JMESI Flashcards
accreditation
objective performance review in key functional activities
*safety & quality of care
CAP
college of american pathologists
accreditation for labs
CAP = College of amerian pathologists
NCQA
National Committee on Quality Assurance
what is an organization requestion when it seeks accreditation
by seeking accreditation, a healthcare organization is asked to be measured against national standards
benefits of a healthcare organization being accredited
- 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
does a healthcare organization have to be accredited?
accreditation is voluntary
Joint Commission visits
first visit is by invitation
rest are uninvited
2 characteristics of Joint Comission
not for profit
independenct
2 organizaitons affiliated w/Joint COmission
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)
Joint Comission for Transforming Healthcare
an organization affiliated w/Joint COmmission
*aims to solve halthcare’s most critical safety and quality problems
Joint Commission Resources
an organizaiton affiliated w/JOint COmission
provides consulting, education, and publications
process for Joint Comission surveys
Focused Standards Assesment
On-site survey
INtracycle MOnitoring
Focused Standards Assessment
Joint Commision
*hospital annual self-evaluation tool.
for every noncompliant standard, the hospital needs a POA (Plan of Action)
FSA
Focused Standards Assessment
hospital annual self-evaluation tool to gauge adherence to JOint Commission standards
what do you do if Joint COmission identifies a problem
for every noncompliant standard, the hospital needs a POA (plan of action)
how often does the JOint Comission do on-site surveys
q3yrs
how does the JOint COmission decide if a standard is in compliance
JC’s performance expectations for determining if a standard is in compliance are included in its elements of performance (EP)
EP (Joint comission term)
Elements of PErformance
*details specific performance expectations/structures/porcesses that must ibe in place for an organization to be in compliance t
what happens if the Joint Comission identifies a EP (element of performance) is out of compliance
if an EP is out of compliance, it is cited as a RFI (requirement for improvement)
RFI (joint commission term)
Required for Improvement
*aka, Joint Commission has identified an Element of Performance (EP) is not within standards
what does the Joint Commission do with RFI
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)
SAFER
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)
5 joint commission decisions
limited tempoary accredition accredited accredited w/follow up survey preliminary denial of accreditation denial of accreditation
limited tempoary accreditation (final ruling by JOint Commission)
1/5 possible Joint Commission decisions
surevy piroir to opening (Early Service POlicy option) w follow up 6 months later
accreditation (final ruling by Joint Comission)
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
accreditaion w/follow up survey (final ruling by the JOint COmmission)
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
preliminary denial of accreditation (final ruling by the JOint COmmission)
false/misrepresented, immediate threat to safety/failure to meet standards w/follow-up survey
denial of accredition (final joint comission ruling)
all avilable review and appeal opportunities have been denied
who can access the Joint Commission’s Accreditation Survey findings
only the hospital
NOT public
purpose of the Accreditation Survey Findings
identifies streangths and RFI
what happens if the Joint Commission identifies a RFI
organization ahs 60 days to submit an Evidence of Car (ESC) reprot to address comments of RFI
what is an ESC (joint comission term)
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
ORYX measures
flu immunization perinatal care ED visits tobaccao substance absuse inpt psych **initiative integrates performance measurement data intot he accreditation process
sentinel event
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
when is suicide considered a sentinel event
suicide while in round-the-clock care or within 72hrs of hospital discharge
sentinel events & reporting to Joint Commission
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
who can self-report sentinel events to JOint COmission
family/pt/staff/medic
how should a hospital respond to Joint Commission
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
comprehensive systems analysis
root cause analysis.
- focuses on systems & processes, not individual performance
- *done in the aftermath of a sentinel event
corrective action plan
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,
goal of TJC sentinal event database
increases general knowledge of pt safety events, their contributing factors, stragehies to decrease
what does accredition challenge a healthcare organization to do
review healthcare delivery practices
2 things a healthcare organization needs s/p sentinel event
root cause analysis aka comprehensive systems analysis
action plan
accreditation for labs
CAP = COllege of American Pathologists
accreditation for ambulatory surgery/primary care/clinics/occupational health
AAAHC = Accreditation Association for Ambuatory Health Care
AAAHC
Accreditation Association for Ambulatory Health Care
*accreditation for ambulatory survery, primary care, clinics, occupational health
4 main organizations who provide accreditation for healthcare organizations
ER/Inpatient Hospitals = TJC
Ambulatory Care/Clinics = AAAHC
Lab = CAP
Health plans = NCQA
accreditation for health plans
NCQA
what does accreditation require
accreditation rewquires continuous process improvements = pathways to change
*well run health orgs live not just meet standards
aka process improvement
critical pathway
what is ORYX
TJC database that compiles standardized performance indicators
TJC self-tool for annual audits for hopsitals
Focused Standards Assessmebt
most important question to ak when doing a root cause analysis s/p sentinel event
why
benchmarking
systematic approach of measuring/comparing the results of key work processes w/those up to the best performers
balanced scorecard
set of measures that describe critical aspects of an organization
*connects practice, outcomes, quality, values, costs, & reveals the interdependence of an organization
clinical value compass
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
outcome indicators
stattical measures to track performance of fucnitons, processes, and outcomes over time
*ask clear relevant Q’s., develop targeted data collection/systems/tools
characteristics of effective measurement tools
justify/change, motivate, give feedback on progress towards goals
results = reliable, valid, reproductible, trustoworkthy
key Q’s for designing a tool to measure outcomes
what is the goal? what will be measured? how will data be colelcted? what is the method of data anlysis? what is the indicator?
who is interested in outcome measurement ?
all stakeholders have an interest in outcomes measurement results and have specific infomration needs that shoudl be considered when designing a data collection tool
what do the most effective measuresment tools contain
collect information that justifies change, motivations actions, or gives feedback in progress towards goals
3 Recommended Outcome Measurement Tools
practice guideliens
benchmarking
outcome measures
**used to translate strategic plans into action plans
ways to translate strategic plans into action plans
3 examples of Outcome Measurement Tools
*practice guidelines, benchmarking, outcome measures
CPG
Clnical Practice Guidleines
*recommended courses of treatment for a sspecific health condition or pt population. “best practice standards”
recommended COA for specific health conditions or pt population
Clinical Practice Guideliens
what is benchmarking
process of discovering/incorporating best practice into day-to-day operations
process of discovering/incorporating best practices into day-to-day operations
benchmarking
goal of benchmarking
produce improvements that set new standarrds for performance
2 tools for senior administrators to access vital information quickly
Balance Scorecard
Clinical Value Compass
how is the Balanced Scorecard structured
includes measures from 4 functional prespectives
financial, internal businesses processes, learning & growth, pt/customer
vital indicators on the balanced scorecard
structures, processes, outcomes, values, quality, costs
financial perspective in therms of hte balanced scorecard
return on investment cash flow litigation avoidance activity-bast organizaiton cycle time cost of quality database
employee value in terms of the balanced scorecard
wellbeing, development, retention, satisfaction, pt focused integration
4 directions on the clinical value compass
functional
satisfaction
costs
clinical
2 things a well-designed process can improve
a well designed process can improve pt clinical outcomes and stimulate administraty efficiendy
what do key outcomes contribute
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
what is needed in order to have effective change
effective change doen’t occur w/o outcome measurement tools
who is interested in cost effective quality healthcare outcomes
all hosptial stakeholders
what does an effective bargaining strategy include
gathering desired information from specific dept withing your organizaiton, similiar institution, similar area business
what is the WRONG/ineffective way to approach negotiation
do not approach negotioation as a test of strength or a power struggle
How to be a successful mediator
introduction problem determination options/determion clarification documentation follow
who is the audience of FITREPS
the selection board, not the member
what should each FITREP cycle demonstrate
document growth
constant movement towards leadership
activies
how does a leader improve workflow
ask teh people
what do you do when there is a problem
blame the problem not the people
what should you know when you are counseling someone
know the CofC of the person you are counsleing
what does “manpower” mean in the Navy
“places or spaces” not people
validated needs to accomplish the mission function, tasks (funded/unfunded)
what does authorization mean in terms of manpower
funded portion
what does a billet mean in terms of manpwer
requied and quality rate/rating
*designator/paygrade`
JOMIS
joint op medicine information systems
EUT
end user training
what is the expectation of nurse corp
always ready
why don’t they like to see back-to-back operational assignments
head back to MTF to get skills back up to par
why doesn’t moonlighting count towards clinical sustainmnet
we can’t see/evaluate your process
what does demands of a job not allow you do do
be clinically relevant
ORM
operational risk management
what must leders do to plan in advance
leaders must plan in advance for all foreseeable situation and circumstances
risk takign
make bold decisons in the face of uncertainty accept fully respnsibility four holdign ot the chosen despite challenges/difficulty
what is needed in order to be an effective team
trust
confines in each other
what is duty imposed by
treaty statute regulation lawful order SOP customs
derelict of duty
willfully/negligently failt to perform that person’s duties or in a culpability inefficient manntere
not derelicit in performance of duty
fails to perform those duties is causd by ineptitude reather than willfulness, negilgence, or culpability inefficient and may bto be charged undr that article
aka intentionally, acted purposefully, knowingly
willfully
JP-1
Doctrine for the Armed Forces of the US
what helps a leader know when things may/can go wrong
w/experience and maturity
one benefit of underway/deployment
show stakeholders progress is being made
O&S
operations and support phase
* a system is used and supported by users in the field
R&E
research and enginerign
important thing to remember about a nation developing technology
“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”
what is one of hte most difficult things about COIN
prepare to take aggressive action agianst het enemy, ID noncombatants from enemy, avoid abusive behavior, or use excessive force
PKO
peacekeeping Ops
PO
peaCE OPERATIONS
Constitution about Congress & religion
constitution says congress can;’t make any low prohibiting the free expression of religion
what characteristics do peace operations need -7
independence professionalism self-discipline flexibility patience recognize cultural norms work ethics
affect of peace operations on echnomic growth
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
what should the CO consider when you do a port visit/enter a country for an operations
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
important thing to remember about hte procurement process in a foreign contingency environment
can be very prone to fraud, waste, abuse
why does fraud, wase, and abuse
b/c decreased edu on the acquisition process pressure to meet mission requirements, scarcity of contract oversight personnel
what should you do if something of an ethical nature is ever in doubt
contact legal advisoir
FWA in Operation Enduring Freedom/Iraqi Freedom
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
FWA in Operation Enduring Freedom/Iraqi Freedom
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
problems of high op tempo
- 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
what happens if stress is untreated
ripple effect of stress
what is critical in meeting the challenges of trauma spectrum
leader awareness & engagement
s/s of PTSD - 4
nightmares
flashbacks
difficulty sleeping
feeling emotionally numb
how do you help family members of servicemembers who are highly deployable into combat zones
prepare their family for possible response to traumam from combat
s/s TBI
HA memory gap confusion tinnitus N/V fatigue slow reaction time performance/sleep drop irritable attention problems
immediate eval after blast explosion
TBI
hormones that increase in stress
adrenaline |
cortosol
AME
assess, monitoring, and evaluation
ASEAN
association of SE Asian Nations
largest AFRICOM exercise
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.
