Recommandé
Recommandé
Contenu connexe
Tendances
Tendances (20)
Similaire à Regulating Healthcare - Lecture A
Similaire à Regulating Healthcare - Lecture A (20)
Plus de CMDLearning
Plus de CMDLearning (20)
Dernier
Dernier (20)
Regulating Healthcare - Lecture A
- 1. Introduction to Health Care and Public Health in the U.S. Regulating Health Care Lecture a This material (Comp 1 Unit 6) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
- 2. Regulating Health Care Learning Objectives - 1 • Describe the role of accreditation, regulatory bodies, and professional associations in health care in the U.S. (Lecture a) • Describe the basic concepts of law in the United States: the legal system, sources of law, classification of laws, the court system, and the trial process. (Lecture b) 2
- 3. Regulating Health Care Learning Objectives - 2 • Describe legal aspects of medicine involving the Affordable Care Act, professional standards in health care, medical malpractice, tort reform, and Medicare and Medicaid fraud and abuse (Lecture c) 3
- 4. Regulating Health Care Learning Objectives - 3 • Describe key components of the Health Insurance Portability and Accountability Act (HIPAA) and describe efforts to promote patient safety in the U.S. (Lecture d) • Discuss the need for quality clinical documentation for the use of the health record as a legal document, communication tool and a key to prove compliance for health care organizations. (Lecture e) 4
- 5. Accreditation, Regulation, and Professional Associations • Nonprofit Accrediting Organizations – The Joint Commission (TJC) – URAC (formerly called Utilization Review Accreditation Commission) – National Committee for Quality Assurance (NCQA) • Regulatory Agencies – Food and Drug Administration (FDA) • Professional Associations 5
- 6. TJC History - 1 • 1910: The forerunner of TJC was called the “end-result” system • 1951: Joint Commission on Accreditation of Hospitals (JCAH) is created and starts accrediting health care organizations • 1987: JCAH changed its name to Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 6
- 7. TJC History - 2 • 2007: Name simplified to The Joint Commission (TJC); currently accredits and certifies nearly 21,000 organizations and programs in the USA • 1994: Joint Commission International (JCI) offers an international accreditation and has touched more than 90 countries since then. 7
- 8. TJC’s Mission Statement • “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” (The Joint Commission, 2016) 8
- 9. TJC Accreditation - 1 • TJC accreditation signifies an organization meets TJC’s standards for patient care • Accreditation is earned by an entire health care organization (hospital, nursing home, office-based surgery practice, etc.) • Procedure manual: emergency management, environment of care, HR, infection prevention and control 9
- 10. TJC Accreditation - 2 • Tools TJC uses to measure performance – Integrated Survey Process (ISP): An in-person visit to evaluate performance across an organization – Outcome Research Yields Excellence (ORYX): System for health care organizations to report information to TJC about patients with certain conditions (core measure sets) o The core measure sets reported depend on the type and size of the organization 10
- 11. ORYX: Core Measure Sets - 1 • Examples – Heart attack – Pneumonia – Inpatient psychiatric care – Children’s asthma – Stroke 11
- 12. ORYX: Core Measure Sets - 2 • Specific performance measures are associated with each core measure set – For example, the TJC looks at whether children with asthma received certain drugs in the hospital and were sent home with a management plan 12
- 13. TJC Certification • TJC-accredited organizations and providers of health care staffing services can also earn certification for specific programs or services – For chronic diseases and conditions o Examples: asthma, diabetes, heart failure programs – Programs can be within the medical center or in the community 13
- 14. TJC Patient Safety Activities • National Patient Safety Goals • Universal Protocol • Office of Quality Monitoring • Speak Up™ Program • Sentinel Event Policy 14
- 15. Nonprofit Accrediting Organizations • The Joint Commission • URAC, formerly the Utilization Review Accreditation Commission 15
- 16. URAC • Mission: “To promote continuous improvement in the quality and efficiency of healthcare management through processes of accreditation, education, and measurement” • Has more than 30 accreditation and certification programs for various types of health care organizations 16
- 17. URAC Privacy & Security Accreditation - 1 • Outlines best practices for maintaining privacy and security of health information • Allows organizations to demonstrate compliance with privacy and security requirements specified by: – Health Insurance Portability and Accountability Act (HIPAA) – Health Information Technology for Economic and Clinical Health Act (HITECH) • See http://www.urac.org 17
- 18. URAC Privacy & Security Accreditation - 2 • These health care organizations must comply with HIPAA: – Health plans: Health insurance companies, employer-funded health plans, and government programs that pay for health care, such as Medicare or Medicaid – Health care providers that conduct certain tasks electronically – Health care clearinghouses (organizations that process health information) 18
- 19. The National Committee for Quality Assurance (NCQA) • Accreditation body for: – Health plans – Health plan contracting organizations – Accountable Care Organizations – Accreditation process includes assessments of clinical performance and consumer experience o Healthcare Effectiveness Data and Information Set (HEDIS) o Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey 19
- 20. Regulatory Agencies • Under the authority of Congress, federal agencies enforce standards in a specific field in the private sector • Agencies create regulations, known as “rules”, to carry out public policy • The goal is consumer protection. Example: Food and Drug Administration (FDA) 20
- 21. FDA Overview • Categories of FDA regulated products: 6.1 Figure: As part of Department of Health and Human Services, the FDA is charged with oversight of these areas. (FDA, 2016) 21
- 22. FDA Mission • Protect public health – Regulates drugs o Performs drug approvals o Provides drug safety information o Spreads the message about medication errors – Helps speed up product innovations – Helps public obtain accurate, science-based information 22
- 23. Centers for Medicare & Medicaid Services (CMS) • Under U.S. Department of Health & Human Services • CMS regulates reimbursement for health care products and services, including: – Medicare – Medicaid – Children’s Health Insurance Program (CHIP) 23
- 24. CMS - Medicare • Federally funded health care program for individuals who: – Are over age 65 – Are under age 65 with certain disabilities – Have permanent kidney failure requiring dialysis or transplant 24
- 25. CMS – Medicaid and CHIP • Medicaid and CHIP provide health care for low income adults and children. – Programs are administered by individual states 25
- 26. Office of the National Coordinator for Health Information Technology (ONC) • ONC a federal entity within the Department of Health & Human Services • Coordinates nationwide efforts to implement and use electronic health records • Promotes the exchange of electronic health information across care settings 26
- 27. Professional Associations - 1 • Nonprofit organizations that support: – A particular profession – The interests of individuals engaged in that profession o Physicians o Hospital administrators – The public interest 27
- 28. Professional Associations - 2 • Sets requirements: – For entry into the profession o May require license or certificate – For maintaining membership in the profession • Members generally have a significant amount of education, training, or experience 28
- 29. American Board of Medical Specialties (ABMS) - 1 • Mission: “to serve the public and the medical profession by improving the quality of health care through setting professional standards for lifelong certification in partnership with Member Boards.” • Board certification differs from licensure, which sets minimum competency for physicians 29
- 30. American Board of Medical Specialties (ABMS) - 2 • Member boards certify specialist physicians – Also subspecialists; for example, adolescent medicine is a subspecialty of family medicine 30
- 31. American Hospital Association (AHA) • Nearly 5,000 organizational members • 43,000 individual members • Major programs – Advocacy o Lobbying and media campaigns to influence political and economic policies – Resource center o Database of information on health planning and admin. – Annual survey of U.S. hospitals – Reports and studies 31
- 32. American Medical Association (AMA) • Nearly 225,000 members – Physicians with an MD or DO degree, or a recognized international equivalent – Resident physicians and fellows – Medical students • Major programs – Resources for physicians – Advocacy – Publishing medical journals 32
- 33. American Nurses Association (ANA) • Nonprofit professional organization that represents the interests of the USA’s 3.4 million registered nurses • Focus areas – Fostering high standards of nursing practice – Promoting a safe and ethical work environment – Bolstering the health and wellness of nurses – Advocating for nurses and the public 33
- 34. Regulating Health Care Summary – 1 – Lecture a • Hospitals and other health care organizations are accredited by TJC • TJC also certifies specific health care programs and conducts patient safety activities • URAC accredits and certifies a wide range of health care organizations, and it has an accreditation program for IT professionals 34
- 35. Regulating Health Care Summary – 2 – Lecture a • Regulatory agencies such as the FDA protect consumers by setting and enforcing standards • Professional associations establish standards for their members to enhance the safety and quality of health care 35
- 36. Regulating Health Care References – 1 – Lecture a References American Board of Medical Specialties. http://www.abms.org. Accessed January 26, 2017. American Hospital Association. http://www.aha.org. Accessed January 26, 2017. American Medical Association. http://www.ama-assn.org. Accessed January 26, 2017. Center for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Medicare- General-Information/MedicareGenInfo/index.html. Accessed January 26, 2017. Medicaid. https://www.medicaid.gov/. Accessed January 26, 2017. Office of the National Coordinator. https://www.healthit.gov/newsroom/about-onc. Accessed January 26, 2017. Robeznieks A. AMA saw membership rise 3.2% in 2012. May 9, 2013. http://www.modernhealthcare.com/article/20130509/NEWS/305099950. Accessed January 26, 2017. Regulatory agency (definition). Encyclopedia Britannica. http://www.britannica.com/EBchecked/topic/496265/regulatory-agency. Accessed January 26, 2017. 36
- 37. Regulating Health Care References – 2 – Lecture a References The Joint Commission. http://www.jointcommission.org/facts_about_the_joint_commission/ Accessed January 26, 2017. The Joint Commission International. http://www.jointcommissioninternational.org/about- jci/who-is-jci/. Accessed January 26, 2017. U.S. Department of Health & Human Services. Health information privacy. http://www.hhs.gov/hipaa/index.html. Accessed January 26, 2017. U.S. Food and Drug Administration. http://www.fda.gov. Accessed January 26, 2017. URAC. http://www.urac.org. Accessed January 26, 2017. Charts, Tables, Figures Figure 6.1: Part of Department of Health and Human Services, charged with oversight of the areas displayed. http://www.fda.gov/. Accessed January 26, 2017. 37
- 38. Introduction to Health Care and Public Health in the U.S. Regulating Health Care Lecture a This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. 38
Notes de l'éditeur
- Welcome to Introduction to Health Care and Public Health in the U.S.: Regulating Health Care. This is lecture a. The component, Introduction to Health Care and Public Health in the U.S., is a survey of how health care and public health are organized and how services are delivered in the U.S. It covers public policy, relevant organizations and their interrelationships, professional roles, legal and regulatory issues, and payment systems. It also addresses health reform initiatives in the U.S.
- The learning objectives for Regulating Health Care are to: Describe the role of accreditation, regulatory bodies, and professional associations in health care in the U.S. Describe the basic concepts of law in the U.S.: the legal system, sources of law, classifications of laws, the court system, and the trial process
- Describe legal aspects of medicine involving the Affordable Care Act, professional standards in health care, medical malpractice, tort reform, and Medicare and Medicaid fraud and abuse.
- Describe key components of the Health Insurance Portability and Accountability Act, or HIPAA, and current issues concerning privacy and patient safety in the U.S. And discuss the need for quality clinical documentation for use of the health record as a legal document, communication tool, and a key to prove compliance for health care organizations.
- In this lecture, we’ll describe health care accreditation bodies, regulatory agencies, and professional associations. We’ll begin by reviewing three nonprofit groups that accredit health care organizations. These are The Joint Commission, or TJC, URAC, which was originally known as the Utilization Review Accreditation Commission, and the National Committee for Quality Assurance or NCQA. The following discussion will concern regulatory agencies, including the Food and Drug Administration, or FDA, a consumer protection agency that approves and regulates drugs and medical devices. Finally, professional associations will be considered in terms of their role in boosting the quality of the medical profession.
- This slide reviews the history of TJC, a nonprofit accrediting organization. More than 100 years ago, a medical doctor proposed a system to promote hospital reform based on outcomes management in patient care. It was called the “end-result” system. Under this system, hospitals tracked all of their patients long enough to determine whether the hospital treatment was effective. If it was not, hospital officials attempted to determine why, so similar cases could be treated successfully in the future. This model of continuing to study and improve medical outcomes formed the basis for TJC, which accredits and certifies nearly 21,000 health care organizations and programs in the United States. The vision of TJC, is that: “All people always experience the safest, highest quality, best-value health care across all settings.” In 1951, the Joint Commission on Accreditation of Hospitals was formed and begins accrediting health care organizations. In 1987, their name changed to the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO. Many health care professionals are in the habit of using this name, so it is helpful to know this history.
- In 2007, JCAHO simplified its name to The Joint Commission, or TJC. In 1994, TJC founded Joint Commission International or JCI, which identifies, measures, and shares best practices in quality and patient safety across the world. To date, JCI has touched more than 90 countries.
- Linked to TJC’s vision is its mission statement: “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.”
- TJC performs two functions to keep patients safe. Achieving accreditation signifies that an organization meets TJC’s standards for patient care. Accreditation is earned by an entire health care organization, such as a hospital or a long term care facility. Each organization accredited by TJC has to follow a procedure manual customized for that type of organization. Sample topics in the manual include emergency management, environment of care, human resources, and infection prevention and control.
- The Joint Commission collects data for accreditation through on-site surveys and performance measurement. The Integrated Survey Process, or ISP, is an on-site survey that usually lasts at least three days and involves extensive meetings between TJC’s survey team and leaders of the health care organization being accredited. Secondly, TJC requests that organizations submit data through a performance measurement system known as Outcome Research Yields Excellence, or ORYX. This tool is directly relevant to information technology professionals. Hospitals are required to collect and transmit data to TJC about patients with certain conditions. Treatments for these conditions are considered core measures of the health care organization’s performance and improvement.
- A hospital might choose to provide data on various medical conditions, such as heart attack, or acute myocardial infarction, pneumonia, psychiatric care, children’s asthma, or stroke.
- For each of these conditions, TJC requires the hospital to report on certain performance measures. For example, if a child is treated for asthma, the hospital must report whether certain drugs were given and whether the child was sent home with a management plan.
- The second main function of TJC is certification. Certification is a designation that specific criteria, deemed essential to the provision of specific health care services, are in place. Any health care organization and any provider of health care staffing services can earn certification for programs or services that address certain chronic diseases. A chronic disease is one that exists over the long term, such as diabetes. Programs eligible for certification may be located within a medical center or in the community.
- Patient safety is also a major focus of TJC. The National Patient Safety Goals program has created lists of tips for health care professionals to follow to prevent errors. For example, before administering a medication, a nurse should make sure he or she is administering medication to the correct patient by identifying the patient in two different ways, such as by name and birth date. The Universal Protocol is a standard procedure for surgery teams to follow to avoid performing the wrong procedure, operating on the wrong body site, or even operating on the wrong person. Some of the steps include marking the correct site and taking a “time out” before surgery, when the team pauses to take stock and agree that their plans are appropriate. The Joint Commission’s Office of Quality Monitoring is interested in the details of patient complaints. It does not resolve complaints, but it uses information from patients to identify possible noncompliance with accreditation or certification standards. The Speak Up program encourages patients to help prevent medical errors by asking questions, educating themselves, and actively participating in their treatment. Finally, TJC reviews how health care organizations respond to sentinel events. That term refers to an unexpected death, an unexpected serious physical or psychological injury, or the risk of such an event. These events need immediate investigation and response.
- The second major nonprofit accrediting organization is URAC, which, as mentioned earlier, was originally chartered as the Utilization Review Accreditation Commission.
- Its mission is “To promote continuous improvement in the quality and efficiency of health care management through processes of accreditation, education, and measurement.” URAC is one of the fastest growing health care accreditation agencies, with more than 30 programs addressing multiple aspects of health care, including health care management, health care operations, health plans, pharmacy quality management, and providers. The accreditation process includes a review of policies and procedures, plus an on-site visit to the organization to determine that it is operating according to its stated policies and national standards. In recent years, URAC has established an accreditation for accountable care organizations. Accountable care organizations, known as ACOs, are health care organizations characterized by a payment and care delivery model that ties payment to quality metrics to achieve reduced cost of care for an assigned population of patients. URAC has more than 30 accreditation and certification programs for various types of health care organizations.
- URAC offers privacy and security accreditation for health care organizations. This accreditation allows organizations to demonstrate that they are using the policies and procedures necessary to protect individual’s health information and comply with privacy and security requirements specified within HIPAA, and within the Health Information Technology for Economic and Clinical Health act, or HITECH act. The HITECH Act extends HIPAA privacy and security requirements to third-party organizations that have access to electronic health information.
- Three groups in the health care market must comply with HIPAA requirements. These are: Health plans, such as health insurance companies; company health plans; and Medicare and Medicaid. Most health care providers must comply, assuming that they conduct certain tasks electronically. The other group that must observe HIPAA regulations is health care clearinghouses, which are organizations that process health information. HIPAA will be covered in more depth later in this unit.
- The National Committee for Quality Assurance, or NCQA, is a non-profit organization focused on improving health care quality. NCQA offers accreditation for health plans, health plan contracting organizations that provide disease management and other services, and accountable care organizations. The NCQA accreditation process includes an assessment of both clinical performance and consumer experience. The NCQA Healthcare Effectiveness Data and Information Set, known as HEDIS, assesses clinical performance through measurements of health care quality. The Consumer Assessment of Healthcare Providers and Systems Survey, known as CAHPS, invites consumers to report on their experiences in obtaining health care services through their health plan.
- Another group of organizations that help keep the public safe are regulatory agencies. A regulatory agency is a public authority at the state or federal level that is established by legislative act to enforce standards in a specific field in the private sector. An agency’s rules have the force of law, and an agency can also act somewhat like a trial court, with the authority to conduct hearings and hand down judgments. In the United States, health care focused agencies are part of the Department of Health and Human Services, or HHS. The goal of agencies within HHS is to promote health and provide consumer protection. In the health care field, the best-known example is the Food and Drug Administration, or FDA.
- The FDA is a regulatory agency. It oversees the safety of eight categories of products: food; drugs; medical devices; vaccines, blood and biologic products; animal feed and veterinary drugs; cosmetics; radiation-emitting products; and tobacco products.
- The FDA takes numerous actions to protect the public’s health. First and foremost, it regulates drugs by performing drug approvals, providing drug safety information, and alerting the public to actual and potential medication errors. It also helps drug companies and medical device companies speed up the development of new products. Finally, the FDA helps Americans get the accurate information they need in order to use medicines, devices, and foods to improve their health.
- The Centers for Medicare and Medicaid Services, or CMS, is an agency within the U.S. Department of Health and Human Services responsible for the administration of several key federal health care programs. CMS regulates reimbursement for the provision of health care products and services for Medicare, Medicaid, and the Children’s Health Insurance Program, also known as CHIP.
- Medicare is a federally funded health care program for individuals over 65 years of age, under 65 with certain disabilities, and individuals of all ages with permanent kidney failure that requires dialysis or a kidney transplant.
- Medicaid and CHIP are programs designed to provide health care for low income adults and children. Both Medicaid and CHIP are administered by individual states within the USA.
- The Office of the National Coordinator, commonly known as ONC, was established through an Executive Order in 2004, and was legislatively mandated in the Health Information Technology for Economic and Clinical Health, or HITECH, Act of 2009. ONC is the office within the Department of Health and Human Services that coordinates nationwide efforts to promote the adoption of electronic health records and to promote the electronic exchange of health information between care providers.
- Professional associations are another group of organizations that work to keep health care safe. A professional association is a nonprofit organization of people who want to support a particular profession, the interests of individuals in that profession such as physicians or hospital administrators, and the interests of the public.
- Most professional associations set requirements for entry into the profession and for maintaining membership. These requirements may include a license or certificate from a state or private authority. In most cases, entry and maintenance requirements are significant and involve testing, training, experience, and continuing education. This lecture discusses four associations that are prominent in the health care field: the American Board of Medical Specialties, the American Hospital Association, the American Medical Association, and the American Nursing Association.
- The American Board of Medical Specialties, or ABMS works in collaboration with 24 specialty Member Boards to maintain the standards for physician certification. The mission of the ABMS is to serve the public and the medical profession by improving the quality of health care through setting professional standards for lifelong certification in partnership with Member Boards. Through the ABMS, physicians can become certified as a specialist in one or more fields. For example, if a physician is “board-certified in pediatrics,” this indicates that the physician has expertise in that field. This is different from a doctor’s state license, which sets the minimum competency required to practice in the state.
- Some doctors also become certified in subspecialties. For example, adolescent medicine is a subspecialty of family medicine.
- The vision of the American Hospital Association, or AHA, is of “a society of healthy communities where all individuals reach their highest potential for health.” The AHA has nearly 5,000 organizational members, including hospitals, health care systems, networks, and other providers. It also has 43,000 individual members. A major emphasis of the AHA is advocacy, which means working to influence political and economic policies through activities such as lobbying and media campaigns. The AHA also provides an extensive resource center, a database of information about health planning and administration, an annual survey of U.S. hospitals, and other reports and studies.
- The mission of the American Medical Association, or AMA, is to promote the art and science of medicine and improve public health. There are close to 225,000 members, primarily comprised of physicians who have a U.S. doctor of medicine degree, a U.S. doctor of osteopathic medicine degree, or a recognized international equivalent. Also eligible for membership are resident physicians and fellows, who have their medical degree but are still in training, and medical students. Major activities of the AMA include educating physicians, advocating for the medical profession, and publishing medical journals.
- The American Nurses Association, or ANA, is a nonprofit organization which represents the interests of the nation’s three point four million registered nurses. The ANA’s areas of focus are: Fostering high standards of nursing practice Promoting a safe and ethical work environment Bolstering the health and wellness of nurses Advocating on health care issues that affect nurses and the public
- This concludes lecture a of Regulating Health Care. In summary, hospitals and other health care organizations are accredited by The Joint Commission, or TJC. TJC also certifies specific health care programs and conducts patient safety activities. URAC accredits and certifies a wide range of health care organizations, and it has an accreditation program for IT professionals.
- Regulatory agencies such as the FDA protect consumers by setting and enforcing standards. Professional associations establish standards for their members to enhance the safety and quality of health care.
- References slide. No audio.
- References slide. No audio.
- No Audio.