CAQ-HM cheat sheet

ACA Medicaid expansion: federal matching at 90% for newly eligible adults (2014 onward); states may opt out; uncompensated care and churn are key trade-offs.

EMTALA: Medicare-participating hospitals must provide a medical screening examination and stabilizing treatment regardless of insurance; transfer only for medical benefit or patient request.

HIPAA Privacy Rule: minimum necessary standard for uses/disclosures; 18 identifiers define de-identified data; breach notification within 60 days of discovery.

Stark Law (physician self-referral): prohibits referrals for designated health services to entities with which the physician or immediate family has a financial relationship, unless an exception applies.

Anti-Kickback Statute: criminal prohibition on remunerating referrals for federally reimbursed items/services; safe harbors protect specific arrangements.

CMS Conditions of Participation: deemed status via Joint Commission or DNV; survey findings can trigger plans of correction and termination from Medicare.

340B Drug Pricing Program: eligible hospitals/clinics purchase outpatient drugs at discounted prices; covered entity must meet disproportionate share and registration rules.

Site-neutral payment: CMS extends OPPS-equivalent rates to clinic visits at off-campus provider-based departments (MPFS site-neutral codes).

Board fiduciary duties: duty of care, duty of loyalty, duty of obedience; conflict-of-interest policy and quorum rules govern votes on related-party transactions.

Mission–vision–values hierarchy: mission states purpose, vision states future state, values state behavioral norms; strategy bridges mission to measurable goals.

SWOT analysis: internal strengths/weaknesses, external opportunities/threats; pairs with PESTLE for macro-environment scanning.

Balanced Scorecard perspectives: financial, customer/patient, internal process, learning and growth; each objective needs measure, target, and initiative.

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound; used to cascade strategic objectives to department-level accountability.

Change management: Kotter's 8 steps (urgency, coalition, vision, communicate, empower, short-term wins, consolidate, anchor); Lewin's unfreeze–change–refreeze.

Governance structures: full board, executive committee, finance/audit, quality/patient safety, and medical executive committee; bylaws define delegated authority.

Physician engagement: alignment models include employment, professional services agreements, co-management, and clinically integrated networks with shared savings.

Revenue cycle sequence: scheduling → registration → charge capture → coding → claim submission → remittance posting → denial management → collections.

Payer mix = payer revenue ÷ total revenue; a shift toward Medicare/Medicaid lowers net revenue per case because of lower contractual rates.

Net patient service revenue = gross charges − contractual allowances − charity care − bad debt (where policy permits).

DRG payment = DRG relative weight × hospital base rate × wage index adjustment; outliers and IME/DSH add-ons apply separately.

Contribution margin = net revenue − variable costs; used to decide service line expansion or discontinuation when fixed costs persist.

Days in accounts receivable = (net A/R ÷ net patient revenue) × 365; benchmark varies by payer and specialty.

Cost-to-charge ratio: used to convert charges to costs; critical for Medicare cost reports and for calculating margin by service line.

Value-based contracts: shared savings, bundled payments, and capitation shift risk from payer to provider; require actuarial modeling of total cost of care.

PDSA cycle: Plan (define change and prediction), Do (small-scale test), Study (compare results to prediction), Act (adopt, adapt, or abandon).

Lean waste categories (TIMWOOD): transportation, inventory, motion, waiting, overproduction, overprocessing, defects.

Six Sigma DMAIC: Define, Measure, Analyze, Improve, Control; aims to reduce process variation to ≤3.4 defects per million opportunities.

Little's Law: average work-in-process = arrival rate × average time in system; used for capacity and flow analysis.

Control charts: distinguish common-cause (random) from special-cause (assignable) variation; use p-charts for proportions and X-bar/R charts for continuous data.

OEE = availability × performance × quality; a single metric for equipment effectiveness in procedural and imaging suites.

Root cause analysis (RCA): structured retrospective review after a sentinel event; outputs include causal statements and action plans with owners and due dates.

Failure Mode and Effects Analysis (FMEA): prospective risk assessment scoring severity × occurrence × detectability (RPN) to prioritize mitigation.

EHR meaningful use (now Promoting Interoperability) requires certified EHR technology, e-prescribing, health information exchange, and security risk analysis.

HL7 v2 messages use segments (MSH, PID, OBX) and pipe delimiters; FHIR uses RESTful resources (Patient, Observation) with JSON/XML payloads.

Data quality dimensions: completeness, accuracy, timeliness, consistency, validity, uniqueness; each must be measured before analytics use.

Dashboards: leading indicators predict future performance (e.g., readmission risk score); lagging indicators report past results (e.g., mortality rate).

Predictive model validation: discrimination (AUC/C-statistic) and calibration (predicted vs observed event rates); both required for clinical deployment.

Interoperability standards: IHE profiles, C-CDA documents, and USCDI data classes define required exchange content for certified systems.

Security: HIPAA Security Rule requires administrative, physical, and technical safeguards; risk analysis is the foundational requirement.

Analytics maturity: descriptive → diagnostic → predictive → prescriptive; most health systems operate at descriptive/diagnostic stages.

FTE = paid hours ÷ 2,080; productive FTE excludes benefit, education, and orientation hours.

Nursing turnover cost: replacement cost typically 0.75–2× annual salary; includes recruitment, orientation, and temporary staffing.

Credentialing and privileging: primary source verification of licensure, training, and malpractice history; reappointment typically every 2 years.

Competency assessment: age-specific, cultural, and role-specific competencies must be documented at hire and annually.

Workforce planning: demand (volume × productivity standard) minus supply (current staff × availability) identifies gap and hiring need.

Just culture: distinguishes human error (console), at-risk behavior (coach), and reckless behavior (sanction); supports nonpunitive reporting.

Succession planning: identify key positions, assess bench strength, and develop high-potential staff through stretch assignments and mentoring.

FLSA: exempt employees are salaried and not eligible for overtime; non-exempt employees must be paid overtime for hours over 40 per week.

Sentinel event: unexpected occurrence involving death or serious harm; Joint Commission requires root cause analysis within 45 days.

Never events (CMS): serious reportable events such as wrong-site surgery, retained foreign object, and air embolism; nonpayment and reporting required.

Informed consent elements: diagnosis, nature of procedure, risks, benefits, alternatives, and consequences of refusal; documented in the record.

Malpractice elements: duty, breach, causation, and damages; plaintiff must prove all four by a preponderance of evidence.

Risk management process: identify → assess → mitigate → monitor; includes event reporting, claims analysis, and insurance/self-insurance decisions.

Patient safety culture: measured by AHRQ Survey on Patient Safety Culture; dimensions include teamwork, staffing, and event reporting frequency.

Disclosure: adverse event disclosure to patients is required by many states and accreditors; apology laws vary by jurisdiction.

Emergency preparedness: CMS Emergency Preparedness Rule requires risk assessment, emergency plan, policies, communication plan, and training/testing.

Population health management: identify attributed population → risk stratify → intervene on high-risk cohorts → measure outcomes and cost.

Risk stratification tools: HCC (Hierarchical Condition Category) risk scores, LACE index for readmission, and Charlson Comorbidity Index.

Care coordination models: patient-centered medical home, accountable care organizations, and community health workers; key is shared care plans.

Social determinants of health (SDOH): food insecurity, housing, transportation, and social isolation; screen with validated tools and refer to community resources.

Readmission reduction: transitional care interventions (medication reconciliation, follow-up within 7 days, teach-back) reduce 30-day readmissions.

HEDIS measures: quality metrics used by payers (e.g., HbA1c testing, breast cancer screening); tied to value-based payment and Star Ratings.

Preventive care: USPSTF grades A and B are covered without cost-sharing under the ACA; screening intervals follow evidence-based guidelines.

Care transitions: warm handoff, discharge summary timeliness, and post-acute follow-up are core measures for reducing avoidable utilization.