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Healthcare ch 10/11

Quality Management

Utilization management planning, organizing, directing, and controlling healthcare products in a cost-effective manner while maintaining quality of patient care and contributing to the organization's goals
Medically necessary Appropriate and consistent with diagnosis and, according to accepted standards of practice in the medical community, imperative to treatment to prevent the patient's condition or the quality of the patient's care from being adversely affected
Underuse failure To provide appropriate or necessary services, or provision of an inadequate quantity or lower level of service than that required
Overuse Provision of healthcare services that do not benefit the patient and are not clearly indicated or are provided in excessive amounts or in an unnecessary setting
Utilization Use of medical services and supplies, commonly examined in terms of patterns or rates of use of a single service or type of service, such as hospital care, physician visits, and prescription drugs
Utilization review Process for monitoring and evaluating the use, delivery, and cost-effectiveness of healthcare services
Pay-for-performance systems Performance-based payment arrangements that control costs directly or indirectly by motivating providers to improve quality and reduce inappropriate utilization
Prospective review A method of determining medical necessity and appropriateness of services before the services are rendered
Concurrent review An assessment of patient care services that is completed while those services are being delivered to ensure appropriate care, treatment, and level of care
Retrospective review A method of determining medical necessity and appropriateness of services that have already been rendered
Preadmission certification Review of the need for medical care or services that is completed before the care or services are provided
Physician advisor A practicing physician who supports utilization review activities by evaluating appropriateness of admissions and continued stays, judging the efficiency of services in terms of level of care and place of service,and seeking appropriate care alternatives
Clinical paths Description of key patient care interventions for a condition, including diagnostic tests, medications, and consultations, which, if completed as described, are expected to produce desired outcomes
Protocols Formal outlines of care; treatment plans
Discharge planning Evaluation of patients' medical and psycho-social needs for the purpose of determining the type of care they will need after discharge from a healthcare facility
Case managers Experienced healthcare professionals who work with patients, providers, and insurers to coordinate medically necessary and appropriate healthcare services
High-performing healthcare organization An organization that is committed to success and continuously produces outstanding results and high levels of customer satisfaction
Governing body The individual, group, or agency with ultimate legal authority and responsibility for the overall operation of the organization; often called the board of trustees, board of governors, or board of directors
Quality management system A set of interrelated or interacting elements that organizations use to direct and control the implementation of quality policies and achieve quality objectives
Quality management plan A formal document that describes the organization's quality management system in terms of organizational structure, responsibilities of management and staff, lines of authority, and required interfaces for those planning, implementing, and assessing
Organized medical staff A formal organization of physicians and dentists with the delegated responsibility and authority to maintain proper standards of medical care and plan for continued betterment of that care
Risk management The act or practice of dealing with risk, which includes planning for risk, assessing risk areas, developing risk-handling options, monitoring risks to determine how they have changed, and documenting the over-all risk management program
Organizational culture prevalent patterns of shared beliefs and values that provide behavioral guidelines or establish norms for conducting business
Performance excellence Term introduced by Tom Peters and Robert Waterman in their book In Search of Excellence to refer to an overall way of working that balances stake-holder concerns and increases the probability of long-term organizational success
Created by: chochi