SHO Management flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

SWOT analysis

A strategic assessment tool that lists internal strengths and weaknesses and external opportunities and threats to inform goal setting and competitive positioning.

SMART goals

A goal-setting criterion requiring objectives to be specific, measurable, achievable, relevant, and time-bound so progress can be tracked objectively.

Balanced Scorecard

A performance framework measuring financial, customer, internal process, and learning and growth perspectives to link strategy with operational metrics.

Mission versus vision

Mission states the organization's current purpose and scope; vision describes the desired future state that strategy aims to achieve.

Operating margin

Operating income divided by operating revenue; measures profitability of core patient-care operations before non-operating items such as investments or grants.

Days cash on hand

Cash plus marketable securities divided by daily cash operating expenses; estimates how many days the organization can operate without new revenue.

Break-even volume

Fixed costs divided by the difference between price per unit and variable cost per unit; the volume at which total revenue equals total cost.

Budget variance

The difference between budgeted and actual amounts; favorable when revenue exceeds budget or expense is below budget, unfavorable when the reverse occurs.

FTE calculation

Full-time equivalents equal paid hours divided by 2,080 annual full-time hours; used to size staffing budgets and productivity ratios.

Nursing HPPD

Nursing hours per patient day equals total nursing hours divided by patient days; a benchmark used to compare staffing intensity across units.

Turnover rate

Separations divided by average headcount, multiplied by 100; annualize partial-year data so periods are comparable across departments.

FLSA exempt status

Exempt employees are salaried and not eligible for overtime; non-exempt employees must receive 1.5 times pay for hours over 40 per week.

Position control

A system assigning each approved position a unique requisition; hiring beyond budgeted FTE requires formal approval before recruitment begins.

CMS Conditions of Participation

Federal requirements that hospitals must meet to participate in Medicare and Medicaid; state licensure adds separate local requirements.

Deemed status

CMS acceptance of Joint Commission accreditation in lieu of routine federal survey for participating hospitals that meet accreditation standards.

HIPAA breach notification

Affected individuals must be notified within 60 days of discovery; HHS notification is required for breaches affecting 500 or more individuals.

EMTALA

Requires a medical screening examination and stabilizing treatment for anyone presenting to an emergency department, regardless of insurance or ability to pay.

Stark Law

Prohibits physician self-referral for designated health services when a financial relationship exists, unless a specific regulatory exception applies.

PDSA cycle

Plan, Do, Study, Act: a quality improvement method that tests small changes, compares results to predictions, and adopts, adapts, or abandons them.

Six Sigma DMAIC

Define, Measure, Analyze, Improve, Control; a structured method to reduce process variation toward 3.4 defects per million opportunities.

Sentinel event

An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, requiring immediate investigation and response.

Donabedian model

A quality framework linking structure (resources), process (what is done), and outcome (result for the patient) to evaluate care delivery.

Root cause analysis

A structured retrospective review after a sentinel event that identifies contributing system factors and actions to prevent recurrence.

FMEA

Failure mode and effects analysis: a prospective team method that identifies ways a process can fail and prioritizes risks before harm occurs.

Occupancy rate

Patient days divided by the product of beds and days in the period; expresses how much of available inpatient capacity is in use.

All-hazards approach

Emergency preparedness planning that addresses mitigation, preparedness, response, and recovery for a broad range of potential disasters rather than single scenarios.

Life Safety Code

NFPA 101 standards governing egress, fire alarm, and sprinkler requirements; accredited facilities must conduct and document required fire drills.

Par level

A predetermined supply quantity that triggers reordering when inventory falls to that point, balancing stockouts against holding costs.

Data steward

A role responsible for maintaining data definitions, quality, and consistency within a domain, while data owners approve access and use.

Least privilege

An access control principle granting users only the permissions required for their job function, reducing risk of unauthorized ePHI disclosure.

Business associate agreement

A contract required before a vendor handles protected health information on behalf of a covered entity, specifying safeguards and breach obligations.

RTO and RPO

Recovery time objective is the maximum acceptable downtime after disruption; recovery point objective is the maximum acceptable data loss measured in time.