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Contents: Top - 0–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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A

Academic Medical Center

A group of related institutions including a teaching hospital or hospitals, a medical school and its affiliated faculty practice plan, and other health professional schools.

Access

The patient's ability to obtain medical care. The ease of access is determined by such components as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation and cost of care. An individual's ability to obtain appropriate health care services. Barriers to access can be financial (insufficient monetary resources), geographic (distance to providers), organizational (lack of available providers) and sociological (e.g., discrimination, language barriers). Efforts to improve access often focus on providing/improving health coverage.

Accountable Health Plan (AHP)

AHPs can be IDSs, MCOs, Health Networks, partnerships or joint ventures between practitioners, providers or payers that would assume responsibility for delivering medical care and managing the funds required to pay for the services rendered. Physicians and other providers would work for, contract with or own these health plans. When an IDS or hospital group or IPA operates one or more health insurance benefit products, or a managed care organization acquires a large scale medical delivery component, it qualifies as an Accountable Health System or Accountable Health Plan.

Accreditation

The process by which an organization recognizes a provider, a program of study or an institution as meeting predetermined standards. Two organizations that accredit managed care plans are the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO).

Action Plans

Specific actions that respond to short and longer-term strategic objectives. Action plans include details or resource commitments and time lines for accomplishment.

Active Learning

Interactive instructional techniques that engage students in such higher order thinking tasks as analysis, synthesis, and evaluation, using recourses beyond faculty such as libraries, Web sites, interviews, or focus groups to obtain information.

Activity-Based Costing (ABC)

Activity-based costing defines healthcare costs in terms of a healthcare organization's processes or activities. The costs are then associated with significant activities or events. It relies on the following 3 step process: 1) Activity mapping, which involves mapping activities in an illustrated sequence; 2) Activity analysis, which involves defining and assigning a time value to activities; and, 3) bill of activities, which involves generating a cost for each main activity.

Acute Care

Medical treatment rendered to individuals whose illnesses or health problems are of a short-term or episodic nature. Acute care facilities are those hospitals that mainly serve persons with short-term health problems.

Adjusted Admissions

A common measure of output in the hospital industry is admissions. However, this measure does not reflect the outpatient population served by the acute care hospitals. Therefore, hospitals generally modify this measure based on the relationship between inpatient and outpatient revenue. This output measure is called adjusted admissions. It is calculated by increasing each hospital's inpatient admissions, using revenue as a representation of outpatient activity. [(Total Patient Revenue/Inpatient Revenue) x Inpatient Admissions]

Administrative Costs

Costs related to utilization review, insurance marketing, medical underwriting, agents' commissions, premium collection, claims processing, insurer profit, quality assurance programs, and risk management. Administrative costs also refer to certain allowable costs on hospital CMS cost reports, usually considered overhead. Rules exist which disallow certain expenses, such as marketing. Costs not linked directly to the provision of medical care. Includes marketing, claims processing, billing, and medical record keeping, among others.

Admission Certification

Methods of assuring that only those patients who need hospital care are admitted. Certification can be granted before admission (preadmission) or shortly after (concurrent). Length of stay for the patient's diagnosed problem is usually assigned upon admission under a certification program.

Admissions Per 1,000

Number of patients admitted to a hospital or hospitals per 1,000 health plan members. An indicator calculated by taking the total number of inpatient and/or outpatient admissions from a specific group, e.g., employer group, HMO population at risk, for a specific period of time (usually one year), dividing it by the average number of covered members in that group during the same period, and multiplying the result by 1,000. This indicator can be calculated for behavioral health or any disease in the aggregate and by modality of treatment, e.g., inpatient, residential, and partial hospitalization, etc.

Adverse Event

An injury to a patient resulting from a medical intervention.

Affiliation

An agreement between two or more otherwise independent entities or individuals that defines how they will relate to one another. Agreements between hospitals may specify procedures for referring or transferring patients. Agreements between providers may include joint managed care contracting.

Affinity Diagram

A tool used to group complex, apparently unrelated data into natural and meaningful groups of data.

Agency for Health Care Policy and Research (AHCPR)

The agency of the Public Health Service responsible for enhancing the quality, appropriateness and effectiveness of health care services.

Agency for Healthcare Research and Quality (AHRQ)

AHRQ, a part of the U.S. Department of Health and Human Services, is the lead agency charged with supporting research designed to improve the quality of healthcare, reduce its cost, improve patient safety, decrease medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on healthcare outcomes; quality; and cost, use, and access. The information helps healthcare decision makers—patients and clinicians, health system leaders, and policymakers—make more informed decisions and improve the quality of healthcare services.

Aggregate Margin

This is computed by subtracting the sum of expenses for all hospitals in the group from the sum of revenues and dividing by the sum of revenues. The aggregate margin compares revenues to expenses for a group of hospitals, rather than one single hospital.

Aggregate PPS Operating Margin/Aggregate Total Margin

This is computed by subtracting the sum of expenses for all hospitals in the group from the sum of revenues and dividing by the sum of revenues. A PPS operating margin or total margin that compare revenue to expenses for a group of hospitals, rather than a single hospital.

Alignment

Consistency of plans, processes, information, resource decisions, actions, results, and analysis to support key organization-wide goals. Effective alignment requires a common understanding of purposes and goals.

All Patient Diagnosis Related Groups (APDRG)

An enhancement of the original DRGs, designed to apply to a population broader than that of Medicare beneficiaries, who are predominately older individuals. The APDRG set includes groupings for pediatric and maternity cases as well as of services for HIVrelated conditions and other special cases.

All Payer System

A system in which prices for health services and payment methods are the same, regardless of who is paying. For instance, in an all payer system, federal or state government, a private insurer, a self-insured employer plan, an individual, or any other payer could pay the same rates. The uniform fee bars health care providers from shifting costs from one payer to another. See cost shifting.

Allowable Costs

Covered expenses within a given health plan. Items or elements of an institution's costs, which are reimbursable under a payment formula. Both Medicare and Medicaid reimburse hospitals on the basis of only certain costs. Allowable costs may exclude, for example, luxury travel or marketing. CMS publishes an extensive list of rules governing these costs and provides software for determining costs. Normally the costs which are not reasonable expenditures, which are unnecessary, which are for the efficient delivery of health services to persons covered under the program in question are not reimbursed. The most common form of cost reimbursement is the "cost report" methodology used for DRGexempt services, such as many outpatient hospital based programs, longterm care and skilled nursing units, physical rehab, psychiatric and substance abuse inpatient programs. Some specialty hospitals receive all of their CMS reimbursement as cost based reimbursement.

Alternate Delivery Systems

Health services provided in other than an inpatient, acute care hospital or private practice. A phrase used to describe all forms of health care delivery except traditional fee-for-service, private practice. The term includes HMOs, PPOs, IPAs, and other systems of providing health care. Examples within general health services include skilled and intermediary nursing facilities, hospice programs, and home health care. Alternate delivery systems are designed to provide needed services in a more cost-effective manner. Most of the services provided by community mental health centers fall into this category.

Ambulatory Care

Health services provided without the patient being admitted. Also called outpatient care. The services of ambulatory care centers, hospital outpatient departments, physicians' offices and home health care services fall under this heading provided that the patient remains at the facility less than 24 hours. No overnight stay in a hospital is required.

Analysis

Examination of facts and data to prove a basis for effective decisions. Often involves determination of cause-effect relationships.

Ancillary Services

Supplementary services such as laboratory, radiology, physical therapy, and inhalation therapy that are provided in conjunction with medical or hospital care.

Anecdotal

Process information that lacks specific methods, measures, deployment mechanisms, and evaluation/improvement/learning factors. Frequently uses examples and describes individual activities rather than systematic processes.

Appropriateness

Appropriate health care is care for which the expected health benefit exceeds the expected negative consequences by a wide enough margin to justify treatment. This term is not to be confused with "usual and customary" or "approved" service. The extent to which a particular procedure, treatment, test, or service is clearly indicated, not excessive, adequate in quantity, and provided in the setting best suited to a patient's or member's needs.

Assessment

Using data to identify areas for improvement, and to track and analyze progress towards the achievement of vision and goals.

Assisted Living

Broad range of residential care services, but does not include nursing services. Normally lower in cost than nursing homes.

Attending Physician=

A physician who specializes in a certain area of medicine or surgery. In a teaching hospital, an attending physician will supervise the care you receive from a resident physician and/or medical students. He/she is responsible for involving other members of your health care team including consulting physicians in your prescribed plan of care.

Average Length of Stay (ALOS)

Refers to the average length of stay per inpatient hospital visit. Figure is typically calculated for both commercial and Medicare patient populations.

Avoidable Hospital Condition

Medical diagnosis for which hospitalization could have been avoided if ambulatory care had been provided in a timely and efficient manner.

B

Bed Days

Number of inpatient hospital days per 1,000 health plan members for a specified period, usually annual.

Behavioral Health, Behavioral Healthcare

An umbrella term that includes mental health, psychiatric, marriage and family counseling, addictions treatment and substance abuse. Services are provided by a myriad of providers, including social workers, counselors, psychiatrist, psychologists, neurologists and even family practice physicians. Many states have "parity" laws that attempt to require that behavioral health insurance coverage be provided "on par" to physical health coverage.

Benchmark

A goal to be attained. These goals are chosen by comparisons with other providers, by consulting statistical reports available or are drawn from the best practices within the organization or industry. Benchmarks are used in quality improvement programs to encourage improvement of care, efficiencies or services. Benchmarks are also used for length of stay comparisons, costs, utilization review, risk management and financial analysis. The benchmarking process identifies the best performance in the industry (health care or non-health care) for a particular process or outcome, determines how that performance is achieved, and applies the lessons learned to improve performance.

Benchmarking

Information and data regarding processes and results that represent best practices and performance, inside or outside your industry.

Block Grant

Federal funds made to a state for the delivery of a specific group of related services, such as drug abuse related services.

Board Eligible

Describes a physician who is eligible to take the specialty board examination by virtue of being graduated from an approved medical school, completing a specific type and length of training, and practicing for a specified amount of time. Some HMOs and other health facilities accept board eligibility as equivalent to board certification, significant in that many managed care companies restrict referrals to physicians without certification.

Brainstorming

An idea generating technique that uses team interaction to generate many ideas in a short time period.

Bundled Payment

A single comprehensive payment for a group of related services. Bundled payments have become the norm in recent years and CMS and other payers investigate unbundled services closely. Unbundling service charges has been a common form of fraud as defined by CMS.

C

Capital Costs

Capital costs usually involve equipment and physical plant costs, not consumable supplies. Included in these costs can be interest, leases, rentals, taxes and insurance on physical assets like plant and equipment.

Capital Expenditure Review

A review of proposed capital expenditures of hospitals or providers to determine the need for, and appropriateness of, the proposed expenditures. The review is usually done by a designated regulatory agency and has a sanction attached that prevents or discourages unneeded expenditures. Often this is related to CMS or Medicare and the willingness of the federal government to provide allowances for capital costs.

Capitation (Cap, Capped, Capitate)

Specified amount paid periodically to health provider for a group of specified health services, regardless of quantity rendered. Amounts are determined by assessing a payment "per covered life" or per member. The method of payment in which the provider is paid a fixed amount for each person served no matter what the actual number or nature of services delivered. The cost of providing an individual with a specific set of services over a set period of time, usually a month or a year. A payment system whereby managed care plans pay health care providers a fixed amount to care for a patient over a given period. Providers are not reimbursed for services that exceed the allotted amount. The rate may be fixed for all members or it can be adjusted for the age and gender of the member, based on actuarial projections of medical utilization.

Case Management

Method designed to accommodate the specific health services needed by an individual through a coordinated effort to achieve the desired health outcome in a cost effective manner. The monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high cost or extensive services. The process by which all health related matters of a case are managed by a physician or nurse or designated health professional. Physician case managers coordinate designated components of health care, such as appropriate referral to consultants, specialists, hospitals, ancillary providers and services. Case management is intended to ensure continuity of services and accessibility to overcome rigidity, fragmented services, and the misutilization of facilities and resources. It also attempts to match the appropriate intensity of services with the patient's needs over time.

Case Manager

A nurse, doctor, or social worker who works with patients, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate health care.

Case Mix

The mix of patients treated within a particular institutional setting, such as the hospital. Patient classification systems like DRGs can be used to measure hospital case mix. Measurement reflecting servicing needs, uses of hospital capabilities, and the general rate of hospital admissions. The types of inpatients a hospital or post acute facility treats. The more complex the patients' needs, the greater the amount spent for patient care. Case mix is generally established by estimating the relative frequency of various types of patients seen by the provider in question during a given time period and may be measured by factors such as diagnosis, severity of illness, utilization of services, and provider characteristics.

Case Mix Index (CMI)

The average DRG weight for all cases paid under PPS. The CMI is a measure of the relative costliness of the patients treated in each hospital or group of hospitals. A measure of the relative costliness of treating in an inpatient setting. An index of 1.05 means that the facility's patients are 5 % more costly than average.

Case Rate

Flat fee paid for a client's treatment based on their diagnosis and/or presenting problem. For this fee the provider covers all of the services the client requires for a specific period of time. Also bundled rate, or Flat-Fee-Per-Case. Very often used as an intervening step prior to capitation. In this model, the provider is accepting some significant risk, but does have considerable flexibility in how it meets the client's needs. Keys to success in this mode: (1) properly pricing case rate, if provider has control over it, and (2) securing a large volume of eligible clients.

Case Severity

A measure of intensity or gravity of a given condition or diagnosis for a patient. May have direct correlation with the amount of service provided and the associated costs or payments allowed.

Cause

A proven reason for the existence of a problem not to be confused with symptoms. When the cause is addresses, the process is improved.

Cause and Effect Diagram

A structured form of brainstorming that graphically shows the relationship of causes and subcauses to an identified effect (problem). The diagram is also known as a fishbone diagram or Ishikawa diagram.

Centers for Medicare and Medicaid Services (CMS)

The Centers for Medicare & Medicaid Services (CMS) is a Federal agency within the U.S. Department of Health and Human Services. Programs for which CMS is responsible include Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), HIPAA and CLIA. Formerly was HCFA. Centers for Medicare & Medicaid Services has historically maintained the UB92 institutional EMC format specifications, the professional EMC NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid programs. CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set.

Certificate of Authority (COA)

Issued by state governments, it gives a health maintenance organization or insurance company its license to operate within the state.

Certificate of Coverage (COC)

Outlines the terms of coverage and benefits available in a carrier's health plan.

Certificate of Need (CON)

In some states, a state agency must review and approve certain proposed capital expenditures, changes in health services provided, and purchases of expensive medical equipment. Before the request goes to the state, a local review panel (the health systems agency or HSA) must evaluate the proposal and make a recommendation. CON is intended to control expansion of facilities and services by preventing excessive or duplicative development of facilities and services. Many states have sunsetted or eliminated their CON processes and requirements.

Certified Health Plan

A managed health care plan, certified by the Health Services Commission and the Office of the Insurance Commissioner to provide coverage for the Uniform Benefits Package to state residents. Regulations vary by state since some states require only HMOs to certify but not PPOs, IPAs or MSOs. Increasingly these regs are becoming more consistent state by state.

Chain of Trust Agreement

Referred to in HIPAA rules, this is a contract needed to extend the responsibility to protect health care data across a series of subcontractual relationships.

CHAMPUS

Civilian Health and Medical Program of the Uniformed Services.

Charges

These are the published prices of services provided by a facility. CMS requires hospitals to apply the same schedule of charges to all patients, regardless of the expected sources or amount of payment. Controversy exists today because of the often wide disparity between published prices and contract prices. The majority of payers, including Medicare and Medicaid, are becoming managed by health plans that negotiate rates lower than published prices. Often these negotiated rates average 40% to 60% of the published rates and may be all-inclusive bundled rates.

Check sheet

A form used to record the frequency of specific events during a data collection period.

Chronic Care

Long term care of individuals with long standing, persistent diseases or conditions. It includes care specific to the problem as well as other measures to encourage self-care, to promote health, and to prevent loss of function.

Claim

A request by an individual (or his or her provider) to that individual's insurance company to pay for services obtained from a health care professional.

Clinic Without Walls (CWW)

Similar to an independent practice association and identical to a practice without walls (PWW). Practitioners form CWWs and PWWs when they want the economies of scale and bargaining power offered by centralizing some administrative functions, but still choosing to practice separately. Many of these were formed to allow practitioners the ability to effectively contract with managed care.

Clinical Data Repository

That component of a computer based patient record (CPR) which accepts, files, and stores clinical data over time from a variety of supplemental treatment and intervention systems for such purposes as practice guidelines, outcomes management, and clinical research. May also be called a data warehouse.

Clinical Decision Support

The capability of a data system to provide key data to physicians and other clinicians in response to "flags" or triggers which are functions of embedded, provider created rules. A system that would alert case managers that a client's eligibility for a certain service is about to be exhausted would be one example of this type of capacity. Also a key functional requirement to support clinical or critical pathways.

Clinical Laboratory Improvement Amendments (CLIA)

CMS regulates all laboratory testing (except research) performed on humans in the U.S. through the Clinical Laboratory Improvement Amendments (CLIA). In total CLIA covers approximately 175,000 laboratory entities. The Division of Laboratory Services, within the Survey and Certification Group, under the Center for Medicaid and State Operations has the responsibility for implementing the CLIA Program. The objective of the CLIA program is to ensure quality laboratory testing. Although all clinical laboratories must be properly certified to receive Medicare or Medicaid payments, CLIA has no direct Medicare or Medicaid program responsibilities.

Clinical or Critical Pathways

A "map" of preferred treatment/intervention activities. Outlines the types of information needed to make decisions, the timelines for applying that information, and what action needs to be taken by whom. Provides a way to monitor care "in real time." These pathways are developed by clinicians for specific diseases or events. Proactive providers are working now to develop these pathways for the majority of their interventions and developing the software capacity to distribute and store this information.

Closed Access

Gatekeeper model health plan that requires covered persons to receive care from providers within the plan's coverage. Except for emergencies, the patient may only be referred to and treated by providers within the plan. A managed health care arrangement in which covered persons are required to select providers only from the plan's participating providers.

Code of Cooperation

A list of actions/behaviors agreed to by the team that fosters cooperative team interactions and effective team decisions.

Code Set

Under HIPAA, this is any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. This includes both the codes and their descriptions.

Coded Data

Data are separated from personal identifiers through use of a code. As long as a link exists, data are considered indirectly identifiable and not anonymous or anonymized. Coded data are not covered by the HIPAA Privacy Rule, but are protected under the Common Rule.

Coding

A mechanism for identifying and defining physicians' and hospitals' services. Coding provides universal definition and recognition of diagnoses, procedures and level of care. Coders usually work in medical records departments and coding is a function of billing. Medicare fraud investigators look closely at the medical record documentation, which supports codes and looks for consistency. Lack of consistency of documentation can earmark a record as "upcoded" which is considered fraud. A national certification exists for coding professionals and many compliance programs are raising standards of quality for their coding procedures.

Common Cause

A cause of variation in a process that is random and uncontrollable.

Community Care Network (CCN)

This vehicle provides coordinated, organized, and comprehensive care to a community's population. Hospitals, primary care physicians, and specialists link preventive and treatment services through contractual and financial arrangements, producing a network that provides coordinated care with continuous monitoring of quality and accountability to the public. While the term, Community Care Network (CCN), often is used interchangeably with Integrated Delivery System (IDS), the CCN tends to be community based and nonprofit.

Comorbid Condition

A medical condition that, along with the principal diagnosis, exists at admission and is expected to increase hospital length of stay by at least one day for most patients.

Competitive Bidding

Can be viewed by some as a pricing method that elicits information on costs through a bidding process to establish payment rates that reflect the costs of an efficient health plan or health care provider. Competitive bidding is also the process of offering reduced rates to health plans to obtain exclusive contracts from payers.

Complication

A medical condition that arises during a course of treatment and is expected to increase the length of stay by at least one day for most patients.

Computer Based Patient Record (CPR)

Based Patient Record (CPR) A term for the process of replacing the traditional paper based chart through automated electronic means; generally includes the collection of patient specific information from various supplemental treatment systems, i.e., a day program and a personal care provider; its display in graphical format; and its storage for individual and aggregate purposes. Also called “digital medical record” or “electronic medical record”.

Concurrent Review

Review of a procedure or hospital admission done by a health care professional (usually a nurse) other than the one providing the care, during the same time frame that the care is provided. Usually conducted during a hospital confinement to determine the appropriateness of hospital confinement and the medical necessity for continued stay.

Consensus

A decision made after all aspects of an issue, both positive and negative, have been brought out to the extent that everyone understands and supports the decision and the reasons for making it.

Constancy of Purpose

Continuous effort to understand the needs, expectations and satisfaction levels of your stakeholders.

Continuous Improvement

Operational philosophy that increasing quality is an ongoing responsibility of everyone in the organization. The focus is on exceeding customer expectations by using data to incrementally improve key processes.

Continuous Improvement Team

A group of people at Arizona State University who meet to identify, analyze, and improve a process.

Continuous Quality Improvement (CQI)

An approach to health care quality management borrowed from the manufacturing sector. It builds on traditional quality assurance methods by putting in place a management structure that continuously gathers and assesses data that are then used to improve performance and design more efficient systems of care. Also known as quality improvement (QA) and total quality management (TQM).

Contract

A legal agreement between a payer and a subscribing group or individual which specifies rates, performance covenants, the relationship among the parties, schedule of benefits and other pertinent conditions. The contract usually is limited to a 12month period and is subject to renewal thereafter. Contracts are not required by statute or regulation, and less formal agreements may be made.

Control Chart

A chart showing sequential or time related performance of a process that is used to determine when the process is operating in or out of statistical control, using control limits defined on the chart.

Co-Payment, Copayment, Copay

Payment, Co-payment, Co-pay A cost sharing arrangement in which the HMO enrollee pays a specified flat amount for a specific service (such as $10 for an office visit or $5 for each prescription drug). The amount paid must be nominal to avoid becoming a barrier to care. It does not vary with the cost of the service and is usually a flat sum amount such as $10 for every prescription or doctor visit, unlike coinsurance that is based on a percentage of the cost.

Cost benefit analysis (Evaluation)

An analytic method in which a program's cost is compared to the program's benefits for a period of time, expressed in dollars, as an aid in determining the best investment of resources. For example, the cost of establishing an immunization service might be compared with the total cost of medical care and lost productivity that will be eliminated as a result of more persons being immunized. Cost benefit analysis can also be applied to specific medical tests and treatments.

Cost Consequence Analysis (CCA)

A form of analysis that compares alternative interventions or programs in which the components of incremental costs and consequences are listed without aggregation.

Cost Containment

Control of inefficiencies in the consumption, allocation, or production of health care services that contribute to higher than necessary costs. Inefficiencies are thought to exist in consumption when health services are inappropriately utilized; inefficiencies in allocation exist when health services could be delivered in less costly settings without loss of quality; and, inefficiencies in production exist when the costs of producing health services could be reduced by using a different combination of resources. Cost containment is a word used freely in healthcare to describe most cost reduction activities by providers.

Cost Effectiveness (Evaluation)

The efficacy of a program in achieving given intervention outcomes in relation to the program costs. Follow-up studies, outcome studies and TQM programs attempt to assess treatment efficacy, while cost effectiveness would provide a ratio of this measurement with costs. This analysis may determine the costs and effectiveness of certain interventions compared to similar alternative interventions, determining the relative costs and degree to which they will obtain desired health outcomes.

Cost Minimization Analysis (CMA)

An assessment of the least costly interventions among available alternatives that produce equivalent outcomes.

Cost of Illness Analysis (COI)

An assessment of the economic impact of an illness or condition, including treatment costs.

Cost Outlier

A case that is more costly to treat compared with other patients in a particular diagnosis related group. Outliers also refer to any unusual occurrence of cost, cases that skew average costs or unusual procedures.

Cost Sharing

Payment method where a person is required to pay some health costs in order to receive medical care. The general set of financing arrangements whereby the consumer must pay out-of-pocket to receive care, either at the time of initiating care, or during the provision of health care services, or both. This includes deductibles, coinsurance and co-payments, but not the share of the premium paid by the person enrolled.

Cost Shifting

Charging one group of patients more in order to make up for underpayment by others. Most commonly, charging some privately insured patients more in order to make up for underpayment by Medicaid or Medicare.

Cost Utility Analysis

A form of effectiveness analysis where outcomes are rated in terms of utility, or quality of life.

Credentialing

Review procedure where a potential or existing provider must meet certain standards in order to begin or continue participation in a given health care plan, on a panel, in a group, or in a hospital medical staff organization. The process of reviewing a p

Criteria

The standards, rules, needs and/or tests used to evaluate each project idea. Criteria are used to narrow down a brainstorming list and to determine what is most important.

Criteria Matrix

A method for evaluating solutions against criteria relating to their effectiveness, efficiency and adaptability, etc....

Current Procedural Terminology (CPT)

The coding system for physicians' services developed by the CPT Editorial Panel of the American Medical Association; basis of the HCFA Common Procedure Coding System.

Cycle Time

the time it takes, from start to finish, to complete a particular business process. The time required to fulfill commitments or to complete tasks.

D

Dashboard

A Dashboard enables an organization as a whole and each component of an organization to continually monitor how it is performing in areas that determine strategic success. Dashboards provide visibility to activities across an organization and help communicate and align efforts to enterprise objectives (balanced scorecard) while navigating an organization toward greater success.

Data Condition

A description of the circumstances in which certain data is required.

Data Mapping

The process of matching one set of data elements or individual code values to their closest equivalents in another set of them. This is sometimes called a crosswalk.

Data Use Agreement (DUA)

HIPAA Regulation states that a health care entity may use or disclose a "limited data set" if that entity obtains a data use agreement from the potential recipient and can only be used for research, public health or healthcare operations.

Database Management System (DBMS)

The separation of data from the computer application that allows entry or editing of data.

Day Outlier

A patient with an atypically long length of stay compared with other patients in a particular diagnosis related group.

Days (Or Visits) Per Thousand

A standard unit of measurement of utilization. Refers to an annualized use of the hospital or other institutional care. It is the number of hospital days that are used in a year for each thousand covered lives. The formula used to calculate days per thousand is as follows: (# of days/member months) x (1000 members) x (# of months). An indicator calculated by taking the total number of days (for inpatient, residential, or partial hospitalization) or visits (for outpatient) received by a specific group for a specific period of time (usually one year). A measure used to evaluate utilization management performance.

Decision Support Systems

Computer technologies used in healthcare that allow providers to collect and analyze data in more sophisticated and complex ways. Activities supported include case mix, budgeting, cost accounting, clinical protocols and pathways, outcomes, and actuarial analysis.

Deductibles

Amounts required to be paid by the insured under a health insurance contract, before benefits become payable. Usually expressed in terms of an "annual" amount.

Deemed Status

A health care facility that participates in the Medicare/Medicaid program by virtue of its accreditation by a national accrediting organization, whose standards have been determined to be at least equivalent to those of Medicare/Medicaid. For Medicare, the facility is deemed to meet the Medicare conditions of participation, and is not surveyed by the SA for Medicare purposes. Currently, hospitals accredited by the Joint Commission and the AOA have a deemed status.

Defensive Medicine

Doctors in recent years have admitted to and have been accused of prescribing additional tests or procedures to justify their care, strengthen support for their decisions or simply to corroborate their diagnosis. This defensiveness is a result of lawsuits, malpractice claims and the onslaught of external UR entities questioning care decisions. Defensive medicine is said to be one of the primary causes of the increasing cost of health care. Many physicians and the AMA fight for tort reform to reduce the need for defensive medicine. However, patient groups and patient advocates, not in favor of tort reform, explain that the right to sue for malpractice is a valid method of holding physicians accountable for mistakes made.

Deming Wheel

Another name for Dr... Shewhart's Plan, Do, Check, Act (PDCA) cycle. To achieve quality improvement, Dr.. Deming says you must plan for it, implement it (do), analyze the results (study), and take action (act) for continuous improvement.

Department of Health and Human Services (HHS)

The federal agency that oversees Medicare, Medicaid and other federal health care programs. (Also see DOJ, Fraud and FBI)

Deployment

The extent to which an approach is applied in addressing the requirements of a Baldrige Criteria item.

Designated Mental Health Provider

Person or place authorized by a health plan to provide or suggest appropriate mental health and substance abuse care.

Designated Record Set

A health care provider's medical and billing records about individuals and any records used by the provider to make decisions about individuals. Individuals, including research subjects, have the right under the HIPAA Privacy Rule to access and amend protected health information in a Designated Record Set.

Diagnosis Related Groups (DRGs)

An inpatient or hospital classification system used to pay a hospital or other provider for their services and to categorize illness by diagnosis and treatment. A classification scheme used by Medicare that clusters patients into 468 categories on the basis of patients' illnesses, diseases and medical problems. Groupings of diagnostic categories drawn from the International Classification of Diseases and modified by the presence of a surgical procedure, patient age, presence or absence of significant comorbidities or complications, and other relevant criteria. System involving classification of medical cases and payment to hospitals on the basis of diagnosis. Used under Medicare's prospective payment system to reimburse inpatient hospitals, regardless of the cost to the hospital to provide services.

Direct Utilization (Evaluation)

Explicit utilization of specific ideas and findings of an evaluation by decision makers and other stakeholders.

Disease Management

A type of product or service now being offered by many large pharmaceutical companies to get them into broader healthcare services. Bundles use of prescription drugs with physician and allied professionals, linked to large databases created by the pharmaceutical companies, to treat people with specific diseases. The claim is that this type of service provides higher quality of care at more reasonable price than alternative, presumably more fragmented, care. The development of such products by hugely capitalized companies should be the entire indicator necessary to convince a provider of how the healthcare market is changing. Competition is coming from every direction other providers of all types, payers, employers who are developing their own in-house service systems, the drug companies.

Disproportionate Share (DSH) Adjustment

A payment adjustment under Medicare's PPS for Medicaid utilization at hospitals that serve a relatively large volume of low-income patients, pregnant patients or other patients under the Medicaid program. Disproportionate share has been a continuing topic in Congress. Some wish to eradicate to reduce costs. Rural facilities, teaching hospitals and hospitals in poverty areas claim that the reduction or elimination of disproportionate share payments would cause hospitals to close, move or reduce care to the poor. DSH is a method whereby the government recognizes that hospitals treating high percentages of Medicaid payments would not be able to cover their costs and remain in service without additional government subsidy.

Drug Formulary

Varying lists of prescription drugs approved by a given health plan for distribution to a covered person through specific pharmacies. Health plans often restrict or limit the type and number of medicines allowed for reimbursement by limiting the drug formulary list. The list of prescription drugs for which a particular employer or State Medicaid program will pay. Formularies are either "closed," including only certain drugs or "open," including all drugs. Both types of formularies typically impose a cost scale requiring consumers to pay more for certain brands or types of drugs.

Drug Utilization Review (DUR)

Review of an insured population's drug utilization with the goal of determining how to reduce the cost of utilization. Reviews often result in recommendations to practitioners, including generic substitutions, use of formularies, use of co-payments for prescriptions and education. In some cases, practitioners are now penalized or rewarded depending on their drug prescription related costs and utilization. Some speculate that these incentives can adversely effect doctor decisions.

Durable Medical Equipment (DME)

Items of medical equipment owned or rented which are placed in the home of an insured to facilitate treatment and/or rehabilitation. DME generally consist of items that can withstand repeated use. DME is primarily and customarily used to serve a medical purpose and is usually not useful to a person in the absence of illness or injury.

E

Economic Credentialing

The use of economic criteria unrelated to quality of care or professional competency in determining an individual's qualifications for initial or continuing hospital medical staff membership or privileges. Economic credentialing has become a controversial topic involving much concern about ethics; yet, economic credentialing remains the most powerful form of controlling the behavior of doctors. Other forms of control include utilization review, certification, exclusive provider panels and more.

EDI Translator

Used in electronic claims and medical record transmissions, this is a software tool for accepting an EDI transmission and converting the data into another format, or for converting a nonEDI data file into an EDI format for transmission.

Education Delivery

The deployment of instructional approaches modes of teaching and organizational activities and experiences so that effective learning takes place. Examples: Active learning, distance education, online tutorials, teleconferencing, self paced learning.

Effect

An observable action or evidence of a problem.

Effective

A process that delivers the desired product or service to the stakeholder, while using recourses effectively. How well a process or a measure addresses its intended purpose.

Efficacy

The net health benefits achievable under ideal conditions for carefully selected patients.

Efficient

A process that operates effectively while consuming the minimum amount of resources (labor, time, etc..).

Electronic Claim

A digital representation of a medical bill generated by a provider or by the provider's billing agent for submission using telecommunications to a health insurance payer. Most claims are electronically submitted.

Electronic Data Interchange (EDI)

The automated exchange of data and documents in a standardized format. In health care, some common uses of this technology include claims submission and payment, eligibility, and referral authorization. Refers to the exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols.

Electronic Media Claims

A flat file format used to transmit or transport claims, such as the 192byte UB92 Institutional EMC format and the 320byte Professional EMC NSF.

Electronic Medical Record (EMR)

A computer based record containing health care information. This technology, when fully developed, meets provider needs for real-time data access and evaluation in medical care. Together with clinical workstations and clinical data repository technologies, the EMR provides the mechanism for longitudinal data storage and access. A motivation for healthcare entities to implement this technology derives from the need for medical outcome studies, more efficient care, speedier communication among providers and management of health plans. This record may contain some, but not necessarily all, of the information that is in an individual's paper based medical record. One goal of HIPAA is to protect identifiable health information as the system moves from a paper based to an electronic medical record system.

Emergency

Sudden unexpected onset of illness or injury which requires the immediate care and attention of a qualified physician, and which, if not treated immediately, would jeopardize or impair the health of the Member, as determined by the payer's Medical Staff. Significant in that Emergency may be the only acceptable reason for admission without precertification.

Emergency Center

Non-hospital affiliated health facility that provides short-term care for minor medical emergencies or procedures needing immediate treatment; also called urgicenter, urgent center or free standing emergency medical service center.

Employee Assistance Program (EAP)

A service, plan or set of benefits that are designed for personal or family problems, including mental health, substance abuse, gambling addiction, marital problems, parenting problems, emotional problems or financial pressures. This is usually a service provided by an employer to the employees, designed to assist employees in getting help for these problems so that they may remain on the job. EAP began with a primary drug and alcohol focus with an emphasis on rehabilitating valued employees rather than terminating them for their substance problems. It is sometimes implemented with a disciplinary program that requires that the impaired employee participate in EAP in order to retain employment. With the advent of managed care, EAP has sometimes evolved to include case management, utilization review and gatekeeping functions for the psychiatric and substance abuse health benefits.

Empowerment

Refers to giving faculty and staff the authority and responsibility to make decisions and take actions. Results in decisions being made closest to students and stakeholders, where work related knowledge and understanding reside.

Encounter

A contact between an individual and the health care system for a health care service or set of services related to one or more medical conditions.

Encounter Data

Data relating to treatment or service rendered by a provider to a patient, regardless of whether the provider was reimbursed on a capitated or fee-for-service basis. Used in determining the level of service.

Environmental Interventions

Adjustments made within the work environment, either by eliminating barriers that prevent performance or increasing support mechanisms for obtaining and enhancing desired accomplishments. Examples include: providing tools and equipment to do a job, creating standards and policies to guide performance and strengthening a deployment system.

Episode of Care

A term used to describe and measure the various health care services and encounters rendered in connection with identified injury or period of illness.

Ethical Behavior

How an organization ensures that all its decisions, actions, and stakeholder interactions confirm to the organization's moral and professional principles.

Evidence-based Medicine

Evidence based health care is the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services. Term used in quality improvement and peer review programs in hospitals and health plans.

Experiential Learning

An approach to learning that actively involves participants and applies the use of new skills through a variety of instructional methods (e.g., case studies and role plays).

External Quality Review Organization (EQRO)

States are required to contract with an entity that is external to and independent of the State and its HMO and HIO contractors to perform an annual review of the quality of services furnished by each HMO or HIO contractor.

External Stakeholder

The stakeholder who is outside the organization.

F

Facilitator

A person who functions as the coach/consultant to a group or team. In quality improvement, the facilitator focuses on the interpersonal process which the team leader focuses on content.

Feedback Systems

Means of communication whereby individuals receive information about their progress in mastering a skill or activity or achieving their learning objectives.

Fiscal Intermediary

The agent (e.g., Blue Cross) that has contracted with providers of service to process claims for reimbursement under health care coverage. In addition to handling financial matters, it may perform other functions such as providing consultative services or serving as a center for communication with providers and making audits of providers' needs. This entity may also be referred to as TPA or third party administrator. A private organization, usually an insurance company, that serves as an agent for the Health Care Financing Administration (CMS), which is part of HHS, that determines the amount of payment due to hospitals and other providers and paying them for the Medicare services they have provided. Intermediaries make initial coverage determinations and handle the early stages of beneficiary appeals.

Fiscal Soundness

The requirement that managed care organizations have sufficient operating funds, on hand or available in reserve, to cover all expenses associated with services for which they have assumed financial risk.

Fiscal Year

A 12-month period for which an organization plans the use of its funds, such as the Federal government's fiscal year (October 1 to September 30). Fiscal years are referred to by the calendar year in which they end; for example, the Federal fiscal year 1998 began October 1, 1997. Hospitals can designate their own fiscal years, and this is reflected in differences in time periods covered by the Medicare Cost Reports.

Fishbone Diagram

A structured form of brainstorming that graphically shows the relationship of causes and subcauses to an identified effect (problem). The diagram is also known as a cause effect diagram or Ishikawa diagram.

Fixed Costs

Costs that do not change with fluctuations in census or in utilization of services.

Flexible Spending Account (FSA)

A plan that provides employees a choice between taxable cash and nontaxable benefits for unreimbursed health care expenses or dependent care expenses. This plan qualifies under Section 125 of the IRS Code.

Flowchart

Flowchart that shows the people responsible for tasks as well as the flow of tasks in a process.

Formative Assessment

Frequent or ongoing evaluation during courses, programs, or learning experiences that give an early indication of what students are learning, as well as their strengths and weaknesses. Often used as a diagnostic tool for students and faculty, providing information with which to make real-time improvements in instructional methods, materials, activities, techniques, and approaches.

Formative Evaluation

Formative evaluation, including pretesting, is designed to assess the strengths and weaknesses of materials or campaigning strategies before implementation. It permits necessary revisions before the full effort goes forward. Its basic purpose is to maximize the chance for program success before the communication activity starts.

Formatting and Protocol Standards

Data exchange standards which are needed between CPR systems, as well as CPT and other provider systems, to ensure uniformity in methods for data collection, data storage and data presentation. Proactive providers are current in their knowledge of these standards and work to ensure their information systems conform to the standards.

Formulary

An approved list of prescription drugs; a list of selected pharmaceuticals and their appropriate dosages felt to be the most useful and cost effective for patient care. Organizations often develop a formulary under the aegis of a pharmacy and therapeutics committee. In HMOs, physicians are often required to prescribe from the formulary.

FTEs

FTEs are a standard measure for quantifying hospital staffing. FTEs more accurately measure staffing than number of employees since not all employees work the same number of hours. Paid FTEs is calculated by dividing the total number of paid hours by 2080 (40 hours a week times 52 weeks a year).

G

Gainsharing

Is an incentive program focused on improving operating results, typically implemented at the group or organizational level.

Gatekeeper

A primary care physician, utilization review, case management, local agency or managed care entity responsible for determining when and what services a patient can access and receive reimbursement for. An arrangement in which a primary care provider serves as the patient's agent, arranges for and coordinates appropriate medical care and other necessary and appropriate referrals. A PCP is involved in overseeing and coordinating all aspects of a patient's medical care. In order for a patient to receive a specialty care referral or hospital admission, the PCP must preauthorize the visit, unless there is an emergency. The term gatekeeper is also used in health care business to describe anyone (EAP, employer based case manager, UR entity, etc.) that makes the decision of where a patient will receive services.

Global Budgeting

Limits placed on categories of health spending. A method of hospital cost containment in which participating hospitals must share a prospectively set budget. Method for allocating funds among hospitals may vary but the key is that the participating hospitals agree to an aggregate cap on revenues that they will receive each year. Global budgeting may also be mandated under a universal health insurance system.

Global Fee

A total charge for a specific set of services, such as obstetrical services that encompass prenatal, delivery and postnatal care. Managed care organizations will often seek contracts with hospitals that contain set global fees for certain sets of services. Outliers and carveouts will be those services not included in the global negotiated rates.

Goals

Broad statements describing how you will reach your vision, answering the questions "how will we know when we've arrived?" and "how will we get there?" Short or long-term future conditions or performance level that you intends to attain.

Governance

The system or management and controls exercised in the stewardship of an organization. Includes the responsibilities of your governing body. Ensuring effective governance is important to stakeholders' and society's trust and to organizational effectiveness.

Gross Charges Per 1,000

An indicator calculated by taking the gross charges incurred by a specific group for a specific period of time, dividing it by the average number of covered members or lives in that group during the same period, and multiplying the result by 1,000. This is calculated in the aggregate and by modality of treatment, e.g., inpatient, residential, partial hospitalization, and outpatient. A measure used to evaluate utilization management performance.

Gross Costs Per 1,000

An indicator calculated by taking the gross costs incurred for services received by a specific group for a specific period of time, dividing it by the average number of covered members or lives in that group during the same period, and multiplying the result by 1,000. This is calculated in the aggregate and by modality of treatment, e.g. inpatient, residential, partial hospitalization, and outpatient. A measure used to evaluate utilization management performance. This is the key concept for the provider. What matters is our cost and, in managed care, we must control this indicator and make sure it is below our collections per 1,000.

Group Practice

A group of persons licensed to practice medicine in the State, who, as their principal professional activity, and as a group responsibility, engage or undertake to engage in the coordinated practice of their profession primarily in one or more group practice facilities, and who in their connection share common overhead expenses if and to the extent such expenses are paid by members of the group, medical and other records, and substantial portions of the equipment and the professional, technical, and administrative staffs. Group practices use the acronyms PA, IPA, MSO and others. Group practices are far more common now than a decade ago because physicians seek to lower costs, increase contracting power and share payer contracts.

Group-Based Learning

A learning method in which a group of participants receives training from one or more trainers.

H

Health and Human Services (HHS)

The Department of Health and Human Services that is responsible for health related programs and issues. Formerly HEW, the Department of Health, Education, and Welfare. The Office of Health Maintenance Organizations (OHMO) is part of HHS and detailed information on most companies is available here through the Freedom of Information Act.

Health Care Clearinghouse

A public or private entity that does either of the following (Entities, including but not limited to, billing services, repricing companies, community health management information systems or community health information systems, and “value-added” networks and switches are health care clearinghouses if they perform these functions): 1) Processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction; 2) Receives a standard transaction from another entity and processes or facilitates the processing of information into nonstandard format or nonstandard data content for a receiving entity. This term is used in the HIPAA rules.

Health Care Financing Administration (HCFA)

The federal government agency within the Department of Health and Human Services which directs and oversees the Medicare and Medicaid programs (Titles XVIII and XIX of the Social Security Act) and conducts research to support those programs. It is now called CMS and generally it oversees the state's administrations of Medicaid, while directly administering Medicare. See CMS, or Center for Medicare and Medicaid Services.

Health Care Operations

Institutional activities that are necessary to maintain and monitor the operations of the institution. Examples include but are not limited to: conducting quality assessment and improvement activities; developing clinical guidelines; case management; reviewing the competence or qualifications of health care professionals; education and training of students, trainees and practitioners; fraud and abuse programs; business planning and management; and customer service. Under the HIPAA Privacy Rule, these are allowable uses and disclosures of identifiable information "without specific authorization." Research is not considered part of health care operations.

Health Care Provider

Providers of medical or health care or researchers who provide health care are health care providers. Normally health care providers are clinics, hospitals, doctors, dentists, psychologists and similar professionals.

Health Care, Healthcare

Care, services, and supplies related to the health of an individual. Health care includes preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, among other services. Healthcare also includes the sale and dispensing of prescription drugs or devices.

Health Information

Information in any form (oral, written or otherwise) that relates to the past, present or future physical or mental health of an individual. That information could be created or received by a health care provider, a health plan, a public health authority, an employer, a life insurer, a school, a university or a health care clearinghouse. All health information is protected by state and federal confidentiality laws and by HIPAA privacy rules.

Health Insurance

Financial protection against the health care costs of the insured person. May be obtained in a group or individual policy.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

A Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. This legislation sets a precedent for Federal involvement in insurance regulation. It sets minimum standards for regulation of the small group insurance market and for a set group in the individual insurance market in the area of portability and availability of health insurance. As a result of this law, hospitals, doctors and insurance companies are now required to share patient medical records and personal information on a wider basis. This widebased sharing of medical records has led to privacy rules, greater computerization of records and consumer concerns about confidentiality. In addition, HIPAA required the creation of a federal law to protect personally identifiable health information; if-Kassebaum Bill, the Kassebaum-Kennedy Bill, K2, or Public Law 104191

Health Level Seven (HL7)

A data interchange protocol for health care computer applications that simplifies the ability of different vendor supplied IS systems to interconnect. Although not a software program in itself, HL7 requires that each healthcare software vendor program HL7 interfaces for its products.

Health Maintenance Organization (HMO)

An entity that provides, offers or arranges for coverage of designated health services needed by members for a fixed, prepaid premium. There are three basic models of HMOs: group model, individual practice association (IPA), and staff model.

Health Plan Employer Data and Information Set (HEDIS)

A set of performance measures developed to support health plan and Medicaid agency efforts to improve the health status of Medicaid beneficiaries, support the strengthening of health care delivery systems for the Medicaid population, promote standardization of managed care reporting across public and private sectors, and promote the application of performance measurement technology across Medicaid programs.

Health Resources and Services Administration (HRSA)

HRSA is a component of the U.S. Department of Health and Human Services. Included in HRSA responsibilities is administration of the Ryan White Care funds with a budget of about $1 billion/year to support a continuum of care services for persons with HIV infection.

Home Health Care

Full range of medical and other health related services such as physical therapy, nursing, counseling, and social services that are delivered in the home of a patient, by a provider.

Horizontal integration, Horizontal Consolidation

Merging of two or more firms at the same level of production in some formal, legal relationship. In hospital networks, this may refer to the grouping of several hospitals, the grouping of outpatient clinics with the hospital or a geographic network of various health care services. Integrated systems seek to integrate both vertically with some organizations and horizontally with others. When local health plans (or local hospitals) merge. This practice was popular in the late 1990s and was used to expand regional business presence. See vertical integration.

Hospice

Facility or program providing care for the terminally ill.

Hospital

A health care facility that has a governing body, an organized medical and professional staff, and inpatient facilities and provides medical, nursing, and related services for injured patients.

Hospital Affiliation

A contractual agreement between a health plan and one or more hospitals whereby the hospital provides the inpatient services offered by the health plan.

Hospital Alliances

Groups of hospitals joined together to share services and develop group purchasing programs to reduce costs. May also refer to a spectrum of contracts, agreements or handshake arrangements for hospitals to work together in developing programs, serving covered lives or contracting with payers or health plans.

Hospital Audit Companies

Retrospective audit providers that typically achieve a 1520 percent savings of billed claims

Hospital Days (per 1,000)

A measurement of the number of days of hospital care HMO members use in a year. It is calculated as follows: Total Number Of Days Spent In A Hospital By Members divided by Total Members. This information is available through HHS, OHMO and a variety of sources.

I

Impact Evaluation

Impact evaluation is the most comprehensive of the four evaluation types. It is desirable because it focuses on the long-range results of the program and changes or improvements in health status as a result. Impact evaluations are rarely possible because they are frequently costly, involve extended commitment and may depend upon other strategies in addition to communication. Also, the results often cannot be directly related to the effects of an activity or program because of other (external) Influences on the target audience which will occur over time.

Improvement

An approach to enhance organizational performance through the use of databased decisions making, process improvement, and constituent involvement.

Incidence

In epidemiology, the number of cases of disease, infection, or some other event having their onset during a prescribed period of time in relation to the unit of population in which they occur. Incidence measures morbidity or other events as they happen over a period of time. Examples include the number of accidents occurring in a manufacturing plant during a year in relation to the number of employees in the plant, or the number of cases of mumps occurring in a school during a month in relation to the number of pupils enrolled in the school. It usually refers only to the number of new cases, particularly of chronic diseases. Hospitals also track certain risk management or quality problems with a system called incidence reporting.

Incurred But Not Reported (IBNR)

Refers to a financial accounting of all services that have been performed but, as a result of a short period of time, have not been invoiced or recorded. Estimates of costs for medical services provided for which a claim has not yet been filed. Refers to claims that reflect services already delivered, but, for whatever reason, have not yet been reimbursed. These are bills "in the pipeline." This is a crucial concept for proactive providers who are beginning to explore arrangements that put them in the role of adjudicating claimsas the result, perhaps, of operating in a subcapitated system. Failure to account for these potential claims could lead to some very bad decisions. Good administrative operations have fairly sophisticated mathematical models to estimate this amount at any given time.

Independent Practice Association (IPA) or Organization (IPO)

A delivery model in which the HMO contracts with a physician organization, which in turn contracts with individual physicians. The IPA physicians practice in their own offices and continue to also see their FFS patients. The HMO reimburses the IPA on a capitated basis; however, the IPA may reimburse the physicians on an FFS or capitated basis.

Indicator

A measure of a specific component of a health improvement strategy.

Innovation

making meaningful change to improve programs, services and processes to create new value for students and stakeholders. Involves the adoption of an idea, process, technology, or product hat is ether new or new to its proposed application. Can result in breakthrough improvement or change in approach or outputs.

Inpatient

A person who has been admitted at least overnight to a hospital or other health facility.

Institute of Medicine (IOM)

The nation turns to the Institute of Medicine (IOM) of the National Academies for science-based advice on matters of biomedical science, medicine, and health. A nonprofit organization specifically created for this purpose as well as an honorific membership organization, the IOM was chartered in 1970 as a component of the National Academy of Sciences. The Institute provides the framework of government to ensure scientifically informed analysis and independent guidance. The IOM's mission is to serve as adviser to the nation to improve health. The Institute provides unbiased, evidence-based, and authoritative information and advice concerning health and science policy to policy-makers, professionals, leaders in every sector of society, and the public at large.

Integration

the harmonization of plans, processes, information, resource decisions, actions, results and analysis to support key organization wide goals.

Intensive Care Management

Intensive community services for individuals with severe and persistent mental illness that are designed to improve planning for their service needs. Services include outreach, evaluation, and support.

Intermediate Care Facility

A facility which is licensed under state law to provide on a regular basis, health-related care and services to individuals who do not require the degree of care or treatment which a hospital or skilled care facility would require.

Internal Medicine

Generally, that branch of medicine that is concerned with diseases that do not require surgery, specifically, the study and treatment of internal organs and body systems; it encompasses many subspecialties; internists, the doctors who practice internal medicine, often serve as family physicians to supervise general medical care.

Internal Rate of Return (Evaluation)

The calculated value for the discount rate necessary for total discounted program benefits to equal total discounted program costs.

Internal Stakeholder

The stakeholder who is inside the organization, e.g., fellow workers, other departments.

Intervention

An activity, process, event or system that is designed to correct a problem or change a situation and improve performance.

Intervention Strategy

A generic term used in public health to describe a program or policy designed to have an impact on an illness or disease. Hence a mandatory seat belt law is an intervention designed to reduce automobile related fatalities.

Ishikawa Diagram

A structured form of brainstorming that graphically shows the relationship of causes and subcauses to an identified effect (problem). The diagram is also known as a cause effect diagram or a fishbone diagram.

Issue Statement

A clear, concise and measurable statement of the problem the team plans to work on.