Healthcare Regulations and Excellence Programs

Healthcare Regulatory Agencies and Healthcare Reform

• Regulatory agencies play a critical role in shaping healthcare delivery by establishing standards and guidelines for healthcare facilities to ensure quality care.
• Compliance with regular standards, guidelines, and monitoring ensures that providers and facilities provide quality and safe services to clients.
• The state of healthcare in the United States includes several challenges:
  • Many individuals remain uninsured.
  • There is a limited ability to pay for prescription medications.
  • There is limited access to general healthcare services.
• Health care reform efforts aim to make care affordable and accessible for all individuals.
• The Patient Protection and Affordable Care Act (ACA):
  • Signed into law in $2010$ by President Barack Obama.
  • Primary goals: Improve healthcare quality, lower costs, and increase access to care.
  • Expanded eligibility for the Medicaid program.
  • Focused on disease prevention: Clients are encouraged to seek preventive care to remain healthy.
  • Financial incentives for prevention: Clients with insurance are not charged co-payments or deductibles for screenings for preventable diseases.
  • Goal of maintenance care: Help clients avoid costly chronic or long-term illnesses.
• Challenges of the ACA:
  • Many clients still do not utilize primary care for preventive screenings.
  • Some individuals must choose between paying for living expenses or purchasing medication.
  • While it provides coverage for those with pre-existing conditions, some cannot afford premiums on the ACA Marketplace (the health exchange platform for individuals, families, and businesses).
  • In $2020$, The New York Times reported that health insurance premiums had more than doubled in just a few years, and high deductibles were preventing Americans from obtaining care despite being covered.
• The American Rescue Plan (ARP) Act:
  • Implemented in $2021$ by the Biden-Harris administration.
  • Intended to strengthen the ACA by further lowering healthcare costs.
  • Reduced health premiums and closed the gap in Medicaid coverage, increasing the number of insured individuals.

State Regulation and the Board of Nursing

• Each state has specific regulations that healthcare organizations must follow. Organizations use managers and directors to ensure policies and procedures comply with these state regulations.
• State Interpretation: States can interpret federal definitions in ways they feel are appropriate.
• Medicaid and Funding:
  • States regulate how Medicaid funding is dispersed, as dollars are administered at both the state and federal levels.
  • Each state has its own State Child Health Insurance Program (SCHIP).
  • States can pass legislation related to pharmaceuticals, such as capping the cost of insulin for Medicare recipients and capping annual out-of-pocket costs.
• Regulation of Practitioners:
  • States regulate how practitioners operate within their borders.
  • Example: South Carolina's Labor Licensing Regulation includes a division known as the State Board of Nursing (BON).
  • Functions of the BON:
    • Determines eligibility requirements for nursing practice.
    • Issues licenses.
    • Governs policies.
    • Reviews disciplinary cases for Practical Nurses (PNs), Registered Nurses (RNs), and Advanced Practice Registered Nurses (APRNs).
    • Provides guidance to other state agencies on healthcare and wellness.
• National Council of State Boards of Nursing (NCSBN):
  • A nonprofit organization offering guidance to each state's BON.
  • Provides position statements and standards.
  • Develops and administers nursing licensing examinations.

Accreditation and The Joint Commission (TJC)

• Accreditation is awarded by outside organizations to assure that a facility has policies and procedures to maintain quality and safety.
• Accrediting bodies develop operational standards for everyday practice (environmental, human resources, client safety, documentation).
• The Joint Commission (TJC):
  • A nonprofit organization that accredits various settings, from inpatient hospitals to pharmacies.
  • Known as the Joint Commission on Accreditation of Healthcare Organizations until $2007$.
  • TJC sends expert surveyors to perform accreditation visits involving documentation review, policy review, observations, and interviews.
  • Full accreditation from TJC is valid for $3$ years.
  • Many state regulatory bodies recognize TJC accreditation in place of additional state certifications.
• TJC Standards and Compliance:
  • Facilities must meet standards in the TJC manual specific to their level of care.
  • Facilities must demonstrate compliance through discussion, demonstration, chart review, or written policies.
  • Example (Client Record Standard): Assessments must be completed and documented within a specific time period. The nurse must be able to explain the policy and show documentation that complies with it.
• National Patient Safety Goals (NPSGs):
  • Published annually by TJC for specific settings (ambulatory, behavioral health, critical access, home care, hospital, laboratory, nursing care center, office-based surgery).
  • $2024$ NPSG for Nursing Care Centers: Prevention of pressure injuries (identifying at-risk clients and taking preventative action).
  • $2024$ NPSG for Hospitals: Identifying clients safely, using medications safely, preventing suicide, preventing infection, preventing surgery mistakes, improving staff communication, and improving healthcare equity.

Sentinel Events

• A Sentinel Event is an adverse event that resulted in a client's death or permanent/severe harm. These are events that should never occur.
• Examples of Sentinel Events:
  • Administration of blood products with the incorrect blood type.
  • An infant death.
  • Surgical procedures performed on the incorrect limb (wrong arm or leg).
• Process After a Sentinel Event:
  • Immediate investigation to identify the root cause.
  • Implementation of systems to change practices and decrease recurrence risk.
  • Reporting to TJC helps other organizations by calling attention to potential risks and allowing for preventive measures.

Quality Assurance and Nursing Excellence Programs

• National Committee for Quality Assurance (NCQA):
  • An independent nonprofit organization.
  • Accredits healthcare plans, providers, facilities, and case management companies.
  • Focuses on improving healthcare through evidence-based standards.
• American Nurses Credentialing Center (ANCC):
  • Supports nurses through education, certifications, and professional designations.
  • Developed the Magnet Recognition Program and the Pathway to Excellence program.
• Magnet Recognition Program:
  • Recognizes acute care facilities demonstrating nursing excellence based on $5$ categories.
  • Goals: Promote quality in professional practice, identify excellence in delivery, and disseminate best practices.
  • Magnet status leads to better client quality indicators (decreased fall rates, improved skin integrity) and higher client satisfaction.
  • Application is a lengthy process involving all levels of staff and an on-site survey team visit.
  • Designation is valid for $4$ years.
• The Five Components of the Magnet Model:
  1. Structural Empowerment: Administration empowers nurses to work with the community and organization to meet goals.
  2. Exemplary Professional Practice: Nurses apply new information and evidence-based practice (EBP) safely.
  3. New Knowledge, Innovations, or Improvements: Active engagement in producing EBP research and new care models.
  4. Transformational Leadership: Visionary leadership that questions how to improve and grows the team.
  5. Empirical Outcomes: The "report card" of the organization, measuring data like nursing turnover, mortality rates, and patient satisfaction.
• Pathway to Excellence Program:
  • Recognizes organizations (often long-term or outpatient) committed to a healthy workplace.
  • Focuses on factors like turnover, workplace engagement, productivity, teamwork, and job satisfaction.
  • Involves an application and a confidential survey completed by nurses to validate practices.
  • Unlike Magnet, there is no on-site review.
  • Designation is valid for $4$ years.

Measuring Client Satisfaction

• High client satisfaction is used to attract clients and insurers in a competitive market.
• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS):
  • Standardized tool for acute care facilities to measure client satisfaction and allow comparisons between facilities.
  • Consists of $29$ items covering topics like food temperature, promptness of help, pain management, and transition to post-hospital care.
  • Administered to a random sample of clients via phone, mail, or automated message between $48$ hours and $6$ weeks after discharge.
  • Publicly reported to ensure accountability and transparency.
• Press Ganey:
  • A survey tool often administered by a private third-party vendor focusing on the client's perception of experience in the outpatient setting.
  • Includes metrics on access to care, wait times, and interactions with the healthcare team.
  • Administered to every client via email after the visit to encourage timely feedback.

Comparison: HCAHPS vs. Press Ganey

• HCAHPS:
  • When: $48$ hours to $6$ weeks after visit.
  • To Whom: Random sample of clients.
  • How: Phone call, mail, automated voice message, or mail with phone follow-up.
  • Evaluated: Client satisfaction.
• Press Ganey:
  • When: After the visit.
  • To Whom: Every client.
  • How: Email.
  • Evaluated: Healthcare delivery and client satisfaction.