This paper will propose how TriCity Medical Center will monitor performance, achieve regulatory and accreditation compliance, and improve overall organizational performance. It will describe ways TCMC will communicate with leadership to ensure alignment of organizational goals and gain buy-in from staff to achieve compliance with the standards and requirements issued by regulatory and accreditation bodies. Also it will determine how compliance with the regulations and development of risk- and quality-management systems for the organization contributes to the organization’s overall performance-management system.
About & Similarities The similarities between Promise Hospital and Tri City Medical Center, is to provide “patient care” ranging from long term and mental conditions as well as acute care. While the three organizations specifically cater to a particular need, ultimately, quality of life is its main objective. However, it does have several differences. Tri City Medical Center, for example, provides a wide range of medical capabilities, from acute to chronic care.
It has full surgical range with an intensive care unit. Acute care services range from emergency care to post surgical recovery and other short-term medical condition. Sharp Mesa Vista also provides a wide range of healthcare services. In particular, the Mental Healthcare facility provides services regarding substance abuse, depression, anxiety, schizophrenia, eating and behavioral disorders. It caters to adults, children, and adolescents while providing both cognitive and dual recovery treatment.
Lastly, Promise Hospital, a long term care facility, provides care to those who are not able to care for themselves and for an indefinite amount of time, for example; individuals that are in renal failure and will require dialysis, or life support. These needs are best suited in a facility that have the necessary equipment and staff support. TriCity Medical Center is a full-service, acute-care hospital with two advanced clinical institutes and physicians practicing in 60 specialties. TCMC is a Gold Seal Approved facility in
North San Diego County serving Carlsbad, Oceanside, Vista and surrounding areas. TCMC is a community owned healthcare facility, owned and operated, with 397 beds and over 500 physicians. Key products and services provided at TriCity Medical Center include: Heart Care, Orthopaedics, Robotic Surgery, Emergency Services, Woman’s Care and Cancer treatment, 24-hour inpatient care, including the following basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services.
TCMC provides services to the insured and uninsured. Monitoring performance, regulatory and accreditation compliance, and improving organizational performance Although all three organizations have differences, monitoring performance can be assessed in the same manner. By implementing a program, like that of suggested by the Mayo Clinic, to gather a streamline of data, streamline planning, modeling, forecasting, and productivity can be achieved (Accreditation and Regulatory Standards: Mayo Clinic, 2013).
Next, real time control can observe the organization’s current and future situation. This solution can be applied to prevent patient flow congestion, which will affect the quality of care and performance. Lastly, data archiving can account for patterns to better identify cost management, revenue opportunities, and resource allocation based on needs. These performance management programs through data monitoring, effective decision-making, and data archiving can greatly improve performance and quality.
To achieve regulatory and accreditation compliance, quality and risk management must ensure full cooperation of all staff members. To aid in this, at times, difficult task, the Healthcare Compliance Association will warrant the necessary resources. According to the Healthcare Compliance Association (2013), “HCCA exists to champion ethical practice and compliance standards in all organizations and to provide the necessary resources for compliance professionals and others who share these principles” (para 1).
A system of checks and balance must be performed to maintain efficiency and productivity that can only be achieved through regulatory and accreditation programs. Outcome based processes geared towards improving outcomes by implementing performance improvement checks on all complaints or negative feedback acquired from patients, healthcare providers, employees, vendors (all stakeholders) and environment of care rounds. These would include QC measures, infectious control measures, ACC measures, HCAP measures to name a few.
Align with nationally recognized locators for healthcare facilities to compare our organization with local and nationally recognized healthcare organizations to see where we rank. Strategic goals established by The Joint Commission and initiatives by CMS will help improve overall performance. The Joint Commission has targeted solution tools (TST) applicable to the Joint Commission standards and National Patient Safety Goals covering; value-based purchasing/pay for performance (P4P), healthcare-acquired conditions, hospital readmissions, risk reduction, staff education.
There are more tools The Joint Commission provides which are: Leading Practice Library, Standards BoosterPak, Core Measure Solution Exchange, Portals:HAI, High Reliability, and Trasitions of Care, FSA and Intracycle Monitoring Process, Sentinel Event Alert, Speak up Program. Targeted Solutions Tool (TST) and Center for Transforming Healthcare “The TST is a unique online tool that can help accurately measure your organization’s performance around complex quality and safety problems, identify barriers to excellent performance, and direct your team to proven solutions that are customized to address your organization’s specific barriers.
The Joint Commission Center for Transforming Healthcare provides targeted solutions to help solve health care’s complex problems, including hand hygiene, wrong site surgery, and hand-off communications” (The Joint Commission, 2013). Leading Practice Library “The Leading Practice Library is a collection of real-life solutions that have been successfully implemented by organizations. Solutions address such areas as assessing suicide risk, anesthesia orders, and patient turning schedules” (The Joint Commission, 2013). Standards BoosterPak A searchable document that provides detailed information about a standard or National Patient Safety Goals area, including evidence, rationale, references, and FAQs. Topics include medication labeling and storage, suicide prevention, laboratory specimen collection and handling, and focused and ongoing professional practice evaluations” (The Joint Commission, 2013). Core Measure Solution Exchange “A database of success stories from accredited hospitals that have attained excellent performance on core measures – including accountability measures.
Learn how hospitals that are Top Performers achieve this status. Core measure sets cover heart attack, heart failure, pneumonia, surgical care, children’s asthma care, hospital-based inpatient psychiatric services, stroke, and venous thromboembolism” (The Joint Commission, 2013). Portals: HAI, High Reliability and Transitions of Care “Online portals are available on health care-associated infections, high reliability, and transitions of care. These portals serve as a virtual repository of valuable resources from throughout The Joint Commission.
Access: HAI Portal – http://www. jointcommission. org/hai. aspx High Reliability Portal – http://www. jointcommission. org/highreliability. aspx Transitions of Care Portal – http://www. jointcommission. org/toc. aspx” (The Joint Commission, 2013). Focused Standards Assessment (FSA) and Intracycle Monitoring Process “The FSA (which replaces the Periodic Performance Review or PPR) focuses on the organization’s assessment of its standards compliance combined with The Joint Commission’s knowledge of high risk areas that are critical to patient safety and quality.
The new Intracycle Monitoring process focuses on a number of activities to help identify risk points in health care organizations along with resources for addressing patient safety and quality problems” (The Joint Commission, 2013). Sentinel Event Alert “A periodic newsletter that highlights strategies that health care organizations can take to address patient safety risks. Examples of topics are addressing health care worker fatigue, radiation safety, preventing wrong site surgery, and safe use of opioids” (The Joint Commission, 2013).
Speak Up program “Speak Up is a patient safety education program that includes brochures, animated videos and posters that are available for free download. Brochures are easy-to-read and available in English and Spanish. Videos are also available in English and Spanish. Topics include infection control, surgical safety, medications, medical tests, patient rights, pain management, child safety, falls, diabetes, dialysis, breastfeeding, and stroke” (The Joint Commission, 2013).
CMS has 41 models that include initiatives, which test various payments, and service delivery models that aim to achieve better care for patients, better health for our communities, and lower costs through improvement for our health care system (“Cms Centers For Medicare & Medicaid Services”, 2013). Communication to align organizational goals, buy-in from staff to achieve compliance with the standards and requirements To ensure the alignment goals and gain buy-in from staff to achieve compliance with the standards and requirements issued by the regulatory and accreditation bodies is to have an open line of communication.
Without this single element, all is lost. Communication only works if the intended message is successfully passed on, with a clear interpretation from the receiver, and feedback is given back to the sender. The various services in healthcare such as, mental health, long term care, and acute care, communication between the chain of command and down to the main workforce cannot be broken. With this concept, the goals of the organization can be reached. The Studer Program is a common leadership development used, which embraces the all-in concept and open communication.
This system is used to align the goals of the organization and assist in achieving buy-in from staff. This will in turn help achieve compliance with all standards and requirements as well as increase quality and reduce risk. Compliance with regulations and development of risk- and quality-management systems contributes to the organization’s performance-management system Policies and procedures are implemented to help ensure the goals of the organization are understood and achieved. The goals of the organization are aligned with the mission or vision of the healthcare organization.
The risk management system is put into place to help reduce the likelihood of not achieving the goals and getting off track of the main mission as well as reduce the risk to the facility. Risk is reduced and can eliminate fines, fee’s lawsuits, harm to the reputation and many other negative outcomes. Performance management systems for healthcare facilities key points encompass a stringent risk management program as well as: quality improvement processes (use data for decisions to improve policies, programs and outcomes.
Manage changes, create a learning organization), performance measurement (refine indicators and define measures, develop data systems, collect data), performance standards (identify relevant standards, select indicators, set goals and targets, communicate expectations), reporting of progress (analyze data, feed data back to managers, staff, policy makers, and constituents. Develop a regular reporting cycle).