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Index A Access to care, 117, 234 barriers to, 41, 46, 67, 102, 103 concerns about, 11, 14, 73, 100 Medicare status and, 63 Accreditation, 52, 142 of ambulatory facilities, 196-197, 198 Community Health Accreditation Program, 243-244 of HMOs, 196, 210 for home health agencies, 243-244 hospital programs, 146-147, 149; see also Joint Commission international efforts, 149 issues and options, 333-336 limitations of quality assurance through, 244, 331-332 for PPOs, 198 role in quality assurance, 332-333 of specialty boards, 195 voluntary systems, 22, 146, 196, 243-244 see also Conditions of Participation; Hospital standards Accreditation Association for Ambulatory Health Care, 196 Accreditation Council for Graduate Medical Education, 195 Activities of Daily Living, 248, 250 439 Administrative Conference of the United States, 379 Administrative Procedure Act, 345, 421 Admission reviews, 246 Adverse patient occurrences, 185, 261 risk of, 182 see also Sentinel events Advocacy, 245, 251 Aetna, 17 Algorithms, 213 ambulatory patient care evaluation, 218-219 clinical decision making, 312 for converting scores on survey report forms, 330 patient management, 143, 200-203 uniform clinical data set, 394, 396 AMA, see American Medical Association Ambulatory care, 20 accreditation of facilities, 19~197, 198 algorithms, 21 8-219 case management, 207 clinical reminder systems, 201, 206 commercial systems for quality assurance, 232-234 complaint coding systems, 227 components of quality assessment programs, 216-227

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440 INDEX continuing education in, 200 continuous quality improvement, 227 correcting quality problems in, 234-236 credentialing systems, 193, 198-200 detecting quality problems in, 207, 209-234 external quality assurance methods, 193-198, 207, 209-211, 234-236 geriatric programs, 206 health accounting program, 212 health status measures, 220-221, 226 historical efforts and research projects applicable to, 211-216 HMO-related quality assurance activities, 197-198, 235 incident reporting systems, 227 indicators in, 196, 216-218 institution-related quality assurance, 196-197 internal quality assurance methods, 198-207, 211-234, 236 member education and outreach, 206 mission statement, 207-209 monitoring arid clinical quality indicators, 218 mortality and morbidity review, 220 organization-specific quality assurance programs, 227-232 outcome measures, 219-220 patient education, 206 patient reports, 221, 227 peer review, 219 physician-related quality assurance, 193-195 PPO-related quality assurance, 198, 427 practice guidelines and algorithms, 143, 200-201 preventing quality problems in, 193-207 problems reported by HMOs, 102 process measures, 216-218 profiling, 21B retrospective evaluation of process of care, 218-219 retrospective review criteria set, 217 sentinel events, 220, 222-225 structural requirements of practices, 200 surgical case review, 165 Ambulatory Care Medical Audit Demonstration Project, 212-213 American Academy of Family Physicians Peer Assistance Recovery Program, 188 American Academy of Home Care Physicians, 137 American Academy of Otolaryngology, 134 American Academy of Pediatrics, 215 American Academy of Physical Medicine and Rehabilitation, 134 American Association of Homes for the Aging, 17 American Association of Preferred Provider Organizations, 198 American Association of Retired Persons, 242 American Bar Association, 237 American Board of Medical Specialties, 134, 195 American College of Physicians, 296 Clinical Privileges Project, 17 Medical Knowledge Self-Assessment Program, 188, 200 American College of Surgeons, 184 Hospital Standardization Program, 296, 300 development of early voluntary standards for hospitals, 296, 300 Surgical Education Self-Assessment Program, 188 American Dental Association, 296 American Diabetes Association, 119, 134 American Gastroenterological Association, 134 American Health Care Association, 134 American Health Care Institute, 134 American Hospital Association, 137. 255, 296

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INDEX American Medical Association, 55, 137,180,296,374 Council on Medical Education, 195 American Medical Peer Review Association, 400, 404, 416 American Medical Review Research Center, 398 American Nurses Association, 119, 138 American Osteopathic Association, 292, 337 American Psychiatric Association, 17 American Public Health Association, 243 American Society of Internal Medicine, 232 Appropriateness, 19, 234, 247 Evaluation Protocol, 182-183 evaluation standards, 5, 191, 315 guidelines, 5, 162, 397-398 see also Practice guidelines Arizona Health Care Cost Containment System, 215-216 Arkansas Foundation for Medical Care, 13~135 Art of care, 48, 56, 73, 75 Autopsies, 171, 186 findings, 182 timeliness problems, 101, 191 California B Beneficiaries community outreach to, 376 complaints, 207, 376 hospital notices of noncoverage, 375-376 Medicare statement of rights to, 37~375 PRO relations with, 374-376 Beneficiary focus groups characteristics of participants, 40, 42-43, 74 choice in selection of providers/ services, 54-55, 74 concepts of quality, 48-50, 73-74 findings from, 41, 46-58, 73-75 Medicare Part B knowledge of, 57 441 moderator's guide, 37-38, 76-80 information desired/needed on health care, 54-57 issues addressed in, 35-36 personal experiences of participants, 41 pre-recruitment specifications, 38-39 problem handling by, 51-52, 157 recruiting screener, 86-88 satisfaction with health care, 41' 46~8, 73, 74-75 sites of, 37 suggestions for improving quality, 57-58 understanding of health care monitoring, 51-53, 74-75 Blood usage/transfusions problems with, 101 review by hospitals, 170, 177 Board certification, 142, 199 recertification, 69, l9S value and effectiveness of, 12 Boiling Air Force Base, site visit in, 98 Bureau of Health Insurance, 302-303 C HMO regulation in, 197, 210 home health care home visits, 240 Hospital Home Health Care Agency of, 254 Knox-Keene Health Care Service Plan Act, 197 Prepaid Health Research, Evaluation and Demonstration Project, 214-215 publication of names of disciplined physicians in, 235 site visits in, 96-97 California Medical Association, 135 Capitated payment systems, 250 Case conferences, 181-182, 186, 254 Case-finding, 160 Case management, 103, 104 in ambulatory care, 207 in home health, 244-245

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442 Catastrophic coverage, 58 Centers for Disease Control, 183 Certification funding for Medicare activities, 325 HHA, 239 of hospital laboratories, 146 issues and options, 333-336 limitations of quality assurance through, 331-332 role in quality assurance, 332-335 see also Board certification; Conditions of Participation; Hospital standards CHAMPUS review, 382 Chart audits/review, 12, 171, 213, 219, 231; see also Medical records review CIGNA, 199 Claims review, 19, 218, 230, 231, 234 Clinical guidelines, value and effectiveness of, 12 Clinical indicators, 48, 100, 101, 156, 157, 162, 170, 218 CME, see Continuing Medical Education CMPs, see Competitive Medical Plans College of American Pathologists, 146, 232 College of Family Physicians of Canada, 213-214 Colorado Data Commission, 15~157 Comparative rate indicators, 162, 170 Competitive Medical Plans accountability for problems, 427Jr28 ambulatory care review, 427 limited review, 426~27 peer review, 425 PRO review of, 207, 383-384, 425~28 PRO/HCFA actions related to, 235 records and case selection for Complaints review, 425~26 beneficiary, 207, 376 coding systems of HMOs, 227 about home health care, 251, 252, 259-260 INDEX patient, 103, 157-158, 185, 186, 236, 238 Computers, see Data bases and medical programs Concurrent review by home health agencies, 254 by hospitals, 162-164, 183,184 Conditions of Participation complaint handling under, 251 current standards, 29~295 development of, 301-304,317, 324-325 evaluation of, 5 evolution of, 308-311 for hospitals, 145-146,292-337; see also Hospital standards in home health care, 239-241,242, 244,251 Medicare quality assurance, 322-323 monitoring compliance with, 293 noncompliance of hospitals with, 306-307 procedures for revising, 309-310 responsibility for revising, 293 Confidentiality disclosure of information/data by PROs, 378-380 of medical records, 18, 70, 378-379 Congressional Research Service, 38~381 Consolidated Omnibus Budget Reconciliation Act of 1985, 147-148, 3~1~1 345, 355, 383, 419 Continuing medical education, 12 in ambulatory care, 200 case conferences as, 181-182 effectiveness of, 69,76 focused approaches, 188 in home health, 245 hospital-based clinical conferences, 70-71,72,75,76 literature reading, 69, 188-189 miniresidency programs, 188 hours, types, and time permitted for, 189 self-education/self-assessment approaches, 188, 235-236 state-required, 72

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)7V~EX subject areas for, 188-189 Continuing stay review, 246 Continuity of care concerns about, 15, 104 as dimension of quality, 127-128 measuring, 154, 234 Medicare reimbursement policies and, 65 Continuous quality improvement, 118, 212 in ambulatory care, 227, 229 effectiveness, 13 hospital approaches, 160, 185, 192-193 model, 13, 160, 185, 192 COOP charts, 220-221 Cost containment communitywide approach to, 157 and quality of care, 12, 14, 18, 237 Cost effectiveness, 1 17 Costs average adjusted per capita cost, 382-383 of quality assessment and assurance activities, 16-17,19,288-289, 326,380-382 PRO, 38o-382 problems of patients, 4~47,73 suggestions for addressing, 58 see also Financial barriers Credentialing, 180,229 of physicians, 192,193,198-200; see also Board certification; Licensure value and effectiveness of, 12, 141 Criteria, quality assurance, 19 clinic-specific, 233 evaluation standards, 5 for PPO accreditation, 198, 199 for retrospective ambulatory record review, 217 Critical care screens, 100, 174 Current Review Technology, 234 D Data bases and medical programs, 20, 142 443 administrative, 151, 155-156,214,216 AmbuQual, 234 APACHE software, 102, 183 Appropriateness Evaluation Protocol, 182-183 claims data analysis, 151, 234 clinical reminder systems, 201, 205-206 Computer-Stored Ambulatory Record (COSTAR), 206, 227, 229 Computerized Severity Index software, 183 Disease Staging software, 183 HCFA mortality rates, 154-155 hospital discharge data, 15~157 incident tracking, 159 indicator tracking, 192 ISD-A Review System, 182 Medical Management Analysis system, 159-160, 232, 234 Medicare Automated Data Retrieval System, 154 MedisGroups software, 156, 157, 183 National Practitioner Data Bank, 194-195,211,379 Patient Management Categories software, 183 Physician Reminder of Medical Protocol Tasks (PROMPT), 206 PROMPTS-2, 400~01 severity-of-illness software, 183 small area variations analysis, 155 Statewide Planning and Research Cooperative System, 156 types of data sets, 151-154 uniform clinical data set, 156, 157, 388-396 utilization review software, 182,234 volume of services, 155-156 Decision making on health care elderly role in, 12 by fiscal intermediaries, 14 and patient-physician realtionships, 66 by PROs, 14 by utilization review staff of third- party payers, 14

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444 Deemed status, 244, 292, 296 Deficit Reduction Act of 1984, 344 Defining quality of care accessibility, 124 acceptability/satisfaction dimension, 124-125 committee's definition, 128-128 competency of practitioners/ providers, 123 INDEX Office of Health Maintenance Organizations, 196-197 sanctioning responsibilities, 369-372 Diagnosis-related groups, 74, 156, 171, 343 categories, 351 validation by PROs, 360-361, 403 Diagnosis-related problems, 103, 104-105 Direct care providers continuity of care, 127-128 coordination of services, 127-128 dimensions used in, 13, 74-75, 117-128, 129-130 goal-oriented care, 120-121, 124 organizations in home health care, 246 interpersonal skills of practitioners, 123-124 management of care, 127-128 methods, 116-118 nature of entity evaluated, 118-119 outcome aspects in, 121-122 patient/consumer-related constraints, 127 recipient role arid responsibility in, 122 resource constraints, 125-126 risk versus benefit tradeoffs, 121 scale of quality, 118, 125 sources/examples for this study, 3~, 130-139 standards of care, 125, 126 technological constraints, 122-123 testimony in public hearings on, 13, 18 type of recipient, 119-120 use, specific statements about, 128 see also Indicators/measures of quality of care Delaware, ban on financial incentives in HMOs, 198 Delivery of health care effects of Medicare reimbursement system on, 62-63, 75 monitoring problems in, 227 Department of Defense, 135 Department of Health and Human Services effectiveness of quality assessment and assurance systems, 17, 19-20 see also Health maintenance Discharge appeals of, 147 data from hospitals, 151, 156-157 from home health care, 248 planning, 102, 159-160, 161, 165, 183, 242 review, 360 from teaching hospitals, 104 see also Premature discharge Disciplinary actions, 180, 186, 189, 194, 235 reporting of, 210 Documentation HMO problems with, 103 hospital problems with, 101 physician problems with, 104 Drugs and medications inappropriate use of, 101, 103, 158-159, 216 practice guidelines, 189 prescription, 64, 189 usage evaluation, 170-171, 178 Due process, 18, 19, 194, 419 Elderly Eaccess to Medicare benefits, 14 assessing needs of, 13 barriers to care, 12 compliance to treatment plans, 60 chronically ill, 14 health care decision making role, 12

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INDEX humaneness of care, 15 positive and negative aspects of caring for, 60 quality assessment/assurance role in, 12 Emergency medicine problems in, 101, 103 screens, 148, 175 Ethical issues, 19 prolongation of life and quality of life, 15 rationing health care, 15 Expenditures, see Health expenditures Experimental Medical Care Review Organizations, 5 Extended care, 100, 242 External reviews and reviewers effectiveness of, 19-20 resources for, 19 F Falls resulting in fracture, 100, 101, 158-159 Family practice indicators of care, 17~175 Federation Licensing Examination, 194 Federation of American Health Systems, 135 Federation of State Medical Boards, 194 Fee-for-service settings outpatient care, 103 quality assurance approaches in, 231-232 Financial barriers to health care, 41, 46, 67 Financial incentives negative, legislation affecting, 198 for overuse, 198 for underuse, 14 Fire Safety Evaluation System, 306 Fiscal intermediaries, 14, 242, 380 Florida, HMO regulation in, 209-210 Focus groups benefits and limitations of, 35-36 composition of, 38~0, 42~5 445 concepts of quality, 48-50 findings of, 41, 46-76 methods, 4, 36~0 moderator's guide, 37-38, 76-85 objectives of, 73 physicians, 39, 44~5, 59-73 process, 40 recruiting process, 38 site selection, 37 subcontractor selection, 36-37 see also Beneficiary focus groups; Physician focus groups Focused review of care, 171, 207 For-profit enterprises, concerns about. 1, 237 Foundation for Hospice and Home Care, 244 Freedom of Infonnation Act, 260, 380 G General Accounting Office, 305, 378 Generic screens, 192 categories of, 105 controversies over, 408~13 HHA, 358, 364 in hospitals, 159-160, 164-165, 184, 185, 356-360, 364 New York State Department of Health, 100 nonhospital, 363-365 outpatient surgery, 358, 364 PRO, 99-100, 105, 151, 354-360, 363-365, 408=r13 problems flagged by, 99 problems with, 17, 18, 99-100 process, 151, 161 skilled nursing facility, 364 value of, 141 see also Sentinel events Georgia Academy of Family Physicians Education Foundation, 188 site visits in, 97 Geriatric programs, 206 Group Health Association of America, 221, 227

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446 Group Health Cooperative of Puget Sound, 199, 206, 218 quality management program, 229-230 H Harvard Community Health Plan, 227-228 HCQIA, see Health Care Quality Improvement Act of 1986 Health accounting program, 212 Health Care Financing Administration, 19 actions related to HMOs and CMPs, 235 Bureau of Eligibility, Reimbursement and Coverage, 293 Bureau of Health Standards and Quality, 293, 346 demonstration projects, 215-216 home health care quality assurance actions, 255-259 Medicare Automated Data Retrieval System, 154 mortality rates, 154-155 National Practitioner Data Bank, 194-195, 211, 379 PRO administration, 346 uniform clinical data set, 156, 157 Health care information for choosing providers/services, 54-55 sources of, 55 types desired by patients, 55-57 Health care personneVprofessionals competency of, 123, 128 geographic distribution of, 15 interpersonal skills of, 123-124 supply of, 15 training of, 15 see also Physicians Health Care Purchasers Association, 138 Health Care Quality Improvement Act of 1986, 179-181 liability of professional reviewers under, 178-181 INDE3f physician monitoring under, 19~195 Health expenditures medical malpractice and, 21(~211 and changes in health care environment, 1 Health Insurance Benefits Advisory Council, 304 Health Insurance Plan of New York, 199, 207 Health Maintenance Organization Act of 1973, 197 Health maintenance organizations, 17, 211 accountability for problems, 427-428 accreditation of, 196, 210 ambulatory care review, 427 credentialing, 198-199 financial incentives in, 198 grievance procedures, 236, 238 group-model, 200, 227-230, 238 IPA-model, 200 201, 230 limited review, 426~27 Medicaid enrollee studies, 214, 216, 220 member education and outreach, 206 morbidity and mortality review, 220 patient problem-halldling with, 51 peer review, 425 prevention of quality problems in,: 197-197 PRO/HCFA actions related to, 235 PRO review of, 207, 220, 383-384, 425-428 problems reported by, 103 quality assurance approaches in, 227-230, 23~237 RAND study of, 216 records and case selection for review, 425~26 staff-model, 227-230 state regulation of, 197-198, 209-210 see also Ambulatory care Health Resources and Service Administration, 194

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INDEX Health services coordination of, 104 and quality of care, 55 rates offense, 1 Health status measures' 162, 226 instruments, 220-221 HHA, see Home. health agenciesicare Hill-Burton Act, 301 Home health agencies/care, 100 aides, 239, 2~40, 245, 246 backup systems for patient safety, 245-246 caregiver burden, 250 client. knowledge and self-care ability,. 250 case management in, 244-245 certification, 339 complaints, 251, 252, 259-260 concerr~s about, 237 Conditions of Parti:cipat~on, 239-241 correcting problems in, 2-55-260- deteci~ng. problems in, 246 - 255 enforcement remedies,. 255-260 external quality assurance methods for, 239-245,. 246-252,. 255-260 federal responsibilities,. 239 generic screens, 358 HCFA regulation of,. 255-259 in-home audits,. 25~255 incident reporting systems, 255, 259 internal quality assurance methods for, 245-246, 252-255, 260 licensure, 242-243 long-term-care ombudsman program, 25 I-252 Medicare participants, 293 needfor, 14, 47, 64 patient bill of rights, 246 physician assessment, 252 performance evaluation,. 255 prevention of problems in,. 239-246 PRO rev iew, 105, 25 1, 3 62-3 63 424 425 problems reported by, 104 provider, senice, and fading mechanisms for, 262 regulation under OBRA, 241-242, 259 447 retrospective record review, 252, 254-255 satisfaction survey, 252, 253 staff selection, supervision, and continuing education, 245 state responsibilities, 239, 243 uniform needs assessment, 242 state department of health regulation, 259 survey process, 240, 241-242 visiting nurse services, 245 voluntary accreditation, 243-244 HMO, see Health Maintenance Organizations Hospital Association of New York State, 157 Hospital Association of Rhode Island, 157 Hospital Corporation of America, 139, 160, 185 Hospital standards, 292-293 capacity-to-performance shift, 313-314 enforcement of, 329-330 Governing Board Standards, 146, 147 government, 301,334-335 improving, 334 JCAHO (1990),297-299 Life Safety Codes, 147 medical staff standards, 146, 147, 149-150, 160 origin and development, 296-311 structure and process orientation of, 146, 311-313 survey process for ensuring compliance with, 325-329 voluntary, 296-300 see also Accreditation; Certification; Conditions of Participation Hospitals (acute care) accreditation programs, 146-147, 149; see also Joint Commission accredited, number, 292 anti-dumping legislation, 147-148 autopsy findings, 182 blood usage review, 170, 177

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448 INDEX case-by-case problem detection, 186-187 case conferences, 181-182 characteristics, 276-277, 281-282 choosing, 54 clinical conferences, 70-71, 72, 75, 76 committees and services, 277, 282 complaints by patients, 185 concurrent review by, 162, 164 . . . continuous improvement approaches, 192-193 convalescence in, 100 corporate resources and assessment, 275-276 correcting problems in, 187-193 costs, 58 data bases, 151-157 department-specific quality assurance activities, 166-169 detecting problems in, 151-187 discharge data, 151, 156-157 discharge planning, 102, 104, 159-160, 161, 165, 183, 242 discharge policies, see Premature discharge drug usage evaluation, 170-171, 178 event-based corrective actions, 189-190 external quality assurance methods, 145-159, 187-189 focused review of care, 171 generic screening, 161, 164-165 grievance systems for patients and families, 184, 185 infection control, 159, 161, 183-184 information systems, 287 internal quality assurance methods, 149-151, 159-187, 189-193 international quality assurance efforts, 148-149 length-of-stay restrictions, 64 malpractice claims against, 159 malpractice insurance underwriters' discounts for risk management, 148 medical record review, 171 military, 146-147, 185 monitoring activities of, 162, 172-173 mortality rates, 5 6, 154-155 notices of noncoverage to Medicare beneficiaries, 375-376 observations activities in quality assurance, 185 organization-based corrective actions, 191-192 patient surveys, 284, 290 peer review, 70-71, 72, 75, 76, 171-1 81 pharmacy and therapeutics review, 171 practice pattern-based corrective actions, 19~191 pre-admission processes, 192-193 preventing problems in, 145-151 problem handling by patients, 51 problems reported by, 101-102 PRO corrective actions against, 187-189 PRO review activities, 355-362, 397 quality assurance committees and departments, 161-162 quality management programs, 277-288 readmissions, 102, 251, 354 risk management, 147, 148, 150-151, 159, 172-173, 184-185, 284, 286, 288, 289 satisfaction surveys for patients and employees, 185, 186 size of, and quality management program characteristics, 161-162, 163,281-289 small area variations analysis, 155 state corrective actions against, 189 state licensing and safety requirements, 147 . . state reporting requirements, 158-159 surgical case review, 165, 170, 176 survey of quality management programs, staff alla resources, 142, 146-147, 161, 273-291

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INDEX time allocated for quality assurance, 278-279, 282-287 unexpected/problematic admissions, 103 utilization review, 159, 161, 165, 172-173, 182-183, 277, 285-286, 289 volume of services, 155-15 6, 281 Humaneness of care, 15 Illinois, site visits in, 94 Impaired-physician program, 190 Incentives, see Financial incentives Incident reporting, 100, 148, 184, 186, 191, 227 in home health care, 255, 259 state requirements for, 158-159 Independent practice associations office standards for, 200-201 quality assurance approaches in, 23~23 1 Indicators/measures of quality of care, 311 in ambulatory care, 196, 216-218 analysis in aggregate, 218 art of care, 48, 56 beneficiaries' perceptions of, 48-50 case-mix, 250 clinical, 48, 100, 101, 156, 157, 162, 170, 171, 218 competency of physician, 48, 61 critical care unit screens, 174 data collection, 231 department-specific, 174-175, 218 emergency medicine screens, 175 in family practice, 174-175 frequency of surgical procedures, 56 health status, 162, 22~221, 2~6 hospital mortality rates, 56 in internal medicine, 174 malpractice claims frequency, 56 for monitoring, 162 mortality data, 155 nursing home inspection reports, 56, 57 449 physician personality and interpersonal skills, 48, 58 physicians' perceptions of, 61-62 psychiatry screens, 175 of satisfaction with care, 213 systemwide, 218 weightings of, 234 see also Outcome measures of quality; Process measures of . qua sty Infections, nosocomial, 100-102, 183-184, 313 control in hospitals, 159, 161, 183-184, 261-262 Information, see Data bases and medical programs; Health care Information Informed consent, 101, 148 Instrumental Activities of Daily Living, 248 Intergovernmental Health Policy Project, 242 Internal medicine screens, 174 Iowa, site visits in, 95 IPAs, see Independent practice associations J JCAH, see Joint Commission on Accreditation of Hospitals JCAHO, see Joint Commission on Accreditation of Healthcare Organizations Joint Commission on Accreditation of Healthcare Organizations, 17, 19, 146, 218, 292, 384 Accreditation Manual for Hospitals, 206 Accreditation Program for Ambulatory Health Care, 196 Agenda for Change, 162, 317 Ambulatory Health Care Standards Manual, 196 clinical indicator initiative, 157 composition of, 296 definition of quality, 131

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INDEX reporting of disciplinary actions, 210 site visit, 98 MassPRO, 136 Measures of quality of care, see Indicators/measures of quality of care Medicaid, studies involving enrollees, 21~216 Medical information systems, see Data bases and medical programs Medical malpractice caps on insurance premiums arid settlements, 72 and HCQIA, 210-21 1 internal peer review and, 70 Medicare reimbursement policy and, 60, 66 monitoring payments of claims, 19~195 Medical records, 234 abstraction of, 219, 389, 394 care plans in, 242-243 confidentiality of, 18, 19 documentation problems, 18, 19, 101, 104 review, 151, 159, 164, 171-172, 182, 184, 207, 214, 215, 256, 386-387; see also Generic screens; Peer review Medicare access to benefits, 14, 73 availability for future generations, 58 Case Mix Index, 277, 281 certification procedures for hospitals, 311-331; see also Conditior~s of Participation; Hospital standards costs, 58, 380-381 data bases, 151, 154, 155-156 denials of payment, 64 due process under, 19 effects on patient-physician relationships, 66 fraud, 4~47, 58 hospitals participating in, 292-293, 337 JCAH and, 304 308 451 length of stay restrictions, 64 letters of noncoverage or substandard care, 64 limitations of financing structure, 12 monitoring role, 53 Part A, 151, 154, 380, 381 Part B. 17, 57, 154, 380, 381 physicians' views of, 62-65 and quality of care, 49-50, 62-65, 75 reimbursement policies and quality of care, 6~65, 73, 75 risk contracts, see Risk contract plans satisfaction with, 41 strengths and weaknesses of, 15-16 treatment settings restricted by, 63-64 Medicare and Medicaid Patient Program Protection Act of 1987, 344, 345 Medicare Peer Review Organizations (PROs) actions regarding physicians and hospitals, 187-189 actions related to HMOs and CMPs, 235 admission review, 360 AMPRA 1989 Impact Survey, 404 appeals process, 403~04, 42Q appropriateness guidelines, 397-398 beneficiary relations, 374-376 budgets, 381 community outreach programs, 207, 376 complaints about, 98-99 contracts, 346-348, 382-388; see also Risk contracts controversiaVproblematic activities 4C8Jt28 corrective action plans, 187-188 coverage review, 361 data acquisition, sharing, and reporting, 377-380 data collection, management, and reporting requirements, 404-408 data exchange reports, 407 decision making on health care by, 14

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452 INDEX denials for substandard quality of care, 419~21 determination of source of problem, 365 discharge review, 360 documentation emphasis of, 127 DRG validation, 360-361 effectiveness of, 17-18, 71, 332-333 generic screens, 99-100, 105, 151, 354-360, 363-365, 408~13 HHA review, 105, 251, 362-363, 424~25 HMO/CMP review, 207, 220, 425~28 historical record of interventions and sanctions, 372-374 . . . . . hospital Inpatient review activities, 355-362 internal organizations contrasted with, 70-71, 72 intervention plan, 365-374; see also Sanctions/sanctioning process invasive procedure review, 360 management information reports, 406~08 medical record review, 207, 386 medical review activity reports, 407 methods used by, 151 nonhospital review, 362-365 noninstitutional review, 394, 397 organizational characteristics, 346 patient complaint review, 158 physician attestation, 361 physician office-based care review, 4144415 physicians' attitudes about, 71, 415, 425 pilot projects for, 394, 397-399 pre-admission and pre-procedure review, 155, 361-362, 386, 413~14 problems reported by, 99-100 profiling, 366-367, 405, 406 PROFs reporting systems, 405~06 PROMPTS-2, 400~01, 423 provider relations, 376-377 quality control reports, 407~08 reconsiderations of intervention activities, 373 reduced hospital review, 397 rural provider review, 362 sanctions/sanctioning process, 186, 187, 368-374, 415~19 scopes of work, see PRO scopes of work severity levels and weights, 36S site visits to, 5, 99-100 skilled nursing facility review, 105, 362-363 small area variations analysis, 398 time frames for quality review, 366 see also SuperPROs; Utilization arid Quality Control Peer Review Organization Program Medigap insurance, 40 Mental health services, 103 Mercy Health Services analysis, 274-275 content validation and decision rules, 274-275, 330-331 hospital characteristics, 276-277 methodology, 273-274 responses, 274 Minnesota, site visits in, 95 Missouri, home health care home visits, 240 Monitoring of health care beneficiary understanding of means for, 51-53 and clinical quality indicators, 218 concurrent, 162-164 indicators for, 162 by hospitals, 162, 166-169, 172-173 of patient status, 100 procedures and complications for, 232 Morbidity and mortality review in ambulatory care, 220 in hospitals, 182 N National Association of Boards of Examiners for Nursing Home Administrators, 17

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INDEX National Association for Home Care, 24D, 243, 244 National Association of Retired Federal Nursing Employees, 136 National Association of Social Workers, 136 National Board of Examiners for Osteopathic Physicians and Surgeons, 194 National Bureau of Standards, 306 National Committee for Quality Assurance, 196, 210, 383, 384 National Fire Protection Association, 313 National HomeCaring Council, 244 National Institute on Aging, 136 National League for Nursing, 243, 244, 247, 255 National Long Term Care Channeling Demonstration, 252 National Medical Association, 138 National Medicare Competition Demonstrations, 216 National Multiple Sclerosis Society, 138 National Rural Health Association, 138 Nationwide Evaluation of Medicaid Competition Demonstrations, 215-216 Netherlands, quality assessment activities, 149 New Hampshire Hospital Association, 157 New Mexico Experimental Medical Care Review Organization, 216 State Medical Society, 37 New York complaint investigation, 251 HMO regulation in, 209 hospital quality assurance requirements, 160 infection control requirements in, 184 site visits in, 94 State Department of Health, 100, 156, 157, 158-159, 251, 260 453 Statewide Planning and Research Cooperative System, 156 community health, 247 interventions for patients at high risk of falls, 152-153 JCAHO scoring for first nursing services atandard, 327-328 QA monitors, 170 shortages, 15, 47, 102 Nursing homes bed shortages, 47 costs, 58 inspections, 56, 57 patient problem-handling with, 52 regulation, 241, 248 selection by potential resident, 54-55 see also Long term care o OBRA, see Omnibus Budget Reconciliation Acts Ochsner Medical Institutions, 220, 22~225 Office of Inspector General, sanctioning responsibilities, 368, 369, 372, 374, 378, 416 Office of Management and Budget, 384 Office of Technology Assessment, 119-120, 136 Ohio Department of Health Services, 215 Quality Assurance Project, 252, 254 site visit In, 98 Older Americans Act, 239, 251 Ombudsmen, 53 hospital programs, 185, 190 long-term-care program, 251-252 Omnibus Budget Reconciliation Act of 1986 establishment of PRO review, 344, 345, 355 legislative charges for this study, 1-2 HMO/CMP regulation under, 384

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454 home health care regulation under, 242, 363 post-acute care assessment under, 362-363 uniform needs assessment, 242, 398-399 Omnibus Budget Reconciliation Act of 1987, 344 denials for substandard quality of care, 419 home health care regulation under, 241-242, 259 PRO contract provisions, 345, 355, 422 rural provider protections under, 362 Omnibus Budget Reconciliation Act of 1989, 421 Outcome measures of quality, 19, 48, 49, 61, 312 in ambulatory care, 219-220 clinical, 170 discharge records, 248 discomfort, 249 in home health care, 247-249, 255, 258 in hospital care, 313-314 research in, 247-249 see also Satisfaction Outcomes adverse, see Adverse patient occurrences; Sentinel events . . . . . clinician Interaction and coordination and, 191 data sources, 219-220 definition of, 247 generic terms for, 121-122 process of therapy linked with, 17 quality problems and, 18 volume of services/procedures and, 155-156 Outpatient care, 19 Outpatient clinics, 231 Overuse, 18, 128 of drugs, 103 estimates of, 67 for financial gain, 67 hospital problems with, 102 INDEX medical liability fears and, 6~67 methods to identify, 23D, 234 physician competency and, 67 and quality of care' 14 pi Pacemakers, inappropriate use, 100 Pap smears, 103 Paralyzed Veterans of America, 17 Patient assessment surveys, 185, 221, 227' 252 bill of rights, 241, 246 choice in selection of providers! services, 54-55 complaints, 148, 157-158, 18~186, 236, 238 compliance, 234 education of, 72, 76, 192, 206, 250 falls resulting in fracture, 100, 101, 158-159 follow-up of, 103-104 grievance systems for families and, 185 management algorithms, 143, 20~203 problems generated by, 104 reports, 221, 227 satisfaction surveys, 185, 186, 213, 220, 221, 227, 252, 253 see also Beneficiaries; Beneficiary focus groups Patient care assessment, 148 Patient-physician relationship, 1, 103 cost issues in, 46 effects of Medicare program on, 66 for-profit enterprises and, 1 and quality of care, 1 1 see also Physician focus groups; Physicians Peer review in ambulatory care, 194, 219, 237 effectiveness of, 11, 237 Health Care Quality Improvement Act of 1986 and, 179-181 in hospitals, 171-181

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INDEX internal versus external, 70-71, 72, 75 see also Medicare Peer Review Organizations Pennsylvania Buy Right Committee, 156 Health Care Cost Containment Commission, 156 HMO regulation in, 210 publication of names of disciplined physicians in, 235 site visits in, 95 Performance competency, 234 and focused review, 171 measures of, 12-13, 231 need to measure, demonstrate, and prove, 12-13 review, areas of, 199 Pharmaceutical Manufacturers Association, 119, 138 Pharmacology, problems with, 100 Pharmacy and therapeutics review, 171 see also Drug use review Phlebitis, 101 Physician advisor reviewers, 17, 19-20 assessment in home health care, 252 attestation, 361 balance billing, 46, 58 choosing, 54 competency, 48, 61, 67, 68, 102 corrective actions directed at, 190-191; see also Continuing medical education credentials, 193-195 external quality assurance methods directed at, 193-195 fee variation with location, 46 licensure, 142, 193-194 malpractice claims against, 159 miscoding of documentslbillings, 19, 46, 64, 74 monitoring under HCQIA, 194-195 participation in Medicare, 65 patient problem-handling with, 51 PRO interventions for, 373 455 PRO office-based care review, 414-415 problems in office-based practice, 103-104 recertification, 213 specialty certification and recertification, l9S surveys, 213 see also Health care personnel/ professionals; Patient-physician relationship Physician focus groups characteristics of participants, 40, ~ ~5 concepts of quality, 61~2 evaluation of effectiveness of quality assurance mechanisms, 69-71 findings from, 59-73, 75-76 identification of quality problems, 66-68 issues addressed in, 36 Medicare program issues for, 62-65 moderator's guide, 37-38, 81-85 positive and negative perceptions of medical care, 59~1 pre-recruitment specificiations, 39 recruiting screener, 88-90 sites of, 37 . ~ . . . suggestions ~ for unprovlng quality, 71-73 Pneumothorax, 100 PPOs, see Preferred provider organizations Practice guidelines in ambulatory care, 20(~201 prescription, for hospitals, 189 Practitioners, see Health care personnel/ professionals Preferred provider organizations accreditation for, 198 characteristics of, 23() 231 quality assurance approaches in, 230-23 1 screening process, 199-200 Premature discharge, 14, 47, 64, 74, 100 appeals of, 147

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456 corrective actions against physicians for, 188 review of, 360 Preoperative status, 101 Prepaid group practices quality assurance approaches in, 227-230 see also Health maintenance organizations Pre-procedure review, 155, 230, 361-362, 413~14 Preventive health care, 64 compliance with guidelines, 104 screening standards, 204 underuse of, 103 PRO, see Medicare Peer Review Organizations PRO scopes of work, 376, 415 first, 351-354. 405 second, 354-355, 405 third, 348-351, 355-365 Process measures of quality in ambulatory care, 216-21 B in definitions of quality, 130 in home health care, 243-244, 247 outcomes linked with, 17 survey instrument for, 247 Professional associations, costs of quality assessment and assurance activities, 16 Professional Standards Review Organizations, 5, 307-308, 343, 346, 360, 361, 363, 381, 397 Profiling, 218, 366-367 Prospective Payment Assessment Commission, 408, 423 Prospective payment system, 250, 343 Provider groups, costs of quality assessment and assurance activities, 16 Psychiatry screens, 175 Public hearing process, 3 abstraction and recording of information, 9, 10 data base system, 10 findings, 10-27 interest groups involved in, 9 INDEX invitations to submit testimony, 7-8 limitations of document abstraction, 10 locations of, 8 methods, 7-10, 27-28 questions asked in, 7, 28-29 respondents to invitations to submit testimony, 8 responses to specific questions, 13-27 themes of documents, 11-13 types of documents submitted, 8-9, 30 see also Testimony at public hearings Q Quality assessment adequacy of, 17-20, 21 in ambulatory care, 207, 209-234 components of programs, 216-227 continuity of care, 15 coordination with quality assurance activities, 22-23 elderly role in, 12 gaps in information, 11 government role in, 22 historical efforts and research applicable to, 211-216, 246-250 in home health care, 246-255 in hospital care, 151-187 practitioner supply and training, 15 profiling, 218 resources for, 19, 20 responsibility for, 22-22 staging approach, 214-215 testimony at public hearings on, 13-27 tools and methods, 21-22 see also Indicators/measures of quality of care Quality assurance programs/activities adequacy of, 17-20, 22 in ambulatory care settings, 193-236 coordination of federal efforts, 336 coordination with quality assessment activities, 22-23

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INDEX correction-oriented, 189-193, 234-236, 255-260 costs of, 5, 288-289 detection-oriented, 151-187, 209-234, 246-252; see also Medicare Peer Review Organizations effectiveness of, 69-71 elderly role in, 12 evaluation of effectiveness, 215 external methods for, 151-159, 207, 209-211, 234-236, 246-252, 255-260 government role in, 22 in home health care, 236-260 of hospitals (acute-care), 144?-193 individually focused mechanisms, 69 internal methods, 149-151, 198-207, 211-234, 236, 239-246, 252-255, 260 international efforts, 148-149 least effective activities, 21 limitations of, 102 by malpractice insurance underwriters, 148 medical staff standards, 149-150 most effective activities, 20 patient-centered, 12 physicians' perceptions of, 62, 69-71 prevention-oriented, 149-151, 193-207, 239-246 purpose of, 129 resources for, 19, 142, 161, 284, 288-289 responsibility for, 22-23 staffing of, 5, 282 tools and methods, 21-22 see also Accreditation; Licensure; Medicare Peer Review Organizations; Risk management; am1 specific care settings Quality of care beneficiary concepts of, 48-50 cost containment issues, 14 costs of care and, 12, 14 criteria for review, see Criteria, quality assurance 457 ethical dimensions, 15 financial status of patient and, 59 humaneness of care, 15 and Medicare, 49-50 Medicare benefits, 14 Medicare strengths and weaknesses, 15 now and in the past, 50 patient physical condition and diagnoses and, 62 problems identified by physicians, 66-68 quality of service distinguished from, 15 satisfaction with, 1 scale of, 118 suggestions for improving, 57-58, 71-73 variations in, 55 see also Defining quality of care; Indicators/measures of quality of care Quality of care problems, 1 Quality of life, 14 prolongation of life and, 15 Quality Review Organizations, 207, 384-385 R RAND HMO study, 216 Health Insurance Experiment, 220 Rationing health care, 15 Recommendations, from public testimony accountability to elderly, 24 competitiveness, 24 consumer education, 25 coordination of quality assurance efforts, 24 financial incentives, 25 financing, 23-24 geriatrics, 24 home health care, 25 medical education, 26 practice in rural areas, 24 practitioner support for quality assurance, 24

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458 quality assessment methods, 25 quality assurance activities, 25-26 record keeping and documentation, 25 regulatory activities, 26 research and development, 26-27 review atmosphere, 25 scope of quality assessment and assurance activities, 24 staffing and training, 25 transfers to and from skilled nursing facilities, 24 Regulation/regulations of financial incentives to overuse of services, 198 HMO-related, 197-198, 209-210 of home health care, 241-242, 255-260 PRO, 345-346 reporting requirements for hospitals, 158-159 risk management program requirements, 147 Rehabilitation, measures of, 248 Research/studies of quality assessment methods administrative data base studies, 216 Aftercare study, 249 Ambulatory Care Medical Audit Demonstration Project, 212-213 caregiver burden, 250 in case-mix measures, 250 client knowledge and self-care ability, 250 College of Family Physicians of Canada, 213-214 health accounting, 212 in home health care, 246-250 on Medicaid enrollees, 214-216 Medical Outcomes Study, 220 Michigan Project, 210 Minnesota Project, 220 National Long Term Care Channeling Demonstration, 252 National Medicare Competition Demonstrations, 216 INDEX Nationwide Evaluation of Medicaid Competition Demonstrations, 215-216 in outcomes measures, 247-249 Prepaid Health Research, Evaluation and Demonstration Project, 214-215 Rand HMO study, 216 retrospective evaluation of process of care, 218-219 University of Minnesota Study of Post Acute Care, 248 Resource constraints, 100, 102, 104, 117, 125-126 Resource utilization groups, 250 Respiratory therapy, 100 Retrospective review, 19, 160, 163, 184, 354 of hospital admissions, 360 in ambulatory care, 217, 218-219, 231 in home health care, 252, 25~255 in-home audits, 254-255 performance evaluation, 255 of surgical cases, 165, 170 Risk contract plans, 206, 207 basic review, 387 complaint-handling requirements, 235 enrollments, 382 history of, 382-385 intensified review, 387 limited review, 386-387 review process, 387-388 types of HMO and CMP review, 385-387 underuse in, 384 see also Competitive Medical Plans; Health maintenance organizations Risk management, 192 corporate-level responsibilities for, 275-276 by hospitals, 147, 148, 150-151, 159,172-173,184-185,284, 286,288,289,261 malpractice insurance discounts for, 148

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INDEX Rochester Area Hospitals Corporation, 157 Rural provider review, 362 S Sanctions and sanctioning process, 18 adequacy of notice of grounds for, 419 controversies over, 415~19 DHHS responsibilities, 369-373 historical record of, 372-374 monetary penalties, 417 GIG responsibilities, 369, 374 PRO responsibilities, 368-369, 372-374, 415~17 timing of, before hearings, 419 "unwilling and unable" provisions and, 418 Satisfaction with health care, 1 beneficiary focus group participants, 41, 46J,8, 73, 74-75 in definition of quality, 124-125 with hospital care, 102 in Medicare program, 41 measures of, 213 problems reported by HMOs, 103 surveys of patients and employees, 185, 186, 213, 221, 227, 252, 253, 284, 290 Scopes of work,, see PRO scopes of work Screens/screening ambulatory and inpatient care, 154 cancer, guidelines, 201-202 case-f~ding as, 160 clinic-specific criteria, 233 concurrent' 183 critical care unit, 174 emergency room, 148, 175 example of health care screening standards, 204 failures/variations, 165 health care standards, 204 internal medicine, 174 occurrence, 18~185 by PPQs, 199 - 200 459 psychiatry, 175 surgical review, 176 for underuse, 155 see also Generic screens Second opinion programs, 230 Sentinel events, 162, 164, 170, 207, 220, 222-225, 248, 386 Settings of care, see Ambulatory care; Home health agencies/care; Hospitals Sheppard-Tower Act of 1921, 296 Site visits, 141 confirmation letter, 10~109 documentation of, 93, 97 follow-up, 19, 157 guide for, 92, 109-115 HHA problems reported during, 104 HMO problems reported during, 103 hospital problems reported during, 101-102 issues discussed during, 97-99 locations, t5, 94-98 meetings, 93, 94-97 methods, 92-97 to organizations, 92-93, 9~97 physician in office-based practice, problems reported during, 103-104 PRO problems identified during, 99-100 purpose of, 91 quality/quality assurance problems identified during, 99-104 schedule and planning, 92 value of, 5 Skilled nursing facilities Medicare participants, 293 PRO review, 105, 362-363, 365 Small area variations analysis, 155, 398 Social Security Act amendments' 292, 296, 301, 302, 305, 325, 344, 382 Social Services Block Grant, 239 Specialty certification, see Board certification Standards of care in ambulatory care, 196 in defining quality of care, 125, 126

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460 State regulation CME requirements, 72 of HMOs, 197-198, 209-210 home health care, 259-260 of hospitals, 301 Study design and implementation commissioned papers, 4 data collection, 3-6 defining quality of care, 3 - focus groups, 4 main tasks, 3-5 OBRA charges for, 1-2 phases, 3 public hearing process, 3 site visits, 4-5 Technical Advisory Panel, 2 SuperPROs, 365 appeals process, 403~04 effectiveness of, 17, 18, 402-403, 423 future plans, 403-404 original procedures, 401~02 Surgery case review, 165, 170 frequency of procedures as indicator of quality of care, 56 outpatient, generic screens, 358 problems linked to, 101 review screens, 176 Surveys AMPRA 1989 Impact Survey, 404 of home health care, 252, 253 of hospital patients and employees, 185, 186 patient, 185, 213, 220, 221, 284, 290 of hospital quality management programs, staff, and resources. 142, 146-147, 273-291 of process of care in home health care, 247 satisfaction, 185, 186, 213, 220, 221, 252, 253 T Tax Equity and Fiscal Responsibility Act, 344, 382, 383, 414 INDEX Testimony at public hearings access issues, 11, 14 adequacy of quality assessment and assurance, 17-20, 21-22 assessing needs of elderly, 13 assessment of contemporary health care, 13-16 clinical guidelines, 12 continuity of care issues, 15 continuous quality improvement, 13 coordinating quality assessment and assurance activities, 22-23 costs of care and quality, 12, 14 credentialing, 12 defining quality of care, 13 by direct care providers, 19-20 elderly's role in quality assessment/ assurance, and decision making, 12 effectiveness of quality assurance activities, 20-21 by external quality review groups, 18-19 gaps in quality assessment information, 11 guidelines for, 27-28 humaneness of system to the elderly, 15 Medicare benefits, 14 organizations submitting, 27, 30-34 patient-centered quality assurance system, 12 patient-physician relationships, 11 peer review effectiveness, 11 performance competency, 12-13 practitioner supply and training, 15 by PROs, 17-18 recommendations, 23 speciality board certification, 12 by SuperPRO, 18 by third-party payers and purchasers, lo _ . . . ~. Texas see also Public hearing process Medical Foundation, 188 site visits in, 96 Third-party payers decision making on health care, 14

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INDEX effectiveness of quality assessment and assurance systems, 17, 18 Tracer conditions/methodology, 141, 213, 215, 216 Transitional care, 100 Tufts University Center for Study of Dmg Development, 135 U Underuse, 207, 218 data sources on, 221 estimates of, 67 financial incentives for, 14, 198 Medicare reimbursement policies and, 65 of mental health services, 103 of preventive services, 103 reasons for, 67 in risk contract programs, 384 screening for, 155, 212 Uniform needs assessment, 156 in home health care, 242 instrument, 399 United Auto Workers, 138, 210 University of Chicago Hospitals group, data collection tool, 231 University of Minnesota Study of Post Acute Care, 248 U.S. Healthcare, 200, 230 Utilization and Quality Control Peer Review Organization Program administration, 346, 421~23 costs of program, 17, 380-382 evaluating activities of, 399~00, 423~24 Freedom of Information Act exemption, 380 legislation, 344-345 461 predecessor to, 5 public oversight of, 421~23 purpose of, 343 regulations, 345-346 uniform clinical data set, 388-396 uniform needs assessment, 398-399 see also Medicare Peer Review Organizations (PROs) Utilization review, 14, 230, 254 corporate-level responsibilities for, 275-276 decision making on health care by staff of third-party payers, 14 in hospitals, 159, 161, 165, 172-173, 182-183, 277, 285-286, 289 JCAH standard, 304 profiling of patterns, 218 software, 182, 234 V Virginia Instructional Visiting Nurse Association, 254 Insurance Reciprocal, 148 site visits in, 97 very-small-practice quality assurance approach, 231-232 Volume of serviceslprocedures, 155-156 W Washington Home Care Association of, 255 site visits in, 96 Washington, D.C., site visit, 98 Wisconsin, site visit in, 98