Healthcare Delivery System Overview and Key Concepts

Healthcare Delivery System Overview

• Healthcare delivery includes the structure of the healthcare system, resources for financing and funding.
• Discussion topics will include:
  • Healthcare disparities
  • Care settings
  • Interprofessional team members
• Emphasis on the importance of preparation before discussions and presentations.

Regulatory Agencies in Healthcare

• Various regulatory agencies have specific requirements for different healthcare settings (e.g., hospitals, outpatient clinics).
• To receive reimbursement from insurance companies:
  • Healthcare facilities must meet specific criteria regarding care documentation and client outcomes.
  • Awareness of the number of individuals without health coverage and how this affects different care levels.

The Joint Commission

• Nonprofit organization that accredits healthcare organizations to ensure quality and safety in client care.
• Accreditation process includes:
  • Documentation review, policy assessment, and staff interviews.
  • Valid for three years.
• Healthcare facilities must demonstrate compliance with standards outlined by the Joint Commission:
  • Must provide evidence of adherence through discussions, documentation, and policies.
• The Joint Commission publishes national patient safety goals and updates them with new safety trends.

Sentinel Events

• Defined as "never events" that should never occur in healthcare settings.
• Common examples include:
  • Infant death
  • Administering wrong blood products
  • Surgical errors (e.g., wrong limb surgery)
• Importance of adherence to safety protocols like timeouts to prevent sentinel events.
• Facilities must report sentinel events to the Joint Commission to enhance system improvement and client safety.

National Committee for Quality Assurance (NCQA)

• A nonprofit organization focusing on accreditation for healthcare plans and providers.
• Emphasis on improving healthcare through evidence-based practices.
• Offers tools like the Healthcare Effectiveness Data and Information Set (HEDIS) to assess patient care standards.

American Nurses Credentialing Center (ANCC)

• Develops programs to recognize nursing excellence such as:
  • Magnet Recognition Program
  • Pathway to Excellence Program
• Magnet Recognition:
  • Awarded to organizations demonstrating excellence in nursing through five categories:
  1. Structural Empowerment: Community and goal-related empowerment of nurses.
  2. Exemplary Professional Practice: A safe practice environment for nurses.
  3. New Knowledge: Implementation of evidence-based changes in practice.
  4. Transformational Leadership: Leadership committed to improvement.
  5. Empirical Outcomes: High satisfaction indicators from clients and staff.
  • Requires a rigorous application and documentation process.
• Pathway to Excellence:
  • Focuses on nursing work environment satisfaction and teamwork.
  • Application involves a confidential staff survey without onsite review.

Patient Satisfaction Surveys

• Surveys used to gather client feedback:
  • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS):
  • Measures patient satisfaction post-discharge.
  • Includes 29 items addressing various care aspects.
  • Press Ganey Score:
  • Administered immediately after visits for timely feedback.
  • Evaluates client satisfaction and healthcare delivery.
  • Difference: Immediate feedback vs. HCAHPS’s extended post-visit timeframe.

Medicare and Medicaid Overview

• Medicare:
  • Covers individuals 65+ and certain disabled individuals.
  • Funded primarily through payroll taxes (2.9%) and beneficiary premiums.
  • Has parts:
  • Part A: Hospitalization, skilled nursing facilities, hospice.
  • Part B: Doctor services.
  • Part D: Prescription drugs.
  • Medicaid:
  • For low-income individuals and families, varying by state.
  • Managed federally but administered on a state-by-state basis.
  • Covers outpatient/inpatient services, physician services, at determined state rates.
  • May include cost-sharing mechanisms except for certain populations.
• Dual Eligibility:
  • Individuals qualifying for both Medicare and Medicaid, receiving comprehensive coverage

Affordable Care Act (ACA)

• Signed into law in 2010 to improve healthcare quality and reduce costs.
• Expanded Medicaid eligibility and banned lifetime insurance caps.
• Promotes preventative care and aims to cover individuals with pre-existing conditions.
• Challenges include rising insurance premiums and high out-of-pocket costs despite ACA.

Closing Notes

• Importance of understanding the healthcare delivery landscape including funding, regulatory standards, and patient care outcomes.
• Emphasis on active engagement and filling out satisfaction surveys for system improvement interest.