This memo emphasizes on the areas of Compliance and Noncompliance, and some ideas that might help to improve in the noncompliant areas. Over the last review period General Hospital has had a number of compliance achievements including, for the incident reports there were minimal number of incidents reactions to blood transfusion, as for the operative reports they had many of them dictated in a timely manner, the health & physical reports were also dictated in a timely manner at a rate of approximately 74% compliance, as for the physician orders Dr. Jones had a turnaround rate in the positive manner 2/3 of the time, the release of information is at a 60% rate. In the Core Measure Report in the area of Heart Attack Care there are certain areas
Compliance is pertaining to the adherence to laws and regulations that the company is subject. Raven Head Ranch did not follow this objective when they were writing checks approved by the same person and putting them in unapproved projects, for example the Volunteer Fire Department. The VFD had been receiving funds from misappropriate accounts for three years. Fifty individual disbursements were taken from the community checking account and had no proper recording, just charged to random accounts, which breaks the regulations and laws of proper accounting. One of the BoD members, Sam, was not even a resident of RHR and was on board supervising the employees with no legal right
The Hospitals medical staff including on call- physician and their designees should be made aware of Hospital bylaws or policies and procedures.
Springfield General Hospital (SGH) is committed to high quality healthcare for patients, and providing tools to support physicians, nurses and pharmacists. SGH leadership approved the computerized physician order entry (CPOE) system as a solution to reduce prescription errors, and the results of the CPOE project are disappointing. The data show increased prescribing errors after implementing the CPOE; resulting in increased costs for adverse drug events, rather than the planned cost reduction (Spector, 2013). This change management plan provides the SGH board of directors and executive management team pragmatic steps to increase quality for patients by assessing the root issue of hospital
A powerful speech given by Don Berwick on December 2004 explains ways in which healthcare industries needs to implement in order to save lives and to reduce the mortality death rates that occur in the healthcare (i.e. no needless death). In his speech entitled “Some Is Not A Number…. Soon Is Not A Time” invites all healthcare care organization U.S. and the world to come together to save 100,000 lives by June 14th 2006 at 9am exactly 18 months from the day of the speech. In order to achieve this goal Dr. Berwick suggests there should be a high standards protocol that will help improve care and reduce patients harm.
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
Its responsibilities includes deficiency verification, assigning physician notices of deficiency record. This process requires to be time, if the physician does not comply with the given notice, they are reported to the chief of staff. The record are stored in accordance to the completion standards which is defined by the federal regulation for persons with the age above 18years, their records should be kept for a minimum of 6 years, while children who are under 18years their records should be kept until they attain an age of 21years plus a minimum of 6
The above compliance failures illustrate the importance of maintaining a compliant company culture. Managers must create and participate in a top down culture of compliance to succeed. Attempting to change an established noncompliant culture encourages employee resistance and unfortunately often meets with failure. Companies must get this right from the start, or suffer many negative and serious consequences, including the complete withdrawal of substances from FDA
The Joint commission, is a private agency with considerable power over healthcare institutions in that it performs certain responsibilities yet it is outside of the government. One of the Joint commission’s roles is monitoring quality in hospital services. This includes monitoring that standards are met in hospital laboratories. It is also responsible for auditing logs and confirming that instrumentation calibration is keep to standards. JCAHO is also well known for announcing their arrival for inspection in a few days to surprise inspections. In many cases this
I had the opportunity to meet with Dee Laguerra for a few hours and learned so much about the Medical records side of our facility and its impact on healthcare organization. As Director of Health Information Management (HIM) she is responsible for many aspects of managing the medical record; which is a legal document. I did not realize how complex this department is and how vital this department is to the legal and financial position of the organization. Dee’s position as director is the responsibility for the collection, organizing, scanning, and completions of the medical records in a timely matter after the patient is discharged. The reason for the timeliness of scanning the medical records is for the preparation for the coders to review all the charts to code for insurance billing. The time requirement for th...
The problem of poor communication stems from an environment of high stress levels. After a consulting company scrutinized processes throughout the hospital related to care coordination and patient flow, the evidence was clear. The company identified areas for improvement around communication at many different levels. In order for patients to have a seamless transition from admission to discharge, the lines of communication needed to change. Daily face-to-face meetings were productive for the staff, hospital and overall satisfaction. The consulting firm worked for the hospital for several months, but as they departed, the prior culture of poor communication started to engulf...
The major complaint was that the score cards give a single letter grade for twenty six patient safety measures. Many hospitals claim that the score cards had within them the wrong questions. They insist that they should address matters of how much the hospitals are doing to better themselves in respect to patient safety. The point, however, is research has shown that many hospitals are doing little to nothing to better their patient safety.
Golden Age Hospital (GAH) will seek to improve operating performance to increasing review of patient outcomes and satisfaction. The healthcare organization will thus base its operations on the core competences and functions to improve its financial outlook and service delivery. These core competencies include; designing and implementing patient-centered, economic value, the patient experience, safety, and clinically integrated models of care that optimize quality. Therefore, GAH, as parts of care systems, will have the capacity to integrate with healthcare providers as clinical and economic partners, to redesign and create the synergy for delivery systems.
This paper’s brief intent is to identify the policies and procedures currently being developed at Midwest Hospital. It identifies how the company’s Management Committee was formed and how they problem solved and delegated responsibilities. This paper recognizes the hospital’s greatest attributes and their weakest link. Midwest Hospital hired Dr. Herb Davis to help facilitate the development and implementation of resolutions for each issue.
...d procedures are now being monitored to improve clinical processes. Ensuring that these processes are implemented in a timely, effective manner can also improve the quality of care given to patients. Management of the processes ensures accountability of the effectiveness of care, which, as mentioned earlier, improves outcomes. Lastly, providing reimbursements based on the quality of care and not the quantity also decreases the “wasting” and overuse of supplies. Providers previously felt the need to do more than necessary to meet a certain quota based on a quantity of supplies or other interventions used. Changing this goal can significantly decrease the cost of care due to using on the supplies necessary to provide effective, high-quality care. I look forward to this implementation of change and hope to see others encouraging an increase in high-quality healthcare.
A study showed an increase in a hospital 's Press Ganey scores after the implementation of bedside reporting. The areas that showed improvements includes nurse attitude toward requests, more attention to personal needs, nurses kept patients informed regarding their treatments, and better pain control. (Ferris, 2013)