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Chapter 11 is Clinical Quality Performance Improvement and Management Chapter 12 is Healthcare Delivery Systems

A detailed step-by-step guides used by healthcare practitioners to make clinical decisions related directly to patient care

Clinical practice guidelines

Utilization management is:

Process of determining whether the medical care provided to a specific patient is necessary

Discharge utilization review is:

Assessment of a patient's readiness to leave the hospital

Preadmission utilization review is:

A review conducted prior to a hospital admission to determine whether the planned services are medically necessary and require treatment in an acute care setting.

Admission utilization review is:

Review conducted at the time of a hospital admission to determine the medical necessity and appropriateness of care in an acute care setting

Retrospective utilization review is:

Review of records some time following the patient's discharge to determine any of several issues, including the quality or appropriateness of the care provided

Which of the following statements does not represent a fundamental principle of performance improvement?
a- Teamwork is an optional element in performance improvement.
b- Celebration of communication
c- Open communication
d- Leaders and team members knowing the facilities mission and goals

A- Teamwork is an optional element in performance improvement.

T/F - The purpose of quality improvement organizations is to review the reimbursement claims for Medicare and Medicaid inpatients to ensure that the care was medically necessary, appropriate, and of high quality.

True

What was the main result of the publication of the Flexner report?

Medical school standards were established.

What is the goal of the Health Care Quality Improvement Program?

Improving the health of Medicare beneficiaries

Which organization initiated the ORYX initiative as a program for developing outcome measures?

The Joint Commission

Which organization sponsors the HEDIS reporting system?

NCQA-
HEDIS (Healthcare Effectiveness Data and Information Set) is a registered trademark of the National Committee for Quality Assurance. It is a tool used by more than 90 percent of America's health plans to measure performance on important areas of care and service. Altogether, HEDIS consists of 71 measurements across 8 areas of care. HEDIS measures address areas of care such as asthma medication use and controlling high blood pressure.

What is the primary goal of integrated healthcare delivery systems?

To ensure that patients receive high-quality, cost-effective care in the most appropriate setting

Every healthcare organization's risk management plan should include the following components: _________________.

A- Safety management, security management, claims management, technology management, and facilities management

b-Objectives, key elements, responsibilities, methods, and areas of focus for the current year

B- Objectives, key elements, responsibilities, methods, and areas of focus for the current year

Medicare is a:

A federal program that finances healthcare services for the elderly

I started a new job. I have several choices for my health insurance. I want a managed care plan so my obvious choice is:
A- HMO
B- Tricare
C- Preferred provider organization

c- Preferred provider organization

Under the ORYX system, all hospitals and skilled nursing facilities must report outcome measures on at least what percentage of their patients?
a- 15%
b- 80%
c- 30%
d- 20%

D- 20%

Which governmental entity (entities) administer(s) the Medicaid program?
a- federal
b- state
c- they both work together

b- state

Who is responsible for implementing the policies and strategic direction of the hospital or healthcare organization and for building an effective executive management team?

The chief executive officer

Which federal legislation enacted the Medicare and Medicaid programs?

Public Law 89-97 of 1965

Which of the following historical events had the most influence on the U.S. government's role in financing healthcare delivery?
a- civil war
b- great depression
c-immigration
d- 9/11

b- great depression

What dictates how the medical staff operates?

Medical staff bylaws

Match the following terms with their definitions. (Definitions may be used more than once or not at all.)
1.Performance
2.Performance improvement
3.Infection control
4.Utilization management
5.Risk Management

A.A group of processes used to measure how efficiently healthcare organizations use their resources
B. Involving personnel in the ongoing improvement of services provided
C- Execution of pattern
D- The process of preventing the spread of communicable diseases in compliance with applicable legal requirements
E-The process of overseeing the medical, legal, and administrative operations within a healthcare organization

1.Performance- C. Execution of pattern
2.Performance improvement- B. Involving personnel in the ongoing improvement of services provided
3.Infection control- D. The process of preventing the spread of communicable diseases in compliance wit applicable legal requirements
4.Utilization management- A. A group of processes used to measure how efficiently healthcare organizations use their resources
5.Risk Management- E. The process of overseeing the medical, legal, and administrative operations within a healthcare organization

T/F- The Medicare Conditions of Participation require all healthcare facilities to institute utilization management program.

False- Acute care hospitals are required to have a UM program.

What type of healthcare organizations are privately owned; that is which of the following healthcare organizations pays out their excess revenues in the form of bonuses and dividends to managers, owners, and investors?

For profits are operated by individuals. partnerships or corporations, can sell stock and pay out profits to investors, must pay taxes, and may also provide charity care.

What federal legislation provides funding for the implementation of nationwide health information exchange?

American Recovery and Reinvestment Act of 2009

Jane started a new job. She has several choices for her health insurance. She wants one with a high deductible and more control over how her money is spent. She should consider which plan?

Health Savings Accounts- (HSAs) were created in 2003 so that individuals covered by high-deductible health plans could receive tax-preferred treatment of money saved for medical expenses.

I had surgery this morning. My surgery only lasted 30 minutes and I was ready to leave the facility 2 hours later. I must have had my surgery at which type of facility?

Freestanding ambulatory surgery center

What term is used for the process of determining whether the medical care provided to a specific patient is medically necessary?

Utilization review-
A utilization review is a procedure to evaluate how services are being used and delivered, to confirm that they are being utilized in a way which is efficient and cost effective. Utilization reviews are most commonly seen in the context of health care, where they may be conducted by insurance companies, hospitals, and other institutions involved in the delivery of health care.

Which of the following would be categorized as voluntary hospitals
a- university hospital
b- U.S. Air Force hospital

A-University hospitals
Voluntary hospitals are not-for-profit hospitals owned by universities, churches, charities, religious orders, unions, and other not-for-profit entities.

Which organization developed the first hospital standardization program?

The Amercian College of Surgeons

What can be defined as a voluntary system of institutional review in which an apparently independent body periodically evaluates the quality of the services provided by healthcare organizations against written criteria?

Accreditation

What is a predefined statements of the criteria against which the performance of a healthcare organization will be assessed during a voluntary review process?

Accreditation standards

Medicaid is:

A joint federal-state program that finances healthcare services for low-income families

Who is primarily responsible for setting the overall direction of an acute care hospital?

The board of directors

What documents the results of care for individual patients as well as for specific types of patients grouped by diagnostic category?

Outcome measures.

What refers to the organization of physicians according to clinical assignment?

Medical staff classification

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