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Instructor : Errol L. Biggs
Product Id : 20053PACK

Overview: Hospital and health system board members face increasing challenges, with healthcare reform and other laws demanding improved accountability and efficiency. This webinar reveals the secrets of effective board structure and function, including responsibilities of board members, term limits, recruiting new members and working with the CEO.

Other aspects of a board's work, including monitoring quality, providing financial oversight, and completing a self-assessment process, are also covered. Board members, regardless of their expertise, will find this webinar interesting and educational.

Why should you attend: Governance of hospitals and health systems is important work. How well it is done has tremendous consequences for healthcare organizations and the communities they serve. Also, there are consequences for patients, medical staffs, and employees. This webinar is intended to help new and experienced board members learn "best practices" of effective healthcare boards.

Areas Covered in the Session:
  • Types of hospital boards and health systems
  • Role and responsibility of hospital boards
  • Role and responsibility of individual board members
  • Role and responsibility of board chairperson
  • Information governing boards should receive
  • Governance vs. management
  • Selecting physician board members
  • Optimizing board CEO relationships and CEO as a member of the board
  • Term limits for board members
  • Age limits for board members
  • Designing an effective board orientation program
  • Key committees the board should have
  • Board's role in monitoring quality of healthcare
  • Conflict of interest issues
  • How the board should conduct a "self-assessment" process

Who Will Benefit:
  • Hospital and Health System Board Members
  • CEO's of Hospital and Health Systems
  • Other Top Executives in a Healthcare Organization
Dr. Biggs primary research and consulting activities include work with hospitals to improve the governance of those organizations. He teaches governance in both the graduate on-campus and executive programs in Health Administration at the University of Colorado. He is also a faculty member of the American Hospital Association's Center for Healthcare Governance and Chairman of the Practical Governance Group, both of which offer educational programs for hospital governing boards.

Dr. Biggs is a Fellow in the American College of Healthcare Executives. He is also a member of the National Association of Corporate Directors; BoardSource; the Association of University Programs in Health Administration; Medical Group Management Association, and the Healthcare Financial Management Association. He was named by the National Association of Corporate Directors as a "Director to Watch in 2013."

Dr. Biggs has been involved in both the investor-owned and nonprofit hospital industries, including twelve years as the CEO of large, teaching hospitals, and directed the first merger of an osteopathic (D.O.) hospital and an allopathic (M.D.) hospital in the United States.

Additionally, he has served on several nonprofit and investor-owned boards of directors. He conducts seminars and retreats for hospital boards of directors, and is the author of several articles on governance. Dr. Biggs is also the author of the book The Governance Factor: 33 Keys to Success in Healthcareand co-author of the popular book, Practical Governance, both published by Health Administration Press. His third book on hospital boards, Healthcare Governance: A Guide for Effective Boards was recently published by Health Administration Press
Instructor : Sue Dill Calloway
Product Id : 20053PACK

Overview: Did you know there are new changes to nine of the tag numbers in the nursing service chapter? Did you know there were ten recent memos of importance to nurse managers and chief nursing officers? There are many changes to this section in the recent past including timing of medications, standing orders, restraint, plan of care, verbal orders, blood transfusions, IV medication, third revised worksheet, and drug orders. CMS made over two dozen changes to the hospital CoP regulations effective July 16, 2012.

There are many changes to the final interpretive guidelines effective June 7, 2013 and August 30, 2013 with a new CoP hospital manual being issued August 30, 2013. In fact, there were two new tag numbers added to the nursing standards section and changes to seven existing sections including tags 405-409 and 410 through 413. Every hospital that accepts Medicare and Medicaid reimbursement must follow the CMS (Center for Medicare and Medicaid Services) Conditions of Participation (CoPs) and it must be followed for all patients. This program will cover the nursing services section in the hospital CoP manual.

Facilities accredited by the Joint Commission, American Osteopathic Association, CIHQ, and DNV Healthcare must also follow these regulations. Recently, there has been increased scrutiny and surveillance to make sure that all hospitals are in compliance with the hospital CoPs. Don't be caught off guard and put your hospital's reimbursement at risk. This program will also reference other important sections that all nurses should be aware that are found outside the nursing services section such as medication standards, verbal orders, history and physicals, visitation, restraint and seclusion and grievances, and privacy and confidentiality.

CMS issues the privacy and confidentiality memo, safe injection practices memo and insulin pen memo. This program will include what is in the CMS discharge planning worksheet. It will include tips to prevent unnecessary readmissions. This section contains many problematic standards for hospitals including the nursing care plan standards and that an order is required for all medication especially if standing order or protocol used. Staffing, medications, new three time frame for administering medications and educational requirements will be discussed along with changes standing orders and protocols.

Areas Covered in the Session:
  • Introduction into the CMS hospital CoPs
  • Where to locate a copy
  • How to get apprised of changes
  • Revised CMS Hospital work sheets and importance
  • Recent CMS memos of interest
    • Rewrote all the discharge planning standards
    • Hospital deficiencies
    • Reporting to the PI system
    • Insulin pens and safe injection practices
    • New interpretive guidelines
    • Luer misconnections
    • Discharge planning standards
    • CMS complaint manual
  • OPO contract
  • Hospital complaint manual and reported to AO memo
  • Humidity memo
  • Interpretive guidelines effective June 7, 2013 and August 30, 2013
  • New Manual issued
  • Many recent changes to 9 tag numbers
  • Starts at Tag 385 and goes to tag 413
  • Nursing Services and 24 hours services
  • Third revised worksheet
  • Social Security Administration Act  RN on duty
  • Integrated with hospital wide PI program
  • Organizational chart and nursing
  • Chief Nursing Officer (CNO) responsibilities
  • CNO requirements
  • CNO approval of nursing policies
  • Staffing and delivery of care
  • 24 hour nursing services and supervision
  • Valid license for nurses and verification
  • RN to evaluate to care of all patients
  • Nursing care plans
  • Changes to the plan of care
  • Agency nurse requirements
  • Orientation of agency nurses
  • Medication administration
  • Order required for all medications
  • Standing orders and protocols
  • Three medications timing changes
  • Protocols, standing orders, order sets
    • Tag 405 standards moved to 457
  • Requirements for complete drug order
  • Verbal orders
  • Verbal orders changes
  • Blood transfusions and IV medications changes
  • Self administered medications
Other important sections nurses should be aware of:
  • Restraint and seclusion changes
  • Grievances
  • Medications policies
  • Visitation

Who Will Benefit:
  • Chief nursing officer (CNO)
  • Nurse Managers
  • HIM Staff
  • Compliance Officer
  • Chief of Medical Staff
  • Medical Staff Coordinator
  • Risk Manager
  • Patient Safety Officer
  • Regulatory Officers
  • Legal Counsel
  • Chief Risk Officer
  • Audit Staff
Sue Dill Calloway R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal and risk management issues and writes numerous publications.

Sue has been a medico-legal consultant for over 30 years. She has done many educational programs for nurses, physicians, and other health care providers on topics such as nursing law, ethics and nursing, malpractice prevention, HIPAA medical record confidentiality, EMTALA anti-dumping law, Joint Commission issues, CMS issues, documentation, medication errors, medical errors, documentation, pain management, federal laws for nursing, sentinel events, MRI Safety, Legal Issues in Surgery, patient safety and other similar topics. She also does a monthly series on the sections of the Conditions for Coverage for Ambulatory Surgery Centers along with other ASC programs such as Safe Injection Practices. She also writes articles on ambulatory surgery and present educational programs on ambulatory surgery issues. She was affiliated with Mount Carmel College of Nursing as an adjunct nursing professor for over fifteen years. She was also a trial attorney for eight years defending nurses, physicians and healthcare facilities.

She has been employed in the nursing profession for more than 30 years. Ms. Calloway has legal experience in medical malpractice defense for physicians, nurses and other health professionals. She is also certified in healthcare risk management by the American Society of Healthcare Risk Managers. Ms. Calloway received her AD in nursing from Central Ohio Technical College, her BA, BSN, MSN (summa cum laude) and JD (with honors) degrees are from Capital University in Columbus. She is a member of many professional organizations. She has a certificate in insurance from the American Insurance Institute.
Instructor : Sue Dill Calloway
Product Id : 20053PACK

Overview: There were two new patient flow standards 2014 for hospitals. This program will also discuss the three new ones that were implemented in 2013. This program is a must attend webinar for every hospital for two additional reasons. First the Joint Commission has emergency department (ED) quality measures along with CMS who has ED throughput measures which includes evaluation of the average time spent in the ED before they were admitted as an inpatient. There are now over four million who signed up for health coverage under the affordable care act which will most likely increase utilization of the emergency department. Managing patient flow is even more important now that ever. This program will also include many evidenced based recommendation for reducing boarding and overcrowding.

The Joint Commission has standards on patient flow to prevent overcrowding and boarding of patients especially patients in the emergency department and in other temporary locations. The Joint Commission also has a patient flow tracer that is used during the survey process. The tracer was amended in 2014. Both of these will be covered in this webinar.

Patient flow is a hospital issue that has a major impact on the emergency department. It is recommended that boarding time frames should not exceed four hours. How do you meet the 2014 expectation? Attendees will get a memo summarizing both of these in additional to the power point slides.

Why should you attend: This program is designed for anyone who is involved with implementing and following the Joint Commission patient flow standards.
  • Recall that the Joint Commission has made changes to the patient flow standards in both 2013 and 2014
  • Discuss that the Joint Commission has a patient flow tracer that is evaluated by surveyors during a survey
  • Describe the four hour rule on getting patients to their room when admitted

Areas Covered in the Session:
  • History
  • Introduction
  • Rationale
  • Management of patient flow throughout the hospital
  • Processes to support the flow of patients
  • Tips to prevent overcrowding and boarding
  • Plans for care in patients in overflow location
  • Criteria for ambulance diversions and EMTALA
  • Measurement of the component of the patient flow process
    • Available beds
    • Efficiency in areas where patients receive care
    • Safety of overflow areas
    • Access to support services
  • Measurement results to those who manage patient flow process
  • Measurement results to hospital leaders
  • Data drives patient flow process
  • Managing the boarding of ED patients
  • Behavioral health patients and boarding
  • Four hour window
  • Population at risk for boarding
  • PC.01.01.01 on boarding of behavioral health patients
  • Behavioral health patients-a safe and monitored location
  • PI.03.01.01 actions taken to sustain improvements in patient flow

Who Will Benefit:
  • Chief Operating Officer
  • Chief Regulatory Officer
  • Quality Improvement Staff
  • Chief Nursing Officer
  • Patient Safety Officer
  • Emergency Department Nurses
  • Chief Medical Officer
  • Compliance Officers
Sue Dill Calloway R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal and risk management issues and writes numerous publications.

Sue has been a medico-legal consultant for over 30 years. She has done many educational programs for nurses, physicians, and other health care providers on topics such as nursing law, ethics and nursing, malpractice prevention, HIPAA medical record confidentiality, EMTALA anti-dumping law, Joint Commission issues, CMS issues, documentation, medication errors, medical errors, documentation, pain management, federal laws for nursing, sentinel events, MRI Safety, Legal Issues in Surgery, patient safety and other similar topics. She also does a monthly series on the sections of the Conditions for Coverage for Ambulatory Surgery Centers along with other ASC programs such as Safe Injection Practices. She also writes articles on ambulatory surgery and present educational programs on ambulatory surgery issues. She was affiliated with Mount Carmel College of Nursing as an adjunct nursing professor for over fifteen years. She was also a trial attorney for eight years defending nurses, physicians and healthcare facilities.

She has been employed in the nursing profession for more than 30 years. Ms. Calloway has legal experience in medical malpractice defense for physicians, nurses and other health professionals. She is also certified in healthcare risk management by the American Society of Healthcare Risk Managers. Ms. Calloway received her AD in nursing from Central Ohio Technical College, her BA, BSN, MSN (summa cum laude) and JD (with honors) degrees are from Capital University in Columbus. She is a member of many professional organizations. She has a certificate in insurance from the American Insurance Institute.
Instructor : Sue Dill Calloway
Product Id : 20053PACK

Overview: The Office of Civil Rights (OCR) released the long awaited final regulations that affect four things; the privacy law, the security law, the HITECH rules and Genetic Information Nondiscrimination Act (GINA). These become effective September 23, 2013. These mean big changes to hospitals. This document was 563 pages long and is referred to as the mega rule. Hospitals will need to rewrite some of their policies and procedures. Staff will need to be educated.

Hospitals will need to revise their Notice of Privacy Practice which is provided to patients. Hospitals will need to revise their Business Associate (BA) agreements. Additional resources will be provided on this issue. The penalties have been increased. The kid gloves have come off and now it is more important than ever that every hospital ensure compliance with the new HIPAA regulations. The Office for Civil Rights has issued a number of guidance notices in addition to the some model notices of privacy practices. This includes a new guidance on the following: marketing and refill reminders, decedents, and immunizations. OCR also issues a HIPAA Law Enforcement Guide and a sample business associate contract.

There are many changes to the HITECH law including the new standard that will replace the "harm standard." Changes have been made for the use and disclosure of medical record information, commonly referred to as protected health information (PHI). Changes have been made to fundraising research authorization and expanded protection for the medical records or PHI of a patient who is deceased

Why should you attend:All hospitals and other healthcare providers and entities must be compliant with the HIPAA regulations. This includes compliance with recent changes in privacy, security, HITECH (breach notification law) and the Genetic Information Nondiscrimination Act (GINA). The government has taken the kid gloves off when it comes to HIPAA. There are new penalties and OCR now has staff that go out and audit to ensure compliance.

Areas Covered in the Session:
  • Introduction
  • OCR Model NPP (Notice of Privacy Practices)
  • OCR Business Associate Sample Contract
  • Office for Civil Rights and HIPAA
  • Topics discussed in Final Rules
  • Topics not addressed in the Final Rules
  • History
  • How to locate a copy of the final rule
  • Revised Notice of Privacy Practices
  • New penalties and enforcement
  • Patient rights to receive an electronic copy of their medical records
    • Exceptions, cost,
    • Access to protected health records
    • HIPAA compliant authorization form
  • PHI of deceased patients
    • OCR Guidance
  • Revision of hospital policies and procedures
  • Staff education
  • Changes to the Breach Notification Rule
    • Definition of breach
    • No longer to do a "harm analysis"
    • Four objective factors to determine if PHI is compromised
    • Document the risk assessment
    • Exceptions
  • Marketing, fundraising and the sale of PHI
    • Definitions
    • Exceptions
    • Case managers, care coordination
    • What costs are permitted
    • OCR Guidance on Refill Reminders and Marketing
  • Immunization records
    • OCR Guidance
  • GINA Genetic Information Nondiscrimination Act
  • Relationship to the CMS hospital CoP grievance standard
  • CMS Hospital Memo on Privacy and Confidentiality

Who Will Benefit:
  • HIPPA Privacy and Security Officers
  • Compliance Officer
  • Risk Management
  • Chief Nursing Officer
  • Nurses
  • Physicians
  • Director of Health Information Management (HIM)
  • Medical Records Staff (HIM)
  • Chief Financial Officer
  • Operational Directors
  • Chief Medical Officer
Sue Dill Calloway R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal and risk management issues and writes numerous publications.

Sue has been a medico-legal consultant for over 30 years. She has done many educational programs for nurses, physicians, and other health care providers on topics such as nursing law, ethics and nursing, malpractice prevention, HIPAA medical record confidentiality, EMTALA anti-dumping law, Joint Commission issues, CMS issues, documentation, medication errors, medical errors, documentation, pain management, federal laws for nursing, sentinel events, MRI Safety, Legal Issues in Surgery, patient safety and other similar topics. She also does a monthly series on the sections of the Conditions for Coverage for Ambulatory Surgery Centers along with other ASC programs such as Safe Injection Practices. She also writes articles on ambulatory surgery and present educational programs on ambulatory surgery issues. She was affiliated with Mount Carmel College of Nursing as an adjunct nursing professor for over fifteen years. She was also a trial attorney for eight years defending nurses, physicians and healthcare facilities.

She has been employed in the nursing profession for more than 30 years. Ms. Calloway has legal experience in medical malpractice defense for physicians, nurses and other health professionals. She is also certified in healthcare risk management by the American Society of Healthcare Risk Managers. Ms. Calloway received her AD in nursing from Central Ohio Technical College, her BA, BSN, MSN (summa cum laude) and JD (with honors) degrees are from Capital University in Columbus. She is a member of many professional organizations. She has a certificate in insurance from the American Insurance Institute.