Description

Objectives:-

• Recall the requirement for and elements of a QAPI program
• Describe the need for radiology policies, including one on radiation safety and the need for qualified staff
• Discuss the new option of credentialing the dietician to order diets – if allowed by the state
• Describe the need for a facility maintenance program to include water management

Quality Assessment and Performance Improvement

• PI program requirements
• Final changes
• Revised tag numbers
• Tracking of medical errors and adverse events
• Identifying opportunities for improvement
• Patient safety

Medical Staff, Board, and CEO

• Medical staff and Board requirements
• Shared medical staff
• MS by-laws
• Appraisal of MS
• Accountability of MS for quality of care
• Credentialing and privileging
• Telemedicine – hospital, and entity-based
• Hospitals part of a system – shared medical staff
• History and physicals

Radiological Services

• Radiation exposure
• Standard of care
• Scope and complexity
• Therapeutic radiology
• Adverse reaction to agents
• Safety precautions
• Shielding of patients
• Supervision of staff
• The signing of radiology reports
• Radiopharmaceuticals on off-hours

Laboratory Services and Look Back Program

• Lab services
• Tissues specimens
• Blood bank
• Recordkeeping
• Look back program

Food and Dietary Services

• Diets and menus
• Credentialing RD or nutrition specialist to write diet orders
• Patient nutritional needs
• Diet manual and therapeutic menus
• Qualified director required
• 7 required dietary policies
• Nutritional assessment
• Order required
• Therapeutic diets and nutritional needs

Utilization Review

• Composition of UR committee
• Admission or continuous stays
• Medicare patient discharge appeal rights
• UR plan
• Scope and frequency of reviews
• Notice Law and MOON form

Physical Environment

• Buildings and equipment
• Facility and building maintenance
• Security factors to consider – including ligature risks
• Emergency systems and life safety code
• Trash
• Emergency preparedness
  • Emergency power and lighting
  • Emergency gas and water
  • Ventilation, light, temperature