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Terms in this set (46)
purpose is to assure the policy and procedures, vision, mission, and goals are being carried out
the degree to which a health-care organization increases the likelihood of desired health outcomes
What happens to the patient, The care delivered by the provider, The organization's management, The external environment (regulations in health care)
What does quality depend on?
To Err Is Human
publication in 2000 by IOM. Identified that as much as 98,000 people die each year as a result of medical error >>> Clinton administration enacted multiple measures to improve the statistics >>> The Balanced Budget Act (1997) >>> Crossing the Quality Chiasm (2001) >>> Improving the Medicare Quality Improvement Organization Program- report to Congress (2008)
Quality improvement initiatives
includes: Agency for Healthcare Research and Quality (AHRQ), Quality Improvement Organizations (QIO), MedQUIC, Institute for Healthcare Improvement (IHI), National Committee for Quality Assurance (NCQA)
Agency for Healthcare Research and Quality (AHRQ)
Federal agency focused on improving quality care
(focused on research that shows how to improve quality)
Quality Improvement Organizations (QIO)
Federally sponsored but contracted privately. Plays role in all areas of healthcare in monitoring quality
(organizations that monitor improvement of quality)
created by CMS. Electronic data sharing for quality measures
Institute for Healthcare Improvement (IHI)
Provides tools and training in form of publication, videos, etc on health care quality improvement
(institute = school = learn how to improve healthcare quality)
National Committee for Quality Assurance (NCQA)
accreditation agency. Focus on quality
(the people who accredit people and their quality)
Safety, effectiveness, efficient, timeliness, patient-centered, equitable and fair
What are the six dimensions of quality improvement measures created by Crossing the Chiasm
Dimension of quality improvement measure for avoiding injuries
Dimension of quality improvement measure for evidence-based, identified standard of care; not providing services that are not beneficial
Dimension of quality improvement measure for cost effective, eliminate waste
Dimension of quality improvement measure for no waits or delays in service delivery
Dimension of quality improvement measure for care should revolve around the patient's needs and preferences; patient in control; respectful
Equitable and fair
Dimension of quality improvement measure for disparities (gender, ethnicity, socioeconomic) should be eradicated
Examples of gathering data/monitoring systems
Joint Commission requires certain data, State Board of Health Accreditation, MIPS, CMS (produces quality indicators), Data usually generated in software systems designed for quality assurance
85% of quality care issues are ____________, not people or equipment failure.
Positive patient outcomes, customer satisfaction, good work environment, good financial performance
Quality management will lead to
FOCUS PDCA Quality Improvement Model
Find a process to improve,
Organize an improvement team and necessary resources,
Clarify current knowledge about the process,
Understand the process and sources of variation in it, and
Select an improvement or intervention.
Plan how to implement the intervention,
Do it by initiating the intervention on a small scale at first,
Check the results of the early implementation, revising as necessary until it proves itself as an improvement, and
Act on what was learned in the check step. If the change was successful, incorporate it on a larger scale
Patients need both technical skills and service-delivery quality. Managers must assure both qualities are met for patient satisfaction. Ways to improve technical skills?. What are service-delivery qualities? (Timely, respectful, to tell them what we're doing, etc.). Implement Patient Satisfaction Surveys. Inspect what you're expecting - do what you expect from your PCP. "It takes 10 positive comments to overcome 1 negative comment." Avoiding negative impressions is easier than reversing those negative impressions. Patient satisfaction can set your organization apart from the competition. Only way to know what truly matters to a patient is to ask them.
Management role in patient satisfaction
Train staff to smile, introduce themselves, make eye-contact, display common courtesies. Empower employees to eliminate patient disappointments immediately. Need to address any complaints IMMEDIATELY. Create a welcoming environment that gives the perception of quality, cleanliness, security, and caring. Encourage patients and families to contribute to their own health-care experience.
Merit-Based Incentive Payment System (MIPS)
CMS is required by law to have a quality payment incentive program. Value based reporting system that rewards or penalizes private practice PT clinics based on quality measures. PT included in 2019 and going forward. Only applies to private practice PT clinics that bill Medicare Part B. Does not apply to hospital OP, SNF, or IRF. Individual PT's report to CMS using NPI number. This was designed to tie payments to quality and cost efficient care, drive improvement in care processes and health outcomes, increase the use of healthcare information, and reduce the cost of care. Push towards value based reimbursement
Bill > $90,000 in allowed charges to MC, Report > 200 MC beneficiaries, Have > 200 billed MC services (services = any line on claim form you have received payment for)
What are the 3 criteria (on QPP website) that must be met to participate in in MIPS?
MUST participate in MIPS or receive 7% payment reduction penalty.
What happens if you exceed the three criteria for MIPS?
Quality (50 points), Cost (10 points), Improvement Activities (15 points), Promoting interoperability (25 points)
What are the MIPS categories that clinics must report on?
Quality (85%), improvement activities (15%)
What are the MIPS categories for PHYSICAL THERAPY reporting?
Receive + % incentive up to 7%
What do people get in response to >30 points when reporting with MIPS?
Neutral, neither lose nor gain
What do people get in response to 30 points when reporting with MIPS?
Will receive % penalty up to 7%
What do people get in response to <30 points when reporting with MIPS?
4+ process measures (Preventative care screening of BMI, documentation of current meds, pain assessment prior to treatment, functional outcome assessment) and outcomes measures (self reported outcomes measures such as - Oswestry, DASH, FOTO)
What quality measures must be reported to CMS?
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation, Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear;
Preventive Care and Screening: Screening for Depression and Follow-Up Plan, Tobacco Use - Screening and Cessation in Intervention;
Falls: Risk Assessment, Plan of Care, Screening for Future Fall Risk;
Elder Maltreatment Screen and Follow-Up Plan;
Dementia: Cognitive Assessment;
Functional Status Change for Patients with Neck Impairment
CMS is proposing to add several new measures to the physical therapy and occupational therapy set of measures. These include:
Earn 2 bonus points for each additional outcome and patient experience measures that meet case minimum and data completeness requirements and have a performance rate >0%. Earn 1 bonus point each for other high-priority measures that meet case minimum and data completeness requirements and have a performance rate >0%. Small practices are eligible for a 6 measure bonus points in the numerator of the quality performance category if the clinician submits data to MIPS on at least 1 quality measure.
Though bonus points for MIPS are capped at 10% of the denominator of the quality category (60 points), what bonus points are available?
Utilization Management (UM)
Purpose of review is to assess patient care to determine that it is efficient, effective, medically necessary, and appropriate. Is care consistent with their individual needs and consistent with care required of past patients with similar conditions? Managing cost of care and services. Performed by review of medical record and billing records
ACA, Rising health care cost, Aging population leading to increase demand for rehab services, Wide variable in care, Fraud and abuse in system
Why is there an increased use of UM?
Identify area for quality improvement. Provide constructive feedback to providers. Identify best practices in documentation and methods to improve care. Decrease unwarranted treatment variations. Improve outcomes. Improve care coordination. Reduce costs.
Effective UM includes:
Decisions that were once made by MDs and patients are now being made by UM and 3rd party payers. No consistency among UM on their processes or decision making. Decisions made not based on evidence or meaningful data. Best interest of patient sometimes lost to incentives of UM and insurance company.
UM concerns include:
Precertification, Concurrent (Admission review, Continued stay review, Discharge planning), Retrospective review
Types of Utilization Reviews include:
Certifies the medical necessity of care before a patient can be admitted for inpatient or outpatient care. Control of cost before admission by assuring care is provided in the most appropriate setting. Determined by third party payer. Varies between third party payers. May prevent or limit services received by patient.
Concurrent utilization review. Conducted after a patient has been admitted for care to determine medical necessity and the appropriateness of inpatient care within one working day. Assess documentation of the planned course of treatment. Determines the expected cost within the episode of care. Could prevent or limit services.
Continued Stay Reviews
Concurrent utilization review. Reviews conducted periodically throughout care episode until discharge. Usually requires approval for continuation of care. Approved only as long as necessary to reach expected outcomes. Will identify options for alternative, less expensive continued care settings. Could curtail current services.
Concurrent utilization review. Process of facilitating the transfer of a patient to an alternative most appropriate setting when the goals of care have been reached or appear to be unreachable in a reasonable amount of time. Involved continued care recommendations. May curtail or end current or future services.
Occurs post-discharge and medical record documents/billing reviewed for medical necessity and reasonable time frames. Documentation can make or break your claim. Recovery Audit Contractors - RAC audits. Probe Reviews. Could result in denial and cause money to be taken away or refused.
ADR [Additional documentation review. Requested by the MAC (Medicare Administrative Contractor) or FI (Fiscal Intermediary)] >>> 1st Level Appeal (Redetermination - requested by the MAC/FI) >>> 2nd Level Appeal (Reconsideration - requested by an independent contractor) >>> 3rd Level Appeal (ALJ - Administrative Law Judge) >>> 4th Level Appeal (Medicare Appeals Council) >>> 5th Level Appeal (Judicial Review in Federal District Court)
Explain the denial process
PT role in compliance
Document well - paint a picture so that they see that the skills of a PT are necessary and reasonable. Safety, timely, efficient, etc. Abide by practice act. P&P. Ethical practice.
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