Module Components

• Overview
• Assignments

Topics

• Administrative Systems
• Reporting Requirements
• Managing Organizational Information Presentation

Nurs 736 - Technology Solutions for Knowledge Generation in Healthcare

Module 4: Managing Organizational Information

Reporting Requirements

Reporting Requirements for Centers for Medicare & Medicaid Services: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ClinicalQualityMeasures 

The National Database of Quality Indicators (NDNQI) is a database sponsored by the American Nurses Association that is used to collect and evaluate unit specific nurse sensitive quality indicators.  Some of the specific indicators are: 

• patient falls with and without injury
• pressure ulcers
• restraint prevalence
• healthcare associated infections.
• skill mix
• nursing hours per patient per day
• nurse turnover

Click the link for more information about NDNQI: https://www.nm.org/about-us/quality/quality-measures/sites-of-care/northwestern-memorial-hospital/national-comparisons/ndnqi-national-database-of-nursing-quality-indicators 

The Joint Commission (TJC) accredits and certifies more than 19,000 health care organizations.  Both accreditation and certification are achieved through evaluation of compliance with standards, demonstrated improvement in activities and verification of outcomes. 

In 1999, The Joint Commission in conjunction with a variety of stakeholders and the Centers for Medicare & Medicaid Services focused on the development of core measures that hospitals should collect and report. The initial measures common to both groups were related to acute myocardial infarction and heart failure. In 2003, TJC worked to align all the measures so there were a common set of measure specifications for Joint Commission accredited hospitals.

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. Core measure sets are:

1. Stroke
2. Venous Thromboembolism
3. Perinatal Care
4. Substance Use
5. Tobacco Treatment
6. Hospital Outpatient Department
7. Pneumonia Measures
8. Heart Failure
9. Acute Myocardial Infarction
10. Surgical Care Improvement Project
11. Hospital-Based Inpatient Psychiatric Services
12. Emergency Department
13. Children's Asthma Care
14. Immunization

Click the link for more information about The Joint Commission: http://www.jointcommission.org/