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Four core processes

TEST (Name the four core process involved in care, treatment, and service to patients)
1 - Assessing the patient's needs
2 - Planning care, treatment, and services
3 - Providing care, treatment, and services
4 - Coordinating care, treatment, and services

1 - Assessing the patient's needs

Initial assessment determines the patient's appropriateness for admission to the facility and the level of care to be rendered

Assessing the patient's needs

- Physical, psychological, and social assessment
-- addictions, abuse, pain
-- H&P within 24 hours of admission (or 30 days prior)
-- Nursing assessment within 24 hours
- Nutrition and hydration status
- Functional status (activities of daily living)
- Social, spiritual, and cultural variables

2 - Planning care, treatment, and services

Establishment of an interactive, written care plan based on previous assessments

3 - Providing care, treatment, and services

The care pathway defines the specific treatment and its timing and frequency
- core measures monitoring program
- Patient's status is continuously monitored for signs of stabilization, improvement, or destabilization
- Labs, radiology, pharmacy, dietary, nursing, and therapy
- Patients and families should be involved

4 - Coordinating care, treatment, and services

There is a defined process in the healthcare facility to receive and share patient info when the patient if referred
-- Primary care provider
-- Community resources, i.e. home health
-- Family or friends
-- Rehab and long-term care settings
Prevent duplication of services
Inform patient of what to do when discharged, i.e. activity, medications, weight, sex, diet

Optimizing patient care

Step 1 - Conduct patient care outcome reviews
Step 2 - Conduct eval of seclusion, restraints, and protective devices
Step 3 - Conduct eval of lab services and use of lood products
Step 4 - Conduct eval of medication system & process
Step 5 - Conduct policy, procedure, and docuemntation review
Step 6 - Eval standards of care and caer pathways

Step 1 - Conduct patient care outcome reviews

Improve safety and outcomes by collecting data

Step 2 - Conduct eval of seclusion, restraints, and protective devices

Behavioral management procedures
- Denial of food, shelter, clothing, restraints, etc
-- The use of restraints involves an increased risk of client deaths
Non-behavioral use of restraints
- Use of restraints based on patient's needs
- Use least-restrictive
- Safe application
Ordered by licensed independent practitioner
- written or verbal order within 12 hours
- examined with 24 hours
- monitored at least every 2 hours
Limit orders to 4 hrs > 17, 2 hours 9-17, 1 hours <9

Step 3 - Conduct eval of lab services and use of lood products

Two patient identifiers are used when administering blood products
- patient to blood product; blood product matched to order
- One person must be qualified transfusionist

Step 4 - Conduct eval of medication system & process

One of the most complex healthcare processes

Step 5 - Conduct policy, procedure, and documentation review

Policies are updated and revised as national standards of care and NPSGs change.
Poor documentation leads to the largest number of risk management and legal situations in the industry

Step 6 - Eval standards of care and caer pathways

Standards of care and clinical practice standards
- model defines practice based on diagnosis
- variation, sentinel events, and high-risk activities must be examined

National Patient safety Goals (NPSGs)

Identify patient correctly
Improve staff communication
Use medications safely
Prevent infection
Give med list to next provider/next of kin
Prevent bed sores

National standardization of health care

Clinical guidelines
Critical pathways
Evidence-based medicine

P4P initiatives

Hospital Quality Initiative
Physician Quality Reporting
OASIS in home health care
MDS for Long-Term Care

HEDIS (Health Plan Employer Data and Information Set)

Measures quality, access, membership, utilization, and financial performance

Continuum of Care

- Perform preadmission planning
- Perform care planning at the time of admission
- Review the progress of care
- Conduct discharge planning
- Conclude postdischarge planning

Step 1 - Preadmission care planning

- PCP contacts a healthcare organization to schedule an episode of care service
- Case manager reviews the patient's projected needs
- Admission criteria are established on the basis of a suggested diagnosis
- Case manager may contact the patient or the patient's payer for preauthorization

Step 2 -Perform care planning at the time of admission

- Case manager confirms that the patient meets the admission criteria
- Case manage confirms that the patient requires services that can be performed at the facility
- Case is assigned ot the appropriate critical pathway

Step 3 -Review the progress of care

- Case manager compares the patient's progress with the pathway
- Case manager plans with the patient, the patient's family, and the clinical team, the services the patient will need after discharge

Step 4 - Conduct dicharge planning

- The patients continued care after discharge is planned
- A detailed list of current medications is forwarded to the next provider

Step 5 - Conclude postdischarge planning

Case manager conveys information about the patient's course of treatment to the clinicians who will continue to care for the patient

Case management (112)

Optimizes the patients continuum of care

Community of needs assessment (112)

Identify the community's characteristics as a healthcare client, and assess that set of clients by collecting and analyzing information about the community needs.

Continuum of care (106)

The emphasis is treating individual patients at the level of care required by theur course of treatment.
- The overall goal of the U.S. healthcare system is to achieve equilibrium between healthcare and spendiing
- At some point for every patient within the healthcare system, no additional benefit would be achieved by further spending
- Regulatory approaches seek to control expenditures on individuals who cannot benefit from them and spend the monies on patients who can benefit.

Critical pathway (112)

An outline of anticipated care within an appropriate tiemframe to aid the patient inmoving progressively through a clinical experience that ends in a positive outcome.

Gantt chart (119)

Divide a horizontal scale into days, weeks, or months and a vertical scale into project activities or tasks

Indicator (118)

A performance measure that enables healthcare organizations to moitor a process to determine whether it is meeting requirements

Case managers

Work with physicians and hospital employees to ensure that the care ordered was appropriate to the diagnosis and that it was payable under the insurance policy

Real life Example

- Patients were admitted for care when they could have recieved appropriate care in a less intensive setting
- hospital stays were continued when the patient could have receive appropriate care in a less intensive setting
- Families were not involved
- Insurance carriers were denying claims that had not been preauthorized
- Health records contained inadequate documentation


Criteria that has been developed by many of the same agencies for use across the continuum of care and in various regions of the country

Core measure criteria

All except diabetes mellitus

Standards of care


Clinical guidelines


Clinical pathways


Clinical standards


Standard precautions


Proper handwashing

Most important means of preventing infection

Healthcare associated infection


Community-acquired infection


JC manages NNIS

False, CDC Divison of Healthcare Quality Promotion does


Performed by humans


Evaluate the process

Double walled rectangle

Carried out the same way each time

Obtuse Rectangle

Record in computer or paper-based

Process icon

Skips to another common point of the process

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