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Objective Independent Assessment
The Process

Review Documents:

þ     Board structure, size and composition

þ     Board member position description and resumes

þ     Board and Employee Orientation programs

þ     Board committee charges and composition

þ     Board meeting agendas and minutes

þ     Medical staff and Medical executive committee meeting agendas and minutes

þ     Mission, vision (organizational and clinical), values statement

þ     Strategic and current annual operating plan

þ     Operating and capital budget

þ     Medical Director position descriptions and evaluations

þ     Marketing collateral materials

þ     Marketing and advertising plans

 

Interview Leaders

þ     Board members

þ     Senior management

þ     Departmental administrative and nurse leaders

 

Perform Assessments

þ     Governance, leadership and communications

þ     Physician integration

þ     Culture

þ     Market position and perception

þ     Employee productivity and satisfaction

þ     Systems (CPOE, clinical decision support, bar coding, incident capture and reporting, medical records/clinical information, medication control and dispensing, scheduling, billing, etc.)

 

 

þ     Financial and operating  statements

þ     Bond Offering statement and ratings

þ     Managed Care Contracts

þ     Denial reports

þ     Foundation Annual Report

þ     Market share data by service and geography

þ     Patient and employee surveys

þ     Independent assessments and performance scores (i.e. JCAHO, BCBS/Payer, Healthgrades, Solucient Top 100)

þ     Pathways/protocols/guidelines

þ     Clinical Quality reports

þ     Incidence, adverse drug and sentinel events reports

þ     Risk Management Plan, ethics and compliance plan

 

 

 

þ     Physicians

þ     Consumer/Patient representatives

þ     Employer/Payer representative

 

 

þ     National Quality Forum Safe Practices and Hospital Performance Measures

þ     Clinical process and outcome (benchmarking)

þ     Care management (emergency and call coverage, credentialing and privileging, Intensive Care / Specialty Unit management, patient education and informed consent)

þ     Financial performance (benchmarking)

 

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Revised: 07/21/04