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Chapter 25
Management and Policy
25-2Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Quality in Healthcare: A Glimpse of the Past
Florence Nightingale• Recognized that environmental
considerations impact client recovery.• Held nurses accountable for using
assessment skills and sound clinical judgment.
25-3Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Quality Initiatives through Accreditation
Accreditation• Recognition or approval bestowed by an
authorized organization or agency
Benchmark• Standard of excellence
25-4Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Quality Initiatives through Accreditation
Florence Nightingale provided a foundation for statistical measures in health care.
Ernest Codman, MD, developed a system to track clients to determine the effectiveness of care (1910).
25-5Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Quality Initiatives through Accreditation
American College of Surgeons (ACS) began inspecting hospitals based on “The Minimum Standard” (1918).
25-6Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Quality Initiatives through Accreditation
Joint Commission on Accreditation of Hospitals (JCAH) began hospital accreditation in 1953.
Began charging for accreditation survey services in 1964.
25-7Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Quality Initiatives through Accreditation
JCAH accreditation recognized as a benchmark (standard of excellence) for hospital reimbursement for Medicare and Medicaid (1965).
25-8Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Quality Initiatives through Accreditation
Donabedian published a framework for assessment of quality in health care (1966).
Accreditation focus shifted from minimum to optimal standards of quality (1970).
25-9Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Quality Initiatives through Accreditation
Donabedian’s quality assurance framework changed the scope of the survey to include the entire organization.
Registered nurses and administrators joined the JCAH survey team.
25-10Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Donabedian’s Quality Assurance Framework
Structure Process Outcome
25-11Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Donabedian’s Quality Assurance Framework
Structure• Health care settings • Resources• Payment and billing systems
25-12Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Donabedian’s Quality Assurance Framework
Process • Examination of actual health care delivery
activities to achieve “good medical care.”• A variety of procedures are compared to
published practice guidelines.
25-13Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Donabedian’s Traditional Quality Assurance Framework
Outcome• Client or provider-focused. • Defined in terms of recovery, restoration of
function, and of survival.• Involves peer review of physician or nursing
practice.
25-14Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Quality Improvement
Multidisciplinary Approach All customers are treated with dignity.
• Client• Staff• Nurses• Physicians
25-15Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
From Quality Assurance to Quality Improvement
FOCUS PDCA is a model for continuous quality improvement used in many health care organizations.
25-16Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
The JCAHO Accreditation Survey Process
Performed every three years. Evaluates every area of the organization. An additional, unannounced random
survey may occur.
25-17Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Role of the Nurse and other Caregivers in the Survey Process
Personal Interviews Assessment of Clinical Competencies Assessment of Organizational
Competencies
25-18Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Role of Management in the Survey Process
Administrative and Human Resource Functions• Policies • Educational program• Documentation of policies• Credentialing process for medical staff• Compliance with federal mandates
25-19Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Organizational Safety and the JCAHO
“Environment of Care” (EOC) Standards• Accreditation standards intended to improve
safety in the care environment.
All clinical personnel are involved. Seven broad areas with a program
manager assigned to each area
25-20Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Organizational Safety and the JCAHO
Partnership with the Occupational Safety and Health Administration (OSHA) • Increased emphasis on employee safety and
health
25-21Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
JCAHO Survey Outcomes
Eligibility for Medicare, Medicaid, and other third-party reimbursements is contingent upon JCAHO accreditation.
Several levels of JCAHO accreditation reflect full compliance or requirements for improvement with recommendations.
25-22Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
JCAHO Survey Outcomes
The most serious deficiencies are: • Type 1 recommendation (most serious)• Supplemental recommendations
25-23Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
The 21st Century—A Quality Revolution
Health Policies• Written decisions directing or influencing the
actions or decisions of others• Impact health of the affected population or
individual by altering health determinants
25-24Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Types of Health Policies
Laws are enacted to achieve a specific objective.• Title XVIII of the Social Security Act
(Medicare) Rules and regulations provide specific
guidance for implementation of a law. Judicial decisions are decisions made by
a judge and based on the interpretation of laws.
25-25Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Health Policy Making, Implementation, and Analysis
An issue with a proposed solution is presented to a legislator.
The issue may be drafted and introduced in Congress.
A regulation is developed to guide implementation.
Modifications to the policy are made to achieve the desired result.
25-26Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Health Policy-Making Process
Can be impacted by politics. Politics is the use of power to effect
change. Politics can either impede or propel the
policy-making process.
25-27Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
The Nurse’s Role in Policy Making
Nurses are in a position to mobilize in response to legislation impacting client care through professional organizations or individually.
25-28Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Organizational Policy Making and Excellence in Nursing Practice
Health care policies at the organizational level define nursing practice.
Standard of Care• Clinical practice guidelines, procedures, and
algorithms are tools used to integrate health policy and “best practices” into nursing practice.
25-29Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Organizational Policy Making and Excellence in Nursing Practice
Professional Accountability • The nurse is expected to remain
knowledgeable about organizational and clinical policies, nursing practice guidelines, and additional information needed to deliver high-quality client care.