Form 1: Proposal for a new field oftechnical activity
Circulation date:2015-12-18
Closing date for voting:2016-03-18

Reference number(to be given by Central Secretariat)

Proposer :ISO/TS/PANSI (United States)

256

A proposal for a new field of technical activity shall be submitted to the Central Secretariat, which
will assign it a reference number and process the proposal in accordance with the ISO/IEC
Directives (part 1, subclause 1.5). The proposer may be a member body of ISO, a technicalcommittee, subcommittee or project committee, the Technical Management Board or a General
Assembly committee, the Secretary-General, a body responsible for managing a certification system
operating under the auspices of ISO, or another international organization with national bodymembership. Guidelines for proposing and justifying a new field of technical activity are given in the
ISO/IEC Directives (part 1, Annex C).
The proposal (to be completed by the proposer)
Title of the proposed new committee (The title shall indicate clearly yet concisely the new
field of technical activity which the proposal is intended to cover.)Healthcare Administration

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Scope statement of the proposed new committee (The scope shall precisely define thelimits of the field of activity. Scopes shall not repeat general aims and principles
governing the work of the organization but shall indicate the specific area concerned.)Standardization in the field of healthcare administration will include classification, terminology andnomenclature, management practices and metrics that comprise the “business” operations among
healthcare entities. Covered subjects would include healthcare supply chain, capital (financial)management, patient admission and discharge approaches, human resource management specific tohealthcare management, facilities management specific to healthcare facilities”, and all other non-clinicalorganizational support functions. These practices and metrics will be limited to staff and operational
management of healthcare entities. For the purposes of this committee’s work, this proposal
identifies healthcare entities as those organizations “whose principal operations consist of agreeing
to provide health care services and entities whose primary activities are the planning, organization,and oversight of such entities, such as parent or holding companies of healthcare providers.” 1 This
proposal adopts seven broad categories of healthcare entities for the purpose of this area oftechnical inquiry. 2 (SEE ATTACHED Appendix). The scope of this standard will principally be in the
Health System and Related Sectors column in the chart below.
Standards that directly affect patient care and medical research are outside the scope of thisstandards effort. Test methods and specifications that are applicable to materials, appliances,
instruments, and equipment that are in the practice of traditional and modern medicine are notwithin the scope of this standards effort. Clinical performance in patient safety and satisfaction
standards will not be pursued by this standards setting body. These standards will not address
water supply, sanitation, food relief and related services that have a healthcare benefit but are notexclusive responsibilities of healthcare entities. These standards will also not address 1) the
management or administration of organizations that practice dentistry, 2) the production and use of
medical devices or instruments, and 3) the capture and analysis of clinical medical information orprocedures.

1 Prince PhD, Thomas R. 1998. Strategic Management for Healthcare Entities. Chicago. American Hospital

Association. p.4.
2 Ibid.

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Proposed initial programme of work (The proposed programme of work shall correspondto and clearly reflect the aims of the standardization activities and shall, therefore, show
the relationship between the subject proposed. Each item on the programme of work shallbe defined by both the subject aspect(s) to be standardized (for products, for example,
the items would be the types of products, characteristics, other requirements, data to besupplied, test methods, etc.). Supplementary justification may be combined withparticular items in the programme of work. The proposed programme of work shall alsosuggest priorities and target dates.
The proposed program of work for the standardization of healthcare administration:
1) Primary management standards
a. Terminology
b. A standard that describes and defines a classification systemc. A standard that defines effective healthcare administrationi. Cost and productivity management (e.g. Admission and continuation ofservices, materials management, food service management, complaint
management) (in liaison with ISO/TC 267 Facilities management)
ii. Financial management (e.g. revenue/patient served, budget planning
process, capital expenditure planning, revenue cycle operations, payrol l andvendor disbursements)
iii. Human resource/labor management (e.g. engagement, exit interview
process, vacancy reporting, separation rates, volunteer management, conflict
management, turnover) (in liaison with ISO/TC 260 Human resource
management)
2) Secondary support standards
a. Supply chain management (in liaison with ISO/PC 277 Sustainable procurement)b. Health related disaster relief administrationc. Pharmacy managementd. Risk management (in liaison with ISO/TC 262 Risk management)e. Internal controls systems
f. Asset management (in liaison with ISO/TC 251 Asset management)
g. Maintenance management
h. Transportation management
The priority of work will be establishing terminology, classification, cost and productivity
standards that will resonate with the market place and provide immediate value to consumers,
patients and end users.

Indication(s) of the preferred type or types of deliverable(s) to be produced under the
proposal (This may be combined with the "Proposed initial programme of work" if moreconvenient.)
Preferred deliverables from this work would include ISO Standards and technical specifications
on the effective administration of healthcare entities.

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A listing of relevant existing documents at the international, regional and national levels.
(Any known relevant document (such as standards and regulations) shall be listed,regardless of their source and should be accompanied by an indication of theirsignificance.)
PAHO:
Establishment of Technical Competency Standards for Emergency Response.
Professionals Providing Care in a Mass Casualty Event.
PAHO: International Public Sector Accounting Standards. Pan American Health Organization(Washington, D.C, PAHO, 2007-10)
WHO:
HospitalstandardsforAccreditation
examplesfrom
Afghanistan
2006, Ministry of Health Afghanistan and USAID: Management of Human Resource (Section 5);
Pharmacy Management (Section 4)
ISO 31000 - Risk management
ISO Guide 73:2009, Risk management - Vocabulary complements ISO 31000 by providing a collectionof terms and definitions relating to the management of risk.
ISO/IEC 31010:2009, Risk management – Risk assessment techniques focuses on risk assessment.
ISO 9000 - Quality management
ISO 9001:2008 - sets out the requirements of a quality management system
ISO 9000:2005 - covers the basic concepts and language
ISO 9004:2009 - focuses on how to make a quality management system more efficient and effective
ISO 19011:2011 - sets out guidance on internal and external audits of quality management systems.
ISO 45001 - Occupational health and safety
ISO 26000:2010 - Social responsibility
Guidelines on occupational safety and health management systems, ILO -OSH 2001
C150 - Labour Administration Convention, 1978 (No. 150) Convention concerning Labour Administration:Role, Functions and Organisation (Entry into force: 11 Oct 1980)
ISO 55000:2014 Asset management -- Overview, principles and terminology
ISO 55001:2014 Asset management -- Management systems -- Requirements
ISO 55002:2014 Asset management -- Management systems -- Guidelines for the application of
ISO 55001
ISO Guide 73:2009 Risk management -- Vocabulary
ISO 31000:2009 Risk management -- Principles and guidelines
ISO/TR 31004:2013 Risk management -- Guidance for the implementation of ISO 31000
IEC 31010:2009 Risk management -- Risk assessment techniques
Association of periOperative Registered Nurses’ ANSI standard: AORN Guidance Statement:
Perioperative Staffing, AORN MAN-833-2013
Joint Commission standards(US)American Nursing Credentialing Center Magnet Certification Program Standards (US)National Safety and Quality Health Service Standards: Standard 1: Governance for Safety and Quality in
Healthcare Organizations (Australian Commission on Safety and Quality in Health Care)
Community Health Accreditation Program Standards (US)FORM 1 – Proposal for a new field of technical activity (Healthcare Administration)
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A statement from the proposer as to how the proposed work may relate to or impact on
existing work, especially existing ISO and IEC deliverables. (The proposer should explain
how the work differs from apparently similar work, or explain how duplication and conflict
will be minimized. If seemingly similar or related work is already in the scope of othercommittees of the organization or in other organizations, the proposed scope shalldistinguish between the proposed work and the other work. The proposer shall indicate
whether his or her proposal could be dealt with by widening the scope of an existingcommittee or by establishing a new committee.)
The singular and prominent role that healthcare has in society calls for its own expression ofproper management in medical environments. Meanwhile, the TC will learn from and likely
normatively reference the relevant ISO and IEC deliverables that were developed in othercommittees. The new TC will also develop fresh commentary standards that best serve theinterest of the medical market place. The new TC offers existing medical devices, medical testing,informatics, and other related standards developers a management environment where healthcare
entities more effectively implement their standards. Finally, the healthcare sector more readily
embraces conformity assessment schemas and management systems. Healthcare entities seeorganizational credentialing as a positive indicator and differentiator of value to its customer base.
Stemming from the educational and professional foundations of medicine, the new TC anticipatesstrong interest in a conformity assessment solution that could arise from these healthcare
administration standards.

A listing of relevant countries where the subject of the proposal is important to theirnational commercial interests.
All countries and regions of the world have healthcare entities that would fall under the scope of
this standard. Their Ministries of Health and equivalent organizations have a paramount interestin providing the highest quality healthcare and the best possible cost. Developing countries andrural communities, which do not have the resources to experiment with management practices or
to hire consultants to advise them on effective practices would directly benefit from the access ofeffective management practices and tools for more developed countries.

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A listing of relevant external international organizations or internal parties (other ISO
and/or IEC committees) to be engaged as liaisons in the development of thedeliverable(s). (In order to avoid conflict with, or duplication of efforts of, other bodies, it
is important to indicate all points of possible conflict or overlap. The result of any
communication with other interested bodies shall also be included.)
The new Technical Committee (TC) will actively seek opportunities to coordinate and liaison withall of the international organizations below. Some of these international organizations have selfdescribed management standards. These standards are small in number and mostly focus onleadership effectiveness, accounting, safety, quality, and performance management practices.
These standards frequently support an existing conformity assessment schema. Instead ofstandards, some organizations below provide checklists, guidelines and other tools to help
improve healthcare entity management.
Multilateral Organizations:
United Nations (UN)World Health Organization (WHO)Pan American Health Organization (PAHO)UN Economic and Social Council (UNESCO)The United Nation Children’s Fund (UNICEF)
United Nations Development Program (UNDP)World Bank and WHO Special Program for Research and Training in Tropical Diseases
International Labor Organization (ILO) has a standard for labor management which will notconflict with the work of this committee.
Bilateral Agencies:
United States Agency for International Development (USAID)
Non-Governmental Organizations:
Project Hope (USA)Oxfam International (UK)
Refugee and Disaster Relief Organizations:International Red Cross Red Crescent Movement
Medecins san Frontieres(MSF)

The new Technical Committee will actively seek opportunities to coordinate and liaison with all of
the internal parties below. The new TC’s scope prohibits standards development for clinical careor medical devices. Therefore the new standards will be complementary, mutually reinforcing
documents. The TC will have an opportunity to normatively reference standards from committees
with existing relevant content: human resources, asset, facilities, risk and quality management.
ISO/IEC Technical Committees:
ISO/TC 106 Dentistry
ISO/TC 168 Prosthetics and orthotics
ISO/TC 170 Surgical instruments
ISO/TC 176 Quality management and quality assurance
ISO/TC 194 Biological and clinical evaluation of medical devices
ISO/TC 198 Sterilization of health care products
ISO/TC 210 Quality management and corresponding general aspects for medical devices
ISO/TC 215 Health informatics
ISO/TC 249 Traditional Chinese medicine
ISO/TC 251 Asset management
ISO/TC 260 Human resource management
ISO/TC 262 Risk management
ISO/TC 267 Facilities management
ISO/TC 276 Biotechnology
ISO/PC 277 Sustainable procurement
ISO/PC 283 Occupational health and safety management systems
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A simple and concise statement identifying and describing relevant affected stakeholder
categories (including small and medium sized enterprises) and how they will each benefit
from or be impacted by the proposed deliverable(s).
Patients and consumers of healthcare will benefit from slower increases in the cost of health careand the resulting access to care. UK and US research also shows that patients are more satisfied
and are healthier when receiving services from better managed healthcare organizations.
Organizations that provide healthcare benefits will enjoy either a reducti on in their benefits costs ormore predictable, slower increase in the costs of coverage as efficiencies in healthcare
management are transferred to the policy holders.
Insurance companies and nation Ministries of Health will more accurately monitor and co mpare thequality of management and assess cost control as they determine which healthcare entity provides
the best value for their customers and populations.
Developing countries and rural healthcare providers will more easily access and adopt the mosteffective practices and metrics of more established and better resourced healthcare systems.
Healthcare entities will enjoy the sharing of effective management practices that will drive better
outcomes for patients and will reduce the increase in spending of non-clinical services.
Society in general will be better informed about the effectiveness of their healthcare system andgain access to a better quality of care.

An expression of commitment from the proposer to provide the committee secretariat if the
proposal succeeds.
ANSI is prepared to assume the secretariat of this ISO committee if formed. It is ANSI’s intention todelegate administrative responsibility for the secretariat to the University of Texas Medical Branch (UTMB).
The President of the UTMB fully supports the development of these ISO standards and has provided
the Chief Human Resources Officer (CHRO) of UTMB the material support and the direction to staff
and to support development of these standards. The UTMB CHRO will establish a standards
development staff that will be dedicated to the proper administration of TC. At minimum this staff will
have an organizational leader with primary responsibility for the administrati on of this effort with adirect reporting relationship to the CHRO. The Administrator will be permanent official management
position at UTMB. If UTMB is granted the responsibility to administer the TC, that role will also be apermanent management position. UTMB also commits to sending this staff to all training andmeetings that will sufficiently prepare them to accomplish these duties. UTMB will also participate instandards support activities to further the interest of standards development in general.

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Purpose and justification for the proposal. (The purpose and justification for the creation ofa new technical committee shall be made clear and the need for standardization in thisfieldshall be justified. Clause C.4.13.3 of Annex C of the ISO/IEC Directives, Part 1 contains amenu of suggestions or ideas for possible documentation to support and purpose andjustification of proposals. Proposers should consider these suggestions, but they are notlimited to them, nor are they required to comply strictly with them. What is most important isthat proposers develop and provide purpose and justification information that is most
relevant to their proposals and that makes a substantial business case for the market
relevance and the need for their proposals. Thorough, well-developed and robust purpose
and justification documentation will lead to more informed consideration of proposals andultimately their possible success in the ISO IEC system.)
Below are nine justifications that provide compelling support for the start of this new technical area.
They are discussed in more detail in the attached Appendix.
Justification 1: Establishing healthcare administrative standards will slow if not reduce thecost of providing healthcare through the widespread adoption of interoperable metrics andpractices.



Justification 2: Reducing the cost of healthcare will make these services more affordable
and thereby provide an opportunity for greater access to society.

Justification 3: Improving the administrative and managerial performance of healthcare
entities results in better healthcare outcomes for patients.

Justification 4: Although numerous standards exist for the laboratory protocols, clinicalservices and patient care functions of healthcare organizations, there are scant standards
that address administrative functions or these standards are specific to a particular
healthcare entity.

Justification 5: Standardizing Healthcare administrative metrics will create apple -to-applecomparisons of organizations performance that will better educate consumers and drive
process improvement activities.



Justification 6: Rural communities and developing countries will have access to effective
practices that offer a roadmap to improve their own quality of healthcare services theyreceive.



Justification 7: Positive support has been received from other standards developers andmembers of the healthcare technical community.

Justification 8: Standards will complement standards developing efforts of existing ISO
standards developing committees.

Justification 9: The healthcare community and its stakeholders are highly receptive tostandardization and certification and will adopt approaches from these sources readily.

A proposed framework for these standards is presented on the attached scope (Appendix). This
framework is based on the view that reducing cost while improving the quality of outcomes is apatient centered, value focused view of providing healthcare. In addition, improving the speed ofservices that customers receive during the patient care lifecycle multiplies the positive effects ofthis value centered approach.

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Signature of the proposer

Steven P. Cornish
Senior Director - International Policy
American National Standards Institute (ANSI)
25 West 43rd Street,
4th floor
New York, NY 10036
P: 212.642.4969
E: SCORNISH@ansi.org

Further information to assist with understanding the requirements for the items above can be foundin the Directives, Part 1, Annex C.

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Appendix
Categories of Healthcare Entities within Scope








Clinics, medical group practices, individual practice associations, individual practitioners,
emergency care facilities, laboratories, surgery centers, and other ambulatory care organizations
Continuing care retirement communities
Health maintenance organizations and similar prepaid care plans
Home health agencies
Hospitals
Nursing homes that provide skied, intermediate, and less intensive levels of health care
Drug and alcohol rehabilitation centers and other rehabilitation facilities.

Preliminary Framework for Standards Projects
Labor
Metrics
Vacancy (Rates and Costs)
Cost of Vacancy
Healthcare Costs Per Employee
Clinical and Classified Absence (Rate and Cost)
Clinical and Classified Turnover (Rate and Cost)
1 st Year Service Turnover Rate (Vol and Invol)
Average Tenure for Each Job Category
Clinical and Classified Diversity
Separation Rates (Probationary and Annual)Training Costs per Employee
Salary and Benefits Costs per Employee
Classified and Clinical Operating Costs /FTE
Defining Healthcare FTE
Labor Costs per FTE
Overtime Pay Percent for Job Categories
Clinical and Classified Workforce ROI
Percentage of Positions filled Internal/External
Cost Per HireTime to Accept
HR Staff Costs Per Employee
Time to Fill
Recruiting Source Yield Ratios
Training and Development \ FTE
Workers Compensation Cost and Incident Rates
Workers Compensation Severity Rate (days out)
Finance
Metrics
Clinical and Classified Value Added
Revenue / Clinical (or Classified)
Revenue / Patient Served
Cost and Productivity
Metrics
Supply cost per patient-day
Full-time staff equivalents (FTEs) per patient-day

Practices
Engagement
Performance Management
Exit Interview Process
In-Service and Continuing Education

Practices
Budget Planning Process
Capital Expenditure Planning
Billing and Reimbursement
Payroll and Vendor Disbursements
Practices
Patient Acceptance Criteria
Admission and Continuation of Services
Processes
Food Services Management
Material Management
Phlebotomy
Pediatric patient experience
Trauma Patient Experience
Clinical Patient Experience

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Obstetric Patient Experience
Clinical and Classified Employee
Emergency and Disaster Preparedness
Direct Contract Services and Products
Accepted Administrative Terms andAbbreviation
Public Disclosure of Information
Complaint Management (Internal andExternal)
Investigation and Research Management
Safety Program for Administrative Areas
Discharge Process
Physical Facilities Evaluation

Purpose and Justification for the Proposal
Background: Based on 2010 data from the World Health Organization, the total global expenditure on
health was 6.5 trillion US dollars. Among the member countries of the Organisation for Economic Cooperation and Development, the United Spends the most on per person on health ($8,832) while theaverage for OECD members spends $4380. Since 1960 the cost of healthcare has shown steady increases
in most OCED countries with the United States leading the way at 16.4% of GDP in 2012 dollars.

Chart 01 Health Spending Total % of GDP,1960 – 2012 3
Source: Health expenditure and financing: Health expenditure indicators

Chart 02 Health Spending Total % of GDP,1960 – 2012 4
Source: Health expenditure and financing: Health expenditure indicators

3 Accessed from https://data.oecd.org/healthres/health-spending.htm
4 Accessed from https://data.oecd.org/healthres/health-spending.htm

on August 17, 2015
on August 17, 2015

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As a function of access to care, the number of people seeking doctor’s consultations has stayed
steady or increased, particularly in developing countries. Their stays in hospitals havedramatically decreased over time while discharge rates are continuing to in crease. This datasuggests that a higher number of patients are seeking care and are being moved through thestages of the healthcare system. This increasing rate of delivery of healthcare services is likely
due to improved clinical services and greater illness prevention and wellness initiatives. However,this increase in the flow of patients within the healthcare system creates stress upon the patientcare management system. Using redundant and antiquated management systems, healthcare
providers must spend more money to keep ahead of the demand in services.

Chart 03 Health Spending Total % of GDP,1960 –2012 5
Source: Health expenditure and financing: Healthexpenditure indicators

Chart 04 Health Spending Total % of GDP,1960 –2012 6
Source: Health expenditure and financing: Healthexpenditure indicators.
Chart 05 Health Spending Total % of GDP,1960 – 2012 7
Source: Health expenditure and financing: Healthexpenditure indicators

Below are nine reasons why UTMB believes the creation of this technical area of work is timely, would be
supported by the technical community, and provides significant social and economic benefits to its stakeholders.
Justification 1: Establishing healthcare administrative standards will slow if not reduce the cost ofproviding healthcare through the widespread adoption of interoperable metrics and practices. Standards inhealthcare administration will facilitate the sectors movement from a volume-driven systems to value based, patient
centered systems of care while encouraging coordinated healthcare services across entities. The proper
application of voluntary standards to an area of management can dramatically reduce the cost of “back office”
functions support the organizations principal operations.8
For healthcare entities, the most important assets are not the buildings or investment portfolios. Instead it is
the workforce — the individuals who directly or indirectly care for patients. The recruitment, management
and retention of the hospital workforce have a direct impact on the cost of patient care. The American
Hospital Association (AHA) reports that labor costs are the single most important driver of spending growthfor hospitals, accounting for about 35 percent of overall growth. Growth in labor costs also accounted for5 Accessed from https://data.oecd.org/healthres/health-spending.htm

on August 17, 2015
on August 17, 2015
7 Accessed from https://data.oecd.org/healthres/health-spending.htm on August 17, 20158 http://www.standardsboostbusiness.org/case-cost.aspx
6 Accessed from https://data.oecd.org/healthres/health-spending.htm

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more than half of the growth in the cost of purchased goods and services. Other components included:prescription drugs, 5 percent; professional fees, 5 percent; professional liability insurance, 2 percent; andall others, 18 percent. All told, the increased cost of these goods and services purchased to provide
care represented 64 percent of overall growth in spending on hospital care from 2004 to 2008 . By
comparison, rising demand for care (i.e., change in the number of services provided) drove 34 percent ofspending growth, while increased intensity of hospital care and other factors accounted for only 2 percent of
the increase.9 The lion’s share of cost in the healthcare field is found in management costs. Lower ing
healthcare operational costs will result in lower insurance premiums. For employers, the reduction inpremiums can be translated into more money for growth and expansion of business.
Justification 2: Reducing the cost of healthcare will make these services more affordable andthereby provide an opportunity for greater access to society. The WHO has identified steady increases
in the expenditures on healthcare among developing countries. These increases are attributed topopulation movements to urban centers where a more sedentary lifestyle has increased the risk of heartdisease, cancer and other maladies that require longer term care. The WHO estimates that the minimum
spending per person per year needed to provide basic, life-saving services is $44 US. 10 Currently there are
34 countries that spend $50 or less per person on healthcare. Among the OCED countries 84% of theworld's total financial resources devoted to their healthcare needs while they comprise only 18% of theworld’s population. 11 Healthcare standardization will relieve cost pressures for developing countries and willoffer them the opportunity to spend more of their limited healthcare funds on clinical needs. In the US theCenters for Disease Control (CDC) has reported the result of three National Health Interview surveys thatindicate that the cost of healthcare is restricting the access to these services. 12 The table below indicatesthat the problem is getting progressively worse. Administrative standards that reduce the variety of backoffice practices and metrics will generate economies of scale and reduce redundanc y and waste inclassified (non-clinical/ non-revenue generating) activities in healthcare organizations. The normalizationof these practices and metrics should translate into lower costs, improved service cycle time, and greater
accessibility by consumers. These standards could dramatically achieve a social good once they bend thecost curve toward greater healthcare access.

Chart 06: Health expenditure, total (% of GDP ) 13

9 http://www.fiercehealthcare.com/story/labor-costs-are-key-driver-hospital-cost-growth/2010-03-15
10 Accessed from http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS/countries/1W -7E-4E-ZF-XJ?display=graph on

17 August 2015
11 Accessed from http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS/countries/1W -7E-4E-ZF-XJ?display=graph on

17 August 201512 http://www.cdc.gov/nchs/health_policy/reduced_access_due_to_cost.htm
13 Accessed from http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS/countries/1W -7E-4E-ZF-XJ?display=graph on

17 August 2015

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Chart 07: Wealth and health expenditure are correlated (2009) 14

Reduced access to medical care during the past 12 months due to cost among adults 18-64 years of age:
United States, 1997-2007(Data are based on household interviews of a sample of the civilian noninstitutionalized population)

Did not get medical care due Delayed medical care due to Did not get prescription drugs due
to costcost
to costTotal,
crude

1997

2006

2007

1997

2006
2007
Percent

1997

2006

2007

6.0

7.8

7.8

9.5

10.2

6.3

9.3

9.6

10.3

Justification 3: Improving the administrative and managerial performance of healthcare entities
results in better healthcare outcomes for patients. As in other process driven environments, if key lines
of service are managed more effectively, the end user will more l ikely be satisfied with their experience.
This appears to be true in healthcare as well. A 2011 study of the nursing staff of Magnet® hospitals showsthat “superior work environments and better nurse and patient outcomes in Magnet® recognizedhospitals…” 15 Hospitals that follow Magnet® standards also demonstrate “lower surgical mortality andfailure to rescue….” 16 A 2013 study found that “improving nurses’ work environment and reducing nurses’
workload are organization-wide reforms that could result in fewer readmissions for Medicare beneficiaries
with common medical conditions. 17 Preventable hospital readmissions are a source of unnecessary costs to
Medicare – over $15 billion annually. 18 Another 2013 study found that Registered Nurse “workgroup job
satisfaction is significantly and inversely associated with patient falls….” 19 This study again highlights therelationship between effective management practices for clinical staff and better patient outcomes.
According to Greta Cummings in a 2011 article in Perspectives in Nursing Leadership, “After controlling forpatient demographics, co-morbidities and institutional and hospital nursing characteristics, high -resonant
14 Accessed from http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS/countries/1W -7E-4E-ZF-XJ?display=graph on

17 August 201515 Kelly, Lesly A., McHugh, Matthew, Aiken, Linda H. October 2011. “Nurse Outcomes in Magnet® and Non-Magnet

Hospitals.” The Journal of Nursing Administration. Volume 41, Number 10, pp 428-433,
16 McHugh, Matthew D., Kelly, Lesly A, Smith, Herbert L., Wu, Evan S, Vanak, Jill M. and Aiken, Linda H. Aiken. (2013)“Lower Mortality in Magnet Hospitals.” Medical Care, 2013;51(5):382-388. Reprinted in JONA • Vol. 43, No. 10, p.387
17 McHugh, Matthew and Ma, Chenjuan.

.January 2013. “Hospital Nursing and 30-Day Readmissions Among
Medicare Patients With Heart Failure, Acute Myocardial Infarction, and Pneumonia.” Medical Care. Volume 51,
Number 1. Reprinted in JONA • Vol. 43, No. 10. p. 57
18 Ibid p. 51
19 Choi, JiSun Choi and Boyle, Diane K. 2013. “Workgroup Job Satisfaction and Patient Falls in Acute Care Hospital

Units.” The Journal of Nursing Administration. Volume 43, Number 11, pp 586-591, Copyright B 2013 Wolters Kluwer
Health | Lippincott Williams & Wilkins, p. 590

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nursing leadership contributed to lower patient mortality rates at statistically significant levels.” 20 Finally andinternational study of the relationship between patient outcomes and effective staff management found that“deficits in hospital care quality were common in all countries. Improvement of hospital work
environments might be a relatively low cost strategy [Emphasis Added] to improve safety and quality in
hospital care and to increase patient satisfaction.” 21 Improving patient and staff outcomes could also beenjoyed by not only hospitals, but also other healthcare entities once interope rable healthcare
administrative standards are established and adopted. The chart below shows that the “living” year of 59%
of the lower income populations is shorter than the living year of upper income populations (8%). We also
see that life expectancy is correlated with healthcare expenditures.

Chart 07: DALYs lost by World Bank income region projected 2005 22

Chart 08: Correlation between expenditure on health and outcomes (2009 ) 23

Justification 4: Although numerous standards exist for the laboratory protocols, clinical services
and patient care functions of healthcare organizations, there are scant standards that addressadministrative functions or these standards are specific to a particular h ealthcare entity. The best
known organizational standards setting and certifying bodies in healthcare focus their efforts on clinicaleffectiveness and patient outcomes. Their impact on healthcare resembles the effects that quality andsafety standards have on manufacturing and engineering environments. These narrowly focused categories
of standards and certifications also tend to serve specific healthcare entities and not others: Magnet® fornursing and hospitals, Joint Commission for hospitals, and CHAP for home health organizations. The UN,
though the WHO has standards for leadership, accounting and performance management in healthcare, but
most of the non-clinical guidance they give are in guidelines, research, and nonbinding checklists. As
healthcare organizations consolidate and acquire different healthcare entities to diversity their service lines,
maintaining and integrating the requirements and certifications of these “boutique” standards bodies will be

20 Cummings, Greta. June 2011. “The Call for Leadership to Influence Patient Outcomes “ Perspectives in Nursing Leadership. 24(2) June

2011: 22-25.doi:10.12927/cjnl.2011.22459 http://www.longwoods.com/content/22459
21 Aiken, Linda H et al.2013. “Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses

and patients in 12 countries in Europe and the United States.” BMJ 2012;344:e1717
22 Accessed from http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS/countries/1W -7E-4E-ZF-XJ?display=graph on

17 August 201523 Accessed from http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS/countries/1W -7E-4E-ZF-XJ?display=graph on

17 August 2015

FORM 1 – Proposal for a new field of technical activity (Healthcare Administration)
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problematic. Establishing a new standards setting body that can serve as a “rallying point” foradministrative standards seems timely and appropriate.
Justification 5: Standardizing Healthcare administrative metrics will create apple -to-applecomparisons of organizations performance that will better educate consumers and drive process
improvement activities. Healthcare entities regularly share metrics with regulators, certifying
organizations, patients, and insurers. The most common form these metrics take are:









Financial- Track overall facility/system financial performance from a business perspective.
Utilization - Characterize the number/type of basic services rendered and resources used (without
regard to cost).
Cost/Productivity - Principally used by healthcare providers to reduce supply/labor costs andincrease productivity.
Clinical Performance - Characterize the quality of patient care (e.g., mortality); also called "patient
outcome" data.
Patient Safety - Nearly 100,000 Americans die each year from preventable medical mistakes dur ing
in-patient hospitalizations (Institute of Medicine, 1999); many more mistakes lead to permanent
disabilities and longer recoveries. These metrics characterize preventable medical mistakes that are
made.
Patient Satisfaction - Measure satisfaction from a patient's perspective and are typically based on
patient surveys after treatment/release. 24

Since clinical performance, patient safety, and patient satisfaction are measurements that have formany years determined reimbursements by payers, these metrics a re relatively uniform and consistent.
However, financial, facility, utilization, cost, labor, and productivity measures are often determined
locally, since they are considered the proprietary information each individual healthcare entity. This
proprietary view of core administrative metrics curtails their development into generally accepted
measurements for data each in the marketplace. Payers, investors, patients, and healthcare entities
themselves lose the opportunity to compare performance and pursue evidence-based organizational
improvement strategies where the largest cost of the healthcare enterprise resides. E stablishing patient
focused, industry wide administrative measures and practices in healthcare would provide far ranging
benefits for the patient, the healthcare provider, insurance companies, employers , health ministries andother societal stakeholders.
Justification 6: Rural communities and developing countries will have access to effective
practices that offer a roadmap to improve their own quality of healthcare services they receive.
Due to the high cost of healthcare services, providers in rural communities and developing countries
tend to offer fewer options of often lesser quality in healthcare. The also lack the discretionary
resources to hire consultants or purchase off-the-shelf solutions for their administrative and operational
challenges. The charts below show that a richer population quintiles of the get a greater share ofhealthcare spending within the same country than poor quintiles. The second chart shows that poor
quintiles tend to use critical services less. The table below shows the access to healthcare based on
income levels in the U.S. Percent of poverty level is based on family income and family size andcomposition using U.S. Census Bureau poverty thresholds. This table reveals the more impoverished aperson is, the less likely they are to receive care.

24 http://www.rwilliford.com/healthcare_metrics.html

FORM 1 – Proposal for a new field of technical activity (Healthcare Administration)
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Reduced access to medical care during the past 12 months due to cost among adults 18-64 years of age,by percent of poverty level: United States, 1997-200725(Data are based on household interviews of a sample of the civilian noninstitutionalized population)

Percent ofpoverty level
Below 100%100%-less than200%
200%-less than400%
400% or more

Did not get medical caredue to cost

Delayed medical care due Did not get prescription drugs
to costdue to cost

1997

1997

2006

2007

1997

2006

2007

14.8

19.7

18.8

2006

2007

14.1

16.1

16.1

16.5

Percent
17.9
17.9

11.1

14.0

14.3

15.8

16.3

17.0

11.6

16.4

17.2

5.2

7.4

8.3

9.5

10.6

11.4

5.5

8.7

10.6

1.6

2.8

2.7

4.2

4.8

4.7

1.7

3.0

3.0

The next table shows that people in communities outside of “metropolitan statistical areas” (MSA) are
generally less likely to access care due to cost.
Reduced access to medical care during the past 12 months due to cost among adults 18-64 years of age,by location of residence: United States, 1997-200726(Data are based on household interviews of a sample of the civilian noninstitutionalized population)

Location ofresidence

Did not get medical caredue to cost

Delayed medical caredue to cost

Did not get prescription
drugs due to cost

1997

1997

2006

1997

9.0
11.3

Percent
9.8
9.9
12.2
12.9

Within MSA 5.7
Outside MSA 6.9

2006
7.3
10.1

2007
7.5
9.9

2007

5.9
7.9

2006
8.9
11.0

2007
9.2
11.7

In 2009, patients living in rural areas of the United States were transferred to other facilities for care at a
rate three times higher than that of patients in large central metropolitan areas. 27 Healthcare services for
Native American communities is uniformly of less quality that their urban counterparts. 28 It is self-evident
that actions to improve the performance and keep open healthcare entities in rural communities will improve
the patient outcomes in those communities.
Justification 7: Positive support have been received from other standards developers and membersof the healthcare technical community. UTMB has reached out to other technical experts to determine ifthey 1) see a need for these standards and 2) would be willing to participate. We categorize the feedback
as follows:
Strong need for the

University of Texas Health System (Six Campuses)

25 http://www.cdc.gov/nchs/health_policy/reduced_access_due_to_cost.htm
26 http://www.cdc.gov/nchs/health_policy/reduced_access_due_to_cost.htm
27 Kindermann, D; Mutter, R; Pines, JM (February 2006). "Emergency Department Transfers to Acute Care Facilities,

2009: Statistical Brief #155". PMID 24006549

Yvette Roubideaux (2004) “A REVIEW OF THE QUALITY OF HEALTH CARE FOR AMERICAN
INDIANS AND ALASKA NATIVES.” The Commonwealth Fund.
28

FORM 1 – Proposal for a new field of technical activity (Healthcare Administration)
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standards andwillingness toparticipate
Intrigued by theidea, would like to
study theapplication before
making a decision
to participate

Aware but not
involved at thistime

Northwestern University, Searle Center on Law, Regulation and Economic
GrowthMurray State University, Baurenfeind College of Business
OrcaEyes Workforce Planning and Analytics (healthcare analytics company)
Member countries of ISO TC 260
American Hospital Association
American Dental Association (ANSI ASD)
British National Health Service
ANSI B11 Standards
US Department of Health and Human Services
ISO
Chartered Institute of Personnel and Development (CIPD)
Joint Commission
The Walt Disney Foundation
The Moody Foundation
White House, Washington DC
UK National Health Service

Once this application and its procedures have been submitted for review and placement into Standards
Action, UTMB will reach out to its network of healthcare organization, payers, consultants, and otherstakeholders and gather additional information about their support for these standards. UTMB will submit
this feedback to ANSI and its members to consider with this application.
Justification 8: Standards will complement standards developing efforts of existing ISO standards
developing committees.


UTMB is eager to work with the American Dental Association to develop joint standards where
dentistry practices and metrics overlap with the administrative standards we would develop.
UTMB will encourage the relevant consensus bodies to adopt existing healthcar e standards that areadministrative in nature. For example, UTMB would encourage the adoption of the Association of
periOperative Registered Nurses’ ANSI standard: AORN Guidance Statement: Perioperative
Staffing, AORN MAN-833-2013
UTMB would recommend that the consensus body use the existing management system ISO9001
as the way to organize and develop its body of standards, rather than attempt to create a distinct
system of standards around healthcare administration.

Justification 9: The healthcare community and its stakeholders are highly receptive tostandardization and certification and will adopt approaches from these sources readily.
Unlike other sectors, healthcare entities welcome legitimate standards and certifications. Besides assuring
patients that the organization provides the highest levels of care, healthcare entities also use these
credentials as marketing tools to entice new healthcare customers and employees. 89.7% of hospitals
agreed that the hospital’s reputation was influenced by patient experience measures; agreement was 77.4%
for mortality, 69.9% for readmission, 76.3% for process measures, 66.1% for cost measures, and 54.0% forvolume measures. 29 This high interest in organizational credentialing in the medical field is understandable
since there are particular regulatory and policy expectations that staff achieve personal certification in thearea of professional specialty.
Prominent Standards Accrediting Organizations in U.S. Healthcare 30

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) : Hospitals (see 2004
accreditation criteria), ambulatory care facilities, assisted living facilities, laboratories, long -termcare facilities, and others
Accreditation Association for Ambulatory Health Care: Ambulatory care facilities
Continuing Care Accreditation Commission

29 Lindenauer PK, Lagu T, Ross JS, et al. October 2014. “Attitudes of Hospital Leaders Toward Publicly Reported

Measures of Health Care Quality.” JAMA Intern Med. Published online.. doi:10.1001/jamainternmed.2014.5161.
30 http://www.rwilliford.com/healthcare_metrics.html

FORM 1 – Proposal for a new field of technical activity (Healthcare Administration)
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: Nursing homes, assisted living facilities, and retirement communities

National Committee for Quality Assurance (NCQA): Health plans (e.g., HMOs, PPOs)

A Short list of Commercial Healthcare Metrics Providers 31







Solucient: Healthcare provider comparison data/tools
Ingenix: An Internet subscription service offering healthcare provider comparison data/tools
Premier: Healthcare provider comparison data/tools
National Committee for Quality Assurance (NCQA): Health plan provider (e.g., HMO, PPO)
comparison data/tools based upon the Health Plan Employer Data and Information Set (HEDIS)
measures.
Truven Health Analytics

31 Ibid.

FORM 1 – Proposal for a new field of technical activity (Healthcare Administration)
Version 01/2015