HCQM - QUALITY IMPROVEMENT,
MANAGEMENT, & ASSURANCE
QUESTIONS AND VERIFIED ANSWER
2 factors to be considered when designing an outcomes
measure. - correct answer- Direct causality and
efficiency
2 Process focused models - correct answer-
Lean and Six Sigma
3 core functions of QIOs - correct answer- 1.
Improving quality of care 2. Protecting the integrity of the
Medicare Trust Fund by ensuring that Medicare pays only
for services and goods that are reasonable and necessary
and that are provided in the most appropriate setting 3.
Protecting beneficiaries by expeditiously addressing
individual complaints such as beneficiary complaints,
provider based notice appeals, violations of the
Emergency Medical Treatment and Labor Act (EMTALA),
and other related responsibilities as articulated in QIO
related law.
,4 Goals of Quality Improvement System for Managed Care
- correct answer- to establish objective and
measurable standards to improve the health of
Medicare/Medicaid beneficiaries. 1. Clarify the
responsibilities of CMS and the states in promoting quality
as value-based purchasers of services for vulnerable
populations 2. Promote opportunities for partnership
between CMS and the states and other public and private
entities involved n quality improvement efforts. 3.
Develop coordinated Medicare and Medicaid quality
oversight system to reduce duplicate or conflicting efforts
and send a uniform message on quality to organizations
and consumers. 4. To make effective use of quality
measurement and improvement tools while allowing
sufficient flexibility to incorporate new developments.
4 steps of an Effective Process Improvement Process -
correct answer- 1. Find an opportunity to
improve 2. Assess the opportunity 3. Act on an
opportunity 4. Measure results
,5 Basic steps of Stanley Campbell, Research Design -
correct answer- 1. Establish definitions,
procedures, and scripts to be followed so that there is
reproducibility among data collection processes and
assure data integrity. 2. Get baseline or pre-test
measurement (T1) 3. Apply the treatment for a pre-
selected amount of time (X). 4. Measure again (T2). 5.
Determine the statistical significance between T1 and T2.
1993's Quality Assurance Reform Initiative (QARI) -
correct answer- Assists states in the
development of continuous quality improvement systems,
internal and external quality assurance programs, and
focused clinical studies. Provides a general approach for
state Medicaid agencies to follow, but does not offer
specific tools or methodologies.
1996's Quality Improvement System for Managed Care
(QISMC) - correct answer- CMS developed this
to act as a guide to quality management oversight for
federal and state health care purchasers and is required
of all health plans participating in Medicare and is a
voluntary guide for state Medicaid programs.
, 1997's Balanced Budget Act (BBA) - correct
answer- Included new provisions for Quality
Assessment and Performance Improvement and a
comprehensive revision of federal statutes governing
Medicaid managed care.
2002's Quality Improvement Organization (QIO) -
correct answer- PROs became QIOs which better
describe their proactive role in improving health care.
CMS issued a final rule to implement BBA provisions
relating to how quality measurement and performance
improvement programs should be applied the Medicaid
Managed Care. These provisions updated the approach
outlined in QISMC and specified that the programs
develop and implement a comprehensive quality
assessment and improvement process in both clinical and
nonclinical areas and that states conduct an annual
external quality review of MMC organizations.
2006's Physician Quality Reporting Initiative (PQRI) -
correct answer- Established by Tax Relief and
Health Care Act of 2006 (TRHCA) and authorized the
MANAGEMENT, & ASSURANCE
QUESTIONS AND VERIFIED ANSWER
2 factors to be considered when designing an outcomes
measure. - correct answer- Direct causality and
efficiency
2 Process focused models - correct answer-
Lean and Six Sigma
3 core functions of QIOs - correct answer- 1.
Improving quality of care 2. Protecting the integrity of the
Medicare Trust Fund by ensuring that Medicare pays only
for services and goods that are reasonable and necessary
and that are provided in the most appropriate setting 3.
Protecting beneficiaries by expeditiously addressing
individual complaints such as beneficiary complaints,
provider based notice appeals, violations of the
Emergency Medical Treatment and Labor Act (EMTALA),
and other related responsibilities as articulated in QIO
related law.
,4 Goals of Quality Improvement System for Managed Care
- correct answer- to establish objective and
measurable standards to improve the health of
Medicare/Medicaid beneficiaries. 1. Clarify the
responsibilities of CMS and the states in promoting quality
as value-based purchasers of services for vulnerable
populations 2. Promote opportunities for partnership
between CMS and the states and other public and private
entities involved n quality improvement efforts. 3.
Develop coordinated Medicare and Medicaid quality
oversight system to reduce duplicate or conflicting efforts
and send a uniform message on quality to organizations
and consumers. 4. To make effective use of quality
measurement and improvement tools while allowing
sufficient flexibility to incorporate new developments.
4 steps of an Effective Process Improvement Process -
correct answer- 1. Find an opportunity to
improve 2. Assess the opportunity 3. Act on an
opportunity 4. Measure results
,5 Basic steps of Stanley Campbell, Research Design -
correct answer- 1. Establish definitions,
procedures, and scripts to be followed so that there is
reproducibility among data collection processes and
assure data integrity. 2. Get baseline or pre-test
measurement (T1) 3. Apply the treatment for a pre-
selected amount of time (X). 4. Measure again (T2). 5.
Determine the statistical significance between T1 and T2.
1993's Quality Assurance Reform Initiative (QARI) -
correct answer- Assists states in the
development of continuous quality improvement systems,
internal and external quality assurance programs, and
focused clinical studies. Provides a general approach for
state Medicaid agencies to follow, but does not offer
specific tools or methodologies.
1996's Quality Improvement System for Managed Care
(QISMC) - correct answer- CMS developed this
to act as a guide to quality management oversight for
federal and state health care purchasers and is required
of all health plans participating in Medicare and is a
voluntary guide for state Medicaid programs.
, 1997's Balanced Budget Act (BBA) - correct
answer- Included new provisions for Quality
Assessment and Performance Improvement and a
comprehensive revision of federal statutes governing
Medicaid managed care.
2002's Quality Improvement Organization (QIO) -
correct answer- PROs became QIOs which better
describe their proactive role in improving health care.
CMS issued a final rule to implement BBA provisions
relating to how quality measurement and performance
improvement programs should be applied the Medicaid
Managed Care. These provisions updated the approach
outlined in QISMC and specified that the programs
develop and implement a comprehensive quality
assessment and improvement process in both clinical and
nonclinical areas and that states conduct an annual
external quality review of MMC organizations.
2006's Physician Quality Reporting Initiative (PQRI) -
correct answer- Established by Tax Relief and
Health Care Act of 2006 (TRHCA) and authorized the
