Medicare -- Copyright -- Contents -- 1 Overview Of The Study To Design A Strategy For Quality Review And Assurance In Medicare -- STUDY COMMITTEE AND TECHNICAL ADVISORY PANEL -- CONDUCT OF THE STUDY -- Phases Of The Study -- Data Collection And Other Study Activities -- Main Study Tasks -- Hospital Conditions Of Participation -- Medicare Peer Review Organizations -- CONCLUDING REMARKS -- 2 Oral And Written Testimony From The Public Hearings -- METHODS -- Invitations To Submit Testimony -- Respondents To The Invitations -- Types Of Documents Submitted -- Development And Testing Of Abstract Form -- Data Base System -- Limitations Of The Analysis -- FINDINGS -- Main Themes -- Gaps In Information -- Peer Review -- Access Issues -- Patient-Physician Relationship -- Role Of The Elderly In Quality Assessment And Assurance And Health Care Decision Making -- Interrelationship Of Quality, Costs, And Financing -- Patient-Centered Quality Assurance System -- Clinical Guidelines, Specialty Board Certification, And Credentialing -- Need To Measure, Demonstrate, And Prove Performance Competency -- Assessing The Needs Of The Elderly -- Continuous Quality Improvement -- Responses To Specific Questions -- Defining Quality Of Care -- Assessment Of Contemporary Health Care -- Cost Containment And Quality Health Care -- Medicare Benefits -- Costs Of Quality Assessment And Assurance Activities -- Assessment Of Adequacy Of Quality Assessment And Assurance -- Comments Of Pros -- Comments of Superpro -- Comments Of Other Groups Conducting External Quality Reviews -- Comments Of Third-Party Payers And Purchasers -- Comments Of Direct Care Providers -- Most Effective And Least Effective Activities -- Adequacy Of Current Level Of Quality Assessment -- Adequacy Of Current Quality Assessment And Assurance Tools Or Methods.

Coordinating Quality Assessment And Assurance Activities -- Recommendations -- Recommendations For Improving The Quality Of Health Care Generally -- Recommendations Concerning Broad Quality-Of-Care Topics -- Recommendations Concerning Quality Assessment Methods -- Recommendations Concerning Specific Quality Assurance Activities -- Recommendations For Research And Development -- CONCLUDING REMARKS -- Appendix A Guidelines For Written Testimony A Study To Design A Strategy For Quality Review And Assurance In Medicare -- PART A. BACKGROUND -- PART B. KEY QUESTIONS -- PART C. FORMAT -- Appendix B Organizations Submitting Testimony -- 3 Results of The Medicare Beneficiary and Physician Focus Groups -- BENEFITS AND LIMITATIONS OF FOCUS GROUPS -- STUDY METHODS -- Subcontractor Selection -- Focus Group Site Selection -- Development Of The Moderator's Guide -- The Recruiting Process -- Focus Group Composition -- Pre-Recruitment Specifications Of The Beneficiary Focus Groups -- Pre-Recruitment Specification Of The Physician Focus Groups -- Final Composition Of The Groups -- Focus Group Process -- FINDINGS OF THE BENEFICIARY FOCUS GROUPS -- Personal Experience And Satisfaction With Health Care -- Recent Experience -- Satisfaction With Care -- View Of The Concept Of Quality -- Quality Of Care And Medicare -- Quality Of Care Now And In The Past -- Understanding How Health Care Is Monitored -- How Respondents Handle Problems -- Awareness Of How Medical Care Is Monitored -- Desire For Information About Quality Of Care -- Patient Choice -- Variations In Quality Of Care -- Sources Of Health Care Information -- Types Of Information Desired -- Knowledge Of Medicare Part B -- Suggestions For Improving The Quality Of Medical Care -- FINDINGS OF THE PHYSICIAN FOCUS GROUPS -- Positive And Negative Aspects Of Medical Care -- Views On The Concept Of Quality.

Does The Medicare Program Affect The Quality Of Care Physicians Provide? -- Identification Of Quality Problems -- Effectiveness Of Quality Assurance Mechanisms -- Ways To Improve Quality Of Care -- CONCLUDING REMARKS -- Findings From The Beneficiary Focus Groups -- Findings From The Physician Focus Groups -- NOTES -- REFERENCE -- APPENDIX A -- Appendix B Moderator's Guide For The Physician Focus Groups -- Appendix C Recruiting Screener: Medicare Beneficiary Focus Groups -- Appendix D Recruiting Screener: Physician Focus Groups -- 4 Site Visits -- METHODS -- Site Visit Schedule And Planning -- Visits To Organizations -- Meetings -- Documentation -- ISSUES -- PROBLEMS OF QUALITY AND QUALITY ASSURANCE -- Problems Reported By Pros And Other External Regulatory Bodies -- Generic Screens -- Other Problems -- Problems Reported By Hospitals -- Problems Reported By Hmos -- Problems Reported By Physicians For Office-Based Practice -- Problems Reported By Hhas -- CONCLUDING REMARKS -- NOTES -- Appendix A Confirmation Letter Regarding Site Visit -- Appendix B Guide For Site Visitors Strategies For Quality Review And Assurance In Medicare -- HEALTH CARE FACILITIES WITH INTERNAL QUALITY ASSURANCE PROGRAMS: -- Assessment -- Interventions/Assurance -- Impact Of Interventions/ Restudy -- Costs and Burdens (For Internal And External Review) -- Advocacy/ Shared Decision Making -- 5 Defining Quality of Care -- METHODS -- KEY DIMENSIONS USED BY SEVERAL GROUPS IN DEFINING QUALITY -- A Scale Of Quality -- The Nature Of The Entity Evaluated, Or The Quality Of What? -- Type Of Recipient -- Goal-Oriented Care -- Risk Versus Benefit Tradeoffs -- Aspects Of Outcomes Specified Or Not -- Role And Responsibility Of Recipient Asserted -- Constrained By Technology And The Existing State Of Scientific Knowledge -- Technical Competency Of Practitioners And Providers.

Interpersonal Skills Of Practitioners -- Accessibility -- Acceptability -- Constrained By Resources -- Standards Of Care -- Constrained By Consumer And Patient Circumstances -- Documentation Required -- Continuity, Management, And Coordination -- Specific Statements About Use -- THE COMMITTEE'S DEFINITION -- CONCLUDING REMARKS -- REFERENCES -- APPENDIX EXAMPLES AND SOURCES OF DEFINITIONS OF QUALITY -- 6 A Quality Assurance Sampler: Methods, Data, And Resources -- INTRODUCTION -- Purpose Of Chapter -- Sources Of Information -- Site Visits -- Other Sources -- Organization Of Chapter -- Setting Of Care -- Purpose Of Quality Activity -- Locus Of Activity -- Comment -- HOSPITAL -- External Methods Of Preventing Problems In Hospitals -- Medicare Conditions Of Participation -- The Joint Commission -- Other Accreditation Programs -- State Licensing And Safety Requirements -- Other Hospital-Related Requirements -- Malpractice Insurance Underwriters -- International Efforts -- Internal Methods Of Preventing Problems In Hospitals -- Medical Staff Standards -- Common Internal Organization Actions -- Risk Management -- External Methods Of Detecting Problems In Hospitals -- Medicare Pros -- Federal, State, Community, And State Hospital Association Data Bases -- Types Of Data Sets.3 -- Hcfa Mortality Rates -- Small Area Variations Analysis (Sava) -- Volume Of Services (Individual Or Organization) -- State And Local Hospital Discharge Data -- Complaints -- State Reporting Requirements -- Malpractice Claims -- Internal Methods Of Detecting Problems In Hospitals -- Quality Assurance Committee -- Quality Assurance Department -- Monitoring -- Concurrent Review -- Generic Screening -- Surgical Case Review -- Blood Usage Review -- Drug Usage Evaluation -- Pharmacy And Therapeutics Review -- Medical Record Review -- Focused Review -- Peer Review.

The Health Care Quality Improvement Act Of 1986 -- Case Conferences -- Autopsy Findings -- Utilization Review -- Discharge Planning -- Infection Control -- Risk Management -- Patient And Family Grievance Systems -- Patient And Employee Satisfaction Surveys -- Patient Complaints -- Observation -- Note On Individual-Case Methods -- External Methods Of Correcting Problems In Hospitals -- Pro Actions Regarding Physicians And Hospitals -- Actions By State Entities -- Internal Methods Of Correcting Problems In Hospitals -- Event-Based Actions -- Practice Pattern-Based Actions -- Organization-Based Actions -- Continuous Improvement Approaches -- AMBULATORY CARE -- Preventing Problems In Ambulatory Care -- External Methods Of Preventing Problems Directed At Individuals (Physicians) -- Credentials, Licensure, And Specialty Certification -- Physician Licensure -- The Health Care Quality Improvement Act Of 1986 -- Specialty Certification And Recertification -- External Methods Of Preventing Problems Directed At Institutions -- Accreditation -- External Methods Of Preventing Problems Directed At Prepaid Or Managed Health Care Plans -- Federal Hmo Act -- State Hmo Regulations -- Accreditation For PPOs -- Legislation Related To Negative Financial Incentives -- Internal Methods Of Preventing Problems In Ambulatory Care -- Credentialing -- Continuing Education -- Other Structural Requirements Of Practices -- Practice Guidelines And Algorithms -- Clinical Reminder Systems -- Member Education And Outreach -- Patient Education -- Geriatric Programs -- Case Management -- Mission Statement -- External Methods Of Detecting Problems In Ambulatory Care -- Pro Review Of Hmos And Cmps -- State HMO Review -- Other External Review -- Medical Malpractice And The HCQIA -- Internal Methods Of Detecting Problems In Ambulatory Care.

Historical Efforts And Research Projects Applicable To Internal Quality Assessment Efforts.