HIM 125 Ch 1-3

What are the three entities that have deeming authority from CMS?
Joint Commission, Healthcare Facilities Accreditation Program (HFAP), and Det Norske Veritas Healthcare, Inc (DNV)
What is a voluntary process and is not required by law?
The most important issue for hospitals is that deemed status obtained from successful accreditation allows hospitals to:
Receive reimbursement from Medicaid and Medicare as third-party payers.
Hospitals not accredited who want to bill for Medicaid and Medicare must:
Undergo a CMS survey conducted by the state
What is the largest deeming authority?
Joint Commission
What is the frequency on on-site surveys for TJC, HFAP, and DNV?
Every 3 years for TJC and HFAP, and annually for DNV
When was TJC founded and why?
1951, Result of efforts by the ACS to create standardization w/in hospitals
In what year was the National Patient Safety Goals introduced?
2002 w/expected compliance in 2003
Why were NPSG developed?
To focus on issues identified as areas of concern/root causes for sentinel events.
Who is responsible for reviewing and vetting potential new patient safety goals?
Patient Safety Advisory group
Behavior health units in acute care hospitals will be surveyed under the:
Hospital Standards
The laboratory program is on a how many year accreditation cycle?
2 year
A hospital w/no more than 25 beds, keeps pts less than 96 hrs, and is certified by its state is considered a:
Critical access hospital
In 2006, TJC was awarded deeming authotrity for:
Home medical equipment, orthotics and prosthetics, and medical supply services
If your hospital occupies fewer than 20 skilled beds on a daily basis, you can opt for:
The long-term care component to be surveyed with the hospital.
Are there federal deeming arrangements for nursing home facilities?
What accreditation is reserved for organizations that have fewer than 4 practitioners and a re physician-owned/operated?
Office-based surgery accreditiation
What program offers certification for clinical prgms that are in compliance w/standards, used evidence based practice guidelines, and implement performance improvement activities through data collection?
Disease-specific care
What was the first Joint Commission “advanced” certification program?
Primary Stroke Center (PSC)
Accreditation occurs:
Certification occurs:

Every 3 years
Every 2 years
When was ACS founded?
What is the short list of requirements designed to regulate care called?
Minimum Standards for Hospitals
What are the minimum requirements hospitals must meet to qualify for reimbursement from Medicare and Medicaid?
Conditions of Participation
What inititave focused on pt safety and quality and encouraged physicians and staff members to participate in the survey process?
Shared Visions-New Pathways
The survey process today involves ______ documentation review and _______ interaction with staff members and pts at the “point of care”?
10%; 90%
On 1 Jan 2008, who was commissioned president of TJC?
Mark R. Chassin
These elements of performance (EP) are linked to a structural or foundational requirment; easily remembered by “either you have it or you don’t” or “yes or no”.
Category A
These EPs address isssues that can quantified or counted; “three strikes and you’re out”.
Category C
How many levels of criticality are there?
Criticality level 1 (worst-highest)
Describe the criticality levels.
Criticality level 1 – Immediate jeopardy
Criticality level 2 – Situational Decision Rules
Criticality level 3 – Direct Impact Requirements (corrected w/in 45 days of survey)
Criticality level 4 – Indirect Impact Requirements (corrected w/in 60 days of survey)
CMS has how many days in which to conduct a validation survey?
How are patients selected for tracers each morning to the surveyors?
From the census
What tracer is where the surveyor performs a deep and detailed exploration of a particular process/subject? Focuses on areas w/high risk/criticality.
Second Generation Tracer
Is an organization required to report a sentinel event to TJC?
What organization is dedicated to finding solutions for healthcare issues affecting quality and safety of care?
The Center for Transforming Healthcare
True or False: If your hospital wants reimbursement for Medicare and Medicaid, it must seek accreditiation from a CMS deeming authority.
True or False: The Disease Specific Care Certification Program runs on the same triennial cycle as the hospital and its decision is not factored into the hospitals accreditiation process.
True or False: Standards are scored at the EP level.
What data is included in the S3 risk assessment?
True or False: The center for transforming healthcare was developed to provide real solutions that can be applied to quality and safety issues in healthcare, including hygiene and handoff communications.
When did the new version of staffing effectiveness go into effect?
1 Jul 2010
How does deeming authority relate to TJC and Medicare reimbursement?
It allows the hospitals to receive reimbursement from Medicaid and Medicare as third-party payers.
What is the difference between accreditation and certification?
Accreditation evaluates quality of work against stds…every 3 years Certification evaluates an individual, institution…every 2 years
In what year was JCAH established?
What year did Medicare Act pass?
What level does scoring take place?
EP (elements of performance) level
What type issues fall under Criticality Level 1?
Inoperable fire alarm
Adult strength meds on pediatric cart
Lack of master alarms for medical gas system
Pts w/known antibodies rcvg transfusions w/out units being typed for the corresponding antigen
What type issues fall under Criticality level 2?
Facility w/out licensure
Individual w/out a license when a license is required
Failure to implement LSC corrective actions
What type issues fall under Criticality level 3?
Care processes affcting pt quality/safety
What type issues fall under Criticality level 4?
Planning/evaluation of care processes
Name the different types of tracers.
Individual (Pt)/Second Generation (High risk/criticality)
Systems (Medication mgmnt/infection control/data use/emergency mgmnt)
What is the Standards Improvement Initiative?
Aimed at: clarifying stds language ensures stds are program specific deleting redundant/nonessential stds consolidating stds
CMS has how many days to conduct a post survey validation?
60 days
What is the Periodic Performance Review (PPR)?
Lengthy mid-cycle self-assessment tool to promote continuous std compliance.
What is the difference between Organized Medical Staff (OMS) and Medical Executive Committee (MEC)?
MEC – Oversees the functions/duties of the medical staff
OMS – Develops/adopts/amends medical staff by-laws
What is the preanesthesia assessment timeframe and standards?
Evaluations must be documented by a qualified individual to administer anesthesia w/in 48 hrs of inducing. Must include:
Pt history
Pt interview
Pt exam
Anesthesia risk
Anesthesia plan of care
What is the post anesthesia assessment timeframe and standards?
Must be documented w/in 48 hrs after the pt is brought into recovery. Should include:
Respiratory functions
Cardiovascular functions
Mental status
What is the telemedicine credentialing process?
The hospitals governing body accepts physicians into its medical staff and grant privileges after thorough examination.
What does TJC say about contracted services?
Expects the care to be the same regardless of who provides it
What is an RFI?
Requirement for Improvement
What are the top Life Safety Code (LSC) issues?
Egress issues, fire protection, and protection of individuals
What are the pain assessment requirements?
Comprehensive pain assessment is consisitent w/pts condition and treatment plan Pain assessmenets are pt-centered
Action is taken and pain is reassessed
Pain is treated or pt is referred
What is the Conceptual model form?
Combines assessment, care planning, education, and shift documentation into one document
What are environment of care issues?
Caused by aging facilities………..
Risks to pts, staff, visitors
Emergency Power
Safety and security
Medical gases
Fire safety/equipment
Mxs of written inventory of all operating components of utility systems
What are the nursing assessments?
Initial assessment w/in 24 hrs of pts admission
Hospital defines info to be collected
Functional/nutritinal screen w/in 24 hrs
Written guidelines
Care planning/Multidisciplinary approach to care
Pt education
What does PAL stand for?
Pour and Label
Difference between Focused Profession Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)?
FPPE – Providers seeking privileges or for current practitioners seeking the addition of new privileges

OPPE – Monitor and improve care and that the indicators are approved by the medical staff.
The information is used for during the re-credentialing process

What are the differences between REVIEW, RULE and RATE indicators?
Review – Identifies significant event that would ordinarily require analysis by physician peers to determine cause, effect, and severity.

Rule – Represents general rule, std, or generally recognized professional guideline or accepted practice of medicine where individual variation does not directly cause adverse pt outcomes.

Rate – Identifies cases/events that are aggregated for statistical analysis prior to review.

Medication Reconciliation Information
Obtain and document a patient’s current medications
Decide what info is needed in outpt setting (IN WRITING)
Compare home meds to on order meds
Give pt written med info/provide education

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