CA registry management principles and practice ch 32 TJC

Quality Assurance Progs transformed into
Performance Improvement Progs
A common performance improvement model used in many hospitals is the
plan, do, check, and act model
Descriptions of key elements in the process of care that should be accomplished to achieve max quality and max cost
Critical pathways
TJC’s initiative to integrate performance processes into the accreditation process
TJC defines a core measure set as a “unique grouping of __________ carefully selected to provide, when viewed together, a robust pic of the care provided in a given area”
performance measures
T OR F: The conception of TJC began with Dr Ernest Codman
T OR F: Hospital standardization was on of the first activities of the newly formed ACOS
T OR F: The request for accreditation was and continues to be considered mandatory
T OR F: Hospitals are required to collect and transmit data on the noncore measures
How many standards were there in the minimum standard?
the ACOS was founded by _______ with other Drs in 1910
Dr Martin and Dr Codman
4 underlying concepts for the Agenda for Change
1. Pt outcomes are influenced by all of the activities of a healthcare org
2. Continuous improvement in the quality of care should be a priority of healthcare orgs
3. TJC should focus on these activities of healthcare orgs that are most important to quality of care
4. traditional assessments of compliance with standards should be complemented by accredited org’s collection, analysis, and feedback of data that reflect their actual performance in undertaking key activities
3 major initiatives for Agenda for change
1. Redesign of TJC’s standards to stress the entire org’s effectiveness in pt services
2. Redesign of survey process to provide more interactive consultative services
3. Development of nat’l performance measurement system, commonly known as the Indicator Measurement System
Agenda for Change
new movement in the 1980s that was a response to the dramatic increase in healthcare costs
Performance measurement system
inter-related set of outcomes and/or processes that support internal comparisons or org’s performance over time and external comparison of performance among orgs at comparable times
retrospective tool to assess quality of care
clinical practice guidelines
outlines of strategies for pt management that describes a range of acceptable ways to dx, manage, or prevent specific dz and conditions
quality assurance
formal approach to one of the original TJC’s min standards

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