Checklist: What Can My Organization Do?

Size: px
Start display at page:

Download "Checklist: What Can My Organization Do?"

Transcription

1 Checklist: What Can My Organization Do?

2 2 Introduction About The Framework This is an evidence and consensus-based framework for successful clinical outcomes in long term and post-acute care. The framework was built by the AHCA Clinical Practice Committee with the goal of developing solutions for reducing rehospitalizations and adverse events. Quality of care drives business success or failure in long term and post-acute care. This framework acknowledges that clinical results need both an organizational and a clinical foundation. The framework outlines guiding elements such as individualized care approaches, effective transitions of care, QAPI concepts, safety, risk management, team-based care, and diagnostic quality. Care providers that use such a framework can more effectively apply knowledge through organizational approaches and clinical care that leads to optimal patient outcomes and quality of life. Vignettes and worksheets complement this framework to help build prevention into everyday practice. In addition, references at the end of the document provide additional detail on existing resources and tools that centers can readily acquire and use. The framework can be used as a desktop reference guide at various times when reflecting on one s practice or contemplating challenges and seeking solutions. Why Is This Important? Success in achieving positive resident/patient outcomes is even more critical now than ever before. The link between quality and payment in long term and post-acute care is growing stronger, as evidenced by the SNF Value Based Purchasing Program (VBP), Improving Post-Acute Care Transformation (IMPACT) Act, SNF Quality Reporting Program (QRP) and more. In addition, regulatory activity is intensifying through focused surveys on adverse events, dementia care and MDS. The Five-Star Rating system and Nursing Home Compare have been revised and will add items in the future as it broadens public reporting and transparency. Most importantly, consumers expect and deserve high quality care. Overall, applying the items in this framework will provide a strong foundation for improved resident/patient outcomes in addition to more efficient use of staff, time, and resources.

3 3 Framework Outline This framework outlines key elements from both an organizational and clinical nature that are critical to successful clinical and organizational outcomes. Positively, these elements reflect common denominators that cross multiple care situations. Therefore, instead of being yet another initiative or single focused project to achieve just one outcome, it is a way of acting, thinking and being that will benefit multiple areas across an organization. These are the common denominators and core elements that cross multiple care situations: Organizational Foundation Culture of safety Right thing in the right way thinking Systems driven Team based care Principles of person-centered care Clinical Foundation Consistent use of evidence-based practice First of all, do no harm thinking built into practice Diagnostic quality Cause identification Clinical assessment Effective monitoring Timely provision of necessary care Individualized care approaches reflected in care planning Each element is addressed in detail throughout this document. Key questions that are answered for each element include: What does this mean? Why is this important? What are some examples? What is my part (as an individual employee, manager or practitioner)? In addition, key takeaways, probing questions and some useful resources and tools are included for further exploration. This document is an excerpt of the sections for each element of the framework. Start somewhere, pick one element and work through it with your team. Enjoy the journey!

4 4 Organizational Foundation: Culture of Safety Leadership engages and empowers patients, residents, families, staff, visitors, and others to keep the culture of safety alive and well. Conduct a Survey on Patient Safety Culture. Leadership can create an environment that encourages and does not penalize observing and reporting safety concerns. Incorporate safety considerations into the center s QAPI program. The QAPI program should use appropriate tools and approaches to discuss safety issues and monitor whether they are addressed promptly and definitively. Organizational Foundation: Right thing in the right way thinking Make sure there are clear, complete, well organized, and easily accessible instructions and procedures that are consistent with reliable sources such as medical and geriatrics references. Share a good article about how to reduce risk. Make it an expectation that staff will ask for help in unfamiliar situations and receive a supportive response when doing so. Show examples of documentation about various aspects of care that are considered clear, accurate, and complete. Remind staff not to cut corners and support them in doing the right thing. Give staff an easy way to inform someone about procedures or instructions that are unclear, confusing, or incomplete. Show staff how to use a computer to search quickly for information needed to do the work. Organizational Foundation: Systems Driven Promote consistent approaches to care, to operations, and to overall problem solving and prevention activities Foster systems-driven decision making and an environment in which residents / patients are satisfied and experience the best possible outcomes. Ensure adequate training and development of staff. Ensure processes of various tasks are clearly defined. Promote pride in working for the organization and sharing in the reward of good service, which may help increase staff engagement and retention.

5 5 Organizational Foundation: Team Based Care Hold everyone accountable for proficient job performance, recognizing that the chain is only as strong as its weakest link. Create and reinforce a culture of giving care in the proper context of the big picture and not in silos. Ensure that individual disciplines practice within the scope of their licensure, knowledge, and skills, and that they review any significant potential recommendations for tests, treatments, and consults with the group to ensure that they are pertinent and have taken into account all relevant issues. Promote a culture of safety built in to everyday practice, including good clinical reasoning and problem solving that leads to proficient care and avoids doing harm due to erroneous conclusions and guessing. Encourage everyone to make and report relevant observations and information about the residents, including evidence of the effectiveness of care plan interventions. Embrace proficient interdisciplinary care as a means to the end of providing personcentered care and reducing adverse events. Management staff must support and train staff in culture change to focus on the person in their care as an individual. Organizational Foundation: Principles of Person-Centered Care Create a culture that focuses on individualized care. o Establish and enforce the mechanisms to make it happen, including systems-driven and team-based care, consistent use of evidence-based practice, proficient cause identification and diagnostic quality, accurate clinical assessment, effective monitoring, timely interventions, and individualized care planning. Educate everyone about early detection of signs of potential adverse events. Work with the medical director to hold all practitioners accountable and ensure that they try to tailor interventions to the individual residents or provide a valid clinical rationale why it is not feasible to do so. Clinical Foundation: Consistent Use of Evidence Based Practice Reinforce to staff that evidence-based practice is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and resident care data with clinical expertise and resident preferences and values. Continue to provide education about, and support the use of evidence-based practice in the work environment. Support the delivery of evidence-based practice in a context of caring and in a supportive organizational culture, which will lead to the highest quality of care and best patient outcomes

6 6 Clinical Foundation: First of All Do No Harm Thinking Built into Practice Inform staff about how to distinguish conclusions from rationale (information to support conclusions) and how to verify and validate significant information and not just accept conclusions. Have care-related discussions and meetings that emphasize the big picture and the context of all symptoms and test results. Foster a culture of care that focuses on obtaining adequate detail and not cutting corners. Show staff how to look up information in reliable references about medications and treatments, and how to interpret information such as side effects. Use readily available references at meetings to discuss resident/patient care, and to look up indications and side effects of medications and treatments. Emphasize the correct care delivery process and clinical reasoning and problem solving approaches and make sure they are used in resident/patient-related conferences and meetings. Set up a framework for discussing residents / patients that focuses on adequate and objective description of symptoms and condition changes. Foster a facility culture that focuses on validating assumptions, not jumping to conclusions, and minimizing guessing. Clinical Foundation: Diagnostic Quality Recognize that diagnostic quality is an organization-wide issue, not just the domain of physicians and other medical practitioners. Teach techniques to avoid cognitive error. Inform staff on how to distinguish conclusions from the rationale (objective supporting information) and how to verify and validate information and not just accept conclusions. Have care-related discussions and meetings that emphasize the big picture and the context of all symptoms and test results. Foster a culture of care that focuses on obtaining adequately detailed and objective description of symptoms and condition changes detail and not cutting corners. Use readily available references at meetings to discuss resident/patient care, including to look up how medication-related side effects can cause symptoms. Emphasize the correct care delivery process and clinical reasoning and problem solving approaches and make sure they are used in resident/patient-related conferences and meetings. Foster a facility culture that focuses on validating assumptions, not jumping to conclusions, and on minimizing guessing. Be vigilant about who is allowed to write orders and make recommendations, and ensure that they are acting within the scope of their knowledge and training when they propose causes of symptoms and related tests and treatments.

7 7 Clinical Foundation: Cause Identification Provide resources and tools to help identify causes, both for resident care and for systems issues. Incorporate proven cause identification methods into everyday processes so they are used in real time throughout the day to get the best possible results, as well as retroactively to analyze situations that already occurred. Provide education and training on how to gather information systematically to describe and clarify issues or problems, and how to use tools for improvement. Involve staff in performance improvement projects to examine and improve care in areas that have been identified as needing attention. Foster a culture that makes continuous quality improvement a priority. Set expectations around resident-centered choice, rights, safety, and respect, and ensure staff accountability. Create an environment that encourages and supports staff to identify and report quality issues as well as identify opportunities for improvement. Clinical Foundation: Clinical Assessment Teach and coach staff about the proper approaches to assessment. Check staff understanding of how to observe, examine, describe, define, document, and report information. Check that staff know how to organize, document, and report information as a coherent and meaningful story about a condition or situation. Help staff access references and resources that explain components of various assessments, whether comprehensive or focused, and check that the resources are used as needed. As part of the QAPI program: o Review assessment quality (for example, by reading and critiquing nursing and other progress notes) and look for ways to improve the documentation and reporting of information. o Evaluate the accuracy and pertinence of conclusions reached on the basis of assessments, to be sure that staff are not exceeding the scope of their training and knowledge and that residents / patients are not having adverse consequences such as hospitalization as a result of inadequate, incorrect, or misinterpreted information gathered during assessments. Clinical Foundation: Effective Monitoring Provide education, task practice and adequate resources to perform designed review activities as intended. Leadership can provide on-going feedback via process review and quality data as to how the processes are working. Focus attention on how to monitor appropriately and use results to adjust interventions, both for clinical care and for systems and organizational issues.

8 8 Clinical Foundation: Timely Provision of Necessary Care Scrutinize existing systems and processes to make them more efficient. Hold everyone accountable to doing their jobs, so that the system runs smoothly and does not waste staff time. Commit to a culture of safety. Review and address issues affecting timeliness of care as part of the QAPI program. Commit to staff training and coaching about task performance and use the information to improve systems and individual performance. Clinical Foundation: Individualized Care Approaches Reflected in Care Planning Support resources and processes that help familiarize staff more readily with each person s care plan; for example, through daily rounding; weekly IDT rounds at report time; point-of-care devices, and other means. Promote a culture of sound clinical reasoning, good problem solving, enhanced diagnostic quality, knowledge of potential treatment complications, and improved coordination and communication with practitioners.

Community Care Coordination Cross Continuum Care IHC Medical Home Conference September 5, 2012 Des Moines IA

Community Care Coordination Cross Continuum Care IHC Medical Home Conference September 5, 2012 Des Moines IA Community Care Coordination Cross Continuum Care IHC Medical Home Conference September 5, 2012 Des Moines IA Peg Bradke, RN, MA Director of Heart Care Services St. Luke s Hospital, Cedar Rapids, IA Session

More information

5D QAPI from an Operational Approach. Christine M. Osterberg RN BSN Senior Nursing Consultant Pathway Health Pathway Health 2013

5D QAPI from an Operational Approach. Christine M. Osterberg RN BSN Senior Nursing Consultant Pathway Health Pathway Health 2013 5D QAPI from an Operational Approach Christine M. Osterberg RN BSN Senior Nursing Consultant Pathway Health Objectives Review the post-acute care data agenda. Explain QAPI principles Describe leadership

More information

Drivers of HCAHPS Performance from the Front Lines of Healthcare

Drivers of HCAHPS Performance from the Front Lines of Healthcare Drivers of HCAHPS Performance from the Front Lines of Healthcare White Paper by Baptist Leadership Group 2011 Organizations that are successful with the HCAHPS survey are highly focused on engaging their

More information

BETHESDA HEALTH. Commitment to Care: Partnering with Care Logistics to Adopt a Patient-First System for Care

BETHESDA HEALTH. Commitment to Care: Partnering with Care Logistics to Adopt a Patient-First System for Care BETHESDA HEALTH Commitment to Care: Partnering with Care Logistics to Adopt a Patient-First System for Care Success Snapshot Commitment to Care transformation initiative has driven $11 million in annual

More information

PointRight: Your Partner in QAPI

PointRight: Your Partner in QAPI A N A LY T I C S T O A N S W E R S E X E C U T I V E S E R I E S PointRight: Your Partner in QAPI J A N E N I E M I M S N, R N, N H A Senior Healthcare Specialist PointRight Inc. C H E R Y L F I E L D

More information

SafetyFirst: The Journey to High Reliability

SafetyFirst: The Journey to High Reliability SafetyFirst: The Journey to High Reliability Course Audio Transcript Module 1: Navigating SafetyFirst: The Journey to High Reliability Welcome Welcome to SafetyFirst: The Journey to High Reliability. This

More information

QAPI- CREATING A CULTURE FOR IMPROVMENT Guide to the Basic Principles of Quality Improvement. Patty Austin, RN, CPHQ Project Coordinator

QAPI- CREATING A CULTURE FOR IMPROVMENT Guide to the Basic Principles of Quality Improvement. Patty Austin, RN, CPHQ Project Coordinator QAPI- CREATING A CULTURE FOR IMPROVMENT Guide to the Basic Principles of Quality Improvement Patty Austin, RN, CPHQ Project Coordinator QA + PI = QAPI QAPI takes a systematic, comprehensive, and data-driven

More information

Quality Laboratory Practice and its Role in Patient Safety

Quality Laboratory Practice and its Role in Patient Safety Quality Laboratory Practice and its Role in Patient Safety (Policy Number 06-01) Policy Statement ASCP supports the development and maintenance of high quality practice standards for laboratory testing

More information

WORKING DRAFT. Standards of proficiency for nursing associates. Release 1. Page 1

WORKING DRAFT. Standards of proficiency for nursing associates. Release 1. Page 1 WORKING DRAFT Standards of proficiency for nursing associates Page 1 Release 1 1. Introduction This document outlines the way that we have developed the standards of proficiency for the new role of nursing

More information

Uses a standard template but may have errors of omission

Uses a standard template but may have errors of omission Evaluation Form Printed on Apr 19, 2014 MILESTONE- BASED FELLOW EVALUATION Evaluator: Evaluation of: Date: This is a new milestone-based evaluation. To achieve a level, the fellow must satisfy ALL the

More information

Baptist Health Nurse Leader Competency Model

Baptist Health Nurse Leader Competency Model Baptist Health Nurse Leader Competency Model Strategic Visionary Systems Thinking Quality Care and Performance Improvement Fiscal and Management Excellence Management of Self and Others 1 - Strategic,

More information

Enhancing Patient Quality and Safety with Compliance

Enhancing Patient Quality and Safety with Compliance Enhancing Patient Quality and Safety with Compliance April 23, 2013 John Kalb, JD, CCEP, CHPC Operational Excellence Executive/ Compliance Officer Kootenai Health Content A successful compliance program

More information

Table of Contents. TeamSTEPPS Framework and Competencies Key Principles. Team Structure Multi-Team System For Patient Care

Table of Contents. TeamSTEPPS Framework and Competencies Key Principles. Team Structure Multi-Team System For Patient Care Table of Contents TeamSTEPPS Framework and Competencies Key Principles Team Structure Multi-Team System For Patient Care Leadership Effective Team Leaders Team Events Brief Checklist Debrief Checklist

More information

Certified Healthcare Safety Nursing (CHSN) Examination Blueprint/Outline

Certified Healthcare Safety Nursing (CHSN) Examination Blueprint/Outline Certified Healthcare Safety Nursing (CHSN) Examination Blueprint/Outline (Effective October 1, 2017) Exam Domains 135 Items 1. Patient Safety Fundamentals 54 Items/40% 2. Healthcare Safety Management 54

More information

Reducing the Risk of Wrong Site Surgery

Reducing the Risk of Wrong Site Surgery Joint Commission Center for Transforming Healthcare Reducing the Risk of Wrong Site Surgery Wrong Site Surgery Project Participants The Joint Commission s Center for Transforming Healthcare aims to solve

More information

Value Based Care in LTC: The Quality Connection- Phase 2

Value Based Care in LTC: The Quality Connection- Phase 2 Value Based Care in LTC: The Quality Connection- Phase 2 Joseph J. Tomaino, M.S., R.N., Principal Healthcare Transformation Consulting ChemRx/PharmMerica Geriatric Skilled Nursing Seminar December 7, 2017

More information

QUALITY AND COMPLIANCE

QUALITY AND COMPLIANCE 2015 HCCA SOUTHEAST CONFERENCE JANUARY 23, 2015 QUALITY AND COMPLIANCE Katie Fink Donna Lewis Susan Walberg Presenters Katie Fink Senior Counsel Office of Counsel to the Inspector General U.S. Department

More information

9/27/2017. Getting on the Path to Excellence. The path we are taking today! CMS Five Elements

9/27/2017. Getting on the Path to Excellence. The path we are taking today! CMS Five Elements Getting on the Path to Excellence QAPI DESIGN AND IMPLEMENTATION Demi Haffenreffer, RN, MBA www.consultdemi.net The path we are taking today! The requirements at F944 (formerly F520) Key elements Survey

More information

Effective Care Transitions to Reduce Hospital Readmissions

Effective Care Transitions to Reduce Hospital Readmissions Effective Care Transitions to Reduce Hospital Readmissions November 8, 2017 Anchorage, Alaska The vicious cycle of readmissions What is Care Transitions? The movement of patients across settings, referred

More information

TRANSITIONS of CARE. Francis A. Komara, D.O. Michigan State University College of Osteopathic Medicine

TRANSITIONS of CARE. Francis A. Komara, D.O. Michigan State University College of Osteopathic Medicine TRANSITIONS of CARE Francis A. Komara, D.O. Michigan State University College of Osteopathic Medicine 5-15-15 Objectives At the conclusion of the presentation, the participant will be able to: 1. Improve

More information

3/14/2014. Preventing Rehospitalizations How to Change Your When in Doubt, Send em Out Way of Thinking. Objectives. Background Information

3/14/2014. Preventing Rehospitalizations How to Change Your When in Doubt, Send em Out Way of Thinking. Objectives. Background Information Preventing Rehospitalizations How to Change Your When in Doubt, Send em Out Way of Thinking Jennifer Moore, RN Content Developer Objectives Describe two reasons why returns to the hospital are not desirable

More information

Optimizing Operational and Financial

Optimizing Operational and Financial BUNDLING POISED TO TAKE OFF IN MANY MARKETS: White ARE YOU Paper March READY 2016 Optimizing Operational and Financial Performance Darrin Hull Vice President of Senior Care Solutions Health Dimensions

More information

DOCUMENT E FOR COMMENT

DOCUMENT E FOR COMMENT DOCUMENT E FOR COMMENT TABLE 4. Alignment of Competencies, s and Curricular Recommendations Definitions Patient Represents patient, family, health care surrogate, community, and population. Direct Care

More information

Managing employees include: Organizational structures include: Note:

Managing employees include: Organizational structures include: Note: Nursing Home Transparency Provisions in the Patient Protection and Affordable Care Act Compiled by NCCNHR: The National Consumer Voice for Quality Long-Term Care, April 2010 Part I Improving Transparency

More information

Communication and Teamwork for Patient Safety 1.0 Contact Hour Presented by: CEU Professor

Communication and Teamwork for Patient Safety 1.0 Contact Hour Presented by: CEU Professor Communication and Teamwork for Patient Safety 1.0 Contact Hour Presented by: CEU Professor 7 www.ceuprofessoronline.com Copyright 8 2008 The Magellan Group, LLC All Rights Reserved. Reproduction and distribution

More information

Microbicides Readiness Assessment Tool A tool for diagnosing and planning for the introduction of microbicides in public-sector health facilities

Microbicides Readiness Assessment Tool A tool for diagnosing and planning for the introduction of microbicides in public-sector health facilities Microbicides Readiness Assessment Tool A tool for diagnosing and planning for the introduction of microbicides in public-sector health facilities BACKGROUND This tool is intended to help evaluate the extent

More information

Creating High Reliability Organizations. Enhancing the Culture of Safety for Our Patients & Our Organizations

Creating High Reliability Organizations. Enhancing the Culture of Safety for Our Patients & Our Organizations Creating High Reliability Organizations Enhancing the Culture of Safety for Our Patients & Our Organizations OUR TRUST by Dr. Don Berwick Reliability from the Patient s Perspective Don't kill me (no needless

More information

Being Prepared for Ongoing CPS Safety Management

Being Prepared for Ongoing CPS Safety Management Being Prepared for Ongoing CPS Safety Management Introduction This month we start a series of safety intervention articles that will consider ongoing CPS safety management functions, roles, and responsibilities.

More information

Quality Framework. for a High Performing Health and Wellness System in Nova Scotia

Quality Framework. for a High Performing Health and Wellness System in Nova Scotia Quality Framework for a High Performing Health and Wellness System in Nova Scotia Quality Framework for a High Performing Health and Wellness System in Nova Scotia Crown copyright, Province of Nova Scotia,

More information

CAP Forensic Drug Testing Accreditation Program Standards for Accreditation

CAP Forensic Drug Testing Accreditation Program Standards for Accreditation CAP Forensic Drug Testing Accreditation Program Standards for Accreditation Preamble Forensic drug testing is a laboratory specialty concerned with the testing of urine, oral fluid, hair, and other specimens

More information

Innovations for Integrating Quality and Safety in Education and Practice: The QSEN Project

Innovations for Integrating Quality and Safety in Education and Practice: The QSEN Project Innovations for Integrating Quality and Safety in Education and Practice: The QSEN Project Linda Cronenwett, PhD, RN, FAAN Principal Investigator, QSEN Gwen Sherwood, PhD, RN, FAAN Co-Investigator, QSEN

More information

4/13/2015. I am the former Director of the CMS Division of Nursing Homes. I am not currently a CMS official; I work as a contractor for CMS.

4/13/2015. I am the former Director of the CMS Division of Nursing Homes. I am not currently a CMS official; I work as a contractor for CMS. Alice Bonner, PhD, RN, FAAN Northeastern University April 30 th, 2015 Photo:Alex Tenappel I am the former Director of the CMS Division of Nursing Homes. I am not currently a CMS official; I work as a contractor

More information

Question Patient #1 Patient #2 Patient #3 Patient #4 Patient #5 Number of days between the last discharge and this readmission date?

Question Patient #1 Patient #2 Patient #3 Patient #4 Patient #5 Number of days between the last discharge and this readmission date? Worksheet A: Chart Reviews of Patients Who Were Readmitted Conduct chart reviews of the last five readmitted patients. Reviewers should be physicians or nurses from the hospital and community settings.

More information

Report on Feasibility, Costs, and Potential Benefits of Scaling the Military Acuity Model

Report on Feasibility, Costs, and Potential Benefits of Scaling the Military Acuity Model Report on Feasibility, Costs, and Potential Benefits of Scaling the Military Acuity Model June 2017 Requested by: House Report 114-139, page 280, which accompanies H.R. 2685, the Department of Defense

More information

Delegation of Controlled Acts Direct Orders and Medical Directives

Delegation of Controlled Acts Direct Orders and Medical Directives Delegation of Controlled Acts Direct Orders and Medical Directives The Regulated Health Professions Act, 1991 (RHPA) identifies thirteen controlled acts that may only be performed by an authorized regulated

More information

Behavioral Health Services. Division of Nursing Homes

Behavioral Health Services. Division of Nursing Homes Behavioral Health Services Division of Nursing Homes 483.40 Behavioral Health Services Overview F740 Introduction to Behavioral Health Services F741 Sufficient and Competent Staff F742 Treatment/Services

More information

Tag Description Page. F607 Policies to Prohibit and Prevent Abuse, Neglect, Exploitation 125. F622 Transfer & Discharge 155

Tag Description Page. F607 Policies to Prohibit and Prevent Abuse, Neglect, Exploitation 125. F622 Transfer & Discharge 155 Tag Description Page F607 Policies to Prohibit and Prevent Abuse, Neglect, Exploitation 125 F622 Transfer & Discharge 155 F626 Permitting Residents to Return to Facility 170 F656 Comprehensive Care Plans

More information

Presentation Objectives

Presentation Objectives Transforming to Value-Based Purchasing (VBP) QI tools can drive your value proposition Paul Mulhausen, MD, AGSF, FACP Medical Director Telligen Quality Improvement Network Quality Improvement Organization

More information

High Reliability Organizations Healing Without Harm by 2014

High Reliability Organizations Healing Without Harm by 2014 Please click your mouse or use the enter button to move onto the next slide High Reliability Organizations Healing Without Harm by 2014 1.1 Stand up if You have suffered harm as a patient at a hospital

More information

HealthPartners and the Triple Aim. IHI Open School August 23, 2012 Beth Waterman, RN MBA Chief Improvement Officer HealthPartners

HealthPartners and the Triple Aim. IHI Open School August 23, 2012 Beth Waterman, RN MBA Chief Improvement Officer HealthPartners HealthPartners and the Triple Aim IHI Open School August 23, 2012 Beth Waterman, RN MBA Chief Improvement Officer HealthPartners HealthPartners Not for profit, consumer governed Integrated care and financing

More information

Cognitive Level Certified Professional in Patient Safety Detailed Content Outline Recall. Total. Application Analysis 1.

Cognitive Level Certified Professional in Patient Safety Detailed Content Outline Recall. Total. Application Analysis 1. Cognitive Level Certified Professional in Patient Safety Detailed Content Outline Recall Application Analysis Total 1. CULTURE 2 12 4 18 A. Assessment of Patient Safety Culture 1. Identify work settings

More information

Safety Culture At the University of Virginia. Policy Statement

Safety Culture At the University of Virginia. Policy Statement Safety Culture At the University of Virginia Policy Statement It is an expectation of the Commonwealth of Virginia s Radioactive Materials Program and the U.S. Nuclear Regulatory Commission that: Individuals

More information

Continuous Value Improvement in Health Care

Continuous Value Improvement in Health Care webinar summary Continuous Value Improvement in Health Care Featuring Kedar Mate Chief Innovation and Education Officer Institute for Healthcare Improvement October 26, 2017 sponsored by webinar summary

More information

STEER YOUR MAGNET JOURNEY LET PROPHECY ASSESSMENTS BE YOUR GPS

STEER YOUR MAGNET JOURNEY LET PROPHECY ASSESSMENTS BE YOUR GPS Prophecy Predicting Employee Success STEER YOUR MAGNET JOURNEY LET PROPHECY ASSESSMENTS BE YOUR GPS www.prophecyhealth.com www.aps-web.com 617.275.7300 The journey to Magnet is both exhilarating and challenging!

More information

QUALITY MEASURES WHAT S ON THE HORIZON

QUALITY MEASURES WHAT S ON THE HORIZON QUALITY MEASURES WHAT S ON THE HORIZON The Hospice Quality Reporting Program (HQRP) November 2013 Plan for the Day Discuss the implementation of the Hospice Item Set (HIS) Discuss the implementation of

More information

CMS Proposed Rule. The IMPACT Act. 3 Overhaul Discharge Planning Processes to Comply With New CoPs. Arlene Maxim VP of Program Development, QIRT

CMS Proposed Rule. The IMPACT Act. 3 Overhaul Discharge Planning Processes to Comply With New CoPs. Arlene Maxim VP of Program Development, QIRT Overhaul Discharge Planning Processes to Comply With New CoPs Arlene Maxim VP of Program Development, QIRT 1 CMS Proposed Rule Included discharge planning specifics However, when the CoPs were finalized,

More information

PALLIATIVE CARE NURSE PRACTITIONER

PALLIATIVE CARE NURSE PRACTITIONER PALLIATIVE CARE NURSE PRACTITIONER Responsible to Regional Director of Palliative Care with dotted line to Medical Director Description The Nurse Practitioner (NP) works independently and in collaboration

More information

Implementation Guide Version 4.0 Tools

Implementation Guide Version 4.0 Tools Implementation Guide Version 4.0 Tools Program Overview Purpose of the Guide This Guide is intended primarily for INTERACT champions and trained educators who are responsible for implementing and sustaining

More information

Mental Health Accountability Framework

Mental Health Accountability Framework Mental Health Accountability Framework 2002 Chief Medical Officer of Health Report Injury: Predictable and Preventable Contents 3 Executive Summary 4 I Introduction 6 1) Why is accountability necessary?

More information

Preventable Harm: California Fails to Follow Through With Patient Safety Laws

Preventable Harm: California Fails to Follow Through With Patient Safety Laws Preventable Harm: California Fails to Follow Through With Patient Safety Laws March 2010 I. INTRODUCTION More than 10 years after the Institute of Medicine (IOM) first estimated that nearly 100,000 Americans

More information

GERIATRIC SERVICES CAPACITY ASSESSMENT DOMAIN 4 ALTERNATE LIVING ARRANGEMENTS

GERIATRIC SERVICES CAPACITY ASSESSMENT DOMAIN 4 ALTERNATE LIVING ARRANGEMENTS GERIATRIC SERVICES CAPACITY ASSESSMENT DOMAIN 4 ALTERNATE LIVING ARRANGEMENTS Table of Contents Introduction... 2 Purpose... 2 Serving Senior Medicare-Medicaid Enrollees... 2 How to Use This Tool... 2

More information

Model of Care Scoring Guidelines CY October 8, 2015

Model of Care Scoring Guidelines CY October 8, 2015 Model of Care Guidelines CY 2017 October 8, 2015 Table of Contents Model of Care Guidelines Table of Contents MOC 1: Description of SNP Population (General Population)... 1 MOC 2: Care Coordination...

More information

Engaging Leaders: From Turf Wars to Appreciative Inquiry

Engaging Leaders: From Turf Wars to Appreciative Inquiry Engaging Leaders: From Turf Wars to Appreciative Inquiry Principles of Leadership for a Quality and Safety Culture Harvard Safety Certificate Program 2010 Gwen Sherwood, PhD, RN, FAAN Gwen Sherwood, PhD,

More information

The Milestones provide a framework for the assessment

The Milestones provide a framework for the assessment The Transitional Year Milestone Project The Milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency in a

More information

PATIENT-CENTERED MEDICAL HOME ASSESSMENT (PCMH-A)

PATIENT-CENTERED MEDICAL HOME ASSESSMENT (PCMH-A) SAFETY NET MEDICAL HOME INITIATIVE PATIENT-CENTERED MEDICAL HOME ASSESSMENT (PCMH-A) Organization name Site name Date completed Introduction To The PCMH-A The PCMH-A is intended to help sites understand

More information

A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES

A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES 23 rd Annual HPRCT Conference June 12-15, 2017 Thomas Diller, MD, MMM; Executive Director University

More information

HT 2500D Health Information Technology Practicum

HT 2500D Health Information Technology Practicum HT 2500D Health Information Technology Practicum HANDBOOK AND REQUIREMENTS GUIDE Page 1 of 17 Contents INTRODUCTION... 3 The Profession... 3 The University... 3 Mission Statement/Core Values/Purposes...

More information

Quality Metrics in Post-Acute Care: FIVE-STAR QUALITY RATING SYSTEM

Quality Metrics in Post-Acute Care: FIVE-STAR QUALITY RATING SYSTEM Quality Metrics in Post-Acute Care: FIVE-STAR QUALITY RATING SYSTEM Nicholas G. Castle, Ph.D. CastleN@Pitt.edu Department of Health Policy and Management, Graduate School of Public Health, University of

More information

Professional Standards of Practice for School Nurses. LEVEL OF PERFORMANCE Unsatisfactory Basic Proficient Distinguished

Professional Standards of Practice for School Nurses. LEVEL OF PERFORMANCE Unsatisfactory Basic Proficient Distinguished DOMAIN 1: Planning and Preparation 1a: Demonstrating Knowledge of Nursing Standards and Practices Applies current nursing practices Relates nursing knowledge to students, parents and staff Serves as health

More information

9/8/2017. Making the Connection: Linking the Facility Assessment and QAPI Plan. Cindy Mason VP Provider Services. Final Rule. Providigm, LLC,

9/8/2017. Making the Connection: Linking the Facility Assessment and QAPI Plan. Cindy Mason VP Provider Services. Final Rule. Providigm, LLC, Making the Connection: Linking the Facility Assessment and QAPI Plan Cindy Mason VP Provider Services Final Rule Providigm, LLC, 2017 1 Final Rule Effective Date These regulations are effective as of November

More information

Re: Rewarding Provider Performance: Aligning Incentives in Medicare

Re: Rewarding Provider Performance: Aligning Incentives in Medicare September 25, 2006 Institute of Medicine 500 Fifth Street NW Washington DC 20001 Re: Rewarding Provider Performance: Aligning Incentives in Medicare The American College of Physicians (ACP), representing

More information

Alberta Health Services. Strategic Direction

Alberta Health Services. Strategic Direction Alberta Health Services Strategic Direction 2009 2012 PLEASE GO TO WWW.AHS-STRATEGY.COM TO PROVIDE FEEDBACK ON THIS DOCUMENT Defining Our Focus / Measuring Our Progress CONSULTATION DOCUMENT Introduction

More information

INTERACT 4 Patty Abele, FNP BC

INTERACT 4 Patty Abele, FNP BC INTERACT 4 Patty Abele, FNP BC (No relevant financial relationships to disclose) TODAY WE WILL Identify the risks and disadvantages associated with avoidable hospitalizations Identify the goals of the

More information

Effective Tools to Prevent and Manage Adverse Events

Effective Tools to Prevent and Manage Adverse Events Effective Tools to Prevent and Manage Adverse Events Based on Office of Inspector General Adverse Events Report Diane C. Vaughn, RN, C-DONA/LTC; LNHA vaughndiane@hotmail.com Objectives Upon completion

More information

January 04, Submitted Electronically

January 04, Submitted Electronically January 04, 2016 Submitted Electronically Mr. Andy Slavitt Acting Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Room 445-G, Hubert H. Humphrey Building

More information

MERCY MEDICAL CENTER. Mercy Medical Center Improves Patient Care, Lowers Costs with the Hospital Operating System

MERCY MEDICAL CENTER. Mercy Medical Center Improves Patient Care, Lowers Costs with the Hospital Operating System MERCY MEDICAL CENTER Mercy Medical Center Improves Patient Care, Lowers Costs with the Hospital Operating System Success Snapshot Reduced acute LOS from 4.6 to 3.74 and observation LOS from 1.51 to 1.31

More information

The STAAR Initiative

The STAAR Initiative The STAAR Initiative Getting Started Kit for the STAAR Collaborative September 2010 Institute for Healthcare Improvement, 2010 Page 1 Table of Contents STAAR Collaborative Charter... 3 Statement of Need...

More information

Challenging Behaviour Program Manual

Challenging Behaviour Program Manual Challenging Behaviour Program Manual Continuing Care Branch Table of Contents 1.0 Introduction... 2 2.0 Purpose... 2 3.0 Vision... 2 4.0 Mission... 3 5.0 Guiding Principles... 3 6.0 Challenging Behaviour

More information

ECU Teacher s in Quality Academy Vidant Health Quality Program. Learning Session 1 March 24, 2014

ECU Teacher s in Quality Academy Vidant Health Quality Program. Learning Session 1 March 24, 2014 ECU Teacher s in Quality Academy Vidant Health Quality Program Learning Session 1 March 24, 2014 Objectives 1. Describe organizational approach to patient safety/quality improvement at Vidant Health and

More information

Assessment of Chronic Illness Care Version 3

Assessment of Chronic Illness Care Version 3 Assessment of Chronic Illness Care Version 3 Please complete the following information about you and your organization. This information will not be disclosed to anyone besides the ICIC/IHI team. We would

More information

Clinical Nurse Leader (CNL ) Certification Exam. Subdomain Weights for the CNL Certification Examination Blueprint (effective February 2012)

Clinical Nurse Leader (CNL ) Certification Exam. Subdomain Weights for the CNL Certification Examination Blueprint (effective February 2012) Clinical Nurse Leader (CNL ) Certification Exam Subdomain Weights for the CNL Certification Examination Blueprint (effective February 2012) Subdomain Weight (%) Nursing Leadership Horizontal Leadership

More information

Using Internal Audits for Successful Grant Administration

Using Internal Audits for Successful Grant Administration Using Internal Audits for Successful Grant Administration Welcome & Speakers Session Objectives Explain key rules and requirements for complying with CDBG-DR Internal Audit requirements Discuss role of

More information

Breaking Down Silos of Care: Integration of Social Support Services with Health Care Delivery

Breaking Down Silos of Care: Integration of Social Support Services with Health Care Delivery Breaking Down Silos of Care: Integration of Social Support Services with Health Care Delivery Betty Shephard Lead VP, Care Management HealthCare Partners National Health Policy Forum October 19, 2012 HCP

More information

Transitions of Care: From Hospital to Home

Transitions of Care: From Hospital to Home Transitions of Care: From Hospital to Home Danielle Hansen, DO, MS (Med Ed) Associate Director, LECOM VP Acute Care Services & Quality/Performance Improvement, Millcreek Community Hospital Objectives Discuss

More information

When you have to be right. Increase Competence. Improve Outcomes. Health. Lippincott Professional Development Collection. Lippincott Solutions

When you have to be right. Increase Competence. Improve Outcomes. Health. Lippincott Professional Development Collection. Lippincott Solutions When you have to be right Increase Competence. Improve Outcomes. Health Lippincott Professional Development Collection Lippincott Solutions Lippincott Professional Development Collection Lippincott Professional

More information

Preventing Medical Errors

Preventing Medical Errors Presents Preventing Medical Errors Contact Hours: 2 First Published: March 31, 2017 This Course Expires on: March 31, 2019 Course Objectives Upon completion of this course, the nurse will be able to: 1.

More information

Standards for Laboratory Accreditation

Standards for Laboratory Accreditation Standards for Laboratory Accreditation 2017 Edition cap.org 2017 College of American Pathologists. All rights reserved. [ T y p e t h e c o m p a n y a d d r e s s ] CAP Laboratory Accreditation Program

More information

Florida Health Care Association 2013 Annual Conference

Florida Health Care Association 2013 Annual Conference Florida Health Care Association 2013 Annual Conference The Westin Diplomat Resort & Spa Session #53 Assess and Educate to Prevent Rehospitalizations Thursday, August 8 10:00 to 11:30 a.m. Regency 1 Upon

More information

Summary and Analysis of CMS Proposed and Final Rules versus AAOS Comments: Comprehensive Care for Joint Replacement Model (CJR)

Summary and Analysis of CMS Proposed and Final Rules versus AAOS Comments: Comprehensive Care for Joint Replacement Model (CJR) Summary and Analysis of CMS Proposed and Final Rules versus AAOS Comments: Comprehensive Care for Joint Replacement Model (CJR) The table below summarizes the specific provisions noted in the Medicare

More information

Chapter 2 Nursing Process

Chapter 2 Nursing Process Chapter 2 Nursing Process Definition of the Nursing Process Organized sequence of problem-solving steps Used to identify and manage the health problems of clients Accepted standard for clinical practice:

More information

What Story Is Your SNF Data Telling?

What Story Is Your SNF Data Telling? What Story Is Your SNF Data Telling? Holly Harmon, RN, MBA, LNHA Senior Director of Clinical Services Thank you to our Launch Sponsor: Objectives Recognize the value of data informed practice Identify

More information

Accountable Care Atlas

Accountable Care Atlas Accountable Care Atlas MEDICAL PRODUCT MANUFACTURERS SERVICE CONTRACRS Accountable Care Atlas Overview Map Competency List by Phase Detailed Map Example Checklist What is the Accountable Care Atlas? The

More information

Home and Community-Based Services (HCBS) Settings Evaluation Provider Self-Assessment

Home and Community-Based Services (HCBS) Settings Evaluation Provider Self-Assessment Attn: Hope Roberts, HCBS Policy Administrator Ohio Department of Medicaid FROM: RE: LeadingAge Ohio Home and Community-Based Services (HCBS) Settings Evaluation Provider Self-Assessment February 18, 2016

More information

UW HEALTH JOB DESCRIPTION

UW HEALTH JOB DESCRIPTION Senior Transplant Coordinator Job Code: 850005 FLSA Status: Exempt Mgt. Approval: C Bowman Date: 8-17 Department : OPO/Transplant HR Approval: CMW Date: 8-17 JOB SUMMARY The Senior Transplant Coordinator

More information

HIMSS Davies Award Enterprise Application. --- Cover Page --- IT Projects and Operations Consultant Submitter s Address: and whenever possible

HIMSS Davies Award Enterprise Application. --- Cover Page --- IT Projects and Operations Consultant Submitter s  Address: and whenever possible HIMSS Davies Award Enterprise Application --- Cover Page --- Name of Applicant Organization: Truman Medical Centers Organization s Address: 2301 Holmes Street, Kansas City, MO 64108 Submitter s Name: Angie

More information

Maximizing the Power of Your Data. Peggy Connorton, MS, LNFA AHCA Director, Quality and LTC Trend Tracker

Maximizing the Power of Your Data. Peggy Connorton, MS, LNFA AHCA Director, Quality and LTC Trend Tracker Maximizing the Power of Your Data Peggy Connorton, MS, LNFA AHCA Director, Quality and LTC Trend Tracker Objectives Explore selected LTC Trend Tracker reports & features including: re-hospitalization,

More information

Hospital Readmissions Survival Guide

Hospital Readmissions Survival Guide WHITE PAPER Hospital Readmissions Survival Guide The Long-Term Care Provider s Ultimate Survival Guide to Incorporating INTERACT into Health Information Technology (HIT) March 2017 In this survival guide,

More information

CAPE/COP Educational Outcomes (approved 2016)

CAPE/COP Educational Outcomes (approved 2016) CAPE/COP Educational Outcomes (approved 2016) Educational Outcomes Domain 1 Foundational Knowledge 1.1. Learner (Learner) - Develop, integrate, and apply knowledge from the foundational sciences (i.e.,

More information

Creating a Culture of Quality and Compliance

Creating a Culture of Quality and Compliance Creating a Culture of Quality and Hospice of the Upstate 1835 Rogers Road Anderson, South Carolina 29621 864-224-3358 or 1-800-261-8636 www.hospiceoftheupstate.com INTRODUCTIONS Monica Isbell, RN, BSN

More information

Transitioning Care to Reduce Admissions and Readmissions. Sven T. Berg, MD, MPH Julie Mobayed RN, BSN, MPH

Transitioning Care to Reduce Admissions and Readmissions. Sven T. Berg, MD, MPH Julie Mobayed RN, BSN, MPH Transitioning Care to Reduce Admissions and Readmissions Sven T. Berg, MD, MPH Julie Mobayed RN, BSN, MPH Disclaimer: Potential for Error Type One Error Rejecting the null hypothesis when it is true

More information

Healthcare 2015: Win-win or lose-lose?

Healthcare 2015: Win-win or lose-lose? IBM Institute for Business Value Healthcare 2015: Win-win or lose-lose? A portrait and a path to successful transformation Presented at Disease Management Colloquium May 19, 2008 Jim Adams, IBM Center

More information

(a) Licensure. A facility must be licensed under applicable State and local law.

(a) Licensure. A facility must be licensed under applicable State and local law. 42 C.F.R. 483.705. Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental,

More information

COMMON FACTORS CHECKLIST

COMMON FACTORS CHECKLIST COMMON FACTORS CHECKLIST For Identifying Causes and Contributory Factors When attempting to identify potential causes and contributory factors related to an incident or system failure review the following

More information

The Journey to Quality Creating a culture of quality improvement for dental health

The Journey to Quality Creating a culture of quality improvement for dental health The Journey to Quality Creating a culture of quality improvement for dental health Knowing that our quality improvement initiatives and community-focused service delivery enhanced patient and staff satisfaction

More information

Upcoming Changes in Infection Prevention: What Skilled Nursing Facilities Need to Know

Upcoming Changes in Infection Prevention: What Skilled Nursing Facilities Need to Know Upcoming Changes in Infection Prevention: What Skilled Nursing Facilities Need to Know Aimee Ford, QI Consultant, Qualis Health June 8, 2016 Qualis Health A leading national population health management

More information

Tool: Discharge Planning Process (c)(1)

Tool: Discharge Planning Process (c)(1) Purpose & Intent 483.21(c)(1): To develop a discharge plan to help as many residents who want to return back to the community, to be effectively discharged from the nursing center back to the community.

More information

RMC CODE OF PROFESSIONAL CONDUCT

RMC CODE OF PROFESSIONAL CONDUCT RMC CODE OF PROFESSIONAL CONDUCT 1. This document shall be referred to as the RMC Code of Professional Conduct. The RMC Code of Professional Conduct has been developed to comply with requirements of TR

More information

Leadership for Transforming Health Care

Leadership for Transforming Health Care Presenters have nothing to disclose. Leadership for Transforming Health Care Partnerships with Patients and Families Barbara Balik, RN, EdD Kris White, RN, MBA November 4, 2014 This presenter has nothing

More information

Mary Baum President & CEO BA&T September 18, 2015

Mary Baum President & CEO BA&T September 18, 2015 Mary Baum President & CEO BA&T September 18, 2015 Objective Why patient safety is so difficult to solve? The problem remains Advances in clinical workflow A collaborative approach Metrics matter Just start.

More information

Assessment of Chronic Illness Care Version 3.5

Assessment of Chronic Illness Care Version 3.5 Assessment of Chronic Illness Care Version 3.5 Please complete the following information about you and your organization. This information will not be disclosed to anyone besides the Learning Collaborative

More information