PRX325 Accreditation, Credentialing, and Quality Measures

credential

is a documented evidence of professional qualifications for an individuals

• credentials includes: diplomas, licenses, certificates, and certifications + in a variety of abbreviations that individuals place after their names

credentialing

the process by which an organization or institution obtains, verifies, and assesses an individual’s qualifications to provide patient care services in a subject or an area

privileging

the process by which a health care organization, having reviewed an individual health care provider’s credentials and performance and found them satisfactory, authorizes that individual to perform a specific scope of patient care services within that organization

accreditation

the process by which a private association, organization or government agency, after initial and periodic evaluations, grants recognition to an organization, site or program that has met certain established criteria or standards as determined through initial and periodic evaluations

• ACPE* for pharmacy schools (accreditation council for pharmacy education)

• TJC** for hospitals and others (the Joint Commission)

Joint Commission

measures organizations against national standards defined by health care professionals

medicare

a federal health insurance program that pays for medical care for the elderly and Americans with certain disabilities

• administered by the Centers for Medicare & Medicaid Services (CMS)

Medicare Part A

Hospital insurance

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

Medicare Part B

Medical insurance

outpatient doctors visits

some medical supplies (e.g. diabetes)

some vaccinations

Medicare Part C

(AKA Medicare Advantage Plans)

Customizes plans for more specific medical needs

Medicare Part D

covers prescriptions medications either within a Part C Medicare Advantage Plan or as an add-on to Part B

Medicaid

insurance that covers low-income families, administered on a STATE-LEVEL

examples; Public Assistance, DPA, Welfare