Read the Patient Safety and Quality Improvement Act of 2005 (FOUND BELOW) and review the information on the Measures (FOUND BELOW). web page of The Joint Commission website. Pick one of the core measures from the list on the right-hand side of this web page. For this assignment, create a PowerPoint presentation in which you explain how a hospital would typically put policies and procedures into place to ensure that it is following your selected core measure.

In your presentation,

  • Describe the core measure you chose.
  • Analyze how your hospital will follow the requirements in the chosen core measure.
  • Examine the penalties that will occur if this policy/procedure is not followed.

You are basically creating the policy/procedure and presenting it on the PowerPoint as if you were presenting to an audience.

Create a PowerPoint presentation using the guidelines below. Your presentation must utilize at least two scholarly sources from the last five to seven years, in addition to the textbook, that contain research regarding how your policy and/or procedure would be put into place in a hospital setting.

The Core Measures PowerPoint presentation assignment

  • Must be five to seven slides (excluding the title slide and reference slides) and be formatted according to APA style.
  • Must use speakers notes as follows: (GIRL VOICE PLEASE)
    • The Patient Safety and Quality Improvement Act of 2005

      The Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41), signed into law on July 29, 2005, was enacted in response to growing concern about patient safety in the United States and the Institute of Medicine’s 1999 report, To Err is Human: Building a Safer Health System. The goal of the Act is to improve patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients.

      The
      Patient Safety and Quality Improvement Act signifies the Federal Government’s commitment to fostering a culture of patient safety. It creates
      Patient Safety Organizations (PSOs) to collect, aggregate, and analyze confidential information reported by health care providers. Currently, patient safety improvement efforts are hampered by the fear of discovery of peer deliberations, resulting in under-reporting of events and an inability to aggregate sufficient patient safety event data for analysis. By analyzing patient safety event information, PSOs will be able to identify patterns of failures and propose measures to eliminate patient safety risks and hazards. Many providers fear that patient safety event reports could be used against them in medical malpractice cases or in disciplinary proceedings. The Act addresses these fears by providing Federal legal privilege and confidentiality protections to information that is assembled and reported by providers to a PSO or developed by a PSO (“patient safety work product”) for the conduct of patient safety activities. The Act also significantly limits the use of this information in criminal, civil, and administrative proceedings. The Act includes provisions for monetary penalties for violations of confidentiality or privilege protections. Additionally, the Act specifies the role of PSOs and defines “patient safety work product” and “patient safety evaluation systems,” which focus on how patient safety event information is collected, developed, analyzed, and maintained. In addition, the Act has specific requirements for PSOs, such as:

      • PSOs are required to work with more than one provider.
      • Eligible organizations include public or private entities, profit or not-for-profit entities, provider entities, such as hospital chains, and other entities that establish special components.
      • Ineligible organizations include insurance companies or their affiliates.

      Finally, the Act calls for the establishment of a Network of Patient Safety Databases (NPSD) to provide an interactive, evidence-based management resource for providers, PSOs, and other entities. It will be used to analyze national and regional statistics, including trends and patterns of patient safety events. The NPSD will employ common formats (definitions, data elements, and so on) and will promote interoperability among reporting systems. The Department of Health and Human Services will provide technical assistance to PSOs.

      For Additional Information

      To contact PSO Office staff, go to the PSO site at

      http://www.pso.ahrq.gov/contact/contact.htm.

      Page last reviewed
      October 2014

      Page originally created June 2008

      Internet Citation: The Patient Safety and Quality Improvement Act of 2005. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.
      http://www.ahrq.gov/policymakers/psoact.html


    • MEASURES

      In early 1999, The Joint Commission solicited input from a wide variety of stakeholders (e.g., clinical professionals, health care provider organizations, state hospital associations, health care consumers) and convened a Cardiovascular Conditions Clinical Advisory Panel about the potential focus areas for core measures for hospitals. In May 2001, the Joint Commission announced four initial core measurement areas for hospitals, which included acute myocardial infarction (AMI) and heart failure (HF).

      Simultaneously, The Joint Commission worked with the Centers for Medicare & Medicaid Services (CMS) on the AMI, and HF sets that were common to both organizations. CMS and the Joint Commission worked to align the measure specifications for use in the 7th Scope of Work and for Joint Commission accredited hospitals. Hospitals began collecting AMI measures for patient discharges beginning July 1, 2002.

      In November of 2003, CMS and The Joint Commission began to work to precisely and completely align these common measures so that they are identical. This resulted in the creation of one common set of measure specifications documentation known as the Specifications Manual for National Hospital Inpatient Quality Measures to be used by both organizations. The Manual contains common (i.e., identical) data dictionary, measure information forms, algorithms, etc. The goal is to minimize data collection efforts for these common measures and focus efforts on the use of data to improve the health care delivery process.

 
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