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To determine internal priorities for performance improvement, a health care organization must consider the:

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Needs and expectations of all the stakeholders

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A component of the organization's quality management activities that is often documented in the performance improvement plan:

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performance improvement model used by the organization

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The lead Federal agency in health care quality research.

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Agency for Healthcare Research & Quality

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!!! The 3 components of health care quality management

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measurement, assessment and improvement

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Which of the following dimensions of health care was NOT identified by the Institute of Medicine in 2001 as needing improvement?

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Convenience

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Group that sponsors the HEDIS performance measurement system for managed care organizations.

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National Committee for Quality Assurance

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The reporting structure for quality management activities in a hospital is commonly documented in the organization's:

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performance improvement plan

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"Championing Quality" throughout the organization is the job of:

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Senior Management

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A basic responsibility of the quality management department in a healthcare organization.

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Help other departments identify potential quality problems

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Group ultimately responsible for the quality of health care in a healthcare organization.

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governing board

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A way of doing business which continuously improves products and services to achieve ever better levels of performance.

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Quality management

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To determine compliance with departmental standards, the manager of the hospital registration department is collecting data on the accuracy of patient demographic information that has been into the computer system by registration clerks. This activity is an example of:

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Measuring performance

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Performance measurement data are collect primarily for the purpose of:

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identifying opportunities for improvement

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!!! For performance measure, "Percentage of surgery patients who develop a wound infection," what number is used for the denominator?

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Number of surgery patients

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!!! A PROCESS measure used to evaluate care provided to patients in the emergency department.

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Percent of records that include name of patient's next of kin.

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Examples of Outcomes measures

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1. Rate of uninsured patients 2. Percent of patients that develop wound infections 3. Rate of readmission to the emergency department within 24 hours

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The first step in developing a performance measurement

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Select the process to be evaluated

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Which of the following statements about performance measurement is TRUE? A. Performance measurement requires a computerized information system B. An organization selects measures based on its improvement priorities C. Performance is improved when all stakeholders are involved D. Patient outcome rates are the most valid measure of perfiormance

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B. An organization selects measures based on its improvement priorities

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For the performance measure, :Percentage of patients who develop deep vein thrombosis or pulmonary embolus following a surgical procedure," what population would be included in the numerator?

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Surgical patients who develop deep vein thrombosis or pulmonary embolus during the study time period

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!!! "Baseline" performance is a measure of

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Current performance

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An OUTCOME measure of performance for a nursing home.

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Percent of residents that develop a pressure ulcer

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Example of STRUCTURE measure

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Number of fire drills held annually

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A STRUCTURE measure of performance for a renal dialysis facility

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Number of health inspection violations

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A source of information on the critical activities to be done while caring for patients.

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clinical practice guidelines

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Example of an objective performance goal

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Dictated reports shall be transcribed within 24 hours

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One of the recommendations of the Joint Commission is: Improve the accuracy of patient identification. Which of the following performance measures would a hospital use to evaluate success at achieving this goal? A Percent of time the patient's name is verified prior to drawing blood for a lab test. B Number of medication errors per 1000 medication doses administered C Average time from patient arrival at the hospital until the admission process is complete D Percent of patients designated as non-English speaking

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A. Percent of time the patient's name is verified prior to drawing blood for a lab test.

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Surveys developed by the Agency for Healthcare Research and Quality to be used to evaluate patient satisfaction in healthcare organizations.

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Consumer Assessment of Healthcare Providers and Systems

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A criterion considered by the National Quality Forum in its endorsement of performance measures.

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Useability

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Which of the following data collection methods would be BEST for gathering reliable information about physician compliance with a hospital's hand washing procedures?

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Direct observation

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What is an advantage to using billing data as a source of information for evaluating the quality of patient care?

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Billing data are readily available

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Instrument used to gather performance measurement data.

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Check sheet

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When the quality coordinator reviews the record of every tenth clinic patient to determine whether it contains up-to-date medication information, what sampling method is being used?

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Systematic

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Which of the following performance measurement data sources is the most costly to use in terms of manpower required to gather information?

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Paper-based patient records

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What data collection instrument is commonly used to gather information on patient's satisfaction with healthcare services?

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Questionnaire

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A tool used to standardize the processes necessary for capturing data performance measures.

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Data collection plan

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Data for the e-measures used by a hospital to monitor its performance are found in

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Automated sources

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Continuous quality improvement in healthcare organizations require

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A planned and systematic approach

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Six key dimensions of healthcare performance that need improving.

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1. Safe 2. Effective 3. Patient-Centered 4. Timely 5. Efficient 6. Equitable

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Public evaluations on healthcare quality on the Web in the form of:

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Report cards Provider profiles Consumer reports

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Purpose of public disclosure of evaluations on healthcare quality:

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1. To facilitate informed choices 2. Stimulate quality improvement

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Governing board in a healthcare organization does..

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1. Important role in assuring quality care is continually delivered to patients 2. Legally and morally responsible for ensuring the quality of care to patients

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Structure measure

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Used to asses the healthcare facility"s capacity to provide quality patient care. Used to judge the adequacy of the environment for delivering care. ex--Physical facilities, equipment, staff, qualifications of medical staff, organizational structure.

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Process measure

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Used to assess satisfactory completion of required health care tasks. Used to judge completion of important tasks(those activities with the greatest impact on healthcare quality). Was the task performed? Was it performed as expected?

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Outcome measure

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Used to assess the end result of healthcare services. Results can be physiologic, psychosocial, or biologic. Used to judge results of patient care.

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Structure measure examples

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Ratio: Registered nurses to patients number of fire drills conducted annually percent of employees who receive the influenza vaccination Hospital has norms for Heparin administration using a nomogram

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Process measures examples

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Percent of patients assessed for fall risk at time of admission Percent of patients w/ stage III colon cancer who receive chemotherapy Percent of operative reports dictated immediately following surgery. Percent of patient records containing patient demographic errors. Percent pf patients who are discharged on antiplatelet therapy.

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Outcome measure examples

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Rate:Number of patient falls per 1000 days Percent of patients w/ the principal diagnosis code of stroke that expire in the hospital. Average admitting times for inpatients, emergency, and outpatients. Percent of patients who reported being "very Satisfied" w/ admission process

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Six key dimensions by IOM:

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1. Effectiveness-based on scientific knowledge, service provided to all who can benefit, service should not be provided to those not to benefit 2. Efficiency-Avoidance of waste-equipment, supplies, time, energy, and ideas 3. Equity- Quality doesn't change cause of patient's personal characteristics, gender, ethnicity, geographic location, and social status 4. Patient-centeredness-Care is provided respectfully of and responsive to patient preferences, needs, and values 5. Safety-Unintended patient injuries should be avoided 6. Timeliness-No unnecessary waits and delays for those receiving care

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Developing Measures

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1. Select process to be evaluated a. accreditation & regulatory requirements b. topics of national importance c. strategic quality goals d. customer needs & expectations 2. Determine what you want to know 3. Translate "What you want to know"(the critical activities/the process as a whole) into a performance measure. 4. Establish performance goals. a. regulation & accreditation standards b. organizational quality goals c. guideline accommodations d.performance in other organizations.

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Customers: 3 stakeholders groups

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1. Providers 2. Purchasers 3. Consumers

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Quality Management- AKA

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Performance improvement Continuous quality improvement Total quality management Performance management

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When using comparative data to asses performance, what is the first step that should be taken to ensure a worthwhile assessment?

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Verify data accuracy

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"Benchmarking" is a measure of

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Current performance compared to an exemplary organization

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Purpose of risk adjusting patient outcome data

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To enable fair statistical comparisons between different groups of patients

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Which parameters on a control chart represent an estimate of the standard deviation for the data plotted on the chart?

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Control limits

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What graphic data display is used for analyzing performance trends?

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Line graph

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Example of significant performance trend in the HIM department:

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For 8 weeks in a row the number of coding errors has decreased.

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What graph used to display performance measurement data can help managers predict future performance results?

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Control chart

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A concise report of quality measurement data that provides leaders w/ a snapshot of the organization's current performance in several different areas.

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Radar chart/spider chart

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When interpreting a risk-adjusted patient outcome report, statistical significance is important because it expresses:

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Magnitude of the outcome difference

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An evaluation of time-series data for the purpose of detecting significant changes in performance

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trend analysis

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Graph that displays the most extreme values, the lower & upper quartiles, and the median in a set of performance data.

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box plot

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A data display that shows the contribution of parts to a whole.

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Pie chart

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When the data points on a control chart do not fall outside the control limits, what type of performance variation is being exhibited?

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Common cause

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AHRQ

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Agency for Healthcare Research and Quality, Agency for health care research and quality (assures quality of health services)

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CDC

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Center for Disease Control and Prevention , An agency under the U.S. Department of Health and Human Services. It is recognized as the leading Federal Agency for protecting the health and safety of people, and for providing credible information to enhance health decisions.

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FDA

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Food and Drug Administration. The agency that is responsible for determining if a food or drug is safe and effective enough to be sold to the public.

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NIH

answer

National Institutes of Health, improve nation's health by conducting & supporting research into causes, diagnosis, prevention, and cure of human diseases.

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QIO

answer

Quality improvement organizations: external agencies that review the quality or care and use of insurance benefits by individual physicians and patients for Medicare and other insurers.

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AAAHC

answer

Accreditation Association for Ambulatory Healthcare - a professional organization that offers accreditation programs for ambulatory and outpatient organizations such as single and multispecialty group practices, ambulatory surgery centers, college/university health services, and community health centers.

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ACHC

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Accreditation Commission for Health Care - A private nonprofit accreditation organization offering accreditation services for home health, hospice, and alternate site healthcare such as infusion nursing, and home/durable medical equipment supplies.

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CARF

answer

Commission on the Accreditation of Rehabilitation Facilities, provides accreditation for organizations offering behavioral health physical and occupational rehabilitation services as well as assisted living continuing care community services employment services and others.

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CoC

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Commission on Cancer of the American College of Surgeons-Approves cancer programs

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NIAHO

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National Integrated Accreditation for Healthcare Organization

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NCQA

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National Committee on Quality Assurance. A not-for-profit organization that performs quality oriented accreditation reviews on HMOs and similar types of managed care plans.

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JC

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Joint Commission for Accreditation of Healthcare Organizations, -sets standards and accredits most general, long-term, psychiatric hospitals, substance abuse programs, outpatient surgery centers, urgent care clinics, group practices, community health centers, hospices and HH agencies, lab

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IOM

answer

Institute of Medicine of the National Academies; a nonprofit organization created to provide unbiased, evidence based and authoritative information and advice concerning health and science policy,-- care should be safe, effective, patient centered, efficient and equitable

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NAHQ

answer

National Association for Healthcare Quality

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NQF

answer

national quality forum, for healthcare quality measurement and reporting, not for profit, (National Quality Forum) is a not for profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting.

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Governing board

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aka-Board of Trustees--Has ultimate responsibility for the quality of patient care and services provided. Responsibility of the support in the organization's mission& strategic priorities.

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Senior Leaders

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President, COO(chief operating officer) vice presidents, medical director--Responsible for ensuring continuous quality improvement and for establishing and cultivating a culture of safety.

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Second tier groups

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Quality management oversight committees or councils.

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Third tier groups

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Multi-disciplinary, interdepartmental committees charged with conducting quality management activities in a particular service or function.

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Quality management plans

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Often required by state or federal regulations. The plan describes the organization's approach to management of patient safety and quality. Provides framework for all measurement, assessment and improvement activities.

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Quality management plan should include:

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1. An outline of the program structure & content 2. Designation of the committee responsible for overseeing the program. 3. Role, structure, function, and frequency of meetings of the program oversight committee and other relevant committees.

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Numerator

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Number that provides a magnitude (how much). Goes on top of the fraction. Represents a part/population.

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Denominator

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Represents the entire part/population. Goes on the bottom of fraction.

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HEDIS

answer

Healthcare Effectiveness Data and Information Set Comparison of the performance of health plans. This data set was developed by the National Committee for Quality Assurance to aid consumers with health-related issues with information to compare performance of clinical measures for health plans:

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Manuel data collection tools

answer

Survey, questionnaire, check sheet, tally sheet, direct observation

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MEDPAR file

answer

A common source of data for publicly available health care performance measurement results. The Medicare claims database.

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