups began to emerge in the 1970s and the public had growing expectations for quality and safety in patient care. The American Hospital Association was also interested in seeing patients become more active advocates to understand their rights and responsibilities related to healthcare and drafted the Patient’s Bill of Rights in 1973; a newer iteration of this document is often provided to patient’s today known as the Patient Care Partnership. One of the earliest consumer-led patient safety advocacy organizations was Consumers for Medical Quality (established in 1983).
Managed care: HMO Act of 1973 provided federal funding to explore the use of HMOs as a mechanism to provide quality care in a cost-effective way. HMOs created from this legislation were required to focus their efforts extensively on quality; among the areas of emphasis within their quality programs were health outcomes and review of physicians and other professionals providing care.
In the 1990s – 2000s, patient safety became an industry focus and various reports were published about suboptimal environments in US healthcare. To Err is Human illustrated the toll of human lives lost as well as massive expense associated with unsafe care. Crossing the Quality Chasm called for a complete redesign of US healthcare.
The work of the IHI is largely based in applying the scientific method to study patient safety and healthcare quality. Their approach, the Triple Aim, is widely cited in the healthcare industry and has had influence on health policy.
The next slides will describe the role of accreditation standards, regulatory requirements, value-based payments, and consumer engagement
Examples of Accreditation Organizations
The Joint Commission
Accreditation Association for Ambulatory Healthcare
American College of Radiology
Commission on Accreditation of Rehabilitation Facilities
Federal regulations stem from federal law. A variety of federal laws influence healthcare. This slide shows a handful of examples of federal laws that address unique aspects of healthcare delivery, but all share a theme that quality is a focus within the laws.
EMTALA – addresses access to care in ERs; CLIA – address lab testing quality; Medicare Prescription Drug, Improvement, and Modernization Act – addresses access to prescription drugs and enhancements to Medicare; HITECH – addresses the need to expand EHR adoption, which has potential to improve quality and reduce costs; ACA – addresses access to health insurance
Reporting of quality indicators to stakeholders that subsequently makes the data available for public consumption has influenced a new era of transparency in healthcare. Critiques of this type of transparency argue that healthcare organizations that treat certain populations, such as the uninsured or poor, will have an unfair advantage because their data will look unfavorable. Another critique of this type of transparency is that the public has access to this information but may not be equipped to accurately appraise the information. Regardless, the movement toward transparency will likely only continue.
A wide variety of value-based payment methods are currently being used in US healthcare. Value-based payments are any method of healthcare reimbursement that either financially incentivizes providers for good quality and outcomes or those which penalize providers for inadequate quality and outcomes. For the purpose of this chapter, understand that value-based payments are a radical shift from the previous methods of reimbursement used in which reimbursement did not account for the quality of care provided. Reimbursement models in value-based care focus on quality not quantity.
Patients today, more so than ever before, can shop around before choosing a healthcare provider. As more and more data is transparently available on the Internet, it’s important that healthcare providers and organizations can establish themselves as first-class destinations for care that focus on quality and safety and engage the community they serve.
Organizations that commit to a culture of quality are more likely to achieve quality. The following slides describes the influence of mission and vision, leadership, organizational culture, interprofessional education and practice, and change management on quality.
If the organization does not embrace and implement the mission and vision in all it does, the mission and vision are not actualized. Mission and vision statements are succinct and state the mission and vision of an organization.
Managers cannot be the only source of leadership within an organization. Anyone can be given a job title of manager but that doesn’t mean they possess leadership skills. It is expected that managers provide leadership, however, the reality is that not all can or do. Some of the most effective leadership can come from within the ranks of an organization, particularly in healthcare where peers respond well to each other for insight, direction, and motivation. Regarding the ability for leadership to influence quality, quality is a shared responsibility and effective leadership on the topic from anywhere within the organization should be welcomed.
Organizational Culture Can be:
Positive or negative
Formative or punitive
Collaborative or silos
It’s important to recognize how organizational culture influences quality
If quality was easily achievable, the US healthcare system would not still struggle with quality. Therefore, change management comes into play in situations when staff must change practice habits, processes and procedures, roles, philosophies, culture, and more in order to improve performance related to quality.
Data collected during reviews is often submitted for various external reporting requirements; organizations often use the same data for various internal uses as well.
Internal benchmarking “identifies best practices within an organization, to compare best practices within an organization, and to compare current practice over time” (Hughes 2008). Example of internal benchmarking – comparing rates of healthcare associated infections acquired during hospitalization among nursing units of a hospital
External benchmarking “uses comparative data between organizations to judge performance and identify improvements that have proven to be successful in other organizations” (Hughes 2008). Example of external benchmarking—comparing measures on Nursing Home Compare website between one’s own skilled nursing facility and other skilled nursing facilities
Collecting the data is not just for reporting requirements—it is also to identify opportunities for needed improvement
PDCA is frequently used in healthcare organizations for quality and performance purposes. PDCA is continuous and cyclical in nature. W. Edwards Deming was a famous engineer, statistician, and management consultant.
Prior to the Healthcare Quality Improvement Act, a growing concern emerged that physicians could move freely around the country and re-establish their practice with little question after having been found liable for injury, death, or other harm experienced by patients under their care.
The National Practitioner Data Bank (NPDB) is “An information clearing house . . . to collect and release certain information related to the professional competence and conduct of physicians, dentists, and in some cases, other healthcare practitioners” (HHS 2015)
See chapter for examples of when a physician may be subject to peer review.
In addition to entities who can query the NPDB to find out information about physicians and other practitioners; healthcare practitioners, entities, providers, and suppliers are authorized to query on themselves for information reported to the NPDB
See textbook chapter for details on who, in addition to MD physicians, may be members of a medical staff per CMS.
Is replicated by healthcare organizations to monitor compliance with accreditation standards and identify potential areas of deficiency.
Findings from CER can inform not only the risks and benefits of treatment options, as examples, but can also illustrate the costs of such options. The textbook chapter described a 2013 peer reviewed study on the use of cesarean section delivery versus vaginal delivery of newborns to illustrate an example of CER.
CER is a better known concept today as a result of the Patient-Centered Outcomes Research Institute, funded by the Patient Protection and Affordable Care Act of 2010.
The AHRQ is a federal agency that aims to support health services research designed to improve the outcomes and quality of healthcare, reduce costs, address patient safety and medical errors, and broaden access to effective services.
Certain approaches, methods, protocols, and treatments have been proven to produce the best results for patients. Effective clinical care still requires clinical judgment and knowledge from clinicians. An early critique of evidence-based practice was that it thwarted the autonomy of physicians and their role in clinical decision-making. However, an increasing body of scientific evidence demonstrates the value of evidence-based practice when it’s applicable.
Clinical pathways do not exist for every single clinical scenario; however, when they do exist there are benefits to patients in using them. Clinical pathways expand the concept of a care plan because the pathway is established with the intent that the care plan accounts for the needs of the patient as well as promotes the interdependent nature of the health professions to achieve more cohesive patient care.
Case management is extremely valuable in the US because of the fragmented and complex nature of our healthcare system.
Without case management, patients are at risk for
Readmission
Medication mismanagement
Inadequate follow up care
Implementing health IT by itself does not improve quality; Instead, doing so in an effective way provides more opportunities for improvement
Many HIM professionals credentialed as RHIAs or RHITs work in quality management roles because their knowledge and background uniquely qualifies them for various roles in quality. HIM professionals working in quality management likely already possess on the previously mentioned quality-specific certifications, or plan to obtain them for career advancement.
EHRs emphasize the need for professionals who also understand data stewardship and information governance. Data stewardship and IG are two areas in which HIM professionals possess competency and can provide leadership in these areas. Risks to inaccurate and improper EHR documentation heightens the need for professionals understanding these areas to work in healthcare organizations. Compromised data and information quality in EHRs pose great risks to healthcare organizations and their patients, including risks that relate to quality.
When social media first came about, healthcare organizations did not jump on board. There were concerns about non-compliance with HIPAA on the mediums, depending on how they communicated with the public (who may be patients). The waters have been navigated in this regard and now healthcare organizations typically have a social media presence. Even if a healthcare organization is not on social media, their patients likely are –and the good and bad experiences, especially those perceived as bad by patients, will be shared with others. There are risks to the reputation and brand if a healthcare organization consistently has negative feedback and complaints
Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications. (Health Resources and Services Administration, n.d.), Quality must be considered and measured in telehealth settings. Questions to consider include:
How are appropriate physician partners established?
Are services offered beyond traditional medical care (PT, OT, others)?
How is documentation captured and managed?
Will patient satisfaction be measured?
How does telehealth affect care continuity?
This IOM report highlights that despite increasingly available information (also available in greater amounts than ever before), the US healthcare system has stalled in leveraging information as an asset to improve care. The concept of the learning health system relies in large part on smart and effective use of information to inform individual episodes of care as well as overarching efforts to improve health services delivery to large populations.