Quality Management in Healthcare

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.
• .

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.