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Accreditation Standards

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Statements of expectation set by a competent authority concerning a degree or level of requirement, excellence, or attainment in quality or performance.

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Assessment

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Use of performance information to determine the degree to which an acceptable level of quality has been achieved.

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Continuous improvement

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System in which individuals in an organization look for ways to do things better, usually based on understanding and control of performance variation.

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Governing Board

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Individuals, groups, or agency with ultimate legal authority and responsibility for overall operation of an organization; sometimes called board of trustees

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Healthcare Quality

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Degree to which health services for individuals and population increase like the likelihood of desired health outcomes and are consistent with current professional knowledge.

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Improvement

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Planning and making changes to current practices so performance will be better in the future.

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Measurement

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Collection of information for the purpose of understanding current performance and seeing how performance changes over time.

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Medical staff executive committee

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Leadership group of a hospital's organized medical staff that exercises primary authority over activities of the medical staff and over performance of individuals with hospital clinical privileges

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Misuse

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Health services misuse includes incorrect diagnoses as well as medical errors and other sources of avoidable complications

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Overuse

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Overuse occurs when a health service is provided even though its risk of harm exceeds its likely benefit.

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Patient safety

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Actions taken to reduce the risk of patients being unintentionally harmed by effects of healthcare services.

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Processes

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Collections of actions following prescribed procedures for bringing about a result

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Quality Management

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Way of doing business which continuously improves products and services to achieve even better levels of performance.

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Quality management plan

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Written description of the organizational structure, responsibilities, procedures, processes and resources supporting an organization's quality management system

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Quality Management System

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Organizational structure, responsibilities, procedures, processes and resources supporting the design, measurment, assessment and improvement of key functions and key processes, sometimes referred to as the quality program or performance improvement program

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Stakeholder

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Person, group, organization, or entity with a direct or indirect stake in an organization because it can affect or be affected by that organization's actions, objectives and performance

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Underuse

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Occurs when a health service is not provided though it would have been medically beneficial

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Providers

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Any organization or individual that is licensed or trained to give healthcare.

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Purchasers

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Any organization or individual that pays for healthcare services either directly or indirectly.

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Consumers

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Any recipient of healthcare services.

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Key Dimensions of Healthcare Quality Identified by the Institute of Medicine

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Safe, Effective, Patient-Centered, Timely, Efficient, and Equitable

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Three Primary Activities of Quality Management

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measurement, assessment, and improvement

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Quality is the responsibility of

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everyone working in healthcare

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Case Manager

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this individual often a nurse or social worker, helps coordinate patient services among and between caregivers and provider sites.

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compliance officer

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This individual helps assure the organization adheres to external regulations and accreditation requirements related to quality management

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Health Data Analyst

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this individual gathers, evaluates and reports information in support of various quality management activities--may have clinical, health information management or informatics expertise

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Infection control practitioner

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this individual collects and analyzes health data related to patient infections and disseminates information on prevention of infections--typically filled by nurse, physician, epidemiologist or medical technologist

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Patient representative

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this individual serves as a liaison and primary customer service contact for patients and family members--often gather patient and family complaint data for performance measurment purposes

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Patient safety officer

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this individual oversees patient safety improvement activities which may include evaluation of patient incident data, facilitation of safety improvement projects and coordination of information flow about patient safety among relevant administrative and medical staff committees

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Physician advisor

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this individual serves as a full or part-time quality management advisor-- works closely with the quality department and medical staff president to ensure appropriate physician participation in, and communication of, quality management activities--may serve as advisor for UM activities

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Quality Director

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this individual serves as the administrative head of the quality department and performs or coordinates functions assigned to that department-- assists senior leadership in facilitating compliance with quality-related accreditation standards, government regulations and purchaser requirements

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Risk Manager

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this individual provides guidance and assistance in support of liability control programs including reporting and analysis of patient and employee incidents and identification and control of liability risks throughout the organization

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Utilization Coordinator

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this individual is involved in resource management activiites to prevent underuse and overuse of services--determine appropriateness of care--collect utilization-related data for quality management purposes

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CMS and NCQA requires a quality management plan but

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TJC does not but is implied that it is desirable

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Quality management is the means by which high quality patient care is maintained and improved in all levels of the system --

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individual, departmental and organizational

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What involves gathering information to determine current levels of performance?

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Measurement

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What involves finding the cause of performance gaps and implementing interventions to correct cause of undesirable performance?

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Improvement

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What involves evaluating current levels of performance to determine if there are gaps between expected and actual quality?

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Assessment

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What are the Core Elements of a quality management system?

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--leadership oversight and accountability--quality infrastructure, including routine meetings with cross-departmental representation --involvement of stakeholders and transparency of performance data --performance measurement of key clinical and service areas --activities aimed at improving performance in clinical and service areas

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What is the range of groups involved in the quality management system of a healthcare organization?

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BoardSenior Leaders Second Tier Groups Third Tier Groups Quality Management Support Services

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Who is responsible for ensuring continuous quality improvement and for establishing and cultivating a culture of safety?

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The Senior Leaders (president, chief operating officer, vice presidents, medical director)

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Quality management oversight committees or councils: coordinates quality management activities

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evaluate the performance of physicians involving credentialling, privileging, and PPEs,Second Tier Groups (Medical staff executive committee in hospital)

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Any number multi-disciplinary committee or group formed to support various areas of quality management:

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3rd tier groups (cancer committee) Medical staff and administrative committees

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Quality Management Support Services: vary considerably among organizations:

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Case Manager, Compliance Officer, Health Data Analyst , Infection control practitioner, Patient representative, Patient safety officer, Physician adviser, Quality Director , Risk Manager, Utilization Coordinator

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To determine internal priorities for performance improvement

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a health care organization must consider the:,Needs and expectations of all the stakeholders

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A component of the organization's quality management activities that is often documented in the performance improvement plan:

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performance improvement model used by the organization

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The lead Federal agency in health care quality research.

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Agency for Healthcare Research & Quality

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The 3 components of health care quality management

answer

measurement, assessment and improvement

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Group that sponsors the HEDIS performance measurement system for managed care organizations.

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National Committee for Quality Assurance

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The reporting structure for quality management activities in a hospital is commonly documented in the organization's:

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performance improvement plan

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A basic responsibility of the quality management department in a healthcare organization.

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Help other departments identify potential quality problems

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Group ultimately responsible for the quality of health care in a healthcare organization.

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governing board

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A way of doing business which continuously improves products and services to achieve ever better levels of performance.

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Quality management

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To determine compliance with departmental standards

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the manager of the hospital registration department is collecting data on the accuracy of patient demographic information that has been into the computer system by registration clerks. This activity is an example of:,Measuring performance

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Performance measurement data are collect primarily for the purpose of:

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identifying opportunities for improvement

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The first step in developing a performance measurement

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Select the process to be evaluated

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"Baseline" performance is a measure of

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Current performance

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Continuous quality improvement in healthcare organizations require

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A planned and systematic approach

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Public evaluations on healthcare quality on the Web in the form of:

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Report cards Provider profiles Consumer reports

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Purpose of public disclosure of evaluations on healthcare quality:

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1. To facilitate informed choices2. Stimulate quality improvement

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Governing board in a healthcare organization does..

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1. Important role in assuring quality care is continually delivered to patients2. Legally and morally responsible for ensuring the quality of care to patients

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Six key dimensions by IOM:

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1. Effectiveness-based on scientific knowledge, service provided to all who can benefit, service should not be provided to those not to benefit2. Efficiency-Avoidance of waste-equipment, supplies, time, energy, and ideas 3. Equity- Quality doesn't change cause of patient's personal characteristics gender, ethnicity, geographic location, and social status 4. Patient-centeredness-Care is provided respectfully of and responsive to patient preferences needs, and values 5. Safety-Unintended patient injuries should be avoided 6. Timeliness-No unnecessary waits and delays for those receiving care

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Customers: 3 stakeholders groups

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1. Providers 2. Purchasers 3. Consumers

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Quality Management- AKA

answer

Performance improvement , total quality improvement

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"Benchmarking" is a measure of

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Current performance compared to an exemplary organization

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AHRQ

answer

Agency for Healthcare Research and Quality, Agency for health care research and quality (assures quality of health services)

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CDC

answer

Center for Disease Control and Prevention, An agency under the U.S. Department of Health and Human Services. It is recognized as the leading Federal Agency for protecting the health and safety of people, and for providing credible information to enhance health decisions.

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FDA

answer

Food and Drug Administration. The agency that is responsible for determining if a food or drug is safe and effective enough to be sold to the public.

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NIH

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National Institutes of Health, improve nation's health by conducting & supporting research into causes, diagnosis, prevention, and cure of human diseases.

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QIO

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Quality improvement organizations: external agencies that review the quality or care and use of insurance benefits by individual physicians and patients for Medicare and other insurers.

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AAAHC

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Accreditation Association for Ambulatory Healthcare - a professional organization that offers accreditation programs for ambulatory and outpatient organizations such as single and multispecialty group practices, ambulatory surgery centers, college/university health services, and community health centers.

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ACHC

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Accreditation Commission for Health Care - A private nonprofit accreditation organization offering accreditation services for home health, hospice, and alternate site healthcare such as infusion nursing, and home/durable medical equipment supplies.

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CARF

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Commission on the Accreditation of Rehabilitation Facilities, provides accreditation for organizations offering behavioral health physical and occupational rehabilitation services as well as assisted living continuing care community services employment services and others.

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CoC

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Commission on Cancer of the American College of Surgeons-Approves cancer programs

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NIAHO

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National Integrated Accreditation for Healthcare Organization

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NCQA

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National Committee on Quality Assurance. A not-for-profit organization that performs quality oriented accreditation reviews on HMOs and similar types of managed care plans.

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JC

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Joint Commission for Accreditation of Healthcare Organizations, -sets standards and accredits most general, long-term, psychiatric hospitals, substance abuse programs, outpatient surgery centers, urgent care clinics, group practices, community health centers, hospices and HH agencies, lab

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IOM

answer

Institute of Medicine of the National Academies; a nonprofit organization created to provide unbiased, evidence based and authoritative information and advice concerning health and science policy,-- care should be safe, effective, patient centered, efficient and equitable

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NAHQ

answer

National Association for Healthcare Quality

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NQF

answer

national quality forum, for healthcare quality measurement and reporting, not for profit, (National Quality Forum) is a not for profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting.

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Governing board

answer

aka-Board of Trustees--Has ultimate responsibility for the quality of patient care and services provided. Responsibility of the support in the organization's mission& strategic priorities.

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Senior Leaders

answer

President, COO (chief operating officer) vice presidents, medical director--Responsible for ensuring continuous quality improvement and for establishing and cultivating a culture of safety.

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Second tier groups

answer

Quality management oversight committees or councils.

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Third tier groups

answer

Multi-disciplinary, interdepartmental committees charged with conducting quality management activities in a particular service or function.

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Quality management plans

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Often required by state or federal regulations.The plan describes the organization's approach to management of patient safety and quality. Provides framework for all measurement, assessment and improvement activities.

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Quality management plan should include:

answer

1. An outline of the program structure & content2. Designation of the committee responsible for overseeing the program. 3. Role structure, function, and frequency of meetings of the program oversight committee and other relevant committees.

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HEDIS

answer

Healthcare Effectiveness Data and Information SetComparison of the performance of health plans. This data set was developed by the National Committee for Quality Assurance to aid consumers with health-related issues with information to compare performance of clinical measures for health plans

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MEDPAR file

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A common source of data for publicly available health care performance measurement results.The Medicare claims database.

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3 primary activities of quality management are:

answer

measurement, assessment, improvement

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