OPERATING BUDGET COMPONENTS:
  Revenue: patient services revenue (gross) - contractual adjustments = net revenue
  Expenses: salaries/benefits (~55-60%), supplies (~15-20%), overhead, depreciation
  Operating income: net revenue - operating expenses
  Operating margin: operating income / net revenue × 100 (target 3-5% nonprofit)

MEDICARE PAYMENT SYSTEMS:
  IPPS (Inpatient Prospective Payment): DRG-based flat payment
    Base rate × DRG weight × geographic adjustment = payment
    Outlier payments for extremely high-cost cases
  OPPS (Outpatient Prospective Payment): APC-based
    APC (Ambulatory Payment Classification) — similar to DRG for outpatient
  RBRVS (Resource-Based Relative Value Scale): physician payment
    RVU (relative value unit) × conversion factor = payment
    Work RVU + Practice Expense RVU + Malpractice RVU = total RVU

COST ACCOUNTING:
  Direct costs: attributed to specific department (nursing, pharmacy)
  Indirect costs: allocated across departments (administration, utilities)
  Cost per discharge: total costs / total discharges
  Break-even analysis: fixed costs / (revenue per unit - variable cost per unit)

CAPITAL BUDGETING:
  ROI (Return on Investment): net profit / total investment × 100
  NPV (Net Present Value): discounted value of future cash flows
  Payback period: initial investment / annual net cash flow
  Certificate of need (CON): some states require before capital projects

QUALITY FRAMEWORKS:
  Donabedian Model:
    Structure: resources and systems in place
    Process: activities and services provided
    Outcome: results (mortality, readmissions, satisfaction)

  IHI Triple Aim (quadruple aim):
    Better health for populations
    Better care for individuals
    Lower per-capita cost
    (+ Provider wellbeing in quadruple aim)

PATIENT SAFETY EVENTS:
  Sentinel event: unexpected death or serious harm (must report to TJC)
  Near miss: error caught before reaching patient
  Adverse event: harm to patient from medical treatment
  Root cause analysis (RCA): systematic investigation after serious event
  FMEA (Failure Mode and Effects Analysis): proactive risk assessment

HOSPITAL ACQUIRED CONDITIONS (HAC):
  Medicare does not pay additional for HACs
  Examples: CAUTI, CLABSI, surgical site infection, falls, pressure injuries
  HAC Reduction Program: hospitals in bottom 25% get 1% Medicare payment reduction

READMISSION REDUCTION:
  Hospital Readmissions Reduction Program (HRRP)
  Targeted conditions: AMI, HF, pneumonia, COPD, hip/knee arthroplasty, CABG
  30-day readmission rates compared to expected
  Penalty: up to 3% Medicare payment reduction

STAFFING RATIOS:
  California mandate: 1:5 nurse-to-patient ratio (medical/surgical floor)
  ICU: 1:1 or 1:2 depending on acuity
  ED: varies by triage category and census
  Overtime and agency staff: increase costs significantly

PROVIDER CREDENTIALING:
  Primary source verification (PSV): verify licenses, education, training
  Privileging: specific procedures a provider may perform at this facility
  OPPE/FPPE: ongoing and focused professional practice evaluation
  Peer review: confidential quality oversight (protected from discovery)

WORKFORCE CHALLENGES:
  Nursing shortage: projected 200,000+ vacancies nationally
  Burnout: high after COVID-19 pandemic, travel nurse costs
  CRNA/NP/PA: expanded roles in many states due to physician shortage
  Locum tenens: temporary physicians to fill gaps