Consultative Support and Governing Bodies Flashcards
Governing body
a. organizations incorporated by state charter are required to have this
b. carries legal authority and responsibility for all care provided by organization
Factors that impact board’s ability to effect change
a. size and structure of board
b. experience and knowledge of it’s members
c. management infrastructure, including leadership, objectives, agendas, meetings, education, and assessment
d. functions, roles and responsibilities, such as formulating vision and strategic goals, ensuring quality, developing policies, decision making, and oversight
To integrate quality findings into governance and management activities ______ to ________ is required.
a. governing board and administration must commit
b. restructuring and re-engineering
Findings must be incorporated into___.
strategic goals
Broad changes required of process:
a. Aligning payment and incentive systems, to tie rewards into clinical objectives for improving healthcare
b. Establishing a new culture of organization-wide management, rather than focusing management on departments
c. Integrating the administrative and management infrastructure to include planning for resource allocation, marketing, human resource development, and quality care
d. assessing populations to determine needs within the community
e. Providing services in accordance with needs assessment, including adequate access to services
f. utilizing technology for assessment and evaluation
g. establishing critical care pathways and protocols, and utilizing continuous improvement processes with interdisciplinary teams.
h. Establishing case management
By-laws
define lines of authority, responsibility, accountability, and communication within organization.
Functions of by laws
a. specify formation and structure of governing board, and procedures for selecting officers and committees
b. establish relationship between governing board and medical staff and define conflicts of interest
c. specify lines of authority and responsibility at all levels in the organization related to quality, safety, patient care, credentialing, privileging, and process improvement
d. Budget development (central purpose of governing board).
What are strategic goals?
Based on quality findings and input from quality professionals, board must ensure integration of the findings into governance and management.
Governing board must:
a. provide organization wide support for strategic goals
b. Utilize performance improvement measures as part of business planning and resource allocation
c. support use of performance measures to provide current information about performance organization wide, such as balanced scorecards or dashboards
d. provide resources for education and training
Managers must:
a. exhibit commitment to performance improvement and create a culture of quality
b. empower staff to facilitate change
c. provide adequate training, support, and resources for performance improvement activities
d. participate in the quality improvement process and incorporate it into job descriptions
e. evaluate compliance with quality performance goals
f. monitor effectiveness of performance activities and conduct evaluations
g. provide continuous education regarding quality performance to all levels of the organization
h. provide reports and education to the governing board
To integrate recommendations into organization:
a. Administrative commitment to utilize resources to meet and exceed recommendations
b. Organization wide education of standards and compliance issues
c. root cause analysis to determine areas of improvement
d. Utlization of analysis as part of peer review and/or performance appraisal
e. planning and development of action plans for improvement
f. implementation of action plans
g. ongoing assessment and modification of plans as needed to achieve target outcomes
h. evaluation of action plans in a report to the governing board
