Introduction to Healthcare
and Public Health in the US
Regulating Healthcare
Lecture a
This material (Comp1_Unit6a) was developed by Oregon Health and Science University, funded by the Department of Health
and Human Services, Office of the National Coordinator for Health Information Technology under Award Number
IU24OC000015.
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Regulating Healthcare
Learning Objectives
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Describe the role of accreditation, regulatory bodies, and professional
associations in healthcare in the US. (Lecture a)
Describe the basic concepts of law in the United States: the legal system,
sources of law, classification of laws, the court system, and the trial
process. (Lecture b)
Describe legal aspects of medicine involving the Affordable Care Act,
professional standards in healthcare, medical malpractice, Tort reform, and
Medicare and Medicaid Fraud and Abuse (Lecture c)
Describe key components of the Health Insurance Portability and
Accountability Act (HIPAA) and current issues of privacy and patient safety
in the US (Lecture d)
Discuss the need for quality clinical documentation for the use of the health
record as a legal document, communication tool and a key to prove
compliance for healthcare organizations. (Lecture e)
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
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Topics in This Lecture
• Nonprofit Accrediting Organizations
– The Joint Commission (JC)
– URAC (formerly called Utilization Review
Accreditation Commission)
• Regulatory Agencies
• Professional Associations
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
3
Joint Commission (JC) History
• 1910: The forerunner of JC is called the “end-result”
system
• 1951: Joint Commission on Accreditation of
Hospitals (JCAH) is created and starts accrediting
and certifying healthcare organizations
• 1987: Name changed to Joint Commission on
Accreditation of Healthcare Organizations (JCAHO)
• 2007: Name simplified to Joint Commission (JC);
currently accredits and certifies more than 18,000
organizations and programs in the US
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
4
Joint Commission (JC) Mission
“To continuously improve healthcare for the public,
in collaboration with other stakeholders, by
evaluating healthcare organizations and inspiring
them to excel in providing safe and effective care
of the highest quality and value.”
(The Joint Commission, 2011)
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
5
Joint Commission (JC) Accreditation
• Earned by an entire healthcare organization (hospital,
nursing home, office-based surgery practice, etc.)
• Tools the JC uses to measure performance
– Integrated Survey Process (ISP): Evaluates
performance across organization
– ORYX: System for healthcare organizations to report
to the JC about patients with certain conditions (core
measure sets)
• The core measure sets reported depend on the type and size
of the organization
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
6
ORYX: Core Measure Sets
• Examples
– Heart attack
– Pneumonia
– Inpatient psychiatric care
– Children’s asthma
– Stroke
• Each core set has performance measures
– For example, the JC looks at whether children
with asthma received certain drugs in the hospital
and were sent home with a management plan
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
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Joint Commission (JC) Certification
• JC-accredited organizations and providers of
healthcare staffing services can also earn
certification for specific programs or services
– For chronic diseases and conditions
• Examples: asthma, diabetes, heart failure
programs
– Programs can be within the medical center or
in the community
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
8
Joint Commission (JC) Patient Safety
Activities
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National Patient Safety Goals
Universal Protocol
Office of Quality Monitoring
Speak Up™ program
Sentinel Event Policy
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
9
URAC
• Formerly known as the Utilization Review
Accreditation Commission (URAC)
• Mission: “To promote continuous improvement
in the quality and efficiency of healthcare
management through processes of accreditation
and education”
• Has more than 25 accreditation and certification
programs for various types of healthcare
organizations
(URAC,2011)
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
10
URAC Health
IT Accreditation
• Outlines best practices for an effective
compliance program, including:
– Health websites
– HIPAA (Health Insurance Portability and
Accountability Act) privacy and security
• Designed for a wide range of organizations
involved in healthcare IT
• See http://www.urac.org
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
11
URAC Health
IT Accreditation (continued)
• These healthcare organizations must comply with
HIPAA:
– Health plans—health insurance companies,
employer-funded health plans, and government
programs that pay for healthcare, such as Medicare
or Medicaid
– Health care providers that conduct certain tasks
electronically
– Health care clearinghouses(organizations that
process health information)
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
12
Regulatory Agencies
• Public authorities at state or federal level,
established by legislative act to enforce
standards in a specific field in the private sector
• Agency’s regulations = laws
• Agency might conduct hearings and hand down
judgments
• Goal is consumer protection
• Example: Food and Drug Administration (FDA)
Health IT Workforce Curriculum
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Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
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Food and Drug Administration (FDA)
Overview
6.1 Figure: As part of Department of Health and Human Services, the FDA is charged with oversight of these areas. (FDA, 2011)
Health IT Workforce Curriculum
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Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
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FDA Mission
• Protect public health
– Regulates drugs
• Performs drug approvals
• Provides drug safety information
• Spreads the message about medication errors
– Helps speed up product innovations
– Helps public obtain accurate science-based
information
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
15
Professional Association
• A nonprofit organization that wants to support:
– A particular profession
– The interests of individuals engaged in that profession
– The public interest
• Sets requirements:
– For entry into the profession—possibly requires
license or certificate
– For maintaining membership in the profession
• Members generally have a significant amount of
education, training, or experience
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
16
American Board of Medical Specialties
(ABMS)
• Description: “An organization of medical specialty
boards with shared goals and standards related
to the certification of medical specialists”
• Member boards certify specialist physicians
– Also subspecialists; for example, adolescent
medicine is a subspecialty of family medicine
• Board certification differs from licensure, which
sets minimum competency for physicians
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
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American Hospital
Association (AHA)
• 5,600 organizational members
• 41,000 individual members
• Major programs
– Advocacy
– Resource center (47,000 books on healthcare)
– Health Planning and Administration (HEALTH)
database
– Annual survey of US hospitals
– Reports and studies
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
18
American Medical
Association (AMA)
• 240,000 members
– Physicians with an MD or DO degree, or a recognized
international equivalent
– Resident physicians and fellows
– Medical students
• Major programs
– Resources for physicians
– Advocacy
– Publishing medical journals
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
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Regulating Healthcare
Summary – Lecture a
• Hospitals and other healthcare organizations are
accredited by the Joint Commission
• The Joint Commission also certifies specific healthcare
programs and conducts patient safety activities
• URAC accredits and certifies a wide range of healthcare
organizations, and it has an accreditation program for IT
professionals
• Regulatory agencies such as the FDA protect consumers
by setting and enforcing standards
• Professional associations govern their members but not
the public at large
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
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Regulating Healthcare
References – Lecture a
References
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American Board of Medical Specialties. http://www.abms.org. Accessed April 12, 2011.
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American Hospital Association. http://www.aha.org. Accessed April 12, 2011.
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American Medical Association. http://www.ama-assn.org. Accessed April 12, 2011.
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Peck P. AMA: after one-year increase, AMA membership declines again. June 25, 2007.
http://www.medpagetoday.com/MeetingCoverage/AMA/6006. Accessed April 12, 2011.
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Regulatory agency (definition). Encyclopedia Britannica.
http://www.britannica.com/EBchecked/topic/496265/regulatory-agency. Accessed April 12, 2011.
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The Joint Commission. http://www.jointcommission.org/facts_about_the_joint_commission/ Accessed April 12,
2011.
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US Department of Health & Human Services. Understanding health information privacy.
http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html. Accessed April 12, 2011.
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US Food and Drug Administration. http://www.fda.gov. Accessed April 12, 2011.
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URAC. http://www.urac.org. Accessed April 12, 2011.
Charts, Tables, Figures
6.1 Figure: Part of Department of Health and Human Services, charged with oversight of the areas displayed.
http://www.fda.gov/ . Accessed April 12, 2011.
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Regulating Healthcare
Lecture a
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