Operations & Meeting Management (#4)

Question 1

Management Information System (MIS)

Answer 1

MIS- Organized method of providing the necessary information needed in the decision making process
Data- Statistics, opinions, facts that are stored and retrieved
Information- Data organized in order to be relevant to the decision making process
Database- Collection of the organization’s data resources

Question 2

Credentials Chart Audits

Answer 2

• Periodic audits of credentials files to verify compliance with requirements of bylaws, accrediting agencies, and state/ federal regulations
• Ensure verifications are completed within the required timeframe
• Evaluate corrective action plans

Question 3

Release of Information/ Responding to Requests

Answer 3

• Draft policies regarding the release of information
• Practitioner must provide a signed release specific to the organization
• Standardized response for verification letters
• Confidential peer review information should not be relayed to third parties even if you have a signed consent & release form
• Updates to website are implemented immediately when changed occur

Question 4

HIPAA Regulations

Answer 4

• HIPAA requires US Department of Health & Human Services (DHHS) to develop standards and requirements for maintenance and transmission of health information the identifies individual patients
• Healthcare organizations are prohibited from using or disclosing health information except as authorized by the patient or as specifically permitted by the regulation

Question 5

Medicare Attestation Statement

Answer 5

• MCR payment based in part on patient’s diagnoses evidenced by physician’s entries in patient’s medical record
• Hospital required to have signed & dated acknowledgement from the attending physician
• Completion of acknowledgment: Acknowledgment must be completed by physician at the time the physician is granted admitting privileges at the hospital & remains in effect as long as the physician has admitting privileges at the hospital

Question 6

Delegation to a CVO

Answer 6

TJC: Outlines 9 principles to evaluate a CVO agency
HFAP: PCO (Professional Credentialing Organization) can be used to perform PSV, but PCO must follow HFAP standards
NCQA: Delegation agreement- description of functions, activities, reporting requirements & evaluation of the delegated entity’s performance; organization required to complete annual review of delegated functions; annual file audit 5% or 50 practitioner files; can use 8/30 methodology (review 8; review 30 if one of the 8 fails)
AAAHC: CVO is allowed

Question 7

Medical Staff Meeting Management

Answer 7

“Committee of the whole”- MS as a whole carries out the governance functions
Roles in Meetings: “Robert’s Rules of Order,” “Newly Revised,” or “Sturgis’s Standard Code of Parliamentary Procedure”
Quorum: minimum number of members required to attend for meeting to be valid
Consent agenda: Can be used for items that are routine issues & do not require discussion
Be aware of state, federal & organizational confidentiality requirements

Question 8

Parliamentary Procedure

Answer 8

Code of rules & ethics for working together in groups
Main motions: bring an item of business to the body for consideration
Subsidiary motions: assist the body in considering or disposing of a main motion
Privileged motions: do not relate to the pending business, but have to do with special matters of immediate importance that should be allowed to interrupt the consideration of anything else
Incidental motions: deal with questions of procedure arising out of other motions or business
Motions that bring a question: can only be made while no business is pending
Motions are considered & voted on in reverse order to their proposal

Question 9

Taking & Transcribing Meeting Minutes

Answer 9

Minutes are taken to provide documentation that a meeting was held, what action was taken, what recommendations were made, and what action will be carried out
Dos: Keep it short, conclusions or recommendations, what actions were taken, what follow-up is necessary, ask the chair if you can read back what you wrote for accuracy
Don’t: Insert your opinion, include who made/ seconded motions
After meeting minutes are transcribed and approved, the tape should be erased or taped over

Question 10

Corrections to Minutes

Answer 10

Once the authorized person signs minutes, they constitute the official business of the meeting and should not be retyped
Corrections to minutes should be made at the first meeting after the mistake is recognized
The chair should initial the correction

Question 11

Minutes Do’s

Answer 11

• Keep it short & to the point
• Topics discussed, conclusions or recommendations, actions taken, follow-up necessary
• Ask for help from chair if needed, ask the chair if you can read back what you noted

Question 12

Minutes Don’ts

Answer 12

• Do not include your opinion
• Don’t include remarks made “for the record”
• Record who made or seconded motions unless needed to reflect conflict of interest

Question 13

Attendance requirements

Answer 13

If bylaws require mandatory attendance, use a sign-in sheet and keep it for your records. Include staff status.