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Title: Introduction%20to%20Healthcare%20and%20Public%20Health%20in%20the%20US

Introduction to Healthcareand Public Health in
the US
Regulating Healthcare
  • Lecture a

This material (Comp1_Unit6a) was developed by
Oregon Health and Science University, funded by
the Department of Health and Human Services,
Office of the National Coordinator for Health
Information Technology under Award Number
Regulating Healthcare Learning Objectives
  • Describe the role of accreditation, regulatory
    bodies, and professional associations in healthcar
    e in the US. (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)
  • Describe legal aspects of medicine involving the
    Affordable Care Act, professional standards in
    healthcare, medical malpractice, Tort reform, and
    Medicare and Medicaid Fraud and Abuse (Lecture c)
  • Describe key components of the Health Insurance
    Portability and Accountability Act (HIPAA) and
    current issues of privacy and patient safety in
    the US (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 healthcare organizations.
    (Lecture e)

Topics in This Lecture
  • Nonprofit Accrediting Organizations
  • The Joint Commission (JC)
  • URAC (formerly called Utilization Review
    Accreditation Commission)
  • Regulatory Agencies
  • Professional Associations

Joint Commission (JC) History
  • 1910 The forerunner of JC is called the
    end-result system
  • 1951 Joint Commission on Accreditation of
    Hospitals (JCAH) is created and starts
    accrediting and certifying healthcare
  • 1987 Name changed to Joint Commission on
    Accreditation of Healthcare Organizations (JCAHO)
  • 2007 Name simplified to Joint Commission (JC)
    currently accredits and certifies more than
    18,000 organizations and programs in the US

Joint Commission (JC) Mission
  • To continuously improve healthcare for the
    public, in collaboration with other stakeholders,
    by evaluating healthcare organizations and
    inspiring them to excel in providing safe and
    effective care of the highest quality and value.
  • (The Joint Commission, 2011)

Joint Commission (JC) Accreditation
  • Earned by an entire healthcare organization
    (hospital, nursing home, office-based surgery
    practice, etc.)
  • Tools the JC uses to measure performance
  • Integrated Survey Process (ISP) Evaluates
    performance across organization
  • ORYX System for healthcare organizations to
    report to the JC about patients with certain
    conditions (core measure sets)
  • The core measure sets reported depend on the type
    and size of the organization

ORYX Core Measure Sets
  • Examples
  • Heart attack
  • Pneumonia
  • Inpatient psychiatric care
  • Childrens asthma
  • Stroke
  • Each core set has performance measures
  • For example, the JC looks at whether children
    with asthma received certain drugs in the
    hospital and were sent home with a management plan

Joint Commission (JC) Certification
  • JC-accredited organizations and providers of
    healthcare staffing services can also earn
    certification for specific programs or services
  • For chronic diseases and conditions
  • Examples asthma, diabetes, heart failure
  • Programs can be within the medical center or in
    the community

Joint Commission (JC) Patient Safety Activities
  • National Patient Safety Goals
  • Universal Protocol
  • Office of Quality Monitoring
  • Speak Up program
  • Sentinel Event Policy

  • Formerly known as the Utilization Review
    Accreditation Commission (URAC)
  • Mission To promote continuous improvement in
    the quality and efficiency of healthcare
    management through processes of accreditation and
  • Has more than 25 accreditation and certification
    programs for various types of healthcare
  • (URAC,2011)

URAC HealthIT Accreditation
  • Outlines best practices for an effective
    compliance program, including
  • Health websites
  • HIPAA (Health Insurance Portability and
    Accountability Act) privacy and security
  • Designed for a wide range of organizations
    involved in healthcare IT
  • See http//

URAC HealthIT Accreditation (continued)
  • These healthcare organizations must comply with
  • Health planshealth insurance companies,
    employer-funded health plans, and government
    programs that pay for healthcare, such as
    Medicare or Medicaid
  • Health care providers that conduct certain tasks
  • Health care clearinghouses(organizations that
    process health information)

Regulatory Agencies
  • Public authorities at state or federal level,
    established by legislative act to enforce
    standards in a specific field in the private
  • Agencys regulations laws
  • Agency might conduct hearings and hand down
  • Goal is consumer protection
  • Example Food and Drug Administration (FDA)

Food and Drug Administration (FDA) Overview
  • 6.1 Figure As part of Department of Health and
    Human Services, the FDA is charged with oversight
    of these areas. (FDA, 2011)

FDA Mission
  • Protect public health
  • Regulates drugs
  • Performs drug approvals
  • Provides drug safety information
  • Spreads the message about medication errors
  • Helps speed up product innovations
  • Helps public obtain accurate science-based

Professional Association
  • A nonprofit organization that wants to support
  • A particular profession
  • The interests of individuals engaged in that
  • The public interest
  • Sets requirements
  • For entry into the professionpossibly requires
    license or certificate
  • For maintaining membership in the profession
  • Members generally have a significant amount of
    education, training, or experience

American Board of Medical Specialties (ABMS)
  • Description An organization of medical
    specialty boards with shared goals and standards
    related to the certification of medical
  • Member boards certify specialist physicians
  • Also subspecialists for example, adolescent
    medicine is a subspecialty of family medicine
  • Board certification differs from licensure, which
    sets minimum competency for physicians

American HospitalAssociation (AHA)
  • 5,600 organizational members
  • 41,000 individual members
  • Major programs
  • Advocacy
  • Resource center (47,000 books on healthcare)
  • Health Planning and Administration (HEALTH)
  • Annual survey of US hospitals
  • Reports and studies

American MedicalAssociation (AMA)
  • 240,000 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

Regulating HealthcareSummary Lecture a
  • Hospitals and other healthcare organizations are
    accredited by the Joint Commission
  • The Joint Commission also certifies specific
    healthcare programs and conducts patient safety
  • URAC accredits and certifies a wide range of
    healthcare 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 govern their members
    but not the public at large

Regulating HealthcareReferences Lecture a
  • References
  • American Board of Medical Specialties.
    http// Accessed April 12, 2011.
  • American Hospital Association. http//
    Accessed April 12, 2011.
  • American Medical Association. http//www.ama-assn.
    org. Accessed April 12, 2011.
  • Peck P. AMA after one-year increase, AMA
    membership declines again. June 25, 2007.
    06. Accessed April 12, 2011.
  • Regulatory agency (definition). Encyclopedia
    Britannica. http//
    pic/496265/regulatory-agency. Accessed April 12,
  • The Joint Commission. http//www.jointcommission.o
    rg/facts_about_the_joint_commission/ Accessed
    April 12, 2011.
  • US Department of Health Human Services.
    Understanding health information privacy.
    /index.html. Accessed April 12, 2011.
  • US Food and Drug Administration.
    http// Accessed April 12, 2011.
  • URAC. http// Accessed April 12,
  • Charts, Tables, Figures
  • 6.1 Figure Part of Department of Health and
    Human Services, charged with oversight of the
    areas displayed. http// . Accessed
    April 12, 2011.