About the Course

Course Title and Number

HAP 547 Regulatory Requirements for Health Care Systems (3:3:0)

Course Description

This course is designed to help health care professionals understand the linkage between the infrastructures of the organization and the regulatory/accreditation processes for health care organizations. An overview covers the major accrediting agencies, their roles, the accreditation principles, and the survey process. Applications will focus on hospitals, with reference to ambulatory care, managed care organizations, rehabilitation centers, laboratories, home health and long-term care facilities. Emphasis will be placed on the requirements of the Joint Commission on Accreditation of Healthcare Organization (JCAHO) and the regulations mandated by the Health Care Finance Administration (HCFA).

Objectives

By the end of the course participants will be able to:

1. Examine the standards related to Healthcare Organizations Structure including Governance, Management, Medical Staff and Nursing that meet the requirements of the Regulatory Agencies.
2. Identify the organization's employee job responsibilities and functions as they relate to the regulatory/ accreditation process.
3. Identify the various roles of the major regulatory agencies in USA.
4. Describe the accreditation process and how to prepare for surveys.
5. Explain the role of Leadership in meeting the standards of care and improving organization performance.
6. Identify JCAHO requirements regarding Management of Human Resources and Management of Information.
7. Interpret JCAHO standards and HCFA regulations related to patient focused functions including patient rights, assessment and care of patients, education and continuum of care.
8. Implement a project related to JACHO requirements.     

Required textbook

None, reading material are posted to the course web or are available on the web.

Recommended Textbook

None

Teaching Strategy / Methods

Course material are posted to the web.  Students are asked to actively participate in discussions.  Students are evaluated through projects.  There are no exams.

Course Requirements

Students will benefit from this course if:

1. They are in a graduate program
2. They are comfortable with doing online searches
3. They are comfortable with independent project work.
4. Microsoft Power Point is needed for viewing some portions of reading and lectures. Some assignments require recording a narration to accompany slides. To record a narration, students need to have a good quality microphone on their computer. Typically, a microphone that sits on top of the head and moves with the person is preferred to a stationary desk top microphone. An audio guide on how to narrate slides is available. 

Course Evaluations

Grading	Value
Class Participation	10%
Assignments completion and submission on time	40%
Strategy paper on how to implement a set of Patient Functions standards	20%
Getting ready for Accreditation plan and presentation	30%

Your evaluation will be based on the following scale:

Graduate work is benchmarked at a grade of B. This grade indicates that the student has demonstrated competency in the course subject matter, has fulfilled all course requirements in a timely manner, has demonstrated a clear grasp of the course material and concepts and has applied this understanding in a well organized, articulate, well reasoned and logical fashion, both oral and in writing. Only a B or higher is considered acceptable (passing). A B- is not a passing graduate level grade (students can get a maximum of 2 of these across their course of studies and a C, or lower, must be repeated).

Topical Outline

Date/ Time	Topic	Readings	Assignment	Due Date
May 23	Definitions of Licensure, Certification and Accreditation Licensure, Certification and Accreditation; how they contribute to improving quality in healthcare	Handouts Instructor Power point presentations	Choose one healthcare organization where you can apply regulatory requirements Contact this organization to learn about the regulatory agencies that this organization must deal with. Submit in one page a report on the organization and brief summary about the regulatory agencies	May 30
May 30	State Survey for Licensure of Hospitals	State requirements for Licensure	Develop a self assessment tool for a hospital  to prepare for state licensure based on the requirements for hospital licensure on the web site of Virginia health Department  Submit first draft for the self assessment tool for licensure	June 6
June 6	An overview that covers the major accrediting agencies, their roles	Handouts on Major regulatory agencies	Web search for the major regulatory agencies in USA Submit two page report on one of the regulatory agencies  that deals with the facility you chose	June 13
June 13	Introduction to the Joint Commission on Accreditation of Healthcare Organizations JCAHO Shared Visions-New Pathways—Understanding the Accreditation Process	JCAHO Hospital Accreditation Standards 2005 Page 11-87	Describe the JCAHO survey process as it relates to the organization that you chose in 10 power point slides presentation	June 20
June 20	Overview JCAHO Accreditation Standards 2005 Patient Focused functions 2005 National Patient Safety Goals	JCAHO Hospital Accreditation Standards 2005	Select one set of standards in the patients focused functions and develop a strategy for your organization on how get ready to comply with them Submit a 3-5 page strategy paper	June 27
June 27	Overview JCAHO Accreditation Standards 2005 Organization Functions Role of Leadership in meeting the standards of care and improving organization performance. JCAHO requirements regarding Management of Human Resources and Management	JCAHO Hospital Accreditation Standards 2005	Consult with your healthcare organization of their preparation to JCAHO Accreditation strategies Prepare a plan to get ready for accreditation Email the plan to the Instructor before July 12	July 10
July 11	Presentation of the plans

Honor Code

“To promote a stronger sense of mutual responsibility, respect, trust, and fairness among all members of the George Mason University community and with the desire for greater academic and personal achievement, we, the student members of the university community, have set forth this honor code: Student members of the George Mason University community pledge not to cheat, plagiarize, steal, or lie in matters related to academic work” (George Mason University Catalog, 2006-2007, p. 31).

Disability Accommodations

If you are a student with a disability and you need academic accommodations, please see Debbie Wyne and contact the Disability Resource Center at 703 993-2474.  All academic accommodations must be arranged through the Disability Resource Center.

George Mason University is committed to complying with the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 by providing reasonable accommodations for disabled applicants for admission, students, applicants for employment, employees, and visitors. Applicants for admission and students requiring specific accommodations for a disability should contact the Disability Resource Center at 703-993-2474, or the Equity Office at 703-993-8730. Applicants for employment and employees should contact Human Resources at 703-993-2600 or the Equity Office. Students and employees are responsible for providing appropriate documentation and requesting reasonable accommodation in a timely manner (George Mason University Catalog, 2006-2007, p. 55).

 

Recently Asked Questions

Question:  Dr. Ismail, I am on now,through the email you just sent. I am not sure what has happened I have been able to access it before and as a fact have printed the suggested readings etc. Shirley  Answer:  Sorry there was a bug in the system and teh answers were not being posted correctly.

Question:  When will the remaining sessions be available online?  Answer:  Sessions will be posted on a weekly basis as they become available.

Question:  When will the remaining sessions be available online?  Answer:  Sessions will be posted on a weekly basis as they become available.

Question:  When will the remaining sessions be available online?  Answer:  It will be available within two weeks. Right now the sessions for the next two weeks are posted.

 

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