Free Chapter 02: The Health Care Delivery System

Chapter 02: The Health Care Delivery System

Potter et al.: Fundamentals of Nursing, 9th Edition

MULTIPLE CHOICE

1. The nurse is caring for a patient whose insurance coverage is Medicare. The nurse should consider which information when planning care for this patient?

a.

Capitation provides the hospital with a means of recovering variable charges.

b.

The hospital will be paid for the full cost of the patient’s hospitalization.

c.

Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost.

d.

Medicare will pay the national average for the patient’s condition.

ANS: C

In 1983, Congress established the prospective payment system (PPS), which grouped inpatient hospital services for Medicare patients into diagnosis-related groups (DRGs), each of which provides a fixed reimbursement amount based on assigned DRG, regardless of a patient’s length of stay or use of services. Capitation means that providers receive a fixed amount per patient or enrollee of a health care plan. DRG reimbursement is based on case severity, rural/urban/regional costs, and teaching costs, not national averages.

DIF:Understand (comprehension)REF:15

OBJ: Compare the various methods for financing health care. TOP: Planning

MSC:Management of Care

2. A nurse is teaching the staff about managed care. Which information should the nurse include in the teaching session?

a.

Managed care insures full coverage of health care costs.

b.

Managed care only assumes the financial risk involved.

c.

Managed care allows providers to focus on illness care.

d.

Managed care causes providers to focus on prevention.

ANS: D

Managed care describes health care systems in which the provider or the health care system receives a predetermined capitated (fixed amount) payment for each patient enrolled in the program. Therefore, the focus of care shifts from individual illness care to prevention, early intervention, and outpatient care. The actual cost of care is the responsibility of the provider. The managed care organization (provider) assumes financial risk, in addition to providing patient care.

DIF:Understand (comprehension)REF:15

OBJ: Explain the structure of the United States health system. TOP: Teaching/Learning

MSC:Management of Care

3. A nurse is teaching a family about health care plans. Which information from the nurse indicates a correct understanding of the Affordable Care Act?

a.

A family can choose whether to have health insurance with no consequences.

b.

Primary care physician payments from Medicaid services can equal Medicare.

c.

Adult children up to age 26 are allowed coverage on the parent’s plan.

d.

Private insurance companies can deny coverage for any reason.

ANS: C

Adult children up to the age of 26, regardless of student status, are allowed to be covered under their parents’ health insurance plan. All individuals are required to have some form of health insurance by 2014 or pay a penalty through the tax code. Primary care physician payments for Medicaid services increased to equal Medicare payments. Implementation of insurance regulations prevents private insurance companies from denying insurance coverage for any reason and from charging higher premiums based on health status and gender.

DIF:Remember (knowledge)REF:15-16

OBJ: Explain the structure of the United States health system. TOP: Teaching/Learning

MSC:Management of Care

4. A nurse is caring for a patient in the hospital. When should the nurse begin discharge planning?

a.

When the patient is ready

b.

Close to the time of discharge

c.

Upon admission to the hospital

d.

After an order is written/prescribed

ANS: C

Discharge planning begins the moment a patient is admitted to a health care facility. When the patient is ready may be too late. Close to the time of discharge and after an order is written/prescribed are too late.

DIF:Remember (knowledge)REF:19

OBJ: Discuss the role of nurses in different health care delivery settings.

TOP:PlanningMSC:Management of Care

5. The nurse is applying for a position with a home care organization that specializes in spinal cord injury. In which type of health care facility does the nurse want to work?

a.

Secondary acute

b.

Continuing

c.

Restorative

d.

Tertiary

ANS: C

Patients recovering from an acute or chronic illness or disability often require additional services (restorative care) to return to their previous level of function or reach a new level of function limited by their illness or disability. Restorative care includes cardiovascular and pulmonary rehabilitation, sports medicine, spinal cord injury programs, and home care. Secondary acute care involves emergency care, acute medical-surgical care, and radiological procedures. Continuing care involves assisted living, psychiatric care, and older-adult day care. Tertiary care includes intensive care and subacute care.

DIF:Understand (comprehension)REF:20

OBJ: Discuss the types of settings that provide various health care services.

TOP:ImplementationMSC:Management of Care

6. A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing?

a.

Primary care

b.

Preventive care

c.

Restorative care

d.

Continuing care

ANS: B

Preventive care includes immunizations, screenings, counseling, crisis prevention, and community safety legislation. Primary care is health promotion that includes prenatal and well-baby care, nutrition counseling, family planning, and exercise classes. Restorative care includes rehabilitation, sports medicine, spinal cord injury programs, and home care. Continuing care is assisted living and psychiatric care and older-adult day care.

DIF:Understand (comprehension)REF:17

OBJ: Discuss the types of settings that provide various health care services.

TOP: Implementation MSC: Health Promotion and Maintenance

7. A nurse is following the PDSA cycle for quality improvement. Which action will the nurse take for the letter “A”?

a.

Act

b.

Alter

c.

Assess

d.

Approach

ANS: A

There are many models for quality improvement and performance improvement. One model is the PDSA cycle: plan, do, study, and act. “A” does not stand for alter, assess, or approach.

DIF:Understand (comprehension)REF:27

OBJ:Describe the components of a quality improvement program.

TOP:ImplementationMSC:Management of Care

8. The nurse is trying to determine how well a certain health plan compares with other health plans. To gather this type of data, which information will the nurse utilize?

a.

Pew Health Professions Commission

b.

Healthcare Effectiveness Data and Information Set (HEDIS)

c.

American Nurses Credentialing Center (ANCC) Magnet Recognition Program

d.

Hospital Consumer of Assessment of Healthcare Providers and Systems (HCAHPS)

ANS: B

Health plans throughout the United States rely on the Healthcare Effectiveness Data and Information Set (HEDIS) as a quality measure. HEDIS compares how well health plans perform key areas: quality/effectiveness of care, access to care, and patient satisfaction with the health plan and doctors. The Pew Health Professions Commission, a national and interdisciplinary group of health care leaders, recommended 21 competencies for health care professionals in the twenty-first century. The Hospital Consumer of Assessment of Healthcare Providers and Systems (HCAHPS) is a standardized survey developed to measure patient perceptions of their hospital experience. The Magnet Recognition Program recognizes health care organizations that achieve excellence in nursing practice.

DIF:Understand (comprehension)REF:24

OBJ: Explain the impact of quality and safety initiatives on delivery of health care.

TOP:AssessmentMSC:Management of Care

9. An older adult patient has extensive wound care needs after discharge from the hospital. Which facility should the nurse discuss with the patient?

a.

Hospice

b.

Respite care

c.

Assisted living

d.

Skilled nursing

ANS: D

An intermediate care or skilled nursing facility offers skilled care from a licensed nursing staff. This often includes administration of IV fluids, wound care, long-term ventilator management, and physical rehabilitation. A hospice is a system of family-centered care that allows patients to live with comfort, independence, and dignity while easing the pains of terminal illness. Respite care is a service that provides short-term relief or “time off” for people providing home care to an individual who is ill, disabled, or frail. Assisted living offers an attractive long-term care setting with an environment more like home and greater resident autonomy.

DIF:Apply (application)REF:20-21

OBJ: Discuss the types of settings that provide various health care services.

TOP:Teaching/LearningMSC:Management of Care

10. A nurse working in a community hospital’s emergency department provides care to a patient having chest pain. Which level of care is the nurse providing?

a.

Continuing care

b.

Restorative care

c.

Preventive care

d.

Tertiary care

ANS: D

Hospital emergency departments, urgent care centers, critical care units, and inpatient medical-surgical units provide secondary and tertiary levels of care. Patients recovering from an acute or chronic illness or disability often require additional services (restorative care) to return to their previous level of function or reach a new level of function limited by their illness or disability. Continuing care is available within institutional settings (e.g., nursing centers or nursing homes, group homes, and retirement communities), communities (e.g., adult day care and senior centers), or the home (e.g., home care, home-delivered meals, and hospice). Preventive care is more disease oriented and focused on reducing and controlling risk factors for disease through activities such as immunization and occupational health programs.

DIF:Apply (application)REF:18

OBJ: Discuss the types of settings that provide various health care services.

TOP:ImplementationMSC:Management of Care

11. A nurse is teaching about the effects of globalization. Which information should the nurse include in the teaching session?

a.

Increased spread of communicable diseases

b.

Increased homogeneous mix of nursing staff

c.

Decreased poverty and increased “health tourism”

d.

Decreased urbanization as populations shift to the suburbs

ANS: A

Although globalization of trade, travel, and culture has improved the availability of health care services, the spread of communicable diseases such as tuberculosis and severe acute respiratory syndrome (SARS) has become more common. In an effort to improve the quality of care, health care institutions are recruiting nurses from around the world to work in the United States, forcing hospitals to better understand and work with nurses from different cultures. Poverty is still deadlier than any disease and is the most frequent reason for death in the world today. The growth of urbanization also is currently affecting the world’s health. Improved communication, easier air travel, and easing of trade restrictions are making it easier for people to engage in “health tourism.”

DIF:Understand (comprehension)REF:26

OBJ: Discuss the implications that changes in the health care system have on nursing.

TOP:Teaching/LearningMSC:Management of Care

12. A nurse is using research findings to improve clinical practice. Which technique is the nurse using?

a.

Performance improvement

b.

Integrated delivery networks

c.

Nursing-sensitive outcomes

d.

Utilization review committees

ANS: A

Performance improvement activities are typically clinical projects conceived in response to identified clinical problems and designed to use research findings to improve clinical practice. Larger health care systems have integrated delivery networks (IDNs) that include a network of facilities, providers, and services organized to deliver a continuum of care to a population of patients at a capitated cost in a particular setting. Nursing-sensitive outcomes are patient outcomes and nursing workforce characteristics that are directly related to nursing care such as changes in patients’ symptom experiences, functional status, safety, psychological distress, registered nurse (RN) job satisfaction, total nursing hours per patient day, and costs. Medicare-qualified hospitals had physician-supervised utilization review (UR) committees to review the admissions and to identify and eliminate overuse of diagnostic and treatment services ordered by physicians caring for patients on Medicare.

DIF:Understand (comprehension)REF:27

OBJ: Explain the relationship between evidence-based practice and performance improvement.

TOP:ImplementationMSC:Management of Care

13. Which finding indicates the best quality improvement process?

a.

Staff identifies the wait time in the emergency department is too long.

b.

Administration identifies the design of the facility’s lobby increases patient stress.

c.

Director of the hospital identifies the payment schedule does not pay enough for overtime.

d.

Health care providers identify the inconsistencies of some of the facility’s policy and procedures.

ANS: A

The quality improvement process begins at the staff level, where problems are defined by the staff. It is not identified by administration, the hospital director, or health care providers.

DIF:Apply (application)REF:27

OBJ:Describe the components of a quality improvement program.

TOP:EvaluationMSC:Management of Care

14. A nurse is providing home care to a home-bound patient treated with intravenous (IV) therapy and enteral nutrition. What is the home health nurse’s primary objective?

a.

Screening

b.

Education

c.

Dependence

d.

Counseling

ANS: B

Health promotion and education are traditionally the primary objectives of home care, yet at present most patients receive home care because they need nursing care. Screening is preventive care. The home health nurse focuses on patient and family independence. Counseling is through psychiatric care.

DIF:Understand (comprehension)REF:20

OBJ: Discuss the role of nurses in different health care delivery settings.

TOP:PlanningMSC:Management of Care

15. A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse’s best response?

a.

“Technology use has to be combined with nursing judgment.”

b.

“The focus of effective nursing care is technology.”

c.

“If it’s so easy, why don’t you do it?”

d.

“That is true in the 20th century.”

ANS: A

In many ways, technology makes work easier, but it does not replace nursing judgment. Technology does not replace your critical eye and clinical judgment. Most importantly, it is essential to remember that the focus of nursing care is not the machine or the technology; it is the patient. Using “why” is not beneficial when communicating with others. Agreeing with the statement furthers misconceptions.

DIF:Apply (application)REF:26

OBJ: Explain the impact of quality and safety initiatives on delivery of health care.

TOP: Communication and Documentation MSC: Management of Care

16. A nurse is completing a minimum data set. Which area is the nurse working?

a.

Nursing center

b.

Psychiatric facility

c.

Rehabilitation center

d.

Adult day care center

ANS: A

Nurses who work in a nursing center (nursing home or nursing facility) are required to complete a minimum data set on each patient. Minimum data set is not needed for psychiatric, rehabilitation, or adult day care centers. Patients who suffer emotional and behavioral problems such as depression, violent behavior, and eating disorders often require special counseling and treatment in psychiatric facilities. Rehabilitation restores a person to the fullest physical, mental, social, vocational, and economic potential possible. Patients require rehabilitation after a physical or mental illness, injury, or chemical addiction. Adult day care centers provide a variety of health and social services to specific patient populations who live alone or with family in the community. Services offered during the day allow family members to maintain their lifestyles and employment and still provide home care for their relatives.

DIF:Understand (comprehension)REF:21

OBJ: Explain the role of nurses in different health care delivery settings.

TOP:ImplementationMSC:Management of Care

MULTIPLE RESPONSE

1. Which government-instituted programs should the nurse include in a teaching session about controlling health care costs? (Select all that apply.)

a.

Professional standards review organizations

b.

Prospective payment systems

c.

Diagnosis-related groups

d.

Third-party payers

e.

“Never events”

ANS: A, B, C

The federal government, the biggest consumer of health care, which pays for Medicare and Medicaid, has created professional standards review organizations (PSROs) to review the quality, quantity, and costs of hospital care. One of the most significant factors that influenced payment for health care was the prospective payment system (PPS). Established by Congress in 1983, the PPS eliminated cost-based reimbursement. Hospitals serving patients who received Medicare benefits were no longer able to charge whatever a patient’s care cost. Instead, the PPS grouped inpatient hospital services for Medicare patients into diagnosis-related groups (DRGs). In 2011, the National Quality Forum (not a government facility) defined a list of 29 “never events” that are devastating and preventable. Through most of the twentieth century, few incentives existed for controlling health care costs. Insurers or third-party payers paid for whatever health care providers ordered for a patient’s care and treatment.

DIF:Understand (comprehension)REF:15

OBJ: Explain the various methods for financing health care. TOP: Teaching/Learning

MSC:Management of Care

2. A nurse is teaching the staff about the Institute of Medicine competencies. Which examples indicate the staff has a correct understanding of the teaching? (Select all that apply.)

a.

Use informatics.

b.

Use transparency.

c.

Apply globalization.

d.

Apply quality improvement.

e.

Use evidence-based practice.

ANS: A, D, E

The Institute of Medicine competencies include: Provide patient-centered care; work in interdisciplinary teams; use evidence-based practice; apply quality improvement; and use informatics. Transparency is included in the 10 rules of performance in a redesigned health care system, not a competency. While globalization is important in health care, it is not a competency.

DIF:Understand (comprehension)REF:23

OBJ: Explain the impact of quality and safety initiatives on delivery of health care.

TOP:Teaching/LearningMSC:Management of Care

3. A nurse is evaluating care based upon the nursing quality indicators. Which areas should the nurse evaluate? (Select all that apply.)

a.

Patient satisfaction level

b.

Hospital readmission rates

c.

Nursing hours per patient day

d.

Patient falls/falls with injuries

e.

Value stream analysis for quality

ANS: B, C, D

The American Nurses Association developed the National Database of Nursing Quality Indicators (NDNQI) to measure and evaluate nursing-sensitive outcomes with the purpose of improving patient safety and quality care. Nursing quality indicators include the following: Hospital readmission rates, nursing hours per patient day, and patient falls/falls with injuries. While every major health care organization measures certain aspects of patient satisfaction, it is not a nursing quality indicator. Value stream analysis is a method that focuses on improvement of processes in a health care institution.

DIF:Apply (application)REF:25

OBJ: Discuss opportunities for nursing within the changing health care delivery system.

TOP:EvaluationMSC:Management of Care

4. A nurse is working in a health care organization that has achieved Magnet status. Which components are indicators of this status? (Select all that apply.)

a.

Empirical quality results

b.

Structural empowerment

c.

Transformational leadership

d.

Exemplary professional practice

e.

Willingness to recommend the agency

ANS: A, B, C, D

The American Nurses Credentialing Center (ANCC) established the Magnet Recognition Program to recognize health care organizations that achieve excellence in nursing practice. The five components are Transformational Leadership; Structural Empowerment; Exemplary Professional Practice; New Knowledge, Innovation, and Improvements; and Empirical Quality Results. Willingness to recommend the hospital/agency is a component of the Hospital Consumer of Assessment of Healthcare Providers and Systems survey.

DIF:Understand (comprehension)REF:24-25

OBJ: Discuss opportunities for nursing within the changing health care delivery system.

TOP:AssessmentMSC:Management of Care

MATCHING

A nurse is teaching about the different types of health care plans. Match the correct information to the type of health care plans the nurse should include in the teaching session.

a.

Insurance for low-income families

b.

Federal insurance for people aged 65 and older

c.

Health maintenance focus to specific group of voluntarily enrolled people

d.

Services at a discount for companies under contract

1. Preferred provider organization

2. Managed care organization

3. Medicaid

4. Medicare

1.ANS:DDIF:Understand (comprehension)REF:15-16

OBJ: Compare the various methods for financing health care. TOP: Teaching/Learning

MSC:Management of Care

2.ANS:CDIF:Understand (comprehension)REF:15-16

OBJ: Compare the various methods for financing health care. TOP: Teaching/Learning

MSC:Management of Care

3.ANS:ADIF:Understand (comprehension)REF:15-16

OBJ: Compare the various methods for financing health care. TOP: Teaching/Learning

MSC:Management of Care

4.ANS:BDIF:Understand (comprehension)REF:15-16

OBJ: Compare the various methods for financing health care. TOP: Teaching/Learning

MSC:Management of Care