1. Fundamentals of Health Information – Week 1 Robyn Korn, MBA, RHIA, CPHQ

2. General Information Discussion Board Enter first post by Saturday and a total of 3 posts by Tuesday Assignments Make sure your name is on the assignment attachments when they are submitted

3. General Information Late work will not be accepted unless there are clear and compelling extenuating circumstances. If you have extenuating circumstances that prevent you from completing course assignments/exams you must contact your instructor immediately—prior to the assignment/exam/quiz due-date unless prevented from doing so by emergency circumstances.

4. Welcome Is anyone currently working in Health Care? Please identify the type of facility and length of time you have worked in health care.

5. Facility Ownership ◦ Government (not-for-profit) ◦ Proprietary (for-profit) ◦ Voluntary (not-for-profit)

6. Organizational Structure Governing Board Administration Medical Staff Hospital Departments, Services, Committees Contract Services

7. Governing Board Ultimate Legal Authority Responsible for Hospital Operation Responsible for Quality of Care

8. Hospital Administration CEO – Chief Executive Officer CFO – Chief Financial Officer CIO - Chief Information Officer COO – Chief Operating Office DON – Director of Nursing

9. Joint Commission Leadership Standards LD.01.01.01: The hospital has a leadership structure. LD.01.02.01: The hospital identifies the responsibilities of its leaders. LD.01.03.01: The governing body is ultimately accountable for the safety and quality of care, treatment, and services.

10. Joint Commission Leadership Standards LD.01.04.01: A chief executive manages the hospital LD.01.05.01: The hospital has an organized medical staff that is accountable to the governing body LD.01.07.01: The governing body, senior managers, and leaders of the organized medical staff have the knowledge needed for their roles in the hospital or they seek guidance to fulfill their roles

11. Joint Commission Leadership Standards LD.02.03.01: The governing body, senior managers and leaders of the organized medical staff regularly communicate with each other on issues of safety and quality. LD.04.01.05: The hospital effectively manages its programs, services, sites, or departments

12. Medical Staff Organization Chief Of Staff/President of Medical Staff Associate Chief of Staff Department Chair/Clinical Chief

13. Medical Staff Membership Active Consulting Honorary Non member (contract)

14. Hospital Departments/Services Direct patient care Ancillary services Support Services Environmental/Physical Plant

15. Department Management Titles Administrative Director/Department Head Assistant Director Manager Supervisor Coordinator/Lead

16. Hospital Committees  Multidisciplinary  Forum for decisions  Formal or Informal  Minutes are required at formal meetings  Number and types vary by facility type and size

17. Hospital Committees - TJC Executive Committee only required committee Types of Medical staff Committees ◦ Medical Director Council ◦ Credentials Committee ◦ Quality Council ◦ Utilization Review Committee ◦ Critical Care Committee ◦ Blood Management Committee ◦ Infection Control Committee ◦ Pharmacy and Therapeutics Committee ◦ Health Information Management Committee ◦ Cancer Committee ◦ Peer Review Committee ◦ Tissue Committee

18. Meetings and Meeting Minutes Important to create an accurate and objective description of the meeting Need to transform personalized or opinionated statements into objective and impersonal ones

19. Minute Format Committee Name Date/Time Location (optional) Members Present/Absent Guests

20. Minute Format Old Business New Business Standard Reports Adjournment Subject Discussion Action

21. Minute Format Committee Meeting Minutes Date Member Attendance: Absent: Other Attendees: The meeting called to order at 3:09pm. Subject Discussion Actions: Next Meeting The next meeting is scheduled for Adjournment There being no further business the meeting was adjourned at 4:55pm

22. HOSPITAL : Present: Absent: Facilitator: Guests MINUTES Committee MEETING: DATE: TIME: Agenda Item DISCUSSIONACTION/CONCLUSION Call to order / Announcement Approval of Minutes Old Business New Business Ongoing Medical Record Review Standard Reports Retiring Incomplete Medical Records Other Business Next Meeting Meeting adjourned. ______________________________________________________________________________ Chair CommitteeCommittee Meeting Recorder

23. EXAMPLES Member stated: “I think this is a stupid idea! There is no way the medical staff should stand for this!” Minutes state: “One member of the committee expressed concern with the proposed suggestion. The committee considered the concerns. The committee recommends that…”

24. EXAMPLES Member stated: “How in the $*%& are we supposed to comply with this new regulation! I may look into early retirement if this keeps up!” Minutes state: “Frustration was expressed regarding newly imposed regulations. No action was necessary.”

25. Joint Commission Requirements Medical staff must measure, assess, and improve the following: ◦ Medical assessment and treatment of patients ◦ Use of medications ◦ Use of blood and blood components ◦ Operative and other procedures ◦ Appropriateness of clinical practice patterns (utilization review)

26. Joint Commission Requirements Medical staff must measure, assess, and improve the following: ◦ Significant departures from established clinical patterns ◦ Patient and family education ◦ Coordination of care, treatment and services ◦ Accurate, timely and legible medical records Meeting minutes are an effective way to demonstrate performance of these reviews

27. QUESTIONS