2 - Accreditation, Credentialing, Certification and Healthcare Quality Measures

Medicare is a _________________________ that pays for medical care for the elderly and Americans with certain disabilities. Medicare is administered by the ______________________

federal health insurance program

Centers for Medicare & Medicaid Services (CMS)

Credentials are defined as documented ______________________, including diplomas, licenses, certificates, and certifications. Credentials are reflected in a variety of abbreviations that individuals place after their names.

Accreditation is the process by which an association, organization, or governmental agency grants ________________________ to an organization, site, or program that meets certain __________________________, as determined through initial and periodic evaluations.

evidence of professional qualifications

public recognition

established qualifications or standards

Credentialing is the process by which an organization or institution ________________________ to provide patient care services in a subject or an area.

_________________ is the process by which a health care organization, having reviewed an individual health care provider’s credentials and performance and found them satisfactory, ____________________________ of patient care services within that organization.

obtains, verifies, and assesses an individual’s qualifications

Privileging

authorizes that individual to perform a specific scope

Certification is a voluntary process by which a nongovernmental agency or an association grants _____________________ who has met certain pre-determined qualifications specified by that organization. Certification usually requires __________________________ of the individual’s knowledge, skill, and/or experience.

A certificate is a ____________________ to an individual after the successful completion of a predetermined level of performance in a certificate program or a pharmacy residency or fellowship.

recognition of an individual

initial assessment and periodic reassessments

document issued

Accreditation is the process by which a private association, organization, or government agency, after initial and periodic evaluations, ________________________, site or program that has met certain established criteria.

Important examples of accreditation programs include: _________________________

grants recognition to an organization

- Accreditation Council for Pharmacy Education (ACPE) for pharmacy schools

- The Joint Commission (TJC) for hospitals and others

The Joint Commission (which was formerly known as the __________________) does a _______________________, in which it measures organizations (e.g. ambulatory care, assisted living, etc.) against ______________________.

Joint Commission on Accreditation of Hospitals

“voluntary” accreditation process

national standards defined by healthcare professionals

The benefits of hospital accreditation include: ________________________

- enhancement of public confidence

- stimulation of continuous quality improvement (CQI)

- meeting Medicare/Managed Care certification requirements

The 2019 Joint Commission Acute Care Patient Safety Goals include improving staff communications, patient identification, medication safety/labeling, medication reconciliation, and patient education on medications as well as preventing infections, patient safety risks, and wrong-site surgery.

Medication Reconciliation, which is the process of compiling the most accurate list of medications a patient is taking to avoid errors like duplication, dosing errors, or drug interactions, is to be done at ____________________________

The five basic steps for Med Rec include: ________________________

Hospital Admission and then at Discharge

1.) Develop list of previous meds

2.) List newly prescribed meds

3.) Compare the lists

4.) Respond to differences

5.) Finalize new list to caregivers and patient

"Medicaid" is different from "Medicare." This is because Medicaid: ________________________

Medicaid is aka: __________________________

covers low-income families and is administered on a state level

- Public Assistance

- Down Payment Assistance (DPA)

- Welfare

Medicare Part A covers: ______________________

- Hospital Insurance

- Inpatient care in a hospital, skilled nursing facility, some home health care, and hospice care

Medicare Part B covers: ______________________

- Medical Insurance

- Outpatient doctor's visits

- Some medical supplies (e.g. diabetes test strips)

- Some vaccinations

Medicare Part C is aka ____________________ and covers: ________________________

AKA Medicare Advantage Plans

Custom plans for more specific medical needs

Medicare Part D covers: ______________________

prescription medications either within a Part C Medicare Advantage plan or as an add-on to Part B

ORYX® is a quality performance measure in the U.S. Healthcare System that is initiated by ________________________ and evaluates _____________________ by implementing core measurements to improve the safety and quality of healthcare. Some core measure sets include Acute MI, Children's Asthma Care, Tobacco Treatment, etc.

The Joint Commission and/or Centers for Medicare & Medicaid Services (CMS)

hospitals

HCAHPS, which stands for _______________________, is a quality performance measure in the U.S. Healthcare System that is initiated by ________________________

HCAHPS is a mandated standardized ________________________. It consists of 32 patient questions and includes 18 key aspects of satisfaction, with a pharmacy focus on pain management, communication about medications, and discharge instructions.

Hospital Consumer Assessment of Healthcare Providers & Systems

The Centers for Medicare & Medicaid Services (CMS)

survey allowing valid online comparison of hospitals

HEDIS®, which stands for _______________________, is a quality performance measure in the U.S. Healthcare System that is initiated by the ________________________

HEDIS® centers on the _____________________, with its main purpose to evaluate _____________________

Healthcare Effectiveness Data and Information Set

National Committee for Quality Assurance

quality of care, access to care, and member satisfaction

health plans and physicians

Part D STAR Measures is a quality performance measure in the U.S. Healthcare System that is initiated by ________________________

There are numerous performance measures across several domains of performance, as defined by _________________________, which is a consensus-based process aimed at defining performance measures that focus on the appropriate use of medications and pharmacy services.

The four domains of Part D STAR Measures include:

The Centers for Medicare & Medicaid Services (CMS)

The Pharmacy Quality Alliance (PQA)

1.) Staying healthy

2.) Managing chronic conditions

3.) Drug plan customer service/satisfaction

4.) Drug pricing and patient safety

Part D STAR Measures serve to evaluate __________________

There are five PQA measures in the 4th domain of Part D STAR Measures (Drug pricing and patient safety). These five measures include: ______________________

health plans and pharmacy

medication adherence measures

- 1) HMG-CoA inhibitors (statins)

- 2) Renin-Angiotensin System Antagonists

- 3) Diabetes Medications

- 4) Statin use in persons with diabetes

medication safety / MTM

- 5) Comprehensive Medication Review (CMR)

Medication Therapy Management (MTM) services contribute to the safe, appropriate, and effective use of medications and offer value by: __________________________

- Improving the quality of patient care and outcomes

- Reducing health care expenditures

- Reducing medication-related adverse events