Quality Management in Healthcare

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Questions and Answers

One of your first key issues to determine when evaluating the current QM program is

the extent of leadership knowledge of and involvement in quality activities. (correct)

the operating budgets for the quality, utilization, and risk management departments.

Responses to accreditation recommendations following the last two surveys

the climate for change in each department and service.

In evaluating the current QM program for strengths and weaknesses, it is NOT necessary to assess

alternative QM software products (correct)

managed care contracts.

strategic initiatives.

team minutes.

The written evaluation should include

only recommendations that fall within current budget constraints

recommendations for staff salary raises.

persons concerned about quality problems.

recommendations and resources required to implement them. (correct)

Your initial report should be addressed to the

Vice President, Administrative and Support Services. Signup and view all the answers

The formal functions of management include all except

inspecting Signup and view all the answers

A large emergency department (ED) reduced its average length of stay for discharged patients from 130 minutes to 1 hour with a goal to improve patient satisfaction. How best might the ED know the changes were also effective financially, as part of a cost-benefit analysis?

Increased patient volume and increased net revenue Signup and view all the answers

Which of the following issues might be most important to health maintenance organizations negotiating contracts with providers?

Quality/utilization capabilities, disclosure of data, reimbursement Signup and view all the answers

Which of the following issues might be most important to a medical group or IPA (independent practice association) negotiating contracts with health plans?

Data requirements, credentialing requirements, reimbursement Signup and view all the answers

Which of the following issues might be most important to hospitals negotiating contracts with health plans?

Data requirements, confidentiality of peer review information, reimbursement Signup and view all the answers

A quality professional in a home health agency is charged to develop a quality management/quality improvement strategy. Of the following steps, which should be done first?

Review the organization's scope of care and service Signup and view all the answers

Which of the following is not relevant to include in both utilization management and quality management plans?

Conflict of interest policy Signup and view all the answers

The principle underlying the selection of an organizationwide quality council is

one cross-functional team Signup and view all the answers

Why should a UM Plan include a conflict of interest statement?

To provide for unbiased decisions Signup and view all the answers

The term "corporate compliance plan" refers to the healthcare organization's

program to prevent fraud and abuse. Signup and view all the answers

A hospital Utilization Management Plan generally includes provision for

transition planning. Signup and view all the answers

The managed care organization's use of a 24-hour nurse-staffed telephone hotline to inform member/patient callers of care options and provide self-management education is a type of:

demand management. Signup and view all the answers

The key advantage of case management in managed care is

coordination of care. Signup and view all the answers

The practical motivation for American Healthplan HMO to develop a disease management system based on practice guidelines and clinical paths is

capitation. Signup and view all the answers

An 85-year-old woman is admitted through the Emergency Department with a fractured right hip. When should discharge planning begin?

At time of admission to the acute hospital Signup and view all the answers

As Director of Quality Resource Management for an integrated delivery system, you have been asked to provide information prior to renegotiation of a contract with a national Preferred Provider Network. What data will be most helpful?

Reimbursement minus costs Signup and view all the answers

Negligence means a lack of proper care. In medical malpractice "proper care" is determined by

medical peers. Signup and view all the answers

The written scope of care and service of a healthcare organization is best described as

a logical sequence of operations to be performed to care for and serve delineated populations of patients. Signup and view all the answers

Being immediately responsive and attentive to a family's concerns following a patient's fall in the subacute care facility is

loss reduction activity. Signup and view all the answers

The utilization management committee for a large medical group is concerned about underutilization. Which data supports the concern?

Reduced pediatric hospitalization rates Signup and view all the answers

The key issue in integrating the functions of utilization management, quality management, and clinical risk management revolves around

information management. Signup and view all the answers

Your freestanding Radiology Center did 200 outpatient CT scans each of the last two years. The average reimbursement rate has decreased from $200 to $150. The scanner and room need repairs estimated at $100,000. There are two other CT scanners in your immediate vicinity. The most likely decision resulting from a cost-benefit analysis would be to

contract with a competitor for referral fees. Signup and view all the answers

According to Total Quality Management principles, managers should

lead with participative decision making. Signup and view all the answers

Sunshine Community Medical Center had begun performing angioplasty procedures for cardiac patients in anticipation of providing cardiovascular surgery services. The administration then failed to negotiate a contract with the cardiac surgery team of physicians. The hospital and its cardiologists then negotiated an exclusive contract with another hospital in the area to refer all cardiac patients needing angioplasty to that facility. This action constitutes

risk shifting. Signup and view all the answers

Community case management and disease management programs make the most economic sense for which type of reimbursement?

Shared capitation Signup and view all the answers

Your hospital case management program monitors length of stay (LOS) by condition. LOS for four conditions has decreased slightly each of the last six quarters. To evaluate cost and quality of care impact, you recommend which measures?

Reimbursement, comparison with conditions with increasing LOS, denials Signup and view all the answers

In revising the Utilization Management (UM) Plan, which of the following is most important to consider?

UM performance measure results Signup and view all the answers

How can Quality Management link with Risk Management on peer review cases?

Provide aggregate occurrence data Signup and view all the answers

Of the following, sharing which data best supports risk prevention?

Root cause analysis Signup and view all the answers

One of the three aspects of quality discussed in Chapter I concerns "perceptive quality," the perspective of the recipient or observer of care. Of the following options, how might this aspect of quality best be utilized in linking the QM and RM goals?

Involve the patient in ideas to improve safety. Signup and view all the answers

Comprehensive Health integrated delivery system IDS) consisted of four acute care hospitals, a behavioral health center, two long-term care facilities, and an ambulatory surgery center. One year ago, after cost-benefit analysis, the IDS added a home health agency, with investments in a building, staff, marketing, computer system, and other equipment and materials. Tracking expenses and revenue over time, when would you expect a return on investment (ROI)?

When revenue consistently exceeds expenses Signup and view all the answers

Most commonly the primary purpose for incident/occurrence reporting is to

identify adverse patient events. Signup and view all the answers

At Sunshine Community Medical Center, occurrence forms are sent directly to the risk manager, who summarizes the data and submits quarterly reports of the prior quarter's data (totals and some rates) to administration and the governing body. Use this information to answer questions: Why might this process be considered inadequate, based on Pl process principles?

The process does not trend the data over time. Signup and view all the answers

What is another reason this process should be improved?

The process is not collaborative with other Pl activities. Signup and view all the answers

Over the last few months, the organization has experienced several adverse events concerning trips and falls on the grounds outside, although without serious injury to date. Use this information to answer questions What can the Quality Professional do to best facilitate risk reduction?

Coordinate a root cause analysis. Signup and view all the answers

Which of the following offers the best rationale for the Quality Professional's involvement in this situation?

Successful reactive improvement activities minimize recurrence. Signup and view all the answers

Your organization has approved a new strategic initiative that will change a key clinical service in which a sentinel event occurred. When is it most important for leaders to participate?

During the design process Signup and view all the answers

One of the best ways for a patient safety program to be effective is to provide anonymity in

occurrence/incident reporting. Signup and view all the answers

In a cost-benefit analysis of a bar-code medication administration system, implemented as part of a patient safety program, which of the following would be the best indicator of success:

A decrease in total medication errors Signup and view all the answers

As part of the program to improve patient safety, you will make many core process changes, including changes to improve the organizational culture as it relates to patient safety. The percentage of staff reporting a positive safety climate measures

the results of a process change. Signup and view all the answers

If leadership is the critical success factor for an effective patient safety program, what is the first key responsibility of leaders?

Establish the value system. Signup and view all the answers

The determination of annual National Patient Safety Goals is linked to reported

sentinel events. Signup and view all the answers

Nurses and pharmacists are encouraged to report medication errors upon first knowledge of occurrence. What is the most important thing the organization can do to support them in this effort?

Instill a culture of no blame. Signup and view all the answers

A patient using a large exercise ball in outpatient rehabilitation fractures three ribs when the ball bursts and she falls onto the floor. The risk manager tells the patient that all costs of care will be covered. Of the following, this action best represents risk

transfer or shifting Signup and view all the answers

Study Notes

Systems Management

QM Director Role: Newly appointed QM Director at a 350-bed medical center in San Diego County reports to the Vice President for Administrative and Support Services. Primary responsibility: evaluate and recommend improvements to the quality management program.
Initial Evaluation Focus: The first key issues to evaluate in the QM program include: climate for change in each department/service, extent of leadership knowledge and involvement in quality activities, operating budgets for quality, utilization, and risk management departments, and responses to accreditation recommendations from the two previous surveys.
Evaluation Criteria: Reviewing program strengths and weaknesses should not include an assessment of alternative QM software products, strategy initiatives, managed care contracts, and team minutes.
Report Recipients: The initial report should be addressed to the Vice President, Administrative and Support Services.
Formal Management Functions: The formal functions of management do not include inspecting.
Cost-Benefit Analysis (ED Length of Stay): A cost-effective approach to improve patient satisfaction in an Emergency Department (ED) is to increase net revenue by improving patient volume.
Provider Contract Negotiation: Quality/utilization capabilities, data disclosure, and reimbursement are crucial for healthcare maintenance organizations in negotiating contracts with providers.
Medical Association Contract negotiation: Data requirements, physician credentialing requirements, and reimbursement are important for independent medical associations (IPAs) negotiating provider contract with health plans.
Hospital Contract Negotiation: Data requirements, peer review information confidentiality, and reimbursement are critical issues for hospitals during provider contract negotiations.
Strategic Quality Improvement Steps (Home Health Agency): Developing strategic initiatives is the first step in developing a strategy for quality management and quality improvement in a home health agency.
Utilization and Quality Management Plan: Confidentiality policies, treatment denial appeal processes, conflict of interest policies, and annual program evaluations are applicable in both quality and utilization management plans.
Quality Council Selection: The principle guiding quality council selection is the creation of a single cross-functional oversight body rather than compartmentalized or departmentalized quality control.
Conflict of Interest Statement: A utilization management plan should include a conflict of interest statement to ensure unbiased decisions and maintain the security and integrity of information.
Corporate Compliance Plan: A corporate compliance plan is a program designed to prevent fraud and abuse within a healthcare organization.
Hospital Utilization Management Plan: The utilization management plan for a hospital should include elements for quality and financial planning and transition planning.
Member/Patient Hotline: The use of a nurse-staffed hotline to inform patients about care options and support self-management represents a form of disease management for healthcare organizations.
Case Management Advantage: The key advantage of case management in managed care is coordination of care.
Disease Management Program Motivation: The practical motivation for healthcare plans to develop disease management programs is associated with capitation-based payment models.
Discharge Planning Timing (Fractured Hip): The best time for discharge planning to begin for an 85-year old patient with a fractured hip is when the physician orders discharge planning or when the decision concerning the next level of care is made.
Preferred Provider Network (PDN) Data: To negotiate contracts with PDNs, the most helpful data are reimbursement minus costs.
Negligence/Malpractice: In medical malpractice lawsuits, negligence or "proper care" is defined by medical peers' standards in the field.
Scope of Care: The written scope of care and service for healthcare organizations is best described as a logical sequence or plan of care for specific patient populations.
Subacute Care Response: Responding immediately and attentively to families following a patient fall in a subacute facility is a loss-prevention activity.
Underutilization Indication: Reducing pediatric hospitalization rates suggests underutilization in the medical group, requiring investigation and adjustments to utilization management practices.
Integrating Management Functions: The critical issue in integrating utilization management, quality management, and clinical risk management is effective information management.
CT Scanner Decision: When the average reimbursement for outpatient CT scans decreases considerably and concurrent repair costs exceed the perceived return, the most economical decision is to repair the scanner.
Total Quality Management: According to Total Quality Management, managers implement participative decision making processes and communicate both successes and failures.
Risk Retention/Shifting: If a hospital fails to negotiate contracts with a particular cardiac surgery team when anticipating cardiovascular services and then exclusively contracts with another hospital to refer patients to that hospital, this decision represents risk shifting.
Economic Reimbursement: Community case management and disease management programs effectively benefit from discounted fee-for-service or shared capitation reimbursement models.
Hospital Case Management Evaluation: Evaluation of hospital case management includes examining denial rates comparatively with preceding years, length of stays, readmissions, and reimbursement as it pertains to patient conditions with increasing length of stays.
Utilization Management Improvement Measures: Effective Utilization Management Planning (UM) requires an evaluation strategy to consider accreditation survey results and utilization (UM) performance measure outcomes.
Linking QM/RM on Peer Review: Effective linking needs aggregating patient occurrence data reporting and regularly scheduled meetings with Risk Management.
Data Supporting Risk Prevention: Monthly occurrence reporting and root cause analysis contribute to enhanced risk analysis, enabling effective methods for risk prevention.
Recipient Quality Perspective: Involving patients directly in proposing safety measures or approaches for the care plan would better recognize the "perceptive quality" of care.
Hospital Financial Return: A return on investment (ROI) for comprehensive health services should ideally be seen after a revenue consistently exceeds expenses, or when patients consistently utilize agency services.
Incident/Occurrence Reporting: The prevalent purpose in incident reporting is to identify adverse patient occurrences, which is often linked to the event investigation process's effectiveness.
Medication Error Reporting Improvement: Establishing a clear culture of accountability is the fundamental aspect of fostering a supportive environment for staff who report errors in patient medication occurrences.
Risk Management Response (Exercise Ball): The handling of expenses associated with fractures sustained from an incident using a large exercise ball is typical of handling risk, rather than avoidance, analysis, or transfer.

Quality Improvement and Patient Safety

Sentinel Events and Leadership Participation: Leadership participation is crucial during the design and analysis phases of initiatives, which change key clinical services to prevent further sentinel events..
Patient Safety Program Effectiveness: Effective patient safety programs utilize anonymity in occurrence/incident reporting to promote open and honest reporting and analysis.
Bar Code Medication System Success Metrics: The best indicator of a patient safety program implemented using a bar code medication system is a decrease in adverse drug events from dispensing errors.
Positive Safety Climate Metrics: Measuring the percentage of staff reporting a positive safety climate helps evaluate the effectiveness of safety initiatives as programs to enhance organizational culture.
Leadership's Initial Responsibility in Patient Safety: In Patient Safety programs, leading with assigning a champion is the first step toward achieving goals associated with the program.
Annual National Patient Safety Goals: Annual National Patient Safety Goals are linked to sentinel events.
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Description

Explore the role of a newly appointed QM Director at a medical center and the initial evaluation strategies for improving the quality management program. This quiz focuses on evaluating department climates, leadership engagement, and budget considerations in quality management.