What is HCAHPS?
Nationally standardized publicly reported patient satisfaction
Is there a penalty for not reporting?
Yes!
What are the goals of HCAHPS?
- Comparable date across hospitals
- Increased transparency
- Creates incentive for hospitals to improve quality of care
What are the 10 domains of HCAHPS?
- Communication w/ nurses
- Communication w/ doctors
- Responsiveness of hospital staff
- Communication about meds
- Discharge instructions
- Care transition
- Cleanliness of hospital
- Quietness of hospital
- Overall rating
- Recommendation of hospital
What is the purpose of NDNQI?
To understand the link between nursing staff and patient outcomes; similar to HCAHPS but specific to NURSE SENSITIVE INDICATORS!
NDNQI Clinical Indicators: Structure?
Nurse turnover
ED throughput
Patient volume and flow
Staffing and skill mix
Process Clinical Indicators (NDNQI)?
Pressure Ulcers
Patient Falls
Care Coordination
Restraints
Device Utilization
NDNQI Clinical Indicators: Outcomes?
CAUDIs
CLABSIs
Hospital Readmissions
C-Diff
MRSA
Ventilator Acquired Pneumonia
Pediatric Peripheral IV Infiltration
What is meaningful use?
minimum US government standards for electronic health records
What does HITECH do?
Promote the use of electronic health records in the US and support technology in healthcare
What are the PRIORITIES of meaningful use?
- Improve quality, safety, efficiency, and reduce health disparities
- Improve care coordination
- Improve public/population health
- Ensure privacy and security
What are the MAIN COMPONENTS of meaningful use?
- Electronic Health Record
- Barcode Scanning
- Computerized Provider Order Entry (CPOE)
What is the PURPOSE of risk management?
- Prevent patient injury
- Minimize financial loss
- Preserve the organization’s reputation
What is the law to protect against patient dumping?
EMTALA
What does EMTALA make you do?
give people a medical screening exam BEFORE you can ask for insurance or payment source
What is the role of the risk manager?
Mandatory reporting of abuse & neglect, nosocomial infections (hospital-acquired), and death within 24 hr of
admission
What are reportable events for risk managers?
- Unexpected occurrences or accidents that lead to death
- EMTALA Violations
- Retained surgical objects
- Infant deaths, births, and reportable fetal deaths
- Infants d/c to wrong family
- Pt suicides/attempts
- Sexual assault of patient
- Sentinel events
What should you know about Unusual Occurrence Reports (Incidence Reports)?
They should be objective and confidential; should NEVER be found in a patient’s chart.
What is a sentinel event?
An event that leads to death, permanent harm, or severe temporary harm
Example of Sentinel Events?
Amputating the wrong leg
or
Administering the wrong medication leading to death of the patient
What is a Never Event?
Seriously preventable complication that could have reasonably been avoided
Example of a Never Event?
Development of Stage 3/4 Pressure Ulcer
or
CLABSI
or
CAUTI (CAUDI)
What’s an example of a never event leading to a sentinel event?
RN hangs the wrong blood, patient becomes anaphylactic, and dies.
or
Pt gets CAUTI and becomes septic and dies.
T/F: All never events become sentinel events.
False.
