FACHE Board of Governors Exam Study Group

1. FACHE Board of Governors ExamStudy Group Knowledge Area: Healthcare Brian Sweeney, RN, FACHE Vice President for Clinical and Support Services Thomas Jefferson University Hospitals

2. Exam Overview • Test blueprint – www.ache.org • Section weight on test – 17% • Questions – 34 • Description – “This area includes a broad range of organizations and professions involved in the delivery of healthcare. Included are managed care models, healthcare trends, and ancillary services.”

3. Elements of Knowledge • Healthcare and Medical Terminology • Healthcare Trends • Healthcare Funding and Structures • Services Across Continuum of Care • Levels of Service • Types of Healthcare Providers • Ancillary Services

4. Elements of Knowledge • Support Services • Integration of Healthcare Sectors • Clinician Roles and Criteria • Evidence Based Management • Staff and Functional Role Perspectives • Patient Perspectives • Interrelationship of Access, Quality, and Cost

5. Medical Terminology

6. Health • WHO definition – state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity • Blum’s model – 4 inputs: environment, lifestyle, heredity, and medical care • Medical model – absence of illness or disease • Holistic model – spiritual, physical, mental, and social elements are necessary for well being

7. Definitions • Activities of daily living – eating, bathing, dressing, toileting, continence, out of bed • Acute condition – severe, short, treatable • Chronic condition – exacerbates over time and may never go away or wax and wane • Ambulatory care – non-inpatient services • Continuum of care – longitudinal coordination across different providers • Primary care – main provider and referrer

8. Definitions • Population health – outcomes of group of managed individuals • Incidence – new cases in time period • Prevalence – cases at point in time • ICD-9-CM – classification of morbidity and mortality • DRG – Medicare classification for reimbursement • CPT – coding system for procedures • Shared governance – staff engaged in leading operations

9. Healthcare Trends

10. Macroeconomics • Global recession • 18.2% of GDP is healthcare • Baby boomers increasing • Medicare insolvency • Uninsured growing • Employer benefit cost skyrocketing – can’t be competitive with other nations

11. Industry Trends • Reduction in acute care beds – excess • Declining hospital operating margins • Shift from inpatient to outpatient care • Increased focus on population health • Transformation to pay for performance • Purchasers of services driving changes • Consumers slow to engage • Pricing transparency

12. Industry Trends • Increasing competition • Increasing physician and staff shortages • Deployment of evidence based medicine • Technology changing rapidly • Specialty and niche providers growing • Physician employment • Leading causes of death – heart disease, stroke, and cancer

13. Question What population factor is currently having the greatest impact on healthcare organizations? • Ethnic composition • Economic status • Geographic distribution • Age cohort

14. Question What age group will consume the greatest per capita healthcare resources in the 21st century? • 75 years and over • 65-74 years • 45-64 years • 0-1 year

15. Healthcare Funding and Structures

16. Payers • Government • Medicare • A - hospital • B – medical/physician office visits • D – outpatient prescription drugs • Medicaid – state and CHIP • Commercial insurance/managed care • Fee for service/individual • Employer role

17. Managed Care • Original focus - cost control • Primary care gate keeper • Preferred network providers • Co-payments/deductibles • Provider risk sharing/incentives • Provider report cards • Hospital response - consolidation for leverage • Consumer response - dissatisfaction

18. Managed Care Models • HMO (Health Maintenance Organization) • PHO (Physician-Hospital Organization) • IPA (Independent Physicians Association) • PPO (Preferred Provider Organization) • POS (Point of Service) Plan

19. Question Consumer report card development and distribution has become a high priority for managed care organizations because: • Measurements of performance have now become well-established, standardized, and accepted by all parties • Purchasers are pressuring for disclosure of meaningful performance information for use by buyers and consumers • Consumers in healthcare are now well-organized, and managed care organizations feel a need to satisfy them • Physicians are increasingly encouraging their patients to evaluate managed care organizations based on these report cards

20. Question The agency normally responsible for regulation of the financial solvency and subscriber regulations of HMOs is the: • State insurance commission • U.S. Department of Commerce • U.S. Department of Health and Human Services • Department of Taxation

21. Services Across Continuum of Care

22. Prevention and Non-Acute Care • Primary prevention – reduce odds disease develops • Secondary prevention – early diagnosis/treatment • Public health role • Primary care physicians • Federally qualified health centers – targets medically underserved

23. Ambulatory Care • Physician practices • Multi-specialty centers • Lab • Imaging • Infusion centers • Ambulatory surgery centers (ASC) • Emergency departments

24. Acute Care • The hospital remains the institutional center of the U.S. healthcare system • 2 major agencies that count and classify hospitals: • AHA (Amer Hosp Assn) • NCHS (Natl Ctr for Health Stats) • Hill-Burton Act – 1946: drove growth through grants and loans

25. Acute Care • Community hospitals • Teaching hospitals • Religious-affiliated hospital • Academic medical centers • Specialty hospitals • Critical access hospitals - <25 beds, >35 miles from other hospital, Medicare pays costs

26. Hospital Ownership • Private • Non-profit • Community benefit requirements – charity care • Form 990 • For-profit – investor owned • Public – federal, state, county

27. Post Acute and Sub-acute • Assisted living • Long term care • Home health • Hospice and palliative care

28. Question Investor-owned healthcare systems are usually distinct from nonprofit systems because: • Investor owned healthcare systems provide no uncompensated care • Members of the medical staff of investor-owned healthcare systems may use any healthcare facility owned by the corporation • Investor-owned healthcare systems consolidate balance sheets • Local boards have governing authority

29. Question The primary reason for the decision to move from a freestanding voluntary facility to an investor-owned healthcare organization is: • Economy of scale • Access to the equity market • Access to patients • Improved visibility in the community

30. Integration of Healthcare Sectors

31. Healthcare Systems • Organizational models • Integrated delivery system • Vertical integration – same services • Horizontal integration – different services • Ownership models • Alliances/networks • Joint ventures • Mergers/acquisitions

32. Question Which one of the following characteristics differentiates an integrated delivery system from a network or alliance? • The geographic distribution of its members • The corporate structure • Vertical integration • Horizontal integration

33. Question The principal advantage for an inpatient facility to affiliate with a geriatric care program is that such an arrangement: • Provides for the continuum of care for patients • Permits patients to receive care in the home settings • Requires less skilled personnel to provide care • Is less costly to the patient

34. Ancillary Services

35. Ancillary Services • Diagnostic • Lab • Radiology – ultrasound, MRI, IR • Cardiac catheterization lab • Therapeutic • Anesthesia - Radiation therapy • Respiratory - Social services • Pharmacy • Blood bank

36. Support Services

37. Support Services • Plant operations • Security • Environmental services • Patient transportation • Nutrition and dietetics • Patient services

38. Question Effective facilities maintenance depends on: • Life-cycle planning of equipment • An up-to-date inventory of equipment parts for replacement • A periodic update on a preventative maintenance schedule • Maintaining facilities on a preventive schedule

39. Question The method referred to as value analysis is used in inventory control activities to: • Make adequate substitutions for requisitioned items • Reduce the quantity of items issued to the various departments • Reduce costs without impairing functional efficiencies • Relate quantity and quality of items

40. Clinician Roles and Criteria

41. Physicians • Education • Medical school – MD, DO • Residency and fellowship • Credentialing – hospital function (medical staff office) • Knowledge, skill, ability • Licensure – State Boards of Medicine • National practitioner database • Types • Primary care • Specialists – medical/surgical

42. Physician Organization - Have their own medical staff organization - Focus: clinical quality, patient safety, compliance - Bylaws, rules, and regs approved by hospital board - Specific procedures for election of officers - Officers have authority to enforce rules of physician members - Officers delineate privileges of medical staff - Officers may recommend disciplinary actions

43. Nurses • Florence Nightingale – founder of modern nursing • Educational programs – diploma, associates, bachelors, masters • State licensure • Scope of services • Magnet designation - ANCC • Shared governance model

44. Other Roles • Allied health professionals – healthcare related professions and personnel who assist, facilitate, and complement the work of physician • Physician extenders – NP/PA • Credentialed • Under direct supervision of physician

45. Key Elements of Patient Care Models • Nursing – primary/team based • Multidisciplinary • Interdisciplinary plan of care (IPOC)

46. Question Planning for a patient’s discharge should begin at what point in the hospitalization? • After the physician writes the discharge order • On the day of discharge • On admission • One day after admission

47. Question Your board of trustees has voted to terminate the privileges of a physician. Which of the following organizations must you inform? • American Medical Association • Local medical society • National Practitioner Database • The Joint Commission

48. Question Magnet hospital designation includes an organizational commitment to all of the following except: • Professional autonomy over practice • Nursing control over practice environment • Competitive benefits for all nurses • Effective communication between physicians, administrators, and nurses

49. Evidenced Based Management

50. Key Elements • Guide clinical decision making based on know facts • Published research • Best practices • Benchmarking • National, state, or professional association standards • Health informatics