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Objective Independent Assessment
The Process

Review Documents:

     Board structure, size and composition

     Board member position description and resumes

     Board and Employee Orientation programs

     Board committee charges and composition

     Board meeting agendas and minutes

     Medical staff and Medical executive committee meeting agendas and minutes

     Mission, vision (organizational and clinical), values statement

     Strategic and current annual operating plan

     Operating and capital budget

     Medical Director position descriptions and evaluations

     Marketing collateral materials

     Marketing and advertising plans

 

Interview Leaders

     Board members

     Senior management

     Departmental administrative and nurse leaders

 

Perform Assessments

     Governance, leadership and communications

     Physician integration

     Culture

     Market position and perception

     Employee productivity and satisfaction

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

 

 

     Financial and operating  statements

     Bond Offering statement and ratings

     Managed Care Contracts

     Denial reports

     Foundation Annual Report

     Market share data by service and geography

     Patient and employee surveys

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

     Pathways/protocols/guidelines

     Clinical Quality reports

     Incidence, adverse drug and sentinel events reports

     Risk Management Plan, ethics and compliance plan

 

 

 

     Physicians

     Consumer/Patient representatives

     Employer/Payer representative

 

 

     National Quality Forum Safe Practices and Hospital Performance Measures

     Clinical process and outcome (benchmarking)

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

     Financial performance (benchmarking)

 

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Revised: 07/21/04