Outline

Quality Management

1. Theory and History
1. Industrial and Service Industry Perspectives
1. Major contributors to the development of theory and practice
2. Application to Healthcare
1. Healthcare systems
2. Individual components of healthcare systems

2. Application
1. Organizational
2. Clinical
3. Public Health

3. Methodology, Techniques and Measurement
1. Statistical Systems
1. Indicators and monitors
2. Demographics
3. Statistical techniques
2. Information Systems
3. Outcomes Evaluation
1. Clinical
2. Other
4. Provider/Consumer Survey
5. Performance Based Incentive
6. Techniques
1. CQI/TQM
2. Profiling
3. Performance review
4. Disease management and clinical pathways
5. Individual and population management
6. Credentialing
7. Committees
8. Peer review
9. Outcomes assessment

4. Present Outcomes Assessment Models
1. Health Plan Employer Data and Information Set (HEDIS)
2. Foundation for Accountability (FACCT)
3. Quality Improvement System for Managed Care (QISMC)
4. Orion Project
5. Others

5. Accreditation and Regulatory Oversight
1. National Committee for Quality Assurance (NCQA)
2. Joint Commission for the Accreditation of Healthcare Organizations (JCAHO)
3. Accreditation Association of Ambulatory Health Care (AAAHC)
4. American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (AAHCC/URAC)
5. QISMC
6. State and Federal Government
7. Proprietory
8. Quality Improvement Organizations (QIOs), formerly Peer Review Organizations (PROs) and the Health Care Financing Administration (HCFA)

6. Financing
1. Resources Development and Compliance
2. Cost of Poor Quality

7. The Future

Organization Design and Management

1. Individual and Group Processes
1. Attitudes
2. Motivation
3. Reward Systems
4. Group Dynamics
5. Characteristics of High Performance Groups
6. Internal and External Group Relations
7. Conflict Resolution
8. Communication (internal)
9. Power

2. Organizational Processes
1. Organization Design
2. Strategic Planning and Benchmarking
3. Job Design
4. Decision Making
5. Leadership
6. Organization Culture and Mission
7. Management Information Systems
8. Organization Change and Development
9. Stakeholder Analysis
10. Communication (external)
11. Resource Development and Allocation

3. Organizational Issues
1. Diversity
2. Ethics
3. Technology
4. Internationalization
5. Partnership and Alliance Building
6. Sales, Marketing and Competition
7. Profit vs. Nonprofit
8. Regulatory Compliance/Accreditation
9. Mergers and Acquisitions
10. Integrated Delivery Systems

4. The Future

Utilization Management

1. Scope
1. Precertification
1. Elective inpatient hospitalizations
2. Inpatient rehabilitation
3. Skilled nursing facility admissions
4. Referrals to nonparticipating providers
5. Transplants and pre-transplant evaluations
6. Selected outpatient procedures
7. Home healthcare
8. Hospice
9. Durable medical equipment rental or purchase/prosthetics
10. Ancillary services
2. Prior Approval for Selected Outpatient Services
3. Prior Approval for Off-plan Requests
4. Concurrent Review
1. Fax
2. On-site
3. Telephonic
4. Designate persons responsible
5. Discharge Planning
6. Retrospective Review
1. Manual review
2. Automated review
3. Use of criteria
1. Performance evaluation
2. Patterns review
3. Billing error, abuse and fraud (BEAF)
4. Action plans
7. Case Management
8. Evaluation of New Medical Technology Procedures
9. Use of Clinical Review Criteria
10. Denials/Appeals Trending and Analysis
11. Over/Underutilization
12. Satisfaction with UM Process [survey]
13. Disease Management
14. Physician Profiling
15. Risk Management
16. Pharmacy/Formulary Management
17. Data/Information Systems

2. Structure
1. Organizational Structure and Resources (costs)
2. Appropriate/Qualified Staff to Make Decisions
3. Process for Inter-rater Reliability
4. Committees
5. Use of Consultants/Physician Advisors
6. Coordination with QI Plan
7. Coordination with Credentialing
8. Use of Criteria
1. Milliman and Robertson [M&R]
2. Indications for surgery and procedures [Interqual ISP]
3. Health Care Finance Administration [HCFA]
4. Hospital intermediary manual
5. Local/company criteria
6. Update, revisions, overview by local/consulting physicians
9. Denials
10. Appeals
11. Evaluation of Technology
12. Program Evaluation
1. Provider
2. Consumer
13. Information Systems and Support
14. Statistical Analysis

3. The Future

Economics, Finance and Government

1. Health Economics
1. Changes in the Gross Domestic Product and in per capita spending over the last 35 years
2. Comparisons of health spending and effectiveness of healthcare delivery with other countries
3. Discussions of some cardinal Federal legislation with health economic impact, such as Medicare legislation, Medicaid legislation, Employee Retirement Income Security Act 1974 (ERISA), Tax Equity and Fiscal Responsibility Act 1982 (TEFRA), Comprehensive Omnibus Budget Reconciliation Act 1986 (COBRA), AMTALA, Balanced Budget Amendment, etc., some key state legislation such as Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) enabling legislation

2. Hospitals
1. Private Hospitals
2. For-profit Hospitals
3. Community
4. Boutique and Veterans' Administration
5. Diagnostic Related Group (DRG) Payments
6. Risk Sharing
7. Hospital Health Plan Development
8. Hospitals Employing Physicians

3. Physicians and Other Providers
1. Effect of Competition on Healthcare
2. Provider Payment Systems
3. Incentives for Behavioral Changes
4. Types of Provider Payment
1. Risk contracts
2. Fee-for-service
3. Capitation

4. Insurers and Plans
1. Types of Health Plans and their Financial Underpinnings
1. Indemnity
2. PPO
3. HMO
4. Independent Practice Association (IPA)
5. Benefit design
6. Self-funded
7. Medical Savings Accounts (MSA)
8. Administrative Services Only (ASO)

5. Government Programs
1. Federal
2. State
3. Local
Above a), b), and c) include Medicare, Medicaid, Public Health, Armed Services, Veterans' Administration, Workers' Compensation, Federal Drug Administration (FDA), Health Care Financing Administration (HCFA), Agency for Healthcare Policy and Research (AHCPR)

6. Financial Policy and Oversight
1. Resource Based Relative Value Scale (RBRVS)
2. HCFA
3. McGraw Hill/Milliman Robertson/Erisco
4. Prospective Payment System (PPS)
5. Prospective Payment Assessment Commission (ProPAC)
6. Ambulatory Care Groups (ACG)

6. Current Procedural Terminology (CPT)

7. The Future

Medical Informatics

1. Historical Perspectives
1. Software Systems
2. Hardware/Data Servers

2. Foundation and Strategic Role of Information Systems

3. Information Systems and the Quality Improvement Process

4. Information Systems and Medical Decision-Making

5. Using the Tools: Applications
1. General Applications
1. Word processors
2. Spread sheets
3. Databases
4. Project management
5. Scientific, statistical and data analysis applications
2. Internet Applications
1. Browsers
2. E-mail
3. Group software
4. Audio and video
5. Search applications
3. Healthcare Specific Applications
1. Obtaining and evaluating clinical and health information
2. Electronic medical records
3. Financial systems
4. Medical group and office systems
5. Telemedicine
6. Handheld PCs and software applications
4. Organizational Applications
1. Hospital systems
2. Physician and other provider systems

6. Ethical, Legal and Social Impact

7. The Future

Legal and Ethical Issues

1. Legal Issues
1. Confidentiality
2. Immunity/Protection of QI and Peer Review Processes
3. Legal Ramifications
1. Quality
2. Utilization management
3. Credentialing
4. Risk management
5. Peer review
4. Healthcare Quality Improvement Act
5. Medical Liability—A Quality Process
6. Due Process
7. Appeals
8. Sanctions
9. Mandates (legislative)
10. Informed Consent
11. Accreditation
12. Case Law
13. Regulatory Mandates
14. Antitrust

2. Ethics
1. Basic Ideas
1. Beneficence
2. Autonomy
3. Justice
4. Non-maleficence
2. Professional Patient Relationship
1. Veracity
2. Privacy
3. Confidentiality
4. Fidelity
3. Role of Physician
1. Vs. investigator
2. Vs. third party
4. Role of Medical Decision-Making
1. Informed consent
2. Equal information
3. Use of process
5. Who is to Decide?
1. Patient/physician
2. Clinical practice guidelines
3. Utilization management

3. The Future