QM- Unit 3 test

Terms in this set (79)

The primary purpose of UM is to
A) review patient records against predetermined criteria
B) determine that complications do not occur as a result of a procedure or hospitalization
C) assure that patients receive care in a timely, appropriate, and cost-effective manner
D) assist in finding appropriate discharge planning
assure that patients receive care in a timely, appropriate, and cost-effective manner
Concurrent review criteria are used to
A) determine allocation of resources
B) justify need for continued inpatient hospitalization
C) identify discharge date based on length of stay norms
D) determine efficient use of resources
justify need for continued inpatient hospitalization
Discharge planning criteria are
A) generic criteria developed to review several identified problem areas
B) specific criteria developed to review one identified problem area
C) developed by the physician or individual who has identified the problem
D) developed to assist hospital staff in identifying patients who may need post-hospital care
developed to assist hospital staff in identifying patients who may need post-hospital care
Discharge planning should begin
A) at admission
B) when the physician writes the discharge order
C) when the physician asks for the social service consultation
D) when the physician orders it
at admission
Which of the following is a type of utilization review activity?
A) preadmission review
B) admission review
C) continued stay review
D) all of the above
preadmission review
admission review
continued stay review
Utilization management addresses all of the following EXCEPT:
A) inefficient scheduling
B) underutilization
C) credentialing
D) overutilization
credentialing
Most healthcare facilities use this type of screening criteria for utilization review purposes todetermine the need for inpatient services and justification for continued stay.
A) IS/SI criteria
B) LOS criteria
C) PPO criteria
D) CPHA criteria
IS/SI criteria
For a patient admitted on 2-20-11 (Sunday) when will the first review usually take place by the UR Coordinator?
A) 2-19-11
B) 2-20-11
C) 2-21-11
D) 2-22-11
2-21-11
Which of the following groups require that health care organizations have a discharge planning process?
A) National Committee on Quality Assurance
B) Centers for Medicare and Medicaid Services
C) Case Management Society of America
D) American Hospital Association
Centers for Medicare and Medicaid Services
The UR Coordinator can
A) check for documentation to substantiate the admission
B) deny an admission
C) both #a and #b
D) neither #a and #b
check for documentation to substantiate the admission
Which of the following tasks is commonly performed by a hospital case manager?
A) Develop patient care protocols and clinical paths
B) Educate patients about their medications
C) Assess the patients' need for post-hospital services
D) Obtain prior authorization for elective surgeries
Assess the patients' need for post-hospital services
The UM Committee has asked for a retrospective study done to determine the number of patients treated for cystic fibrosis who are discharged home with a referral to be seen by the home health nurses. Which variables would you choose in your software program to generate those cases?
A) residence and diagnosis
B) payment source and residence
C) diagnosis and disposition
D) disposition and procedure
diagnosis and disposition
Having to reorder laboratory tests because lab technicians mixed up the name labels is an example of
A) underutilization
B) overutilization
C) inefficiency
inefficiency
A UR Coordinator (URC) is reviewing a case for admission and reads in the progress notes that the patient has hyperglycemia with polydipsia. Which of the following diagnoses will this patient most likely have?
A) polyneuritis
B) diabetes mellitus
C) arterial obstruction
D) anemia
diabetes mellitus
A physician asks his office supervisor to obtain authorization from the patient's HMO for a colonoscopy and abdominal ultrasound but fails to give her a diagnosis to give the HMO. The patient's problems are listed on the problem list. Which of the following are the most likely diagnoses to be used?
A) glomerulonephritis and melena
B) hypothyroidism and possible cholelithiasis
C) melena and possible cholelithiasis
D) hypothyroidism and melena
melena and possible cholelithiasis
An approach to controlling a defined illness or injury by integrating all components of the health care system in order to provide the best possible care is referred to as
A) utilization review
B) outcomes management
C) case management
D) disease management
disease management
Which of the following popular resource management initiatives is aimed at decreasing under and over utilization of health care resources
A) utilization review
B) outcomes management
C) computer-aided diagnosis system
D) pay-for-performance
pay-for-performance
Treatment guidelines, education interventions and outcomes assessment are all components of
A) utilization review
B) outcomes management
C) case management
D) disease management
disease management
Identification of an ideal process, operationalizing the process and analyzing the effect of the process are all components of
A) utilization review
B) outcomes management
C) case management
D) disease management
outcomes management
Which of the following popular resource management initiatives helps patients through discharge planning?
A) utilization review
B) outcomes management
C) case management
D) disease management
case management
A system which provides for managing patients at the place where the service of care is provided is referred to as
A) point-of-care
B) clinical path
C) just-in-time
D) protocol
point-of-care
The UR Coordinator reviews inpatient records after admission at regular intervals to justify necessity and appropriateness of care to warrant further hospitalization. Which of the following utilization review activities is being performed?
A) preadmission review
B) admission review
C) continued stay review
D) retrospective review
continued stay review
The UR Committee would like to determine the treatment patterns for patients with congestive heart failure by comparing family practice, internists and cardiologist's patients. What time frame would be the most cost effective to use?
A) prospective
B) concurrent
C) retrospective
D) long term care review
retrospective
Which of the following outcome measures is strongly influenced by patient compliance with treatment recommendations following their initial hospitalization?
A) length of stay
B) rate of bypass surgery
C) readmission rate
D) mean costs
readmission rate
Which of the following activities is a responsibility of the physician advisor for hospital utilization management functions?
A) Evaluating the necessity of patient care services
B) Discharging patients that no longer require hospital care
C) Coding the patient's diagnoses and procedures
D) Serving as a member of the medical staff executive committee
Evaluating the necessity of patient care services
Using the supplemental material for this test (Labeled Chart #1) answer the following question. Type type of report is a:
A) statistical comparison
B) graph
C) narrative report
statistical comparison
Using the supplemental material for this test (Labeled Chart #1) answer the following question. The hospital that has the longest LOS is Hospital
A) Hospital A
B) Hospital B
C) Hospital C
D) Hospital D
E) Hospital E
F) Hospital F
Hospital E
Using the supplemental material for this test (Labeled Chart #1) answer the following question. The hospital that has the highest cost is Hospital
A) Hospital A
B) Hospital B
C) Hospital C
D) Hospital D
E) Hospital E
F) Hospital F
Hospital D
Using the supplemental material for this test (Labeled Chart #1) answer the following question. On the average, a hospital is reimbursed $3000 for CHF patients and the average LOS is 4.2 days. Which of the following hospitals would be of most concern from a resource management perspective and may require review because they fall out of this range?
A) Hospitals A and B
B) Hospitals A, B and C
C) Hospitals D and E
D) Hospital F
Hospitals D and E
Using the supplemental material for this test (Labeled Chart #2) answer the following question. The table above represents which of the following types of presentation formats?
A) statistical comparison
B) graph
C) narrative
statistical comparison
Using the supplemental material for this test (Labeled Chart #2) answer the following question. Given the information in the above table, what could account for the lower length of stay for patients at Your Hospital as compared to patients discharged from other hospitals in the state?
A) higher readmission rates at Your Hospital
B) higher mortality rates at Your Hospital
C) lower overall costs at Your Hospital
D) higher rate of cardiac catheterizations at Your Hospital
higher mortality rates at Your Hospital
Using the supplemental material for this test (Labeled Chart #2) answer the following question. What is the readmission rate at Your Hospital?
A) 2.4%
B) 13.1%
C) 24.1%
D) 44.0%
44.0%
Using the supplemental material for this test (Labeled Chart #2) answer the following question. Given the information in the table, what could account for the higher overall cost of hospitalization at Your Hospital as compared to patients discharged from other hospitals in the state?
A) higher readmission rates at Your Hospital
B) higher mortality rates at Your Hospital
C) higher rate of procedures performed at Your Hospital
D) higher number of patients seen as Your Hospital
higher rate of procedures performed at Your Hospital
Using the supplemental material for this test (Labeled Chart #3) answer the following question. To which committee should the UR Committee refer their concern about the poor results of the femoral-popliteal bypass?
A) Health Information Committee
B) Medical Executive Committee
C) Drug Usage Committee
D) Surgery Committee
Medical Executive Committee
Using the supplemental material for this test (Labeled Chart #3) answer the following question. What do you do as the UR Manager about your UR coordinator's remarks to her mother?
A) seek the advice of the facility's legal counsel.
B) ask your UR Coordinator to meet you in your office and then immediately dismiss your UR coordinator, Lucille's daughter
C) walk into Lucille's room and state that Dr. Ze is a fine surgeon and tell the UR coordinator to lower her voice
D) upon her return to the office, give the UR coordinator a written warning
ask your UR Coordinator to meet you in your office and then immediately dismiss your UR coordinator, Lucille's daughte
Which of the following computer technologies at the point-of-care can remind the practitioner to perform a retinal exam on a diabetic patient.
A) drug dose determination system
B) preventive care notification system
preventive care notification system
The last step in an outcome management project is to
A) define the ideal process
B) operationalize the ideal process
C) analyze the effect of process on outcome
D) show the cost-savings to administration
analyze the effect of process on outcome
During which step in an outcomes management project do the practitioners study whether the ideal process is actually being followed?
A) stabilize the process
B) define the ideal process
C) analyze the process and outcome relationship
analyze the process and outcome relationship
Computer-aided diagnosis systems are an example of a tool used to:
A) help the physician or practitioner arrive at a diagnosis
B) stabilize the patient care process
C) measure the performance of physicians
D) conduct an analysis of current literature
help the physician or practitioner arrive at a diagnosis
Which of the following activities assist physician in performing diagnostic or therapeutic procedures when patients reach certain stages in the process of care?
A) computer-aided diagnosis system
B) protocols
C) active-care advice systems
D) preventive care notification
active-care advice systems
For the following question - Which type of criteria would you classify the following statement: Sight loss.
A) Intensity of service
B) Severity of illness
C) Discharge
Severity of illness
For the following question - Which type of criteria would you classify the following statements: Absence of ketonuria for last 24 hours.
A) Intensity of service
B) Severity of illness
C) Discharge
Discharge
For the following question - Which type of criteria would you classify the following statements: Parenteral fluids.
A) Intensity of service
B) Severity of illness
C) Discharge
Intensity of service
For the following question - Which type of criteria would you classify the following statements: Glucose below 50 mg/dL.
A) Intensity of service
B) Severity of illness
C) Discharge
Severity of illness
For the following question - Which type of criteria would you classify the following statements: IV fluid therapy
A) Intensity of service
B) Severity of illness
C) Discharge
Intensity of service
For the following question - Which type of criteria would you classify the following statement: Hemoglobin < 7 gms.
A) Intensity of service
B) Severity of illness
C) Discharge
Severity of illness
For the following question - Which type of criteria would you classify the following statement: Speech loss.
A) Intensity of service
B) Severity of illness
C) Discharge
Severity of illness
For the following question - Which type of criteria would you classify the following statement: Tumor resection.
A) Intensity of service
B) Severity of illness
C) Discharge
Intensity of service
For the following question - Which type of criteria would you classify the following statement: Steroids regulated for last two days.
A) Intensity of service
B) Severity of illness
C) Discharge
Discharge
For the following question - Which type of criteria would you classify the following statement: Patient demonstrates ability to manage activities at home.
A) Intensity of service
B) Severity of illness
C) Discharge
Discharge
For the following question - Which type of criteria would you classify the following statement: Newly discovered diabetic neuropathy.
A) Intensity of service
B) Severity of illness
C) Discharge
Severity of illness
For the following question - Which type of criteria would you classify the following statement: Admission to telemetry unit.
A) Intensity of service
B) Severity of illness
C) Discharge
Intensity of service
For the following question you are asked to choose the type of review and the timeframe for the following scenario. The UR Coordinator reviews the record of a current patient admitted three days ago to determine if the patient's condition necessitates a long medical stay. This type of review is called
A) preadmission review
B) admission review
C) continued stay review
D) focused review
continued stay review
Based on the scenario above, the timeframe would be:
A) prospective
B) concurrent
C) retrospective
concurrent
For the following question you are asked to choose the type of review and the timeframe for the following scenario. The UR Coordinator reviews the patient's data received at the time a physician's office calls to schedule an admission for the patient. This type of review is called a
A) preadmission review
B) admission review
C) continued stay review
D) focused review
preadmission review
Based on the scenario above, the timeframe would be:
A) prospective
B) concurrent
C) retrospective
prospective
For the following question you are asked to choose the type of review and the timeframe for the following scenario. The UR Committee has identified a potential problem with the interpretation of MRI results made by the neurosurgeons. They decide to have all MRI results interpreted by both a radiologist and a neurosurgeon beginning tomorrow. The QM Coordinator will collect the needed data while the patient is in-house. This type of review is called
A) preadmission review
B) admission review
C) continued stay review
D) focused review
focused review
Based on the scenario above, the timeframe would be:
A) prospective
B) concurrent
C) retrospective
concurrent
For the following question you are asked to choose the type of review and the timeframe for the following scenario. At today's UR Committee meeting, the UR Coordinator reported that she reviewed records of patients who had surgery in OR Suite #3 from November, 2010 to February, 2011 because those patients had a higher than expected nosocomial infection rate than patients having surgery in other OR suites. This type of review is called
A) preadmission review
B) admission review
C) continued stay review
D) focused review
focused review
Based on the scenario above, the timeframe would be:
A) prospective
B) concurrent
C) retrospective
retrospective
For the following question you are asked to choose the type of review and the timeframe for the following scenario. A patient was admitted at 4:00 p.m. today - the UR Coordinator goes to the nursing unit this afternoon to determine the medical necessity of the admission. This type of review is called
A) preadmission review
B) admission review
C) continued stay review
D) focused review
admission review
Based on the scenario above, the timeframe would be:
A) prospective
B) concurrent
C) retrospective
concurrent
For the following question you are asked to choose the type of review and the timeframe for the following scenario. The UR Coordinator reviewedall Friday admissions for January 2011 to determine if there are any physician patterns. This type of review is called
A) preadmission review
B) admission review
C) continued stay review
D) focused review
focused review
Based on the scenario above, the timeframe would be:
A) prospective
B) concurrent
C) retrospective
retrospective
Indicate the NEXT step in the UR process, in the situation outlined below. The Utilization Review (UR) Coordinator reviews a case for medical necessity of admission within the proper timeframe. The facility uses IS/SI criteria. The patient has a rare disease and there is no criteria for this disease.
A) automatically approve the admission
B) refer the case to a physician advisor
C) refer the case to the health information manager
D) ask the medical librarian for help in locating information about the disease
refer the case to a physician advisor
Indicate the NEXT step in the UR process, in the situation outlined below. The UR Coordinator (URC) reviews a case for continued stay and finds that the patient does indeed meet an appropriate severity of illness and intensity of service criteria for continued stay.
A) approve the continued stay
B) refer the case to a physician advisor
C) refer the case to the attending physician
D) refer the case to the discharge planner
approve the continued stay
Indicate the NEXT step in the UR process, in the situation outlined below. The PA reviews a case referred by the UR Coordinator and approves the stay.
A) the UR coordinator should accept the approval and re-review the case the next time she reviews cases
B) the UR Coordinator should deny the admission
C) the UR Coordinator should refer the case to a second PA
D) the UR Coordinator should notify the attending physician to discharge the patient
the UR coordinator should accept the approval and re-review the case the next time she reviews cases
Indicate the NEXT step in the UR process, in the situation outlined below. The Physician Advisor (PA) reviews a case referred to her by the UR Coordinator. After reviewing the case, the PA believes that the patient no longer needs acute care.
A) the PA should write an order to discharge the patient
B) the PA should talk with the attending physician to determine if he is planning a discharge for the patient
C) the UR Coordinator should send a letter to the patient telling him he should be discharged
D) the PA should ask the UR Committee Chairman to discharge the patient
the PA should talk with the attending physician to determine if he is planning a discharge for the patient
Indicate the NEXT step in the UR process, in the situation outlined below. A Physician Advisor reviewed a case referred to her by the UR Coordinator. The PA did not believe the patient should be an acute inpatient and after discussion with the attending physician, the case was referred to a second PA. The second PA reviewed the case and agreed with the attending physician that the patient needed to be admitted.
A) the URC should approve the admission
B) the first PA should still discharge the patient
C) the URC should send a letter to the patient telling him that there is some disagreement among the physicians that he should be an inpatient
D) the first physician advisor should refer the case to a full UR committee for review
he URC should approve the admission
Indicate the NEXT step in the UR process, in the situation outlined below. The PA denies a patient's continued stay because he does not think the patient needs additional care as an acute patient and tells the attending physician. The attending physician disagrees with the PA.
A) the PA should write an order to discharge the patient
B) the PA should talk with the patient and tell him he needs to be discharged
C) the UR Coordinator should inform the Business Office that the patient does not need acute care and to bill the patient for the remaining time in the hospital
D) the PA should refer the case to a second PA
the PA should refer the case to a second PA
Indicate the NEXT step in the UR process, in the situation outlined below. The UR Coordinator reviews an admission of a patient admitted to the hospital from the emergency room early yesterday morning. She discovers that the ER record states the patient has a diagnosis of back pain but the attending physician has not documented a H&P or admission progress note. She cannot tell if the case meets any criteria.
A) the UR Coordinator should approve the admission
B) the UR Coordinator should deny the admission
C) the UR Coordinator should refer the case to a PA
D) the UR Coordinator should notify the attending physician to discharge the patient
the UR Coordinator should refer the case to a PA
The ultimate goal of discharge planning is to get the patient out of the hospital as soon as possible to prevent overutilization of services.
A) True
B) False
False
Discharge planning is performed only for those patients with extensive medical problems, complications and/or inadequate living conditions.
A) True
B) False
False
Critical paths are designed with the input of many members of the health care team.
A) True
B) False
True
Critical paths can help reduce costs and improve care for patients.
A) True
B) False
True
Protocols, standards physician orders and critical paths are examples of care management tools.
A) True
B) False
True
One way that hospitals can improve resource use is to compare the LOS of their hospital to Others in particular MS-DRGs.
A) True
B) False
True
Health plans are more likely to perform a prospective review than an inpatient facility.
A) True
B) False
True
The Conditions of Participation (COP) requires a UR plan.
A) True
B) False
True
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