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D
Glossary and Acronyms
GLOSSARY
Activities of daily living. Activities of basic daily life usually done without
assistance, such as eating, bathing, dressing, and using the bathroom.
Adverse event. An undesirable and usually unanticipated event or injury
in a health care setting, including incidents that have no permanent
effect, such as a fall or administration of improper medication.
Apportionment. A distribution of funds for programs as required by law
(OMB, 2004).
Benchmarking. Comparison of internal processes with best practices or
scores of a comparison group to find new ways to achieve continuous
improvement.
Case review. Retrospective review of a medical record by experts to en-
sure the protection of beneficiaries and the integrity of the Medicare
Trust Fund; also involves the review of appeals and complaints filed by
beneficiaries (see quality review, utilization review, and diagnosis-
related group validation review).
Case Review Information System. Application used by Quality Improve-
ment Organizations to track and report data related to case review
activities.
Clinical Data Abstraction Center. Independent organization that contracts
with the Centers for Medicare and Medicaid Services to abstract data
from medical records.
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474 APPENDIX D
CMS Abstraction and Reporting Tool. Used by providers, Quality Im-
provement Organizations, and Clinical Abstraction Data Centers to
collect and analyze data on hospital-related quality indicators.
Collaborative. An intervention modality designed to bring together stake-
holders working toward quality improvement for the same clinical
topic. Participants usually follow the same processes to reach goals and
interact on a regular basis to share knowledge, experiences, and best
practices.
Communities of practice. Informal groups of people involved in quality
improvement efforts on the same topic area. Groups support each other
via listserves, teleconferences, and other modalities to share knowledge
and best practices. In the Quality Improvement Organization program,
these are often organized around a specific task by the Quality Im-
provement Organizations Support Center.
Conditions of Participation. Standards required of providers for their par-
ticipation in the Medicare and Medicaid programs. The Centers for
Medicare and Medicaid Services designs these standards to improve
quality and protect the health and safety of beneficiaries (CMS, 2005b).
Dashboard. A part of QIONet on which data are displayed for Quality
Improvement Organization activities on contract tasks.
Data abstraction. Process by which specific information and data are
gleaned from medical records.
Data validation. Process by which the accuracy of information and the
data gleaned from medical records are assessed.
Diagnosis-related group validation review. A type of case review that en-
sures that the claim codes match information in the medical record
according to documentation of diagnosis, procedures, and discharge
status.
Electronic health record. A computerized recording of a patient's health
information that is maintained by providers (CMS, 2005c).
Fee-for-service. Financing methodology currently used by Medicare in
which providers are reimbursed for each individual procedure or pa-
tient encounter.
Government Task Leader. A Centers for Medicare and Medicaid Services
representative who has direct responsibility for oversight of a specific
task or special study of the Quality Improvement Organization contract.
Identified participants. Providers with whom Quality Improvement Orga-
nizations work intensively on specific quality improvement projects.
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APPENDIX D 475
Implicit review. Subjective decision making during case review activities,
based on individual professional judgment.
Knowledge transfer. A collective exchange of ideas regarding how to best
promote or provide high quality.
Medicare Advantage (formerly Medicare+Choice). Health plan offered by
an organization (a public or private risk-bearing entity licensed by the
state and certified by the Centers for Medicare and Medicaid Services)
to all Medicare beneficiaries in a single service area at the same pre-
mium and level of cost sharing (CMS, 2005a).
Medicare Quality Improvement Community (MedQIC). A public website
that serves as an informational resource for quality improvement ac-
tivities and that is run by a Quality Improvement Organization Support
Center.
Patient safety. Prevention of harm caused by errors of commission and
omission.
Payment error rate. The rate of incorrect amounts of payments, including
both overpayments and underpayments as well as both inappropriate
denials and inappropriate payments.
PDSA cycle. A methodology for continuous quality improvement: plan
for a change in a process, do a trial of the planned change, study the
results, and act to implement the next steps on the basis of the results.
Performance measurement. "Measurement of data that show the progress
toward specific results that are the intended outcome of specific ac-
tions, thus providing a way to evaluate the actions" (Top 10 by 2010,
2005).
Physician access. Designates an organization that has arrangements for
local physicians to perform case review activities, including at least one
physician for every generally recognized specialty and subspecialty.
Physician sponsored. Designates an organization that has at least 20 per-
cent of physicians in the state as owners or members or that has 10
percent as owners or members and represents an additional 10 percent
through other means.
Program activity reporting tool. Application used by Quality Improve-
ment Organizations to report on deliverables and by Centers for Medi-
care and Medicaid Services to monitor deliverables and approve project
plans.
Project Officer. A Centers for Medicare and Medicaid Services represen-
tative who directly oversees and monitors a specific individual Quality
Improvement Organization contract.
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476 APPENDIX D
Prospective payment system. Financing methodology currently used by
Medicare in which services are reimbursed at a predetermined, fixed
amount on the basis of coding for the services provided.
Provider. An individual or group of individuals (or an institution) who
provide health care services to beneficiaries. Providers in the Quality
Improvement Organization program include hospitals, nursing homes,
home health agencies, physicians, and pharmacies/pharmacists.
Public reporting. "Providing the public with information about the per-
formance or quality of health services or systems for the purpose of
improving the performance or quality of the services or systems"
(Healthcare Infection Control Practices Advisory Committee, 2005).
QIONet. A protected intranet website used by the Quality Improvement
Organization community to share and report information.
Quality assurance. "The process of looking at how well a medical service
is provided. The process may include formally reviewing health care
given to a person, or group of persons, locating the problem, correcting
the problem, and then checking to see if what you did worked" (CMS,
2005a).
Quality improvement. A set of techniques for continuous study and im-
provement of the processes of delivering health care services and prod-
ucts to meet the needs and expectations of the customers of those ser-
vices and products. It has three basic elements: customer knowledge, a
focus on processes of health care delivery, and statistical approaches
that aim to reduce variations in those processes (IOM, 1990).
Quality Improvement Organization. Organization under contract with the
Centers for Medicare and Medicaid Services to assist Medicare provid-
ers with quality improvement and to review quality and cost issues for
the protection of Medicare beneficiaries and the Medicare Trust Fund.
Quality Improvement Organization Support Center. A Quality Improve-
ment Organization (QIO) funded under a support contract to act as a
central resource on a specific task or area of need for the entire QIO
program community.
Quality improvement plan. Devised by providers with Quality Improve-
ment Organization assistance to correct for concerns found during case
review activities, such as treatment patterns that do not meet standards
of care; also known as a corrective action plan, when in conjunction
with a sanction.
Quality of care. The degree to which health services for individuals and
populations increase the likelihood of desired health outcomes and are
consistent with current professional knowledge (IOM, 1990).
Quality review. A type of case review that examines whether the care
provided met recognized standards, was medically necessary, was per-
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APPENDIX D 477
formed in the appropriate setting, and was provided economically with
adequate documentation.
Reduction in failure rate. The change in performance from the baseline to
follow-up (absolute improvement) divided by the difference between
baseline and perfect (100 percent) performance; also known as relative
improvement.
Root-cause analysis. Process for identifying the fundamental cause(s) of
an error or inefficiency in processes or outcomes.
Scientific Officer. A Centers for Medicare and Medicaid Services repre-
sentative who provides scientific or clinical expertise to all Quality Im-
provement Organizations.
Scope of work. A section of the statement of work that provides an over-
all nontechnical description of Quality Improvement Organization pro-
gram activities.
Six aims. Safe: avoiding injuries during care that is intended to help. Ef-
fective: providing services based on scientific knowledge and refraining
from providing services to those not likely to benefit (avoiding underuse
and overuse, respectively.) Patient-centered: providing care that is re-
spectful of and responsive to individual patient preferences, needs, and
values. Timely: reducing delays for those who receive and give care.
Efficient: avoiding waste, including waste of equipment, supplies, ideas,
and energy. Equitable: providing care that does not vary in quality be-
cause of characteristics such as gender, ethnicity, geographic location,
and socioeconomic status (IOM, 2001).
Special studies. Performed under Task 4 of the Quality Improvement Or-
ganization (QIO) core contract. These studies are on topics not ad-
dressed by Tasks 1 to 3 and are performed by QIOs with Centers for
Medicare and Medicaid Services (CMS) approval. They are usually so-
licited by CMS. These studies are often pilot projects that may lead to
future work for the QIO program as a whole.
Standard Data Processing System. The information system for the Quality
Improvement Organization (QIO) program, it contains many data and
reporting tools and was designed and developed in response to the on-
going information requirements of the QIOs and other affiliated part-
ners to fulfill their contractual requirements with the Centers for Medi-
care and Medicaid Services (CMS). This system interfaces with CMS,
53 QIOs, and Clinical Data Abstraction Centers.
Statement of work. Part of the Quality Improvement Organization core
contract that delineates detailed work requirements, a list of deliver-
ables, evaluation criteria, and a budget.
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478 APPENDIX D
Support contracts. These activities contribute to the operation of the Qual-
ity Improvement Organization (QIO) program as a whole but are not a
part of the core contract. Contracts are usually awarded to organiza-
tions that do not hold QIO core contracts.
Survey and Certification. Reviews by State Survey Agencies (or other Cen-
ters for Medicare and Medicaid Services agents) to determine compli-
ance of Medicare providers with Conditions of Participation.
Technical assistance. The process by which Quality Improvement Orga-
nizations work with providers, managed care organizations, and other
stakeholders to improve patient outcomes. This includes root-cause
analysis, assistance with the implementation of interventions and sys-
tems changes, facilitating knowledge transfer, assisting with data col-
lection, and coordinating efforts with other stakeholders.
Transformational change. The Centers for Medicare and Medicaid Ser-
vices' (CMS's) vision that, through the adoption of certain strategies
(measurement and reporting, health information technology adoption,
process redesign, and organization culture change), the Quality Im-
provement Organization program, along with other efforts, can lead to
measurable changes in the health care delivery system to align with the
Institute of Medicine's six aims and CMS's vision of "the right care for
every patient every time" (Pugh, 2005).
Transparency. "The clarity with which a regulation, policy, or institution
can be understood anticipated. Depends on openness, predictability,
and comprehensibility" (Deardorff, 2005).
Utilization review. A type of case review that examines the medical neces-
sity and reasonableness of services or items provided, such as for the
necessity of admission and proper coding.
ACRONYMS
AHQA The American Health Quality Association
BIPA Benefits Improvement and Protection Act of 2000
CAC Consumer Advisory Council
CAHPS Consumer Assessment of Healthcare Providers and Systems
CART CMS Abstraction and Reporting Tool
CDAC Clinical Data Abstraction Center
CEO chief executive officer
CMS Centers for Medicare and Medicaid Services
CPOE Computerized Provider Order Entry
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APPENDIX D 479
CRIS Case Review Information System
DHHS U.S. Department of Health and Human Services
DRG diagnosis-related group
EHR electronic health record
EMCRO Experimental Medical Care Review Organization
EMTALA Emergency Medical Treatment and Labor Act
ESRD end-stage renal disease
FMIB Financial Management Investment Board (Centers for
Medicare and Medicaid Services)
FY fiscal year
HCFA Health Care Financing Administration
HEDIS Health Plan Employer Data and Information Set
HINN hospital-issued notice of noncoverage
HPMP Hospital Payment Monitoring Program
IHI Institute for Healthcare Improvement
IOM Institute of Medicine
IPG identified participant group
MedPAC Medicare Payment Advisory Commission
MedQIC Medicare Quality Improvement Community
MMA Medicare Modernization Act
NODMAR Notice of discharge and Medicare appeal rights
NQCB National Quality Coordination Board
OASIS Outcome and Assessment Information Set
OBQI Outcome-Based Quality Improvement (system)
OBRA Omnibus Budget Reconciliation Act
PARTner Program Activity Reporting Tool
PEPPER Program for Evaluating Payment Patterns Electronic Re-
ports
PRO Peer Review Organization
PSRO Professional Standards Review Organization
QAPI Quality Assessment and Performance Improvement (project)
QIO Quality Improvement Organization
QIOSC Quality Improvement Organization Support Center
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480 APPENDIX D
SDPS Standard Data Processing System
SOW scope of work
TOPS Transmittal of Policy System (a document)
REFERENCES
CMS (Centers for Medicare and Medicaid Services). 2005a. Glossary. [Online]. Available:
http://www.cms.hhs.gov/glossary [accessed November 15, 2005].
CMS. 2005b. Conditions of Participation. [Online]. February 3. Available: http://www.
cms.hhs.gov/cop [accessed November 15, 2005].
CMS. 2005c. 8th Statement of Work (SOW), Version #080105-1. [Online]. Available: http://
www.cms.hhs.gov/qio [accessed November 4, 2005].
Deardorff AV. 2005. Deardorff's Glossary of International Economics. [Online]. Available:
http://www-personal.umich.edu/~alandear/glossary [accessed November 15, 2005].
Healthcare Infection Control Practices Advisory Committee. 2005. Guidance on Public Re-
porting of Healthcare-Associated Infections. [Online]. February 28. Available: http://
www.consumersunion.org/campaigns/PublicReportingGuide [accessed November 15,
2005].
IOM (Institute of Medicine). 1990. Medicare: A Strategy for Quality Assurance, Vol. 1. Wash-
ington, DC: National Academy Press.
IOM. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Wash-
ington, DC: National Academy Press.
OMB. 2004. OMB Circular Number A-11: Preparation, Submission, and Execution of the
Budget. [Online]. Available: http://www.whitehouse.gov/omb/circulars/a11/current_year/
a_11_2004.pdf [accessed November 15, 2005].
Pugh MD. 2005. Final report: CMS Quality Group Planning Project QIOSC contract 500-02-
WA02 final report (revised). Pueblo, CO: Pugh Ettinger McCarthy Associates, LLC.
Top 10 by 2010. 2005. Glossary of Sustainable Indicator Terms. [Online]. Available: http://
www.top10by2010.org/glossary.pdf [accessed November 15, 2005].
Representative terms from entire chapter:
podiatric medicine
