Mod. 2 Organizational Leadership Flashcards
Board of Director’s Quality Role
Identify the alignment between a quality program and organizational systems
What role copes with change by developing vision and aligning subsystems (determine the correct path)?
Leaders
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)?
Managers
How long does it take to implement significant change?
18-24 months
How long does it take to anchor significant change in practice and culture?
10 years
Strategic plans are especially important to…
meeting external demands relative to competition
Mission
Organization’s purpose or reason for existence; why are we here?
Vision
Organization’s statement of its goals for the future
Direction
Built on mission and guided by vision
Core Values
Define organization’s attitudes and help direct vision
Goals
Broad, general statements specifying a purpose or desired outcome
- may be more abstract than objectives
- one goal can have multiple objectives
Objectives
Specific statements that detail how goal(s) will be achieved through specific and measurable action(s)
-relatively narrow and concrete
What are SMART Goals?
- Specific
- Measurable
- Attainable
- Relevant
- Time-bound
How does assessing customer needs help the organization?
Helps refine mission, vision and core values
What is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Standardized method to compare the performance of hospitals and link payment to performance developed by CMS
What does CMS stand for?
Center for Medicare and Medicaid Services
What is a key component of measuring hospital performance as identified by CMS?
Customer perception
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?
Voice of the Customer (VOC)
What are the four aspects of VOC?
- 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
What are the steps to conduct VOC research?
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
Goals and objectives should cascade to…
Every person’s performance appraisal
What are the goals of strategic planning?
- 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
What is Hoshin Planning?
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
What are the steps of Hoshin Planning?
- 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)
What does a balanced scorecard do and what does SCCA use to do this?
Provides an ongoing snapshot of how the organization is performing. SCCA uses Key Performance Indicators (KPIs)
What are some balanced scorecard examples at SCCA?
- 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
What are considerations for Quality initiatives?
- 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
Why do you need to establish recognition and reward systems?
To foster a culture of safety, quality professionals work with others to reward behaviors and practices that contribute to this culture
What are the steps to creating reward systems?
- 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
What is Population Health?
Outcomes for a group of individuals
What are some determinants of health?
- medical care
- public health
- genetics
- personal behaviors and lifestyle
- social factors
- environmental factors
- economic factors
What is Population Health Management (PHM)?
involves improving health within and across populations who are at risk for or have chronic disease
What are examples of “non-health” organizations who are engaged in determinants of health
- schools
- correctional facilities
- transit systems
- land developers
- architects
What are examples of populations?
- 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
When does a care transition occur?
When a patient moves from one healthcare provider or setting to another
What does “transitions of care” refer to?
A patient leaving one care setting (e.g., hospital, emergency department, nurse home, assisted living facility, etc.) and moving to another
According to TJC, what is the percentage of serious medical errors involving miscommunication between caregivers when patients are transferred or handed off?
80%
80% of serious medical errors involve what?
Miscommunication between caregivers when patients are transferred or handed off
What is the definition of a hand off?
A transfer and acceptance of patient care responsibility achieved through effective communication
How are hand offs achieved?
Through effective communication
What are examples of information hand offs should include?
- patient history
- heart rhythm
- infections
- complications
- need for restraints
What is the real time process of passing patient-specific information from one caregiver to another to ensure continuity?
Hand offs
What is the preferred communication method(s) for successful hand offs?
Verbal (face-to-face preferred) and in writing
What should be standardized to ensure successful hand offs?
- critical content to be communicated
- tools and methods to communicate to receivers
- training from both the standpoint of the receive and sender
What are some tools that help achieve successful hand offs
- forms
- templates
- checklists
- protocols
- mnemonics
Where should face-to-face hand offs take place?
In a location free from interruptions (both for team members and patient/family as appropriate)
What are technologies that can enhance hand offs?
- electronic medical records
- apps
- patient portals
How can you improve continuity of medications during care transitions?
- Implement EMR that includes standardized medication reconciliation
- Expand role of pharmacist
How can you establish points of accountability for sending/receiving care?
- implement payment systems that align incentives
- develop performance metrics
Episodes of care can be defined as
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
How are episodes of care generally initiated?
-By referral or admission
What is a PPO?
Preferred Provider Organization-health plan contracts with a network of preferred providers from which to choose
What are the characteristics of a PPO?
- 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
What is an HMO
Health Maintenance Organizations-members need to receive most or all care from network provider
What are the characteristics of an HMO?
- 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
What is an EPO
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
What are the characteristics of an EPO?
- Must receive care exclusively from health care providers with EPO contracts or EPO won’t pay
- Services limited to medically necessary or preventative care
What is managed healthcare?
System of managing cost, quality and access of healthcare (can be from managed indemnity, preferred provider organizations (PPOs) or health maintenance organizations (HMO)
What is fee-for-service?
Providers receive payment for each service provided
What is the method of reimbursement where providers are paid after services have been provided?
Traditional Retrospective payment
What is it called when third party payers manage cost of healthcare and episodes of care?
Managed care reimbursement
What method of reimbursement pays one lump sum for all services related to a condition or disease?
Episode of Care reimbursement
What is Capitation?
Third party payer reimburses providers a fixed per capita amount for a period (per member per month or PMPM)
What is prospective payment?
Payment rates established in advance for a specified time period; pre-determined rates based on average levels of resource use
What is pay for performance?
Provides bonus to healthcare providers if they meet or exceed agreed upon quality or performance measures. May also reward improvement over time
What is the Patient Protection and Affordable Care Act (PPACA)
- 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
What is an ACO?
Accountable care organization
What does an ACO agree to?
- 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
What is an HAC?
Hospital Acquired Conditions-reduces Medicare payments to hospitals for certain hospital-acquired conditions
How does PPACA de-incentivize facilities related to preventable readmissions?
Reducing Medicare payments that would have otherwise been made by a specific percentage
What are the PPACA goals?
- 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
What are provider networks?
Group of healthcare providers that have contracted with a health insurance carrier (HMO, EPO, PPO) to provide discounted care
What is the goal of utilization management?
Facilitate delivery of high-quality, low-cost, efficient and effective care
Process by a which a reviewer determines (prior to services provided) whether an admission is reasonable/necessary
Pre-admission review (utilization management review)
What is a concurrent review?
Performed when the patient is in the facility and covers appropriateness of the level of care by evaluation condition of patient against services provided
Which type of utilization review process takes place after discharge?
Retrospective review
Why are authorization utilization reviews performed?
To ensure payments are appropriate (prior auth.)
Why conduct a length of stay review and what is it?
Attempt to control cost; number of days a patient should stay in facility for certain diagnosis
What is the collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and service to meet individual’s health needs?
Case management
What are clinical pathways?
Multidisciplinary management tool proactively depicting all inclusive important events that should take place in sequence
What is the goal of clinical pathways and guidelines?
Achieve optimal quality of care while minimizing delays and efficient resource utilization
What are some of the benefits of clinical pathways and guidelines?
- 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
What are the two parts of the credentialing process?
- Appointment/reappointment to the medical staff
- granting/renewing and revising clinical privileges
What is the Quality Department’s role in the credentialing process?
Acts a resource for credentialing department
- Gives input
- tracks oversight activities
- ensures work is completed
- manages quality files
Who is responsible overall for credentialing, privileging and quality oversight?
Governing body
What is the purpose of credentialing?
-Provides protection against incompetent or unlicensed professionals or individuals and liability claims
How must you verify certification and/or licensure?
Primary source verification (no copies accepted)
What are the methods for credentialing?
- Single credentials verification organization (CVO) verifies credentials for multiple facilities
- Single facility or system
What are required credentialing elements?
- Current licensure or certification
- Specific relevant training
- Peer or faculty recommendation
- Evidence of physical ability to perform requested privilege
What do peer faculty recommendations include?
- Medical/clinical knowledge
- technical/clinical skills
- clinical judgement
- interpersonal and communication skills
- Professionalism
What are priveleges?
What a practitioner can do in a specific healthcare organization
Who grants privileges?
The governing body
What is provisional privileging?
Type that enables someone to practice as a healthcare provider with certain restrictions.
Who does provisional privileging apply to?
Individuals who do not meet full credentialing requirements
What status type of privileging is given to staff who have met medical criteria and is working within the scope of those granted privileges?
Active
What are consulting privileges?
Granted if staff may respond to requests from attending physicians or department chairs for consultations in their area of clinical expertise
When are temporary privileges granted and by who?
When medical staff are awaiting review and approved by medical executive committee and the governing body. Granted by CEO
For what time period can temporary privileges be granted?
no more than 120 days
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
Emergency
What does the credentialing process normally look like?
- Application
- Primary Source Verification
- Privileges Selected
- Department head review
- credentialing committee review
- medical executive committee review
- governing body review and approval
What is the purpose Focused Professional Practice Evaluation (FPPE)
To demonstrate competency in delivering safe, effective care
When does Focused Professional Practice Evaluation (FPPE) occur?
- At time of first appointment
- At time of new privileges requested to existing provider
- If provider specific issues affecting safe, effective care are identified
What are the six areas of general competencies used in an Focused Professional Practice Evaluation (FPPE) Assessment?
- patient care
- medical and clinical knowledge
- practice-based learning and improvement
- interpersonal communication skills
- professionalism
- systems-based practice
What is the purpose of Ongoing Professional Practice Evaluation (OPPE)?
Demonstrate ongoing competency in delivering safe, effective care
When is OPPE used?
Monitoring performance after initial FPPE completed to determine whether to continue, limit or revoke existing privileging (like a report card)
What is a peer review?
Medical staff involved in measuring, assessing and improving performance of licensed practitioners
What traits make a peer review process effective?
- Consistent: defined procedures
- Defensible: Conclusions reached are supported by rationale
- Balanced: Minority opinions and views of the person being reviewed are considered and recorded
What is important about peer review documentation?
- Should not be included in credentials file (must be stored separately)
- Must be kept confidential and as protected from discovery as possible
What is the purpose of practitioner files?
Track outcomes and manage costs
What should be part of a profile?
-OPPE
data about specific evidence-based care provided
What are examples of performance indicators for privileging?
- Anticipating patient needs
- Preventing chronic disease complications
- avoidable admissions
- improving quality of care
The best information for practitioner profiles use national targets and benchmarks. True or False?
True
Practitioner data for profiles should be meaningful to practitioners?. True or False
True
Are practitioner profiles the same for all practitioners?
No, they vary according to practitioner’s specialty or area of expertise
How can you ensure confidentiality of practitioner profiles?
- 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
Are reports of disruption (with staff or patients) included in Quality portion of practitioner profiles?
Yes
Why is it important that Quality portion of practitioner profiles are kept separate from other files?
They may be discoverable if located with other files
What clinical issues may be included in Quality portion of practitioner profiles?
- treatment errors
- mortality rates
Why is The Joint Commission accreditation important yet voluntary
Required for Medicare and Medicaid reimbursement
Deemed status refers to
accreditation equivalency with a Centers for Medicare and Medicaid Services (CMS) survey
Joint Commission accreditation meets deemed status requirements for CMS. True or False?
True
What is The Joint Commission (TJC)
An independent not-for-profit which accredits and certifies 21,000 healthcare organizations and programs
What is the health and safety requirement for TJC called?
Conditions for Participation (CoPs) or Conditions for Coverage (CfCs)
What is the National Committee for Quality Assurance (NCQA)
A private not-for-profit organization dedicated to improving health care quality in managed care
Organizations must do what to use the NCQA seal?
Pass a rigorous comprehensive review and annually report performance
Which organization reports Healthcare Effectiveness Data and Information Set (HEDIS)?
National Committee for Quality Assurance (NCQA)
How does DNV GL-Healthcare (Det Norske Veritas Germanischer Lloyd) review for accreditation?
Annual visits
Does DNV GL accreditation meet deemed status for CMS?
Yes
What is International Organizations for Standardizations (ISO)?
They develop international standards
What does ISO focus on in healthcare?
Quality management program
ISO 9007 sets criteria for quality management system. True or False?
True
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
Healthcare Facilities Accreditation Program (HFAP)
Which accreditation program is peer-based and focused exclusively on ambulatory healthcare?
Accreditation Association for Ambulatory Health Care (AAAHC)
Which accreditation program focuses mainly on rehab facilities?
Commission on Accreditation of Rehabilitation Facilities (CARF)
Which accreditation organization is membership-based and comprised of acute care and critical access hospitals?
Center for Improvement in Healthcare Quality (CIHQ)
Which accreditation program is part of Department of Health and Human Services?
Centers for Medicare and Medicaid Services (CMS)
Which programs does CMS administer?
- Medicare
- Medicaid
- Children’s Health Insurance Program (CHIP)
- Federall0facilitated health insurance marketplace
Why is it important for Quality to identify survey trends/areas of concern?
They will become part of the performance and process improvement plans
What is the Quality role in survey preparedness?
Coordinate survey preparation and training with managers, leaders, and staff
Survey readiness requires what levels of commitment and assessment?
- leadership commitment
- manager accountability
- routine self-assessment
- corrective action plans
- staff education, recognition and rewards
Why is it advantageous to conduct a pilot training prior to rolling out a progam?
To evaluate and make any changes
What are the training evaluation levels?
- Reaction
- Learning
- Behavior Changes
- Results
- Return on investment
What is Reaction training evaluation and when is it conducted?
Satisfaction in training
-completed at end of training
What is Learning training evaluation and when is it conducted?
Knowledge, skills and attitudes
-occurs pre- and post- training through tests, performance demonstration or role play
What is Behavior Changes training evaluation and when is it conducted?
Transfer to job-measures whether behavior changed -can include pre- and post- class observation, interviews, etc.
What is Results training evaluation?
On purpose for training-measures whether results were achieved
-sometimes difficult to attribute only to training
What is Return on Investment training evaluation?
How the bottom line changes-compares whether the money spent had an impact on the bottom line
This program recognizes national role models with the Presidential Reward to performance excellence
Malcolm Bridge Performance Excellence Program (AKA Baldridge Program)
What are the 7 criteria categories for the Malcolm Bridge Performance Excellence Program?
- leadership
- strategy
- customers
- measurement, analysis, improvement
- workforce
- work processes
- results
What does the Magnet Recognition program do?
Recognizes healthcare organizations for quality patient care, nursing excellence and innovations in nursing practice
What are the five model components of the Magnet Recognition program?
- transformational leadership
- structural empowerment
- exemplary professional practice
- new knowledge, innovation and improvements
- empirical quality report
What does the Occupational Safety and Health Administration (OSHA) do?
Establishes requirements for environmental safety programs
What are some examples of environmental safety programs governed by OSHA?
- Management of blood borne pathogens
- prevention of TB
- keeping patient care areas clear of drinking/eating
- annual posting of staff injuries logs
What does the Health Insurance Portability and Accountability Act (HIPAA) do?
Sets requirements for release of health information and authorization for access to health information
What is the Leapfrog group?
Voluntary initiative to mobilize employer purchasing power to guide healthcare industry
What is the National Quality Forum (NQF)?
Voluntary consensus standards-setting organization that established 34 safety practices
What are the four leaps identified by Leapfrog (using NQF)?
- Computerized physician order entry
- Evidence-based hospital referral
- intensive care unit physician staffing
- safe practices score
What is the Institute for Healthcare Improvement (IHI)?
Independent organization that partners to improve health of individuals and populations
What are the five key areas identified by IHI?
- Improvement capability
- Person and family centered care
- patient safety
- Quality, cost and value
- triple aim for populations (improve care and population health, reduce cost)
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)
Board of Directors
How is culture defined?
Shared values and behavioral norms
Why are core values and norms important?
Inspire commitment
What are narrative examples of culture?
Stories, myths, legends
An element of culture is that councils and committees involve all levels. True or False?
True
