Healthcare Chapter 9: Patient Care Flashcards

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Questions and Answers

What process is defined in the healthcare facility for sharing patient information?

Train staff

Manage billing procedures

Receive or share patient information (correct)

Conduct surgery

A clear picture of the patient's requirements must be developed for which groups?

The primary care provider

Home health agencies

Family or friends

All of the above (correct)

Coordinating care services only involves scheduled appointments.

False

What specific information must be given to the patient regarding their care after discharge?

Information regarding exercise and activity levels, medication regimens, weight monitoring, sexual activity, and acceptable dietary habits. Signup and view all the answers

What is the purpose of the ORYX initiative?

To include core measure sets based on healthcare services provided and required by Medicare participants. Signup and view all the answers

What is patient care?

A systematized approach to PI that can ultimately benefit the patient. Signup and view all the answers

What do accrediting and licensing entities expect from healthcare organizations?

To choose appropriate measures for services offered Signup and view all the answers

Match the following core measure sets with their description:

Surgical Care Improvement Project = Measure for surgical care quality Heart Failure = Care standards for heart failure patients Acute Myocardial Infarction = Guidelines for heart attack treatment Pneumonia Measures = Standards for pneumonia treatment Stroke = Care coordination for stroke patients Signup and view all the answers

Every interaction within the healthcare system provides an opportunity to improve what?

Care processes for patients and their families. Signup and view all the answers

The use of restraints is monitored mainly to ensure patient safety.

True Signup and view all the answers

What can initiate the PI cycle?

The individual medical requirements of a single patient. Signup and view all the answers

What is the critical factor in optimizing the care of patients?

The organization's ability to improve the patients' understanding of their health, ability to care for themselves, independence, and quality of life. Signup and view all the answers

The handling of blood products for transfusions must comply with __________.

regulations and monitoring standards Signup and view all the answers

What must the organization validate before a blood transfusion?

The need for the transfusion and the use of the appropriate type of blood product. Signup and view all the answers

What is the goal of PI in healthcare?

To design and implement systems that provide consistency and quality in all of the patient care processes. Signup and view all the answers

With respect to the provision of care, treatment, and services, what do PI efforts provide?

A process for evaluating every service, provider, setting, and outcome. Signup and view all the answers

The primary care provider has no role in post-discharge patient care.

False Signup and view all the answers

What are the four core processes involved in care, treatment, and services to patients?

Assessing patient needs, planning care, providing care, and coordinating care. Signup and view all the answers

What should be the focus of improvement processes tied to patient-specific data?

The care processes provided at any given facility. Signup and view all the answers

What activities are utilized in providing the four core processes involved in care?

Assessing and providing appropriate access to levels of care, providing interventions, and teaching patients about their care. Signup and view all the answers

What does the Patient Care Process Cycle begin with?

The patient's initial assessment. Signup and view all the answers

What is the cornerstone of good patient care?

The initial assessment. Signup and view all the answers

What types of assessments are required in the initial patient assessment for admission?

Physical, psychological, social, nutrition, hydration status, and functional status, among others. Signup and view all the answers

What items are typically included in an initial alcoholism and substance abuse disorders type of assessment?

Religious beliefs, living situation, financial status, and history of abuse, among others. Signup and view all the answers

How must a pain assessment be conducted?

On admission for level of pain and any management tools used regularly. Signup and view all the answers

What does teamwork in healthcare ensure?

Clinical activities are properly integrated and executed. Signup and view all the answers

What is required for the successful implementation of care pathways?

Continuous monitoring of the patient's status. Signup and view all the answers

How are family members involved in patient assessments?

As a source of data collection if the patient is not capable of providing coherent information. Signup and view all the answers

What is the expected eventual outcome of coordinated care?

An improvement in the patient's condition allowing discharge to home or another care setting. Signup and view all the answers

Study Notes

Patient Care Definition and Importance

Patient care is a systematic approach aimed at improving individual patients' health within the healthcare system.
It involves a complex process starting from the point of entry, spanning brief ED visits to chronic illness management.

Continuous Improvement in Care

Each interaction within the healthcare system provides opportunities to enhance care processes for patients and their families.
Individual medical requirements can initiate the Performance Improvement (PI) cycle.

Optimizing Patient Care

Key factors for optimizing care include enhancing patients' understanding of health, self-care ability, independence, and overall quality of life.

Goals of Performance Improvement

PI aims to design consistent and quality systems across all patient care processes to enhance health outcomes.

Core Processes in Patient Care

The four core processes include assessing patient needs, planning treatment, providing care, and coordinating services.
Activities involved encompass access to care levels, interventions, patient education, and coordination during referrals or discharges.

Patient Care Process Cycle

The patient care process is cyclical, initiated by an assessment and concluding with discharge or referral, often repeating throughout the course of treatment.

Assessment of Patient Needs

The initial assessment is critical for determining admission appropriateness and care level; it must consider physical, psychological, and social variables.
Importantly assesses nutrition, hydration status, functional capability, and cultural influences.

Additional Assessment Considerations

Assessments also cover legal status, abuse history, substance use disorders, and emotional/behavioral disorders.
A thorough examination of alcohol and substance abuse includes history, patterns of use, and treatment responses.

Comprehensive Pain Management

Pain assessments must occur upon admission, accounting for management tools suited to the patient's context and needs.
Both physical and emotional assessments are required to guide treatment.

Family Involvement

Family members can provide essential data for assessments if the patient is unable to participate fully.

Care Planning and Implementation

A collaborative, individualized care plan based on a comprehensive assessment is developed early in treatment.
Goals and interventions are established by the care team, with a focus on prioritizing the most urgent needs of the patient.

Teamwork and Coordination

Effective patient care depends on collaborative efforts among healthcare professionals.
Regular team meetings facilitate decision-making, responsibility assignment, and ongoing situational awareness concerning patient care.

Cultural and Individual Considerations

Care pathways must reflect cultural values and individual patient needs, engaging families in the care process while maintaining privacy.

Core Process Outcomes

The ultimate outcome of coordinated care is improved patient conditions facilitating discharge to home or another health setting.
Assessment, planning, treatment, and re-assessment form an integrated flow of care aimed at enhancing positive health outcomes.### Patient Information Exchange
Defined processes exist for sharing patient information during referrals to internal or external care providers.

Patient Requirement Assessment

Develop a clear picture of patient needs for primary care providers, community resources, family assistance, and rehabilitation settings post-discharge.

Care Coordination

Involves resolving appointment conflicts, preventing service duplication, and ensuring timely care delivery according to patient needs.

Patient Education Post-Discharge

Patients must receive specific information on exercise, medications, dietary habits, and actions to take if their condition worsens post-discharge.

Measuring Patient Care

Patient care treatment can be quantified in various ways to identify issues, ensure regulatory compliance, and improve processes.

Measuring Interventions

Some interventions, such as administering preoperative antibiotics, are easier to measure than their effects on individual patient outcomes.

Variation in Medication Response

Differences among patients can affect medication efficacy; improvement processes must be aligned with patient-specific data.

Review of Patient Care Outcomes

An outcome review aims to enhance safety and quality of care and verify the necessity and appropriateness of medical treatment.

ORYX Initiative

Introduced by the Joint Commission in 1997; it requires organizations to collect performance data and is mandatory for CMS participants.

Performance Data Collection

Collecting outcomes-related performance data enables trend analysis among similar organizations to improve care processes.

Core Measure Sets

Includes various metrics such as Surgical Care Improvement, Heart Failure, Acute Myocardial Infarction, and more for standard care evaluation.

Accrediting Bodies Standards

Healthcare organizations must select appropriate measures reflecting their services, with data reported through performance improvement systems.

Joint Commission Scoring

Core measure data contributes to accreditation scoring, ensuring healthcare facilities maintain quality standards.

Evaluating Seclusion and Restraint Use

Facilities must have behavior management policies approved by clinical leaders dictating permissible and impermissible behavior management techniques.

Prohibited Procedures

Actions that could psychologically or physically harm a patient, such as denial of needs, corporal punishment, or fear tactics, are not allowed.

Compliance Guidelines for Restraints

Restraint usage must adhere to facility, state, and federal guidelines, included in the patient's written care plan.

Protective Restraint Devices

Include wrist restraints, surgical stabilizers, and side rails, aimed at preventing harm during specific interventions.

Risks Associated with Restraints

Restraints increase risks of patient deaths and legal issues, necessitating continuous monitoring during use.

Initial Assessment for Restraint Needs

Assessments must be conducted upon admission, discussing intervention alternatives with the patient and family, documented accordingly.

Credentialing for Restraint Practitioners

Only licensed practitioners trained in restraint application and procedures may assess and apply restraints, with documented competency.

Leadership Commitment to Patient Care

Documenting a facility's commitment to reducing seclusion and restraint practices is crucial for maintaining care quality.

Staff Training Focus

Training emphasizes de-escalation techniques, safety procedures, and organizational philosophy pertaining to restraint use.

Reducing Restraint Frequency

Performance improvement processes aim to minimize risks connected to restraint and seclusion procedures.

Regulatory Concerns on Restraints

Accrediting bodies emphasize restraint and seclusion practices in long-term care settings due to rights infringements and identified risks.

Policy Compliance for Restraints

Policies that ensure compliance with accrediting bodies' mandates for restraint and seclusion must be created and followed.

Distinction in Restraint Regulations

Regulations differ for non-behavioral vs. behavioral health patients, with multiple performance indicators required for restraint use.

Restraint Limitations

Restraints can only be used in emergencies to prevent imminent harm when non-physical interventions fail.

Evaluating Laboratory Services

Compliance with standards and monitoring of laboratory equipment and specimen handling is necessary for quality assurance.

Laboratory Regulations

Governed by Clinical Laboratory Improvement Amendments (CLIA) and CDC protocols, requiring daily monitoring of laboratory values.

Blood Product Handling

Continuous monitoring of blood product ordering, handling, and administration is critical to ensure patient safety.

Transfusion Need Validation

The review process aims to confirm the necessity for transfusions and proper administration procedures.

Patient Identification Protocol

NPSG 01.01.01 mandates using two patient identifiers during medication and blood administration for safety.

Specimen Collection Standards

Two identifiers must also be used when collecting blood samples, ensuring accurate labeling occurs in the patient's presence.

Blood Verification Implementation

Blood product matching prior to transfusions involves a two-person verification or automated technology processes.

Investigating Transfusion Reactions

Any transfusion reaction must be investigated to identify root causes, primarily linked to identification failures.

Risk Reduction Strategies

Effective strategies include in-service training, improved patient identification, and environmental redesign to reduce specimen mishandling.

Medication System Evaluations

Examining medication systems addresses complexity and potential errors, making it a focus for accreditation and improvement efforts.

Multidisciplinary Policy Development

Policy, procedure, and documentation development should involve a multidisciplinary approach, ensuring comprehensive standards adhered to.

Policy Updates and Review Responsibility

Governing boards are responsible for updating policies according to national standards, with timelines set for periodic reviews.

Documentation Quality Concerns

Reliable documentation is crucial for patient care quality; poor documentation increases risk management and legal challenges.

Documentation Standards by Agencies

Accreditation agencies require documentation samples to be regularly reviewed to ensure conditions and treatments are accurately recorded.

Verbal Order Documentation Standards

Each licensing agency sets specific timeline requirements for signing off verbal orders to ensure timely documentation.

Evaluation of Care Standards

Establishing clinical decisions and actions aligned with legal regulations is essential for optimizing care procedures in healthcare organizations.

Clinical Practice Standards Model

Some organizations have shifted to diagnosis-based clinical practice standards, assessing interventions against accepted care standards.

Performance Examination and Action Planning

Baseline performance metrics lead to evaluations of care variations, identifying sentinel events requiring action for improvement.

Need for Further Evaluation

Declining performance metrics or lack of improvement may necessitate redesigning care processes and comparison with peer performance.

Importance of Continuous Development

The performance improvement processes represent ongoing efforts to enhance patient care following accreditation and national developments.

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Description

Explore the critical concepts of patient care as outlined in Chapter 9 of the QP in Healthcare. This flashcard set emphasizes the systematic approaches to improving the provision of care, treatment, and services in the healthcare system. Ideal for both students and professionals aiming to enhance their understanding of patient care processes.