Healthcare QI, Analysis, Utilization and Risk Management

Which of the following documents the results of care for individual patients as well as for specific types of patients grouped by diagnostic category?
Outcome measures
Which of the following organizations provides the most complete view of managed care plan quality?
___are Joint Commission’s standards for improving patient safety.
b. NPSGs
Which of the following is a technique used to generate a large number of creative ideas from a group?
The leader of the coding performance improvement team wants all of her team members to clearly understand the coding process. Which of the following would be the best tool for accomplishing this objective?
The medical transcription improvement team wants to identify the cause of poor transcription quality. Which of the following tools would best aid the team in identifying the root cause of the problem?
Fishbone diagram
Which of the following are detailed step-by-step guides used by healthcare practitioners to make clinical decisions related directly to patient care?
Clinical practice guidelines
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?
An unexpected occurrence involving death or serious physical or psychological injury, or risk thereof is called
Sentinel event
A graphic tool used to organize and prioritize ideas after a brainstorming session is called a/an:
Affinity diagram
Name the four core processes involved in the are, treatment, and services to patients.
1. Assessing Patients needs.
2. Planning Care, treatment and services
3. Providing the care, treatment and services
4. Coordinating care, treatment and services
(the answer is all of the above)
The outcome of this flow of care is an improvement in the patient’s condition that allows discharge to the patient’s home or to a different care setting:
coordinating care, treatment and services
The established criteria against which the decisions and actions of healthcare practitioners and other representatives of healthcare organizations are assessed in accordance with state and federal laws, regulations, and guidelines are called
clinical practices standards
Which of the following statements best defines utilization management?
It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care.
Which of the following is not a type of utilization review?
Documentation utilization review
What is the role of the case manager?
To coordinate medical care and ensure the necessity of the services provided to beneficiaries.
Which of the following is not one of the basic functions of the utilization review process?
Claims management
what term is used for the process of determining whether the medical care provided to a specific patient is medically necessary?
Utilization review
The risk manager’s principal tool for capturing the facts about potentially compensable events is the
occurrence report
Events that occur in a healthcare organization that do not necessarily affect an outcome, but if were to recur, carry significant change of being a serious adverse event are called
near misses
The four components in a fishbone diagram include:
Men, Methods, Machines and Material
( answer is all of the above)
Analysis of a sentinel event from all aspects to identify how each contributed to the occurrence of the event and to develop new systems that will prevent recurrence is called
root-cause analysis
Assessment of a patient’s readiness to leave the hospital
Discharge utilization review
Periodic review during a current admission to determine whether the patient still needs acute care services
Continued-stay utilization review
Review of a planned admission to determine whether the services are medically necessary and whether the patient qualifies for impatient benefits
Prospective utilization review
Process of determining whether the medical care provided to a specific patient is necessary
Utilization management
Review of records some time following the patient’s discharge to determine any of several issues, including the quality or appropriateness of the care provided
Retrospective utilization review
Review conducted at the time of a hospital admission to determine the medical necessity and appropriateness of care in an acute care setting
Admission utilization review
Review conducted prior to a hospital admission to determine whether the planned services are medically necessary and require treatment in an acute care setting
Preadmission utilization review
Review of the patent’s needs for care and the quality of the care provided at the time services are rendered
Concurrent utilization review
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:
post-discharge planning
Every healthcare organization’s risk management plan should include the following components:
Objectives, key elements, responsibilities, methods, and areas of focus for the current year

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