CHC EXAM: Communication,
Education, & Training
Methods to disseminate regulatory guidance materials - ANSPost information on
Organizations website, discuss complaints as she is during routine staff meetings or at
special meetings, provide information about regulations and compliance issues in written
form such as through FAQ sheet and posters, Target information to appropriate personnel
rather than providing information to all, utilize key informants and champions to spread the
information among staff members, Ensure all supervisory personnel are well-versed and
regulations and able to provide guidance and monitor compliance, Provide information and
variety formats, Emphasize how organization may benefit from compliance
SOX act (Sarbanes-Oxley act) - ANSPertains to financial practices and governance
structures in business and applies to for-profit healthcare organizations such as hospitals but
nonprofit hospitals and other healthcare organizations in order to improve internal adding in
management controls and to improve management of finances. Requires that financial
officer certified the accuracy of financial reports and that they contain no false or misleading
information, include internal controls, evaluation of those controls and assessment
effectiveness of controls. Requires the closure of conflict of interest.
FDA medical device reporting regulations - ANSPart of the safe medical devices act require
that user facilities that receive reports of malfunction of medical devices, serious injury, or
deaths associated with their use must report these incidents
Healthcare associated infection - ANSLocalized and systematic infection that occurs 48
hours or more after admission to a healthcare facility because of an adverse reaction to a
pathogenic agent or tocsin
CMS's QAPI rule - ANSQuality assessment and performance improvement rule requiring
hospitals and nursing homes to develop and maintain quality improvement programs
involving all departments to reduce Incident of Medical errors
Call the assessment and performance improvement Elements for hospitals - ANS1. Ensuring
and I'm going comprehensive program addressing all aspects of care and showing miserable
improvement and selected indicators
2. Using data to monitor effectiveness of patient care and services and develop a program
improvement plans
3.Setting priorities for PI activities that focus on high-risk areas
4. Establishing PI projects on the scale appropriate for size and scope of the organization
5. Ensuring the board, administration, And medical staff for an hour responsible for ongoing
PI program, Hospitalwide QAPI efforts addressing priorities and evaluation, patient safety
expectations, provision of adequate resources, annual assessment of QAPI programs
, Quality assessment and performance improvement Elements for nursing homes -
ANSDesign and scope, governance and leader ship, feedback, data systems, and
monitoring, performance improvement projects, systematic analysis and system action
Design and scope - ANSProgram must be comprehensive an ongoing, aiming for patient
safety and high quality care while supporting patient autonomy and choices
Governance and leadership - ANSGoverning board should provide adequate resources for
QAPI efforts, does need one or more persons to be responsible for QAPI, ensure time,
equipment, and training needed. The board to establish a culture of quality and safety
Feedback, data systems and monitoring - ANSThe whole collects data, monitor services
using performance indicators, and reviews findings. All adverse events must be invested
when they occur and action plans implemented
Performance improvement projects - ANSPIP's Should be developed to improve care and
services
Systematic analyst and systematic action - ANSThe organization carries out analyst utilizing
a structured approach and root cause analysis with a focus on continuous improvement
Notifiable disease surveillance - ANSCDC publishes an annual list which may include
infectious diseases, non-infectious disease conditions, and outbreaks
Steps when a patient is diagnosed with a notifiable condition - ANSConfirming the diagnosis,
reporting findings, reporting to CDC, collecting and analyzing, evaluating outbreaks and
disease patterns
Confirming the diagnosis - ANSPhysical examination in laboratory testing
Reporting findings to colleagues, law enforcement professionals, and court officials -
ANSUsually sent it local or state public health department, specific forms may be required
for reporting and time limits may be required
Reporting to the CDC - ANSState public health reviewed the reports and when appropriate
the report is sent by the state public health department to the CDC
Collecting and analyzing - ANSThe national notifiable disease surveillance system team
collects analyzes three ports and sends data to the appropriate program at the CDC
Evaluating outbreaks and disease patterns - ANSThe CDC looks for disease patterns or
outbreaks and determines if assistance needed in outbreak research and containment
Sexual-harassment - ANSProhibits sexual-harassment that applies to only to employers with
15 or more employees. Complaints are submitted to the equal employment opportunity
commission. Employers with fewer employees are covered by various state laws and
regulatory agencies