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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. 473

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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].