Attachment_J-1_BFCC_NCC_Glossary.docx

Attachment J-1 BFCC NCC GLOSSARY

Beneficiary Complaint: A complaint by a Medicare beneficiary or a beneficiary’s representative alleging that the quality of Medicare covered services received by the beneficiary did not meet professionally recognized standards of care. A complaint may consist of one or more quality of care concerns.

Immediate Advocacy: an informal dispute resolution process used to quickly resolve an oral complaint a Medicare beneficiary or his or her representation has regarding the quality of Medicare covered health care received. This process involves a NCC-QIO representative’s direct contact with the provider and/or practitioner.

Outreach item: Any item that is given to a target audience at no cost in order to reinforce messages delivered in print, online, or verbal communications. An outreach item may include a nominal giveaway that a QIOs uses to supplement its CRISP activities and that is used to promote behavior changes or to address barriers to behavior change associated with an intervention the QIO seeks to perform as part of the work of this contract. An outreach item differs from a promotional item (see below) in that the item itself has an inherent and clear connection to the interventions the QIO is attempting to implement, has meaning to a target audience that can influence the outcome of an intervention (i.e., not targeted to the general public at large), and delivers some message or value to the user that encourages them to change behavior or remove barriers to behavior change. All outreach items must conform to CMS and QIO Program branding guidelines. Furthermore, outreach items achieve at least one of the three objectives of the CRISP model: 1) initiation and “will building;” 2) engagement and maintenance; and 3) retention and sustainment throughout the life of the QIO task.

Outreach items may or may not be allowable costs, per COR and CO discretion—any outreach cost over $700 must be pre-approved by CMS to assure it meets this definition.

Paid media: Any communications tactic that requires the QIO (or another organization on behalf of the QIO) to pay money or in-kind services to deliver a message to an audience. Paid media are also known as “publicity items” and “advertisements.” These may take a number of forms, including advertisements and advertorials in newspaper, television, radio, and buses or subways; websites (including web banner space purchased) and services such as Google AdWords or others that optimize search engine prominence for a fee; paid endorsements or sponsorships; conference exhibits and displays for which the QIO pays an exhibition fee; and any signs and billboards for which space is rented for a fee. In determining whether paid media have any cost, QIOs should consider not only the fees/rentals/in-kind services associated with the media channel itself, but also the costs associated with producing the signage, advertisement, or other tactic distributed through the channel. All paid media costs—regardless of cost—must conform to CMS and QIO Program branding guidelines.

Paid media items may or may not be allowable costs, per COR and CO discretion—any paid media cost must be pre-approved by CMS to assure it meets the definition of an outreach item (above) rather than a promotional item (below).

Peer Reviewer: A reviewer who is a health care practitioner in the same professional field as the health care practitioner who ordered or furnished the services under review. See § 1154(a)(1),(a)(5), and (a)(7)(A) of the Act and 42 C.F.R. § 476.1. The Initial Determination Peer Reviewer and Re-Review Peer Reviewer must meet the requirements of this definition. In cases in which there is no peer match available, the NCC-QIO may use another peer reviewer when an exact match is unavailable in accordance with 42 CFR §476.98(a)(2).

PDSA Cycles: A structured trial of a process changes. Drawn from the Shewhart cycle, this effort includes: Plan - a specific planning phase; Do - a time to try the change and observe what happens; Study - an analysis of the results of the trial; and Act - devising next steps based on the analysis.

Promotional item: A souvenir, giveaway, imprinted apparel piece, button, or other memento provided to a broad public audience that creates awareness of the corporate entity that conducts QIO work rather than the work of the Program or the specific objectives and metrics of this contract. A promotional item lacks explicit connection between its intended message and the item user’s ability to change behavior or address change barriers associated with improving healthcare quality. Such an item also fails to achieve at least one of the three aims of the CRIPS model: 1) initiation and “will building;” 2) engagement and maintenance; and 3) retention and sustainment throughout the life of the QIO task. (For instance, giving a pen given to anyone who visits an exhibit at a convention will not build the will needed to recruit faculty for a national healthcare collaborative.)

By definition, promotional items of any kind or quantity are unallowable costs under this contract.

National Campaigns – A method of moving large numbers of people to action to achieve a particular objective; an organized course of action over a specified period of time with specific goals and identified actions to meet the goals.

Quality Improvement Organizations – A Quality Improvement Organization (QIO) consists of groups of doctors and health care experts organized to improve the care given to people with Medicare. QIOs work under the direction of the Centers for Medicare & Medicaid Services to assist Medicare providers with quality improvement and to review quality and cost issues for the protection of Medicare beneficiaries and the Medicare Trust Fund.

QIO Service Area: The defined geographic area, such as the State(s), region(s), area(s) or community(ies), in which the CMS contract directs the QIO to perform.

Quality Improvement Initiative (QII): Any formal activity designed to serve as a catalyst and support for quality improvement that uses proven methodologies to achieve these improvements. The improvements may relate to safety, healthcare, health and value and involve providers, practitioners, beneficiaries and/or communities.

Success story: A narrative description of the QIO’s efforts—with an individual provider or facility—or collectively with a learning network, collaborative, etc. that demonstrates the movement the QIO has achieved in progressing a project’s goals, value, or impact over a specified time period. Success stories may or may not be tied to CMS contract evaluation goals—rather, the “success” articulated through a success story can encompass any achievement the QIO experienced during the performance of the contract, provided both the QIO and CMS agree that the story demonstrates a substantive report of progress, achievement, or lessons learned.

Stakeholder: Also known by social marketing experts as “customer,” “audience,” or “target.” For the purposes of this contract, the term “stakeholder” shall describe the role of any individual or organization outside of the immediate QIO project team who engages in transactions for mutual benefit or gain. QIOs shall consider stakeholders to be their primary audiences, including health care providers and community members engaged in their quality improvement projects; and Medicare beneficiaries, representatives, and advocacy organizations that access or partner with the QIO’s Beneficiary-Centered Care functions.

QIOs should also identify those stakeholders that can “help tell the story” based on firsthand knowledge and experience.

Stakeholder-facing tactic: A stakeholder-facing tactic is any activity performed by a QIO to deliver a message to a stakeholder or group of stakeholders outside of the immediate QIO project team under the CRISP model. A tactic is composed of a message, a channel of distribution, and an execution strategy. The term “tactic” encompasses the mechanisms for stakeholder relations; including email blasts, webinars, website language, newsletters, storytelling, press materials, educational materials, etc. (For instance, a tactic is, “Demonstrate for newly recruited hospitals how the collaborative’s website can help them track their progress in the project through a 90-minute pre-recorded webinar they can review at their leisure.”)

The artifacts of these tactics are defined as those bundles of material and cultural properties packaged in some socially recognizable form such as a Word document, link to a webinar or web page, blog post, etc.

Technical assistance – Technical assistance is the provision of expertise, coaching, information, advice, tools, training and consultancy to individuals or groups who are in need of help in an area in order to move to the next level of improvement. Technical assistance may take many forms depending on the nature of the needs. A needs assessment, root cause analysis, or review of data is often conducted to determine the nature of the needed assistance.

Technical Denial – A technical denial is the denial of a claim as a result of a provider or practitioner not submitting the medical record as requested by the QIO.

Value-Based Purchasing: Aligning payment mechanisms with quality goals to incentivize change by financially supporting areas of importance for desired change in the health care system.