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CPHQ > Mod. 2 Organizational Leadership > Flashcards

Mod. 2 Organizational Leadership Flashcards

1
Q

Board of Director’s Quality Role

A

Identify the alignment between a quality program and organizational systems

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2
Q

What role copes with change by developing vision and aligning subsystems (determine the correct path)?

A

Leaders

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3
Q

What role copes with complexity through planning and budgeting, sets goals, organizes staffing, creates a structure to foster goal attainment, sets up mechanisms for monitoring and controlling results (does the correct thinks to stay on the path)?

A

Managers

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4
Q

How long does it take to implement significant change?

A

18-24 months

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5
Q

How long does it take to anchor significant change in practice and culture?

A

10 years

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6
Q

Strategic plans are especially important to…

A

meeting external demands relative to competition

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7
Q

Mission

A

Organization’s purpose or reason for existence; why are we here?

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8
Q

Vision

A

Organization’s statement of its goals for the future

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9
Q

Direction

A

Built on mission and guided by vision

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10
Q

Core Values

A

Define organization’s attitudes and help direct vision

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11
Q

Goals

A

Broad, general statements specifying a purpose or desired outcome

  • may be more abstract than objectives
  • one goal can have multiple objectives
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12
Q

Objectives

A

Specific statements that detail how goal(s) will be achieved through specific and measurable action(s)
-relatively narrow and concrete

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13
Q

What are SMART Goals?

A
  • Specific
  • Measurable
  • Attainable
  • Relevant
  • Time-bound
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14
Q

How does assessing customer needs help the organization?

A

Helps refine mission, vision and core values

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15
Q

What is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

A

Standardized method to compare the performance of hospitals and link payment to performance developed by CMS

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16
Q

What does CMS stand for?

A

Center for Medicare and Medicaid Services

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17
Q

What is a key component of measuring hospital performance as identified by CMS?

A

Customer perception

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18
Q

What is the process that should be conducted at the start of any new product or service design initiative to better understand the customer’s wants and needs?

A

Voice of the Customer (VOC)

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19
Q

What are the four aspects of VOC?

A
  • customer needs
  • a hierarchical structure
  • priorities
  • customer perceptions of performance
  • -the product is list of needs, wants and desires of the customer of a process output
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20
Q

What are the steps to conduct VOC research?

A

1) identify customers
2) develop a list of questions to ask about process/need
3) refine the list to use with process review and improvement

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21
Q

Goals and objectives should cascade to…

A

Every person’s performance appraisal

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22
Q

What are the goals of strategic planning?

A
  • create a framework for operations
  • create a fit w/external environment (what should the organization do)
  • Establish process for coping with change and renewal (gap analysis)
  • Foster anticipation, innovation and excellence
  • facilitate consistent decision making
  • create organizational focus
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23
Q

What is Hoshin Planning?

A

A Japanese term that means policy development used to ensure that the vision set by top management is being translated into planning objectives and actions

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24
Q

What are the steps of Hoshin Planning?

A
  • Strategy implementation
  • deployment or rolldown to depts. to develop plans including targets and means (KPI)
  • implementation of dept. plans
  • regular process review (monthly + quarterly)
  • annual review (PDSA cycle to happen w/implementation of plans and process review)
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25
Q

What does a balanced scorecard do and what does SCCA use to do this?

A

Provides an ongoing snapshot of how the organization is performing. SCCA uses Key Performance Indicators (KPIs)

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26
Q

What are some balanced scorecard examples at SCCA?

A
  • Financial: operating margin is at or above target
  • Customer: patient-improve overall pt. satisfaction, staff-reduce staff turnover
  • Internal Business Processes (at what must we excel?): reduce central line blood stream infections
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27
Q

What are considerations for Quality initiatives?

A
  • regulatory or contractual requirements
  • performance incentives offered by purchasers or providers
  • alignment with explicit performance incentives (pay for performance)
  • Strategic advantage over competition by bolstering image and reputation/marketing (brand identity)
  • Commitment to provide better care and outcomes
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28
Q

Why do you need to establish recognition and reward systems?

A

To foster a culture of safety, quality professionals work with others to reward behaviors and practices that contribute to this culture

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29
Q

What are the steps to creating reward systems?

A
  • determine priorities, values and behaviors
  • identify criteria for recognition
  • establish a budget
  • determine accountability for recognition
  • obtain feedback through performance appraisal
  • modify program based feedback
  • give rewards based on program
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30
Q

What is Population Health?

A

Outcomes for a group of individuals

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31
Q

What are some determinants of health?

A
  • medical care
  • public health
  • genetics
  • personal behaviors and lifestyle
  • social factors
  • environmental factors
  • economic factors
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32
Q

What is Population Health Management (PHM)?

A

involves improving health within and across populations who are at risk for or have chronic disease

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33
Q

What are examples of “non-health” organizations who are engaged in determinants of health

A
  • schools
  • correctional facilities
  • transit systems
  • land developers
  • architects
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34
Q

What are examples of populations?

A
  • group of patients with similar chronic condition cared for by medical home
  • cluster of asthma patients in a school or community facing environmental risk factors
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35
Q

When does a care transition occur?

A

When a patient moves from one healthcare provider or setting to another

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36
Q

What does “transitions of care” refer to?

A

A patient leaving one care setting (e.g., hospital, emergency department, nurse home, assisted living facility, etc.) and moving to another

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37
Q

According to TJC, what is the percentage of serious medical errors involving miscommunication between caregivers when patients are transferred or handed off?

A

80%

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38
Q

80% of serious medical errors involve what?

A

Miscommunication between caregivers when patients are transferred or handed off

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39
Q

What is the definition of a hand off?

A

A transfer and acceptance of patient care responsibility achieved through effective communication

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40
Q

How are hand offs achieved?

A

Through effective communication

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41
Q

What are examples of information hand offs should include?

A
  • patient history
  • heart rhythm
  • infections
  • complications
  • need for restraints
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42
Q

What is the real time process of passing patient-specific information from one caregiver to another to ensure continuity?

A

Hand offs

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43
Q

What is the preferred communication method(s) for successful hand offs?

A

Verbal (face-to-face preferred) and in writing

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44
Q

What should be standardized to ensure successful hand offs?

A
  • critical content to be communicated
  • tools and methods to communicate to receivers
  • training from both the standpoint of the receive and sender
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45
Q

What are some tools that help achieve successful hand offs

A
  • forms
  • templates
  • checklists
  • protocols
  • mnemonics
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46
Q

Where should face-to-face hand offs take place?

A

In a location free from interruptions (both for team members and patient/family as appropriate)

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47
Q

What are technologies that can enhance hand offs?

A
  • electronic medical records
  • apps
  • patient portals
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48
Q

How can you improve continuity of medications during care transitions?

A
  • Implement EMR that includes standardized medication reconciliation
  • Expand role of pharmacist
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49
Q

How can you establish points of accountability for sending/receiving care?

A
  • implement payment systems that align incentives

- develop performance metrics

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50
Q

Episodes of care can be defined as

A

a short period of care for a specific illness or concern, care on a continuous basis or it may consist of a series of intervals marked by one or more brief separations from care

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51
Q

How are episodes of care generally initiated?

A

-By referral or admission

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52
Q

What is a PPO?

A

Preferred Provider Organization-health plan contracts with a network of preferred providers from which to choose

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53
Q

What are the characteristics of a PPO?

A
  • Do not need to select PCP
  • Do not need referrals to see other network providers
  • Only responsible for annual deductible and copay for visit
  • Pay higher amount if using providers out of network
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54
Q

What is an HMO

A

Health Maintenance Organizations-members need to receive most or all care from network provider

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55
Q

What are the characteristics of an HMO?

A
  • Members need to receive most or all care from network provider
  • Select a Primary Care Provider (PCP) responsible for managing and coordinating all health care
  • A PCP refers to network specialists, lab or radiology
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56
Q

What is an EPO

A

Exclusive Provider Organization-network of individual medical care providers or groups of medical care providers who have entered into a written agreement with an insurer to provider health insurance

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57
Q

What are the characteristics of an EPO?

A
  • Must receive care exclusively from health care providers with EPO contracts or EPO won’t pay
  • Services limited to medically necessary or preventative care
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58
Q

What is managed healthcare?

A

System of managing cost, quality and access of healthcare (can be from managed indemnity, preferred provider organizations (PPOs) or health maintenance organizations (HMO)

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59
Q

What is fee-for-service?

A

Providers receive payment for each service provided

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60
Q

What is the method of reimbursement where providers are paid after services have been provided?

A

Traditional Retrospective payment

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61
Q

What is it called when third party payers manage cost of healthcare and episodes of care?

A

Managed care reimbursement

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62
Q

What method of reimbursement pays one lump sum for all services related to a condition or disease?

A

Episode of Care reimbursement

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63
Q

What is Capitation?

A

Third party payer reimburses providers a fixed per capita amount for a period (per member per month or PMPM)

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64
Q

What is prospective payment?

A

Payment rates established in advance for a specified time period; pre-determined rates based on average levels of resource use

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65
Q

What is pay for performance?

A

Provides bonus to healthcare providers if they meet or exceed agreed upon quality or performance measures. May also reward improvement over time

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66
Q

What is the Patient Protection and Affordable Care Act (PPACA)

A
  • requires virtually every citizen to obtain health insurance
  • establishes a 5 year Medicare voluntary pilot program for integrating care across hospitals/providers during an episode of care
  • establishes value-based purchasing
67
Q

What is an ACO?

A

Accountable care organization

68
Q

What does an ACO agree to?

A
  • Be accountable for overall care of Medicare beneficiaries
  • have adequate participation of primary care physicians
  • define process to promote evidence-based medicine
  • report on quality and cost
69
Q

What is an HAC?

A

Hospital Acquired Conditions-reduces Medicare payments to hospitals for certain hospital-acquired conditions

70
Q

How does PPACA de-incentivize facilities related to preventable readmissions?

A

Reducing Medicare payments that would have otherwise been made by a specific percentage

71
Q

What are the PPACA goals?

A
  • give more individuals access to affordable care
  • reduce growth in healthcare spending in US
  • expand affordability, quality and availability of private/public health insurance through consumer protections, regulations, subsidies, taxes, insurance exchanges and other reforms
72
Q

What are provider networks?

A

Group of healthcare providers that have contracted with a health insurance carrier (HMO, EPO, PPO) to provide discounted care

73
Q

What is the goal of utilization management?

A

Facilitate delivery of high-quality, low-cost, efficient and effective care

74
Q

Process by a which a reviewer determines (prior to services provided) whether an admission is reasonable/necessary

A

Pre-admission review (utilization management review)

75
Q

What is a concurrent review?

A

Performed when the patient is in the facility and covers appropriateness of the level of care by evaluation condition of patient against services provided

76
Q

Which type of utilization review process takes place after discharge?

A

Retrospective review

77
Q

Why are authorization utilization reviews performed?

A

To ensure payments are appropriate (prior auth.)

78
Q

Why conduct a length of stay review and what is it?

A

Attempt to control cost; number of days a patient should stay in facility for certain diagnosis

79
Q

What is the collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and service to meet individual’s health needs?

A

Case management

80
Q

What are clinical pathways?

A

Multidisciplinary management tool proactively depicting all inclusive important events that should take place in sequence

81
Q

What is the goal of clinical pathways and guidelines?

A

Achieve optimal quality of care while minimizing delays and efficient resource utilization

82
Q

What are some of the benefits of clinical pathways and guidelines?

A
  • effective tool for decreasing length of stay and resource utilization
  • Enhance quality of care with continuous/concurrent attention to variances
  • Improve patient satisfaction and communication among team members
83
Q

What are the two parts of the credentialing process?

A
  • Appointment/reappointment to the medical staff

- granting/renewing and revising clinical privileges

84
Q

What is the Quality Department’s role in the credentialing process?

A

Acts a resource for credentialing department

  • Gives input
  • tracks oversight activities
  • ensures work is completed
  • manages quality files
85
Q

Who is responsible overall for credentialing, privileging and quality oversight?

A

Governing body

86
Q

What is the purpose of credentialing?

A

-Provides protection against incompetent or unlicensed professionals or individuals and liability claims

87
Q

How must you verify certification and/or licensure?

A

Primary source verification (no copies accepted)

88
Q

What are the methods for credentialing?

A
  • Single credentials verification organization (CVO) verifies credentials for multiple facilities
  • Single facility or system
89
Q

What are required credentialing elements?

A
  • Current licensure or certification
  • Specific relevant training
  • Peer or faculty recommendation
  • Evidence of physical ability to perform requested privilege
90
Q

What do peer faculty recommendations include?

A
  • Medical/clinical knowledge
  • technical/clinical skills
  • clinical judgement
  • interpersonal and communication skills
  • Professionalism
91
Q

What are priveleges?

A

What a practitioner can do in a specific healthcare organization

92
Q

Who grants privileges?

A

The governing body

93
Q

What is provisional privileging?

A

Type that enables someone to practice as a healthcare provider with certain restrictions.

94
Q

Who does provisional privileging apply to?

A

Individuals who do not meet full credentialing requirements

95
Q

What status type of privileging is given to staff who have met medical criteria and is working within the scope of those granted privileges?

A

Active

96
Q

What are consulting privileges?

A

Granted if staff may respond to requests from attending physicians or department chairs for consultations in their area of clinical expertise

97
Q

When are temporary privileges granted and by who?

A

When medical staff are awaiting review and approved by medical executive committee and the governing body. Granted by CEO

98
Q

For what time period can temporary privileges be granted?

A

no more than 120 days

99
Q

During an emergency, these privileges may be granted to volunteer licensed independent practitioners (LIPs) when emergency operations plan is activated and hospital cannot meet immediate patient needs

A

Emergency

100
Q

What does the credentialing process normally look like?

A
  • Application
  • Primary Source Verification
  • Privileges Selected
  • Department head review
  • credentialing committee review
  • medical executive committee review
  • governing body review and approval
101
Q

What is the purpose Focused Professional Practice Evaluation (FPPE)

A

To demonstrate competency in delivering safe, effective care

102
Q

When does Focused Professional Practice Evaluation (FPPE) occur?

A
  • At time of first appointment
  • At time of new privileges requested to existing provider
  • If provider specific issues affecting safe, effective care are identified
103
Q

What are the six areas of general competencies used in an Focused Professional Practice Evaluation (FPPE) Assessment?

A
  • patient care
  • medical and clinical knowledge
  • practice-based learning and improvement
  • interpersonal communication skills
  • professionalism
  • systems-based practice
104
Q

What is the purpose of Ongoing Professional Practice Evaluation (OPPE)?

A

Demonstrate ongoing competency in delivering safe, effective care

105
Q

When is OPPE used?

A

Monitoring performance after initial FPPE completed to determine whether to continue, limit or revoke existing privileging (like a report card)

106
Q

What is a peer review?

A

Medical staff involved in measuring, assessing and improving performance of licensed practitioners

107
Q

What traits make a peer review process effective?

A
  • Consistent: defined procedures
  • Defensible: Conclusions reached are supported by rationale
  • Balanced: Minority opinions and views of the person being reviewed are considered and recorded
108
Q

What is important about peer review documentation?

A
  • Should not be included in credentials file (must be stored separately)
  • Must be kept confidential and as protected from discovery as possible
109
Q

What is the purpose of practitioner files?

A

Track outcomes and manage costs

110
Q

What should be part of a profile?

A

-OPPE

data about specific evidence-based care provided

111
Q

What are examples of performance indicators for privileging?

A
  • Anticipating patient needs
  • Preventing chronic disease complications
  • avoidable admissions
  • improving quality of care
112
Q

The best information for practitioner profiles use national targets and benchmarks. True or False?

A

True

113
Q

Practitioner data for profiles should be meaningful to practitioners?. True or False

A

True

114
Q

Are practitioner profiles the same for all practitioners?

A

No, they vary according to practitioner’s specialty or area of expertise

115
Q

How can you ensure confidentiality of practitioner profiles?

A
  • tracking activity on profiles
  • a log/sign-out sheet for file removal
  • policies and procedures state where they are kept and when they can be copied
  • develop a mechanism for release of information
116
Q

Are reports of disruption (with staff or patients) included in Quality portion of practitioner profiles?

A

Yes

117
Q

Why is it important that Quality portion of practitioner profiles are kept separate from other files?

A

They may be discoverable if located with other files

118
Q

What clinical issues may be included in Quality portion of practitioner profiles?

A
  • treatment errors

- mortality rates

119
Q

Why is The Joint Commission accreditation important yet voluntary

A

Required for Medicare and Medicaid reimbursement

120
Q

Deemed status refers to

A

accreditation equivalency with a Centers for Medicare and Medicaid Services (CMS) survey

121
Q

Joint Commission accreditation meets deemed status requirements for CMS. True or False?

A

True

122
Q

What is The Joint Commission (TJC)

A

An independent not-for-profit which accredits and certifies 21,000 healthcare organizations and programs

123
Q

What is the health and safety requirement for TJC called?

A

Conditions for Participation (CoPs) or Conditions for Coverage (CfCs)

124
Q

What is the National Committee for Quality Assurance (NCQA)

A

A private not-for-profit organization dedicated to improving health care quality in managed care

125
Q

Organizations must do what to use the NCQA seal?

A

Pass a rigorous comprehensive review and annually report performance

126
Q

Which organization reports Healthcare Effectiveness Data and Information Set (HEDIS)?

A

National Committee for Quality Assurance (NCQA)

127
Q

How does DNV GL-Healthcare (Det Norske Veritas Germanischer Lloyd) review for accreditation?

A

Annual visits

128
Q

Does DNV GL accreditation meet deemed status for CMS?

A

Yes

129
Q

What is International Organizations for Standardizations (ISO)?

A

They develop international standards

130
Q

What does ISO focus on in healthcare?

A

Quality management program

131
Q

ISO 9007 sets criteria for quality management system. True or False?

A

True

132
Q

CMS authorized accreditation organization that surveys hospitals, their clinical laboratories, ambulatory care/surgical facilities, mental health and substance abuse facilities and physical rehabilitation facilities and clinical laboratories

A

Healthcare Facilities Accreditation Program (HFAP)

133
Q

Which accreditation program is peer-based and focused exclusively on ambulatory healthcare?

A

Accreditation Association for Ambulatory Health Care (AAAHC)

134
Q

Which accreditation program focuses mainly on rehab facilities?

A

Commission on Accreditation of Rehabilitation Facilities (CARF)

135
Q

Which accreditation organization is membership-based and comprised of acute care and critical access hospitals?

A

Center for Improvement in Healthcare Quality (CIHQ)

136
Q

Which accreditation program is part of Department of Health and Human Services?

A

Centers for Medicare and Medicaid Services (CMS)

137
Q

Which programs does CMS administer?

A
  • Medicare
  • Medicaid
  • Children’s Health Insurance Program (CHIP)
  • Federall0facilitated health insurance marketplace
138
Q

Why is it important for Quality to identify survey trends/areas of concern?

A

They will become part of the performance and process improvement plans

139
Q

What is the Quality role in survey preparedness?

A

Coordinate survey preparation and training with managers, leaders, and staff

140
Q

Survey readiness requires what levels of commitment and assessment?

A
  • leadership commitment
  • manager accountability
  • routine self-assessment
  • corrective action plans
  • staff education, recognition and rewards
141
Q

Why is it advantageous to conduct a pilot training prior to rolling out a progam?

A

To evaluate and make any changes

142
Q

What are the training evaluation levels?

A
  • Reaction
  • Learning
  • Behavior Changes
  • Results
  • Return on investment
143
Q

What is Reaction training evaluation and when is it conducted?

A

Satisfaction in training

-completed at end of training

144
Q

What is Learning training evaluation and when is it conducted?

A

Knowledge, skills and attitudes

-occurs pre- and post- training through tests, performance demonstration or role play

145
Q

What is Behavior Changes training evaluation and when is it conducted?

A 
Transfer to job-measures whether behavior changed
-can include pre- and post- class observation, interviews, etc.
146
Q

What is Results training evaluation?

A

On purpose for training-measures whether results were achieved
-sometimes difficult to attribute only to training

147
Q

What is Return on Investment training evaluation?

A

How the bottom line changes-compares whether the money spent had an impact on the bottom line

148
Q

This program recognizes national role models with the Presidential Reward to performance excellence

A

Malcolm Bridge Performance Excellence Program (AKA Baldridge Program)

149
Q

What are the 7 criteria categories for the Malcolm Bridge Performance Excellence Program?

A
  • leadership
  • strategy
  • customers
  • measurement, analysis, improvement
  • workforce
  • work processes
  • results
150
Q

What does the Magnet Recognition program do?

A

Recognizes healthcare organizations for quality patient care, nursing excellence and innovations in nursing practice

151
Q

What are the five model components of the Magnet Recognition program?

A
  • transformational leadership
  • structural empowerment
  • exemplary professional practice
  • new knowledge, innovation and improvements
  • empirical quality report
152
Q

What does the Occupational Safety and Health Administration (OSHA) do?

A

Establishes requirements for environmental safety programs

153
Q

What are some examples of environmental safety programs governed by OSHA?

A
  • Management of blood borne pathogens
  • prevention of TB
  • keeping patient care areas clear of drinking/eating
  • annual posting of staff injuries logs
154
Q

What does the Health Insurance Portability and Accountability Act (HIPAA) do?

A

Sets requirements for release of health information and authorization for access to health information

155
Q

What is the Leapfrog group?

A

Voluntary initiative to mobilize employer purchasing power to guide healthcare industry

156
Q

What is the National Quality Forum (NQF)?

A

Voluntary consensus standards-setting organization that established 34 safety practices

157
Q

What are the four leaps identified by Leapfrog (using NQF)?

A
  • Computerized physician order entry
  • Evidence-based hospital referral
  • intensive care unit physician staffing
  • safe practices score
158
Q

What is the Institute for Healthcare Improvement (IHI)?

A

Independent organization that partners to improve health of individuals and populations

159
Q

What are the five key areas identified by IHI?

A
  • Improvement capability
  • Person and family centered care
  • patient safety
  • Quality, cost and value
  • triple aim for populations (improve care and population health, reduce cost)
160
Q

Who bears ultimate responsibility for:

  • setting policy
  • financial and strategic direction
  • quality of care
  • goals and objectives
  • establishing quality priorities (with management and medical staff)
A

Board of Directors

161
Q

How is culture defined?

A

Shared values and behavioral norms

162
Q

Why are core values and norms important?

A

Inspire commitment

163
Q

What are narrative examples of culture?

A

Stories, myths, legends

164
Q

An element of culture is that councils and committees involve all levels. True or False?

A

True

CPHQ (5 decks)

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