01-06a - introduction to healthcare and public health in the us - unit 06 - regulating healthcare -...

Introduction to Healthcareand Public Health in the US

Lecture a

Regulating Healthcare

This material (Comp1_Unit6a) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number

IU24OC000015.

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Regulating Healthcare Learning Objectives

• Describe the role of accreditation, regulatory bodies, and professional associations in healthcare in the US. (Lecture a)

• Describe the basic concepts of law in the United States: the legal system, sources of law, classification of laws, the court system, and the trial process. (Lecture b)

• Describe legal aspects of medicine involving the Affordable Care Act, professional standards in healthcare, medical malpractice, Tort reform, and Medicare and Medicaid Fraud and Abuse (Lecture c)

• Describe key components of the Health Insurance Portability and Accountability Act (HIPAA) and current issues of privacy and patient safety in the US (Lecture d)

• Discuss the need for quality clinical documentation for the use of the health record as a legal document, communication tool and a key to prove compliance for healthcare organizations. (Lecture e)

2Health IT Workforce Curriculum Version

3.0/Spring 2012

Introduction to Healthcare and Public Health in the US Regulating Healthcare

Lecture a

Topics in This Lecture

• Nonprofit Accrediting Organizations– The Joint Commission (JC)– URAC (formerly called Utilization Review

Accreditation Commission) • Regulatory Agencies• Professional Associations


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Lecture a

Joint Commission (JC) History

• 1910: The forerunner of JC is called the “end-result” system

• 1951: Joint Commission on Accreditation of Hospitals (JCAH) is created and starts accrediting and certifying healthcare organizations

• 1987: Name changed to Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

• 2007: Name simplified to Joint Commission (JC); currently accredits and certifies more than 18,000 organizations and programs in the US


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Lecture a

Joint Commission (JC) Mission

“To continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.”

(The Joint Commission, 2011)


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Lecture a

Joint Commission (JC) Accreditation

• Earned by an entire healthcare organization (hospital, nursing home, office-based surgery practice, etc.)

• Tools the JC uses to measure performance– Integrated Survey Process (ISP): Evaluates

performance across organization– ORYX: System for healthcare organizations to report

to the JC about patients with certain conditions (core measure sets)

• The core measure sets reported depend on the type and size of the organization


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Lecture a

ORYX: Core Measure Sets• Examples

– Heart attack– Pneumonia– Inpatient psychiatric care– Children’s asthma– Stroke

• Each core set has performance measures– For example, the JC looks at whether children

with asthma received certain drugs in the hospital and were sent home with a management plan


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Lecture a

Joint Commission (JC) Certification

• JC-accredited organizations and providers of healthcare staffing services can also earn certification for specific programs or services– For chronic diseases and conditions

• Examples: asthma, diabetes, heart failure programs

– Programs can be within the medical center or in the community


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Lecture a

Joint Commission (JC) Patient Safety Activities

• National Patient Safety Goals• Universal Protocol• Office of Quality Monitoring• Speak Up™ program• Sentinel Event Policy


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Lecture a

URAC

• Formerly known as the Utilization Review Accreditation Commission (URAC)

• Mission: “To promote continuous improvement in the quality and efficiency of healthcare management through processes of accreditation and education”

• Has more than 25 accreditation and certification programs for various types of healthcare organizations

(URAC,2011)


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Lecture a

URAC HealthIT Accreditation

• Outlines best practices for an effective compliance program, including:– Health websites– HIPAA (Health Insurance Portability and

Accountability Act) privacy and security• Designed for a wide range of organizations

involved in healthcare IT• See http://www.urac.org


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Lecture a

URAC HealthIT Accreditation (continued)

• These healthcare organizations must comply with HIPAA:– Health plans—health insurance companies,

employer-funded health plans, and government programs that pay for healthcare, such as Medicare or Medicaid

– Health care providers that conduct certain tasks electronically

– Health care clearinghouses(organizations that process health information)


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Lecture a

Regulatory Agencies

• Public authorities at state or federal level, established by legislative act to enforce standards in a specific field in the private sector

• Agency’s regulations = laws• Agency might conduct hearings and hand down

judgments• Goal is consumer protection• Example: Food and Drug Administration (FDA)


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Lecture a

Food and Drug Administration (FDA) Overview

6.1 Figure: As part of Department of Health and Human Services, the FDA is charged with oversight of these areas. (FDA, 2011)


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Lecture a

FDA Mission

• Protect public health– Regulates drugs

• Performs drug approvals• Provides drug safety information• Spreads the message about medication errors

– Helps speed up product innovations– Helps public obtain accurate science-based

information


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Lecture a

Professional Association

• A nonprofit organization that wants to support:– A particular profession– The interests of individuals engaged in that profession– The public interest

• Sets requirements:– For entry into the profession—possibly requires

license or certificate– For maintaining membership in the profession

• Members generally have a significant amount of education, training, or experience

Health IT Workforce Curriculum Version

3.0/Spring 2012


Lecture a

16

American Board of Medical Specialties (ABMS)

• Description: “An organization of medical specialty boards with shared goals and standards related to the certification of medical specialists”

• Member boards certify specialist physicians– Also subspecialists; for example, adolescent

medicine is a subspecialty of family medicine• Board certification differs from licensure, which

sets minimum competency for physicians


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Lecture a

17

American HospitalAssociation (AHA)

• 5,600 organizational members• 41,000 individual members• Major programs

– Advocacy– Resource center (47,000 books on healthcare)– Health Planning and Administration (HEALTH)

database– Annual survey of US hospitals– Reports and studies


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Lecture a

18

American MedicalAssociation (AMA)

• 240,000 members– Physicians with an MD or DO degree, or a recognized

international equivalent– Resident physicians and fellows– Medical students

• Major programs– Resources for physicians– Advocacy– Publishing medical journals


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Lecture a

Regulating HealthcareSummary – Lecture a

• Hospitals and other healthcare organizations are accredited by the Joint Commission

• The Joint Commission also certifies specific healthcare programs and conducts patient safety activities

• URAC accredits and certifies a wide range of healthcare organizations, and it has an accreditation program for IT professionals

• Regulatory agencies such as the FDA protect consumers by setting and enforcing standards

• Professional associations govern their members but not the public at large


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Lecture a

References• American Board of Medical Specialties. http://www.abms.org. Accessed April 12, 2011.• American Hospital Association. http://www.aha.org. Accessed April 12, 2011.• American Medical Association. http://www.ama-assn.org. Accessed April 12, 2011.• Peck P. AMA: after one-year increase, AMA membership declines again. June 25, 2007.

http://www.medpagetoday.com/MeetingCoverage/AMA/6006. Accessed April 12, 2011.• Regulatory agency (definition). Encyclopedia Britannica.

http://www.britannica.com/EBchecked/topic/496265/regulatory-agency. Accessed April 12, 2011.• The Joint Commission. http://www.jointcommission.org/facts_about_the_joint_commission / Accessed April 12,

2011.• US Department of Health & Human Services. Understanding health information privacy.

http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html. Accessed April 12, 2011.• US Food and Drug Administration. http://www.fda.gov. Accessed April 12, 2011.• URAC. http://www.urac.org. Accessed April 12, 2011.

Charts, Tables, Figures6.1 Figure: Part of Department of Health and Human Services, charged with oversight of the areas displayed.

http://www.fda.gov/ . Accessed April 12, 2011.


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Lecture a

Regulating HealthcareReferences – Lecture a

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