issues trends and health policy Flashcards
What are your 2 priorities in therapeutic communication for crisis/acute grief?
acknowledge feelings, offer self
Advance Directive x3
written statement of intent regarding medical treatment
- aka Healthcare Directive
- may include Living Will and/or specifications regarding Durable Power of Attorney (1 or 2 separate documents)
- Patient Self-Determination Act of 1990
Patient Self-Determination Act of 1990
All patients entering hospital MUST be advised of their right to execute an advance directive
Living Will x2
compilation of statements that specify which life-prolonging measures one does AND does not want if incapacitated
- can designate DPOA
Durable Power of Attorney x3
- designated in Living Will
- authorized to make medical decisions if pt incapacitated
- responsible for articulating Advance Directive
COBRA
protects health insurance coverage for workers + fams in if job loss/change
- aka Title I of HIPAA
Patient Safety Rule
Protects patient information to analyze patient safety events and improve
The Privacy Rule: Patient’s Rights x6
- see/receive copy of records
- have corrections added
- receive notice (how info used/shared)
- give permission before info can be used/shared
- receive report: why info was shared
- file complaints if rights denied/info not protected
Patient Safety and Quality Improvement Act (PSQIA) x5
voluntary reporting system, federal privilege
- assess/resolve patient safety & healthcare quality issues
- pt safety info called “pt safety work product”
- providers report/examine events w/o fear of increased liability risk
- Agency for Healthcare Research and Quality (AHRQ) lists pt safety orgs (PSO): external experts that collect/analyze info
Duty to Warn x2
supersedes confidentiality if
- patient’s condition may endanger others
- patient may harm self (protect them!)
Patient is diagnosed with HIV. Duty to Warn applies how?
notify providers, not family
invasion of privacy
damaging reputation d/t sharing info without pt permission
Invasion of Privacy does not apply in what circumstances?
info is accurate & given in good faith
received has valid reason to obtain info
- REMEMBER - when initiating any change in health care delivery
chain of command: hospital, community, region, state, national
- strongest method to evaluate teaching
returned demonstration
- “show me”, “tell me”, grand rounds
when to transfer to teritary care facility?
what is the process? x4
usual scenario: seriously ill/injured patient @ community hospital
- assess all injuries
- stabilize
- assess facility capabilities
- transfer as appropriate
If a patient is reluctant to undergo diagnostics/procedure, what is your priority step?
full educate patient regarding their condition
what is your next step if you are about to discharge a patient (hospital/acute care facility) and they need a screening exam?
DO NOT DELAY DC. Refer to PCP.
- for screening exams that are not vital
most powerful data collected from patient
- their subjective data
- data you observed yourself
caution with interpreting family, friends, others
RN calls you, the night shift NP, and states patient is decompensating. When do you call primary MD?
when patient status changes
What is a scenario in which admitting a patient to a SNF would be the best action?
needing assistance with ADLs
Goals of Healthy People 2020 x2
- increase quality & years of healthy life
- eliminate health disparities among americans
Healthy People 2020 purpose x2
- understand health status of the nation
- plan prevention programs
NP must notify State Health Department of which 5 infectious diagnoses?
gonorrhea chlamydia syphillis HIV TB
NP are required to report… x4
- criminal acts & injury from dangerous weapon = police
- ID: gonorrhea, chlamydia, syphillis, HIV, TB = health dept
- animal bites = animal control (DHHS)
- suspected/actual child/elder abuse (police via social services)
occupational vs physical therapy
physical therapy: strength & coordination
occupational: fine motor skills, swallow test
Medicare
- third party payer -
sets standard for reimbursement & cutting costs
covers 65+ & diabled
Medicaid
- third party payer -
federally supported, state administered
for impoverished fams/individuals
- benefits vary by state
- payments made after other insurance/third party pays
Medicare A
x5
covers inpatient, SNF, home health, hospice assoc w inpt event
most qualify at 65
Medicare B
supplemental with a premium
- physician services, oupt services, labs/diagnostics, med equipment
Medicare B covers how much of bill
80% + patient pays 20%
Medicare D
LIMITED prescription drug coverage w MONTHLY premium
- co-pay for each prescription
- penalty possible if not enrolled when first eligible
- assistance available for those w limited income, resources
Does “direct supervision” require MD to be physically in the room with NP to be eligible for “incident-to” billing
NO, but must be in same office suite and immediately available
Does “incident-to” billing apply in the inpatient setting?
No. NP must bill under their provider number in the hospital setting.
root cause analysis is…
a tool for identifying prevention strategies to ensure safety
- part of the process of building a “culture of safety not a culture of blame”
- interdisciplinary, experts, impartial
- ask why and ID changes needed
Debriefing after an event is an example of what concept?
root cause analysis
sentinel events are…
unexpected occurrences involving death, serious physical or psychological injury, or risk thereof
“sentinel” = immediate investigation/response needed!
Sentinel Event and medical error
not synonymous
not all sentinel events occur because of an error
not all medical errors result in a sentinel event
Response to Sentinel Event
Root Cause Analysis
Scope of Practice
- legal allowances based on individual STATE Nurse Practice Act
- guidelines for nursing practice, key elements of NP role
How can the ACNP demonstrate/advocate for full scope of practice?
by billing independently
State Nurse Practice Acts
authorizes State Board of Nursing to establish statuatory authority for licensure of RNs
- authority over: use of title, scope of practice including prescriptive authority, disciplinary grounds
- states vary in requirements
What dictates prescriptive authority of NPs?
State Nurse Practice Acts
State Board of Nursing
what are NP credentials? x4
required education + licensure + certification to practice as NP
establishes MINIMAL levels of acceptable performance (scope of practice, accountability, professional standards)
licensure
GOVERNMENT: granted by State Board of Nursing
- establishes qualification to perform specific role
certification
NON-GOVT: granted by agencies like ANCC, AANP
- establishes certain STANDARDS met which signify MASTERY of specialized knowledge/skills
licensure vs.certification
licensure: STATE board
certification: NON-GOVT agency, like ANCC
credentialing & privileging
process through which NP granted permission to practice w/in inpatient setting
- via Hospital Credentialing Committee
Hospital Credentialing Committee
grants hospital privilege credentials to NPs
- comprised of physicians w privileges at said hospital
Most common method of documentation in Risk Management?
incident reports
medical futility
interventions unlikely to produce significant benefit
- two types: quantitative vs qualitative
“does the intervention have any reasonable prospect of helping this patient?”
qualitative futility
type of medical futility: quality of intervention benefit is extremely poor
competence is…
decisional capability; state in which pt can make personal decisions about care
- implies ability to understand, reason, differentiate good/bad, communicate
informed consent
state in which pt has rec’d adequate instruction/info regarding aspects of care to make prudent, personal choice regarding tx
- all risks/benefits included
- assumed if life-threatening condition
informed consent if life threatening condition
assumed
ethics
study of moral conduct & behavior
- governs conduct & therefore protects individual rights
NONMALEFICENCE
duty to do no harm
UTILITARIANISM
right act = greatest good for greatest number
BENEFICENCE
duty to prevent harm & promote good
JUSTICE
duty to be fair
FIDELITY
duty to be faithful
VERACITY
duty to be truthful
AUTONOMY
duty to respect individual’s thoughts/actions
How long must medical records be kept after practice closes?
5 years, minimum
three reasons NPs expanded to inpatient setting
managed care
hospital restructuring
↓ medical residency programs
NON-EXPERIMENTAL RESEARCH DESIGN
“no experiment” design
- includes descriptive & ex post facto/correlational research
DESCRIPTIVE STUDY
DESCRIBES situations, experiences, phenomena as they exist - a type of non-experimental design
EX POST FACTO/CORRELATIONAL STUDY
EXAMINES relationships among varables - a type of non-experimental design
CROSS SECTIONAL STUDY
population has a very similar attribute but differs in one specific variable (ex: asthma / age)
finds relationships between variables @ SPECIFIC POINT IN TIME
COHORT STUDY
COMPARES PARTICULAR OUTCOME in groups of individuals who are mostly alike but differ by specific characteristic
ex: lung cancer in female RN smokers vs non-smokers
LONGITUDINAL STUDY
multiple measures of population over an extended period to find relationships between variables
EXPERIMENTAL RESEARCH DESIGN
manipulation of variables using RANDOMIZATION & CONTROLS to test effects of intervention/experiment
QUASI-EXPERIMENTAL RESEARCH DESIGN
manipulation of variables that lacks randomization or controls/comparisons
QUALITATIVE RESEARCH DESIGN
- case studies
- open ended questions
- field study
- participant observation
- ethnographies
explore phenomena via detailed descriptions of people, events, situations, observed behavior; v rich data!
two potential problems of qualitative research
- researcher bias
- generalizability?
level of significance
probability of false rejection of the null hypothesis in a statistical test
- used to establish statistical significance; p value
p value
level of significance
t test
statistical test evaluating difference in means between two groups
RELIABILITY
degree to which instrument measures a population the same way over time
- consistency of measurement
- estimates repeatability of measurement
- reliable = exam score on same test similar when given twice
RELIABILITY: TWO WAYS TO ESTIMATE
test/re-test: more conservative
internal consistency: estimates reliability by grouping questions in questionnaire that measure same concept
- run correlation between two different tests with similar questions
2 administrations of test vs 1
VALIDITY
degree to which a variable measures what it is intended to measure
LIABILITY
Legal responsibility that NP has for actions that fail to meet standard of care resulting in actual or potential harm to patient.
STANDARDS OF CARE
criteria to measure whether negligence has occurred
NEGLIGENCE
Failure of an individual to do what a REASONABLE person would do, resulting in injury to the patient.
NP fails to do an EKG on a patient presenting with chest pain. This is an example of which legal term?
negligence
MALPRACTICE
Failure to render services with the degree of care, diligence, & precaution that another member of same profession under same circumstances would do to prevent injury to patient.
Can include:
- professional misconduct
- unreasonable lack of skill
- illegal/immoral conduct
- other allegations resulting in harm to patient
four scenarios that could contribute to malpractice
- professional misconduct
- unreasonable lack of skill
- illegal/immoral conduct
- other allegations resulting in harm to patient
ASSAULT
intentional act to create apprehension re: imminent harmful/offensive contact
- threat of bodily harm coupled with present ability to cause it
Shaking a fist in the air at someone is an example of which legal term?
assault
BATTERY
illegal, willful, angry, violent, or negligent striking of person, clothes, or anything with which person is in contact
Maliciously striking anything near a person with which they are in contact is an example of which legal term?
battery
assault & battery on an unconscious person
you can commit battery but not assault on an unconscious person
DEFAMATION
communication that causes someone to suffer a damaged reputation
- two kinds: libel & slander
LIBEL
defamation via written material
SLANDER
spoken defamation (to other than defamed party)
Can NPs order restraints?
Yes. Document why restraints are being ordered.
What is the degree to which an instrument works the same way over time?
reliability
How is an advanced directive different from a living will?
Advance directive a component of a living will
Living will designates power of attorney
Can you tell a wife her husband has HIV?
No; encourage husband, “if you were her, wouldn’t you want to know?”
ICU patient is improving but fails a swallow eval. What is your next action?
Patient does not need ICU. Transfer to sub-acute, not med-surg.
Hispanic M does not speak English and you are evaluating pain. What do you use?
Visual pain scale
25 yo. M s/p MVC and cannot feed himself. Who do you consult?
Occupational Therapy
What is the best way for a NP to get involved with policy change?
Join a hospital committee
Family is struggling with father’s declining condition. Before you consult palliative care you should?
Find out if the patient has advance directive.
Your patient is worried about insurance coverage. What should you do?
Consult case management
What is the most important variable in determining significance of research (before implementing the findings)?
Sample size
Who grants a NP permission to practice in the inpatient setting?
Hospital Credentialing Committee
An ACNP notices an MCV and stops at the scene to offer assistance. Which of the following statutes protects the CNP from malpractice in this situation?
Good Samaritan statute
The Federal 1999 Balanced Budget Act allowed for:
Medicare reimbursement for advanced practice nurse services
The ACNP is involved in outcomes research. All of the following are examples of patient outcomes EXCEPT:
a. patient satisfaction
b. length of stay
c. mortality statistics
d. peer review
D. Peer review is not a patient outcome
The nurse practitioner role in research includes:
Utilizing research findings in implementation of guidelines for patient care (evidence based practice)
The ethical principle of “first do no harm” is…?
non-maleficence
35 yo. M is admitted to the hospital with viral PNA. During his hospitalization an HIV test is drawn and it is positive. Pt is married with two small children and states that he will not tell his wife or you have to do it. What is the most appropriate next step in the management of his care?
Explain to him the importance of informing his wife and offering support. Telling the wife would be a breach of confidentiality.
The Medicare program is administered by the:
Health Care Financing Agency
A healthcare plan in which nurse practitioners and MDs are employed directly by the health plan is:
a staff-model health maintenance organization (HMO)
Which of the following services are reimbursed by Medicare:
a. home health aids
b. physical therapy
c. skilled nursing services
d. all of the above
D. all of the above
Health Maintenance Organizations (HMOs) are
a health plan that provide both inpatient and outpatient services through a referral system
The most common mental illness in young adults?
schizophrenia
therapeutic communication tips x5
- listen more than talk
- “tell me…”
- never ask “why?”
- focus on feelings (mad, sad, glad, afraid, ashamed)
- no euphemisms, be blunt
What are your 2 priorities in crisis intervention?
- ensure safety/boundaries (security if necessary)
- establish trust/rapport
HIPAA: Title I
protects health insurance coverage for workers + families if job loss/change
- aka COBRA
Who enforces HIPAA?
Office for Civil Rights
HIPAA: Title II
aka Administrative Simplification provisions
- national standards for electronic health care transactions
- national IDs for providers, health insurance plans, employers
What are the priorities of the Office for Civil Rights to enforce HIPAA?
PRIVACY: individually identifiable health info
SECURITY: of electronic protected health info (Security Rule)
CONFIDENTIALITY: protect identifiable info being used for pt safety improvement (Patient Safety Rule)
Patient Safety Rule
enforced by Office for Civil Rights to protect identifiable info being used for pt safety improvement (confidentiality)
Security Rule
enforced by Office for Civil Rights to protect security of electronic protected health info
Covered Entities required to follow HIPAA x3
- health plans (HMO, PPO, govt - Medicare, Medicaid)
- most health care providers (esp who use electronic billing)
- health care clearinghouses
Are providers allowed to disclose information to a patient’s employer?
Not without written authorization from the patient.
Do life insurers have to follow HIPAA?
NOPE
Do employers have to follow HIPAA?
NOPE
Do workers comp carriers have to follow HIPAA?
NOPE
Do state agencies like child protective services have to follow HIPAA?
NOPE
Does law enforcement have to follow HIPAA?
NOPE
Do health insurance companies like HMOs have to follow HIPAA?
YES
Do Medicaid and Medicare have to follow HIPAA?
YES
Do health care clearinghouses processing health data into standard electronic formats have to follow HIPAA?
YES
Do company health plans have to follow HIPAA?
YES
Patient Safety Act vs Patient Safety Rule
Patient Safety and Quality Improvement (Patient Safety Act) contains a final rule (Patient Safety Rule)
- rule establishes framework by which providers voluntarily report to Patient Safety Organizations (PSOs) for aggregation/analysis of pt safety events
- privileged and confidential
Agency for Healthcare Research and Quality
has responsibility for listing patient safety organizations (PSOs) established by Patient Safety Act to collect/analyze event info
Code goes bad and all involved are talking badly about it on the unit. Next step?
Hold a one time debriefing with everyone involved.
primary indication for a SNF
inability to maintain ADLs
REMEMBER - when ordering diagnostics or procedures
always pick least invasive & least expensive first
who is responsible for determining how to meet Healthy People 2020 goals?
individuals
communities
organizations
Are NPs legally required to report animal bites?
YES
Are NPs legally required to report domestic violence?
NO
NP & domestic violence
most states do not legally require NP to report
What 6 services can be accessed by NP on behalf of patients?
- social
- psych
- police
- security
- physical therapy
- occupational therapy
home health is most appropriate for patients who require what?
less than 15 minutes of care at a time
when is hospice appropriate for a patient?
prognosis is 6 mo or less
comfort measures only
skilled nursing facilities are appropriate for patients requiring what?
lots of physical therapy
what is an expensive alternative to patients who need more than home health care?
private duty nursing
Evaluation & Management Codes are…?
codes that ID level of care/service provided - match to complexity of patient problem
Medicare sets the standard
five categories of third party payers
Medicare
Medicaid
Commercial indemnity insurers
Commercial management organizations (ex HMO)
Businesses or schools (who get health services for employees/students)
four levels of physical exam documentation
problem focused
expanded problem focused
detailed
comprehensive
Medicare reimburses NPs how much?
85% of physician fee delineated in Medicare’s Physician Fee Schedule
Medicare C
aka “Medicare Advantage”
- previously “Medicare+Choice”
- A + B = C
pts entitled to A and enrolled in B are eligible to receive ALL health care via provider rec’d by C (HMO, PPO, etc)
“incident-to” billing
billing “incident-to” physician service = practice reimbursed 100% of Physician Fee Schedule rate given the service is…
- commonly furnished in offices/clinics
- integral but incidental part of physician’s professional service
- commonly w/o charge or included in physician’s bill
- furnished under physician’s “direct supervision” and by physician or employee or independent contractor of physician
Which parts of Medicare involve a premium?
“B & D are not free” !
four examples of NP billing covered by Medicare B
diagnosis
therapy
surgery consult
care plan oversight
three services that do NOT meet Medicare definition of ‘Physician Services”
regular physical exam
health maintenance screening
counseling for well patients
+ more
what part of Medicare covers physician services?
B
three requirements for NP to qualify as a Medicare provider
state license as NP
certified as NP by national certifying body
at least an MSN degree
requirements for NP services to be covered by Medicare
“physician services” (for which Medicare can be billed)
performed in collaboration w physician
within NP scope of practice (state law)
How much does Medicare reimburse NPs for pocedures?
80% of the 85% of the Physician Fee Schedule rate.
How do practices bill Medicare?
Under the provider ID of the clinician who performs a service, with the exception of “incident-to” billing. (In that case, practice may be reimbursed 100% of Physician Fee Schedule rate.)
Can NPs bill under NP provider number for an assistant’s work?
Yes, as long as rules for incident-to billing are followed.
How do NPs bill for NP visits?
For services covered by Medicare A, no physician’s order required to bill under NP number unless NP is providing exclusively nursing services.
Can physicians & NPs see a patient on the same day?
Yes, but coordinated billing to avoid duplicate payment.
How does NP & MD inpatient billing work?
NP & MD must decide which party should bill given amount of services rendered by each on each day
Which Medicare covers inpatient?
A
Which Medicare covers SNF?
A
Which Medicare covers home health?
A
Which Medicare covers hospice?
A
Which Medicare covers physician services?
B
Which Medicare covers outpt?
B
Which Medicare covers lab/diagnostics?
B
Which Medicare covers medical equipment?
B
Which Medicare covers prescription drugs?
D - but limited
Who provides Medicaid?
State administers, federal supports.
How are Medicaid payments made?
After other insurance or third party payers have been payed.
case management is…
comprehensive/systematic approach to quality care
- mobilize, monitor, control resources pt uses during illness while balancing quality & cost
quality assurance (QA) is quality improvement (QI) is continuous process improvement (CPI) is…
health care management process
- monitor
- eval
- continuously review
- improve quality
quality assurance specifically is
process for eval of care using established standards to ensure quality
CQI/QA “critical path” vs “care map”
critical path: key pt care activities (+ time frames for them) needed for specific case type or diagnosis-related group
care map: newer version that is an INTERDISCIPLINARY blueprint for planning/mgmt of care; monitoring outcomes key
sentinel event vs medical error
all sentinel events occur because of error
but not all errors result in sentinel events
expected response to sentinel events
clinicians/institutions must conduct root cause analysis
State Board of Nursing does what 2 functions?
- establish scope of practice
- license
Standards of Advanced Practice
est. 1996 by ANA
- authoritative statements to measure QUALITY of practice, service, education
- generic & specific specialty standards
What does the Drug Enforcement Agency (DEA) do regarding prescriptive authority?
Nothing, state practice acts dictate level of prescriptive authority allowed. DEA merely allows APNs to obtain registration numbers.
Does this constitute patient medical abandonment?
NP refuses patient assignment because she feels she lacks competence for it.
No, as long as NP gave reasonable notice to proper authority.
Does this constitute patient medical abandonment?
NP refuses double shift/over time.
No, as long as “proper notification has been given” (this is a problematic phrase, though)
Does this constitute patient medical abandonment?
NP refers patients to other providers then closes practice.
No, as long as reasonable arrangements for continuation of care are provided.
How does a systematic effort to reduce risk happen?
Start with formal, written risk management plan outlining
- org goals
- program’s scope, components, methods
- delegation of responsibility for implementation/enforcement
- demonstration of board committment
- guarantees confidentiality/immunity for reporting of sensitive info
quantitative futility
medical futility in which likelihood intervention will benefit patient is extremely poor
right to refuse care
patient advised upon admission to FEDERALLY FUNDED institution that they have this right, given comptence
- regarding any, some, or all care
example reasons of why NP might discharge patient from practice x3
abuse from patient
patient refuses to pay
persistent non-compliance
steps to discharge patient from practice x3
- send certified letter that is general in nature & copied for chart (pt should have already consented in writing to practice policies)
- provide general health care coverage 15 to 30 days post-termination deadline
- obtain ROI to send records to subsequent provider
four distinct roles of NPs
clinician
consultant/collaborator
educator
researcher
confidence interval
interval with limits at each end containing a specified probability of including parameter being estimated; smaller = more precise
if same population sampled numerous times and interval estimates are made each time, the resulting intervals would bracket the true population parameter in approximately X% of cases
ex: CI = 2.8 - 3.2 = terminal bone cancer pts in final stage have 2.8 - 3.2 episodes of nausea daily
% of values that fall between one and two SDs of mean?
68% of values fall within one standard deviation
95% of values fall within two standard deviations
correlation
measure of interdependence of two random variables
-1 = negative
0 = absence
+1 = positive
CRONBACH’S ALPHA
common way of computing correlation values among questions on instruments
- closer to 1 = higher reliability of instrument (optimal is 0.70+)
What statute protects NPs from law suits after aiding people in an accident with reasonable emergency care that is within their scope of practice?
Good Samaritan Statutes
