Domain 3 - Quality, Outcomes Evaluation and Measurements Flashcards

1
Q

Key steps in the Evidence Based Practice (EBP) process:

A

Identify the Problem
Design the question
Search, Appraise and Synthesize the Evidence
Implement the change
Evaluate the change
Integrate the Change into practice

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2
Q

Evidence Based Practice

A

A problem-solving approach to practice that integrates:
* Best evidence available from well-designed research studies
* Client values and preferences for care
* Expertise of clinicians in making decisions about the provision of
care for clients/support systems

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3
Q

A cost-benefit report is done to:

A

Formally document savings related to Case Management involvement.

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4
Q

In a cost benefit report, what is the difference between hard savings and soft savings?

A

Hard savings: actual savings based on real numbers (discounts, negotiated reductions,
etc.)
Soft savings: possible or potential savings based on avoidance of services, use experience with like clients, and past experience of the client

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5
Q

How to calculate the cost savings:

A

Cost savings = Potential costs – (Actual cost + cost of Case Management)

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6
Q

Acuity

A

Goes to the need for level and frequency of comprehensive and
integrated case management intervention

Represents the level of complexity of the case management intervention, the severity of the client’s needs, and the response of the healthcare delivery system

Determined through a process of stratification that encompasses many factors and can be a complex process using not only current clinical information, but also historical claims information

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7
Q

Factors impacting acuity:

A

-Current illness or injury, client understanding of the illness or injury, and the complexity of the condition
-How complex are the medical/behavioral needs
-What care is needed immediately and what care might be needed moving forward
-Medication concerns – number, type, and potential for adverse reactions
-What is the extent and engagement of their support system?
-What is their health literacy and understanding of the condition and the care that is and will be required?
-What is the intensity and complexity of needs, and what is the intensity of the resources and services that will be necessary?

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8
Q

Why do case managers stratify risk?

A

To define a specific population, provide the most attention necessary to clients with the greatest needs, consider the desired outcomes for and with those clients, and determine interventions to achieve these outcomes.

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9
Q

Risk Stratification

A

-occurs early in the Case Management Process (Domain 1)
-applies various tools to assess for risk
-determines a client’s risk category, also known as risk class:
* Low, Medium, or High
-Informs the care plan to determine:
* Appropriate level of intervention
* Targeted interventions to enhance outcomes

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10
Q

What is included in the 3 levels of risk stratification?

A

High: intensive case and disease management
Medium: health coaching and lifestyle management
Low: health education and promotion

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11
Q

Predictive modeling

A

Individuals at risk for complications or declining health condition – or whose environment is likely to render them either ineffective at self-care management or unable to follow a medical regimen – are appropriate candidates for case
management services.

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12
Q

HRA

A

Health Risk Assessment

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13
Q

What is a Health Risk Assessment (HRA)?

A

Questionnaire about health and lifestyle used to develop personalized care plan that focuses on clinical conditions, health risk factors, and disease state. Can be delivered telephonically, or written via mail in person. Assesses real-time physical, behavioral, mental, emotional and psychosocial status.

With this type of assessment, clients receive aggressive outreach services and
targeted case management interventions to reduce the likelihood of:
* poor health outcomes such as morbidity, mortality, and avoidable costs.
* HRAs can predict clients’ future healthcare service utilization and costs and the
likelihood of progression toward illness or worsening of an existing condition
(Gurley,2007)

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14
Q

CARS

A

Community Assessment Risk Screen

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15
Q

Community Assessment Risk Screen (CARS)

A
  • used to determine the risk for rehospitalization or ED use for seniors
  • focuses on current health status and lifestyle behaviors
  • similar to the health risk assessment (HRA) tool
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16
Q

Hierarchical Condition Category (HCC)

A

Medicare uses the CMS-HCC model to calculate risk scores that quantify and project the
financial risk of each Medicare beneficiary. CMS uses risk scores created by the CMS-HCC
model to adjust Medicare capitation payments to Medicare Advantage (MA) plans. With
risk-adjusted payments, Medicare pays MA plans more money for patients with greater risk
and less money for patients with less risk. Key points:
* payment methodology for Medicare Advantage members based on “risk”
* payment rate for members in same community based on the amount of risk it
takes to maintain health

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17
Q

LACE Tool

A
  • L=Length of Stay
  • A=Acuity of Admission
  • C=Comorbidities
  • E=ED Visits

The higher the score, the higher the risk of hospital readmission.

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18
Q

Johns Hopkins Adjusted Clinical Group® Scoring System (ACG)

A

allows for more accurate and fairer:
* Evaluation of a healthcare provider’s performance
* Identification of clients at high risk
* Forecasting of healthcare utilization by clients
* Payment structures and rates for the providers of care
* Allocation of appropriate resources

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19
Q

Two ways to evaluate the effectiveness of the case management program are:

A
  • conduct surveys to evaluate the client’s perspective and perceived value
    of case management interventions
  • measure outcomes
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20
Q

Root Cause Analysis

A

Process used by healthcare providers or administrators to identify the basic or causal factors that contribute to variation in performance and outcomes or underlie the occurrence of a sentinel event

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21
Q

Continuous Quality Improvement (CQI)

A
  • Key component of total quality management
  • Uses rigorous, systematic, organization-wide processes to achieve ongoing improvement in quality of healthcare services and operations
  • Focuses on both outcomes and processes
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22
Q

Performance Improvement

A
  • Continuous study and adaptation of the functions and processes of a healthcare organization
  • To increase probability of achieving desired outcomes and better meet client needs
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23
Q

Quality Assurance

A
  • Use of activities and programs to ensure the quality of client care
  • These activities and programs are designed to monitor, prevent, and correct quality deficiencies and noncompliance with the standards of care and practice
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24
Q

Quality Improvement

A

An array of techniques and methods used for collection and analysis of data gathered in the course of current healthcare practices in a defined care setting

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25
Q

Quality Management

A
  • The monitoring, analysis, and improvement of organizational performance
  • It is a formal and planned, systematic approach organization or network wide
  • Standards, the quality of client care and services provided, and the likelihood of achieving desired client outcomes
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26
Q

Outcome Indicators

A
  • Measures of quality and cost of care
  • Metric used to examine and evaluate results of the care delivered
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27
Q

Outcomes Management

A
  • Uses information and knowledge gained from outcomes monitoring
  • Purpose – to achieve optimal outcomes through improved clinical decision making and service delivery
28
Q

Outcomes Measurement

A

systematic, quantitative observation, at a point in time, of outcome indicators

29
Q

Outcomes Monitoring

A
  • repeated measurement over time of outcome indicators
  • Allows for making inferences about characteristics, processes, and resources produced the observed outcomes.
30
Q

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

A
  • Nationally standardized survey of patient perspectives of their hospital experience
  • It was developed by CMS in partnership with the Agency for Healthcare Research and Quality (AHRQ) and endorsed by the National Quality
    Forum (NQF)
    *Is administered to a random sample of adult patients across medical conditions between 48 hours and 6 weeks after discharge
  • Is not restricted to Medicare beneficiaries
  • Hospitals collect minimally 300 responses annually to qualify
  • Hospitals can opt out of the program
  • Can lose 2% percent of overall Medicare reimbursement
  • ACA uses HCAHPS to in value-based incentive payments
31
Q

Long-Stay Resident Survey

A

An in-person structured interview for long-term
residents

32
Q

Discharged Resident Survey

A

A questionnaire for recently discharged short stay residents

33
Q

Family Member Survey

A

A questionnaire that asks family members about
their experiences with the nursing home

34
Q

Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS)

A
  • First national standardized and publicly reported survey of home health care patients’ perspectives of their skilled home care.
  • The survey was nationally implemented on a voluntary basis in October 2009 and required in October 2010.
  • HHCAHPS is a 34-item questionnaire and data collection methodology to measure patients’ perceptions of their skilled home care.
35
Q

Plan-Do-Study-Act (PDSA) cycle

A
  • by planning the test or observation (Plan), including a plan for collecting data
  • trying it (Do) out on a small scale
  • observing the results (Study), setting aside time to analyze the data and study the results
  • acting (Act) on what is learned, and to refine the change based on what was learned from the test
36
Q

Six Sigma

A

Six Sigma is a quality program that, when all is said and done, improves your customer’s experience, lowers your costs, and builds better leaders. Six Sigma at many organizations simply means a measure of quality that strives for near perfection.

37
Q

Six Sigma Process - DMAIC

A

*D= DEFINE: The problem, opportunity, goals, and the customer
*M= MEASURE: Process map for recording the activities and performance
*A= ANALYZE: Determine the Root Cause of the problem
*I= IMPROVE: Eliminate or address the Root Cause to improve process
*C=CONTROL: Control the improved process for future process performance

38
Q

Six Sigma LEAN

A

The core idea is to maximize customer value while minimizing waste. Simply, lean means creating more value for customers with fewer resources.

A lean organization understands customer value and focuses its key processes to continuously increase it. The goal is to provide perfect value to the customer through a perfect value creation process that has zero waste.

39
Q

What are that Quality Indicator Types?

A
  1. Structure – provider capacity, systems, and processes to provide high-quality care
    * Examples – electronic medical records, medication order entry systems, number or proportion of board-certified physicians, ratio of providers to clients
  2. Process – what the provider does to maintain or improve health; typically reflect generally accepted clinical practice
    * Examples – percentage of people receiving preventive services, such as mammograms; percentage of diabetics who had their blood sugar tested and controlled
  3. Outcomes – reflect the impact of the healthcare service or intervention on the health status of clients.
    * Examples – surgical mortality rate (percentage of patients who died because of surgery; rate of surgical complications; rate of hospital acquired infections)
40
Q

What is the purpose of accreditation?

A

A standardized program for evaluating healthcare organizations

  • Ensures a specified level of quality
  • Quality defined by a set of national industry standards
41
Q

Accreditation. What is the difference between Individual and organizational certifications?

A

*Individual certification - Pursued to demonstrate personal excellence in chosen field or specialty
* Organizational - voluntary survey process that assesses the extent of a healthcare organization’s compliance with the standards for improving the
systems and processes of care (performance) and, in so doing, improving client outcomes.

42
Q

Joint Commission (JCAHO) accreditation

A

An objective evaluation process that can help health care organizations measure, assess, and improve performance. The standards focus on important client, individual or resident care, and organization functions that are essential to providing safe, high quality care.

Hospitals must meet eligibility standards established by the federal government to
receive reimbursement from the federally funded programs, Medicare and/or Medicaid. CMS has been designated as the organization responsible for certification of hospitals, deeming them certified and meeting established standards.

The Joint Commission is one of several organizations approved by CMS to certify hospitals. If a hospital is certified by The Joint Commission, they are deemed eligible to receive
Medicare and/or Medicaid reimbursement. Hospitals must be a member and pay a fee to The Joint Commission to be included in their survey
process.

43
Q

NCQA

A

National Committee for Quality Assurance

44
Q

What does the NCQA’s (National Committee for Quality Assurance) Case Management Accreditation do

A
  • Directly addresses how case management services are delivered, not just the organization’s internal administrative processes.
  • Gets right to the core of care coordination and quality of care.
  • Is designed for a wide variety of organizations. It is appropriate for health plans, providers, population health management organizations, and community-based case management organizations.
  • Focuses on ensuring the organization has a process to ensure safe transitions.
44
Q

What is NCQA’s (National Committee for Quality Assurance) Case Management Accreditation

A

A comprehensive, evidence-based accreditation
program dedicated to quality improvement that can be used for case management programs
in provider, payer, or community-based organizations.

45
Q

What does the NCQA’s (National Committee for Quality Assurance) Case Management Accreditation standards address for case management programs

A
  • Identify people who need case management services
  • Target the right services to people and monitor their care and needs over time.
  • Develop personalized, client-centered care plans
  • Monitor people to ensure care plan goals are reached and to adjust as needed
  • Manage communication among providers and share information effectively as people move between care settings, especially when there are
    transitions from institutional settings
46
Q

HEDIS

A

Healthcare Effectiveness Data and Information Set (HEDIS)

47
Q

What does Healthcare Effectiveness Data and Information Set (HEDIS) do

A

*Employers and individuals use HEDIS to measure the quality of health plans
* HEDIS measures how well health plans give service and care to their members
* HEDIS is a comprehensive set of standardized performance measures designed to provide purchasers and consumers with the information they need for reliable comparison of health plan performance.
* HEDIS Measures relate to many significant public health issues, such as
-cancer,
-heart disease,
-smoking,
-asthma
-diabetes

48
Q

How does Healthcare Effectiveness Data and Information Set (HEDIS) work

A

Collect data
Report to NCQA
Outcomes in HEDIS (to see where they are performing well, and where they need to improve. Employers and consumers can also you HEDIS measures when deciding what health plan to choose.)
Measures include:
-Cancer screening
-COPD
-Antidepressant medication management
-Follow-up after hospitalization for mental illness

Health plans collect data about their performance on certain services and types of care. For example, the number of children who get immunizations. They report the data to the National Committee for Quality Assurance (NCQA), which rates health plans based on 81 measures across five areas of care.

49
Q

URAC

A

Utilization Review Accreditation Commission

50
Q

What does URAC do

A

URAC believes that effective case management puts the consumer at the center of all health care decisions and is an essential driver to ensuring that consumers get the right care, in the right setting, at the right time.

51
Q

URAC’s case management standards cover

A

criteria for identifying clients for case management services, disclosure to clients the nature or the case management relationship, documentation of consent, policies to document client assessments,
policy for resolving disagreements, criteria for discharge.

52
Q

URACs organizational ethics and confidentiality standard

A

Policy and procedure to protect confidentiality, promotion of autonomy of decision making, client’s input into the case management plan, respecting rights of client to refuse treatment
or services.

53
Q

URACs complaints standard

A

Policies and procedures for clients and providers to
submit a complaint.

54
Q

CARF

A

Commission on Accreditation of Rehabilitation Facilities

55
Q

What is CARF

A

CARF is the Commission on Accreditation of Rehabilitation Facilities and accredits rehabilitation providers.

56
Q

CARF’s standards focus on

A

CARF’s standards focus on:
* improved service outcomes
* satisfaction of the persons served
* quality service delivery.

57
Q

AHRQ

A

Agency for Healthcare Research and Quality (AHRQ)

58
Q

Agency for Healthcare Research and Quality (AHRQ)’s mission is to

A

Produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work with the U.S. Department of Health and Human Services (HHS) and other partners to make sure that the evidence is understood and used.

59
Q

CMS

A

Centers for Medicare & Medicaid Services (CMS)

60
Q

What does The Centers for Medicare & Medicaid Services (CMS) do

A

The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the U.S. Department of Health and Human Services that uses Clinical Quality Measures, or CQMs to ensure that health care systems deliver effective, safe, efficient, client-centered, equitable, and timely care.

61
Q

NQF

A

National Quality Forum (NQF)

62
Q

What is the National Quality Forum (NQF)

A

The National Quality Forum (NQF) is a not-for-profit, nonpartisan, membership-based organization that’s mission is to improve the quality of healthcare. NQF promotes consensus among a wide variety of stakeholders around specific standards that can be used to measure and publicly report healthcare quality.

63
Q

NDNQI

A

National Database for Nursing Quality Indicators (NDNQI)

64
Q

What is the National Database for Nursing Quality Indicators (NDNQI)

A

The National Database of Nursing Quality Indicators™ (NDNQI®) is the only national nursing database that develops indicators based on empirical research and provides quarterly and annual reporting of structure, process, and outcome indicators to evaluate nursing care at the unit level.