An Overview of Accreditation Knowledge
| Study Hours: |
2 Hours a Week |
| Credit Hours: |
45 CEUs |
| Revised: |
9/6/2002 10:05:05 AM |
| Course Leader: |
Amy Niehaus, CMSC, MBA |
| Phone: |
(314) 923-6168 |
| Email: |
niehausa@bcbsmo.com |
|
Course Description
The course provides an introduction to a broad scope of medical staff services and credentialing topics for self-motivated adults who have a need or desire to know more about medical staff services management. The program is sponsored and administered by the NAMSS Institute, the educational division of the National Association Medical Staff Services.
Professionals who will benefit from the materials covered in this course include: all individuals responsible for staying up-to-date on the accreditation standards of NCQA, JCAHO, ACCME, IRB, and Cancer Committee functions.
Entry-Level Standards To qualify for enrollment, the student must provide proof of high school graduation (i.e., copy of high school transcript or diploma, GED certificate or college transcript or diploma).
Prerequisites: None
Texts and Other Reference Materials
Text: NAMSS Independent Study Course 4
Recommended References: (The following references were used in the development of this course and may be helpful study tools to the student. However, they are not required reading in order to complete the Course.
1. |
Comprehensive Accreditation Manual for Hospitals. Joint Commission on Accreditation of Healthcare Organizations |
2. |
Webman v. Little Company of Mary Hospital, 39 Cal. App. 4th 592; 46 Cal. Rptr. 2d 90 (Ca. 1995) |
3. |
Handbook of Medical and Professional Staff Management , Second Edition (1998). Gassiot, Cindy A., and Searcy, Vicki L, Texas Society for Medical Staff Services, Austin, TX |
| 4. |
http://www.npdb-hipdb.org/pointer/npdb.html |
| 5. |
http://www.npdb-hipdb.org/pointer/hipdb.html |
| 6. |
http://www.jcaho.org/standard/clarif/ri_temppriv.html |
7. |
JCAHO Clarifies Use of Temporary Privileges - Again, NAMSS Synergy, May/June 2001, K. Matzka. |
8. |
Topics in Health Record Management. 12 (1), 52-59. Lewis, K.S. (1991). Medical record review for clinical pertinence |
9. |
"Make Clinical Pertinence Review Part of Quality Review." Medical Records Briefing. March 1992. |
| 10. |
" The Quality Resource" The Clinical Pertinence Review Process . May/June 1992 |
11. |
"Briefings on Medical Staff.” Thompson, Richard. OPUS Communication, November 1992. |
12 |
Healthcare Quality and Productivity . Kirk, R. (1988). Rockville, MD: Aspen Systems Corporation. |
13 |
The Health Care Managers Guide to Continuous Quality Improvement. Leebov, W. & Ersoz, C.J. (1991). Chicago: American Hospital Association. |
14. |
Journal of AHIMA. 63(11): 38-44, Van Matre, J.G. (1992). The D*A*T approach to total quality management |
15. |
Journal of Health Information Management Research. Slovensky, D.J., Blide, L., & Van Matre, J.G. (1993). The health information professional in hospital quality programs 2(1): 29-41. |
16. |
Medical Record Management . Huffman, E.K. (1990). Brewyn, IL: Physician's Record Company |
17. |
The Measurement Mandate. Joint Commission on Accreditation of Healthcare Organizations (1993). |
18. |
Organization and Change in Health Care Quality Assurance. Luke, R.D., Krueger, J.C. & Modrow, R.E. (1983). Rockville, MD: Aspen Systems Corporation. |
19. |
The Quality Management Professional 's Study Guide, Brown, J.A. (1992). Pasadena, CA: Managed Care Consultants |
20. |
Accreditation Procedures for Physician Continuing Medical Education Activities in Alabama. Montgomery, AL: Medical Association of the State of Alabama, 1991 |
21. |
The Medical Staff and the Modern Hospitals. Eisle, M.D., C. Wesley; Fifer, M.D., William R.; and Wilson, MPA, Toma C. (1985). Englewood, CO: Estes Park Institute |
22. |
The Physician's Recognition Award, Eligibility Requirements, Version 3.0. ( http://www.ama-ssn.org/ama/pub/category/2923.html ) Chicago, IL: American Medical Association. |
23. |
The Physician's Recognition Award, Information Booklet for CME Providers, Version 3.0. ( http://www.ama-assn.org/ama/pub/category/2923.html ) Chicago, IL. American Medical Association. |
24. |
http://www.accme.org/index.asp |
25. |
ACCME's Essential Areas, Elements, and Decision-Making Criteria, July 1999. ( http://www.accme.org/sec_docs_f.asp ) |
26. |
Handbook of Medical Staff Management . Orsund-Gassiot, C.A. & Lindsey, S., Gaithersburg, MD: Aspen Publishers, Inc. |
27. |
Commission on Cancer. (9/88). Benefits of a Hospital Cancer Program. Chicago, IL, American College of Surgeons, Commission on Cancer. |
28. |
Commission on Cancer. (1991). Cancer Program Manual. Chicago, IL American College of Surgeons |
29. |
Fritz, A. (1993). Public Law 102-515: The National Program of Cancer Registries. The Abstract: National Tumor Registrars Association. 19(2), 24-25. |
30. |
Kelly, C.K. (1993). Software registry companies provide innovative cancer data management. Advances of Health Information Management Professionals. King of Prussia, PA: Merion Publications, Inc. |
31. |
National Institute of Health. (1992). SEER Program Self Instructional Manuals for Tumor Registrars. Book Two. (3rd ed.) (NIH Publication No. 92-993). Washington, D.C.: U.S. Government Printing |
| 32. |
http://www.cdc.gov/cancer/npcr/register.htm |
| 33. |
http://www.facs.org/dept/cancer/coc/cocar.html |
| 34. |
http://www.facs.org/dept/cancer/coc/whatis.html |
| 35. |
http://www.facs.org/dept/cancer/coc/howacc.html |
| 36. |
http://www.fda.gov/oc/ohrt/irbs/ |
| 37. |
http://ohrp.osophs.dhhs.gov/irb/irb_chapter2.htm |
- Chapter Topics
- Lesson 1 Medical Staff Membership and Privileges
- Lesson 2 Review, Evaluation and Monitoring of Medical Staff Participation in Patient Focused Functions
- Lesson 3 Medical Staff Participation in Organizational Functions
- Lesson 4 National Committee for Quality Assurance
- Lesson 5 Medical Staff Participation in Continuing Education
- Lesson 6 Cancer Programs
- Lesson 7 Institutional Review Boards
- Course Objectives
Course 4 is designed to provide an overview of the standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA), American College of Surgeons Commission on Cancer (ACS), and other agencies that approve or regulate healthcare facilities.
- Instructional Processes
Students have three months to complete each course offered through the ISP. The entire NAMSS ISP usually takes 15 months to complete. Each course offers 45 hours of NAMSS Continuing Education Units (CEU) at the completion of each course.
- Expectations For Student Performance
Prior to beginning the course, students should familiarize themselves with the course design by reviewing the syllabus, the interactive capabilities such as the discussion board and contact information for the Course Leader and Executive Office. The Course Leader is available to students with questions regarding content and the Executive Office can be contacted with questions/comments about student accounts.
Internet Access
Students should have access to a computer with internet connection to complete reading material, quizzes and a two hour multiple choice exam.
Time Management
Students are given three months to complete the course. Students should set interim goals and deadlines to complete the course within the given timeframe. Students unable to complete the course within the given timeframe may request a three month extension for $50.00.
- Evaluation
Quizzes At the end of each section, there is a quiz to emphasize the learning objectives of that section. Students are encouraged to take the quizzes as many times as needed. The quizzes are marked for completion only and the score is not recorded.
Course Exam
At the end of Course 4, there is a multiple choice exam of 50 questions. The student must earn a passing grade (80% of questions answered correctly), within three attempts. Should a student fail the initial exam, a $50 fee will be assessed for the second attempt. The student will have 30 days to complete the second exam.
The student will be responsible for obtaining a qualified proctor to supervise the examination. The proctor cannot be a current enrollee in the NAMSS ISP, a co-worker in the same department or a relative of the student. An example of an appropriate proctor would be someone from the staff development or staff education department.
Grading Scale: 93-100 A; 87-92 B; 80-86 C; less than 80 is a failing grade.
- Policies
The student should refer to the contract signed at the time of enrollment in the NAMSS ISP for applicable policies.
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