The document discusses the credentialing and privileging process for licensed independent practitioners (LIPs) in healthcare organizations. It outlines the core criteria for credentialing including licensure, training, competence, and ability. It also describes the credentialing/re-credentialing process, delineation of clinical privileges, practitioner profiling for monitoring performance, and the appointment/reappointment process for medical staff members.
Clinical Privileging and Scope of Practiceheidikiehl
Addresses practice considerations and regulatory aspects affecting the role of the clinical dietitian working in California hospitals and health care facilities.
Medical Diagnostics Labs in India have the option of choosing ISO 9001, NABH Medical Lab Certification, ISO 15189 - NABL Lab Accreditation, CAP Accreditation programs for implementing Lab Quality Management Systems Programs.
Joint Commission International 6th Edition standards interpretation FAQ'sJoven Botin Bilbao
Joint Commission International (JCI) works to improve patient safety and quality of health care in the international community by offering education, publications, advisory services, and international accreditation and certification.
oint Commission International Accreditation Standards for Hospitals, 6th Edition, provides the basis for accreditation of hospitals throughout the world. Joint Commission International (JCI) standards define the performance expectations, structures, and functions that must be in place for a hospital to be accredited by JCI. The standards are divided into two main sections: 1) patient-centered care and 2) health care organization management.
Clinical Privileging and Scope of Practiceheidikiehl
Addresses practice considerations and regulatory aspects affecting the role of the clinical dietitian working in California hospitals and health care facilities.
Medical Diagnostics Labs in India have the option of choosing ISO 9001, NABH Medical Lab Certification, ISO 15189 - NABL Lab Accreditation, CAP Accreditation programs for implementing Lab Quality Management Systems Programs.
Joint Commission International 6th Edition standards interpretation FAQ'sJoven Botin Bilbao
Joint Commission International (JCI) works to improve patient safety and quality of health care in the international community by offering education, publications, advisory services, and international accreditation and certification.
oint Commission International Accreditation Standards for Hospitals, 6th Edition, provides the basis for accreditation of hospitals throughout the world. Joint Commission International (JCI) standards define the performance expectations, structures, and functions that must be in place for a hospital to be accredited by JCI. The standards are divided into two main sections: 1) patient-centered care and 2) health care organization management.
Admission Disposition: Inpatient or Outpatient Observationampeterson03
This was a staff presentation for Rio Grande Hospital staff in 2012 regarding the correct admission status for patients, billing, and the impact that RACs auditors have on the hospital
A standard is a statement of excellence, or an explicit predetermined expectation that defines the key functions, activities, processes and structures required for healthcare facilities to assure the provision of safe and quality care and services.
Standards are developed by peer experts in the field and it is against the standards that conformity of the healthcare facility is evaluated. Simply stated, the standard describes a healthcare facility’s acceptable performance level. Broadly speaking, CBAHI’s standards are of three major types depending on which area they are addressing.
Credentialing refers to the process of collection and verification of the evidences of credentials of a doctor who is to be given the responsibility of
treating patients in the hospital. The process
ensures the authenticity of the details provided
by the healthcare practitioner or doctor.
Admission Disposition: Inpatient or Outpatient Observationampeterson03
This was a staff presentation for Rio Grande Hospital staff in 2012 regarding the correct admission status for patients, billing, and the impact that RACs auditors have on the hospital
A standard is a statement of excellence, or an explicit predetermined expectation that defines the key functions, activities, processes and structures required for healthcare facilities to assure the provision of safe and quality care and services.
Standards are developed by peer experts in the field and it is against the standards that conformity of the healthcare facility is evaluated. Simply stated, the standard describes a healthcare facility’s acceptable performance level. Broadly speaking, CBAHI’s standards are of three major types depending on which area they are addressing.
Credentialing refers to the process of collection and verification of the evidences of credentials of a doctor who is to be given the responsibility of
treating patients in the hospital. The process
ensures the authenticity of the details provided
by the healthcare practitioner or doctor.
Compliatric continuous compliance series chapter 5Compliatric
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.
This month’s webinar will focus on the following chapter:
Chapter 5: Clinical Staffing
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
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.
This month’s webinar will focus on the following chapter:
Chapter 5: Clinical Staffing
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
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 5: Clinical Staffing
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
Nursing Audit Dr. Rangappa. S .Ashi SDM Institute of Nursing sciences Shri D...rangappa
Nursing audit one of the control tools, responsible for controlling the activities of the nurses that focuses on providing the best possible nursing care. The actual nursing rendered is compared with the standards. This is mainly refers to clinical nursing audit. The nursing management audit is an evaluation of nursing management as a whole. It is critically examination of the entire nursing management process.
Explain the relevance that medical standards of practice have to one.pdfjyothimuppasani1
Explain the relevance that medical standards of practice have to one as a practioner?
Solution
\'Providing care\' incorporates, however isn\'t restricted to any care,
treatment, counsel, administration or merchandise gave in regard
of the physical or emotional well-being of a man, regardless of whether
compensated or genius bono.
\'Practice\' implies any part, regardless of whether compensated or not,
in which the individual uses their aptitudes and learning
as a specialist in their controlled wellbeing calling. For
the motivations behind this Code, rehearse isn\'t limited to
the arrangement of direct clinical care. It additionally incorporates utilizing
proficient learning in a direct nonclinical relationship
with patients or customers, working in administration,
organization, instruction, look into, warning, administrative or
arrangement improvement parts and whatever other parts that effect
on sheltered, powerful conveyance of wellbeing administrations in the wellbeing
calling.
Keeping up and creating learning, aptitudes and
proficient conduct are center parts of good practice.
This requires self-reflection and support in pertinent
proficient advancement, rehearse change and
execution evaluation procedures to persistently create
proficient capacities. These exercises must proceed
through a specialist\'s working life as science and
innovation create and society changes.
giving specialists who are patients or customers with
a similar nature of care gave to different patients or
customers
b). informing the sheets if treating another enrolled
specialist who has set patients or customers in danger
of significant mischief while rehearsing their calling
since they have an impedance (allude to the
board\'s rules on compulsory detailing) this is a
proficient and also a statutory obligation under
the National Law
At the point when specialists are engaged with look into that includes
patients or customers, great practice incorporates:
a). regarding the privilege of patients or customers to pull back
from an investigation without partiality to their treatment
b). guaranteeing that a choice by patients or customers not to
take an interest does not bargain the specialist
tolerant/customer relationship or the care of the patient or
customer..
1. Is it important the hospital to have a licensure to ensure that.docxambersalomon88660
1. Is it important the hospital to have a licensure to ensure that the licensees the minimal degree of competency necessary to ensure that public health,. safety, and the welfare are protected. Typically, they are granted at the state level, if the individual works in multiple jurisdictions, then they must licensed in each jurisdiction. Which the government authorize for grants permission to an individual practitioner or health care organizations to operate or to engage in an occupation or profession. Lincensure regulations are generally established to ensure that an organization or individuals is usually granted after some form of examination or proof of education and may be renewed periodically through payment of a fee and or proof of continuing education or professional competence. Organizational licensure is granted following an on site inspection to determine if minimum health and safety standards have been met. Maintenance of licensure is an on going requirement for the health care organization to operate and care for patients. Requirements needed to deliver when comes to health care to maintaining the licensure. Maintain the quality as new technology, financial resources, improve quality such to reduce waiting time, and implementing process to reduce the rate post operative infections.Ensure public safety the hospital is responsible the patients will not be harmed, responsibility to comply with laws and regulations related to public safety, and reduce staff injury within the organizations. When a hospital don't have a licensure some of them when dont follow rules such malpractice insurers, when don't comply with Joint Commission could seem poor management.
2. The general public does not have adequate information to judge provider qualifications or competence; thus, professional licensure laws are enacted to assure the public that practitioners have met the qualifications and minimum competencies required for practice. Licensure by a governmental agency signifies that the individual has met the minimal degree of competency and proficiency needed to ensure the safety and well-being of the consumer, clients or population being served. Licensure is necessary when the regulated activities are complex and require specialized knowledge and skill and independent decision making. The licensure process determines if the applicant has the necessary skills to safely perform a specified scope of practice by predetermining the criteria needed and evaluating licensure applicants to determine if they meet the criteria. Typically, licensure requirements include some combination of education, training and examination to demonstrate competency. Licensure requirements also involve continuing education, training, and, for some, periodic re-examination. If a hospital did not have this licensure there would be chaos. Readmission rates would be high, there would be no set standards of practice, no protocols or rules to follow and there would be confusion wit.
2. THE PRACTITIONER APPRAISAL
PROCESS
CREDENTIALING OF LICENSED
INDEPENDENT PRACTITIONERS
Credentialing and privileging (in provider
organizations) are processes of confirming the
clinical competence and professional
performance of, at a minimum, all licensed
independent practitioners
3. A licensed independent practitioner (LIP) is
any individual who is professionally licensed
by the state (U.S.) and permitted by the
organization to provide patient care services
without direction or supervision, within the
scope of that license
4. Core Criteria for credentialing /
privileging
Four core criteria that help validate the
practitioner's skills and physical and mental
ability to discharge patient care
responsibilities:
1-Current licensure
2-Relevant training and experience
(professional schools, residencies,
fellowships, postdoctoral programs, board
certifications, clinical certifications)
5. 3-Current competence (informed opinions
from authoritative sources concerning
current clinical judgment and technical
skills, peer recommendations);
4-Ability to perform the privileges requested
or essential functions of the position
6. General Competencies for
Credentialing / Privileging
Patient Care: "Provide patient care that is
appropriate, and effective for the promotion
of health, treatment of disease, and at the end
of life";
Medical/Clinical Knowledge: "Demonstrate
know/edge of established and evolving
clinical, and social sciences and apply to
patient care and education of others";
7. Practice-based Learning and Improvement: "Be
able to use scientific evidence and methods to
investigate, evaluate, and improve patient care
practices";
Interpersonal and Communication Skills:
"Demonstrate interpersonal and communication
skills that enable them to establish and maintain
professional relationships with patients, families,
and other members of health care teams";
8. Professionalism: "Demonstrate behaviours that
reflect a commitment to continuous professional
development, ethical practice, an understanding
and sensitivity to diversity and a responsible
attitude toward their patients, their profession
and society";
Systems-based Practice: "Demonstrate both an
understanding of the contexts and systems in
which health care is provided, and the ability to
apply this knowledge to improve and optimize
health care. "
9. Credentialing/Re-credentialing Process
Definition: The verification of the
practitioner's right and competency to provide
patient care in the appropriate setting.
10. Criteria of Credentialing / privileging
Current, valid license to practice
Current competence
History of loss of license and, history of loss or
limitation of privileges or disciplinary actions .
Evidence of physical ability to perform the requested
privilege (or) inability to perform essential functions
of the position
11. CLINICAL PRIVILEGING/REPRIVILEGING
PROCESS
Clinical privileging and re-privileging
cannot be centralized. This process must
always be setting-specific, based on services
available, so it has to be accomplished at each
provider site
12. Definition: "Privileging" means granting
permission to provide specific medical
or other patient care services in the organization,
within well-defined limits, based on the
individual's professional license and his or her
experience, competence, ability, and judgment
and on the organization's ability to provide and
support the service.
13. Delineation of privileges: Clinical privileges are
granted individually, based on criteria established
by the organization, usually using privilege control
sheets that are specific to each department, section,
service, or specialty. The criteria determine the
level of competency appropriate for each privilege,
e.g., the number of procedures that
must be performed every two years for the
practitioner to be considered currently competent
and to retain the privilege
14. Privilege status
Temporary: Temporary privileqe to practice until
credentialing and individual privilege delineation has been
processed and approved by the governing body.
Approved: Delineated privileges approved for the time period
specified by the institution, but never longer than two years
Emergency: Any practitioner is permitted to do everything
possible to save a life or protect a patient from further or
serious harm within the scope of his/her license, regardless of
membership status, credentialing status, or approval of
specific privileges.
15. Proctoring
As part of the process of granting initial
privileges or a new privilege to a practitioner,
proctoring by peers (observation and/or a
review of cases) may occur within guidelines
established in the medical/professional staff
bylaws, rules and regulations, medical staff
department.
16. PRACTITIONER PROFILING
Represent a performance monitoring and
analysis, helping to effectively communicate
appropriate findings to those leaders who
need to know.
Profiles are practitioner-specific data and
information summaries used in the reappraisal
process, usually in conjunction with re-
credentialing and re-privileging activities.
17. Ideally profiling should be as concurrent as
possible, with review, analysis, and
reporting at least quarterly, to identify better
practices, as well as permit appropriate
intervention in quality of care and patient
safety issues.
18. Profiling in Hospital process
All independent practitioners with delineated clinical
privileges, whether or not they are medical staff
members, are profiled, based on an ongoing
measurement process. Department chairs, section
chairs, medical/clinical directors, or chief medical
officers, depending on the setting and structure, must
review the profile data for both positive findings and
any areas of concern.
19. Practitioner profiles
Used in :
1-Monitoring of clinical processes, e.g., mortality review
findings; peer-reviewed events with rating below standard of
care; performance on core measures.
2--Use of operative and other procedures placing patients at
risk, e.g., unplanned return to operating room;
--Use of medications, e.g., use of preoperative antibiotics; use
of beta blockers post CABG
--Use of blood and blood products, e.g., usage not meeting
criteria after peer review (inpatient and outpatient )
20. 3-Significant infection surveillance
findings,
4--Utilization management findings, e.g.,
readmissions related to previous
hospitalization w/in 31 days; total
inpatient stays and average length of stay ,
total inpatient and outpatient procedures;
5--Pharmacy and therapeutics function
21. 6-Patient safety findings, including adverse
events, root cause analyses;
--Risk management findings;
7---Medical record review.
8--Pertinent findings/successes resulting
from QI Team activities;
22. 9-Pertinent findings from external review,
including the Quality Improvement
Organization (QIO), State Department of
Health, private review and case
management companies.
10-Information concerning patient care
activity in the organization, e.g., numbers
of patients admitted or treated, numbers
and types of procedures performed;
23. 11-Outpatient activity, e.g., unscheduled
inpatient admissions due to adverse
outcome from outpatient procedure;
12--Information concerning fulfillment of
administrative responsibilities, e.g.,
meeting attendance, committee
membership, QI team participation,
productivity, etc.;
24. Practitioner profiles must:
-Be maintained in a strictly confidential
environment, As part of a credentials file
or In a separate locked file, stamped as
"Confidential-Part of Credentials File.
-Be released only in accordance with bylaws, rules
and regulations, and/or policy, to authorized
individuals or committees, within the limits of
the law; Except for activity data, be comprised
only of peer-reviewed findings; raw data is
unacceptable, as it has not been validated
25. Be reviewed and signed off by:
--Medical directors and/or peer review
committee
--Department chairs, at the time of reappraisal
for reappointment to the medical staff and
re-privileging in hospitals; or
26. APPOINTMENT/REAPPOINTMENT
(Medical/Professional Staff Membership
• Eligibilitv: The medical/professional staff
includes fully licensed physicians and may
include other licensed individuals permitted
by law and the organization to provide
independent patient care services (e.g.,
psychologists, podiatrists, dentists).
27. Initial appointment is provisional
Initial appointment is provisional, with a time period
consistent for all applicants, generally 6 months to 1
year, as determined by the medical staff bylaws.
The full appointment period is also determined by
the bylaws, but cannot exceed two years, as The
Joint Commission accreditation standards require
renewal of privileges at least every two years.
28. Initial Appointment
Once the provisional time period has elapsed
and required proctoring is completed, the
practitioner is advanced to an active staff
(depending on the categories available and the
bylaws provisions)
29. Reappointment
Reappointment includes reappraisal of:
-Re-credentialing: Updated information concerning
current activity, licensure and certifications/
registrations, liabilities/claims leading to judgments
against the practitioner, and malpractice insurance
coverage;
-Current competency review (profile information):
Quality management activities; peer review activities
30. Reappointment
-Review of other reasonable indicators of continuing
qualifications, sometimes including attendance at
medical/ professional staff, department, and assigned
committee and team meetings;
-Peer and departmental recommendations;
-Review and renewal of specific clinical privileges
31. Reappointment
Compliance with continuing medical
education requirements.
Reappointment is granted for the time period
specified in the bylaws or policies/procedures,
but never for longer than two years, again
based on Joint Commission accreditation
standards requirement regarding renewal of
privileges.
32. PATIENT/MEMBER ADVOCACY AND
FEEDBACK PROCESSES
One of the most exciting results of the emphasis on
continuous quality improvement concepts is the
renewed interest in the patient/member as:
Integrally involved in, and controlling, his or her
care;
A "customer", with specific needs and expectations;
A "processor" and "supplier" in the process of
patient care;
Having very specific rights, as well as
responsibilities, within the process of care.
33. The Organization's Responsibilities to the
Patient/Member Include:
Respect for:
-The patient/member as an individual with unique
healthcare needs, including consideration of
psychosocial, spiritual, and cultural variables
influencing the perception of illness and
accommodation of right to religious/spiritual
services;
-Personal dignity and the right to considerate and
respectful care.
34. Reasonable responses to requests and needs for
treatment or service (access), including pain
management
Information concerning the patient's/member's
right, in collaboration with his or her physician
and to the extent permitted by law, to make
decisions regarding his or her care, treatment, and
services, including providing informed consent
and making the decision to refuse treatment.
35. Development of policies regarding provision or
withholding of resuscitation, life sustaining
treatment, and decisions concerning end of life
care and treatment;
Policies and procedures to both protect and
permit the exercise of patient/member rights,
including mechanisms for the communication of
needs, and resolution of patient/member
complaints or grievances
36. Protection, within the limits of the law, of
personal privacy, security, and
confidentiality of information; appropriate
consents obtained, including recording or
filming for purposes other than
identification, diagnosis, or treatment;
Freedom from mental, physical, sexual,
verbal abuse, neglect
37. Communication of information related to
ethical issues or human experimentation
or other research projects affecting his or
her care or treatment;
Protection as research subjects and
respect of rights during research,
investigation, and clinical trials;
38. Patient / Member Responsibilities to the
Provider of Care
Provide, to the extent possible, information
that providers need to care for them
Follow plans and instructions for care they
have agreed on with their practitioners and
Participate in understanding their health
problems and developing mutually agreed
upon treatment goals
39. Complaints , Grievances, and Appeals
Complaint: An oral or written expression of
dissatisfaction. A person "registers" a
complaint, generally about the processes of
care.
40. Grievance: A formal expression of
dissatisfaction, usually written but may be
oral. A person "files" a grievance,
generally about quality of care or financial
issues.
Appeal: A request to change a previous
decision made by the organization
41. PATIENT/MEMBER FEEDBACK
PROCESSES
Healthcare Quality and Customer Satisfaction
-Consumers will evaluate quality based on such criteria
as:
Access to practitioners
Geographical access
Service
Relationship/connectedness/affinity
Cost
42. Collection of Patient/Member Feedback
Feedback is based on perceptive quality and
may take the form of complaints, positive or
negative perceptions of care, or even
innovative ideas for improvement
43. Patient/member satisfaction and risk
management
Patient satisfaction is one of the key factors
in quality management and performance
improvement that provides perceptive
quality information and helps measure
outcomes of care and service.
Patient dissatisfaction is one of the key
factors in risk management that prompts
patient/family action to file a claim.
44. Patient feedback systems in loss prevention
and reduction
To establish effective outcome databases;
use of patient feedback in outcomes management
There must be a system of distribution of aggregated
patient feedback information to all who need to
know in order for appropriate response to take place:
45. Patient / Member Feedback Processes
-Surveys/questionnaires (written and Internet)
--Patient perception of care/satisfaction --Health
status
-Telephone and face-to-face interviews
-Focus group
Internet e-mail communications (questions,
comments, etc.)
-Complaint and grievance processes
46. PATIENT AND FAMILY EDUCATION
PROCESS
The educational assessment should:
-Address the relevant healthcare needs,
abilities, and readiness to learn;
-Include cultural and religious beliefs,
emotional barriers, desire and motivation,
physical and / or cognitive limitations, and
language barriers
47. The education should:
-Be understandable;
-Include instruction necessary to meet ongoing healthcare
needs, including, if relevant:
--Plan for care, treatment, and services
--Basic safety health practices
--Safe and effective use of medication
--Safe and effective use of medical equipment and supplies
--Education about pain management, including risk, assessment,
and methods
-for management --Potential drug-food interactions --Counseling
on nutrition and modified diets
48. REPORTING MECHANISMS
information for hospital governing body review may include :
-Activity: Admissions, patient days, encounters, etc., as
applicable
-Unplanned admissions / readmissions as defined by the
organization or the appropriate reference database;
-Discharges against medical advice
-Summaries of media stories;
-Satisfaction survey trends: patient, staff (professional and
organization);
49. REPRTING MECHANISM
Complaints: patient, professional staff,
organization staff;
-Pattern analyses of --Occurrences --Claims
--Mortalities
Summary utilization data: --Average length of
stay --Cost per case --Cost avoidance
50. REPORTING MECHANISM
Rates: --C-sections --Mortalities, e.g.,
neonatal/maternal
--Medication errors
--Healthcare-associated infections, e.g., surgical site,
outbreaks
A balanced scorecard/dashboard is a good way to
organize the data, with key performance measures
supported by other department/service measures as
relevant
51. EVALUTAION OF QM / PI FUNCTION
Evaluation of QM/PI activities is critical to
determine whether processes in the
organization have really improved and
whether strategic and operational goals and
objectives have been met.
52. COMPONENTS OF EXCELLENCE
Valid, reliable data and information about
important functions and associated processes
of care and service and patient safety;
Collaboration for continuous improvement in
organizational performance by all appropriate
leaders, medical staff, departments/services,
cross-functional teams, and committees;
53. Timely assessment of data to identify significant
variations in processes and outcomes, both
undesirable and best practices;
Identification and prioritization of quality activities ,
performance measures, variances, and other
opportunities to improve care and. services;
Validated effectiveness of actions/strategies
implemented to improve care processes;
54. Communication of clear information across
and within all appropriate
departments/services, organizations, etc.;
Complete documentation and follow-up;
Evidence of supportive QM structure and
systems, including information
management
55. Evidence of support and involvement of all
key leaders;
Integration with all other pertinent activities,
including utilization management, risk
management, and safety;
Ongoing quality education efforts
organization wide.
56. Any of these components can be prioritized
as annual objectives for organization wide
quality strategy improvement or as a
checklist for annual evaluation of
effectiveness of the function.
57. EVALUATION OF PI PROCESSES AND
OUTCOMES
Evaluation of quality
management/performance improvement
activities must address their relevance to the
organization's mission, vision, and strategic
plan
58. Process effectiveness:
Viability of the Plan, given current resources,
including the practicality of OM/PI activities;
-Ability to measure patient outcomes and
improvement in the quality of patient care
(utilizing as many outcome parameters as
possible);
-Accurate communication of information to
the appropriate persons, teams, committees,
board, or other groups;
59. Documentation to support compliance with The
Joint Commission, NCOA, and other standards
and state and federal regulations, as applicable;
-Cost-effectiveness and efficiency benefits of the
activities;
Patient and staff safety benefits of the activities;
-Ability of all QM/PI activities to assess customer
needs and expectations and to meet or surpass
those needs.
60. Outcome effectiveness:
-Degree to which Strategic Ouality Initiatives
were met;
-Degree to which outcome objectives for
quality initiatives were met;
-Comparison of current performance
measures (indicators) with previous ratings
61. -Comparison of the current findings from patient
and staff surveys/questionnaires with previous
measures;
-Evidence of improved clinical performance;
Amount of new information available to leaders
for the next planning period: --Strategic and
quality goals; --Organizational objectives;
--Strategic Ouality Initiatives.
62. Evaluate QM activities
-Are strategic goals and objectives being met?
-Are program strengths being maintained?
-Are weaknesses being corrected?
-Are quality objectives and activities meeting current
standards, regulations, and other review
requirements?
-AreQM/PI activities comprehensive, including all
relevant disciplines, teams and committee -Is OM/PI
activity coordination efficient and effective?
63. Are QM/PI activities supported by the governing
body, administration, and physicians/LIPs?
Does each understand their role and
responsibilities?
-Are important and meaningful problems and
issues identified, analyzed, and resolved?
-Are all appropriate and available data sources
being utilized to support teams and to measure
and assess performance?
-Are predetermined, valid performance measures
used when appropriate?
64. Are data aggregated, displayed, analyzed,
trended, and reported?
-Are improvements recommended?
Are they implemented?
Are they evaluated for effectiveness?
-Are all OM activities adequately and accurately
documented?
-Are reporting mechanisms adequate (frequent
enough; to all appropriate persons, departments,
teams, committees, settings; clear communication
tools)?
65. • Methods of evaluation
Review of patient processes and outcomes
(data summaries, activity reports, critical
events, claims information);
-Review of perceptions and attitudes
(observation, interview, questionnaires,
complaints);
Review of services (availability, timeliness,
and quality based on critical events, adverse
outcomes, patient satisfaction).
66. Infection Prevention and Control
Infection: "The transmission of a pathogenic
microorganism to a host, with subsequent
invasion and multiplication, with or without
resulting symptoms of disease." [The Joint
Commission]
67. Healthcare-associated (nosocomial): Infections
that patients acquire during the course of
receiving treatment for other conditions or that
healthcare workers acquire while performing
their duties within a healthcare setting. [CDC]
Iatrogenic: An infection or other complication of
treatment induced in a patient by a physician's or
other licensed independent practitioner's activity,
manner, or therapy
68. Epidemic infection: .~ higher than expected level of
infection by a common agent in a defined population during a
defined period.“
individuals with a healthcare-associated infection
The ratio describing the number of individuals with a healthcare-
associated infection [numerator] divided by the number of
individuals at risk of developing healthcare-associated
infections [denominator], for a specified group, e.g., surgical
site infections, probably stratified by type of procedure,
condition, location (geographic or body part), etc., based on
the organization's population and experience
69. Goal and scope
Goal: "...reduce the risk of acquisition and
transmission of health care-associated
infections
Evidence of goal achievement: Reduced
healthcare-associated infection rates.
70. Scope of the function:
Coordination of all activities related to the
surveillance, prevention, and control of
healthcare associated infections;
- Linkages with support systems to reduce the
risks of infection from the environment,
including food and water sources.
71. Responsibilities of the QC ,team or
committee
Approval of the type and scope of surveillance
activities, including data collection and analysis
methodologies;
-Approval of actions taken to prevent or control
infections
Documentation in minutes of conclusions,
recommendations, actions, and person(s) responsible
for implementation of action;
72. Responsibilities of the QC or Committee
Communications to the medical executive
committee, if applicable, CEO, nurse
executive, persons responsible for
organization wide quality management
activities, and governing body;
--Review and approval of all infection control
policies and procedures;
73. Responsibilities of the infection control
professional
-Development and management of
policies/procedures/processes; -Participation
in strategic and other organizational planning;
-Participation in organization wide PI
activities/strategic initiatives;
-Quality control/monitoring/review of equipment
and/or processes
74. Responsibilities of the infection control
professional
Budgeting/management reporting (Infection
control needs, occurrences, etc.);
-Participation in safety inspections,
emergency/disaster preparedness, drills;
-Participation in space, resource, and service
allocation;
-Staff performance evaluation/competency
review
75. Responsibility as a patient safety activity
Preventive activities :
Policies and procedures, education, and infection
control measures
Surveillance :
case finding, investigation of significant infections,
data analysis, and reporting
-All of these processes and steps have as their goal a
safe experience for the patient and should be
integrated with the patient safety program
76. The Joint Commission states that a
healthcare-associated infection involving a
death or permanent disability should be
considered a sentinel event, requiring
intensive analysis and root cause analysis
The key element is collaboration among
infection control professionals, physicians,
other clinical staff, administrative directors,
and others as identified.
77. A typical hospital policy statement
It might read: "Healthcare-associated
infections are defined as those infections not
present or incubating at the time of
admission.
78. As a rule, an infection will be considered
healthcare-associated if there is documentation of
infection occurring 48 hours after the admission
date, or if the physician indicates a diagnosis of
healthcare-associated infection.
Specific criteria will be used for identifying
healthcare-associated infections by site, based on
the guidelines established by the Centers for
Disease Control and Prevention.
These guidelines shall be approved by the
[Infection Control] Committee and the [Medical
Executive] Committee [or Quality Council]. "
79. Disease surveillance
It is an epidemiological practice by which the spread
of disease is monitored in order to establish patterns
of progression. The main role of disease surveillance
is to predict, observe, and minimize the harm caused
by outbreak, epidemic, and pandemic situations, as
well as increase our knowledge as to what factors
might contribute to such circumstances. A key part
of modern disease surveillance is the practice of
disease case reporting.
81. Minimal Requirements for Surveillance
Monitor infection patterns (sites, pathogens, risk
factors, location within the facility)
Detect changes in the patterns that may indicate an
infection problem
Direct the rapid implementation of control measures
Monitor antibiotic use and resistance
Provide the staff with exactly the information they
need in order to improve infection prevention
practices.
82. Types of surveillance approaches include:
100% surveillance
--Detection and recording of all healthcare-associated
infections occurring on every service in every area at
every setting;
--Calculation of infection rates to identify potential
infection problems in specific areas;
--Appropriate analyses include collection of
denominators;
--Continuous conduction (e.g., lab report screening) or
periodically (e.g., 100% every 3 months for 1
month).
83. Types of surveillance approaches include
Priority-directed, targeted surveillance
--Specific services, e.g.:
-All patients in surgical settings;
-All patients in special care areas in hospitals
84. Priority-directed, targeted surveillance
Targeted patient populations (disease-specific
or based on adverse occurrence), e.g.:
---All patients with Class I surgical wounds who
develop infections;
---All patients on ventilators who acquire
pneumonia;
---Patients developing infection from certain
antibiotic-resistant bacteria.
85. Priority-directed, targeted surveillance
Procedures, e.g.:
--All ambulatory cardiac and orthopedic surgical
procedures;
---All Swan-Ganz catheter insertions in
hospitals.
86. Types of surveillance approaches
C-Problem-oriented or outbreak response
surveillance
--Conducted to measure the occurrence of specific
infection problems;
--Further evaluation as necessary, collecting
comparable data from control groups to identify risk
factors and appropriate control measures;
--Continued surveillance to determine effectiveness
of control measures
87. Standards for infection control
• CDC guidelines as infection control standards
The CDC has specific guidelines for prevention
of healthcare-associated infections, e.g.,
pneumonia, surgical site, intravascular device,
catheter associated urinary tract, isolation,
environmental, hand hygiene, personnel
safety, home care, long term care.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr521