Chapter 25 Management and Policy. 25-2 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Quality in Healthcare: A Glimpse of the

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.


Quality Initiatives through Accreditation

Accreditation• Recognition or approval bestowed by an

authorized organization or agency

Benchmark• Standard of excellence



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).



American College of Surgeons (ACS) began inspecting hospitals based on “The Minimum Standard” (1918).



Joint Commission on Accreditation of Hospitals (JCAH) began hospital accreditation in 1953.

Began charging for accreditation survey services in 1964.



JCAH accreditation recognized as a benchmark (standard of excellence) for hospital reimbursement for Medicare and Medicaid (1965).



Donabedian published a framework for assessment of quality in health care (1966).

Accreditation focus shifted from minimum to optimal standards of quality (1970).



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.


Donabedian’s Quality Assurance Framework

Structure Process Outcome



Structure• Health care settings • Resources• Payment and billing systems



Process • Examination of actual health care delivery

activities to achieve “good medical care.”• A variety of procedures are compared to

published practice guidelines.


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.


Quality Improvement

Multidisciplinary Approach All customers are treated with dignity.

• Client• Staff• Nurses• Physicians


From Quality Assurance to Quality Improvement

FOCUS PDCA is a model for continuous quality improvement used in many health care organizations.


The JCAHO Accreditation Survey Process

Performed every three years. Evaluates every area of the organization. An additional, unannounced random

survey may occur.


Role of the Nurse and other Caregivers in the Survey Process

Personal Interviews Assessment of Clinical Competencies Assessment of Organizational

Competencies


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


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


Organizational Safety and the JCAHO

Partnership with the Occupational Safety and Health Administration (OSHA) • Increased emphasis on employee safety and

health


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.


JCAHO Survey Outcomes

The most serious deficiencies are: • Type 1 recommendation (most serious)• Supplemental recommendations


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


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.


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.


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.


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.


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.


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.

Documents

Chapter 25 Management and Policy. 25-2 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Quality in Healthcare: A Glimpse of the