A

AAAHC, see Accreditation Association for Ambulatory Health Care

ABA, see American Bar Association

ABMS, see American Board of Medical Specialties

Access

barriers, 2, 24, 29, 31, 96, 110, 225–227, 258, 276, 369

to care, 2, 52, 344, 346, 389, 402

to information, 36, 37, 170, 248, 293, 350

to PRO rules, 192

public programs for improving, 34, 96, 256

research needs, 344, 346, 381

to services, 19, 29, 52, 79–80, 225, 288, 346

underdiagnosis/undertreatment, 226–227

underuse and, 23, 52, 225–226, 275, 284, 389

utilization management and, 30, 111

Accountability, for quality of care, 20, 32, 36, 37, 241

and autonomy, 290

and continuous quality improvement, 62–64

and oversight for PRO program, 193, 197, 372, 379–383, 420

and prepaid practice, 193–195

professional, 49, 244

for public monies, 7, 52, 145

Accreditation, 53, 56, 267–269;

see also Joint Commission on Accreditation of Healthcare Organizations

Accreditation Association for Ambulatory Health Care, 268

Accreditation Manual, 124, 267

Accreditation Council for Graduate Medical Education, 271

ACGME, see Accreditation Council for Graduate Medical Education

Activities of daily living, 83, 89–90, 91, 390

ADLs, see Activities of daily living

Administrative data sets, 274–276

Administrative Procedure Act, 148

Adverse patient occurrences, 281–283

incidence, 214–215, 218

Agenda for Change, 56, 61, 125, 355, 396;

see also Joint Commission on Accreditation of Healthcare Organizations

AHA, see American Hospital Association

Algorithms, clinical (patient care), 178, 272–273, 278–279, 307, 310, 322, 327, 395

AMA, see American Medical Association

Ambulatory care

certification, 268

quality problems, 246–250

research needed, 355

review in, 142, 177, 194, 196–197, 238, 256–257, 407–408

American Bar Association, 219

American Board of Medical Specialties, 270, 271

American Hospital Association, 120, 307

American Medical Association, 220, 270, 271

American Medical Peer Review Association, 182

American Medical Review Research Center, 179, 346, 355

AMPRA, see American Medical Peer Review Association

AMRRC, see American Medical Review Research Center

Appropriateness

of care, 111, 159, 221–224, 316, 391

guidelines, 3, 272–273, 304–306, 319–321, 325, 328, 370, 418;

see also Practice guidelines

research, 345, 353–354

Art of care, 25, 219, 350–351;

see also Quality-of-care indicators/ measures

Attributes

of criteria sets, 311–319

implementation, 316–319

of medical profession, 289–292

of QA methods, 49–50, 266–267

substantive, 3, 311–316

Autopsy, 266, 286, 287

B

Beneficiary

complaints, 170, 217–218, 252

number of, 100

relations, 169–170

Bi-cycle model, 62, 293;

see also Quality assurance, models

Burden of harm

differentiating among contributing factors, 209–210

overuse and, 208, 210, 220–224

of poor quality care, 27, 31–32

quality problems and, 207

sources of information about, 210–211

of technical and interpersonal quality, 207–208, 209–210, 211–219

underuse and, 209–210, 225–230

C

Capacity building, 3, 14–15, 360–363, 384–385, 418–419

and continuous improvement, 362–363

patient education, 362

professional education, 361–362

research needs, 343

Career paths, 361

Carriers, 102, 374, 395;

see also Medicare, claims processing

Case conferences, 228, 286–288

Case-finding

complaints, 170, 217–218

generic screens, 154–156, 160, 183–186, 228, 281–283, 307–388, 323

see also Individual case methods

Case management, 219, 252

Case mix, 11, 12, 247, 259, 308, 356, 378, 409

Certification

board, of health professionals, 53, 246, 266, 267, 269, 270–272, 278, 361

Home Health Agencies, 82, 251, 252

hospitals, 111, 120, 121–122, 128, 129, 130, 135, 371, 420

physician attestation, 156

preadmission, 140

see also Licensure;

Survey and Certification

CHAP, see Community Health Accreditation Program

Claims data, 54, 248, 249, 255;

see also Medicare Statistical System

Clinical indicators, 132–133, 283–284, 308, 396

Clinical information systems, 243–244, 248–249

research needs, 358

CME, see Continuing medical education

CMP, see Competitive medical plans

Coding

accuracy, 242–243, 255, 275–276, 277, 279, 280, 281

ambulatory, 249, 255

ICD-9-CM, 242–243, 257, 275

Part B, 255–256

see also Common Procedural Terminology

Common Procedural Terminology, 257, 275;

see also Coding

Community Health Accreditation Program, 252, 268

Competitive medical plans, 100–102

research needed, 356–357

review in, 173–177, 188, 193–195, 256–257

see also Health maintenance organizations;

Prepaid care

Complaints

beneficiary, 170, 217–218, 252

patient, 287–288, 288–289

Complication rates, medical, 266, 281;

see also Quality-of-care indicators/measures

Computers, see Clinical information systems;

Data

Conditions of Participation, 7–8, 111, 138, 396, 401–402

enforcement, 129–131

federal role, 131–132

HCFA and, 8, 124–125, 128–131, 134–135

history, 120–124

inspection, 128–129

quality assurance condition, 125–128

recommendations, 383–384

shift from capacity to performance standards, 124–125

Continuing Medical Education, 162, 270, 292–293, 354, 361;

see also Physician education

Continuity of care, 13–14, 29–30, 392

Continuous quality improvement, 294, 374–375

accountability, 58, 62–64

applications, 61

capacity building and, 362–363

customers and suppliers, 46, 59–60

defined, 46

model assumptions and constructs, 58–61, 387–388

PDCA cycle, 59

research, 352, 362–363

see also Industrial quality control

Corrective actions/plans, 160–163, 216–217

Cost containment, 97, 111, 309, 360, 374, 394–395

CPT, see Common Procedural Terminology

Credentialling, 269

Criteria, quality assurance development, 323–325

for allocation of resources, 393–394

for evaluation and management of care, 322–322

for successful quality assurance, 3, 49–52

mapping, 249

relationship among criteria sets, 308–309

sets, 277–279, 303–309, 310–319

and standards, 277–279

Customers, 58–60;

see also Continuous quality improvement

D

Darling v. Charleston Community Hospital, 241

Data

bases, 243–244, 274–277, 281, 403–404, 415;

see also Medicare Statistical System

collection and analysis, 178, 400, 404–408, 415

disclosure/reporting/dissemination/sharing, 15–16, 34, 170–171, 359–360, 408–410, 415–416

fee-for-service, 255–256

hospital, 243

prepaid care, 256–258

see also Claims data;

Clinical information systems

Decertification, 129, 130, 131, 133, 181–182,

Decision making, 20–25, 56

patient, 22, 362, 385, 402, 407–408

physician, 22, 63, 207–208, 244, 278, 315, 327, 402, 408

and population-based outcomes, 36–37

Deemed status, 7–8, 111, 119, 134;

see also Medicare Program to Assure Quality

Defining quality of care, 2, 4–5, 20–25, 375–377

Delegated review, 142–143, 179, 199;

see also Professional Standards Review Organizations

Department of Health and Human Services, 1, 140

current responsibilities, 102, 119

evaluation of PRO program, 192–193

PRO contracting authority, 149

recommended responsibilities, 6–8, 14, 378, 379, 381–385, 413–414, 416, 420

regulatory and enforcement authority, 135, 163, 216–217

DHHS, see Department of Health and Human Services

Diagnosis-related groups, 97, 224, 228

definition, 108–109

validation, 156–159

Discharge

planning, 223, 224, 156, 178, 184

premature, 156, 223, 225, 227–228, 245

review, 156

Disciplinary actions, 48, 215–216

DRGs, see Diagnosis-related groups

E

Education

patient, 169, 362

physician, 139, 162, 177, 292–293, 361–362

Effectiveness/efficacy, 30

medical care, 19, 23, 178

of interventions, 289–297

research, 348–350, 354–355

Elderly

access to care, 2, 31–32, 79–80, 93, 96, 230, 369, 399

activity limitations, 89–90

chronic illness and impairment, 2, 88–89

expenditures, 105–108

federal role in support of, 84–85

geographic distribution, 72–73

health insurance, 75

health status, 85–91

income, 75–79

life expectancy, 2, 85–86

living arrangements, 73–75

Medicare issues for, 2

mental health, 90–91

mortality, 86–88

nursing home residents, 74–75, 81–82

race and ethnicity, 71

rate of population growth, 2, 69–71

satisfaction with care, 1

sex ratios, 71

support ratios, 71

Elderly, use of services

community-based services, 83–84

home health care, 82–83

hospital, 79

long term care, 81–84

nursing home, 81–82

physician, 79–81

EMCROS, see Experimental Medical Care Review Organizations

Enforcement, 128–131, 133–134, 253;

see also Sanctions and sanctioning process

DHHS authority, 135, 163, 216–217

OIG authority, 145, 163–167, 189, 200, 411

Episodes

of care, 177, 239, 247–248, 405–406

of illness, 239

Ethics, in health care

autonomy, 23, 290

beneficence, 25

equity, 24

fidelity, 25

fiduciary relationship, 25

nonmaleficence, 25

Evaluation of programs

PRO, 180–182, 192–193, 260

MPAQ, 379–383, 399–400, 414, 417–418

MQRO, 398–399

Exemplary performance, 16, 47, 323, 416;

see also Incentives

Expenditures

by elderly for health care, 105–108

health care, 28–29, 103–105

Medicare, 28–29, 105–108

Experimental Medical Care Review Organizations, 139

F

Federation of State Licensing Boards, 215, 216

Fee-for-service, 3, 73, 254–256

and accountability for care, 194–195

alternatives to, 100–102, 112

conflict of interest, 25, 48

data, 255–256

and medical records availability, 193

and overuse, 140, 230

prepaid system contrasted with, 254

prevention of quality problems, 246, 255–257

quality review in, 173, 175, 177, 182, 188, 194–195, 196, 254, 401

types of problems, 256

Feedback, 408–409

to clinicians, 254, 292–293, 359, 415–416

loop, 15, 249

FI, see Fiscal intermediaries

Findings and conclusions, 2–4, 369–371

Fiscal intermediaries, 102, 138, 225, 374

FSLB, see Federation of State Licensing Boards

Funding

for MPAQ, 9–10, 385–387

for MQRO, 396–397

for PRO program, 171–173

for research, 363

G

GAO, see General Accounting Office

General Accounting Office, 145–146, 167, 183, 192–193, 212, 217, 383

Generic screens

case-finding, 323

characteristics, applications, and processes, 154–156, 160, 281–283

limitations and problematic aspects of, 183–186, 282–283

strengths, 282

see also Adverse patient occurrences;

Occurrence screens

Guidelines, 30

appropriateness, 3, 272–273, 304–306, 319–321, 325, 328, 370, 418

patient management, 272–273, 306–307, 322–323

research, 353–354

see also Generic screens;

Practice guidelines

H

HCFA, see Health Care Financing Administration

HCQIA, see Health Care Quality Improvement Act

Health accounting, 62;

see also Quality assurance models

Health Care Financing Administration

Bureau of Policy Development (BPD), 121

and Conditions of Participation, 8, 124–125, 128–131, 134–135

Health Standards and Quality Bureau (HSQB), 120, 121, 128, 132, 140, 346, 363

and HMO/CMP review, 177–182

hospital-specific mortality rates, 35, 280, 308

Office of Research and Demonstrations (ORD), 346, 351, 363

procedures, 148, 192–193

and PSROs, 143, 145

research, 346

responsibility for Medicare program, 120

responsibility for quality, 34, 110

Health care personnel/professionals distribution

manpower, 27–28, 58, 159, 343

training, see Capacity building

see also Physician

Health Care Quality Improvement Act, 148, 171, 410

Health maintenance organizations, 100–102

accountability, 193–195

data, 256–258

quality review in, 173–177

prevention of problems, 246, 256

research needed, 356–357

see also Competitive medical plans;

Prepaid care

Health services research, 344

Health status assessment, 20, 26, 34, 57, 286, 406–407;

see also Activities of daily living

of the elderly, 85–91

research needs, 351–352

HMOs, see Health maintenance organizations

Home health

agencies, 82

case management financing, 250–251

homebound provisions, 82, 83, 356

Medicare certification, 82, 251–252

quality problems, 282–219, 250–254

research needed, 356

review in, 186–187, 406–407

state licensure, 251–252

visits per person, 82–83

voluntary certification, 252

Hospitals

adequacy of QA mechanisms, 3

certification, 111, 120, 121–122, 128, 129, 130, 135, 371, 420

data, 243

discharge rate surveys, 79

elderly use of care, 79

mortality rates, 208, 280, 291;

see also Quality-of-care indicators/measures

nosocomial infections, 125, 154, 156, 184

outcomes of care, small area analysis, 179

readmissions, 161, 186, 227, 275

Hospital care, 79, 241–245

I

Incentives, 16, 47, 51, 293–294, 416

Individual case methods, 247, 286–289, 307–309

Industrial quality control, 58–61;

see also Continuous quality improvement

Information management, see Clinical information systems;

Data

Inspection, state

Conditions of Participation, 128–129

see also Certification;

Licensure

Intermediaries, see Fiscal Intermediaries

Intervening care, 160, 187, 196;

see also Medicare Peer Review Program;

Readmission, to hospital

J

JCAHO, see Joint Commission on Accreditation of Healthcare Organizations

Joint Commission on Accreditation of Healthcare Organizations

Agenda for Change, 56, 61, 125, 355, 396

decision rules, 129–130, 134

deemed status, 7–8, 111, 119, 134

see also Certification;

Conditions of Participation;

Decertification

L

Legislative charges to IOM, xii

Liability, 159, 211–215;

see also Malpractice

Licensing, 162, 171, 269–270

Licensure, 251–252, 269–270;

see also Certification

Life expectancy, 26, 85, 86

Long term care, 81–84, 91–93

M

Malpractice, 35–37, 211–215, 220;

see also Liability)

Market forces and competition, 33, 35, 37, 220–221, 296

Medical records, 134, 141, 178, 191, 241–242, 255, 258, 318, 358–359

Medicare

administration, 102

claims processing, 102

Conditions of Participation, 111

data systems, see Medicare Statistical System

deductibles and coinsurance, 104

enrolled population, 100

expenditures, 28–29, 105–108

financing, 103

HMO and CMP risk contracts, 100–102

Hospital Insurance (Part A), 97

legislation related to, 98

Medicare Insured Groups, 102

mission, 4–5, 96, 375–377

prospective payment system, 79–80, 82–83, 107–109, 394–396

quality assurance goals, 5, 110–111;

see also Conditions of Participation;

Medicare Peer Review Organizations;

Utilization Management

Supplementary Medical Insurance (Part B), 99

Medicare Peer Review Organizations (PROs)

ambulatory review, 194, 256–257

beneficiary complaints, 170

beneficiary relations, 169–170

contracts, 148–149

data acquisition, sharing, and reporting, 170–171

denials for substandard quality of care, 190–191

DRG validation, 149, 156–159

funding, 171–173

generic screens, 154–155, 160, 183–186

HMO and CMP review, 173–177, 193–195

home health review, 186–187

intervening care, 160

interventions (QIP), 161–163

Manual, 148

nonhospital review, 159–160, 196–197

organizational characteristics, 148

outreach, 170

oversight, 193, 197, 372, 379–383, 420

physician review, 187

preadmission and preprocedure review, 159

PRO pilots, 179–180

provider relations, 170

quality interventions, 161–3

required review activities, 149–160, 169–171

review of rural care, 159, 188–189

sanctions, 163–169, 189–190

scope of work, 154–156, 159

triggers (weighted), 162–163

waiver of liability, 159

Medicare Peer Review Organization Program

administration of program, 148

administrative procedures, 192

controversial aspects of, 182–195

costs, funding, 171–173

enabling legislation, 147–148

evaluation (program), 180–182, 192–193, 260

peer review, 188–189

PROMPTS-2, 180

review of rural care, 159, 188–189

SuperPRO, 180–182

UCDS (Uniform Clinical Data Set), 177–179

Medicare Program to Assure Quality, 1, 10–14, 378, 387–400

allocation of resources, 393–394

evaluation/public oversight, 379–383, 399–400, 414, 417–418

implementation strategy, 14–17, 412–419

funding, 9–10, 385–387

operational overview, 12–14, 389–392

problems and limitations, 392–393

research, 418

responsibilities, 394–400

special projects, 416–417

structure, 388–389

Medicare Quality Review Organization, 378–379, 400–410

data, data collection, and analysis, 401–408, 415

evaluation, 398–399

feedback, data reporting, and data sharing, 408–410, 415–416

funding, 396–397

quality interventions, 410–412

reconsideration of PRO functions, 395–396

review topics, 404–405

Medicare Statistical System (MSS), (M/MDSS), 117–118

Mental health, 90–91

MPAQ, see Medicare Program to Assure Quality

MQRO, see Medicare Quality Review Organization

N

NAQAP, see National Association of Quality Assurance Professionals

National Association of Quality Assurance Professionals, 361

National Center for Health Services Research, 346

National Center for Health Statistics, 69, 79, 90

National Committee on Quality Assurance, 268

National Council on Medicare Quality Assurance, 379, 382–383

National League for Nursing, 252, 268

National Practitioner Data Bank, 171, 396

NCHS, see National Center for Health Statistics

NCHSR, see National Center for Health Services Research

NCQA, see National Committee on Quality Assurance

Net benefit, 4, 21, 22, 320

NLN, see National League for Nursing

Nosocomial (hospital-acquired) infections, 125, 154, 156, 184

Notices of denial, 196;

see also Medicare Peer Review Organization Program

Nursing homes, 74–75, 81–82

O

OBRA, see Omnibus Budget Reconciliation acts

Occurrence screens, 307–308;

see also Adverse patient occurrences;

Generic screens

Office of Inspector General

activity on interventions and sanctions, 167, 169, 217

enforcement authority, 145, 163–167, 189, 200, 411

evaluation of PRO program, 193

procedures for recommending sanctions to, 166

recommendations on penalties, 189–190

recommended role of, 383

OIG, see Office of Inspector General

Omnibus Budget Reconciliation Act of 1986, 1, 148, 173, 180

Omnibus Budget Reconciliation Act of 1987, 102, 148, 149, 190, 252, 253

Omnibus Budget Reconciliation Act of 1989, 191

Organizational change, 294–295

Outcome measures, 266, 405

in ambulatory care, 247, 406–407

in Conditions of Participation, 128

in data bases, 276, 358;

see also Outcomes data

distinguishing providers on basis of, 16

in health status assessment, 284, 286

for home health care, 253, 406

limitations of, 13, 128, 132, 259, 276, 286, 358, 391, 402, 409

in MPAQ, 12–13, 386, 389–391

nonintrusive, 266

OBRA requirements, 253

patient-provider decision-making process and, 36

process links with, 6, 21, 51, 62, 54, 316, 348, 353, 357, 364, 377, 391–392

research needs on, 273, 351, 353, 357, 383–384

scales, 253

severity adjustment, 351

strengths of, 286

in structure-process-outcome model, 53, 56–58

Outcomes

art-of-care and, 350–351

assessment, 247, 253, 266–267, 276, 277, 319, 405, 406

and burden of harm, 207

continuity of care and, 13–14

of the elderly, 200

in home health care, 218, 250–251, 253

of hospital care, small area analysis, 179

longitudinal, 196

management, 74, 407

physician certification and, 271–272

population, 11, 196, 259

provider-patient relationship and, 25

research, 8, 327, 346–347, 397–398

underuse and, 226

volume of services and, 276–277

see also Surgical mishaps

Outcomes data

collection of, 390–391, 393, 397, 404–408, 415

confidentiality, 360, 409

from data bases, 273–275

general points, 279–280

hospital mortality rates, 280

lack of, 58, 134, 135

medical complications, 281

recommended scope of, 403

uses, 5, 7, 10, 12, 15, 247, 377, 383, 387, 388–389

Outliers, 46–47, 141, 208, 416–417;

see also Physician, performance

Outreach, 170

Overuse

and burden of harm, 208–209, 210, 220–224

defined, 208

fee-for-service and, 140, 230

and underuse, 210

P

Patient

complaints, 287–289

compliance, 241

decision making, 22, 362, 385, 407–408

education, 169, 362

management guidelines, 272–273, 306–307, 322–323

privacy/confidentiality, 359–160

records, 242;

see also Medical records

reports, 284–285

satisfaction, 244, 284–285, 347, 350–351

Patrick v. Burget, 245

PDCA cycle, 59

Peer review, 148, 154, 170, 188–189, 198, 244

Performance

exemplary, 16, 47, 323, 416

profiles, 244, 410–411

standards, 62, 124–125

Physician

attestation, 140

education, 139, 162, 177, 292–293, 361–362;

see also Continuing Medical Education

manpower, 27–28

payment, 31, 99–100

performance, 16, 47, 141, 416–417;

see also Outliers

Physician Payment Review Commission, 110–111, 187–188

Pilot projects, PRO, 179–180

Policies and procedures, 192, 241

Population-based measures, 36–37, 63;

see also Quality-of-care indicators/measures

Potentially compensable events, 213;

see also Liability

PPRC, see Physician Payment Review Commission

PPS, see Prospective payment system

Practice guidelines, 272–273, 328

research needs, 353–354;

see also Guidelines

Practice variations, 222

small area analysis, 222–223

Premature discharge, 156, 223, 225, 227–228, 245

Prepaid care, 100–102, 194–195, 246, 256–258;

see also Competitive Medical Plans;

Health maintenance organizations

Preventable deaths, 214

PROs, see Medicare Peer Review Organizations

Process measures of quality, 54–56, 277–279, 350–351, 391–392, 402–403

linking process with outcomes, 279–280, 353

see also Quality-of-care indicators/measures

Professional Standards Review Organizations

activities, 140–142

costs, 143

delegated review, 142–143

impact, 146

National Council, 144

sanctions, 145–146

structure, 140

Professional incompetence, 215

Professionalism, 18, 32–33, 291

ProPAC, see Prospective Payment Assessment Commission

Prospective Payment Assessment Commission, 17, 29, 107, 109–110, 184, 227–228, 346, 382

Prospective payment system, 79–80, 82–83, 107–109, 227

and cost containment, 109, 394–396

PSROs, see Professional Standards Review Organizations

Public good, 34, 379

Public oversight

MPAQ, 399–400, 417–418

PRO, 193, 197, 372, 379–383, 420

Q

Quality assessment, defined, 45–46

Quality assurance

defined, 45

ideology, 296

international perspective, 61–62

leadership, 296

purpose of, 46–47

professional responsibility for, 32–33

public responsibility for, 33–34

Quality assurance, models

bi-cycle model, 62, 293

continuous improvement, 58–61

focus, 3

health accounting, 62

MPAQ, 371–373

structure/process/outcome, 53–58, 387

traditional and continuous improvement models compared, 62–64

Quality assurance, programs

criteria for judging success of, 49–52

external, 48–49

federal, see Conditions of Participation;

Medicare Peer Review Organization Program

findings and conclusions, 2

internal, 47–49, 268, 388–389

Quality of care

criteria for review, see Criteria, quality assurance

definitions, 4–5, 20–25, 375–377

effect of organization and financing, 295–297

research needed, 357–358

Quality-of-care indicators/measures

complication rates, 281

mortality rates, 280

nosocomial infections, 125, 154, 156, 184

reliability and validity, 266–267, 311–314

retrospective methods, 221, 226, 277–279

structural measures, 53–54

volume of service, 276–277

see also Generic screens;

Outcome measures;

Population-based measures;

Process measures of quality

Quality-of-care problems

in ambulatory care, 246–250

correcting, 244–245, 249–250, 253–254

detecting, 242–244, 247–249, 252–253

differentiating among problems, 209–210

in home health, 218–219, 250–254

interpersonal care, 208

overuse, 220–224

preventing, 241, 246, 251–252

technical care, 207–209, 211–219

underdiagnosis/undertreatment, 226–227, 228–229

underuse, 209, 225–230

see also Art of care

Quality interventions

MQRO, 410–412, 416

PRO, 161–163, 167–169

QualPAC, see Quality Program Advisory Commission

Quality Program Advisory Commission, 7, 379–382

R

Readmission, to hospital, 161, 186, 227, 275

Reappointment and privileging, 240, 241

Recommendations

capacity for quality, enhancement of, 8–9, 384–385

funding, 9–10, 385–387

goals for Medicare quality assurance, 6, 377–378

Medicare Conditions of Participation, 8–9, 383–384

mission of Medicare, 5–6, 375–377

National Council on Medicare Quality Assurance, 7, 379, 382

PRO program restructuring, 6, 378–379

public accountability and evaluation program, 6–7

Quality Program Advisory Commission, 7, 379–381

report on quality of care, 7, 379

research into efficacy, effectiveness, and outcomes of care, 8–9, 384–385

Regulation, in medicine, 33

Administrative Procedure Act, 148

Code of Federal Regulations, 120

PRO, 192, 147–148

PSRO, 145–146

TEFRA, 101, 110, 147–148, 188

see also Conditions of Participation

Reliability, 226–227, 311–314

Reminders, clinical, 244, 266, 273–274

Reports, patient, 284–285

Research

access to care, 344, 346, 381

ambulatory care, 355

appropriateness, 345, 353–354

capacity building, 343

clinical information systems, 358

CMPs, 356–357

continuous quality improvement, 352, 362–363

effectiveness, 348–350, 354–355

funding, 363

guidelines, 353–354

HCFA, 346

health services, 344

health status assessment, 351–352

HMOs, 356–357

in home health, 356

MPAQ, 418

outcomes, 8, 327, 346–347, 397–398

practice guidelines, 353–354

practice variations, 222–223

priorities for, 345

rural care, 357

severity of illness, 351

Resource allocation, 393–394

Resource constraints, 24, 377, 402

Retrospective review, 140–141, 162, 221, 277–279, 310

Rewards and penalties, 256, 266, 293;

see also Incentives

Risk

adjustment, 275, 277, 391;

see also Severity of illness

contracts, 100–102

management, 35–37, 208, 241, 283;

see also Liability;

Malpractice

Rulemaking and public notice, 148, 192

Rural care, 27, 29, 99, 108, 135, 159

and peer review, 188–189

research needs, 357

S

Sanctions and sanctioning process, 145–146, 216–217, 412

PRO, 163–169, 189–190

recommendations to OIG, 169

Satisfaction, 1, 20, 21–22, 23

patient, 244, 284–285, 347, 350–351

Severity of illness

adjustment, 12, 243, 255, 280–281, 383, 405

research into, 351

Shifting the curve, 16, 47, 416;

see also Physician, performance

Small area variations analysis, 179–180, 276, 222–223, 346–347;

see also Pilot Projects;

Practice variations

Statistical control (quality control), 58

Structural measure of quality, 53–54, 56–58, 268, 378

Study methods

criteria-setting panel, xiv

focus groups, xiv

public hearings, xiv

site visits, xiv

Suppliers, 35, 59–60;

see also Continuous quality improvement;

Customers

Surgical mishaps, 213

Survey and certification, 4, 7, 8, 14, 121, 124, 128, 129, 132–135, 180, 410;

see also Conditions of Participation;

Joint Commission on Accreditation of Healthcare Organizations

Surveys

of activity limitations in elderly, 90

of defensive medical practices, 220

health status assessment, 407

of home health quality problems, 218, 240

of hospital discharge rates, 79

measurement of quality through, 53, 56

patient satisfaction, 279, 284–285

of PRO impact, 182

recommended, 400

of underuse, 226

T

TAP, see Technical Advisory Panel

Tax Equity and Fiscal Responsibility Act, 101, 110, 147, 148, 188

Technical Advisory Panel, 382–383

Technical quality, 207–208, 211–219

defined, 207–208

and interpersonal care, 207–208, 211–219, 296, 353

see also Quality-of-care problems

TEFRA, see Tax Equity and Fiscal Responsibility Act

U

UCDS, see Uniform Clinical Data Set

Underdiagnosis and undertreatment, 226, 227, 228–230;

see also Quality of care problems

Underuse, 225–230

access to care and, 23, 52, 225, 226, 275, 284, 389

and burden of harm, 209–210, 225–230

defined, 209

and outcomes, 226

and overuse, 210

surveys of, 226

see also Quality-of-care problems

Uniform Ambulatory Care Data Set, 248

Uniform Clinical Data Set, 177–179, 186, 395, 404

Uniform Needs Assessment, 180, 227, 346, 356, 406

Use of services;

see Elderly, use of services;

Overuse;

Underuse

Utilities, 36, 57, 61, 352

Utilization management, 30–31, 36, 37, 111, 140–141, 374, 394–395

Utilization and Quality Control Peer Review Organizations Program, see Medicare Peer Review Organizations;

Medicare Peer Review Organization Program

V

Validity/validation, 51, 316

of appropriateness guidelines, 319–320, 328

of DRGs, 156–159

of patient evaluation and management criteria, 328

of quality of care indicators/measures, 266–267, 311–314

Value purchasing, 36

Variations, 222–223

research, 348–350

small area, 179–180, 222–223, 276

Volume of services, 276–277