CMSA Glossary of Terms Related Quality Indicators
JCAHO: Joint Commission on Accreditation of Health Care Organizations.
Utilization Review Accreditation Commission (URAC): A not-for-profit organization that provides reviews and accreditation for utilization review services/programs provided by freestanding agencies. It is also known as the American Accreditation Health Care Commission.
Commission on Accreditation of Rehabilitation Facilities
Centers for Medicare & Medicaid Services
- health outcomes
- clinical processes
- patient safety
- efficient use of health care resources
- care coordination
- patient engagements
- population and public health
- adherence to clinical guidelines
Utilization Review Accreditation Commission
URAC’s case management standards cover:
- Scope of services standard; types of clients served, delivery model for case management services, qualifications for case management staff.
- Case management staff standard; guidelines for caseload, availability of physician for consultation, a process for training and education of case managers.
- Case management process standard; criteria for identifying clients for case management services, disclosure to clients the nature or the case management relationship, documentation of consent, policies to document patient assessments, policy for resolving disagreements, criteria for discharge.
- Organizational ethics and confidentiality standard; policy and procedure to protect confidentiality, promotion of autonomy of decision making, patient input into the case management plan, respecting rights of patient to refuse treatment or services.
- Complaints standard; policies and procedures for patients and providers to submit a complaint.
National Committee for Quality Assurance
NCQA’s Case Management Accreditation:
- Directly addresses how case management services are delivered, not just the organization’s internal administrative processes.
- Gets right to the core of care coordination and quality of care.
- Is designed for a wide variety of organizations. It is appropriate for health plans, providers, population health management organizations, and community-based case management organizations.
- focuses on ensuring the organization has a process to ensure safe transitions.
The standards address how case management programs:
- Identify people who are in need of case management services;
- Target the right services to people and monitor their care and needs over time.
- Develop personalized, patient-centered care plans;
- Monitor people to ensure care plan goals are reached and to make adjustments as needed;
- Manage communication among providers and share information effectively as people move between care settings, especially when there are transitions from institutional settings;
- Build in consumer protections to ensure people have access to knowledgeable, well-qualified case management staff;
- Keep personal health information safe and secure.
NCQA standards also call for case management program staff to stay up to date on the latest evidence and care management techniques and work towards continuous improvement in patient outcomes and satisfaction.
National Quality Forum
NQF has endorsed performance measures that can be used to measure and quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality care. Once a measure is endorsed by NQF, it can be used by hospitals, healthcare systems, and government agencies like the Centers for Medicare & Medicaid Services for public reporting and quality improvement.
NQF Performance Measures:
- Convenes working groups to foster quality improvement in both public- and private-sectors;
- Endorses consensus standards for performance measurement;
- Ensures that consistent, high-quality performance information is publicly available; and
- Seeks real time feedback to ensure measures are meaningful and accurate.
NQF-endorsed measures are evidence-based and valid, and in tandem with the delivery of care and payment reform, they help:
- Make patient care safer;
- Improve maternity care;
- Achieve better health outcomes;
- Strengthen chronic care management;
- Hold down healthcare costs. New directions are further strengthening how we engage with the healthcare community to drive quality improvements.
Agency for Healthcare Research and Quality
AHRQ’s priority areas of focus are:
- Improve health care quality by accelerating implementation of patient centered outcomes research
- Increase accessibility to health care
- Improve health care affordability, efficiency, and cost transparency
- Make health care safer:
-Prevent healthcare associated infections
-Accelerate patient safety improvement in hospitals
-Reduce harm associated with obstetrical care
-Improve safety and reduce medical liability
-Accelerate patient safety improvements in nursing homes