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Exam 3

Terms in this set (61)

Quality control
Quality is the perceived degree of excellence attributed to a product or service

Activities used to evaluate, monitor or regulate services rendered to consumers
high reliability organizations
"operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents."
How to make quality control happen
Total Quality Management -Demming 1986
TCAB- IHI 2003-2008 (Actively involving all allied health providers and front-line staff)
Patient Safety and Quality Improvement Act (2005) Bill protects medical error information voluntarily submitted from being subpoenaed "Just Culture"
Quality control- six sigma/lean
Toyota
PDSA
Include all members of healthcare team-
including patients
Change Culture
Culture and safety
Outcomes

Behaviors

Culture
Is the shared values and beliefs in the organization (the way we act when no one is looking)
Defining health care quality
The Institute of Medicine (2001) defines health care quality as:

The degree to which services for individuals and populations increase the likelihood of desired health care outcomes and are consistent with current professional knowledge
attributes of health care quality
Safety
Patient-Centered
Timely
Effective
Efficient
Equitable
Communication
quality of process
Regulatory
Incidents
Best Practice

Standard is determined
Data collection to see if standard met
Education or Corrective action if criteria has not been met
Who establishes criteria (standard)?
A standard is a predetermined level of excellence that serves to guide practice.
Predetermined
Established by authority
Communicated to and accepted by the people
Standards are measurement tools they must be objective, measurable, achievable.
Agency for Healthcare Research Quality (AHRQ)
Institute of Medicine (IOM)
Center for Disease Control (CDC)
American College Obstetrics and Gynecology (ACOG)
What information is relevant? Get Data
Retrospective
Concurrent
Prospective

Outcome Audit
Process Audit
Structure Audit
Report Data to:
TJC (The Joint Commission)
DNV (Det Norske Veritas)
CMS
Leapfrog
US News
National Database of Nursing Quality Indicators (NDNQI)
Benchmark
Benchmark with like performing organizations/hospitals - Exemplar organizations as role models
The difference in performance between top preforming healthcare organizations and national average is called a quality gap. Usually small in companies, significant in healthcare.
The joint commission
Formerly known as JCAHO
1981 mandated that all hospitals have QA in place
Monitor Sentinel Events
Core Measures
Patient Safety Goals
Medication Reconciliation
Centers for Medicare & Medicaid Services (CMS)
Set standards and measure quality
Hospital Quality Initiative (HQI)
Made easy to understand data available to consumers via variety of media
Pay for Performance
Value Based Purchasing
Readmissions Reduction
Hospital Acquired Conditions (HACs)
Electronic Health Record (EHR) Incentive Program
Hospital Consumer Assessment of Health Providers and Systems Surveys (HCAHPS)
Leapfrog
Non-healthcare Fortune 500 companies
Goal to modernize healthcare
Four evidence based standards they believe will provide the greatest impact on reducing medical error
Computerized physician -provider order entry (CPOE)
Evidence-based hospital referral
ICU physician staffing
National Quality Forum endorsed safe practices
National Database of Nursing Quality Indicators (NDNQI)
Tracks nursing and patient outcomes
Up to 19 nursing-sensitive quality measures
2,000 hospitals, 98% Magnet hospitals
Developed to establish more effective, targeted nursing-sensitive quality indicators
Improves nursing quality, nurse satisfaction, strengthen the nursing work environment, assess staffing levels etc..
Examples: Falls, Pressure Ulcers, Pediatric Pain, Pediatric PIV infiltration, Restraints, Nosocomial infections, Staffing Mix
The Control Process
Setting Performance Standards
The Joint Commission

Comparing Performance with the Standard
Documented standard performance

Identifying information relevant to the criteria

Ways to collect information

Auditing quality control

Reevaluation of met standards
Hallmark of Quality Control Programs
Support from upper level administration
Commitment by organization to provide human and fiscal resources
Goals reflect a "search for excellence"
Continuous process
Measurement of Health Care Quality
Process indicators
Outcome indicators
Seals of approval
Quality control
Quality control efforts must be proactive, not solely as a reaction to a problem
In Summary: Controlling and Leading Quality Initiatives
Controlling phase of management, performance is measured against predetermined standards, and action is taken to correct discrepancies between these standards and actual performance.
Employees who feel they can influence quality outcomes in work environment experience higher levels of motivation and job satisfaction.
Organizations need control over productivity, innovation
Controlling should NOT be viewed as means of determining success or failure but as a means to grow and learn, personally and professionally
performance appraisal
Very personal process

Highly charged and emotional for most employees

Actual performance is evaluated
Pit falls of performance appraisals
Hallo effect
Horns effect
Central tendency
"Recency effect"
Effective performance appraisals
Employees must know in advance:
What happens if standards are not met
How information will be obtained to determine performance level

Appraisers should be those who directly supervise the employee
Appraisal interviews
Ensure that the employee's self-esteem is maintained
Begin on Informal, warm, and friendly note
Ask employee's opinion about his progress
Self evaluation
Have specific examples of positive & negative behaviors
Never threaten or intimidate
Be sure language is clearly understood
Conduct interview in a participatory manner
Set goals for further growth
360 degree evaluation
Includes an assessment by all individuals who work with the individual being appraised
Includes other supervisors and co-workers
Employee discipline
Not disciplining an employee who should be disciplined jeopardizes an organization's morale

Further action must be taken when employees continue undesirable conduct, either in breaking rules or in not performing their job duties adequately
Constructive discipline
Uses discipline as a means of helping the employees grow, not as a punitive measure

Discipline can also be defined as training, educating or molding
Using progressive discipline
When using progressive discipline, for all but the most serious infractions, the slate should be wiped clean at the conclusion of a predesignated period
Four Common Steps in Progressive Discipline
Verbal admonishment
Written admonishment
Suspension from work without pay
Dismissal
Rights and Responsibilities in Grievance Resolution
Both parties have rights and responsibilities to be heard and to listen
Employee has right to a positive work environment
Also a responsibility to express discontent responsibly
Manager has a right to expect employee to follow the rules
Must make sure employees know and understand the rules
Fiscal planning
Not intuitive; a learned skill that improves with practice
An important but often neglected dimension of planning
A well-prepared capital budget will provide a nursing unit with the appropriate equipment needed for patient care.
Fiscal Planning
Vision
Creativity
The knowledge of the skill and economic forces
A skill increasingly critical to nursing managers because of increased emphasis on finance and "big business" of health care
Balancing Costs and Quality Care
Refers to effective and efficient delivery of services while generating needed revenues for continued organizational productivity
The responsibility of every health-care provider, and the viability of most health-care organizations, today depends on its ability to use its fiscal resources wisely.
Performance that is measured against predetermined standards

Applies to the entire interdisciplinary healthcare Team and supportive personnel

In terms of healthcare, cost and quality do not have a linear relationship
The USA spends more per capita on healthcare than does any other industrialized country and yet our outcomes and access to care are worse than many other countries that spend less.
Responsibility Accounting
Each of an organization's revenues, expenses, assets, and liabilities is someone's responsibility.
At the hospital unit level, this generally falls to the manager; He/She is an active participant in unit budgeting, receive regular data reports that compare actual expanses with budgeted expanses
Forecasting
The Nurse manager must be able to forecast patient census trends for supplies and equipment needed.
Forecasting involves making an educated budget estimate using historical data
Responsibility Accounting- Budget
The clinical staff should understand the budget allowances for supplies and equipment to prevent waste on the unit is:
EVERYONE'S RESPONSIBILTIY
The desired outcome of budgeting is maximal use of resources to meet organizational short- and long-term needs.
Personnel Budget
Personnel - Accounts for the majority of health-care organization's expense
Budget
A financial plan that includes estimated expenses as well as income for a period of time

Accuracy dictates the worth of the budget

The budget's value is directly related to its accuracy

Because the budget is a best a predication, a plan, and not a rule.
operating budget
The operating budget-is the second area of expenditure that involves all managers.
It reflects expenses that change in response to the volume of services.
capital budget
This budget plans for the purchase of building or major equipment that has long life, not used in daily operations, more expansive than operating supplies
Budgeting methods
Incremental budgeting
Zero-based budgeting

Flexible budgeting
Performance budgeting
critical pathways
Strategy for assessing, implementing, and evaluating the cost-effectiveness of patient care
Predetermined courses of progress that patients should make after admission for a specific diagnosis or after a specific surgery.
Critical pathways- adv and dis
Advantage: Provide a means of standardizing medical care for patients with similar diagnoses
Disadvantages: difficulties when accounting for an accepting what are often justifiable in those that deviate from the pathway
How does the hospital get paid
Fee for service - Historically, healthcare facilities placed little or no emphasis on budgeting.
Reimbursement was based on cost incurred to provide the service plus profit (fee for service)
The end result healthcare costs skyrocketing!
Medicare
Primary population are elderly, disabled and renal dialysis Federally assisted and state-administered program to pay for medial services on behalf of certain groups of low-income individuals.
Certain groups of people also qualify for coverage if their incomes and resources are sufficiently low
Medicaid A
Part A- Financed primary through employee payroll deductions and employer contributions.
Covers inpatient hospital care. Limited skill nursing facility, home health and hospice care, although beneficiaries pay a deductible for each inpatient benefit period as well as a co-insurance for hospital and skilled nursing facility stay.
Medicaid B
Part B---Financed largely from general funds.
Is a supplementary medical insurance that covers primary care provider services outpatient diagnostic tests, certain medical supplies and equipment.
Is optional for beneficiaries, most elderly pay the premiums.
Medicare and Medicaid Managed Care
The Centers for Medicare and Medicaid Services is now the largest purchaser of managed care in the country.
MCOs receive reimbursement for Medicare-eligible patients based on a formula established by the CMS, which looks at age, gender, geographic region, and the average cost per patient at a given age. Then, the government gives itself a 5% discount and gives the rest to the MCO.
Patient Protection and Affordable Care
Put in place comprehensive insurance reforms

New Patient Bill of Rights

A major goal of the Affordable Care Act
Diagnosis-Related Groups (DRGs) and the Prospective Payment System (PPS)
Diagnosis-related groups (DRGs) are predetermined payment schedules that reflect historical costs for the treatment of specific patient conditions.
With DRGs, hospitals join the prospective payment system (PPS), whereby they receive a specified amount for each Medicare patient's admission, regardless of the actual cost of care.
Advantages
Disadvantages
Prospective Payment Systems
As a result of the PPS and the need to contain costs, the length of stay for most hospital admissions has decreased greatly.
Prospective Payment Systems
Managed Care
Broadly defined as a system that attempts to integrate efficiency of care, access, and cost of care.
Utilization review is a process used by insurance companies to assess the need for medical care and to assure that payment will be provided for the care.

Capitation - Hallmark of managed care

Capitation is a prospective payment system that pays health plans or providers a fixed amount per enrollee per month
Potential Constraints Affecting Directing
Unions and Employment Laws
Collective bargaining
Historical perspective
Driving forces
Restraining forces
Labor standards
Collective bargaining
Activities occurring between organized labor and management that concern employee relations
Negotiation of formal labor agreements and day-to-day interactions between unions and management
Manager perspectives
Managers must be able to see collective bargaining and employment legislation from four perspectives.

The organization
The worker
General historical/societal
Personal
The Relationship Between Labor and Management
The roots of union activity between employees and management.
The middle manager has the greatest impact on the quality of the relationship
It is possible to create a climate in which labor and management can work together
Historical Perspective
Unions have been present in America since the 1790s.
Nurses' perceptions of quality of supervision have affected the unionization rates of nurses.
Union Representation of Nurses
California Nurses Association (CAN)/National Nurses Organizing Committee
Service Employees International Union (SEIU)
National Union of Healthcare Workers (NUHW)
Dual Role of ANA and Collective Bargaining
ANA mission: nurses advance our profession to improve health of all
State Associations
The states with the most union are New York, California, Pennsylvania, Michigan, and Illinois.
The use of state associations as bargaining agents has been a divisive issue among American nurses.
This conflict has manifested in splitting away of state nurses associations from the parent ANA organization's .
Reasons Why Nurses Join Unions
Increase the power
Increase input into organizational
Eliminate discrimination
Because of social need
Because they are required
Because they believe it will improve patient outcomes
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