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Military Topics > JMESI > Flashcards

JMESI Flashcards

1
Q

accreditation

A

objective performance review in key functional activities

*safety & quality of care

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2
Q

CAP

A

college of american pathologists

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3
Q

accreditation for labs

A

CAP = College of amerian pathologists

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4
Q

NCQA

A

National Committee on Quality Assurance

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5
Q

what is an organization requestion when it seeks accreditation

A

by seeking accreditation, a healthcare organization is asked to be measured against national standards

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6
Q

benefits of a healthcare organization being accredited

A
  • improved pt care
  • strengthens community confidence
  • objectrive performance evaluation
  • publically reported
  • stimulates pt safety and improved quality
  • education on good practices to improve operations
  • aid in professional staff increases
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7
Q

does a healthcare organization have to be accredited?

A

accreditation is voluntary

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8
Q

Joint Commission visits

A

first visit is by invitation

rest are uninvited

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9
Q

2 characteristics of Joint Comission

A

not for profit

independenct

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10
Q

2 organizaitons affiliated w/Joint COmission

A

Joint Comission for Transforming Healthcare (aims to solve healthcare’s most critical safety and quality problems)
JOnt Comission Resources (provides consulting services, educaiton, and publicaitons)

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11
Q

Joint Comission for Transforming Healthcare

A

an organization affiliated w/Joint COmmission

*aims to solve halthcare’s most critical safety and quality problems

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12
Q

Joint Commission Resources

A

an organizaiton affiliated w/JOint COmission

provides consulting, education, and publications

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13
Q

process for Joint Comission surveys

A

Focused Standards Assesment
On-site survey
INtracycle MOnitoring

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14
Q

Focused Standards Assessment

A

Joint Commision
*hospital annual self-evaluation tool.
for every noncompliant standard, the hospital needs a POA (Plan of Action)

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15
Q

FSA

A

Focused Standards Assessment

hospital annual self-evaluation tool to gauge adherence to JOint Commission standards

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16
Q

what do you do if Joint COmission identifies a problem

A

for every noncompliant standard, the hospital needs a POA (plan of action)

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17
Q

how often does the JOint Comission do on-site surveys

A

q3yrs

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18
Q

how does the JOint COmission decide if a standard is in compliance

A

JC’s performance expectations for determining if a standard is in compliance are included in its elements of performance (EP)

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19
Q

EP (Joint comission term)

A

Elements of PErformance
*details specific performance expectations/structures/porcesses that must ibe in place for an organization to be in compliance t

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20
Q

what happens if the Joint Comission identifies a EP (element of performance) is out of compliance

A

if an EP is out of compliance, it is cited as a RFI (requirement for improvement)

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21
Q

RFI (joint commission term)

A

Required for Improvement

*aka, Joint Commission has identified an Element of Performance (EP) is not within standards

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22
Q

what does the Joint Commission do with RFI

A

each Required for Improvement is placed into the SAFER matrix to determine how likely it is to hurt pt/staff/visitors (low/mod/high) and how its scope/prevalence (limited/pattern/widespread)

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23
Q

SAFER

A

Survey Analysis for Evaluating Risk

  • Joint Commission tool used to create a matrix of Required for Improvement (RFI) deficiencies identified as not being within standards per EP (element of Performance)
  • matrix = how likely it will hurt pt/staff/visitors (low, mod, high) and how its scope/prevalence (limited/pattern/widespread)
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24
Q

5 joint commission decisions

A 
limited tempoary accredition
accredited
accredited w/follow up survey
preliminary denial of accreditation
denial of accreditation
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25
Q

limited tempoary accreditation (final ruling by JOint Commission)

A

1/5 possible Joint Commission decisions

surevy piroir to opening (Early Service POlicy option) w follow up 6 months later

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26
Q

accreditation (final ruling by Joint Comission)

A

compliance with all standards or has successfullly addressed all RFI addressed in Evidence of STandars COmpliance (ESC) within 60 days post the FInal Acfcreditation REport

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27
Q

accreditaion w/follow up survey (final ruling by the JOint COmmission)

A

1/5 possible Joint Commission decisions
*incomplete w/standards as determined by an acceptable ESC submission. needs 6 month follow up to assess sustained cimpliance

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28
Q

preliminary denial of accreditation (final ruling by the JOint COmmission)

A

false/misrepresented, immediate threat to safety/failure to meet standards w/follow-up survey

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29
Q

denial of accredition (final joint comission ruling)

A

all avilable review and appeal opportunities have been denied

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30
Q

who can access the Joint Commission’s Accreditation Survey findings

A

only the hospital

NOT public

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31
Q

purpose of the Accreditation Survey Findings

A

identifies streangths and RFI

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32
Q

what happens if the Joint Commission identifies a RFI

A

organization ahs 60 days to submit an Evidence of Car (ESC) reprot to address comments of RFI

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33
Q

what is an ESC (joint comission term)

A

ESC = evidence of care

  • if RFI’s are found, an organizaiton has 60 days to submit an eESC to address teh RFI
  • ESC report must detail actions taken to bring itself into compliance or clarify why they beieve they are in compliance
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34
Q

ORYX measures

A 
flu immunization
perinatal care
ED visits
tobaccao substance absuse
inpt psych
**initiative integrates performance measurement data intot he accreditation process
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35
Q

sentinel event

A

pt safety event that reaches the pt and results in death/harms/ permanent/tempoarty hardm to pt, d/c of pt to wrong family, abduction of pt, unanticipated death of full term infant, suicide while in round the clock care or within 72hrs of discharge from ED

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36
Q

when is suicide considered a sentinel event

A

suicide while in round-the-clock care or within 72hrs of hospital discharge

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37
Q

sentinel events & reporting to Joint Commission

A

optional but encouraged to report to JOint COmission
benefits of self-report: they offer support/experts review /woffice of quality and pt safety
**BUT if they do find out on their own that a sentinel event happened in an accredited hospital, the hospital needs to submit a systems analysis and corrective action plan to TJC within 45 buiness days

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38
Q

who can self-report sentinel events to JOint COmission

A

family/pt/staff/medic

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39
Q

how should a hospital respond to Joint Commission

A

all sentinel events are reviewed by hospital but not needed to report to Joint Comission
*if TJC does become aware, the hospital needs to do a thorough systems analysis and corrective action plan within 45 buisness days and submit to TJC

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40
Q

comprehensive systems analysis

A

root cause analysis.

  • focuses on systems & processes, not individual performance
  • *done in the aftermath of a sentinel event
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41
Q

corrective action plan

A

post sentinel event

  • identifies strategies the hospital needs to implement to decrease repetition after a sentinel event
  • *needs: identifies actions to eliminate/control, casual/contributing factors, timeline for completion, strategies to sustain change,
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42
Q

goal of TJC sentinal event database

A

increases general knowledge of pt safety events, their contributing factors, stragehies to decrease

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43
Q

what does accredition challenge a healthcare organization to do

A

review healthcare delivery practices

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44
Q

2 things a healthcare organization needs s/p sentinel event

A

root cause analysis aka comprehensive systems analysis

action plan

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45
Q

accreditation for labs

A

CAP = COllege of American Pathologists

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46
Q

accreditation for ambulatory surgery/primary care/clinics/occupational health

A

AAAHC = Accreditation Association for Ambuatory Health Care

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47
Q

AAAHC

A

Accreditation Association for Ambulatory Health Care

*accreditation for ambulatory survery, primary care, clinics, occupational health

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48
Q

4 main organizations who provide accreditation for healthcare organizations

A

ER/Inpatient Hospitals = TJC
Ambulatory Care/Clinics = AAAHC
Lab = CAP
Health plans = NCQA

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49
Q

accreditation for health plans

A

NCQA

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50
Q

what does accreditation require

A

accreditation rewquires continuous process improvements = pathways to change
*well run health orgs live not just meet standards

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51
Q

aka process improvement

A

critical pathway

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52
Q

what is ORYX

A

TJC database that compiles standardized performance indicators

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53
Q

TJC self-tool for annual audits for hopsitals

A

Focused Standards Assessmebt

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54
Q

most important question to ak when doing a root cause analysis s/p sentinel event

A

why

55
Q

benchmarking

A

systematic approach of measuring/comparing the results of key work processes w/those up to the best performers

56
Q

balanced scorecard

A

set of measures that describe critical aspects of an organization
*connects practice, outcomes, quality, values, costs, & reveals the interdependence of an organization

57
Q

clinical value compass

A

set of measures taht describe critical saspects of an organizaiotn
*helps healthcare organizations manage/improve healthcare services by established conenctions between fiunctional status, costs, healthcare staisfaction, and clinical outcomes

58
Q

outcome indicators

A

stattical measures to track performance of fucnitons, processes, and outcomes over time
*ask clear relevant Q’s., develop targeted data collection/systems/tools

59
Q

characteristics of effective measurement tools

A

justify/change, motivate, give feedback on progress towards goals
results = reliable, valid, reproductible, trustoworkthy

60
Q

key Q’s for designing a tool to measure outcomes

A 
what is the goal?
what will be measured?
how will data be colelcted?
what is the method of data anlysis?
what is the indicator?
61
Q

who is interested in outcome measurement ?

A

all stakeholders have an interest in outcomes measurement results and have specific infomration needs that shoudl be considered when designing a data collection tool

62
Q

what do the most effective measuresment tools contain

A

collect information that justifies change, motivations actions, or gives feedback in progress towards goals

63
Q

3 Recommended Outcome Measurement Tools

A

practice guideliens
benchmarking
outcome measures
**used to translate strategic plans into action plans

64
Q

ways to translate strategic plans into action plans

A

3 examples of Outcome Measurement Tools

*practice guidelines, benchmarking, outcome measures

65
Q

CPG

A

Clnical Practice Guidleines

*recommended courses of treatment for a sspecific health condition or pt population. “best practice standards”

66
Q

recommended COA for specific health conditions or pt population

A

Clinical Practice Guideliens

67
Q

what is benchmarking

A

process of discovering/incorporating best practice into day-to-day operations

68
Q

process of discovering/incorporating best practices into day-to-day operations

A

benchmarking

69
Q

goal of benchmarking

A

produce improvements that set new standarrds for performance

70
Q

2 tools for senior administrators to access vital information quickly

A

Balance Scorecard

Clinical Value Compass

71
Q

how is the Balanced Scorecard structured

A

includes measures from 4 functional prespectives

financial, internal businesses processes, learning & growth, pt/customer

72
Q

vital indicators on the balanced scorecard

A

structures, processes, outcomes, values, quality, costs

73
Q

financial perspective in therms of hte balanced scorecard

A 
return on investment
cash flow
litigation avoidance
activity-bast 
organizaiton cycle time
cost of quality database
74
Q

employee value in terms of the balanced scorecard

A

wellbeing, development, retention, satisfaction, pt focused integration

75
Q

4 directions on the clinical value compass

A

functional
satisfaction
costs
clinical

76
Q

2 things a well-designed process can improve

A

a well designed process can improve pt clinical outcomes and stimulate administraty efficiendy

77
Q

what do key outcomes contribute

A

key outcomes contribute evidence that can be used to identify gaps in performance, guide the goal setting process, shape strategic planning inititatives, and form the foundstion of contijnous quality mprovemnet

78
Q

what is needed in order to have effective change

A

effective change doen’t occur w/o outcome measurement tools

79
Q

who is interested in cost effective quality healthcare outcomes

A

all hosptial stakeholders

80
Q

what does an effective bargaining strategy include

A

gathering desired information from specific dept withing your organizaiton, similiar institution, similar area business

81
Q

what is the WRONG/ineffective way to approach negotiation

A

do not approach negotioation as a test of strength or a power struggle

82
Q

How to be a successful mediator

A 
introduction
problem determination
options/determion
clarification
documentation
follow
83
Q

who is the audience of FITREPS

A

the selection board, not the member

84
Q

what should each FITREP cycle demonstrate

A

document growth
constant movement towards leadership
activies

85
Q

how does a leader improve workflow

A

ask teh people

86
Q

what do you do when there is a problem

A

blame the problem not the people

87
Q

what should you know when you are counseling someone

A

know the CofC of the person you are counsleing

88
Q

what does “manpower” mean in the Navy

A

“places or spaces” not people

validated needs to accomplish the mission function, tasks (funded/unfunded)

89
Q

what does authorization mean in terms of manpower

A

funded portion

90
Q

what does a billet mean in terms of manpwer

A

requied and quality rate/rating

*designator/paygrade`

91
Q

JOMIS

A

joint op medicine information systems

92
Q

EUT

A

end user training

93
Q

what is the expectation of nurse corp

A

always ready

94
Q

why don’t they like to see back-to-back operational assignments

A

head back to MTF to get skills back up to par

95
Q

why doesn’t moonlighting count towards clinical sustainmnet

A

we can’t see/evaluate your process

96
Q

what does demands of a job not allow you do do

A

be clinically relevant

97
Q

ORM

A

operational risk management

98
Q

what must leders do to plan in advance

A

leaders must plan in advance for all foreseeable situation and circumstances

99
Q

risk takign

A

make bold decisons in the face of uncertainty accept fully respnsibility four holdign ot the chosen despite challenges/difficulty

100
Q

what is needed in order to be an effective team

A

trust

confines in each other

101
Q

what is duty imposed by

A 
treaty
statute
regulation
lawful order
SOP
customs
102
Q

derelict of duty

A

willfully/negligently failt to perform that person’s duties or in a culpability inefficient manntere

103
Q

not derelicit in performance of duty

A

fails to perform those duties is causd by ineptitude reather than willfulness, negilgence, or culpability inefficient and may bto be charged undr that article

104
Q

aka intentionally, acted purposefully, knowingly

A

willfully

105
Q

JP-1

A

Doctrine for the Armed Forces of the US

106
Q

what helps a leader know when things may/can go wrong

A

w/experience and maturity

107
Q

one benefit of underway/deployment

A

show stakeholders progress is being made

108
Q

O&S

A

operations and support phase

* a system is used and supported by users in the field

109
Q

R&E

A

research and enginerign

110
Q

important thing to remember about a nation developing technology

A

“success no longer goes to the country that develops a new technology first, but rather to the one that better integrates it and adapts its way of fighting”

111
Q

what is one of hte most difficult things about COIN

A

prepare to take aggressive action agianst het enemy, ID noncombatants from enemy, avoid abusive behavior, or use excessive force

112
Q

PKO

A

peacekeeping Ops

113
Q

PO

A

peaCE OPERATIONS

114
Q

Constitution about Congress & religion

A

constitution says congress can;’t make any low prohibiting the free expression of religion

115
Q

what characteristics do peace operations need -7

A 
independence
professionalism
self-discipline
flexibility
patience
recognize cultural norms
work ethics
116
Q

affect of peace operations on echnomic growth

A

presence of PO may stimulate economic growth in a lcoal economy, commander smujst be aware of potentially negative effects after the peace operation leaves

  • CO may need a policy to limit # of $ sailors can spend in an area via convert to local currency and to pay the locals hired to support the prevaliling wage for the area
  • policy on leave/pass/liberty/R&R should also consider the economic impacts
117
Q

what should the CO consider when you do a port visit/enter a country for an operations

A

spending/leave/pass/liberty/R&R must consider the economic impact. support the prevailing wage for the area. might have negative effects aftter they elave

118
Q

important thing to remember about hte procurement process in a foreign contingency environment

A

can be very prone to fraud, waste, abuse

119
Q

why does fraud, wase, and abuse

A

b/c decreased edu on the acquisition process pressure to meet mission requirements, scarcity of contract oversight personnel

120
Q

what should you do if something of an ethical nature is ever in doubt

A

contact legal advisoir

121
Q

FWA in Operation Enduring Freedom/Iraqi Freedom

A

audit orgs found numerous instances of FWQ from 2003-2011

*Iraq`/AF wartime contracting abuse = 10-20% of the $200 billion spent FY 2002-2011

121
Q

FWA in Operation Enduring Freedom/Iraqi Freedom

A

audit orgs found numerous instances of FWQ from 2003-2011

*Iraq`/AF wartime contracting abuse = 10-20% of the $200 billion spent FY 2002-2011

122
Q

problems of high op tempo

A
  • longer/recurring deployments
  • dangerous
  • deployment stress, combat exposure, ambiguity, isolation from family/friends, lack of privacy, IED exposure
  • unseen wound from war, cam to support reintegration, decrease stigma for seeking help
123
Q

what happens if stress is untreated

A

ripple effect of stress

124
Q

what is critical in meeting the challenges of trauma spectrum

A

leader awareness & engagement

125
Q

s/s of PTSD - 4

A

nightmares
flashbacks
difficulty sleeping
feeling emotionally numb

126
Q

how do you help family members of servicemembers who are highly deployable into combat zones

A

prepare their family for possible response to traumam from combat

127
Q

s/s TBI

A 
HA
memory gap
confusion
tinnitus
N/V
fatigue
slow reaction time
performance/sleep drop
irritable
attention problems
128
Q

immediate eval after blast explosion

A

TBI

129
Q

hormones that increase in stress

A

adrenaline |

cortosol

130
Q

AME

A

assess, monitoring, and evaluation

131
Q

ASEAN

A

association of SE Asian Nations

132
Q

largest AFRICOM exercise

A

Operation African Lion
U.S. Africa Command’s largest, premier, annual exercise, hosted across Morocco, Ghana, Senegal and Tunisia. This joint, all-domain, multi-component, and multinational exercise includes more than 10,000 participants from more than twenty nations, including contingents from NATO.

133
Q
A

Military Topics (13 decks)

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