State and federal regulations, national accreditation standards, and clinical practice standards are created, and updated regularly. In addition, to these regulations, OIG publishes a compliance work plan annually that focuses on protecting the integrity of the program, and prevention of fraud and abuse. The Office of the Inspector General examines quality‐of‐care issues in nursing facilities, organizations, community‐based settings and occurrences in which the programs may have been billed for medically unnecessary services. The Office of the Inspector General’s work plan for the fiscal year 2011 highlights five areas of investigation for acute care hospitals. Reliability of hospital-reported quality measure data, hospital readmissions, hospital admissions with conditions …show more content…
Under the Social Security Act, it is required that hospitals report quality measures for a set of 10 indicators. If hospitals do not report quality measures to CMS there is a reduction in payments. In the hospital readmission area of investigation, OIG reviews Medicare claims in hospital readmission cases to identify trends and oversights of cases. Readmissions are cases in which the beneficiary is readmitted to the hospital less than 31 days after being discharged from the hospital. Hospitals are only entitled to one diagnosed-related group payment if there is a same-day readmission for symptoms related to prior hospital stay. Quality improvement organizations are required to review hospital readmission cases also this is to see if standard of care are met. For coded conditions as present on admission, it is required for acute hospital to report these diagnoses on Medicare claims. The OIG will review Medicare claims for types of facility or providers most frequently transferring patients to hospital
Kaiser Permanente’s mission is to provide care assistance to those in need. As a health maintenance organization, Kaiser Permanente provides preventive care such as prenatal care, immunizations, diagnostics, hospital medical and pharmacy services. Also, they take responsibility and provide exceptional training for their future health professionals for better clinical performance and treatment for the patients. The organization is to ensure fair and proper treatment towards their employees for a pleasant working environment in hospital and to provide medical services especially in a growing population in suburban communities, such as Tracy and Stockton in California.
Margaret E. O’Kane is the founder and president of the National Committee for Quality Assurance (NCQA). NCQA is one of the nation’s leading advocates for improving healthcare through measurement, reporting, and accountability. NCQA is the foremost accrediting organization for health plans including HMOs, PPOs, and consumer directed plans. (Margaret) “Our goal is to increase the value of NCQA accreditation both to organizations pursuing accreditation and to the audiences who seek help in assessing the quality of health care provided by those organizations”. NCQA has developed, maintained, and expanded the nation’s most widely used health care quality tool, which is known as the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS is responsible for evaluating whether and how well
stationed staff in one area of a hospital ED to treat patients presenting to the ED" (Minott, 2008). This results of this experiment stated that "28 percent of patients diverted back home and avoided hospital readmission" (Minott, 2008). Another study showed that "greater registered nurse hours spent on direct patient care were associated with decreased risk of hospital related death" (Kane, Shamiliyan, Mueller, Duval and Wilt, 2007). This shows that there is a correlation between direct care between healthcare providers and a better outcome amongst patients.
While working seemingly endless days, many nurses do not realize the many influences that affect their professional practice or how client care is delivered. Besides their employer, health care organizations are highly regulated by federal, state, and local laws and regulations. In addition to the rules set by governments, most medical establishments want to be accredited by The Joint Commission (TJC), a non-government regulatory agency. TJC does not have the authority to cite or fine a facility for not meeting standards or responding to its custodian alerts (The Joint Commission, 2011). However, these standards carry considerable weight through the loss of millions of dollars from Medicare and Medicaid programs.
Institute of Medicine’s (IOM’s) 2001 Report, “Crossing the Quality Chasm”, clearly states that U.S. health care quality fails to meet the established industry benchmarks.7 In order to achieve quality improvement and affordability in health care, The Patient Protection and Affordable Care Act (PPACA or Obamacare) was signed in the year 2010. With regard to PPACA the main purpose of this report is to study the following:
Providing the steps to ethically sound excellent care, healthcare providers must acknowledge first the legal and ethical matters involved with proper investigation and then devise a plan for best possible action recognizing the rights of the patient and its benefits followed by the application of the chosen intervention with positive outcome in mind (Wells, 2007). Delivery of excellent and quality of care at a constant level (NMC, 2008) must be marked in any responsibilities and duties of the care provider to promote exceptional nursing practice. Codes of nursing ethics and legal legislation have addressed almost all the necessary actions in making decisions in consideration to the best interest of the patient. Nurses must make sure that they are all guided by the set standard to lead their action and produce desirable and ethically sound outcomes.
Conditions of Participation was created to ensure all facilities participating in Medicare follow a set of regulations that protect the safety of Medicare recipients. In 1986 revisions were made to reinforce accreditation and certification procedures. Participating hospitals that are accredited by the Joint Commission on Accreditation of Healthcare Organizations or American Osteopathic Association have been deemed to meeting Conditions of Participation requirements on the wellbeing of Medicare Recipients. The Joint Commission on Accreditation of Healthcare Organizations also requires that the facilities are licensed by their state. (Lohr, 1990, p.
Abstract The author will choose for the purpose of this deliverable three-accreditation program that could replace the joint commission. This author will compare these agencies to the condition of participation for Medicare and Medicaid services. Then will analyze the cost and benefits of each and their impact on stakeholder groups and rank them according to the author’s rationale. Accreditation Association for Ambulatory Health Care (AAAHC) The Accreditation Association for Ambulatory Health Care was founded in 1979 and accredits ambulatory health care performed in ambulatory surgery centers, office-based surgery centers, and college health centers. The AAAHC has trusted status by the center for Medicare and Medicaid services and is one out
Quality patient care is an ongoing endeavor that involves many different areas of healthcare. One area of healthcare that is often employed is Utilization Management. We read in John’s that UM “is composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care” (John,2011). Things that are used to determine the appropriateness of care include the patient’s diagnosis, site of care, length of stay, and other clinical factors. This system consists of three main functions aimed at improving patient care and controlling healthcare costs. These functions include utilization review, case management, and discharge planning. One source states that it also includes the claim denials and appeals process (Interviewee C. Jarvis, e-mail communication, May 3, 2014). When used correctly, these UM processes can expedite the patient’s care and reimbursement. It also demonstrates to third party payers that the organization is taking measures to help control costs. This monitoring and management of patient healthcare needs ensur...
In the United States, nearly one-fifth of patients discharged from the hospital are readmitted within thirty days, and most of those readmissions are considered to be preventable (Verhaegh et al., 2014). Many opportunities to reduce health care costs and prevent readmissions could save Medicare as much as $12 billion a year (Constantino, Frey, Hall & Painter, 2013). These numbers are significant from a financial standpoint, but do not consider the negative impact on the patient’s experience, the perception of poor care quality and inadequate transitional care. Hospital readmissions may be linked to ineffective discharge planning, lack of care coordination, lack of outpatient follow-up care, client’s non-compliance with treatment regimen, inadequate
Our nation’s healthcare system requires constant monitoring for quality and innovations and guidelines for increasing the quality of care. This process is difficult and complex and requires many separate organizations with differing approaches and objectives in order to be effective. Fortunately, there are many such organizations that strive to continuously increase the health care standards and practices in our nation. They also assist the consumer in making educated decisions on which medical facilities will best suit their needs. Reviewing a few of these quality improvement organizations and the roles they play will increase our understanding of their roles within our nation’s healthcare system.
Hospitals recognized the need for the case management model in the mid 1980’s to manage the lengths of stay of hospitalized patients and the treatment plans (Jacob & Cherry, 2007). In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals ...
Department of Health and Human Services (HHS) key role in the United States health care system is to act upon the different new provision that the Affordable Care Act implemented. It’s role on the Affordable Care Act is to “expand coverage, emphasize prevention, improve the quality of health care and patient outcomes across health care settings, ensure patient safety, promote efficiency and accountability, and work toward high-value health care” (citation 1). The HHS has 11 different division that is set up to tackle the issue that the Affordable Care Act placed on the United Healthcare system when it was passed. The one that focuses on quality of healthcare is the Agency for Health Care Research and Quality (AHQR). The AHQR main goal is to perform research on different intervention to prevent or reduce hospital-acquired conditions. They have done extensive research on Catheter-Associated Urinary Tract Infection, Central Line-Associated Blood Stream Infections, and Adverse drug event, which are the three main ways patient stays in the hospital for an extensive period. According to the statistics that they have compiled, they have saved the United States government approximately $28 million dollars because of their research on Hospital-acquired conditions (AHRQ). The Joint Commission contributes to the United States health system
Quality improvement (QI) involves the regular and constant actions that enable measurable improvement in health care. QI results in enhanced health services, organizational efficiency, quality and safe care to patients, and desired health outcomes for individuals and patient populations (U. S. Department of Health and Human Service, 2011). A successful quality improvement program is patient-centered, a collaboration of teams, and uses data in systems. QI helps to develop a culture of excellence in nursing, identify and prioritize areas of improvement, promote communication and collaboration, collect and analyze data, and encourage continuous evaluation of systems and processes (American Academy
The problems of healthcare that impact quality such as medical errors, health insurance, shortage of healthcare personnel are issues that contribute to a lack of trust in health care systems. Rendering quality care should be appropriate to the need and specific actions taken in accordance to the individual need. Meltzer & Chung (2014), suggest that although quality improvement may sometimes reduce costs, the financial resources, time, and effort available for quality improvement are limited-whether within a single hospital, a payer network, a state, or a