Health Care Risk Management
Helpm31990
Chapter2.pptxChapter 2: Regulatory Environment
Most Regulated Industry
Health Care is one of the most regulated industries in the US.
It is vital to be aware of and understand what regulations may affect the facility.
Standards
Statements concerning proper procedures taken in a given situation:
Explicit or implicit
National or local
Validated or Consensual
Used or ignored
Periodically updated or static
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Legal Standards
Judicial system (court decisions) provides initiative for implementing standards public health rules
Disease reporting requirements
Immunizations
Worker’s comp
Licensing of professionals
Federal Mandatory Regulations
CMS
OSHA
HIPAA
EMTALA
Mammography Quality Standards Act
Safe Medical Devices Act
MedWatch
MWTA
EPA
Medical Waste Tracking Act
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State Mandatory Regulations
Professional Licensure of Providers
Smoke-free Workplaces
Smoke-free Environment
Violence Prevention
Medical Waste Tracking Act
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State Mandated Risk Management Legislation
Risk Management Responsibility
Governing Body Involvement
Risk Identification
Risk Analysis
Risk Management Education
State Mandated Risk Management Legislation
Sharing Information
Patient Grievance Procedures
Immunity and Confidentiality for Providers
Risk Management Follow-up Procedures
Reimbursement Standards
Payers set their own standards for reimbursement
Fee for service
Negotiated fees
Capitation
Prospective payment
RBRVS
Medicare - is a federal program so the standards are the same across the US
Medicaid - is a state run program so each state sets its standards for reimbursement
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Medicare Incentives to Improve Quality
Evidence based medicine in now generally accepted as essential to effective and safe medical practice.
This link was presented in 2 seminal works from IOM:
Crossing the Quality Chasm
To Err Is Human
Deficit Reduction Act 2003 and Beyond
Pay for Posting
Pay for Performance
Value Based Purchasing
Scores and Withhold Determination
False Claims Act
Anti-fraud activities
Lawsuits
Revocation of Medicare participation
Practice Guidelines
Accreditation Programs develop standards and facilities can voluntarily apply for review
Joint Commission on the Accreditation of Healthcare Organizations (Joint Commission)
National Committee for Quality Assurance (NCQA)
Many equate facility accreditation with quality
Medicare accepts a JCAHO accreditation as evidence that a hospital meets Medicare conditions of participation
Summary
IGNORANCE of the Law is no excuse
Know the regulations
Identify which ones are pertinent to the facility
Ensure that appropriate policies are in place
Document compliance
