Chapter 18

Outcomes measurement is complex because: a. budgets are unable to allocate sufficient funds. b. health care is multidimensional. c. patients may not cooperate. d. treatments are not always necessary.

ANS: B Despite the tendency to assume and measure outcomes as a simple linear relationship among client, nursing intervention, and outcome, the reality of what happens is more complex, interactive, and multidimensional

The specific tools used to make quality visible to stakeholders in health care are called: a. indicators. b. outcomes. c. variable selections. d. quality measures.

ANS: A Indicators are "valid and reliable measures related to performance" . They are the specific tools used to make quality visible to stakeholders in health care.

The outcomes concept that emphasizes the multidisciplinary process of providing health care is known as outcomes: a. maintenance. b. management. c. measurement. d. monitoring.

ANS: B Outcomes management is defined as "a multidisciplinary process designed to provide quality health care, decrease fragmentation, enhance outcomes, and constrain costs" (Huber & Oermann, 1998).

Outcome indicators such as nurse burnout, turnover, and job satisfaction are examples of which type of indicator? a. Patient-focused b. Provider-focused c. Organizational-focused d. Nursing-focused

ANS: B Provider-focused outcomes include such phenomena as nurse burnout, turnover, and job satisfaction

To provide the best care to every patient every day through integrated clinical practice, education, and research is an example of a(n): a. accountability agreement. b. mission statement. c. organizational standard. d. vision and value proposal.

ANS: B The mission statement of an organization is a concise statement that answers the question: What business are we in today?

Quality planning establishes the design of a product, service, or process that will meet customer, business, and operational needs to produce the product before it is produced. Quality planning follows a universal sequence of steps. List the universal sequence of steps in order. a. Identify customers and target markets. b. Discover hidden and unmet customer needs. c. Develop a service or product that exceeds customer's needs. d. Transfer these designs to the organization and the operating forces to be carried out. e. Translate these needs into product or service requirements: a means to meet their needs. f. Develop the processes that will provide the service, or create the product, in the most efficient way.

ANS: A, B, E, C, F, D

A Healthcare Failure Modes and Effects Analysis (HFMEA) for a new bar-coding system is being conducted by an interdisciplinary team. List the steps of the HFMEA in the correct order. a. Identifying prevention strategies b. Endorsing action plans for implementation c. Assessing risk points within the process steps d. Flowcharting the steps of the process being studied e. Designing out the most critical of the potential failures f. Recommending process improvements for prevention of the failures g. Ranking key risk points in terms of their impact on the potential failure of the system h. Reporting action plans for implementing prevention strategies to the enterprise leaders

ANS: D, C, G, E, F, A, H, B

2. _____ is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

ANS: Evidence-based practice Evidence-based practice is defined by Sackett and colleagues (1996) as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

The improvement process in which an organization measures its strategies, operations, or internal process performance against that of best-in-class organizations within or outside its industry determines how those organizations achieved their performance levels, and uses that information to improve its own performance is known as _____.

ANS: benchmarking Benchmarking "is the process of comparing a practice's performance with an external standard. Benchmarking is an important tool that facilitators can use to motivate a practice to engage in improvement work and to help members of a practice understand where their performance falls in comparison to others"

A(n) _____ is the result or results obtained from the efforts to accomplish a goal.

ANS: outcome An outcome is the result or results obtained from the efforts to accomplish a goal. The term outcomes has also been defined as the conditions in patients and others that health care delivery aims to achieve.

Mercy Hospital compares its surgical site infection rate to General Heart Hospital, which is known as a best-in-class hospital for its surgical site infection rates. Mercy Hospital studies General Heart Hospital's methods for reducing surgical site infection rates and uses that information to improve its own performance. This quality performance method is called: a. benchmarking. b. evidence-based practice. c. enterprise risk management. d. continuous quality improvement.

ANS: A In ambulatory care (and other settings), benchmarking "is the process of comparing a practice's performance with an external standard. Benchmarking is an important tool that facilitators can use to motivate a practice to engage in improvement work and to help members of a practice understand where their performance falls in comparison to others"

Sentinel Event Alerts are published by TJC to do which of the following? a. Allow facilities to learn from sentinel events that have occurred in other facilities and incorporate recommendations for prevention into their policies. b. Notify hospitals that if a sentinel event occurs during an alert, the hospital will be subject to withdrawal of Medicare and Medicaid certification and reimbursement. c. Prevent a near-miss from occurring. d. Assist hospitals to find national standardized performance measures to benchmark themselves against other similar hospitals.

ANS: A Sentinel Event Alerts are published by TJC to review the lessons learned from those facilities that had experienced these sentinel events. The hope is that other hospitals will incorporate the recommendations into their policy to avoid making similar errors.

A framework for understanding health care improvement has been proposed by the IOM Committee on Quality of Health Care in America. The aims for health care quality improvement propose that health care systems ensure that care is: (Select all that apply.) a. safe. b. timely. c. efficient. d. cost-controlled. e. patient-centered.

ANS: A, B, C, E A framework for understanding health care improvement has been proposed by the IOM Committee on Quality of Health Care in America. These six aims for health care quality improvement propose that health care systems ensure that care is safe, effective, patient-centered, timely, efficient, and equitable.

TJC requires accredited organizations to participate in their core measure initiative. The current core measure sets include: (Select all that apply.) a. stroke. b. tobacco treatment. c. pneumonia measures. d. iatrogenic pneumothorax. e. venous thromboembolism. f. acute myocardial infarction.

ANS: A, B, C, E, F The current core measure sets include perinatal care, stroke, venous thromboembolism, substance use, tobacco treatment, hospital outpatient department, pneumonia measures, heart failure, acute myocardial infarction, surgical care improvement project, hospital-based inpatient psychiatric services, emergency department, children's asthma care, and immunization (TJC, 2016d).

The Baldrige National Quality Award (BNQA) establishes a set of performance standards that define a total quality organization. The standards in areas of excellence include: (Select all that apply.) a. leadership. b. strategic planning. c. environment of care. d. human resource focus. e. medication management.

ANS: A, B, D The standards in seven areas of excellence established by the BNQA are: (1) leadership, (2) strategic planning, (3) customer and market focus (focus on patients, other customers, and markets), (4) information and analysis, (5) human resource focus, (6) process management, and (7) business results (organizational performance results).

Areas of data evaluation on a balanced scorecard include (select all that apply): a. financial. b. customer. c. environmental. d. learning and growth. e. internal business processes.

ANS: A, B, D, E The balanced scorecard uses four areas for data evaluation—internal business processes, learning and growth, customer, and financial—and directs managers to select indicators from each of these areas

A successful enterprise risk management (ERM) program will: (Select all that apply) a. identify risks. b. improve quality. c. prevent damage. d. control occurrences. e. control legal liability.

ANS: A, C, D, E ERM program is defined as an organization-wide program to identify risks, control occurrences, prevent damage, and control legal liability; it is a process whereby risks to the institution are evaluated and controlled.

Key examples of health care practices and interventions outcomes are (select all that apply): a. mortality. b. birth rates. c. health status. d. quality of life. e. ability to function

ANS: A, C, D, E Key examples of health care practices and interventions outcomes are health status, ability to function, quality of life, and mortality; care that is most important to patients, families, payors, and society.

Principles of a fair and just culture include: (Select all that apply.) a. zero-tolerance for reckless behavior. b. reduction of personal accountability and discipline. c. recognition that competent professionals make mistakes. d. errors and unintended events being reported unless no patient harm occurs. e. acknowledgment that even competent professionals develop unhealthy norms.

ANS: A, C, E A fair and just culture "is an approach to medical event reporting that emphasizes learning and accountability over blame and punishment". Everyone throughout the organization is aware that medical errors are inevitable, but all errors and unintended events are reported—even when the events may not cause patient injury. This culture can make the system safer as it recognizes that competent professionals make mistakes and acknowledges that even competent professionals develop unhealthy norms (shortcuts or routine rule violations), but it has zero-tolerance for reckless behavior.

The Agency for Healthcare Research and Quality (AHRQ) developed a set of categories of desirable attributes of a quality indicator. The categories include (select all that apply): a. feasibility. b. efficiency. c. importance. d. cost effectiveness. e. scientific soundness.

ANS: A, C, E Recently, the AHRQ developed a set of three broad categories of desirable attributes of a quality indicator: (1) importance; (2) scientific soundness, including clinical logic and measurement properties; and (3) feasibility.

A nursing quality improvement supervisor is proposing to enhance the current quality improvement program. One of the most important themes that a nursing quality improvement supervisor should consider is: a. budgetary considerations. b. collaboration between health care teams. c. regular staff training programs. d. suggestions from patients.

ANS: B Collaborative partnerships are part of this imperative and shape the way professional nurses act clinically and how they participate in performance and quality improvement efforts. As the complexity of care increases, multidisciplinary and inter-professional teamwork is used to solve complex problems in practice.

Hospitals must submit specific quality performance data regarding Medicare patients or risk: a. an increase in federal tax. b. decreased payments. c. fewer physician referrals. d. sanctions by The Joint Commission (TJC).

ANS: B In 2011, CMS developed the Hospital Value-Based Purchasing Program, which applied to payments beginning in fiscal year 2013 for discharges occurring on or after October 1, 2012.

Which of the following is an example of a nurse-sensitive indicator? a. Cardiac patient mortality b. Hospital-acquired pressure ulcers c. Pulmonary embolus after knee surgery d. Iatrogenic pneumothorax after central line placement

ANS: B Nurse-sensitive indicators refer to the structure, process, and outcomes of professional nursing care.

The process of managing outcomes includes five steps. List the five steps below in the correct order. a. Variances are investigated. b. Data are collected about outcomes. c. Trends are identified from data analysis. d. Changes are implemented and reevaluated. e. Appropriate service delivery changes are determined.

ANS: B, C, A, E, D In managing outcomes, the information derived from measuring client outcomes is collected, trends are identified, variances are examined, and appropriate care needs are determined to improve care to an individual, group, or population.

Implementation of the Transitional Care Model (TCM) has been associated with which of the following favorable outcomes (select all that apply)? a. Decreased length of stay b. Reductions in total health care costs c. Reductions in preventable hospital readmissions d. Increased overall satisfaction with the care experience e. Long-term improvements in physical health, functional status, and quality of life

ANS: B, C, D The TCM is a delivery system innovation that is designed to increase alignment of the care system with the preferences, needs, and values of high-risk individuals and their family caregivers and achieve higher-quality outcomes while reducing health care costs

Which of the following are never events? (Select all that apply.) a. A minor medication error b. A foreign object left in the body during surgery c. Surgery on the wrong body part d. A mismatched blood transfusion e. Hip fracture acquired in the hospital f. Pressure ulcer acquired in the home g. Catheter-associated urinary tract infection h. Surgical site infection

ANS: B, C, D, E, G, H A never event is an event that should never happen. The insurer will never pay. Insurers will no longer pay for never events. A pressure ulcer will be covered if it was not acquired in the hospital facility. A minor medication error that causes no harm to the patient will not cause an insurer to withhold payment.

Tenets embraced by health care professionals and promoted by health care leaders and organizations such as TJC and the IOM include which of the following? (Select all that apply.) a. People and systems are the problems, not processes. b. Quality measurement and monitoring is everyone's job. c. Quality cannot be enhanced by non-punitive work cultures. d. Standardization of processes is key to managing work and people. e. The impetus for quality monitoring is not primarily for accreditation or regulatory compliance.

ANS: B, D, E

Donabedian's aspects of quality include (select all that apply): a. goals. b. process. c. policies. d. structure. e. outcomes.

ANS: B, D, E Indicators are used to measure all three of Donabedian's (1985) aspects of quality: structure, process, and outcomes. Donabedian's framework is useful to understand the relationship between outcomes and the structure and processes that have produced them.

To determine whether her patient has responded favorably to a nursing intervention, a staff nurse should observe the client for: a. improved health. b. increased complaints. c. outcome indicators. d. signs and symptoms.

ANS: C Indicators are defined as "valid and reliable measures related to performance" (Oermann & Huber, 1999). According to the American Nurses Association, indicators measure how nursing care affects clients and therefore would provide evidence of a patient's response to treatment.

The industry-based model for quality management and measurement whose premise is that operational waste needs to be eliminated is: a. Six Sigma. b. ISO 9000. c. Lean Enterprise. d. Baldrige National Quality Award Program.

ANS: C Lean Enterprise is a model of quality measurement that was originally associated with Deming but reintroduced to the United States by Womack in the mid-1990s

Which comment by the nurse manager would indicate that the hospital places a high value on patient safety? a. We have safety posters throughout the hospital that encourage people to report problems. b. We have monthly safety in-services. c. We encourage patients and families to participate in their care. d. All employees are required to update their knowledge of safety practices each year.

ANS: C Nurse leaders will continue to play an important role in designing care delivery systems that promote patient and family engagement

Mary Lou is studying the 48-hour readmission rate of cardiac patients whose care was provided by nurses with associate degrees versus nurses with bachelor's degrees. The type of research Mary Lou is performing is called _____ research. a. quality b. patient outcomes c. nursing outcomes d. outcomes management

ANS: C Nursing outcomes research is a subspecialty within the larger field of health outcomes research that focuses on determining the effect of different contexts and conditions, related specifically to nurses and nursing care, on the health status of patients.

The field in health care that aims at a better understanding of the end results of health care practices and interventions is called: a. patient safety. b. risk management. c. outcomes research. d. quality management.

ANS: C Outcomes research aims at a better understanding of the end results of health care practices and interventions, such as the impacts of care that are most important to patients, families, payors, and society.

A clearly recognizable process of providing care that has an evidence base demonstrating that it reduces the likelihood of harm is: a. risk adjustment. b. a sentinel event. c. a patient safety practice. d. a performance measure.

ANS: C Patient safety practices are "discrete and clearly recognizable processes or manners of providing care that have an evidence base demonstrating that they reduce the likelihood of harm due to the systems, processes, or environments of care"

The degree to which health services for individuals and populations increases the likelihood of desired health outcomes that are consistent with current professional knowledge is known as the: a. care delivery quotient. b. excellence index. c. quality of health care. d. standard of care.

ANS: C Quality of health care is defined as the degree to which health services for individuals and populations increases the likelihood of desired health outcomes that are consistent with current professional knowledge

The risk manager wants to illustrate the causes that have been leading to an increase in patient misidentification. The most appropriate tool to use is a: a. pareto chart. b. control chart. c. fishbone diagram. d. detailed flowchart.

ANS: C The fishbone diagram resembles diagramming sentences.

Nurse managers can create an environment that is devoted to health care safety by doing which of the following? (Select all that apply.) a. Adopting and embracing the concept of disciplining staff who commit errors b. Learning the concepts and tools related to quality improvement and quality assurance c. Becoming a role model for staff and peers in practicing health care safety concepts d. Encouraging staff to be constantly vigilant in identifying potential risks in the care environment e. Creating a sense of partnership with patients and families to promote communication about safety concerns and soliciting their suggestions to correct and prevent potential risks

ANS: C, D, E Nurse managers can personally create an environment that is devoted to health care safety by doing the following: learning the concepts and tools related to risk identification, analysis, and error reduction; adopting and embracing the concept of non-punitive error reporting; advocating for the establishment of a non-punitive culture if it is not currently a strong ideal within the organization; encouraging staff to be constantly vigilant in identifying potential risks in the care environment; creating a sense of partnership with patients and families to promote communication about safety concerns and soliciting their suggestions to correct and prevent potential risks; and becoming a role model for staff and peers in practicing health care safety concepts.

Attributes of a total quality organization according to BNQA include: (Select all that apply.) a. accreditation by TJC. b. a commitment to obtaining Magnet designation. c. strategic planning. d. focus on patients, other customers, and markets. e. organizational performance results.

ANS: C, D, E The Baldrige National Quality Award (BNQA) establishes a set of performance standards that define a total quality organization.

Which of the following responses from the nurse manager is consistent with a culture that promotes patient safety? a. We make sure that we don't have any errors on this unit. b. We identify who made the error and take corrective action. c. We provide remedial training for all staff on the unit when there is an error. d. We report any medical error or near-miss to help us find the root cause of the problem.

ANS: D Health care organizations that embrace a fair and just culture identify and correct the systems or processes of care that contributed to the medical error or near-miss.

Responding to a code called in the psychiatric unit where she works, a staff nurse finds that a patient has committed suicide. The staff nurse correctly identifies this as a: a. benchmark incident. b. quality improvement issue. c. performance breach. d. sentinel event.

ANS: D Specific sentinel event outcomes are considered "reviewable" by TJC. Reviewable sentinel events are events that have resulted in an unanticipated death, permanent harm, or severe temporary harm and include suicide of any patient receiving care, treatment, and services in a staffed around-the-clock care setting.

The purpose of a root cause analysis (RCA) is to: a. discipline the staff involved in the patient safety event. b. disclose the medical error to the patient/patient s family. c. identify the person(s) responsible for committing the error. d. identify the systems issues that led to a sentinel event.

ANS: D The purpose of the RCA is to drill down to the most common cause(s) for the event and determine what process improvements can be made to prevent the sentinel event from occurring in the future.

The consequence of an intervention or treatment is known as a(n): a. achieved benefit. b. benchmark. c. expected response. d. outcome.

ANS: D The term outcomes has been defined as the conditions in patients and others that health care delivery aims to achieve (Peters, 1995). Donabedian (1985) described outcomes as changes in the actual or potential health status of individuals, groups, or communities.

_____ involves accounting for patient factors, the intrinsic risks that a patient brings to the health care encounter in the form of clinical and/or demographic factors, before drawing conclusions about the meaning of different values for indicators.

ANS: Risk adjustment Risk adjustment involves accounting for patient factors, the intrinsic risks that a patient brings to the health care encounter in the form of clinical and/or demographic factors, before drawing conclusions about the meaning of different values for indicators.