Purpose of the RM plan The Risk Management Plan is designed to support the mission and vision of All Aboard Pediatric Hospital as it pertains to clinical risk and patient safety as well as visitor, third party, volunteer, and employee safety and potential business, operational, and property risks. When analyzing the risk management plan the top safety measures must be implemented into the program. The core factors work in sync, patient, all employees, property equipment and the final status of the entity. Evaluating all of these elements individually and together is important. “Having such a perspective helps to ensure every function with in the facility aligns its own activities with that of All Aboard Pediatric Hospital health delivery goals” (Broyles, 2009) Goals of the plan This risk management plan will help showcase the risk associated with All Aboard Pediatric Hospital.
Credentialing is used by healthcare organizations and health plans to verify education, training, and experience of medical staff. When a physician or licensed independent practitioner (LIP) is credentialed they become affiliated with that organization and are members of the medical staff or health care network. The organization’s owner or governing board is held legally accountable for the quality of care and staff conduct and the medical staff is accountable to the governing board for the quality of care they provide. The credentialing process determines if medical staff is competent and capable to treat and care for patients before allowing membership or network affiliation. The medical staff committee is in charge of conducting competency evaluations using established governing board criteria - character, competence, training, experience, and judgment.
We will also take a look into the Affordable Care Act and how the ACO is a part of that. What is the Accountable Care Organization? “Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients” (www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html). The ACO is a component of the Affordable Care Act (ACA). “The Patient Protection
Ebsco Host, p. 423. “Policy, Practice, and Education” article was developed to address effective and acceptable healthcare standards. Author Angela R. Mun explains that information systems relating to patient information must conform to federal, state, and local laws. Also mentioned are some fallacies that healthcare organizations must be aware of such as opportunities, barriers, and limitation plus restriction consideration while developing policy ethics. We have also located statistical facts and additional agency resources that can be consider for this project.
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.
Determination of Medical Necessity Medicare benefits are issued to eligible beneficiaries through a number of Medicare Administrative Contractors (MAC). Similar to the meaningful use requirements that healthcare providers must meet, the MACs must adhere to CMS Federal Guidelines delineating the process of medical necessity determination. As noted in Review of Medical Necessity Decisions, “[The] primary expectation is based on reviewers having knowledge of Medicare coverage requirements… However, reviewers are expected to follow all applicable Medicare requirements, such as adjudication timeframes, in the performance of their duties.” (Medicare Program, 2011, p. 21496). The current medical review process at a proprietary MAC (henceforth referred to as “Well Health”); will be reviewed for the course project. At Well Health, incoming service requests from healthcare providers are received by fax and made available to the nurse reviewers in electronic format using a computerized application.
Utilization management describes proactive procedures, discharge planning, concurrent planning, precertification and clinical case appeals. UM also covers concurrent clinical review and appeals introduced by the provider, payer or patient. Utilization m... ... middle of paper ... ...lanation of Benefit (EOB) is created along with benefit check which is mailed to the patient and the physician respectively. Conclusion Reference:  Selected patient and provider characteristics for ambulatory care visits to physician offices and hospital outpatient and emergency departments: United States, 2009-2010  How Private Insurance Works: A Primer by Gary Caxton, Institution for Health Care Research and Policy, Georgetown University, on behalf of the Henry J. Kaiser Family Foundation.  http://chiroeco.com/chiro-blog/medical-clearinghouse/2009/04/07/paper-claims-vs-electronic-claims/  http://www.ihealthbeat.org/picture-of-health/2013/what-percentage-of-health-insurance-claims-were-filed-by-paper-or-electronic-processes  http://www.wisegeek.org/what-is-claims-adjudication.htm  http://www.staysmartstayhealthy.com/health_insurance_deductibles
Introduction The Healthy Body Wellness Center requires an Information Security Management System (ISMS), in order to implement a plan to maintain and audit the company 's information system security objectives. This necessitated outlining the scope of the ISMS plan as well as an evaluation of the risk assessment conducted by We Test Everything LLC (WTE). We Test Everything LLC was contracted by the Healthy Body Wellness Center 's (HBWC) Office of Grants Giveaway (OGG) to provide a risk assessment of the Small Hospital Grant Tracking System (SHGTS). Business Objectives The HBWC business objectives should be included in the Information Security Management System (ISMS) as this document will represent the organizations approach in designing, implementing, and auditing the company 's information system security objectives. In order for the ISMS to be applicable and appropriate to the organization, an examination of the business objectives of the company is required.
Today health care systems are expected to meet set standards and core measures to earn everything from accreditation and recognition to payment. Reports need to filled to accomplish this, as well as what is being done to improve areas that may not be meeting standards. One way this is done is by utilizing dashboards. The purpose of this paper is to analyze the data from a dashboard and develop a nursing plan for improvement of a low scoring area. Analysis of the Data The Centers for Medicare and Medicaid Services (CMS) have recently begun requiring hospitals to report to the public how they are doing on patient care.
Three areas that define the provisions of comprehensive health care services and are commonly used for utilization monitoring and control are gatekeeping, case management, and utilization review (UR). Gatekeeping is used by HMOs where each member designates a primary care provider (PCP) that is responsible for coordinating all care services needed for the enrollee in a managed care plan. Case management involves an experienced health care professional with knowledge of available health care resources. `Case management services are designed to identify spec... ... middle of paper ... ... The HIM professional may also pursue a position as chief information officer within a managed care organization.