Global Connect, Inc.
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October 26, 2013
Global Connect, Inc. Promoting the culture of safety, quality and excellence with CAT
CAT= Complete, Accurate and Timely communications/documentation!
We Promote Good Governance, Progressive Prosperity and Sustainable Security for all!
Best Business Practice via Good Governance Business Management
Survey Readiness Guide
Best Business Practice Guide
Remember: Safety, Security & Quality matters!
Evidence based Science demands consistent CAT documentation!
For Health Care Organizations
Our Passion is 2 Reach Our Individual & Collective Potential-Always
Our Motto: Do the Right Thing, in the Right Time and the Right Time- Always!
Good Business Practice: Promoting the Culture of “Safety, Wellbeing, Quality and Excellence
” Remember: …“If it is not documented, it did not happen!”
Global Connect Enterprises, Inc. Belai Habte-Jesus, MD, MPH
………Global Connect, Inc. …Promoting GPS …via… GRS… &… CAT Information Systems…… …….….GPS: Good Governance,. …Progressive Prosperity… &…. Sustainable Security… Via … GRS: Green Renaissance Activities…
CAT (Complete, Accurate ad Timely) Media and Information Systems!.
.. Connecting Talent, Innovation, Technology and Investments with Goods, Products and Services …………………..//………//Connecting… TiTi,……. 4… GPS…//… via GRS and CAT………//………………. **********************************************************************************************
Good Governance- Best Business Practice Guide
Table of Contents
1. Good Governance Structure (Value, Vision, Mis, objectives…04
2. Tools for monitoring Performance- Qualitative & Quantitative tools. …05
a. Research Pyramid –asking-(What, Who, When, Where, Why and How) .
b. CORT Analysis (Challenges, Opportunities, Risk and Threats)
c. NDSIM: Need, Demand, Supply Interaction Model
d. Option Appraisal (Best Option, Win-win Option & Compromise Option
e. Decision Science– Evidence based appraisals
3. Promoting the culture of of safety, quality and excellence..06
4. Measuring standards. Comprehensive set of skilled and non-skilled care..07
5. The role of Accreditation Surveys in quality measurement..07
6. SMART Goals, Objectives and Action Plans… 09
7. Accreditation Survey Activity List……10
8. Surveys Readiness……11
9. Pre-Survey Readiness..13
10. Readiness: During, Post Survey and Plan of Corrections…14
11. Calendar based Business Management..15
12. Sample Agenda, Minutes…16
13. Productivity reports- Daily, weekly, monthly, quarterly and Annual Reports…17
14. Notes and References…18
Promoting Good Governance & Best Business Practice
I. Introduction: Terms of reference and definitions.
•Good Governance: The administrative process of managing the resources of public and private enterprises in line with constitutional order, bylaws and shared policies and procedures, towards the desired and defined goal and outcome.
• Best Business Practice. The application of good governance process in the business setting with clear cut, value, vision, mission, goals, objectives and smart activities and implementation with qualitative and quantitative measures of success and according to the professional guidelines, policy and procedure towards the desired outcome. It is Good Practice to have SMART Work Plan and Document Productivity!
• Measure of success. A scientific measure that uses qualitative and quantitative tools for evaluating success as a percentage of compliance to the desired goal and outcomes. i.e., compliance at 100% measure of success. Good Governance= Administrative process that is Participatory, Transparent & Accountable to all stakeholders. GG= PSAT, Participatory, Stakeholder’s accountability and transparency
1.1 Value: Culture of Safety, Security and Excellence! -Our value is to promote the culture of safety, security, quality based prosperity and wellbeing for optimal functionality and performance.
1.2 Vision: 100% Compliance to professional standard! -To foresee a measure of success at 100% Compliance to state, federal and professional standards of quality and productivity.
1.3 Mission: Connecting talent and resources for excellence for success. To connect talent, creative ideas, innovation, technology, and resources for effective and efficient and equitable service that promotes the safety, security and quality of health of our client communities.
1.4 Goal: Promote the culture of excellence and success in all we do. To promote the culture of Safety, Security, Quality, wellbeing towards positive health outcome for individualized optimal functionality and performance of our clients.
1.5 SMART Objectives. Calendar based SMART (Specific, Measurable, Appropriate, Realistic and Time Sensitive) objectives towards results oriented measure of Success at 100% Compliance. SMART Activities. Calendar based activities/productivities that are based on qualitative and quantitative tools of monitoring performance towards 100% compliance to the desired goals and objectives.
II. Scientific Tools for Monitoring Good Governance and Good Business Practice
(Research Pyramid, CORT Analysis, NDSIM, Option Appraisals and Decision Science.)
2.1 Research Pyramid of asking scientific questions to understand Root Cause Analysis of threats, risks, challenges and opportunities. We use Research Pyramid that asks the basic scientific questions-(what, who, when, where, why and how) to undertake research so as to understand root cause analysis of challenges and opportunities for potential solutions.
2.2. CORT Analysis to convert challenges into opportunities. We use CORT (Challenges, Opportunities, Risks and Threat) Analysis towards understanding the issues by eliminating threats, reducing risks and converting challenges into opportunities. Remember: Some one’s challenges are another person’s opportunities!
2.3. NDSIM. Matching Demand, Price and Supply. The Needs, Demands, Supply Interaction Model is a unique tool for needs assessment, and for converting need into demand by price and timing modulations so as to promote a cost effective supply of resources that match the changing needs and demands of the market and clients. Remember: We pay the price that matches the value for goods, products and services within specific time frame of market activities.
2.4. Option Appraisal. This is a scientific tool of decision science, that addresses the different decision options in terms of value, outcome and time (immediate, short and long term impact), benefit and cost tool, by taking into consideration, the options of competitive interests of time, person and space.
Option appraisal is a systematic process that considers the key components of resource and time allocation, distribution and determination of market value from divergent stakeholders perspective, that is (the market, need, demand, price, supply and timely purchase decision, etc.) , that considers the major components of options of time, space, person, product/goods/services and matching resources towards feasible options of:
A. Best Option. The option that is best addresses issues in terms of person, space and person and compliant up to >90 % measure of success.
B. Win-win option. The option that promotes positive aspect of contending interests and compliant up to >80% measure of success.
C. Compromise Options. The option that addresses potential conflict of interests by looking for common shared interests, and compliant to up to >70% measure of success.
2.5 . Decision Science. Use of evidence based scientific tools towards promoting Good governance, Progressive Prosperity and Sustainable security that promotes (3A+3Es) within (CO& FO), that is affordability, accessibility, accountability for effective, efficient and effective (GPS), goods, products and service within (CO) constitutional order that is (bylaws, policies and procedure, etc.) and FO (Freedom of Choice) via (Governing Board, Professional Advisory Committee and Senior Management Team) led productivity reports towards measure of success at >99% Compliance to expected and desired outcome.
III. Good Governance, the basis of Safety, Quality and Security!
We promote GPS=Good Governance, Progressive Prosperity & Sustainable Security as the basis for safety, utility and excellence in all things we do. Our motto is to Do the right thing, in the right way and in the right time-always!
3.1. Good Governance= PSAT=Participation of Stakeholders for, Accountability and Transparency towards a successful performance that respects constitutional order, i.e., bylaws, policy and procedure, standards and desired goals and outcomes that reflect the changing need and client’s perception of care and services.
3.2 Progressive Prosperity and Wellbeing= We promote Comprehensive well being and prosperity of our clients that includes (Physical, Psychological, Emotional, Ecological, Social, Economical and Spiritual well being) with optimal functionality relative to the individual’s age, gender, (dis) ability and educational performance.
3.3 Sustainable Security= Promoting safety, security and positive health within a safe environment of care to meet the changing needs of the individual within the family and community setting.
3.4 Continuous Quality Improvement. Promoting regular proactive internal and external surveillance based performance monitoring via documented qualitative and quantitative tools and CAT (Complete, Accurate and Timely) information system for continuous quality improvement protocol that ensures a measure of success towards 100% Compliance.
IV. Measuring the Provision of Comprehensive set of skilled and non-skilled care
4.1 Individualized and comprehensive Service. Home Health provides a comprehensive set of skilled and non skilled care provided by skilled and non skilled professionals, that include mobile medical, nursing, therapies (PT/ST/OT), medical social services and home health care services that provide support to activities of daily living, that responds to the changing needs of individuals in the comfort of their homes, under the direction and guidance of their respective attending physicians.
4.2 Cost effective and user-friendly services. Providing care in the comfort/security of client’s home. As such home health care is considered to be the best form of cost effective and individual/client user-friendly care and services provided to individuals/clients in their own home environment, surrounded by their own families and community support systems.
4.3 Digitalized ehealth supported Mobile Home Health The success of Mobile home health is complemented by the advent of technological advancement, mobile health and eHealth system, (portable medical record system) and relevant privacy and insurance portability regulations such as HIPAA (Health Insurance Portability & Accountability Act) , and the advent of health insurance exchange market supported with results oriented evidence based science and medicine. Modern eHealth based Home health is user-friendly, cost-effective care and service with increasing benefit to the client community in their own safe home environment.
4.4 Affordable Care Act and Home Health 4.4.1 Cost effective Care. CeC-The ongoing lessons from the Health Care Reforms around the world, and the more recent US based ACA, (Affordable Care Act), otherwise popularly referred to “OBAMA Care” testify to the cost effectiveness and positive benefit of mobile home health care. It is considered the most viable option of care to home bound clients due to injury, disease and disability.
4.4.2 User-friendly and quality care. It is preferred due to its appropriateness and responsiveness to the changing needs of home bound clients, with clear cut guidance and support by their respective attending physicians with MD Plan of Care towards providing care and services to individuals in the comfort of their home is truly an “Idea whose time has come”!
4.4.3 Use of technology and patient choice. As such the advent of digitalized medical record system, face-to-face encounter requirements by the attending physician, the patient education and participation requirement in their care, supported by (HIPAA) privacy and portability of insurance and the exchange market is making home health care the ideal choice for quality and cost effective care. The general public and health professionals need to take notice of this unique opportunity and make it work to our respective client communities. “Mobile Home health” care is an idea whose time has come! It brings modern health care and technology to the patient’s home and communities.
4.4.5 Promoting the culture of safety, security and wellbeing. Our goal is to promote the culture of safety, security and wellness-based prosperity, towards results oriented positive health outcome, confirmed by measure of success towards client satisfaction and compliance to professional standards and desired goals.
V. The role of Accreditation Surveys in the healthcare setting.
5.1 Survey as a tool for quality measure. Accreditation is one of the critical tools that promotes consistent and constant assurance of quality and safety provided to home health care clients and is promoted by constant and consistent positive outcome based surveillance of licensing and certification surveys as well as accreditations and credentialing surveys with professional quality organizations and public and private insurance systems and credentialing authorities respectively. Surveys and interviews as well as productivity reports are critical tools of evaluation and measure of success of compliance to the accepted institutional and professional standards
5.2 Surveys as regular and Consistent Compliance tools. Regular accreditation, licensing and certifications surveys supported by periodic performance review/priority focused activities and processes are critical to ensure the compliance of home health agencies to the CMS Conditions of Participation and the professional Accreditation and Credentialing standards in line with the agencies written and approved policies and procedures.
5.3 Surveys as Year round compliance activities measuring tool. As such surveys be it licensing, certifications, accreditation and credentialing are not a one time event but a consistent annual event supported by a series of weekly productivity reports, monthly senior management reviews, quarterly Professional Advisory Committee reports and Annual Governing Board reviews of compliance.
5.4 Use of Qualitative and Quantitative tools. As such surveys are important tools of qualitative (satisfaction surveys, interviews) and quantitative (ratios, percentages and trends) compliance measures toward a consistent measure of success of compliance.
5.5 Use of Measure of Success for effective compliance. Modern Quality Assurance Protocols use qualitative and quantitative monitoring tools towards a desired outcome that is defined with a measure of success as a percentage of compliance as percentage of the desired goals and outcomes, i.e., >99% of compliance.
5.6 Survey Desired Outcome: Compliance and full accreditation The purpose and ultimate aim of all surveys is to ensure consistent compliance to policy and procedures as well as professional standards for effective certification, licensing and full accreditation and credentialing. As such, periodic surveillance, be it qualitative and quantitative is a vital tool of ensuring consistent compliance at all times.
5.6.1 Survey Objective: Compliance evaluation: o Tracer Activities (individual and system based), looking at high risk areas and complex service systems, as well as Staff and Leadership Interview, observation, analysis and report for root cause analysis towards solution recommendation and action plans for corrections towards consistent compliance of standards. o Continuity of Care (CoC) for care in multiple disciplines and institutions
o Coordination of Care(CoC) for complex cases-multi-disciplinary care within and without the same institutions
o Infection prevention and control program- universal precautions towards integument care, orifices, wound, surgical sites, etc. o Medication Management: name of drugs, dose, frequency, side effects and complications
o The surveyor evaluates the organization’s compliance to professional standards, federal, state and local requirements including CMS Conditions of Participation for HHAs as they relate to the care and services provided to individuals/patients/residents, etc.
5.6.2 Compliance Measure: Qualitative and Quantitative Tools towards percentage (%) compliance as a measure of success.
1. Evaluation: Design, Process and Outcome
2. Monitoring Tools: Qualitative Measures: Satisfaction Surveys, Group and individual interviews and quantitative productivity measure of success reports
3. Measure of Success. Quantitative Measures: Productivity reports in terms of numbers, percentage (%), ratios, proportions, trends over time.
4. Evidence based Outcome. Presentation of data in reports, columns, lines, areas, bars, tables, pie charts, scatter, trends, etc.
5. Sample trending charts: Bar Charts, Pie Charts and trends Pie Chart Sample trending line
6. Recommendations. Option, Solutions and Action Plans
A. Options: Meeting Divergent interests in person, space and time
i. Best Option. Option that meets the needs of all stakeholders in person, space and time (90-100%)
ii. Win-Win Option. Option that meets divergent interests/demands at least 80-90%)
iii. Compromise option. Option that meets the divergent interests/demands at least 70-80%
B. Solutions. SMART Action Plan
i. Activity, responsible person, time frame/deadline
ii. Monitoring tool: Qualitative and Quantitative
iii. Quality Assurance Protocol: Productivity reports of compliance
VI. SMART Goals, Objectives and Action Plans
1. Specific. Identify specific goal, objectives and activities for action
2. Measurable. Measure the activity via reliable tools (qualitative and quantitative)
3. Appropriate. Ensure the activity is appropriate to the specific issue at hand
4. Realistic. Ensure the activity is realistic in responding to the challenges at hand.
5. Time Sensitive. All activities need to be calendar based and time sensitive
5. The SMART Goal: Prepare a Survey Readiness Package at Pre and Post Survey settings.
1. Pre-Survey Readiness
2. During Survey Readiness
3. Post Survey Readiness
4. Plan of Correction Readiness
5. Measure of Success Readiness
6. Periodic Performance Review Readiness
7. Priority Focus Area Readiness
VII. Accreditation Program Document List and Survey Activity List
A. Pre-Survey Planning Sessions
B. During Survey Sessions
C. Post Survey Sessions
D. Plan of Corrections and Compliance Review
E. Calendar based Periodic Performance Review of Consistent Compliance (at weekly, monthly, quarterly and annual interval)
7.1 Preparation and practice with a checklist of activities is key to the success of health care organizations in their effort for successful accreditation.
7.2 Checklist based preparation. The preparation process begins with a checklist for each area of activity and standard of care supported with appropriate measure of success
7.3 Use of monitoring tools. Qualitative and quantitative tools are used for ensuring in the utilization of Quality Assurance Protocol towards a measure of success at>90% or 100% compliance.
7.4 Measure of success via productivity tools. Involves using SMART productivity tools that match the standard and its effective implementation towards a measure of success at >99% compliance.
7.5 Follow up of Checklist. It is always a good idea to have a follow up checklist for each activity and provide evidence of written activities that is dated, signed by all participants.
VII. Pre-Survey Readiness
i. Survey Readiness Documentation
1. Greeting surveyors. Identify staff at the main entrance of the organization: ____________________________________________________________________________
2. Verify Surveyor’s identity. Look for identification badge, a picture ID. _____________________________________________________________________________
3. Who to notify on the arrival. Identify leaders: Administrators, Alternate Adm and DON: names and telephone numbers:_____________________________________________________________________
4. Pyramid Communication List of names, phone numbers, text and email address ____________________________________________________________________________
5. Surveyor contact person during the survey:_____________________________________________
6. Identify alternate individuals:______________________________________________________
7. Identify a location for surveyors as you contact the leadership team ____________________________________________________________________________
8. Identify a location for surveyors that will serve as a base: Usually a conference room with a desk, phone, electrical and internet access ____________________________________________________________________________
9. Validation of Survey. Person responsible for the validation of the survey and surveyors:___________________________________________________________________
10. Readiness Guide and Accreditation Program-specific documentation Lists _____________________________________________________________________________
11. Individual tracer survey: identify who will escort the surveyors _____________________________________________________________________________
12. Identify person who will assist in the review of electronic records of care ______________________________________________________________________________
13. Priority Focus Process. Clinical Servicer Groups and Priority Focus Areas ______________________________________________________________________________
14. Customer Value Assessment: What is important to you and your stakeholders?
15. Promote the culture of Safety, Quality and Excellence to clients, staff and surveyors at all time! Show evidence of compliance: Documentation, charts, trends, qualitative & quantitative tools
16. Evidence of OSHA & Civil Rights regulation compliance- culture of safety & wellbeing Access to :
o Access to nearest Exit
o Electrical outlets
o Ease of use
o Fire, exhaust
o Fall Prevention
o Safety & Wellness
o Mobility, gait, coordination
o Compliance to Civil Rights Regulation
o Professionalism Diversity: Age/Sex/race o Disability/Gender o Nationality/culture
o Environment of Care
o Equal opportunity
o At will employment
o Universal Precautions
o Hand Washing Program o National Patient Safety Goals
o Emergency Management
o Vulnerability Anal
o Risk Assessment
o Emergency Management
o Coordination with local, state and federal agencies.
o Periodic Performance Review
o Priority Focus Areas o Productivity Reports
VIII. During Survey Sessions
A. Leadership, HR, Clinical and Fiscal Management Documentation
1. Governance: Article of Incorporation, Bylaws and Organizational Structure, licenses: state, federal, CLIA, Accreditation and Credentialing Certifications, Contractual Agreements, etc.
2. Review of Policies and Procedures: Human Resources, and Operational Manual, Patient and Staff Orientation Manuals.
3. Productivity Reports: Governing Body, Professional Advisory Committee, Senior Management Team: Weekly minutes and productivity reports
4. Authorizations. Job Descriptions and Appointment Letters and Performance Evaluation
5. MIS/Management Information System: HIPAA Compliance: CAT Documentation, Storage, Retrieval and distribution; Compliance to health record system, OASIS/485, Visit notes, etc.
6. Performance Review. Organizational, Clinical, Fiscal and HR Performance Evaluation Reports
7. Performance Improvement Documentation: Governance, HR, Clinical, Fiscal Documentation
B. Environment of Care
1. Safety and Wellbeing: National Patient Safety Goals and Emergency Management Compliance 2. Home safety- Safety checklist, Oxygen signs, fire extinguishers, smoke alarm
3. Medication error. Do not use abbreviations and approved abbreviations
4. Medication management policy: High risk medications and Look alike and Sound Alike (LASA) drugs list, name, dose, frequency, duration and contra-indications and side effects
5. Emergency Management: Vulnerability Analysis and Risk Assessment and Drills, Pyramid communication list of staff and patients: name, address, contact numbers, diagnosis, insurance, 6. Level of Care: Levels I, II, III Assessment at admission, care, transfer and discharge
7. Universal Precaution. Infection Prevention and control, hand washing, body fluids
8. National Patient Safety Goals: Patient ID, Medication ID: dosage, frequency, duration, side effects and contraindication, medication safety and reconciliation.
C. Plan of Care: Professional Plan of Care-MD/RN/PT/OT/ST/MSW/HHA
1. Admission Protocol: Referral, Demographic data, Insurance verification, billable hours & MD Plan of Care with Written and Signed orders.
2. Assessment and Re Assessment Policies. MD Plan of Care, RN/Therapy Care Plan, HHA Care Plan, Level of Care: I, II, III.
3. Coordination of Care and Continuity of Care: Evidence of compliance with Coordination/Continuity of Care documentation.
4. Case Conferences: Process and policy for case conferences, documentation evidence of compliance
5. Risk Assessment: Patient ID, Pain, Medication, Fall Prevention, Infection Control, Emergency Management, Perception of Care Assessment: PSS & PCR
6. Universal Precautions: Hand washing Program: policy, goals, surveillance data
7. Emergency Management Plan: Annual Drills and evaluation of drills
8. Perception of Care: Complaint Process and policy: Complaint Log, Investigation forms
9. PCR and PSS- Root Cause Analysis, investigation, recommendations and Follow up Action Plans
10. Fiscal Compliance: Budget, Financial Statement, Profit, Loss, AR and Surety Bond, DMEPOS
11. Medical Supply List: Medication list and Equipment Cleaning Policy- DMEPOS
12. Time management. Working hours and after hour on call log-
Mon-Friday and Weekend plans of work with daily and weekly productivity reports.
D. Compliance Checklists
1) Personnel/Human Resource: HR Compliance Checklist (10)
2) Clinical Operations: CO -Compliance Checklist (10)
3) Billing and Finance Compliance Checklist (05)
Selected personnel files for employees and contractors for review
Performance Monitoring and Improvement Documentation:
Show trends, charts, etc. Organization Review and Annual Evaluation
E. Documentation Required for Deemed Status Surveys
1. Unduplicated admission list for the past 12 months (Name, Address, tel no, Date of Admission Diagnosis, Disciplines: MD/RN/PT/OT/ST/MSW/HHA- Name and telephone numbers
2. Discharged patients for the past 12 months with Diagnosis, Start of Care and Disciplines
3. Last state survey report if applicable
4. PAC Meeting Minutes & Board Meeting Minutes
5. Annual Program Evaluation 6. Budget: Capital Expenditures for three years
7. Quarterly Record Review Documentation for past 12 months
8. HHA Training Program, and 12 months education calendar 9. OBQA/OBQI/HHA Provider Reports
a. OBQM: Adverse Outcome Report
b. OBQI: Avoidable Event Report/Outcome Report/Case Mix Report
c. OASIS Submission statistics by Agency
d. Error Summary Report by HHA
X. Home Care Accreditation Survey Activity List
Surveyor Arrival: Usually it is a good idea to expect surveyors to arrive any where at 7:30-7:45 for 8:00 am start of day as documented by the Agency under survey
10.1 Logistical Needs. Identify a location where a surveyor can wait for organizational staff greeting and for a base for surveyors through out the survey period.
1. Implement your Surveyor Readiness Guide
2. Notify Key Organizational Members
3. Validate the surveyor is legitimate
4. Access your Accreditation web site and read the introductory letter
5. Check surveyor name and biographical information
6. Scheduled survey dates
7. Priority Focus Process information. PFA and Clinical Service Groups (CSG)
8. Download your survey agenda
9. Gather and present documentation according to the Document List Application
10. A patient undergoing acute care re-hospitalization
11. A patient receiving personal care and support services
12. A patient receiving alternative or complementary care
13. A patient receiving oxygen therapy
14. A patient in a terminal condition
10.2 Guides to Mock-Tracer Individual and System Activity and Clinical Service Groups Selection Criteria: Cases with Complexity of care and potential risk for complications
A. High Risk patients. Individuals served related to system tracers such as
1. Infection risk. Infection control, patients with risk for infection, wound management,
2. Medication Management. (Patients with high risk medication or pieces of equipment
3. High risk patients: On ventilator care
4. Pediatric populations. A patient less than 18 years 5. Perinatal and less than
5. A patient receiving Maternal and Child Care
6. Infusion patients. A patient receiving IV infusion Care
7. Transfusion patients. A patient receiving Blood to Blood Component administration/transfusion
8. Fall Risk. Patients at risk for fall, Conditions that impact balance and gait: neurological, musculoskeletal, cardiac and metabolic disorders
9. Skin integrity challenges: Wound, burn, injury
10. Orifices: Challenges with discharge from orifices, incontinence- bowl and urine
B. Transitioning patients. Individuals who move between program services such as follow up at Ambulatory care, home care, hospital, long term care, assisted living radiology and laboratory services.
1. Coordination of care
2. Continuity of Care
3. Transfer and Discharge Patients
IX. Post Survey Sessions
1. Exit Interview: Overall performance, strengths, challenges and opportunities
2. Survey Decision: Full Accreditation, Accreditation with Improvement, Conditional Accreditation
3. Plan of Correction: Responding to Who, What, Where, When, and how the compliance is sustained.
4. Measure of Success for four months to six months
5. Measure of Success Review Survey to evaluate Success of Plan of Correction
6. Periodic Performance Review at Quarterly Interview focusing on PFA (Priority Focus Area)
7. Review of Weekly Productivity Reports, Monthly Senior Management Reports, Quarterly PAC and Annual Governing Body Minutes and Reports
XI. Annual Evaluation of Goals and Results based on Five Pillar of Success
1. Profitability: Goals by 10-20% per year
2. Quality Improvement: Organizational, HR, Clinical, Fiscal and Perception of Care
3. Perception of Care: Patient Satisfaction Surveys and Patient Compliant Resolution
4. Growth and Referrals: Referral, Admission, Conversion Rates, Diagnosis and Insurance Group
5. HR: Staff Recruitment, Orientation, Retention and Satisfaction- Performance Evaluation XII. Annual Calendar for Business Management
a. Governing Body: Annually at around 15th January
b. Professional Advisory Committee Meetings: 15 January, 15 April, 15 July, 15 October
C. Monthly Senior Management Meetings
d. Weekly Productivity reports for HR, Clinical, Billing and Management
XIII. Weekly Productivity Meetings
Mondays: Referral/Admission- Weekend Duty Review, Census management,Marketing
Tuesdays: Human Resources and Staffing Coordination
Wednesdays: Clinical Chart Audit and Quality Assurance
Thursdays: Authorizations, Billing- Codes, Account Receivables at 60, 90, 120, 180 days
Fridays: Management Decisions and Readiness for Weekend Admissions.
XIV. Daily Productivity Plan
10:00 am 15 minutes Productivity Plan, Goals, Activities
16:00 pm 15 minutes- Productivity Reports
XV Hourly Productivity Reports
AM: 4 hours PM= 4 hours
XV. Sample Minutes and Agenda
Letter head: Name, address, telephone, fax and web site
Name of the Meeting:
Date of the Meeting:
A. In Attendance
No. Name Title Tel No Signature
1. Greetings and updates
2. Old Business: Review of Past minutes and approval
3. New Business: Challenges and Opportunities
4. Follow up issues: CORT Analysis, Threat elimination, Risk Reduction, Converting challenges to opportunities
5. Next Meeting; Date , time and place/space
C. Talking Points
1. CMS Conditions of Participation
2. Joint Commission Accreditation Guidelines
3. Policies and Procedure Review
Sample Productivity Reports
No. Goals/Objectives/Activities Responsible Person Outcome/Result
Name NA Done, Follow up ____________________________________________________________________________________
PM: 14:00 – 17:00
XIII. Notes and References
Global Connect, Inc.
Connecting talent, innovations, technology, and investment across the globe!
Global Connect, Inc. a US Incorporated Global Enterprises Implementing the Rules of 7, 5 & 3 for Success
I. Rule of 7: Connecting GPS via GRS & CAT… 4… 3As+3Es within CO + FoC
II.Rule of 5: Research Pyramid, CORT Analysis, NDSIM, Option Appraisal, Decision Science
III. Rule of 3: Options:Best, Win-win and Compromise Options
Success comes with practice based on documentation!
Remember: Practice makes perfect and Geniuses are made in 10 years or 10,000 hrs. of practice.
Our best asset is our health and out time!
What a beautiful globe! The only heaven we know in the universe! ….
If only we can survey it periodically for its survival!
Global Connect Inc. is committed to our individual and collective potential success!
Imagine, we can experience our unique integrated life of Body, Mind and Spirit reflecting our Primate, Human and Devine existence, all at the same time!
Only on Earth- our true heaven! What a beautiful world! If only we can survey it periodically for its survival! & Global Connect, Inc. …a Divine Touch Corporation…..
Committed to our individual and collective potential… to be Successful & Divine! that is being Divine: (Living to serve others!)………………………Connecting the dots of 7 Billion people across the world!……