Transcript Section 2 : Organization Functions • Improving Organization Performance • • • • Leadership Management of the Environment of Care Management of Human Resources Management of Information Improving Organization Performance Overview Improving Organization.

Section 2 : Organization Functions
• Improving Organization Performance
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Leadership
Management of the Environment of Care
Management of Human Resources
Management of Information
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Improving Organization
Performance
Overview
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Improving Organization Performance
Performance Improvement Focus
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Improving Organization Performance
Reducing Factors That Contribute To Unanticipated
Adverse Events And/Or Outcomes.
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Improving Organization Performance
●Recognizing and acknowledging risks
●Initiating actions to reduce these risks
● Reporting internally on risk reduction initiatives
● Focusing on processes and systems
●Minimizing individual blame or retribution
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Improving Organization Performance
● Investigating factors that contribute
to unanticipated adverse events and
sharing that acquired knowledge both
internally and with other hospitals
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Improving Organization Performance
● Measuring performance through
data collection
● Assessing current performance
● Improving performance
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Improving Organization Performance
• PI.1.10 The hospital collects data to monitor its
performance.
• PI.2.10 Data are systematically analyzed.
• PI.2.20 Undesirable patterns in performance
analyzed.
• PI.2.30 Processes are defined and
implemented.
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Improving Organization Performance
• PI.3.10 Make changes that improve
performance.
• PI.3.20 An ongoing, proactive program for
identifying and reducing unanticipated
adverse events and safety risks to
patients is defined and implemented.
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Leadership
Overview
● Governance
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Leadership
● Management.
●Planning, designing, and providing
services.
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Leadership
● Improving safety and quality of
care.
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Leadership
● Use of clinical practice guidelines.
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Leadership
● Teaching and coaching staff.
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Leadership
• LD.1.10 The hospital identifies how it is
governed.
• LD.1.20 Governance responsibilities are
defined in writing, as applicable.
• LD.1.30 The hospital complies with applicable
law and regulation.
• LD.2.10 An individual(s) is responsible for
operating the hospital according to the authority
conferred by governance.
• LD.2.20 Each organizational program, service,
site, or department has effective leadership.
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Leadership
• LD.2.50 The leaders develop and monitor an annual
operating budget and, as appropriate, a long-term capital
expenditure plan.
• LD.3.10 The leaders engage in both short-term and longterm planning.
• LD.3.15 The leaders develop and implement plans to
identify and mitigate impediments to efficient patient flow
throughout the hospital.
• LD.3.20 Patients with comparable needs receive the same
standard of care, treatment, and services throughout the
hospital.
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Leadership
• LD.3.30 A hospital demonstrates a commitment to its
community by providing essential services in a timely
manner.
• LD.3.50
Services
provided
by
consultation,
contractual arrangements, or other agreements are
provided safely and effectively.
• LD.3.60 Communication is effective throughout the
hospital.
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Leadership
• LD.3.70 The leaders define the required
qualifications and competence of those staff
who provide care,
• LD.3.80 The leaders provide for adequate
space, equipment, and other resources.
• LD.3.90 The leaders develop and implement
policies and procedures for care, treatment,
and services.
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Leadership
• LD.3.110 The hospital implements policies with the
medical staff’s participation for procuring and donating
organs and other tissues.
• LD.3.120 The leaders plan for and support the provision
and coordination of patient education activities.
• LD.3.130 Academic education is arranged for children and
youth, when appropriate.
• LD.3.140 In hospitals that do not primarily provide
psychiatric or substance abuse services, a written plan
clearly defines the care, treatment, and services or
appropriate referral of patients who are emotionally ill
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Leadership
• LD.3.150 The hospital plans for the appropriate
care, treatment, and services of patients under
legal or correctional restrictions.
• LD.4.10 The leaders set expectations, plan,
and manage processes to measure, assess,
and improve the hospital’s governance,
management, clinical, and support activities.
• LD.4.20 New or modified services or processes
are designed well.
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Leadership
• LD.4.40 The leaders ensure that an integrated patient
safety program is implemented throughout the hospital.
• LD.4.50 The leaders set performance improvement
priorities and identify how the hospital adjusts priorities
in response to unusual or urgent events.
• LD.4.60 The leaders allocate adequate resources for
measuring, assessing, and improving the hospital’s
performance and improving patient safety.
• LD.4.70 The leaders measure and assess the
effectiveness of the performance improvement and
safety improvement activities.
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Leadership
• LD.5.10 The hospital considers clinical practice
guidelines when designing or improving processes, as
appropriate.
• LD.5.20 When clinical practice guidelines are used, the
leaders identify criteria for their selection and
implementation.
• LD.5.30 Appropriate leaders, practitioners, and health
care professionals in the hospital review and approve
clinical practice guidelines selected for implementation.
• LD.5.40 The leaders evaluate the outcomes related to
use of clinical practice guidelines
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Management of the Environment
of Care
Overview
The goal of this function is to provide
a safe, functional, supportive, and
effective environment for patients,
staff members, and other individuals
in the hospital. This is crucial to
providing
quality
patient
care,
achieving good outcomes, and
improving patient safety.
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Management of the Environment of
Care
• Performing strategic and ongoing master
planning
• Educating staff about the role of the
environment in safely, sensitively, and
effectively supporting patient care
• Developing standards to measure staff and
hospital performance in managing and
improving the environment of care
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Management of the Environment of
Care
• Implementing plans to create and
manage the hospital’s environment
of care.
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Management of the Environment of
Care
• Efficient layouts that support staffing
and overall functional operation
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Management of the Environment
of Care
Standards
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Management of the Environment of
Care: Occupancy Types
• Health care occupancy.
• Ambulatory health care occupancy.
• Business occupancy.
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Management of the Environment of
Care: Notes
Note 1: The standards in this chapter do
not prescribe any particular structure
Note 2: The standards do not require
the Statement of Conditions™
compliance document to be completed
by anyone other than an employee of
the hospital.
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Management of the Environment of
Care
Note 3: The standards in this chapter require each
hospital to develop a written plan for the following:
1. Safety management (EC.1.10)
2. Security management (EC.2.10)
3. Hazardous materials and waste management
(EC.3.10)
4. Emergency management (EC.4.10)
5. Fire safety (EC.5.10)
6. Medical equipment management (EC.6.10)
7. Utilities management (EC.7.10)
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Management of the Environment of
Care
Planning and Implementation Activities
• EC.1.10 The hospital manages safety risks.
• EC.1.20 The hospital maintains a safe environment.
• EC.1.30 The hospital implements a policy to prohibit
smoking except in specified circumstances.
• EC.2.10 The hospital identifies and manages its
security risks.
• EC.3.10 The hospital manages
materials and waste risks.
its
hazardous
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Management of the Environment of
Care
• EC.4.10 The hospital addresses emergency
management.
• EC.4.20 The hospital conducts drills regularly
to test emergency management.
• EC.5.10 The hospital manages fire safety risks.
• EC.5.20 Newly constructed and existing
environments of care are designed and
maintained to comply with the Life Safety
Code®.
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• EC.5.30 The hospital conducts fire
drills regularly.
• EC.5.40 The hospital maintains firesafety equipment and building
features
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Management of the Environment of
Care
• EC.5.50 The hospital protects occupants during
periods when a building does not meet the
applicable provisions of the Life Safety Code®.
• EC.6.10 The hospital manages medical
equipment risks.
• EC.6.20 Medical equipment is maintained,
tested, and inspected.
• EC.7.10 The hospital manages its utility risks.
• EC.7.20 The hospital provides a reliable
emergency electrical power source.
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Management of the Environment of
Care
• EC.7.30 The hospital maintains,
inspects its utility systems.
tests,
and
• EC.7.40 The hospital maintains, tests,
inspects its emergency power systems.
and
• EC.7.50 The hospital maintains, tests, and
inspects its medical gas and vacuum systems.
• EC.8.10 The hospital establishes and maintains an
appropriate environment.
• EC.8.30 The hospital manages the design and
building of the environment when it is renovated
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Management of the Environment of
Care
Measuring and Improving Activities
• EC.9.10 The hospital monitors conditions in the
environment.
• EC.9.20 The hospital analyzes identified environment
issues and develops recommendations for resolving
them.
• EC.9.30 The hospital improves the environment.
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Management of Human
Resources
Overview
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Management of Human Resources
● Providing an adequate number of staff.
● Providing competent staff.
● Orienting, training, and educating staff.
● Assessing, maintaining, and improving staff
competence.
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Management of Human Resources
Planning
• HR.1.10 The hospital provides an
adequate number and mix of staff that are
consistent with the hospital’s staffing plan.
• HR.1.20 The hospital has a process to
ensure that a person’s qualifications are
consistent with his or her job
responsibilities.
• HR.1.30 The hospital uses data on
clinical/service screening indicators
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Management of Human Resources
Orientation, Training, and Education
• HR.2.10 Orientation provides initial job training
and information.
• HR.2.20 Staff members, licensed independent
practitioners, students, and volunteers, as
appropriate, can describe or demonstrate their
roles and responsibilities, based on specific job
duties or responsibilities, relative to safety.
• HR.2.30 Ongoing education, including inservices, training, and other activities, maintains
and improves competence.
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Management of Human Resources
Competence Assessment
• HR.3.10 Competence to perform job responsibilities is
assessed, demonstrated, and maintained.
• HR.3.20 The hospital periodically conducts
performance evaluations.
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Management of Information
Overview
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Management of Information
• Identifying information needs
• Designing the structure
management system
of
the
information
• Capturing,
organizing,
storing,
retrieving,
processing,|| and analyzing data and information
• Transmitting, reporting, displaying, integrating, and
using data and information
• Safeguarding data and information
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Management of Information
The standards in this chapter focus on
hospital-wide information planning and
management processes to meet the
hospital’s
internal
and
external
information needs.
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Management of Information
Information Management Planning
• IM.1.10 The hospital plans and designs information
management processes to meet internal and external
information needs.
Confidentiality and Security
• IM.2.10 Information privacy and confidentiality are
maintained.
• IM.2.20 Information security, including data integrity, is
maintained.
• IM.2.30 The hospital has a process for maintaining
continuity of information.
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Management of Information
Information Management Processes
• IM.3.10 The hospital has processes in place to
effectively manage information, including the
capturing, reporting, processing, storing, retrieving,
disseminating, and displaying of clinical/service and
non-clinical data and information.
Information-Based Decision Making
• IM.4.10 The information management system
provides information for use in decision making.
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Management of Information
Knowledge-Based Information
• IM.5.10 Knowledge-based information resources are
readily available, current, and authoritative.
Patient-Specific Information
• IM.6.10 The hospital has a complete and accurate
medical record for every individual assessed, cared
for, treated or served.
• IM.6.20 Records contain patient-specific information,
as appropriate, to the care, treatment, and services
provided.
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Management of Information
• IM.6.30 The medical record thoroughly documents
operative or other high risk procedures and the use of
moderate or deep sedation or anesthesia.
• IM.6.40 For patients receiving continuing ambulatory
care services, the medical record contains a summary
list of all significant diagnoses, procedures, drug
allergies, and medications.
• IM.6.50 Designated qualified personnel accept and
transcribe verbal orders from authorized individuals.
• IM.6.60 The hospital can provide access to all relevant
information from a patient’s record when needed for use
in patient care, treatment, and services.
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Section 3 : Structures with functions
• Medical Staff
• Nursing
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Medical Staff
Overview
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Medical Staff
Organized Medical Staff Structure
• MS.1.10 The hospital has an organized, self-governing medical
staff that provides oversight of care, treatment, and services
provided by practitioners with privileges, provides for a uniform
quality of patient care, treatment, and services, and reports to
and is accountable to the governing body.
• MS.1.20 Medical staff bylaws address self governance and
accountability to the governing body.
• MS.1.30 Neither the organized medical staff nor the governing
body may unilaterally amend the medical staff bylaws or rules
and regulations.
• MS.1.40 There is a medical staff executive committee.
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Medical Staff
• MS.2.10 The organized medical staff oversees the quality of
patient care, treatment, and services provided by practitioners
privileged through the medical staff process
• MS.2.20 The management and coordination of each patient’s
care, treatment, and services is the responsibility of a
practitioner with appropriate privileges.
• MS.2.30 In hospitals participating in a professional graduate
education program(s), the organized medical staff has a
defined process for supervision by a licensed independent
practitioner with appropriate clinical privileges of each member
in the program in carrying out his or her patient care
responsibilities.
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Medical Staff
Performance Improvement
• MS.3.10 The organized medical staff has a leadership
role in hospital performance improvement activities to
improve quality of care, treatment, and services and
patient safety.
• MS.3.20 The organized medical staff participates in
the measurement, assessment, and improvement of
other processes.
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Medical Staff
Credentialing, Privileging, and Appointment
• MS.4.10 The organized medical staff has a
credentialing process that is defined in the medical
staff bylaws.
• MS.4.20 There is a process for granting, renewing, or
revising setting-specific clinical privileges.
• MS.4.30 An organized medical staff may use an
expedited process for appointing to the medical staff
and when granting privileges when criteria for that
process are met.
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Medical Staff
• MS.4.40 At the time of renewal of privileges, the
organized medical staff evaluates individuals for their
continued ability to provide quality care, treatment,
and services for the privileges requested as defined in
the medical staff bylaws.
• MS.4.50 There are mechanisms including a fair
hearing and appeal process for addressing adverse
decisions regarding reappointment, denial, reduction,
suspension, or revocation of privileges that may relate
to quality of care, treatment, and services issues.
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Medical Staff
• MS.4.60 The organized medical staff provides
oversight for the quality of care, treatment, and
services by recommending members for appointment
to the medical staff.
• MS.4.70 Peer recommendations from peers in the
same professional discipline as the applicant are used
as part of the basis for the initial granting of privileges.
Peer recommendations are used to recommend
individuals for the renewal of clinical privileges when
insufficient practitioner-specific data are available.
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Medical Staff
• MS.4.80 The medical staff implements a process to
identify and manage matters of individual health for
licensed independent practitioners. This identification
process is separate from actions taken for disciplinary
purposes.
• MS.4.90 There is a process that defines
circumstances requiring a focused review of a
practitioner’s performance and evaluation of a
practitioner’s performance by peers.
• MS.4.100 Under certain circumstances, temporary
clinical privileges may be granted for a limited period
of time.
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Medical Staff
• MS.4.110 Disaster privileges may be granted when the
emergency management plan has been activated and the
hospital is unable to handle the immediate patient needs
(see standard EC.4.10).
• MS.4.120 Licensed independent practitioners who are
responsible for the care, treatment, and services of the
patient via telemedicine link are subject to the
credentialing and privileging processes of the originating
site.
• MS.4.130 The medical staffs at both the originating and
distant sites recommend the clinical services to be
provided by licensed independent practitioners through a
telemedical link at their respective sites.
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Medical Staff
Continuing Education
• MS.5.10 All licensed independent practitioners and
other practitioners privileged through the medical staff
process participate in continuing education.
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Nursing
Overview
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Nursing
• NR.1.10 A nurse executive directs the hospital’s
nursing services.
• NR.2.10 The nurse executive is a licensed
professional registered nurse qualified by advanced
education and management experience.
• NR.3.10 The nurse executive establishes nursing
policies and procedures, nursing standards of patient
care, treatment, and services, standards of nursing
practice, and a nurse staffing plan(s).
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