10/17/2013
Paul Harper-O’Connor
RN, CPHQ, NHA, MHA
Quality & Continuous Improvement Officer
Maui Memorial Medical Center
Assumptions
Assumptions
Clinician
Quality perspective
Guest at a Compliance Conference
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10/17/2013
Compliance
Case Example
Associations
Areas
Issue
• Stark / Sunshine Law
Compliance
• Core Measure Fall-Outs
• Services performed with expired contract
• Visitor fall
Quality
• Lost wallet
• Staff doing tasks for another agency
• Claim of misdiagnosis
Risk
• Joint Commission / Facility State
Licensure
• Abuse Allegation
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10/17/2013
Associations
Areas
Issue
• Event Reports
Compliance
• Stark / Sunshine Law
• Peer Review
• Immunization not ordered
Quality
• Limited English Proficiency compliance
• CMS Conditions of Participation
• Unhappy with ED wait time
Risk
• Root Cause Analysis
• Sentinel Event
Compliance
com·pli·ance /kəmˈplaɪəns/ [kuhm-plahy-uhns]
noun
1. the act of conforming, acquiescing, or
yielding.
2. a tendency to yield readily to others,
especially in a weak and subservient way.
3. conformity; accordance: in compliance
with orders.
4. cooperation or obedience: Compliance
with the law is expected of all.
5. Physics.
a. the strain of an elastic body expressed as a
function of the force producing the strain.
b. a coefficient expressing the responsiveness of
a mechanical system to a periodic force.
Origin: 1635–45; comply + -ance
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10/17/2013
Compliance
Contractive or Exacting?
Compliance
Contractive or
Exacting?
Assuring meeting minimum
HIPAA - minimum information
shared to fewest
Meeting standard detailed
intent / letter of the law
Audits to assure compliance
with existing standards – e.g.
EMTALA met, complaints /
grievances addressed timely
manner
Education of staff with focus on
meeting established p/p
Quality
qual·i·ty [kwol-i-tee] noun
1. an essential or distinctive
characteristic, property, or
attribute: the chemical qualities
of alcohol.
2. character or nature, as belonging
to or distinguishing a thing: the
quality of a sound.
3. character with respect to
fineness, or grade of excellence:
food of poor quality; silks of fine
quality.
4. high grade; superiority;
excellence: wood grain of quality.
5. a personality or character trait:
kindness is one of her many good
qualities.
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10/17/2013
Quality
6. native excellence or superiority.
7. an accomplishment or
attainment.
8. good or high social position: a
man of quality.
9. the superiority or distinction
associated with high social
position.
10. Acoustics. the texture of a tone,
dependent on its overtone
content, that distinguishes it
from others of the same pitch
and loudness.
11. Phonetics . the tonal color, or
timbre, that characterizes a
particular vowel sound.
Quality
12. Logic. the character of a proposition
as affirmative or negative.
13. Thermodynamics . the proportion or
percentage of vapor in a mixture of
liquid and vapor, as wet steam.
14. social status or position.
15. a person of high social position: He's
quality, that one is.
adjective
16. of or having superior quality: quality
paper.
17. producing or providing products or
services of high quality or merit: a
quality publisher.
Quality
18. of or occupying high social
status: a quality family.
19. marked by a concentrated
expenditure of involvement,
concern, or commitment:
Counselors are urging that
working parents try to spend
more quality time with their
children.
Origin:
1250–1300; Middle English
qualite < Old French < Latin
quālitās, equivalent to quāl ( is )
of what sort + -itās –ity
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10/17/2013
Quality
Expansive
Quality
Expansive
Striving to exceed
HIPAA - maximum # of
those that need to know
given what they need to
improve outcomes
Meeting maximum
outcome possible while
maintaining standards
Focus on broader intent
Audits for identifying
changes needed in existing
standards
Quality
EMTALA exceeded – e.g.
ED throughput,
changing behavior
Processes to prevent
complaints / grievances /
improve satisfaction
Education of staff – new
standards and changed
processes and rationale
Fostering creative rapid
cycle change thinking
Compliance “officer” part of
role of quality officer
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10/17/2013
Case Example
Feedback
What are your thoughts on
the distinctions /
similarities between the
areas of Quality and
Compliance?
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