Read the Patient Safety and Quality Improvement Act of 2005 (FOUND BELOW) and review the information on the Measures (FOUND BELOW).
web page of The Joint Commission website. Pick one of the core measures
from the list on the right-hand side of this web page. For this
assignment, create a PowerPoint presentation in which you explain how a
hospital would typically put policies and procedures into place to
ensure that it is following your selected core measure.

In your presentation,

• Describe the core measure you chose.
• Analyze how your hospital will follow the requirements in the chosen core measure.
• Examine the penalties that will occur if this policy/procedure is not followed.

You are basically creating the policy/procedure and presenting it on the PowerPoint as if you were presenting to an audience.

Create a PowerPoint presentation using the guidelines below. Your
presentation must utilize at least two scholarly sources from the last
five to seven years, in addition to the textbook, that contain research
regarding how your policy and/or procedure would be put into place in a
hospital setting.

The Core Measures PowerPoint presentation assignment

• Must be five to seven slides (excluding the title slide and
  reference slides) and be formatted according to APA style.
• Must use speakers notes as follows: (GIRL VOICE PLEASE)
  • Review the PowerPoint Speaker Notes (Links to an external site.)Links to an external site. video tutorial. (YouTube Accessibility Statement (Links to an external site.)Links to an external site. & Privacy Policy (Links to an external site.)Links to an external site.)
  • Speaker notes are the typed notes that appear below the slide that
    complement the presentation slides. Whereas the slides will have short
    bulleted items, the speaker notes will be more detailed. They are
    essentially what the presenter would say during the presentation to
    explain each of the bulleted points on the slide. Therefore, it is
    important that the speaker notes are concise and detailed when
    explaining the bullet points.
  • It is recommended that PowerPoint Slides contain no more than five
    bullet points and should not contain more than seven to 10 words each.
    Do not type paragraphs or long sentences on the slide. The information
    that explains each bullet point is conveyed via speaker notes or by
    recording your voice to each slide.

• • The Patient Safety and Quality Improvement Act of 2005

    The
    Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41),
    signed into law on July 29, 2005, was enacted in response to growing
    concern about patient safety in the United States and the Institute of
    Medicine’s 1999 report, To Err is Human: Building a Safer Health System.
    The goal of the Act is to improve patient safety by encouraging
    voluntary and confidential reporting of events that adversely affect
    patients.

    The Patient Safety and Quality Improvement Act signifies the Federal Government’s commitment to fostering a culture of patient safety. It creates Patient Safety Organizations
    (PSOs) to collect, aggregate, and analyze confidential information
    reported by health care providers. Currently, patient safety improvement
    efforts are hampered by the fear of discovery of peer deliberations,
    resulting in under-reporting of events and an inability to aggregate
    sufficient patient safety event data for analysis. By analyzing patient
    safety event information, PSOs will be able to identify patterns of
    failures and propose measures to eliminate patient safety risks and
    hazards.
    Many providers fear that patient safety event reports could be used
    against them in medical malpractice cases or in disciplinary
    proceedings. The Act addresses these fears by providing Federal legal
    privilege and confidentiality protections to information that is
    assembled and reported by providers to a PSO or developed by a PSO
    (“patient safety work product”) for the conduct of patient safety
    activities. The Act also significantly limits the use of this
    information in criminal, civil, and administrative proceedings. The Act
    includes provisions for monetary penalties for violations of
    confidentiality or privilege protections.
    Additionally, the Act specifies the role of PSOs and defines “patient
    safety work product” and “patient safety evaluation systems,” which
    focus on how patient safety event information is collected, developed,
    analyzed, and maintained. In addition, the Act has specific requirements
    for PSOs, such as:

    • PSOs are required to work with more than one provider.
    • Eligible organizations include public or private entities, profit or
      not-for-profit entities, provider entities, such as hospital chains,
      and other entities that establish special components.
    • Ineligible organizations include insurance companies or their affiliates.

    Finally, the Act calls for the establishment of a Network of Patient
    Safety Databases (NPSD) to provide an interactive, evidence-based
    management resource for providers, PSOs, and other entities. It will be
    used to analyze national and regional statistics, including trends and
    patterns of patient safety events. The NPSD will employ common formats
    (definitions, data elements, and so on) and will promote
    interoperability among reporting systems. The Department of Health and
    Human Services will provide technical assistance to PSOs.

    For Additional Information

    To contact PSO Office staff, go to the PSO site at http://www.pso.ahrq.gov/contact/contact.htm.

    Page last reviewed October 2014
    Page originally created June 2008

    Internet Citation: The Patient Safety and Quality Improvement Act of
    2005. Content last reviewed October 2014. Agency for Healthcare Research
    and Quality, Rockville, MD.
    http://www.ahrq.gov/policymakers/psoact.html
  • MEASURES
    

    In early 1999, The Joint Commission solicited input from a wide variety
    of stakeholders (e.g., clinical professionals, health care provider
    organizations, state hospital associations, health care consumers) and
    convened a Cardiovascular Conditions Clinical Advisory Panel about the
    potential focus areas for core measures for hospitals. In May 2001, the
    Joint Commission announced four initial core measurement areas for
    hospitals, which included acute myocardial infarction (AMI) and heart
    failure (HF).

    Simultaneously, The Joint Commission worked with the Centers for
    Medicare & Medicaid Services (CMS) on the AMI, and HF sets that were
    common to both organizations. CMS and the Joint Commission worked to
    align the measure specifications for use in the 7th Scope of Work and
    for Joint Commission accredited hospitals. Hospitals began collecting
    AMI measures for patient discharges beginning July 1, 2002.

    In November of 2003, CMS and The Joint Commission began to work to
    precisely and completely align these common measures so that they are
    identical. This resulted in the creation of one common set of measure
    specifications documentation known as the Specifications Manual for
    National Hospital Inpatient Quality Measures to be used by both
    organizations. The Manual contains common (i.e., identical) data
    dictionary, measure information forms, algorithms, etc. The goal is to
    minimize data collection efforts for these common measures and focus
    efforts on the use of data to improve the health care delivery process.

• • Measures ( PICK ONE )

    • Acute Myocardial Infarction
    • Children’s Asthma Care
    • Emergency Department
    • Hospital Outpatient Department
    • Hospital-Based Inpatient Psychiatric Services
    • Immunization
    • Perinatal Care
    • Stroke
    • Substance Use
    • Tobacco Treatment
    • Venous Thromboembolism