Index

A

AAAHC, see Accreditation Association for Ambulatory Health Care

ABA, see American Bar Association

ABMS, see American Board of Medical Specialties

Access

barriers, 2, 24, 29, 31, 96, 110, 225–227, 258, 276, 369

to care, 2, 52, 344, 346, 389, 402

to information, 36, 37, 170, 248, 293, 350

to PRO rules, 192

public programs for improving, 34, 96, 256

research needs, 344, 346, 381

to services, 19, 29, 52, 79–80, 225, 288, 346

underdiagnosis/undertreatment, 226–227

underuse and, 23, 52, 225–226, 275, 284, 389

utilization management and, 30, 111

Accountability, for quality of care, 20, 32, 36, 37, 241

and autonomy, 290

and continuous quality improvement, 62–64

and oversight for PRO program, 193, 197, 372, 379–383, 420

and prepaid practice, 193–195

professional, 49, 244

for public monies, 7, 52, 145

Accreditation, 53, 56, 267–269;

see also Joint Commission on Accreditation of Healthcare Organizations

Accreditation Association for Ambulatory Health Care, 268

Accreditation Manual, 124, 267

Accreditation Council for Graduate Medical Education, 271

ACGME, see Accreditation Council for Graduate Medical Education

Activities of daily living, 83, 89–90, 91, 390

ADLs, see Activities of daily living

Administrative data sets, 274–276



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I Index A AAAHC, see Accreditation Association for Ambulatory Health Care ABA, see American Bar Association ABMS, see American Board of Medical Specialties Access barriers, 2, 24, 29, 31, 96, 110, 225–227, 258, 276, 369 to care, 2, 52, 344, 346, 389, 402 to information, 36, 37, 170, 248, 293, 350 to PRO rules, 192 public programs for improving, 34, 96, 256 research needs, 344, 346, 381 to services, 19, 29, 52, 79–80, 225, 288, 346 underdiagnosis/undertreatment, 226–227 underuse and, 23, 52, 225–226, 275, 284, 389 utilization management and, 30, 111 Accountability, for quality of care, 20, 32, 36, 37, 241 and autonomy, 290 and continuous quality improvement, 62–64 and oversight for PRO program, 193, 197, 372, 379–383, 420 and prepaid practice, 193–195 professional, 49, 244 for public monies, 7, 52, 145 Accreditation, 53, 56, 267–269; see also Joint Commission on Accreditation of Healthcare Organizations Accreditation Association for Ambulatory Health Care, 268 Accreditation Manual, 124, 267 Accreditation Council for Graduate Medical Education, 271 ACGME, see Accreditation Council for Graduate Medical Education Activities of daily living, 83, 89–90, 91, 390 ADLs, see Activities of daily living Administrative data sets, 274–276

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I Administrative Procedure Act, 148 Adverse patient occurrences, 281–283 incidence, 214–215, 218 Agenda for Change, 56, 61, 125, 355, 396; see also Joint Commission on Accreditation of Healthcare Organizations AHA, see American Hospital Association Algorithms, clinical (patient care), 178, 272–273, 278–279, 307, 310, 322, 327, 395 AMA, see American Medical Association Ambulatory care certification, 268 quality problems, 246–250 research needed, 355 review in, 142, 177, 194, 196–197, 238, 256–257, 407–408 American Bar Association, 219 American Board of Medical Specialties, 270, 271 American Hospital Association, 120, 307 American Medical Association, 220, 270, 271 American Medical Peer Review Association, 182 American Medical Review Research Center, 179, 346, 355 AMPRA, see American Medical Peer Review Association AMRRC, see American Medical Review Research Center Appropriateness of care, 111, 159, 221–224, 316, 391 guidelines, 3, 272–273, 304–306, 319–321, 325, 328, 370, 418; see also Practice guidelines research, 345, 353–354 Art of care, 25, 219, 350–351; see also Quality-of-care indicators/ measures Attributes of criteria sets, 311–319 implementation, 316–319 of medical profession, 289–292 of QA methods, 49–50, 266–267 substantive, 3, 311–316 Autopsy, 266, 286, 287 B Beneficiary complaints, 170, 217–218, 252 number of, 100 relations, 169–170 Bi-cycle model, 62, 293; see also Quality assurance, models Burden of harm differentiating among contributing factors, 209–210 overuse and, 208, 210, 220–224 of poor quality care, 27, 31–32 quality problems and, 207 sources of information about, 210–211 of technical and interpersonal quality, 207–208, 209–210, 211–219 underuse and, 209–210, 225–230 C Capacity building, 3, 14–15, 360–363, 384–385, 418–419 and continuous improvement, 362–363 patient education, 362 professional education, 361–362 research needs, 343 Career paths, 361

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I Carriers, 102, 374, 395; see also Medicare, claims processing Case conferences, 228, 286–288 Case-finding complaints, 170, 217–218 generic screens, 154–156, 160, 183–186, 228, 281–283, 307–388, 323 see also Individual case methods Case management, 219, 252 Case mix, 11, 12, 247, 259, 308, 356, 378, 409 Certification board, of health professionals, 53, 246, 266, 267, 269, 270–272, 278, 361 Home Health Agencies, 82, 251, 252 hospitals, 111, 120, 121–122, 128, 129, 130, 135, 371, 420 physician attestation, 156 preadmission, 140 see also Licensure; Survey and Certification CHAP, see Community Health Accreditation Program Claims data, 54, 248, 249, 255; see also Medicare Statistical System Clinical indicators, 132–133, 283–284, 308, 396 Clinical information systems, 243–244, 248–249 research needs, 358 CME, see Continuing medical education CMP, see Competitive medical plans Coding accuracy, 242–243, 255, 275–276, 277, 279, 280, 281 ambulatory, 249, 255 ICD-9-CM, 242–243, 257, 275 Part B, 255–256 see also Common Procedural Terminology Common Procedural Terminology, 257, 275; see also Coding Community Health Accreditation Program, 252, 268 Competitive medical plans, 100–102 research needed, 356–357 review in, 173–177, 188, 193–195, 256–257 see also Health maintenance organizations; Prepaid care Complaints beneficiary, 170, 217–218, 252 patient, 287–288, 288–289 Complication rates, medical, 266, 281; see also Quality-of-care indicators/measures Computers, see Clinical information systems; Data Conditions of Participation, 7–8, 111, 138, 396, 401–402 enforcement, 129–131 federal role, 131–132 HCFA and, 8, 124–125, 128–131, 134–135 history, 120–124 inspection, 128–129 quality assurance condition, 125–128 recommendations, 383–384 shift from capacity to performance standards, 124–125 Continuing Medical Education, 162, 270, 292–293, 354, 361; see also Physician education Continuity of care, 13–14, 29–30, 392 Continuous quality improvement, 294, 374–375 accountability, 58, 62–64 applications, 61

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I capacity building and, 362–363 customers and suppliers, 46, 59–60 defined, 46 model assumptions and constructs, 58–61, 387–388 PDCA cycle, 59 research, 352, 362–363 see also Industrial quality control Corrective actions/plans, 160–163, 216–217 Cost containment, 97, 111, 309, 360, 374, 394–395 CPT, see Common Procedural Terminology Credentialling, 269 Criteria, quality assurance development, 323–325 for allocation of resources, 393–394 for evaluation and management of care, 322–322 for successful quality assurance, 3, 49–52 mapping, 249 relationship among criteria sets, 308–309 sets, 277–279, 303–309, 310–319 and standards, 277–279 Customers, 58–60; see also Continuous quality improvement D Darling v. Charleston Community Hospital, 241 Data bases, 243–244, 274–277, 281, 403–404, 415; see also Medicare Statistical System collection and analysis, 178, 400, 404–408, 415 disclosure/reporting/dissemination/sharing, 15–16, 34, 170–171, 359–360, 408–410, 415–416 fee-for-service, 255–256 hospital, 243 prepaid care, 256–258 see also Claims data; Clinical information systems Decertification, 129, 130, 131, 133, 181–182, Decision making, 20–25, 56 patient, 22, 362, 385, 402, 407–408 physician, 22, 63, 207–208, 244, 278, 315, 327, 402, 408 and population-based outcomes, 36–37 Deemed status, 7–8, 111, 119, 134; see also Medicare Program to Assure Quality Defining quality of care, 2, 4–5, 20–25, 375–377 Delegated review, 142–143, 179, 199; see also Professional Standards Review Organizations Department of Health and Human Services, 1, 140 current responsibilities, 102, 119 evaluation of PRO program, 192–193 PRO contracting authority, 149 recommended responsibilities, 6–8, 14, 378, 379, 381–385, 413–414, 416, 420 regulatory and enforcement authority, 135, 163, 216–217 DHHS, see Department of Health and Human Services Diagnosis-related groups, 97, 224, 228 definition, 108–109 validation, 156–159

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I Discharge planning, 223, 224, 156, 178, 184 premature, 156, 223, 225, 227–228, 245 review, 156 Disciplinary actions, 48, 215–216 DRGs, see Diagnosis-related groups E Education patient, 169, 362 physician, 139, 162, 177, 292–293, 361–362 Effectiveness/efficacy, 30 medical care, 19, 23, 178 of interventions, 289–297 research, 348–350, 354–355 Elderly access to care, 2, 31–32, 79–80, 93, 96, 230, 369, 399 activity limitations, 89–90 chronic illness and impairment, 2, 88–89 expenditures, 105–108 federal role in support of, 84–85 geographic distribution, 72–73 health insurance, 75 health status, 85–91 income, 75–79 life expectancy, 2, 85–86 living arrangements, 73–75 Medicare issues for, 2 mental health, 90–91 mortality, 86–88 nursing home residents, 74–75, 81–82 race and ethnicity, 71 rate of population growth, 2, 69–71 satisfaction with care, 1 sex ratios, 71 support ratios, 71 Elderly, use of services community-based services, 83–84 home health care, 82–83 hospital, 79 long term care, 81–84 nursing home, 81–82 physician, 79–81 EMCROS, see Experimental Medical Care Review Organizations Enforcement, 128–131, 133–134, 253; see also Sanctions and sanctioning process DHHS authority, 135, 163, 216–217 OIG authority, 145, 163–167, 189, 200, 411 Episodes of care, 177, 239, 247–248, 405–406 of illness, 239 Ethics, in health care autonomy, 23, 290 beneficence, 25 equity, 24 fidelity, 25 fiduciary relationship, 25 nonmaleficence, 25 Evaluation of programs PRO, 180–182, 192–193, 260 MPAQ, 379–383, 399–400, 414, 417–418 MQRO, 398–399 Exemplary performance, 16, 47, 323, 416; see also Incentives Expenditures by elderly for health care, 105–108 health care, 28–29, 103–105 Medicare, 28–29, 105–108 Experimental Medical Care Review Organizations, 139

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I F Federation of State Licensing Boards, 215, 216 Fee-for-service, 3, 73, 254–256 and accountability for care, 194–195 alternatives to, 100–102, 112 conflict of interest, 25, 48 data, 255–256 and medical records availability, 193 and overuse, 140, 230 prepaid system contrasted with, 254 prevention of quality problems, 246, 255–257 quality review in, 173, 175, 177, 182, 188, 194–195, 196, 254, 401 types of problems, 256 Feedback, 408–409 to clinicians, 254, 292–293, 359, 415–416 loop, 15, 249 FI, see Fiscal intermediaries Findings and conclusions, 2–4, 369–371 Fiscal intermediaries, 102, 138, 225, 374 FSLB, see Federation of State Licensing Boards Funding for MPAQ, 9–10, 385–387 for MQRO, 396–397 for PRO program, 171–173 for research, 363 G GAO, see General Accounting Office General Accounting Office, 145–146, 167, 183, 192–193, 212, 217, 383 Generic screens case-finding, 323 characteristics, applications, and processes, 154–156, 160, 281–283 limitations and problematic aspects of, 183–186, 282–283 strengths, 282 see also Adverse patient occurrences; Occurrence screens Guidelines, 30 appropriateness, 3, 272–273, 304–306, 319–321, 325, 328, 370, 418 patient management, 272–273, 306–307, 322–323 research, 353–354 see also Generic screens; Practice guidelines H HCFA, see Health Care Financing Administration HCQIA, see Health Care Quality Improvement Act Health accounting, 62; see also Quality assurance models Health Care Financing Administration Bureau of Policy Development (BPD), 121 and Conditions of Participation, 8, 124–125, 128–131, 134–135 Health Standards and Quality Bureau (HSQB), 120, 121, 128, 132, 140, 346, 363 and HMO/CMP review, 177–182 hospital-specific mortality rates, 35, 280, 308 Office of Research and Demonstrations (ORD), 346, 351, 363 procedures, 148, 192–193 and PSROs, 143, 145 research, 346

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I responsibility for Medicare program, 120 responsibility for quality, 34, 110 Health care personnel/professionals distribution manpower, 27–28, 58, 159, 343 training, see Capacity building see also Physician Health Care Quality Improvement Act, 148, 171, 410 Health maintenance organizations, 100–102 accountability, 193–195 data, 256–258 quality review in, 173–177 prevention of problems, 246, 256 research needed, 356–357 see also Competitive medical plans; Prepaid care Health services research, 344 Health status assessment, 20, 26, 34, 57, 286, 406–407; see also Activities of daily living of the elderly, 85–91 research needs, 351–352 HMOs, see Health maintenance organizations Home health agencies, 82 case management financing, 250–251 homebound provisions, 82, 83, 356 Medicare certification, 82, 251–252 quality problems, 282–219, 250–254 research needed, 356 review in, 186–187, 406–407 state licensure, 251–252 visits per person, 82–83 voluntary certification, 252 Hospitals adequacy of QA mechanisms, 3 certification, 111, 120, 121–122, 128, 129, 130, 135, 371, 420 data, 243 discharge rate surveys, 79 elderly use of care, 79 mortality rates, 208, 280, 291; see also Quality-of-care indicators/measures nosocomial infections, 125, 154, 156, 184 outcomes of care, small area analysis, 179 readmissions, 161, 186, 227, 275 Hospital care, 79, 241–245 I Incentives, 16, 47, 51, 293–294, 416 Individual case methods, 247, 286–289, 307–309 Industrial quality control, 58–61; see also Continuous quality improvement Information management, see Clinical information systems; Data Inspection, state Conditions of Participation, 128–129 see also Certification; Licensure Intermediaries, see Fiscal Intermediaries Intervening care, 160, 187, 196; see also Medicare Peer Review Program; Readmission, to hospital J JCAHO, see Joint Commission on Accreditation of Healthcare Organizations Joint Commission on Accreditation of Healthcare Organizations Agenda for Change, 56, 61, 125, 355, 396

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I decision rules, 129–130, 134 deemed status, 7–8, 111, 119, 134 see also Certification; Conditions of Participation; Decertification L Legislative charges to IOM, xii Liability, 159, 211–215; see also Malpractice Licensing, 162, 171, 269–270 Licensure, 251–252, 269–270; see also Certification Life expectancy, 26, 85, 86 Long term care, 81–84, 91–93 M Malpractice, 35–37, 211–215, 220; see also Liability) Market forces and competition, 33, 35, 37, 220–221, 296 Medical records, 134, 141, 178, 191, 241–242, 255, 258, 318, 358–359 Medicare administration, 102 claims processing, 102 Conditions of Participation, 111 data systems, see Medicare Statistical System deductibles and coinsurance, 104 enrolled population, 100 expenditures, 28–29, 105–108 financing, 103 HMO and CMP risk contracts, 100–102 Hospital Insurance (Part A), 97 legislation related to, 98 Medicare Insured Groups, 102 mission, 4–5, 96, 375–377 prospective payment system, 79–80, 82–83, 107–109, 394–396 quality assurance goals, 5, 110–111; see also Conditions of Participation; Medicare Peer Review Organizations; Utilization Management Supplementary Medical Insurance (Part B), 99 Medicare Peer Review Organizations (PROs) ambulatory review, 194, 256–257 beneficiary complaints, 170 beneficiary relations, 169–170 contracts, 148–149 data acquisition, sharing, and reporting, 170–171 denials for substandard quality of care, 190–191 DRG validation, 149, 156–159 funding, 171–173 generic screens, 154–155, 160, 183–186 HMO and CMP review, 173–177, 193–195 home health review, 186–187 intervening care, 160 interventions (QIP), 161–163 Manual, 148 nonhospital review, 159–160, 196–197 organizational characteristics, 148 outreach, 170 oversight, 193, 197, 372, 379–383, 420 physician review, 187 preadmission and preprocedure review, 159 PRO pilots, 179–180 provider relations, 170 quality interventions, 161–3 required review activities, 149–160, 169–171 review of rural care, 159, 188–189 sanctions, 163–169, 189–190

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I scope of work, 154–156, 159 triggers (weighted), 162–163 waiver of liability, 159 Medicare Peer Review Organization Program administration of program, 148 administrative procedures, 192 controversial aspects of, 182–195 costs, funding, 171–173 enabling legislation, 147–148 evaluation (program), 180–182, 192–193, 260 peer review, 188–189 PROMPTS-2, 180 review of rural care, 159, 188–189 SuperPRO, 180–182 UCDS (Uniform Clinical Data Set), 177–179 Medicare Program to Assure Quality, 1, 10–14, 378, 387–400 allocation of resources, 393–394 evaluation/public oversight, 379–383, 399–400, 414, 417–418 implementation strategy, 14–17, 412–419 funding, 9–10, 385–387 operational overview, 12–14, 389–392 problems and limitations, 392–393 research, 418 responsibilities, 394–400 special projects, 416–417 structure, 388–389 Medicare Quality Review Organization, 378–379, 400–410 data, data collection, and analysis, 401–408, 415 evaluation, 398–399 feedback, data reporting, and data sharing, 408–410, 415–416 funding, 396–397 quality interventions, 410–412 reconsideration of PRO functions, 395–396 review topics, 404–405 Medicare Statistical System (MSS), (M/MDSS), 117–118 Mental health, 90–91 MPAQ, see Medicare Program to Assure Quality MQRO, see Medicare Quality Review Organization N NAQAP, see National Association of Quality Assurance Professionals National Association of Quality Assurance Professionals, 361 National Center for Health Services Research, 346 National Center for Health Statistics, 69, 79, 90 National Committee on Quality Assurance, 268 National Council on Medicare Quality Assurance, 379, 382–383 National League for Nursing, 252, 268 National Practitioner Data Bank, 171, 396 NCHS, see National Center for Health Statistics NCHSR, see National Center for Health Services Research NCQA, see National Committee on Quality Assurance Net benefit, 4, 21, 22, 320 NLN, see National League for Nursing Nosocomial (hospital-acquired) infections, 125, 154, 156, 184 Notices of denial, 196; see also Medicare Peer Review Organization Program Nursing homes, 74–75, 81–82

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I O OBRA, see Omnibus Budget Reconciliation acts Occurrence screens, 307–308; see also Adverse patient occurrences; Generic screens Office of Inspector General activity on interventions and sanctions, 167, 169, 217 enforcement authority, 145, 163–167, 189, 200, 411 evaluation of PRO program, 193 procedures for recommending sanctions to, 166 recommendations on penalties, 189–190 recommended role of, 383 OIG, see Office of Inspector General Omnibus Budget Reconciliation Act of 1986, 1, 148, 173, 180 Omnibus Budget Reconciliation Act of 1987, 102, 148, 149, 190, 252, 253 Omnibus Budget Reconciliation Act of 1989, 191 Organizational change, 294–295 Outcome measures, 266, 405 in ambulatory care, 247, 406–407 in Conditions of Participation, 128 in data bases, 276, 358; see also Outcomes data distinguishing providers on basis of, 16 in health status assessment, 284, 286 for home health care, 253, 406 limitations of, 13, 128, 132, 259, 276, 286, 358, 391, 402, 409 in MPAQ, 12–13, 386, 389–391 nonintrusive, 266 OBRA requirements, 253 patient-provider decision-making process and, 36 process links with, 6, 21, 51, 62, 54, 316, 348, 353, 357, 364, 377, 391–392 research needs on, 273, 351, 353, 357, 383–384 scales, 253 severity adjustment, 351 strengths of, 286 in structure-process-outcome model, 53, 56–58 Outcomes art-of-care and, 350–351 assessment, 247, 253, 266–267, 276, 277, 319, 405, 406 and burden of harm, 207 continuity of care and, 13–14 of the elderly, 200 in home health care, 218, 250–251, 253 of hospital care, small area analysis, 179 longitudinal, 196 management, 74, 407 physician certification and, 271–272 population, 11, 196, 259 provider-patient relationship and, 25 research, 8, 327, 346–347, 397–398 underuse and, 226 volume of services and, 276–277 see also Surgical mishaps Outcomes data collection of, 390–391, 393, 397, 404–408, 415 confidentiality, 360, 409 from data bases, 273–275 general points, 279–280 hospital mortality rates, 280 lack of, 58, 134, 135 medical complications, 281

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I   recommended scope of, 403 uses, 5, 7, 10, 12, 15, 247, 377, 383, 387, 388–389 Outliers, 46–47, 141, 208, 416–417; see also Physician, performance Outreach, 170 Overuse and burden of harm, 208–209, 210, 220–224 defined, 208 fee-for-service and, 140, 230 and underuse, 210 P Patient complaints, 287–289 compliance, 241 decision making, 22, 362, 385, 407–408 education, 169, 362 management guidelines, 272–273, 306–307, 322–323 privacy/confidentiality, 359–160 records, 242; see also Medical records reports, 284–285 satisfaction, 244, 284–285, 347, 350–351 Patrick v. Burget, 245 PDCA cycle, 59 Peer review, 148, 154, 170, 188–189, 198, 244 Performance exemplary, 16, 47, 323, 416 profiles, 244, 410–411 standards, 62, 124–125 Physician attestation, 140 education, 139, 162, 177, 292–293, 361–362; see also Continuing Medical Education manpower, 27–28 payment, 31, 99–100 performance, 16, 47, 141, 416–417; see also Outliers Physician Payment Review Commission, 110–111, 187–188 Pilot projects, PRO, 179–180 Policies and procedures, 192, 241 Population-based measures, 36–37, 63; see also Quality-of-care indicators/measures Potentially compensable events, 213; see also Liability PPRC, see Physician Payment Review Commission PPS, see Prospective payment system Practice guidelines, 272–273, 328 research needs, 353–354; see also Guidelines Practice variations, 222 small area analysis, 222–223 Premature discharge, 156, 223, 225, 227–228, 245 Prepaid care, 100–102, 194–195, 246, 256–258; see also Competitive Medical Plans; Health maintenance organizations Preventable deaths, 214 PROs, see Medicare Peer Review Organizations Process measures of quality, 54–56, 277–279, 350–351, 391–392, 402–403 linking process with outcomes, 279–280, 353 see also Quality-of-care indicators/measures Professional Standards Review Organizations activities, 140–142 costs, 143 delegated review, 142–143 impact, 146

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I National Council, 144 sanctions, 145–146 structure, 140 Professional incompetence, 215 Professionalism, 18, 32–33, 291 ProPAC, see Prospective Payment Assessment Commission Prospective Payment Assessment Commission, 17, 29, 107, 109–110, 184, 227–228, 346, 382 Prospective payment system, 79–80, 82–83, 107–109, 227 and cost containment, 109, 394–396 PSROs, see Professional Standards Review Organizations Public good, 34, 379 Public oversight MPAQ, 399–400, 417–418 PRO, 193, 197, 372, 379–383, 420 Q Quality assessment, defined, 45–46 Quality assurance defined, 45 ideology, 296 international perspective, 61–62 leadership, 296 purpose of, 46–47 professional responsibility for, 32–33 public responsibility for, 33–34 Quality assurance, models bi-cycle model, 62, 293 continuous improvement, 58–61 focus, 3 health accounting, 62 MPAQ, 371–373 structure/process/outcome, 53–58, 387 traditional and continuous improvement models compared, 62–64 Quality assurance, programs criteria for judging success of, 49–52 external, 48–49 federal, see Conditions of Participation; Medicare Peer Review Organization Program findings and conclusions, 2 internal, 47–49, 268, 388–389 Quality of care criteria for review, see Criteria, quality assurance definitions, 4–5, 20–25, 375–377 effect of organization and financing, 295–297 research needed, 357–358 Quality-of-care indicators/measures complication rates, 281 mortality rates, 280 nosocomial infections, 125, 154, 156, 184 reliability and validity, 266–267, 311–314 retrospective methods, 221, 226, 277–279 structural measures, 53–54 volume of service, 276–277 see also Generic screens; Outcome measures; Population-based measures; Process measures of quality Quality-of-care problems in ambulatory care, 246–250 correcting, 244–245, 249–250, 253–254 detecting, 242–244, 247–249, 252–253 differentiating among problems, 209–210 in home health, 218–219, 250–254 interpersonal care, 208 overuse, 220–224 preventing, 241, 246, 251–252 technical care, 207–209, 211–219

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I underdiagnosis/undertreatment, 226–227, 228–229 underuse, 209, 225–230 see also Art of care Quality interventions MQRO, 410–412, 416 PRO, 161–163, 167–169 QualPAC, see Quality Program Advisory Commission Quality Program Advisory Commission, 7, 379–382 R Readmission, to hospital, 161, 186, 227, 275 Reappointment and privileging, 240, 241 Recommendations capacity for quality, enhancement of, 8–9, 384–385 funding, 9–10, 385–387 goals for Medicare quality assurance, 6, 377–378 Medicare Conditions of Participation, 8–9, 383–384 mission of Medicare, 5–6, 375–377 National Council on Medicare Quality Assurance, 7, 379, 382 PRO program restructuring, 6, 378–379 public accountability and evaluation program, 6–7 Quality Program Advisory Commission, 7, 379–381 report on quality of care, 7, 379 research into efficacy, effectiveness, and outcomes of care, 8–9, 384–385 Regulation, in medicine, 33 Administrative Procedure Act, 148 Code of Federal Regulations, 120 PRO, 192, 147–148 PSRO, 145–146 TEFRA, 101, 110, 147–148, 188 see also Conditions of Participation Reliability, 226–227, 311–314 Reminders, clinical, 244, 266, 273–274 Reports, patient, 284–285 Research access to care, 344, 346, 381 ambulatory care, 355 appropriateness, 345, 353–354 capacity building, 343 clinical information systems, 358 CMPs, 356–357 continuous quality improvement, 352, 362–363 effectiveness, 348–350, 354–355 funding, 363 guidelines, 353–354 HCFA, 346 health services, 344 health status assessment, 351–352 HMOs, 356–357 in home health, 356 MPAQ, 418 outcomes, 8, 327, 346–347, 397–398 practice guidelines, 353–354 practice variations, 222–223 priorities for, 345 rural care, 357 severity of illness, 351 Resource allocation, 393–394 Resource constraints, 24, 377, 402 Retrospective review, 140–141, 162, 221, 277–279, 310 Rewards and penalties, 256, 266, 293; see also Incentives Risk adjustment, 275, 277, 391; see also Severity of illness contracts, 100–102 management, 35–37, 208, 241, 283; see also Liability; Malpractice

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I Rulemaking and public notice, 148, 192 Rural care, 27, 29, 99, 108, 135, 159 and peer review, 188–189 research needs, 357 S Sanctions and sanctioning process, 145–146, 216–217, 412 PRO, 163–169, 189–190 recommendations to OIG, 169 Satisfaction, 1, 20, 21–22, 23 patient, 244, 284–285, 347, 350–351 Severity of illness adjustment, 12, 243, 255, 280–281, 383, 405 research into, 351 Shifting the curve, 16, 47, 416; see also Physician, performance Small area variations analysis, 179–180, 276, 222–223, 346–347; see also Pilot Projects; Practice variations Statistical control (quality control), 58 Structural measure of quality, 53–54, 56–58, 268, 378 Study methods criteria-setting panel, xiv focus groups, xiv public hearings, xiv site visits, xiv Suppliers, 35, 59–60; see also Continuous quality improvement; Customers Surgical mishaps, 213 Survey and certification, 4, 7, 8, 14, 121, 124, 128, 129, 132–135, 180, 410; see also Conditions of Participation; Joint Commission on Accreditation of Healthcare Organizations Surveys of activity limitations in elderly, 90 of defensive medical practices, 220 health status assessment, 407 of home health quality problems, 218, 240 of hospital discharge rates, 79 measurement of quality through, 53, 56 patient satisfaction, 279, 284–285 of PRO impact, 182 recommended, 400 of underuse, 226 T TAP, see Technical Advisory Panel Tax Equity and Fiscal Responsibility Act, 101, 110, 147, 148, 188 Technical Advisory Panel, 382–383 Technical quality, 207–208, 211–219 defined, 207–208 and interpersonal care, 207–208, 211–219, 296, 353 see also Quality-of-care problems TEFRA, see Tax Equity and Fiscal Responsibility Act U UCDS, see Uniform Clinical Data Set Underdiagnosis and undertreatment, 226, 227, 228–230; see also Quality of care problems Underuse, 225–230 access to care and, 23, 52, 225, 226, 275, 284, 389 and burden of harm, 209–210, 225–230 defined, 209 and outcomes, 226 and overuse, 210

OCR for page 427
Medicare: A Strategy for Quality Assurance - Volume I surveys of, 226 see also Quality-of-care problems Uniform Ambulatory Care Data Set, 248 Uniform Clinical Data Set, 177–179, 186, 395, 404 Uniform Needs Assessment, 180, 227, 346, 356, 406 Use of services; see Elderly, use of services; Overuse; Underuse Utilities, 36, 57, 61, 352 Utilization management, 30–31, 36, 37, 111, 140–141, 374, 394–395 Utilization and Quality Control Peer Review Organizations Program, see Medicare Peer Review Organizations; Medicare Peer Review Organization Program V Validity/validation, 51, 316 of appropriateness guidelines, 319–320, 328 of DRGs, 156–159 of patient evaluation and management criteria, 328 of quality of care indicators/measures, 266–267, 311–314 Value purchasing, 36 Variations, 222–223 research, 348–350 small area, 179–180, 222–223, 276 Volume of services, 276–277