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Annual Report of Quality Improvement Organization (QIO)  Indiana – Health Care Excel  The template below was provided to Health Care Excel, the Indiana Quality Improvement Organization (QIO), by the Centers for Medicare & Medicaid The information in red represents data supplied to the QIO by CMS. The information in blue represents information entered by the Indiana QIO. I. Total # of Reviews – Provide the total number of reviews the QIO performed in CRIS by
Review Type
Percent of
Reviews (%)
Coding Validation (All Other Selection Reasons) Quality of Care Review (101 through 104 -Beneficiary Complaint) Quality of Care Review (All Other Selection Reasons) Utilization (158 - FI/MAC Referral for Readmission Review) Utilization (All Other Selection Reasons) Notice of Non-coverage (105 through 108 - Admission and Preadmission) Notice of Non-coverage (118 - BIPA) Notice of Non-coverage (121 through 124 -Weichardt) Notice of Non-coverage (111-Request for QIO Concurrence) II. Top 10 Principal Medical Diagnoses – Provide the top 10 principal medical diagnoses for
inpatient claims billed for Medicare beneficiaries. Top 10 Medical Diagnoses
Percent of
Beneficiaries
Beneficiaries
Annual Report of Quality Improvement Organization (QIO)  Indiana – Health Care Excel  Top 10 Medical Diagnoses
Percent of
Beneficiaries
Beneficiaries
49121 Obstructive Chronic Bronchitis W(AC) Exacerbation 41401 Coronary Atherosclerosis Native Vessel 71536 Localized Osteoarthritis NOS-Left/Leg 41071 Subendocardial Infarction, Initial III. Provider Reviews Geographics – Provide the count and percent by Rural vs. Urban
geographical locations for Health Service Providers (HSPs) associated with a completed QIO review. Geographical Area
# of Providers
Percent of Providers (%)
IV. Provider Reviews Settings – Provide the count and percent by Setting for Health Service
Providers (HSPs) associated with a completed QIO review. # of Providers
Percent of
Providers (%)
0 - Acute Care Unit of an Inpatient Facility 7 - Dialysis Center Unit of Inpatient Facility C - Free Standing Ambulatory Surgery Center Annual Report of Quality Improvement Organization (QIO)  Indiana – Health Care Excel  # of Providers
Percent of
Providers (%)
O - Setting does not fit into any other existing setting code S - Psychiatric Unit of an Inpatient Facility T - Rehabilitation Unit of an Inpatient Facility U - Swing Bed Hospital Designation for Short-Term, Long-Term Care, and Rehabilitation Hospitals Z - Swing Bed Designation for Critical Access Hospitals A. Quality of Care Concerns Confirmed – Provide the number of concerns by Quality of
Care PRAF Category Code and the number that were confirmed at highest level of review, for completed quality of care reviews. Quality of Care (“C” Category) PRAF Category
Concerns
Concerns
Confirmed
Confirmed
Concerns
C01 - Apparently did not obtain pertinent history and/or findings from examination C02 - Apparently did not make appropriate diagnoses and/or assessments C03 - Apparently did not establish and/or develop an appropriate treatment plan for a defined problem or diagnosis which prompted this episode of care [excludes laboratory and/or imaging (see C06 or C09) and procedures (see C07 or C08) and consultations (see C13 and C14] C04 - Apparently did not carry out an established plan in a competent and/or timely fashion C05 - Apparently did not appropriately assess and/or act on changes in clinical/other status results C06 - Apparently did not appropriately assess and/or act on laboratory tests or imaging study results Annual Report of Quality Improvement Organization (QIO)  Indiana – Health Care Excel  Quality of Care (“C” Category) PRAF Category
Concerns
Concerns
Confirmed
Confirmed
Concerns
C07- Apparently did not establish adequate clinical justification for a procedure which carries patient risk and was performed C08 - Apparently did not perform a procedure that was indicated (other than lab and imaging, see C09) C09 - Apparently did not obtain appropriate laboratory tests and/or imaging studies C10 - Apparently did not develop and initiate appropriate discharge, follow-up, and/or rehabilitation plans C11 - Apparently did not demonstrate that the patient was ready for discharge C12 - Apparently did not provide appropriate personnel and/or resources C13 - Apparently did not order appropriate specialty consultation C14 - Apparently specialty consultation process was not completed in a timely manner C15 - Apparently did not effectively coordinate across disciplines C16 - Apparently did not ensure a safe environment (medication errors, falls, pressure ulcers, transfusion reactions, nosocomial infection) C17 - Apparently did not order/follow evidence-based practices C18 - Apparently did not provide medical record documentation that impacts patient care C99 - Other quality concern not elsewhere classified B. Serious Reportable Events on Quality of Care Reviews - Provide the number of Quality
Improvement Activities (QIAs) initiated (initial activity date within the reporting period) for all quality of care reviews with confirmed concerns. Indicate the number and percent of those QIAs that are associated with quality of care concerns you deemed to fall into the category of “Serious Reportable Events”. Annual Report of Quality Improvement Organization (QIO)  Indiana – Health Care Excel  # of QIAs Initiated
# of QIAs Initiated for
Percent of QIAs Initiated
Serious Reportable Events
for Serious Reportable
Events (%)
C. Confirmed Quality of Care Concerns with Associated Interventions – Provide the
number of Initial Quality Improvement Activities initiated, by Activity Type, for reviews with one or more confirmed Quality of Care concerns. Provide the percent of total activities that each comprises. Initial Quality Improvement
# of Interventions (QIAs)
Percent of Interventions
Activity
with this Initial Quality
(QIAs) with this Initial
Improvement Activity
Quality Improvement
Activity
approach letter 2 - Perform intensified review policy/procedure 5 - Request development of QIP teleconference 8 - Refer to licensing board D. Discharge/Service Termination – Provide discharge location of beneficiaries linked to
discharge/service termination reviews for Selection Reasons 111 (Request for QIO
Concurrence) and 121 – 124 (Weichardt Selection Reasons). Note: Data represents
discharge/service termination reviews from 8/1/2011 – 4/30/2012, 8/1/2012 – 4/30/2013
and 8/1/2013 – 2/28/2014 for the first, second and third annual reports respectively. A
shortened data timeframe is necessary to allow for maturity of claims data which is the
source of “Discharge Status” for these cases.
Annual Report of Quality Improvement Organization (QIO)  Indiana – Health Care Excel  Discharge Status
# of Beneficiaries
Percent of
Beneficiaries (%)
01 - Discharged to home or self care (routine discharge) 02 - Discharged/transferred to another short-term general hospital for inpatient care 03 - Discharged/transferred to skilled nursing facility (SNF) 04 - Discharged/transferred to intermediate care facility (ICF) 05 - Discharged/transferred to another type of institution (including distinct parts) 06 - Discharged/transferred to home under care of organized home health service organization 07 - Left against medical advice or discontinued care 09 – Admitted as an inpatient to this hospital 20 – Expired (or did not recover – Christian Science patient) 21 – Discharged/transferred to court/law enforcement 40 - Expired at home (Hospice claims only) 41 - Expired in a medical facility (e.g. hospital, SNF, ICF or free standing Hospice) 42 - Expired – place unknown (Hospice claims only) 43 - Discharged/transferred to a Federal hospital 61 - Discharged/transferred within this institution to a hospital-based Medicare approved swing bed 62 - Discharged/transferred to an inpatient rehabilitation facility including distinct part units of a hospital 63 - Discharged/transferred to a long term care hospital 64 - Discharged/transferred to a nursing facility certified under Medicaid but not under Medicare Annual Report of Quality Improvement Organization (QIO)  Indiana – Health Care Excel  Discharge Status
# of Beneficiaries
Percent of
Beneficiaries (%)
65 - Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital 66 - Discharged/transferred to a Critical Access Hospital 70 - Discharged/transferred to another type of health care institution not defined elsewhere in code list E. Beneficiary Demographics – Provide the number of beneficiaries for whom a case review
activity was started, by demographic category, and the percent of beneficiaries each category represents. Demographics
# of Beneficiaries
Percent of Beneficiaries
Sex/Gender
Race
Asian
F. Quality of Care Reviews and Concerns by Intervention Type - Using a QIA started
within the reporting period for the current year’s report, please provide a short description as to the type of intervention(s)/QIA(s) employed, per C.6 Technical Assistance requirements in the Contract, for three diverse or different quality categories (C1-99). Intervention/QIA types may include, but are not limited to: Educational or Alternative Approach to Care letter; Continuing Education; Assistance in Developing Policy & Annual Report of Quality Improvement Organization (QIO)  Indiana – Health Care Excel  Procedure; Modification to Existing Policy & Procedure; Formal Quality Improvement
Plan and/or Corrective Action Plan. Note: If the QIO does not have three diverse or
different quality categories, please indicate such on the report.
Some details have been removed from the following case studies for confidentiality purposes.

Description 1 – Type of Intervention for Quality Category C 06 –
Apparently did not
appropriately access and/or act on laboratory tests or imaging study results.

The quality of care concern on this case regarded a medication combination that could
potentially result in severe hypokalemia. The patient was admitted to the hospital
following a complete loss of consciousness at the nursing home where he resides. The
patient was receiving a synthetic corticosteroid and a diuretic for edema. Concomitant
use of these medications should be prescribed with caution. Both medications cause
hypokalemia and when used simultaneously, will usually cause severe hypokalemia as
seen in this case. The QIO sent an educational letter to the hospital and ordering
physician which provided an explanation of the medication interactions and
recommendations for monitoring for these types of interactions in Medicare inpatients.   

Description 2 – Type of Intervention for Quality Category C 02 –
Apparently did not
make appropriate diagnoses and/or assessments.
The quality of care concern on this case regarded insufficient evaluation and assessment
of an obese, diabetic, Medicare beneficiary with a six week history of abdominal pain and
vomiting with an elevated white blood cell count. The QIO offered advice to the
attending physician in the confirmed quality of care letter that imaging studies should
have been obtained at the time the patient presented to the hospital and other conditions
were ruled out. The patient’s symptoms were not resolved at the time of discharge.
Therefore, advice was offered that this patient should have been monitored at the hospital
for an additional period of time rather than sending the patient home with instructions to
return if the symptoms did not resolve.
Description 3 – Type of Intervention for Quality Category C 03 –
Apparently did not
establish and/or develop an appropriate treatment plan for a defined problem or diagnosis
which prompted this episode of care.
Annual Report of Quality Improvement Organization (QIO)  Indiana – Health Care Excel  The quality of care concern on this case was that a Medicare beneficiary’s pain was not
relieved during an Emergency Room visit. The patient was discharged having not
achieved adequate pain control or having an appropriate treatment plan. The QIO sent a
letter to the hospital and attending physician which offered an alternate approach to the
evaluation and treatment of patients with similar complaints. The confirmed quality of
care letter suggested the patient should have been admitted to an observation status
within the hospital where continued pain medication could have been provided, as well as
evaluation and assessment directed at determining the source of the pain.
 
Using one example from the previously identified intervention(s)/QIA(s), describe how the
intervention/QIA was determined, along with any identified “Best Practices” for the
resolution of the identified quality concern.
Example from Description 1: How Interventions Determined/Best Practices
The Peer Reviewer utilized widely available prescribing guidelines when determining
that the concomitant use of these two drugs should be prescribed with caution. The
known side effects when combined had the potential to and in this case did cause
hypokalemia. Prescribing information is available in Physician Desk References (PDR)
and on the drug manufacturer’s Web sites. The recommended best practice is for all
medications prescribed for patients receiving treatment in a hospital or skilled nursing
facility to have the pharmacy department’s involvement in watching for these types of
potential drug interactions and calling the physician’s attention to the situation
immediately. A physician may have determined that the use of these two drugs was
warranted in this situation or might have changed one or both of the drugs. The
physician should document knowledge of the potential interaction and develop a written
plan to monitor for potential side effects in the medical record.
G. Evidence Used in Decision-Making - Drawing upon your QIO’s case review practices,
please describe the one or two most common types of evidence/standards of care criteria used to support Review Analysts’ assessments and Peer Reviewers’ decisions for Medical Necessity/Utilization Review and Appeals. Provide a brief statement of rationale for how the specific evidence/standards of care were chosen. The types of evidence/standards of care may include, but are not limited to, Local Coverage Determinations (LCD), Medicare Conditions Coverage, Medicare Conditions of Participation and National Coverage Determinations (NCD). Annual Report of Quality Improvement Organization (QIO)  Indiana – Health Care Excel  For QoC, describe the one or two most common types of evidence/standards of care criteria used to support Review Analysts’ assessments and Peer Reviewers’ decisions for the specific list of diagnostic categories provided in the table. Note: The list is from other 10th SoW initiatives in which QIOs are involved. If there are any categories for which you did not conduct a QoC review during the reporting period, denote that in the table.    This table contains examples of evidence/standards of care used in the review process. This   list is not all inclusive of the available evidence/standards of care. The QIO does not endorse   any evidence/standards of care.   Review Type
Diagnostic
Evidence/ Standards
Rationale for
Categories
of Care Used
Evidence/Standard of Care
Selected
diagnoses and includes expert commentaries and guideline resources. the Web site where you can search for guidelines by condition/diagnosis. search for guidelines by condition/diagnosis. Ulcers Guidelines for Treatment and Prevention are listed on the Web site. Provide descriptive information to guide correct coding. diagnoses and includes expert commentaries and guideline resources. Annual Report of Quality Improvement Organization (QIO)  Indiana – Health Care Excel  diagnoses and includes expert commentaries and guideline resources. diagnoses and includes expert commentaries and guideline resources. diagnoses and includes expert commentaries and guideline resources. Medicare Benefit Policy This CMS publication is Manual recognized by providers to be the source of coverage information. Please provide three brief examples/case studies where case review was linked to another Aim of the QIO contract, for example, readmissions, pressure ulcers, adverse drug events, etc. Identify the evidence based criteria used to support review decisions on those cases and what influenced the selection of that criteria. Documentation should be two paragraphs or less per example/case study.
Example/Case Study 1

This Medicare beneficiary was admitted to a skilled nursing facility following an acute
inpatient hospital stay to receive skilled therapy services. Per the medical record
documentation provided, the patient had no signs of pressure ulcers on arrival to the
nursing facility. During the stay, the patient developed a grade II ulcer on the sacral-
coccygeal area. The QIO provided information to the skilled nursing facility regarding
the guidelines for prevention of pressure ulcers. The QIO nursing home quality
improvement staff presented an inservice to the BFCC staff regarding prevention and
Annual Report of Quality Improvement Organization (QIO)  Indiana – Health Care Excel  treatment of pressure ulcers. This sharing of knowledge has assisted the BFCC staff in
their review of medical records. The pressure ulcer prevention and treatment guidelines
are also available to the Peer Reviewers. Exchange of information of knowledge
between Aims allows the QIO to present a multi-pronged approach to improving the
quality of care being provided to all Medicare beneficiaries in the state.

Example/Case Study 2

A Medicare beneficiary was admitted to the hospital with painful urination, nausea, and
poor appetite. While hospitalized the patient’s international normalized ratio (INR) was
found to be significantly elevated and the Coumadin dosage was adjusted. The patient
was discharged from the hospital to a skilled nursing facility. However, no
arrangements were made for follow-up monitoring of the INR nor were there medication
orders for Coumadin. Education was provided to the hospital regarding the importance
of appropriate discharge planning and clear, thorough instructions for the next care
provider to follow. This case demonstrates the need for care to be integrated across the
continuum of provider settings. Information has been shared with the Beneficiary and
Family Centered Care (BFCC) staff by the Care Integration’s staff regarding projects
that can be undertaken by a community of providers to improve the hand over process.
This information is shared with providers as appropriate during the medical record
review process.

Example/Case Study 3
This Medicare beneficiary was admitted to the hospital for treatment of atrial fibrillation
with rapid ventricular response. Lasix was indicated due to the patient’s fluid volume
overload noted on x-ray and computerized tomography (CT) scan. Intravenous (IV)
Lasix was mentioned in a physician’s note, but not included in the medication
administration record. Likewise, IV Cardizem is mentioned in a consultant’s note as
being administered; however, there is no record of this administration in the medication
administration record. The discharge instructions do not include an order for Lasix to be
continued at home nor is there an explanation as to why Lasix was not being prescribed.
The quality of care concerns identified in this medical record are related to the poor
documentation of medications actually administered during the hospitalization or
prescribed at the time of discharge. The failure to properly document all medications
administered and prescribed can lead to confusion on the part of the patient and her non-
Annual Report of Quality Improvement Organization (QIO)  Indiana – Health Care Excel  hospital treating physicians. The potential for an adverse drug event to occur is extremely high in this patient. The importance of thorough documentation of all medications administered and prescribed was shared with the hospital and the treating physician. Without appropriate documentation and discharge instructions it would be impossible to perform adequate medication reconciliation. H. Effectiveness of QIAs - Please provide an analysis of how the findings in tables B, C and
F can be used to support the effectiveness of QIAs conducted as part of the BFCC
Aim. The QIO should provide a narrative analysis on the information provided and
recommendations for how the information could be used to make a positive impact on the
work done in other 10SOW Aims.

Narrative Analysis:
The QIO performs Data Analysis of all confirmed quality of care concerns identified
through medical record review. Cases with confirmed quality of care concerns are
analyzed to determine if there are patterns of concern involving individual providers or a
geographic region which includes many different provider types. To date, we have not
determined any quality of care patterns that involve topics the other Aims are focused on,
nor have we identified patterns involving an identified geographic region. If patterns are
identified, the QIO process is to involve representatives from the other QIO Aims to
discuss appropriate Quality Improvement Activities (QIA). We continue to be alert to
ways the BFCC Aim can be involved with and make a positive impact on the work of the
other 10th SoW Aims. Annual education is provided to all QIO staff regarding quality of
care concerns and identified of potential areas of concern are discussed during each Aim’s
workgroup meeting.
This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization for Indiana, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. [10SOW-IN-BFCC-12-001] [09/26/2012]

Source: http://www.hce.org/dev/images/docs/Indiana_AnnualMedServReviewRpt_07.01.11.pdf

Pii: s0142-9612(01)00003-5

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