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Section 2 : Organization Functions


Improving Organization Performance Leadership Management of the Environment of Care Management of Human Resources Management of Information Improving Organization ... – PowerPoint PPT presentation

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Title: Section 2 : Organization Functions

Section 2 Organization Functions
  • Improving Organization Performance
  • Leadership
  • Management of the Environment of Care
  • Management of Human Resources
  • Management of Information

Improving Organization Performance
  • Overview

Improving Organization Performance
  • Performance Improvement Focus

Improving Organization Performance
  • Reducing Factors That Contribute To Unanticipated
    Adverse Events And/Or Outcomes.

Improving Organization Performance
  • ?Recognizing and acknowledging risks
  • ?Initiating actions to reduce these risks
  • ? Reporting internally on risk reduction
  • ? Focusing on processes and systems
  • ?Minimizing individual blame or retribution

Improving Organization Performance
  • ? Investigating factors that contribute to
    unanticipated adverse events and sharing that
    acquired knowledge both internally and with other

Improving Organization Performance
  • ? Measuring performance through data collection
  • ? Assessing current performance
  • ? Improving performance

Improving Organization Performance
  • PI.1.10 The hospital collects data to monitor its
  • PI.2.10 Data are systematically analyzed.
  • PI.2.20 Undesirable patterns in performance
  • PI.2.30 Processes are defined and implemented.

Improving Organization Performance
  • PI.3.10 Make changes that improve performance.
  • PI.3.20 An ongoing, proactive program for
    identifying and reducing unanticipated adverse
    events and safety risks to patients is defined
    and implemented.

  • Overview
  • ? Governance

  • ? Management.
  • ?Planning, designing, and providing services.

  • ? Improving safety and quality of care.

  • ? Use of clinical practice guidelines.

  • ? Teaching and coaching staff.

  • LD.1.10 The hospital identifies how it is
  • LD.1.20 Governance responsibilities are defined
    in writing, as applicable.
  • LD.1.30 The hospital complies with applicable law
    and regulation.
  • LD.2.10 An individual(s) is responsible for
    operating the hospital according to the authority
    conferred by governance.
  • LD.2.20 Each organizational program, service,
    site, or department has effective leadership.

  • LD.2.50 The leaders develop and monitor an annual
    operating budget and, as appropriate, a long-term
    capital expenditure plan.
  • LD.3.10 The leaders engage in both short-term and
    long-term planning.
  • LD.3.15 The leaders develop and implement plans
    to identify and mitigate impediments to efficient
    patient flow throughout the hospital.
  • LD.3.20 Patients with comparable needs receive
    the same standard of care, treatment, and
    services throughout the hospital.

  • LD.3.30 A hospital demonstrates a commitment to
    its community by providing essential services in
    a timely manner.
  • LD.3.50 Services provided by consultation,
    contractual arrangements, or other agreements are
    provided safely and effectively.
  • LD.3.60 Communication is effective throughout the

  • LD.3.70 The leaders define the required
    qualifications and competence of those staff who
    provide care,
  • LD.3.80 The leaders provide for adequate space,
    equipment, and other resources.
  • LD.3.90 The leaders develop and implement
    policies and procedures for care, treatment, and

  • LD.3.110 The hospital implements policies with
    the medical staffs participation for procuring
    and donating organs and other tissues.
  • LD.3.120 The leaders plan for and support the
    provision and coordination of patient education
  • LD.3.130 Academic education is arranged for
    children and youth, when appropriate.
  • LD.3.140 In hospitals that do not primarily
    provide psychiatric or substance abuse services,
    a written plan clearly defines the care,
    treatment, and services or appropriate referral
    of patients who are emotionally ill

  • LD.3.150 The hospital plans for the appropriate
    care, treatment, and services of patients under
    legal or correctional restrictions.
  • LD.4.10 The leaders set expectations, plan, and
    manage processes to measure, assess, and improve
    the hospitals governance, management, clinical,
    and support activities.
  • LD.4.20 New or modified services or processes are
    designed well.

  • LD.4.40 The leaders ensure that an integrated
    patient safety program is implemented throughout
    the hospital.
  • LD.4.50 The leaders set performance improvement
    priorities and identify how the hospital adjusts
    priorities in response to unusual or urgent
  • LD.4.60 The leaders allocate adequate resources
    for measuring, assessing, and improving the
    hospitals performance and improving patient
  • LD.4.70 The leaders measure and assess the
    effectiveness of the performance improvement and
    safety improvement activities.

  • LD.5.10 The hospital considers clinical practice
    guidelines when designing or improving processes,
    as appropriate.
  • LD.5.20 When clinical practice guidelines are
    used, the leaders identify criteria for their
    selection and implementation.
  • LD.5.30 Appropriate leaders, practitioners, and
    health care professionals in the hospital review
    and approve clinical practice guidelines selected
    for implementation.
  • LD.5.40 The leaders evaluate the outcomes related
    to use of clinical practice guidelines

Management of the Environment of Care
  • Overview
  • The goal of this function is to provide a safe,
    functional, supportive, and effective environment
    for patients, staff members, and other
    individuals in the hospital. This is crucial to
    providing quality patient care, achieving good
    outcomes, and improving patient safety.

Management of the Environment of Care
  • Performing strategic and ongoing master planning
  • Educating staff about the role of the environment
    in safely, sensitively, and effectively
    supporting patient care
  • Developing standards to measure staff and
    hospital performance in managing and improving
    the environment of care

Management of the Environment of Care
  • Implementing plans to create and manage the
    hospitals environment of care.

Management of the Environment of Care
  • Efficient layouts that support staffing and
    overall functional operation

Management of the Environment of
Care Standards

Management of the Environment of Care Occupancy
  • Health care occupancy.
  • Ambulatory health care occupancy.
  • Business occupancy.

Management of the Environment of Care Notes
  • Note 1 The standards in this chapter do not
    prescribe any particular structure
  • Note 2 The standards do not require the
    Statement of Conditions compliance document to
    be completed by anyone other than an employee of
    the hospital.

Management of the Environment of Care
  • Note 3 The standards in this chapter require
    each hospital to develop a written plan for the
  • 1. Safety management (EC.1.10)
  • 2. Security management (EC.2.10)
  • 3. Hazardous materials and waste management
  • 4. Emergency management (EC.4.10)
  • 5. Fire safety (EC.5.10)
  • 6. Medical equipment management (EC.6.10)
  • 7. Utilities management (EC.7.10)

Management of the Environment of Care
  • Planning and Implementation Activities
  • EC.1.10 The hospital manages safety risks.
  • EC.1.20 The hospital maintains a safe
  • EC.1.30 The hospital implements a policy to
    prohibit smoking except in specified
  • EC.2.10 The hospital identifies and manages its
    security risks.
  • EC.3.10 The hospital manages its hazardous
    materials and waste risks.

Management of the Environment of Care
  • EC.4.10 The hospital addresses emergency
  • EC.4.20 The hospital conducts drills regularly to
    test emergency management.
  • EC.5.10 The hospital manages fire safety risks.
  • EC.5.20 Newly constructed and existing
    environments of care are designed and maintained
    to comply with the Life Safety Code.

  • EC.5.30 The hospital conducts fire drills
  • EC.5.40 The hospital maintains fire-safety
    equipment and building features

Management of the Environment of Care
  • EC.5.50 The hospital protects occupants during
    periods when a building does not meet the
    applicable provisions of the Life Safety Code.
  • EC.6.10 The hospital manages medical equipment
  • EC.6.20 Medical equipment is maintained, tested,
    and inspected.
  • EC.7.10 The hospital manages its utility risks.
  • EC.7.20 The hospital provides a reliable
    emergency electrical power source.

Management of the Environment of Care
  • EC.7.30 The hospital maintains, tests, and
    inspects its utility systems.
  • EC.7.40 The hospital maintains, tests, and
    inspects its emergency power systems.
  • EC.7.50 The hospital maintains, tests, and
    inspects its medical gas and vacuum systems.
  • EC.8.10 The hospital establishes and maintains an
    appropriate environment.
  • EC.8.30 The hospital manages the design and
    building of the environment when it is renovated

Management of the Environment of Care
  • Measuring and Improving Activities
  • EC.9.10 The hospital monitors conditions in the
  • EC.9.20 The hospital analyzes identified
    environment issues and develops recommendations
    for resolving them.
  • EC.9.30 The hospital improves the environment.

Management of Human Resources
  • Overview

Management of Human Resources
  • ? Providing an adequate number of staff.
  • ? Providing competent staff.
  • ? Orienting, training, and educating staff.
  • ? Assessing, maintaining, and improving staff

Management of Human Resources
  • Planning
  • HR.1.10 The hospital provides an adequate number
    and mix of staff that are consistent with the
    hospitals staffing plan.
  • HR.1.20 The hospital has a process to ensure that
    a persons qualifications are consistent with his
    or her job responsibilities.
  • HR.1.30 The hospital uses data on
    clinical/service screening indicators

Management of Human Resources
  • Orientation, Training, and Education
  • HR.2.10 Orientation provides initial job training
    and information.
  • HR.2.20 Staff members, licensed independent
    practitioners, students, and volunteers, as
    appropriate, can describe or demonstrate their
    roles and responsibilities, based on specific job
    duties or responsibilities, relative to safety.
  • HR.2.30 Ongoing education, including in-services,
    training, and other activities, maintains and
    improves competence.

Management of Human Resources
  • Competence Assessment
  • HR.3.10 Competence to perform job
    responsibilities is assessed, demonstrated, and
  • HR.3.20 The hospital periodically conducts
    performance evaluations.

Management of Information
  • Overview

Management of Information
  • Identifying information needs
  • Designing the structure of the information
    management system
  • Capturing, organizing, storing, retrieving,
    processing, and analyzing data and information
  • Transmitting, reporting, displaying, integrating,
    and using data and information
  • Safeguarding data and information

Management of Information
  • The standards in this chapter focus on
    hospital-wide information planning and management
    processes to meet the hospitals internal and
    external information needs.

Management of Information
  • Information Management Planning
  • IM.1.10 The hospital plans and designs
    information management processes to meet internal
    and external information needs.
  • Confidentiality and Security
  • IM.2.10 Information privacy and confidentiality
    are maintained.
  • IM.2.20 Information security, including data
    integrity, is maintained.
  • IM.2.30 The hospital has a process for
    maintaining continuity of information.

Management of Information
  • Information Management Processes
  • IM.3.10 The hospital has processes in place to
    effectively manage information, including the
    capturing, reporting, processing, storing,
    retrieving, disseminating, and displaying of
    clinical/service and non-clinical data and
  • Information-Based Decision Making
  • IM.4.10 The information management system
    provides information for use in decision making.

Management of Information
  • Knowledge-Based Information
  • IM.5.10 Knowledge-based information resources are
    readily available, current, and authoritative.
  • Patient-Specific Information
  • IM.6.10 The hospital has a complete and accurate
    medical record for every individual assessed,
    cared for, treated or served.
  • IM.6.20 Records contain patient-specific
    information, as appropriate, to the care,
    treatment, and services provided.

Management of Information
  • IM.6.30 The medical record thoroughly documents
    operative or other high risk procedures and the
    use of moderate or deep sedation or anesthesia.
  • IM.6.40 For patients receiving continuing
    ambulatory care services, the medical record
    contains a summary list of all significant
    diagnoses, procedures, drug allergies, and
  • IM.6.50 Designated qualified personnel accept and
    transcribe verbal orders from authorized
  • IM.6.60 The hospital can provide access to all
    relevant information from a patients record when
    needed for use in patient care, treatment, and

Section 3 Structures with functions
  • Medical Staff
  • Nursing

Medical Staff
  • Overview

Medical Staff
  • Organized Medical Staff Structure
  • MS.1.10 The hospital has an organized,
    self-governing medical staff that provides
    oversight of care, treatment, and services
    provided by practitioners with privileges,
    provides for a uniform quality of patient care,
    treatment, and services, and reports to and is
    accountable to the governing body.
  • MS.1.20 Medical staff bylaws address self
    governance and accountability to the governing
  • MS.1.30 Neither the organized medical staff nor
    the governing body may unilaterally amend the
    medical staff bylaws or rules and regulations.
  • MS.1.40 There is a medical staff executive

Medical Staff
  • MS.2.10 The organized medical staff oversees the
    quality of patient care, treatment, and services
    provided by practitioners privileged through the
    medical staff process
  • MS.2.20 The management and coordination of each
    patients care, treatment, and services is the
    responsibility of a practitioner with appropriate
  • MS.2.30 In hospitals participating in a
    professional graduate education program(s), the
    organized medical staff has a defined process for
    supervision by a licensed independent
    practitioner with appropriate clinical privileges
    of each member in the program in carrying out his
    or her patient care responsibilities.

Medical Staff
  • Performance Improvement
  • MS.3.10 The organized medical staff has a
    leadership role in hospital performance
    improvement activities to improve quality of
    care, treatment, and services and patient safety.
  • MS.3.20 The organized medical staff participates
    in the measurement, assessment, and improvement
    of other processes.

Medical Staff
  • Credentialing, Privileging, and Appointment
  • MS.4.10 The organized medical staff has a
    credentialing process that is defined in the
    medical staff bylaws.
  • MS.4.20 There is a process for granting,
    renewing, or revising setting-specific clinical
  • MS.4.30 An organized medical staff may use an
    expedited process for appointing to the medical
    staff and when granting privileges when criteria
    for that process are met.

Medical Staff
  • MS.4.40 At the time of renewal of privileges, the
    organized medical staff evaluates individuals for
    their continued ability to provide quality care,
    treatment, and services for the privileges
    requested as defined in the medical staff bylaws.
  • MS.4.50 There are mechanisms including a fair
    hearing and appeal process for addressing adverse
    decisions regarding reappointment, denial,
    reduction, suspension, or revocation of
    privileges that may relate to quality of care,
    treatment, and services issues.

Medical Staff
  • MS.4.60 The organized medical staff provides
    oversight for the quality of care, treatment, and
    services by recommending members for appointment
    to the medical staff.
  • MS.4.70 Peer recommendations from peers in the
    same professional discipline as the applicant are
    used as part of the basis for the initial
    granting of privileges. Peer recommendations are
    used to recommend individuals for the renewal of
    clinical privileges when insufficient
    practitioner-specific data are available.

Medical Staff
  • MS.4.80 The medical staff implements a process to
    identify and manage matters of individual health
    for licensed independent practitioners. This
    identification process is separate from actions
    taken for disciplinary purposes.
  • MS.4.90 There is a process that defines
    circumstances requiring a focused review of a
    practitioners performance and evaluation of a
    practitioners performance by peers.
  • MS.4.100 Under certain circumstances, temporary
    clinical privileges may be granted for a limited
    period of time.

Medical Staff
  • MS.4.110 Disaster privileges may be granted when
    the emergency management plan has been activated
    and the hospital is unable to handle the
    immediate patient needs (see standard EC.4.10).
  • MS.4.120 Licensed independent practitioners who
    are responsible for the care, treatment, and
    services of the patient via telemedicine link are
    subject to the credentialing and privileging
    processes of the originating site.
  • MS.4.130 The medical staffs at both the
    originating and distant sites recommend the
    clinical services to be provided by licensed
    independent practitioners through a telemedical
    link at their respective sites.

Medical Staff
  • Continuing Education
  • MS.5.10 All licensed independent practitioners
    and other practitioners privileged through the
    medical staff process participate in continuing

  • Overview

  • NR.1.10 A nurse executive directs the hospitals
    nursing services.
  • NR.2.10 The nurse executive is a licensed
    professional registered nurse qualified by
    advanced education and management experience.
  • NR.3.10 The nurse executive establishes nursing
    policies and procedures, nursing standards of
    patient care, treatment, and services, standards
    of nursing practice, and a nurse staffing plan(s).