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Glossary of Terms in Managed Health Care
The following are definitions of commonly used terms in the medical provider, hospital and managed care industries. This dictionary is comprised of 26 individual pages, one for each letter of the alphabet. To find a certain word that starts with this letter of the alphabet, may we suggest that you please try the "find" or "search" function in your browser. Or you may simply scroll down the list. If your word starts with another letter, please use the alphabet index below.
This glossary can also be purchased in printed book format if you would like to have it accessible to your at all times.
QA, QI, or QM - See Quality Assurance, Quality Improvement, or Quality Management.
QARI - See Quality Assurance Reform Initiative.
QISMC - See Quality Improvement System for Managed Care.
Quality - Quality is, according to the Institute of Medicine (IOM), the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Quality can be defined as a measure of the degree to which delivered health services meet established professional standards and judgments of value to consumers. Quality may also be seen as the degree to which actions taken or not taken maximize the probability of beneficial health outcomes and minimize risk and other untoward outcomes, given the existing state of medical science and art. Quality is frequently described as having three dimensions: quality of input resources; quality of the process of services delivery (the use of appropriate procedures for a given condition); and quality of outcome of service use (actual improvement in condition or reduction of harmful effects).
Quality is how well the health plan or health care provider keeps its members or patients healthy or treats them when they are sick. Good quality health care means doing the right thing at the right time, in the right way, for the right person - and getting the best possible results.Quality programs are commonly called QA, TQM, QI, CQI - all referring to the process of monitoring quality in systematic ways.
Quality Assurance (QA) - Activities and programs intended to assure the quality of care in a defined medical setting. Such programs include peer or utilization review components to identify and remedy deficiencies in quality. The program must have a mechanism for assessing its effectiveness and may measure care against pre-established standards. Also called quality improvement. A formal methodology and set of activities designed to access the quality of services provided. Quality assurance includes formal review of care, problem identification, corrective actions to remedy any deficiencies and evaluation of actions taken. See also Continuous Quality Improvement.
Quality Assurance Reform Initiative (QARI) - A process developed by the Health Care Financing Administration (now called CMS) to develop a health care quality improvement system for Medicaid managed care plans. The Quality Assurance Reform Initiative was unveiled in 1993 to assist States in the development of continuous quality improvement systems, external quality assurance programs, internal quality assurance programs, and focused clinical studies.
Qualified Beneficiary - Generally, qualified beneficiaries include covered employees or enrollees, their spouses and their dependent children who are covered under a group health plan. In certain cases, retired employees, their spouses and dependent children may be qualified beneficiaries.Quality Improvement (QI) - Also called performance improvement (PI), QI is a management technique to assess and improve internal operations. QI focuses on organizational systems rather than individual performance and seeks to continuously improve quality rather than reacting when certain baseline statistical thresholds are crossed. The process involves setting goals, implementing systematic changes, measuring outcomes, and making subsequent appropriate improvements. QI implies that concurrent systems are used to continuously improve quality, rather than reacting when certain baseline statistical thresholds are crossed. Quality improvement programs usually use tools such as cross-functional teams, task forces, statistical studies, flow charts, process charts, Pareto charts, etc. This is the more commonly used term in healthcare, replacing QA. See also Continuous Quality Improvement.
Quality Improvement Organization (Medicare) - Groups of practicing doctors and other health care experts that are paid by the federal government to check and improve the care given to Medicare patients. They must review patient complaints about the quality of care given by: inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Private Fee-for-Service Plans, and ambulatory surgical centers. These doctors also review fast-track termination decisions in comprehensive outpatient rehabilitation facilities, skilled nursing facilities, and home health and hospice settings for people in Medicare Health Plans.
Quality Improvement System for Managed Care (QISMC) - A CMS program designed to strengthen MCOs' efforts to protect and improve the health and satisfaction of Medicare and Medicaid enrollees.
Quality Management (QM) - Used interchangeably with Quality Assurance (QA), Quality Management usually involves an internal review process that audits the quality of care delivered and implements corrective actions to remedy any deficiencies identified in the quality of direct patient care, administrative services or support services. The process can employ peer review, outcomes assessment, and utilization management techniques to assess and improve the quality of care. The level of care may be measured against preestablished standards.
Quality Management Committee - The MCO committee that oversees the organization's quality assessment and improvement activities in both clinical and nonclinical areas.
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