The Regulatory Process The Role of Nurse Leaders *

Issues Confronting Nursing Leaders regarding Regulation The Regulatory Burden on Nursing Care Hours Lack of reimbursement for Regulatory activities Staff understanding and education of the regulatory drivers of healthcare processes and procedures. *

Regulators of Hospitals Today Centers for Medicare and Medicaid Services TJC

A Closer Look at Three Major Regulating Agencies Centers for Medicare & Medicaid Services –part of the Department of Health and Human Services Agency for Healthcare Administration The Joint Commission *

Centers for Medicare & Medicaid Services June 2002 Edition *

Centers for Medicare and Medicaid In the past this agency was known as HCFA. It is part of the Department of Health and Human Services. Major areas of regulation include Medicare, Medicaid, SCHIP and HIPAA. Initiator of the Core Measures now being used for Hospital Reimbursement *

Centers for Medicare and Medicaid These quality measures are used to gauge how well an entity provides care. Another quality measure introduced by CMS is the HCAHPS which is the patient’s perspective on care. This survey provides a comparison of patient satisfaction by facility and is posted on the Hospital Compare website for consumers to review.

Agency Responsibilities Enforcement of all legislation related to these programs. Investigation and surveys of facilities where violations are reported – example an EMTALA violation in an emergency room. Provider payment for covered programs. Development of policies on new programs such as HIPAA. Providing the public information about quality issues with providers. *

Agency for Healthcare Administration *

Agency for Health Care Administration Licenses and Regulates health care facilities and HMOs which operate in Florida Responsible for the State Medicaid/Medicare Programs Addresses consumer complaints regarding health care institutions. Conducts State Surveys Oversees the Certificate of Need for Health Care Services Program *

TJC – What is It? *

What is the Joint Commission? An independent, not-for-profit organization, The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

TJC The decision to undergo TJC Survey is noted to be voluntary but is a requirement for healthcare facilities accepting Medicare and Medicaid payments as well as many state programs and those affiliated with colleges of medicine, nursing and other healthcare disciplines. *

Scope Accredited 4365 hospitals in 2015; Total >20,000 organizations and programs Types of hospitals general, psychiatric, children’s, rehabilitation Others: Managed care networks, Preferred Provider Organization (PPOs), home care systems, long-term care, Subacute care, behavioral health facilities (mental health, mental retardation and chemical dependency), ambulatory care centers, clinical laboratories

Establish Standards & Requirements Related to: APR Environment of Care Emergency Management Human Resources Infection Control Information Management Leadership Life Safety Medication Management Medical Staff NPSG Nursing Provision of Care Performance Improvement Record of Care Rights Transplant Safety Waived Testing *

Process Used Healthcare Agencies are surveyed against applicable standards for their mission. Unannounced surveys are conducted approximately every three years but organizations are expected to be survey ready at all times. TJC offers a computer based process where facilities evaluate themselves against the standards and subsequent onsite surveys confirm the information reported. Patient Safety Goals are established each year and organizations are evaluated on compliance with these goals. *

Each Standard Consists of Three Parts: Standard Statement Rationale and/or Notes (not in the excel file) Elements of Performance (EP) These are the score-able elements

FSA Scoring Sample

For Each Standard Ask yourself, ask your staff: Do we do this? Where is it written we do this? How well, or how often do we do this? Show me the evidence that we do this Validate the “doing” with high risk and high priority standards *

5 Steps to doing the Right Thing Well : Sustained Execution=Continuous Readiness Measure compliance or lack of... Is it due to poor design? Inadequate education? Ineffective competency validation? Variation due to work-arounds? Variation due to unit, day of week, time of day, FT/PT/agency staff, etc.? Management Intervention (appropriate action) Manager Measure compliance L I N E M A G R S Manager Validate competency Staff dev. Educate PI team Focus/PDSA/Rapid cycle design

Annual Internal Self-Assessment

Survey Process Opening Conference Leadership (High Reliability) Medication Management Infection Prevention Control Data Management Environment of Care Emergency Management Competency Credentials

Accreditation Decisions Full Accreditation Accreditation with Recommendations Provisional Accreditation – All Requirements for Improvement have not been addressed in the Evidence of Standards Compliance submission, or the organization has failed to achieve appropriate level of sustained compliance as determined by a Measure of Success result (when required).  *

Accreditation Decisions Conditional Accreditation – Number of standards scored not compliant is between two and three standard deviations above the mean number of not compliant standards for organizations in that accreditation program.  The organization must undergo an on-site follow-up survey.

Accreditation Decisions Preliminary Denial of Accreditation – Number of standards scored not compliant is three or more standard deviations above the mean number of not compliant standards for organizations in that accreditation program. There is justification to deny accreditation, but the decision is subject to appeal.

Accreditation Decisions Denial of Accreditation – The organization has been denied accreditation, and all review and appeal opportunities have been exhausted.

Resources – Nurse leaders need to read the Book and Newsletters – sample below is for hospitals

Most Common Areas Generating Deficiencies Physical Environment Surgical Services Nursing Governing Body

Units/Depts Receiving the Most Deficiencies Operative/Invasive Areas OR, Cath Lab, Radiology, Sterile Processing, Endo, Rehab, Anesthesia, Doctors Offices, ICU Behavioral Emergency Department Provide Based Clinics Cancer Centers

Nursing Issues of Current Concern Nurse executive qualifications Nurse executive oversight to all areas providing nursing care

Leadership Areas of Concern Leadership responsibility and accountability Contract management Policies and procedures consistently implemented Space Disruptive behavior Patient flow

Hot Topics with TJC Safety & Security Issues Medication Reconciliation Timeouts Patient Handoffs Pain Management Restraint & Seclusion Staff Competency Our Hot Topics *