HIT 201 final study guide
The following table compares the length of stay for pneumonia at Community Hospital (observed LOS) to the length of stay for pneumonia at similar hospitals (expected LOS). Given this data, which clinical specialty has the lowest mean LOS observed in comparison to the mean LOS expected and might be used for internal benchmarking by Community Hospital? LOS Summary for Pneumonia by Clinical Specialty Clinical Specialty Cases Mean LOS Observed Mean LOS Expected Savings Opportunity Cardiology 1 6 6.36 0 Family Practice 17 8.47 6.26 38 Internal Medicine 34 3.82 4.89 -36 Endocrinology 1 3 3.93 -1 Pediatrics 7 3.43 3.55 -1 https://otc.instructure.com/courses/8964/assignments/118197/submissions/6744
Internal medicine
Root-cause analysis is a key technique used in this quality improvement methodology?
Lean
Which of the following organizations mobilizes employer purchasing power to promote healthcare safety, quality, and customer value and recognize improvements with rewards? Leapfrog Centers for Medicare and Medicaid Premier National Quality Forum
Leapfrog
Match the following definition to its proper term: "grants the healthcare organization legal authority to provide healthcare services within a limited geographical area"
Licensure
In 1965, the United States Congress passed Public Law 89-97, an amendment to the Social Security Act of 1935. This law established:
Medicare and Medicaid
What feature distinguishes the Nominal Group Technique (NGT) from brainstorming?
NGT determines the importance of responses through a rating system
Can We Step Down the Care On This Patient?
DI= Discharge Indicators
In 1965, the court upheld the patient's right to recover damages for malpractice from both the physician and the hospital.
Darling vs.Charleston Community Memorial Hospital
Which quality management theorist developed the total quality management (TQM) as an alternative to authoritarian, top-down management philosophies?
Deming
What is the decision called when all available appeal procedures have been exhausted?
Denial of accreditation
ccredits a variety of organizations from health maintenance organizations (HMOs) to preferred provider organizations (PPOs) to managed behavioral health care organizations (MBHOs), and each program has distinct performance requirements. sponsors the Healthcare Effectiveness Data and Information Set (HEDIS) which is a comparative performance improvement measurement project that evaluates an organization's clinical and administrative systems.
National Committee for Quality Assurance (NCQA)
The hospital's Revenue Cycle Management (RCM) team compiles data each month on the value of discharged not final billed (DNFB) cases. Given the data on this chart, what action by the HIM department should be taken? DNFB
Determine the cause of the DNFB case upward trend and initiate process improvements
Determines and plans for the type and intensity of health care needed after discharge from the hospital.
Discharge Planning
shows points all over the graph and will indicate that "A" does not affect "B".
No correlation
The planning technique provides a structure that requires the project team to identify the order and projected duration of activities needed to complete a project
PERT chart
The health information reception desk is experiencing a huge influx of phone calls on Monday, Tuesday, and Wednesday mornings. This is creating a problem in getting requested patient information out within an acceptable time frame. The reception staff work group has agreed to start recording the reason for the phone calls for the next 4 weeks. They want to focus on solving the response time problem by reducing the turnaround time for the largest category of phone calls. Which QI tool best supports this goal?
Pareto Chart
chart is a type of bar graph (or chart) that uses data to determine priorities in problem solving. it looks like a bar chart, however, there is one distinct difference; the highest-ranking item is listed first, followed by the second, and so forth to the lowest-ranking item (think staircase).
Pareto chart
In the 1700-1800s, this hospital became a model for the development of hospitals in other communities.
Pennsylvania Hospital
focus on patient-provider interactions. examine a health care professional's decision-making process as they direct a specific course of treatment.
Process measures
the review is conducted prior to admission or care.
Prospectively
these causes point directly to the problem.
Proximate Cause
Which of the following terms does the textbook use to identify a variety of methods PI teams can use to accomplish their goals?
QI toolbox techniques
reviews patient records to ensure the care provided by the practitioner meets/exceeds the federal standards for medical necessity, level of care, and quality of care
Quality Improvement Organizations
this review is conducted post-discharge.
Retrospectively
underlying causes, some of which may be the final answer to "why".
Root Cause
How Sick Is the Patient?
SI= Severity of Illness
These particular graphs shows the correlation of two sets of numbers by plotting them where the variables intersect.
Scatter Diagrams
they look at provider characteristics and physical/organizational resources. These measure the capability or potential for providing quality care. are static; evaluated at a certain point in time.
Structure measures
When completing a root cause analysis, there are four (4) steps that must be completed:
1. Collect data- a team will review the who, what, when, where, how, and begin to explore why it happened. 2. Identify the causal factors-these are events or conditions that together with other factors, contributed to the increase in incident likelihood. 3. Identify the root causes- these causes, if corrected, could prevent recurrence. These root causes are the fundamental factors that address the underlying issues, not a single problem or factor. 4. Generate recommendations to correct the problem- these recommendations will fall into three (3) categories: (a) eliminate the chance of error (b) make it easier for people to do the right thing, or (c) mitigate the effects of the error after the occurrence.
Risk Management is associated with three basic components:
1. Identification and Analysis determines the potential extent of liability and the financial impact of the incident on the health care organization. Occurrence Screening Incident Reports Event Report 2. Loss Prevention and Reduction is associated with controlling risks and keeping to a minimum the incidents for which the health care organization might be held liable. This is the job of the Risk Manager. 3. Claims Management pertains to managing the legal and administrative aspects of the health care organization's response to injury claims. This relates to RISK FINANCING.
Which accrediting body requires all accredited healthcare organizations to conduct RCA following any sentinel event?
TJC
Which of the following is NOT a type of managed care?
TQM
The Anesthesia Department is adding a new indicator to its plan. The Chief Anesthesiologist has come to you, the Director of Quality Management, to help her design a data collection methodology. The two of you are now considering who will be doing the data collection. All of the following are factors in your deliberation EXCEPT quality management organizational model of the institution The Joint Commission (TJC) standards and required characteristics the location of data the expertise of the staff
The Joint Commission (TJC) standards and required characteristics
When completing a RCA, how many steps must be completed?
4
What is another tool used to help determine a root cause to a problem?
5 Why's
OTC Hospital discharged 200 patients this past July. During July, OTC Hospital had 15 patients that experienced a nosocomial infection. What is the infection rate for the month of July at OTC Hospital?
7.5 % 15/200 = .075 x 100 = 7.5%
Refer to the Summary of Selected Blood Product Review below. What percentage was unmet in Fresh Frozen Plasma? SUMMARY OF SELECTED BLOOD PRODUCT REVIEW Monitoring Element Packed Red Blood Cells Fresh Frozen Plasma Platelets (N=295) (N=256) (N=29) (N=10) Met N (%) Unmet N (%) Met N (%) Unmet N (%) Met N (%) Unmet N (%) Indications 232 (91%) 24 (9%) 7 (24%) 22 (76%) 10 (100%) 0 (0%) 7% 24% 22% 76% https://otc.instructure.com/courses/8964/assignments/118197/submissions/6744
76%
What criterion is critical in selecting performance indicators for a health information management department?
The indicators must include the most important aspects of performance
During a recent Joint Commission survey, one of the survey team members asked a nurse in the ICU about her patient. The surveyor asked the nurse about the medications that the patient was on and also asked for the nurse to explain how those medications were ordered and received from the pharmacy. After the nurse explained this process, the surveyor then went to the pharmacy and asked the pharmacist to explain his role in the medication process for this specific patient. The surveyor is utilizing what process?
Tracer methodology
The process of determining whether the medical care provided to a specific patient is necessary.
Utilization Review (UR):
Providing or improving access to health care services for millions of US citizens, including new restrictions on the ability of payers to limit coverage on the basis of preexisting conditions, an end to lifetime limits on coverage , and a requirement for payers to spend premium dollars on health care costs and not administrative costs
Affordable Care Act (ACA)
This association was established in 1840 to represent the interests of physician across the United States
American Medical Association
four core processes in the patient care cycle are:
Assessing Planning Providing Coordinating
What feature is a trademark of an effective PI program?
a continuous cycle of improvement projects over time
A histogram is a valuable tool for representing
a frequency distribution with continuous-interval data
the act of granting approval to a healthcare organization-confirms the quality of the services that healthcare organizations provide
accredidation
A patient injury resulting from a medication, either because of a pharmacological reaction to a normal dose or because of a preventable adverse reaction to a drug resulting from an error, is called
adverse drug event
A person who represents the rights and interests of another individual as though they were the person's own is referred to as a patient
advocate
As the new Transcription Manager, you met with the transcription staff to encourage feedback on ways to increase transcription accuracy to meet established benchmarks. The transcriptionists provided feedback through brainstorming that you compiled on flip charts and organized into categories. This is known as a(n)
affinity diagram
A tool used to ensure that every team members knows which items will be discussed or worked on during a meeting is called a
agenda
What is a fishbone diagram used for? determining the root causes of a problem cause-and-effect relationships providing a clear graphical display of the sources of variation all of the above
all of the above
The number of incidences of violence in the workplace would be collected as a risk management measure. This is an example of _________
an outcome measure
Which of the following can be used by a healthcare organization to communicate performance information that emphasizes the organization's mission within the community and their efforts to provide the community with high quality care? annual report dashboard storyboard charts
annual report
The improvement process of comparing the collection of POA(present on admission) indicators at your facility with those of comparable department of superior performance of other health care facilities is referred to as
benchmarking
A type of PI team that constructs relatively simply and quick "fixes" to improve work process without going through the complete PI cycle is called a
blitz team
This team constructs relatively simple fixes that improve work processes without going through the whole PI process and without the need to involve other departments.
blitz team
What is another name for the fishbone diagram? cause and effect diagram problem diagram Ishikawa diagram both a and c
both a and c
You sit on the quality improvement team for the Nursing department that meets to generate ideas to address verbal order documentation problems about the "Read Back Verbal Order" policy. What QI tool would prove useful in sharing input and various recommendations for solving this problem?
brainstorming
A patent for a new drug gives its manufacturer an exclusive right to market the drug for a specific period of time under what type of name?
brand
Principal process by which organizations optimize the continuum of care for their patients
case management
In the fishbone diagram, what is shown on the "bones" of the fishbone diagram?
cause(s) of the effect
This person is responsible for implementing board directives and for action as board representative in managing the operations of the organization
chief executive officer
The stage of project team development in which team members work together easily is called
collaborative teamwork
Which of the following is one of the tools utilized to help HMOs address their specific members' needs? admission planning post-discharge assessment community needs assessment discharge planning
community needs assessment
An infection that was present in the patient before he or she was admitted to the facility is called _____.
community-acquired infection
If the patient presents to the hospital with symptoms of cough, fever, and chills and is later diagnosed with pneumonia the incidence of this infection would be determined as ____.
community-acquired infection
Data found on sites such as Hospital Compare use aggregated data to describe the experiences of unique types of patients with one or more aspects of their care. What is this data collection called?
comparative
Which of the following is the process of meeting a prescribed set of standards or regulations to maintain active accreditation, licensure, or certification status? performance improvement compliance document review deemed status
compliance
Which section of the CRAF minutes should document the results of the discussion and any decisions the group makes?
conclusions
The symbol in flowcharting that is used to mark the point in the process where the analysis skips to another common point of the process is called _____.
connector icon
In order to identify where improvements can be made, performance should be monitored
continuously
The totality of healthcare services provided to a patient and his family in all settings, from the least extensive to the most extensive is called
continuum of care
The board of directors of a 400-bed women's hospital receives a report of key quality indicator results on a periodic basis. The report always includes the quarterly cesarean section rate. This reporting period, they see a rise in the rate and want to know if it is a significant increase. What is the best QI tool for this purpose?
control chart
What is the best tool for differentiating between common cause variation and special cause variation?
control chart
Continuous quality improvement is best described by the following statements EXCEPT: corrective action targets clinicians more so than processes standards are defined, measured, and systemically applied monitoring is ongoing with periodic feedback all personnel support quality improvement efforts, including top management and the governing body
corrective action targets clinicians more so than processes
A multidisciplinary outline of anticipated care within an appropriate time frame to aid a patient in moving progressively through a clinical experience that ends in a positive outcome is called a _____.
critical pathway
The health information professional relies on the patient registrar to accurately identify the patient in the EHR this is an example of a _____.
customer expectation
Patient-specific, aggregated, and comparative fall into this category.
data collection
In the late 1990's some healthcare organizations began to develop these to facilitate PI activities and long-range strategic planning.
data repository
CMS assumes that the organization meets/exceeds CoP if it is currently accredited by either AAAHC, AOA, CARF, or TJC
deemed status
Community Hospital of the West has recently been accredited by the Joint Commission for a full three year period. Based on its accreditation status, CMS assumes that the Community Hospital of the West meets the Conditions of Participation. The reason CMS makes this assumption is because the Joint Commission has been granted _____.
deemed status
All of the following are Joint Commission core measure criteria sets except _____. heart failure acute myocardial infarction pneumonia diabetes mellitus
diabetes mellitus
A staff member is assigned to sit in the waiting room of the physician's office to collect data on patient waiting times. The staff member records the time in which the patient comes in the door and when the patient is called back to the examining room. This is an example of what type of data collection?
direct observation
When creating the fishbone diagram, what is the first step you should do?
document an outcome/goal on the right side of the diagram at the end of the horizontal causal line
As part of the CARF accreditation process, reviewers examine policies and procedures, administrative rules and regulations, administrative records, human resource records, and the case records of patients. This process is called _____.
document review
In the fishbone diagram, what is documented on the "head" of the fishbone?
effect, problem, or quality characteristic
Programs that promote ___________ and _____________ have become the way for providers to add value of the services they provide and ensure their financial viability.
efficiency and effectiveness
Large population based studies are used to identify the care processes or interventions that achieve the best healthcare outcomes in different types of medical practice. This research concept is called _____.
evidence based medicine
The medical transcription improvement team wants to identify the cause of poor transcription quality. Which of the following QI tools from the toolbox will best assist the team in identifying the root cause of the problem?
fishbone diagram
The list of drugs approved for use in the healthcare organization is generally referred to as the
formulary
Refer to the Summary of Selected Blood Product Review table below. Based on the results reported in the table, which blood component or derivative should first be the topic of an in-depth study? SUMMARY OF SELECTED BLOOD PRODUCT REVIEW Monitoring Element Packed Red Blood Cells Fresh Frozen Plasma Platelets (N=295) (N=256) (N=29) (N=10) Met N (%) Unmet N (%) Met N (%) Unmet N (%) Met N (%) Unmet N (%) Indications 232 (91%) 24 (9%) 7 (24%) 22 (76%) 10 (100%) 0 (0%) packed red blood cells fresh frozen plasma platelets unable to determine from the table https://otc.instructure.com/courses/8964/assignments/118197/submissions/6744
fresh frozen plasma
Process of moving questions from a broad theme to a narrow theme in an unstructured interview
funneling
Criteria that have been developed by many of the same agencies for use across the continuum of care and in various regions of the country are referred to as
generic
Storyboards are a method used in health care that
graphically display a performance improvement project conducted
When a PI team first meets and discusses participation expectations, communication methods, and plans for decision making techniques to be used, these are examples of team ___________.
ground rules
In quality review activities, departments are directed to focus on clinical processes that are
high risk
What type of QI tool is this below?
histogram
The three steps to consider when choosing to develop a measure:
identify what you want to know identify the raw data you need define how you will collect the raw data
According to Mrs. Yu's OB death we read about in this lesson, what was the proximate cause of her death?
inability of the OB nurses to assist in an emergency surgical procedure
Which of the following would be an example of a reviewable sentinel event? incidence of infant abduction incidence of hospital acquired infection incidence of unruly patient incidence of blood transfusion reaction
incidence of infant abduction
_______________________ allow organizations to store reports, presentation, profiles, and graphics interpreted and developed from stores of data for reuse in subsequent organizational activities.
information warehouses
Dr. Smith is establishing a clinical trial research study for the patients with lung cancer wishing to participate in a chemotherapy clinical trial. As Assistant Director, you are responsible for clinical abstract of data and advise him to first seek approval of research involving human subjects through the
institutional review board (IRB)
A patient presents to the emergency room acutely dehydrated and is admitted to the hospital for IV therapy to rehydrate the patient. Which admission criteria would be used to justify admitting this patient as an inpatient?
intensity of service
The health information professional is a customer of the admitting department. What type of customer is the health information professional?
internal customer
Physicians are an example of
internal customers
Deploying this type of technology can be used to allow everyone in a healthcare organization to be informed of the current status of performance improvement projects:
intranet-based communication
CLIA and the CDC have established protocols for _____.
laboratory departments
grants the healthcare organization legal authority to provide healthcare services within its scope of service within a limited geographical area
licensure
In a cause and effect diagram the fish bones delineate the causes of the situation in four categories. They are
manpower, material, methods, machinery
HEDIS is responsible for
measuring health plan quality measuring health plan access measuring health plan membership measuring health plan utilization measuring health plan financial performance
Events that occur in a healthcare organization that do not necessarily affect an outcome but carry significant change of being a serious adverse event if they were to recur are called
near misses
will show points clustered at the top left and moving to the lower right.
negative correlation
This data is also called categorical data and includes values assigned to name-specific categories
nominal data
As the HIM Department Director you are asked to chair a committee that will review, select, and implement a CPOE system. The information has been collected, and you bring your committee together to prioritize their suggestions. This method of working with information is known as
nominal group process
The risk manager's principal tool for capturing the facts about potentially compensable events is the
occurrence report
Clarity of terminology in a survey design is called
operational definition
Patient mortality, infection and complication rates, adherence to living will requirements, adequate pain control, and other documentation that describe end results of care or a measurable change in the patient's health are examples of
outcome measures
The final results of care, treatment, and services in terms of the patient's expectations, needs, and quality of life, which may be positive and appropriate or negative and diminishing, are included in what area of performance measurement?
outcomes
A patient satisfaction survey conducted after discharge is a method of quality measurement through
outcomes indicator
Refer to the Summary of Selected Blood Product Review table shown below. Which blood component or derivative had the most units reviewed? SUMMARY OF SELECTED BLOOD PRODUCT REVIEW Monitoring Element Packed Red Blood Cells Fresh Frozen Plasma Platelets (N=295) (N=256) (N=29) (N=10) Met N (%) Unmet N (%) Met N (%) Unmet N (%) Met N (%) Unmet N (%) Indications 232 (91%) 24 (9%) 7 (24%) 22 (76%) 10 (100%) 0 (0%) https://otc.instructure.com/courses/8964/assignments/118197/submissions/6744
packed red blood cells
TJC requires monitoring, investigating, and reporting on the following items from health care organizations:
patient or visitor injuries incidents of property damage occupational injuries or illness security incidents hazardous materials and waste spills and exposures fire prevention problems, deficiencies, and failures utility systems problems, deficiencies, and failures
Which of the following is a common standing committee in most healthcare organizations responsible for coordinating and reporting PI and safety activities?
patient safety and PI Committee
Which type of data collection pertains to the care services provided to each patient?
patient-specific
The organizations reputation for the quality of its services and consumer reaction to these services and products based on their experiences with the organization is called _____.
perceived quality
What process assists a health care facility in continuously looking at the ways that problems develop and seeking ways to prevent problems from happening in the future?
performance improvement
Which of the following is the group that oversees all PI activities within a healthcare organization?
performance improvement council
A quantitative tool that provides an indication of an organization's performance in relation to a specified process or outcome is a/an _____.
performance measure
This phase in the project life cycle includes clear objectives, importance of the project, and the expected outcome on the organization.
planning
The establishment of an interactive treatment plan that is specific, individualized, and based on a thorough assessment of the patient's physical, emotional, social, cognitive, and cultural needs is which core process step?
planning care, treatment, and services
will show points clustered at the lower left and moving up and to the right
positive correlation
Follow-up on a patient after discharge to ensure that the transition has gone smoothly and that the patient is receiving all of the services required is considered this case management step
postdischarge planning
Ann's physician suspects that she has cholecystitis and has ordered a gallbladder ultrasound to be performed. The staff at the physician office contacts Caitlin's third-party payer to determine benefits and coverage for this procedure prior to scheduling the cholecystectomy. What is this process is called?
preauthorization
Inappropriate dose, nonformulary agent, and medication errors to transfer are all examples of this type of medication error
prescribing
The manager of the Quality Department is listing various sources of data. Which of the following data sources would be an external source
quality improvement organization (QIO) information
This type of report is based on the documented meeting minutes and should include information about PI activities such as: summaries of data collection, conclusions, and recommendations.
quarterly report
The level at which an organization can provide an offered product or service when requested and as advertised is called _____.
reliability
When the customer (patient) has judged that the healthcare worker is continuously monitoring both the customer's condition and his or her satisfaction with services, what aspect of quality of care or meeting the customer requirement is being met?
responsiveness
An unexpected occurrence involving death or serious physical or psychological injury, or risk thereof is called
sentinel event
Includes and process variation for which an recurrence would carry a significant chance of a serious adverse outcome is called a;
sentinel event
If a patient comes into the emergency room with left-sided hemiparesis that started within the last three hours, which admission criterion would be used to justify admitting this patient as an inpatient?
severity of illness
used to report count values of "categorical" data (also called nominal data) such as the number of patient visits each day of the week. Each bar on a represents a different category
simple bar chart
The average percent of patients exceeding acceptable waiting times was 3.7%. See table below. The calculated UCL (upper control limit) is 9.4. When you plot the upper and lower limits, what would you suggest as the reason fro the June variation? Year 2015 Percent Patients with Unacceptable Waiting Time (%) January 5 February 4 March 3 April 5 May 3 June 10 July 5 August 2 September 1 October 2 November 1 December 3 common cause variation root cause variation special cause variation unable to determine with the data given https://otc.instructure.com/courses/8964/assignments/118197/submissions/6744
special cause variation
__________________facilitates the use of data by multiple individuals and multiple teams.
standardization
The document in which the leadership of a healthcare organization identifies the organization's overall mission, vision, and goals to help set the long-term direction of the organization as a business entity is called
strategic plan
The foundation of care giving, which includes buildings, equipments, technology, professional staff and appropriate policies
structure
The foundation of care giving, which include buildings, equipment, professional staff, and appropriate policies are included in what area of performance measurement?
systems
Viewing an organization as an open system of interdependencies and connectedness rather than a collection of individual parts and professional enclaves is a critical component of
systems thinking
A document that explains the issues the team was implemented to improve, describe the goals and objectives and desired end state (vision), and lists the initial members of the team and their respective department is called _____________
team charter
A PI team role primarily responsible for ensuring that an effective performance improvement process occurs by serving as advisor and consultant to the PI team, remaining a neutral, nonvoting member, suggesting alternative PI methods and techniques to keep the team on target and moving forward, maintaining group dynamics, acting as coach and motivator for the team, assisting in consensus building when necessary, and recognizing team and individual achievements is the _____.
team facilitator
Which of the following is INCORRECT about the use of control charts? control charts can be used to measure key processes over time the upper and lower control limits are always +/- 2 standard deviations the lower control limits are always +/- 2 standard deviations the upper control limit are always +/- 1.8 standard deviations
the upper control limit are always +/- 1.8 standard deviations
used by an on-site survey team that permits assessment of operational systems of the healthcare organization and their processes in relation to the actual experience of selected patients currently under the healthcare organizations care
tracer methodology
Signs, symptoms, or conditions suffered by a patient as the result of the administration of an incompatible blood products is called _____.
transfusion reaction
management that strives to maintain the highest quality of care and patient satisfaction, while providing services at the lowest cost. It determines the appropriateness of services based upon some key factors. These include but is not limited to patient's diagnosis, site of care, length of stay (LOS) and other clinical factors.
utilization management
Which of the following is an integral component of case management that helps to improve patient outcomes, lower healthcare spending, while still providing appropriate care to patients at the appropriate time?
utilization review
With the passage of Medicare (Title XVIII of the Social Security Act) in 1965, which of the following functions became mandatory?
utilization review
A short description that communicates an organizations social and cultural belief system
values statement
This statement describes what the organization or PI initiative will look like in the future or may describe some milestone the PI team will reach in the future.
vision statement
This type of healthcare organization review is conducted at the request of the healthcare facility seeking accreditation _____.
voluntary review
survey requested by the healthcare organization that is seeking accreditation or certification
voluntary reviews
a publication that reports regulations and legal notices issued by federal agencies, presidential proclamations and executive orders, and other documents as directed by law or public interest.
Federal Register
This survey was developed and initiated to provide a consistent format and process for gathering patient satisfaction and perspectives on hospital care
HCAHPS
Western States University Hospital has a contractual relationship with a municipal managed care health plan in its region. Each year, health plan quality management officials come to University Hospital to review cases against selected screens for health maintenance. What criteria are these health screens based on?
HEDIS
As part of ARRA, this Act requires that healthcare organizations and providers make significant investments in information systems to have a positive impact on the care that they provide:
HITTECH
Which of the following represents a list of potential blood-borne pathogens? Correct! HIV and Hepatitis B Colorado Tick Fever & Pertussis Mumps & HIV Hepatitis B & Pertussis
HIV and Hepatitis B
Organizations that pay close attention to weak signals of trouble to catch problems or errors in the earliest stage are applying the principles of _____.
HRO high reliability organizations
Institute of Medicine (IOM) is now known as
Health and Medicine Division (HMD)
aim is to help those in government and the private sector make informed health decisions by providing evidence upon which they can rely.
Health and Medicine Division (HMD)
Which of the following individuals volunteered to perform the first review of medical college curriculum and education processes leading to more rigorous academic standards for medical schools?
Henry Pritchett
Organizations that have learned to manage the unexpected
High Reliability Organizations (HROs)
are used to identify problems or changes in a system or process by grouping occurrences into categories. all of the bars represent the same category. x axis represents the grouped intervals while the y axis represents the actual number of occurrences.
Histogram
This act established a quality reporting program for skilled nursing care in the United States.
IMPACT
Established a quality reporting program for skilled nursing care
IMPACT (Improving Medicare Post-Acute Care Transformation Act of 2014)
What Type of Service is needed?
IS= Intensity of Service
This group has ultimate responsibility for maintaining the quality and safety of patient care provided by its healthcare organization.
Board of Directors
These standards address areas contribute to high-quality and improved patient care
Information Management Standards
The investigational technique that facilitates the identification of the various factors that contribute to a problem known as a fishbone diagram is also called a/an
Cause-and-Effect Diagram
have a significant impact on the "what" and "how" of performance improvement activities at the provider level.
Centers for Medicare and Medicaid
grants approval for a healthcare organization or an individual healthcare practitioner permission to provide services of a defined scope in a limited geographical area
Certification
When a facility wants to bill Medicare/Medicaid for services rendered, in order to apply to CMS to receive this funding the healthcare organization has to have met which guideline?
CoP
The HIM transcription supervisor has instituted a performance improvement program that includes the use of benchmarks. Benchmarks have been established for total lines per hour of production, and the program was instituted two weeks ago. What should the supervisor do to determine if the benchmark is being met?
Compare individual transcriptionist line production per hour to the benchmark
A HIM department director collects data quarterly on the average number of delinquent health records for the hospital. The following figure provides a graph of these averages. From a performance improvement perspective what is the best way to analyze the data? Average Delinquent Records
Compare the data to an established benchmark
These are performed to fulfill legal or licensure requirements
Compulsory reviews
a "continued-stay utilization review" will determine whether the patient continues to receive a specific level of care.
Concurrently
covers issues related to medical necessity, level of care, and quality of care-any healthcare organization that provides services to Medicare/Medicaid patients has to demonstrate compliance via review process usually completed by the state department of health- this is part of the certification process to bill Medicare/Medicaid for services rendered by the healthcare organization
Conditions of Participation (CoP)
