Regulatory Requirements for Health Care Systems

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:

90 percent and above  A
80 to 89 percent  B
70 to 79 percent  C
69 percent and below  F

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).

 

Minute Evaluation

Get Answers to Your Questions

The sign to the left shows a form you can use to evaluate course lectures.  It takes less than a minute to fill the form. You are encouraged to do so after each lecture.  Your comments, without your name or email, will be posted to the web. The sign to the right is a place you can ask a question and get answers to your questions from the instructor.  Both questions and answers, without your name and email, are posted on the web afterwards.

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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