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157 Cards in this Set
- Front
- Back
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health benefits plan
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a defined set of reimbursable services a person is entitled to receive based on his/her contract with a plan or insurer.
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outcomes management
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process of collecting, analyzing, evaluating, and disseminating the results of processes or procedures to improve decision making and service delivery.
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clinical paths
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Care management tools that organize, sequence, and time the major patient care activities and interventions of the entire interdisciplinary team for a particular diagnosis or procedure.
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CLAIM
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In RM, a patient’s demand for payment for injury, or lost damaged property that results from alleged negligence by the facility, the physician, or the employees or agents of either.
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TRUE
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Under-utilization and over-utilization are both undesirable outcomes in health care
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FALSE
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One significant change that took place in hospitals with the implementation of Medicare’s prospective payment system was a shift to the inpatient setting for services-
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FALSE
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Intensity of service establishes whether the patient is sick enough to require acute care
TRUE OR FALSE |
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TRUE
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Clinical pathways are useful as a care coordination tool because they decrease variation in the process of treating a disease condition
TRUE OR FALSE |
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TRUE
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A recovery auditor is a CMS contractor whose primary task is to review Medicare claims data and determine if the claim was appropriately paid
TRUE OR FALSE? |
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Inpatient coding: does the clinical documentation support the MS-DRG assignment.
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Identify one of the 4 primary focus areas of a RAC.
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ALL of the above- assess and prioritize the person’s health care needs, develop a plan of care that addresses patient’s need in a cost-effective manner, and arrange and coordinate services needed.
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Which of the following is a key activity for a case manager
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Intensity of Service
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A physician has ordered IV antibiotics for a patient with sepsis. The medications will be given by IV every 4 hours. What type of criteria is this?
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Provide clinical expertise to the UM program AND work with UR coordinators in determining the medical necessity of hospital stays and services. (A and B)
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From your lecture notes, what is the role of a physician advisor?
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Average total charges for MS-DRGs
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Which of the following is utilization measure that might be used to monitor a hospital’s resource use?
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Is the service medically necessary for the patient
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Which of the following questions addresses the term of “appropriateness” as it relates to UM activities
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RN OR LVN
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Per your identified UR plan, when does initial admission screening take place by the non-physician reviewer
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within 24 hours
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Per your identified UR plan, when does initial admission screening take place by the non-physician reviewer?
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severity of illness
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A patient’s admitting lab work reveals hemoglobin of 7.5 grams. The UM coordinator documents this as part of her admission review utilizing Interqual criteria. What type of criteria is this?
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Reduce financial and emotional trauma of a patient transfer to a lesser level of care.
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Which of the following is a goal for discharge planning?
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15. Which of the following is a length of stay resource that could be utilized by a case manager?
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Which of the following is a length of stay resource that could be utilized by a case manager?
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Analyze the effect of a new process on the outcome
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What is the last step in an outcomes management project?
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outpatient
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APCs were implemented in August 2000. For hospitals, this brought a prospective payment system the ____ care setting for Medicare patients.
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average length of stay
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Computer technology in the way of clinical decision support systems can help guide patient care. Which of the following is NOT a function of a clinical decision and support system?
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clinical path
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The hospital utilization committee wants to ensure that the care of patients admitted for treatment of pneumonia complies with acceptable standards of care. What interdisciplinary care tool would the committee create to communicate the key interventions that need to cocur on each day of the patient hospitalization?
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interqual
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Which of the following criteria sets used for utilization review purposes include severity of illness criteria
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Hospital acquired infection AND a sponge left in a patient after surgery
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In a pay-for-performance system, which condition would not be reimbursed by Medicare?
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disease management
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Which of the following encompasses lifestyle, medical and surgical approaches to the treatment of conditions in a cost-effective manner?
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The implementation of the Medicare prospective payment system was pivotal
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Hospitals assumed profound financial liability by moving from a cost-based to a diagnosis-related payment structure, AND hospitals saw a shift to the outpatient setting for services which was not yet under
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Will the health care service benefit the patient?
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Which of the following questions addresses the term of “efficacy” as it relates to UM activities?
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Control inappropriate resource utilization.
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Which phrase best describes the overall intent/goal of utilization management?
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1965, when the Medicare law was passed
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Utilization management has been mandated since:
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physician provider
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In the hospital setting, a denial of admission or continued stay is decided by the:
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severity of illness criteria
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The sudden onset of functional impairment such as loss of speech is an example of:
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plan, do, check, act
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Outcomes management is much like the following process:
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utilization review
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A formal review of patient resource use and appropriateness of health care services on a prospective, concurrent, or retrospective basis.
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retrospective review
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Method of determining medical necessity and/or appropriate billing practices for services, which have already been rendered
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managed care
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A system of health care financing and delivery that is designed to affect the cost, volume, and manner of service delivery through organized relationships with health care providers.
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protocols
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Care management tools that describe the process for managing patients with specific clinical conditions.
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disease management
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Approach to controlling a defined illness or injury by integrating all components of health care to provide the best total patient outcomes at the most reasonable or effective cost.
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pay for performance
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- Payment model that rewards physicians, hospitals, medical groups, or other health care providers for meeting certain performance measures for quality and efficiency (also known as value-based purchasing)
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concurrent review
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- Assessment of patient care services to ensure appropriate care, treatment and level of care. This review is performed while the patient is receiving services.
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Medicare severity DRG
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Adopted by Medicare in October 2007, this is a patient classification system used for prospective payment purposes.
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enrollee
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The term used to describe a person covered by a particular health plan
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medically necessary
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Service or treatment that is appropriate and consistent with a patient’s diagnosis, and which, in accordance with the accepted standards of practice in the medical community, cannot be omitted without adversely affecting the patient’s condition or the quality of medical care rendered
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case management
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- process whereby people with specific health care needs are identified and a plan is formulated and implemented to achieve optimum patient outcomes in the most cost-effective manner.
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level of care
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the intensity of medical care being provided by the physician or health care facility.
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utilization management
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- the planning, organizing, directing, and controlling of the health care product in a cost-effective manner while maintaining the quality of patient care and contributing to the overall goals of the organization.
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standard order sets
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Care management tools that streamline the treatment ordering process and help physicians quickly make appropriate patient care decisions.
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discharge planning
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- evaluation of patients’ medical and psychosocial needs in order to arrange for appropriate care after discharge from a health care facility.
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payer
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an organization (such as the federal government for Medicare or a commercial insurance company) who directly reimburses health care providers for their services.
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Medical education reform as a result of the Flexner report.
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the early 1900s, what activity took place that helped give birth to quality programs in health care delivery?
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EFFECTIVE
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Which of the following key dimensions is applicable to health care being based on scientific knowledge and that service should be provided to all who could benefit?
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TRUE
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A health care organization that allows physicians to care for patients must perform credentialing, privilege delineation and reappointment functions
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TRUE
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An event is considered potentially compensable when there is a patient harm that could be attributed to acts of negligence by health care practitioners or other involved individuals.
T OR F? |
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FALSE
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The ability to practice medicine within a health care facility is a right automatically given to every licensed physician and independent practitioner.
T OR F ? |
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FALSE
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Hospitals are not required to have proof of physician’s health status before an appointment to the medical staff is recommended
TRUE OR FALSE? |
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TRUE
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A legal report consisting of active and potential lawsuits will be presented to the governing board.
TRUE OR FALSE? |
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TRUE
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REMedial action such as face to face peer discussion with a physician may be required if a quality of care concern is identified during case review.
T OR F? |
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TRUE
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The purpose of risk management if financial in nature; we want to minimize monetary loss when injuries occur to patients, employees or visitors
true or false? |
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Credential verification (qualifications)
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Which of the following could be outsourced by a hospital?
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Adverse actions taken by state licensing boards.
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Which of the following is an example of physician-specific information that could be found in the national practitioner data bank?
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Core privileges
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Certain types of patient care services that a physic with adequate training within should be able to perform are called _________.
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The hospital or credential verification organization.
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National network of patient safety databases
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National network of patient safety databases
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The purpose of the patient safety and quality improvement act is to create
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Causal factors for an adverse patient incident.
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Root cause analysis is used by a multi-disciplinary team to discover the: |
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24 hours
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What is the timeline for completing and submitting the incident report to risk management?
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Forceps left in a patient after surgery
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Which of the following is an example of a sentinel event
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Failure mode and effects analysis
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Which of the following is a proactive risk analysis technique?
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The risk manager investigates the circumstances surrounding a patient’s claim that articles were stolen from him during his hospitalization.
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Which of the following statements best describes Risk Evaluation
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Patient safety improvement techniques.
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Root cause analysis and failure mode and effect analysis are _____
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Gather the facts surrounding the incident.
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The first step in a root cause analysis is _______.
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Average monthly rates of incidents in other nursing units
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What information needs to be added to the incident summary report to enable staff working in 3 units to see how their number of patient incidences compares to other nursing units?
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Medication Errors
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According to the incident report (view table), what is the most common type of patient incident that occurs in 3 west nursing units?
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A and C: credential committee and medical staff executive committee.
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Which of the following would conduct at least one of the three reviews generally required for a new medical staff appointment?
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2 yrs
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Clinical privileges are granted to the physician for an interval specified in the medical staff bylaws, but no longer than __________ at which time the reappointment process takes place
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Failure mode and effects analysis
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During this type of activity a team would brainstorm what could go wrong in each step of a process:
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Credential review
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. Rogers, who is a new applicant, submitted an application form for appointment to the medical staff. A medical staff committee has reviewed his license, education, post graduate training, experience, and disciplinary actions. This process is:
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risk identification
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Which of the following statements best describes “Risk identification”?
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governing body
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The ultimate authority for making appointments and granting physician privileges is vested in the:
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days
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In the sentinel event policy and per joint commission, a hospital will complete a root cause analysis within ___ of a sentinel event.
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Force field analysis
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A hospital improvement team is considering how to implement changes to the process of discharging patient. During the discussion, the team identifies all the factors that will hinder the success of their improvement plans, as well as those factors that will increase the likelihood of success. The team is using what performance improvement tool?
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RESPONDENT SUPERIOR
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Which of the following legal principles means “let the master answer
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professional practice evaluation
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systematic process to evaluate and confirm the current competency of practitioners based on their performance.
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privilege delineation
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process of defining specific patient care tasks that a physician or a licensed independent practitioner can carry out within a facility based on the individual’s professional license and his or her training, experience, competence, ability, and judgment
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occurrence screening
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System of concurrent or retrospective identification of unusual patient occurrences through medical chart-based review according to objective screening criteria.
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peer
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person who is of equal standing with another or belongs to the same group.
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licensure
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process by which a state grants permission to an individual to engage in an occupation upon finding that the applicant has attained the minimal degree of competency necessary to ensure that the public health, safety, and welfare will be reasonably well protected
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competence
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ability of an individual to perform acceptably or fulfill job responsibilities, with or without licensing, certification, or delineation of privileges.
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case review
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care provided to a patient is evaluated by peer practitioners to identify improvement opportunities.
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due process
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an orderly proceeding wherein a person is served with notice, has an opportunity to be heard, and has the right to defend his or herself.
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sentinel event
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an unexpected occurrence, involving a patient’s death or serious physical or psychological injury or risk thereof.
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root cause
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the most fundamental reasons for an actual or potential adverse event
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risk management
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the process of analyzing risks, and then deciding on the appropriate course of action in order to minimize the risks.
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risk
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the probability and magnitude of harm from a hazard.
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pt safety
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actions undertaken by individuals and organizations to protect health care recipients from being harmed by the effects of health care services.
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malpractice
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- improper or unethical conduct or unreasonable lack of skill by a holder of a professional or official position; often applied to physicians, dentists, lawyers, and public officials to denote negligent or unskillful performance of duties when professional skill are obligatory.
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near miss
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- a situation that could have resulted in an adverse patient event but did not, either by chance or through timely intervention.
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incident
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Any happening not consistent with the routine operation of the facility or routine care of a particular patient that could have or did lead to an undesired result.
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damages
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monetary compensation for an injury.
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failure mode
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different ways that a process, step, or task can fail to provide the anticipated result.
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adverse pt event
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- unexpected occurrences related to medical treatment that result in patient death or serious disability and not related to the natural course of the patient’s illness or underlying disease condition.
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GANTT
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All of the following are considered a method/model for carrying out QI monitoring and evaluation except:
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PIE CHART
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Which type of QI tool would be best for depicting the contribution of parts and how they relate to the whole?
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the prevention and reduction of medical errors.
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major focus of the 2003 revised Medicare conditions of participation is:
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Crosby
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Another quality pioneer established four quality absolutes to improve quality in an organization. This person’s belief is that quality should be defined as conformance to requirements, not just what seems good. This pioneer is:
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Shewhart
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The quality pioneer responsible for the plan, do check act method of QI is:
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Providers, purchasers, consumers
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Stakeholders in health care quality fall into three major categories:
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patient representative
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The person whose role is that of a liaison and primary customer service contact for patients is known as the:
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to enable fair statistical comparisons between different groups of patients.
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The purpose of risk adjusting patient outcome data is
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Control Chart
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Which of the following graphs will display performance measurement by use of a centerline value with upper and lower limits depicted?
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Negative correlation
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The scatter diagram below reveals what type of relationship between scores on patient surveys and patient wait times
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For eight weeks in a row the number of coding errors has decreased.
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Which of the following situations represent a significant performance trend in the HIM department?
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identify responsible people who are familiar with the process
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In establishing a data collection strategy for performance measurement, it is important to
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All of the above- accreditation/regulatory requirements, topics of national importance, and organizational strategic quality goals.
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In selecting a process to measure which of the following would be important to consider?
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BENCHMARKING
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Current performance compared against a performance goal.
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Benchmarking is a measure of:
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Which of the following is an outcome measure for the inpatient admission process?
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Ratio of registered nurses to patients.
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Which of the following is a structure performance measure
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Percent of patients assessed for fall risk at time of admission.
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Which of the following is a process performance measure
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Causal categories
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Phone not answered
The titles of machinery, materials, people, and method at the end of each rib are known as: |
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PHONE NOT ANSWERED
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Consider the QI tool found below for questions 20-21. The undesirable effect in this diagram is:
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RATE
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A performance measure is most often expressed as a:
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Tracer methodology
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The process of following a patient record from admission to discharge during a joint commission survey and talking with the health care team is known as the:
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TEFRA
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The federal legislation which accomplished the creation of peer review organizations is:
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Health care Quality Improvement Act
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Persons who give information and actions that peer review bodies take are two types of immunity provided by the:
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Agency for healthcare research and quality.
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The lead federal agency in health care quality research is:
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Rectangle
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The flowchart symbol which denotes an activity or step in a process is the:
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Measurement, assessment, and improvement.
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The three components or building blocks of health care quality management are:
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health data analysis
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Individuals who support various QM activities by gathering, evaluating, and reporting information are known as
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HEDIS
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Which of the following is NOT a synonym/acronym for quality improvement-QI?
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performance trend
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pattern of gradual change in performance or an average or general tendency of performance data to move in a certain direction over time.
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outcome measure
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a measurement used to determine whether health care activities have had the intended effect.
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pareto diagram
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- improvement tool used to apply the 80/20 rule. It helps differentiate the significant few problems from the trivial many.
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statistical process control
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application of statistical techniques to control performance of a process.
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assessment
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Use of performance information to determine the degree to which an acceptable level of quality has been achieved.
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brainstorming
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improvement tool used for generating ideas and making group decisions.
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check sheet
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paper based manual data collection instrument.
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heath care quality
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the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and professional knowledge.
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control chart
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A line graph that includes statistically calculated control limits.
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Quality management plan
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a written description of the organizational structure, responsibilities, procedures, and resources that support the organization’s QM system
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radar chart
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graphical representation used to display the differences between actual and expected performance for several measures in a defined time period
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validity
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the soundness of the use and interpretation of a measure
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six sigma
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PI model that seeks to create nearly defect free processes. Term used in statistics to denote a 99.9997% defect free yield for a process
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ganatt chart
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A type of bar chart used in process planning and control to display planned work and finished work in relation to time.
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performance goal
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the desired condition or target level of performance against which actual performance can be compared.
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performance variation
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fluctuations in performance results
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storyboard
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report format that uses pictures, diagrams, and short narratives to illustrate the steps of a PI project
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clinical practice guidelines
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systematically developed statements to assist practitioner and patient decisions about appropriate health care for specified clinical circumstances.
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sigma
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a statistical term that measures how much a process varies from perfection
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indicator
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a measure of performance over time
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dashboard
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the metaphor similar to an auto control board that is used to describe a set of performance measures displayed in a concise manner that allows for easy interpretation
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baseline
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the initial level of performance at which an organization, process, or function is operating upon
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flowchart
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- improvement tool that provides a graphic representation of a process.
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Improved documentation of core measures for heart failure and acute myocardial infarction
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In the webs recording about six sigma, what was the team from valley Baptist health system trying to improve by the use of six sigma methodologies?
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lean
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A performance improvement model used by health care organizations to eliminate wasteful steps in a process.
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storming
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Improvement project teams in this stage are characterized by dissension, defensiveness, and competition, little team spirit and increased anxiety.
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affinity diagram
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improvement tool used to organize detailed information into more general categories.
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measurement
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- collection of information for the purpose of understanding how performance changes or improves over time
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