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Organizational Performance Management Table Devos Children’s Hospital
Research your chosen health care organization to complete this table. Then share it with your learning team as you collaborate to write your paper. Include your tables as appendixes to your paper.

Provide a name of or link to a specific organization. Summarize key products or services provided by the organization and identify the primary customers it serves.

Organization Overview

Spectrum Health Helen Devos Children’s Hospital specializes in providing care for children of all ages. They specialize in Cancer and Blood Disorders, Congenital Heart Conditions, Digestive Health Disorders, Emergency and Trauma, Kidney and Urinary care, Pulmonary care, Neonatal care, Neurosciences, Plastic and Craniofacial surgery, and Rheumatology. It is so important to have a hospital that specializes in caring for infants and children, because they are different than adults.
https://www.spectrumhealth.org/locations/spectrum-health-hospitals-helen-devos-childrens-hospital

Outline the overall content of the major regulations, accreditation requirements, and other standards that affect the organization. Provide the title, section, parts, or subparts, or the numbering system, etc. of the specific regulations or accreditation requirements. Response should be at least 100 words.

For example: Use of electronic signatures in electronic medical records is equivalent to handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200 Electronic Signature: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?cfrpart=11

Organization Regulations, Accreditation, and Standards

“U.S. News & World Report has again included Spectrum Health Helen DeVos Children’s Hospital in its Best Children’s Hospital rankings, with a total of six specialty areas being recognized in 2017-18: cancer, cardiology & heart surgery, nephrology, orthopedics, pulmonology and urology. This is the sixth year the children’s hospital has been included.” (Spectrum Health, 2018)
https://www.spectrumhealth.org/about-us/quality-safety-and-patient-experience/awards/2017
They were voted Best Children’s hospitals for 2017-2018 Spectrum Health is recognized by the Joint Commission for providing quality patient care. Facts about Joint Commission Standards. (Sept, 2017) Retrieved from https://www.jointcommission.org/facts_about_joint_commission_accreditation_standards

Highlight the effect of each organization’s regulations, accreditation requirements, and other standards on the risk management functions and activities. Response should be at least 100 words.

Effects on Risk Management

There could be many risks in a hospital setting. For example, Patient Safety, we don’t want patients getting hurt while they are at the facility, it is important to always be on lookout for possible accidents. It is also necessary to keep the employees from getting hurt as well. Keeping the proper equipment throughout the facility to help prevent accidents. Quality improvement I also important, keeping good employee relationships
Within the workplace. The Joint Commission also helps monitor safety in the organization.” The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey is the first national, standardized, publicly reported survey of patients’ perspectives of hospital care. HCAHPS (pronounced “H-caps”), also known as the CAHPS Hospital Survey, is a survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience.” (CMS, 2018) This can also influence risk management.

Specify components of performance-management systems—policies and procedures, self-audits, benchmarking, complaint management, corrective or preventive action, education and training, communication, and other mechanisms—to be used by the organization. Response should be at least 100 words.

Organizational Performance Management Systems

In all organizations there should be policies and procedures for every department. The needs to be corrective action for employees who abuse or take advantage of the rules. The HR department helps monitor these things that are kept track of by the supervisors. Education and training needs to be made available for all employees. When a new person hires in, the proper training and education needs to be offered for the position they are getting. Communication is the most important in any aspect of life, employees need to know they can communicate with management and the other way around as well. Feedback is also important, so that improvements can be made.

Provide links to any relevant sources that will be useful as your learning team completes the paper.

Additional Links

http://work.chron.com/risk-manager-responsibilities-hospital-setting-17331.html
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals.html
https://www.beckershospitalreview.com/quality/4-best-practices-for-hospital-risk-management.html
http://work.chron.com/risk-manager-responsibilities-hospital-setting-17331.html

Organizational Performance Management Table for NCQA
Research your chosen health care organization to complete this table. Then share it with your learning team as you collaborate to write your paper. Include your tables as appendixes to your paper.

Provide a name of or link to a specific organization. Summarize key products or services provided by the organization and identify the primary customers it serves.

Organization Overview

The National Committee for Quality Assurance (NCQA) is a not-for-profit, independent organization main objective is to improve health care quality of providers, and health plans. The organization focuses on improving health care quality by way of administration of evidence-based standards, measures, programs, and accreditation. NCQA can be considered as the liaison that works with policymakers, employers, doctors, and patients. This particular organization primary customers are health care patients ensuring that the overall quality of care and services are being provided.

Outline the overall content of the major regulations, accreditation requirements, and other standards that affect the organization. Provide the title, section, parts, or subparts, or the numbering system, etc. of the specific regulations or accreditation requirements. Response should be at least 100 words.

For example: Use of electronic signatures in electronic medical records is equivalent to handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200 Electronic Signature: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?cfrpart=11

Organization Regulations, Accreditation, and Standards

National Committee for Quality Assurance, Title 42 CFR, Part 422 Electronic Signature: https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=6a1df58ffe1fb21cea2180aceb8be66e&ty=HTML&h=L&mc=true&n=pt42.3.422&r=PART
The overall content of the major regulations of the NCQA is to provide information to purchasers and consumers of managed health care to distinguish the health plan’s quality. The organization has managed national efforts to promote accountability for managed care health plans. The accreditation requirements include five categories: access and service plan, qualified providers in plan, staying healthy: preventive health measures, effective treatments, and management of chronic illness. Additional, the organization other standards provides accreditation standards for disease management and new health plans as well as have been awarded a contract to operate an accreditation program to ensure that the VA medical centers are in compliance with the VA and other related federal regulations intended to protect human subjects of research.

Highlight the effect of each organization’s regulations, accreditation requirements, and other standards on the risk management functions and activities. Response should be at least 100 words.

Effects on Risk Management

The NCQA risk management functions and activities include making sure that they are collecting accurate data because that is the basis of their regulations, accreditation requirements, and their other standards. Recently NCQA have implemented new standards to ensure they are providing quality care and services for patients. The new standards are 1. Team-Based Care that will require greater emphasis on team-based care and practices and have specific roles and responsibilities for care team members. 2. Further Integration With Behavior Health to create a referral agreement with behavioral health providers if they are not a part of a practice. 3. Show Sustained Transformation to ensure that they will continue to evolve to meet PCMH standards within a specific time frame. 4. Meaningful Use Standards Are Updated to ensure that practices meet Stage 2 meaningful use standards instead of previous criteria of meeting Stage 1 standards. 5. Costs for Recognition Remain the Same will help practices to achieve and meet the required Level 3 recognition by providing discounts or not increasing cost to receive NCQA accreditation.

Specify components of performance-management systems—policies and procedures, self-audits, benchmarking, complaint management, corrective or preventive action, education and training, communication, and other mechanisms—to be used by the organization. Response should be at least 100 words.

Organizational Performance Management Systems

NCQA help to regulate health care practices and facilities by evaluating and reporting on the quality of managed care in the United States. Any health care facility that has the NCQA seal is recognized as having quality assurance, as the NCQA symbol is known for signifying that the organization is well managed and delivers high-quality care and services. NCQA provides certifications for various organizations and programs such as disease management, and many other entities. Although NCQA certifies organizations, they also identify and recognize private practices that relate to specific areas, such as heart disease, diabetes, back pain, and patient-centered care.

Provide links to any relevant sources that will be useful as your learning team completes the paper.

Additional Links

https://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/resources/initiatives/ncqa.html
https://www.medpagetoday.com/practicemanagement/practicemanagement/44700
http://www.ncqa.org/

Organizational Performance Management Table Cantex
Research your chosen health care organization to complete this table. Then share it with your learning team as you collaborate to write your paper. Include your tables as appendixes to your paper.

Provide a name of or link to a specific organization. Summarize key products or services provided by the organization and identify the primary customers it serves.

Organization Overview

Cantex Continuing Care Network offers long term care and rehabilitation services for the geriatric community that may need assistance from 24 hour nursing care or may need rehab after a change in condition such as altered mental status affecting activities of daily living, knee replacement, hip replacement, etc. The goal of rehabilitation is to return home and maintain functioning back to their prior level in a safe environment. http://www.cantexcc.com/

Outline the overall content of the major regulations, accreditation requirements, and other standards that affect the organization. Provide the title, section, parts, or subparts, or the numbering system, etc. of the specific regulations or accreditation requirements. Response should be at least 100 words.

For example: Use of electronic signatures in electronic medical records is equivalent to handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200 Electronic Signature: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?cfrpart=11

Organization Regulations, Accreditation, and Standards

Licensing under the Department of Aging and Disability are heavily regulated under this agency. All facilities must remain in compliance at all times and follow regular systems put in place by the agency. There is an active state provided ombudsman that works between the facilities, residents and the state regulatory agency to ensure that the residents needs and state requirements are being met at all times. There are many, many codes and regulations; in fact a long term care facility has as many regulations as a nuclear power plant. Annual surveys are performed and recorded in accordance with state guidelines and facilities are chronically examined to determine a quality measure score. Nursing home surveys are conducted in accordance with survey protocols and Federal requirements to determine whether a citation of non-compliance is appropriate.  Consolidated Medicare and Medicaid requirements for participation (requirements) for Long Term Care (LTC) facilities (42 CFR part 483, subpart B) were first published in the Federal Register on February 2, 1989 (54 FR 5316).

Highlight the effect of each organization’s regulations, accreditation requirements, and other standards on the risk management functions and activities. Response should be at least 100 words.

Effects on Risk Management

This long term care organizations regulatory agencies and licensure system is monitored by the Department of Aging and Disability and performs annual audits on each health care facility and provides a rating on each facility that is made available to the public for each individual to gain knowledge in order to make an informed decision on the health care facility they admit their loved one into. Risk management regularly will monitor and perform random audits on behalf of the resident and ensure that their entire needs are being met and that they are able to function at their highest level of capability.

Specify components of performance-management systems—policies and procedures, self-audits, benchmarking, complaint management, corrective or preventive action, education and training, communication, and other mechanisms—to be used by the organization. Response should be at least 100 words.

Organizational Performance Management Systems

Each long term care facility should have measures in place in every department. Self-audits are often performed on patients medications between each nurse changing shifts. In addition, a patient trust fund audit is performed often in the business office that maintains each resident’s personal accounts. In service training is performed on a regular basis informing all long term care staff proper procedures regarding emergency drills, patient treatments, patient safety, etc. Administrators are required to receive 40 hours of CEU training every two years in a variety of courses such as ethics, staffing, patient nutrition, etc. Nurses are required to receive 20 hours of continuing education every two years.

Provide links to any relevant sources that will be useful as your learning team completes the paper.

Additional Links

https://www.dads.state.tx.us/
https://www.medicare.gov/
https://www.medicare.gov/nursinghomecompare/search.html?

Organizational Performance Management Table Home Health Agency-
Research your chosen health care organization to complete this table. Then share it with your learning team as you collaborate to write your paper. Include your tables as appendixes to your paper.

Provide a name of or link to a specific organization. Summarize key products or services provided by the organization and identify the primary customers it serves.

Organization Overview

Home Health Agency

Provide supportive care in the patient’s home by trained home health care professionals

Level of professional care ranges from a physician, Registered Nurse, Licensed Practical Nurse and A certified nurse’s assistant

Care rendered to the patient ranges from non-medical to medical care

Services provided include assisting in feeding, bathing, bathing and dressing the client

Enabled seniors and others to love independently in their own homme or stay with a family member

Provided access to outside supportive care and assistance when necessary

Provided housekeeping, shopping, mean planning, medication preparation and transportation assistance

Outline the overall content of the major regulations, accreditation requirements, and other standards that affect the organization. Provide the title, section, parts, or subparts, or the numbering system, etc. of the specific regulations or accreditation requirements. Response should be at least 100 words.

For example: Use of electronic signatures in electronic medical records is equivalent to handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200 Electronic Signature: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?cfrpart=11

Organization Regulations, Accreditation, and Standards

FDA regulations; Title 28 Pa. 42 C.F.R.484.36 Part 51, Subpart C, 51 HHA’s
There are a variety of regulations and different organizations that play a vital role for home health care agencies. The joint commission has a major role in the regulations and running of home health companies. Also, the Department of Health and The Health Insurance Portability and Accountability Act have a critical roles within home health agencies. Every state has their own laws and regulations regarding standards of safety to which a home health care agency must follow. If these rules, standards and regulations are not meet or followed the home health agency can face major problems. The problems can include fines and loss of licensing for the home health agency therefore, all rules and regulations must be followed and meet at all times.

Highlight the effect of each organization’s regulations, accreditation requirements, and other standards on the risk management functions and activities. Response should be at least 100 words.

Effects on Risk Management

Home Instead and BrightStar Care are home health agencies that have franchise all across the United States. These home health agencies must meet the health home care regulations within the state that they operate in. Home Instead’s home states is in Nebraska. Each local office must be licensed to operate businesses in each state that they have offices in. The home health franchise must provide a state approved license to care for the patients in their home. If the home health franchise cannot provide the licensees needed by the state, they cannot operate. The local home health care franchise must ensure the safety to all patients and maintain policy and procedures at all times.

Specify components of performance-management systems—policies and procedures, self-audits, benchmarking, complaint management, corrective or preventive action, education and training, communication, and other mechanisms—to be used by the organization. Response should be at least 100 words.

Organizational Performance Management Systems

The home health agency franchise must make sure all employees will be compliant with polices and procedures. The home health care agency must ensure that all health care staff will be responsible in maintaining their proper license. Home health care agency franchise must ensure all employees have a valid Cardiopulmonary Resuscitation (CPR) card. Also, many home health care agency franchises require their employees to have first aid cards as well. Depending on the level of care that the home health care franchise will provide all employees will maintain their continuing education credits (CEU’s). In some cases, the home health care agency franchise will provide these continuing education classes. The HCA Act will comply with an unannounced survey, or interview of the home health care agency.

Provide links to any relevant sources that will be useful as your learning team completes the paper.

Additional Links

http://www.homeinstead.com/about-us/Pages/About-Us.aspx
http://smallbusiness.chron.com

Organizational Performance Management Table for St. Joseph Outpatient
Research your chosen health care organization to complete this table. Then share it with your learning team as you collaborate to write your paper. Include your tables as appendixes to your paper.

Provide a name of or link to a specific organization. Summarize key products or services provided by the organization and identify the primary customers it serves.

Organization Overview

St. Joseph’s Outpatient Surgery Center: As an outpatient surgical center St. Joseph’s provides a broad range of outpatient surgical procedures including specialty areas like ENT,General,GI,Gynecology,Ophthalmology,Orthopedic,Pain,Plastic,Podiatry, and Urology. The facility is equipped with state of the art equipment and has 8 operation rooms and 2 treatment rooms. St. Joseph’s is open to all patients requiring outpatient surgical procedures.
http://sjosc.com/

Outline the overall content of the major regulations, accreditation requirements, and other standards that affect the organization. Provide the title, section, parts, or subparts, or the numbering system, etc. of the specific regulations or accreditation requirements. Response should be at least 100 words.

For example: Use of electronic signatures in electronic medical records is equivalent to handwritten signatures on paper; FDA regulation; Title 21 CFR Part 11, Subpart C, § 11.200 Electronic Signature: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?cfrpart=11

Organization Regulations, Accreditation, and Standards

Ambulatory surgery centers must be hold facility and state licensure. St. Joseph’s is accredited by The Joint Commission and fully licensed by the State of Arizona and Medicare certified (SJOSC, 2018). Ambulatory surgical center or ASC means any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission. The entity must have an agreement with CMS to participate in Medicare as an ASC and must meet the conditions set forth in Subpart B and C of this part. Regulatory surveys are done to ensure licensure and accreditation. Surveyors review compliance with state licensure law, governing body and management, surgical services, quality assessment and performance improvement, environment medical staff, and nursing services, medical records, pharmaceutical services, lab and radiologic services, patient rights, infection control, and patient admission, assessment, and discharge (CMS, 2015).

Highlight the effect of each organization’s regulations, accreditation requirements, and other standards on the risk management functions and activities. Response should be at least 100 words.

Effects on Risk Management

Outpatient surgery centers should perform periodic reviews of their strategies to ensure patient safety and reduce risks. Several measures ranging from proper patient selection to an effective informed consent process to a comprehensive credentialing program are key strategies to reducing risks to patients and managing patient expectations (Wallace & Quattrone, 2016). In patient selection the center should develop general rules and guidelines to ensure that there is uniformity of decision making with regard to patient selection and to ensure that poor candidates for ambulatory surgery are identified. Considering patient and family expectations is also necessary. It is important for patients to be informed of the nature, risk, and alternatives of their surgery to avoid unrealistic expectations and sign an informed consent. The delivery of anesthesia is a risk management concern in a surgical outpatient environment. Pre-anesthesia reviews are a must, as well as ensuring that all resources available at hospitals are available at the ambulatory center. Facilities should also adhere to policies to avoid liabilities in areas like credentialing, discharge, event reporting, and all other areas of risk including medical record keeping and patient confidentiality.

Specify components of performance-management systems—policies and procedures, self-audits, benchmarking, complaint management, corrective or preventive action, education and training, communication, and other mechanisms—to be used by the organization. Response should be at least 100 words.

Organizational Performance Management Systems

The following are elements of performance for an outpatient or ambulatory surgical center. The organization identifies safety and security risks associated with the environment. Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of annual proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts. In regards to medical equipment, the organization has a systematic approach to select and acquire medical equipment. Safety, operational, and functional checks of all equipment should be done. An Emergency management plan established by the organization’s leaders should also be in place.

Provide links to any relevant sources that will be useful as your learning team completes the paper.

Additional Links

CMS (2015). State operations manual. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_l_ambulatory.pdf
The Join Commission. (2010). Standards Sampler for ambulatory surgery centers. Retrieved from https://www.jointcommission.org/assets/1/18/ASC_Standards_Sampler.pdf
Wallace, C. L., & Quattrone, M. S. (2016). Risk management tips for ambulatory surgery centers. The Journal of Ambulatory Care Management, 30(2), 114.

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