CAQ-HM flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

EMTALA

Federal law requiring Medicare-participating hospitals to provide a medical screening examination and stabilizing treatment for emergency conditions regardless of ability to pay.

Stark Law

Prohibits physician self-referral 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 law barring remuneration intended to induce referrals for federally reimbursed items or services; safe harbors protect specified arrangements.

HIPAA minimum necessary

Requires covered entities to limit uses and disclosures of protected health information to the minimum needed for the intended purpose, except for treatment.

340B Program

Requires drug manufacturers to sell outpatient drugs at discounted prices to eligible covered entities that serve low-income and disproportionate-share populations.

Board fiduciary duties

Directors owe the organization duty of care, duty of loyalty, and duty of obedience; these govern decisions, conflicts of interest, and adherence to mission.

Balanced Scorecard

Strategy execution framework measuring performance across financial, customer/patient, internal process, and learning-and-growth perspectives, each with objectives, measures, and targets.

SMART goals

Goal-setting criterion requiring objectives to be Specific, Measurable, Achievable, Relevant, and Time-bound to support accountability and progress tracking.

Kotter's eight steps

Change management sequence: create urgency, form coalition, develop vision, communicate, empower action, generate short-term wins, consolidate gains, anchor changes.

Clinically integrated network

A group of providers that jointly contract with payers and share clinical and financial accountability, often enabling shared savings and quality reporting.

Revenue cycle

End-to-end financial process from scheduling and registration through charge capture, coding, claim submission, payment posting, denial management, and collections.

DRG payment

Prospective inpatient payment calculated as DRG relative weight multiplied by the hospital base rate, adjusted for wage index and add-on factors.

Contribution margin

Net revenue minus variable costs; measures how much each service or case contributes to covering fixed costs and generating profit.

Days in accounts receivable

Financial metric calculated as net accounts receivable divided by net patient revenue, multiplied by 365, indicating collection speed.

Cost-to-charge ratio

Ratio of allowable costs to gross charges, used to convert charges to costs for Medicare cost reports and service-line margin analysis.

PDSA cycle

Quality improvement method with four stages: Plan a change, Do a small-scale test, Study the results against prediction, Act to adopt, adapt, or abandon.

Lean TIMWOOD wastes

Seven waste categories: transportation, inventory, motion, waiting, overproduction, overprocessing, and defects; used to identify non-value-added process steps.

DMAIC

Six Sigma improvement methodology: Define, Measure, Analyze, Improve, Control; targets reduction of process variation and defects.

Little's Law

Queueing relationship stating that average work-in-process equals arrival rate multiplied by average time in the system; used for capacity and flow analysis.

FMEA

Prospective risk assessment method scoring severity, occurrence, and detectability to calculate a risk priority number and prioritize mitigation actions.

FHIR

Fast Healthcare Interoperability Resources; a standards framework using RESTful APIs and modular resources such as Patient and Observation for health data exchange.

HL7 v2

Messaging standard using pipe-delimited segments such as MSH, PID, and OBX to exchange clinical and administrative data between systems.

Predictive model calibration

Agreement between predicted and observed event rates across risk groups; assessed alongside discrimination (AUC) before clinical deployment.

HIPAA Security Rule

Requires administrative, physical, and technical safeguards to protect electronic protected health information; risk analysis is the foundational requirement.

USCDI

United States Core Data for Interoperability; a standardized set of data classes and elements required for certified health IT exchange.

FTE calculation

Full-time equivalent equals paid hours divided by 2,080; productive FTE excludes benefit, education, and orientation hours.

Just culture

Accountability framework distinguishing human error (console), at-risk behavior (coach), and reckless behavior (sanction) to encourage event reporting.

Credentialing and privileging

Process of verifying licensure, training, and malpractice history through primary sources and granting specific clinical privileges, typically renewed every two years.

Sentinel event

Unexpected occurrence involving death or serious physical or psychological harm; requires root cause analysis, often within 45 days for accredited organizations.

Informed consent elements

Required disclosure of diagnosis, procedure nature, risks, benefits, alternatives, and consequences of refusal, documented before treatment.

Malpractice four elements

Plaintiff must prove duty, breach of standard of care, causation, and damages by a preponderance of the evidence to succeed in a negligence claim.

HCC risk score

Hierarchical Condition Category model used by Medicare Advantage to predict cost and risk-adjust payment based on documented diagnoses.