309 Quality Management - Unit 1 & 2

Patient safety is not a key determinant in the accreditation decision process. True False

False

process indicators

Measure the actions by which services are provided, the things people or devices do, from conducting appropriate tests, to making a diagnosis, to actually carrying out a treatment.

brainstorming

Used in the exploratory phase of problem analysis and solution development - Used to identify the positive and negative - requires a LEADER who serves as a FACILITATOR.

bar graph

Used to report count values of categorical data - They are TIME SEQUENCED

cause-and-effect diagram

Useful for solving complicate problems - helps to see the relationship between performance factors and end results - Useful in Plan phase of PDCA

outcome indicators

Measure the actual results of care for patients and populations, including patient and family satisfaction.

structure indicators

Measure the attributes of the setting, such as number and qualifications of the staff, adequacy of equipment and facilities, and adequacy of organizational policies and procedures.

outcome management

Measuring the results of an intervention and the impact it will have on the quality of life.

performance measurement

The process of comparing the outcomes of an organization against pre-established performance plans and standards.

benchmarking

The process of comparing the practices, procedures and performance of an organization with those of another.

utilization management

The process of evaluating the necessity, appropriateness and efficiency of health care services to ensure quality of patient care.

risk management

The process undertaken to identify, control and minimize the impact of uncertain events, with the objective of reducing risk.

Evidenced based medicine

involves the use of current best research evidence in making decisions about the care of individual patients

Six SIGMA

roots in manufacturing industry - eliminates defects and improves the efficiency of its operations - reduces defective work to deliver product at a lower cost and offers superior customer service

nominal group technique

similar to brainstorming but uses silent generation of ideas to ensure participation of all members

root-cause analysis

systematic investigation process that occurs after a complication or adverse event that resulted in a patient injury cased by medical management rather than the underling disease or condition of the patient

efficiency

The effects or end results achieved in relation to the effort expended in terms of money, resources and time; the extent to which the resources used to provide a specific intervention, treatment or service of known efficacy are minimized.

5 Whys tool

1. Why is the customer unhappy? (Because services were not delivered as promised) 2. Why were the services not delivered as promised? (Because it took longer than expected to process the request) 3. Why did it take longer? (Because a new staff member was not aware of the correct procedure). 4. Why was the new staff member not aware of the correct procedure? (Because they were not fully trained). 5. Why was the new staff member not fully trained? (Because the new training manual is not yet complete).

Continuous Quality Improvement (CQI)

A component of Total Quality Management that emphasizes the importance of knowing and meeting customer expectations, reducing variation with processes, and relying on data to build knowledge for improvement; a continuous cycle of planning, measuring and monitoring performance.

continuous quality improvement

A component of Total Quality Management that emphasizes the importance of knowing and meeting customer expectations, reducing variation with processes, and relying on data to build knowledge for improvement; a continuous cycle of planning, measuring and monitoring performance.

flow chart

A graphic tool that uses standard symbols to visually display detailed information of the sequential flow of work an individual or a product as it progresses through a process; flow chart or flow sheet.

brainstorming

A group problem-solving technique that involves the spontaneous contribution of ideas from all members of the group.

Total Quality Management (TQA)

A management philosophy that includes all activities in which the needs of the customer and the organization are satisfied in the most efficient manner by using employee potentials and continuous improvement.

case management

A patient management process that involves a nurse or physician following a patient from admission to post-discharge.

force field analysis

A performance improvement tool used to identify specific drivers of, and barriers to, an organizational change so that positive factors can be reinforced and negative factors reduced.

The Joint Commission

A private, not for profit organization that evaluates and accredits hospitals and other healthcare organizations on the basis of predefined performance standards; formerly known as the Joint Commission on Accreditation of Healthcare organizations (JCAHO).

standards

A scientifically based statement of expected behaviour against which structures, processes and outcomes can be measured. A technical standard is an established requirement, usually issued in a formal document that specifies uniform engineering or technical criteria, methods, processes and practices.

Quality Assurance (QA)

A set of activities designed to measure the quality of a services, product, or process with remedial action, as needed, to maintain a desired standard.

quality improvement

A set of activities that measure the quality of a service or product through systems or process evaluation and then implements revised processes that result in better health care outcomes for patients, based on standards of care.

Balanced Scorecard (BSC)

A strategic planning and management tool that aligns activities related to the vision and strategy of the organization; that improves internal and external communications; that monitors organization performances against strategic goals.

decision (criteria) matrix

A table-formatted problem-solving tool to evaluate, compare, prioritize, and select the best solution.

cause and effect diagram

A visual representation of all direct and indirect causes for the event being analyzed; also known as a fishbone diagram or Ishikawa diagram.

accreditation

A voluntary process of institutional or organizational review in which an accrediting body evaluates the quality of the performance against pre-established criteria; a determination by an accrediting body that an organization complies with applicable standards.

LEAN

A way of thinking adapted from Toyota car industry that is currently being implemented in many health care organizations. LEAN is to eliminate waste and to add value to all steps within a process.

Required Organizational Practices (ROPs)

An essential practice that evidence and consultation have determined an organization must have in place to enhance patient/client safety and to minimize risk.

affinity diagram

An example of a Quality Improvement (QI) tool that organizes and sorts information into related groups, condensing large amounts of information into smaller more manageable groups.

Qmentum

An accreditation program is designed to focus on quality and safety throughout all aspects of an organization`s services—from governance and leadership to direct care and infrastructure—to the benefit of patients, clients, residents, staff and volunteers.

RCI (Rapid Cycle Improvement)

Based on the PDSA model - is an accelerated method to collect and analyze data and make informed changes based on that analysis

special-cause variation

Cause by factors outside the system.

admission management

Considers whether a patient should be admitted to hospital or not

Pareto chart

Go from largest (most frequently occurring) to smallest (least frequently occurring) - Used to demonstrate the most frequent performance problems that are MOST in need of fixing

Performance Improvement (PI)

Incorporates the principles of CQI and aims to improve performance of a system, process, activity, or outcome.

process re-engineering

Involves the redesign of structures, processes, systems, and even values or goals to achieve optimal performance.

required organizational practices (ROPs)

Proven essential practices that an organization must have to enhance patient/client safety and minimize risk.

Qmentum

Quality and momentum in one comprehensive package. The Qmentum accreditation program is designed to focus on quality and safety throughout all aspects of an organizations services.

scorecards

Reports of outcomes measures to help leaders know what they have accomplished.

dashboards

Reports of process measures that help leaders know what is currently going on so that they can plan strategically where they want to go next.

performance indicators

The continuous study and adaptation of a health care organization's functions and processes to increase the likelihood of achieving desired outcomes.

Donabedians Model of Structure

Structure, Process and Outcome

Tenet of Lean Thinking

Value-providing perfect value to the customer by using only value - adding processes and eliminating waste - more concrete less abstract

common-cause variation

Variation that is inherent within the system.

check sheet

Worksheet designed as a table to collect information; a quality management tool.

affinity grouping

a group formed around a shared interest or common goal, to which individuals formally or informally belong.

Which of the following is the best example of a performance measure? a. 95% of all cardiovascular surgery patients will receive prophylactic antibiotics within 1 hour before incision b. 100% of surgery patients should receive prophylactic antibiotics within 24 hours. c. Prophylactic antibiotics must be available in the surgical waiting area for administration before surgery. d. Surgeons must order prophylactic antibiotics they day before surgery.

a. 95% of all cardiovascular surgery patients will receive prophylactic antibiotics within 1 hour before incision

The nosocomial infection rate for a hospital is 0.2%, whereas the rate at a similar hospital across town is 0.3%. This is an example of a. benchmark. b. check sheet. c. data abstract. d. run chart.

a. benchmark.

What technique is used to maximize the number of ideas for problem analysis and solution a. Affinity diagram b. Brainstorming c. Cause and effect diagram d. Pareto chart

b. Brainstorming

A methodology for performance management adopted by many health care organizations and Ministries/Departments of Health is a. Kappa Delta Phi. b. Lean. c. Six Sigma. d. Minimum Standards Program.

b. Lean.

A patient is dissatisfied with his or her care. The individual he or she should contact regarding this is the a. Discharge Planner b. Patient Advocate. c. Risk Manager. d. Utilization Review Coordinator.

b. Patient Advocate.

Methods used to ensure evidence-based practice is implemented are known as a. case management. b. clinical practice guidelines. c. discharge planning. d. outcomes management.

b. clinical practice guidelines.

The primary source for information to support utilization and quality management activities is a. billing data. b. coded data. c. MIS data. d. registration data.

b. coded data.

Shared leadership, within the context of quality management and improvement, means a. all vice presidents and above are involved in the performance improvement program. b. employees are participants in the performance improvement program. c. the board of directors and organizational leadership are responsible for the performance improvement program. d. union leadership and administration lead the performance improvement program.

b. employees are participants in the performance improvement program.

The coding of inpatient records must be completed at a 98% accuracy rate is an example of a a. goal. b. qualitative standard. c. quantitative standard. d. vision statement.

b. qualitative standard.

Utilization management activities are meant to ensure that which of the following resources are used effectively? a. Human b. Non-human c. Both human and non-human d. Neither human or non-human

c. Both human and non-human

Which of the following is a quality improvement technique that visually identifies the steps in a process? a. Affinity diagrams b. Decision matrix c. Flow chart d. Force field analysis

c. Flow chart

Which of the following measures focus on what is done during the delivery of health care? a. Outcome b. Performance c. Process d. Structure

c. Process

Data that drive performance improvement originates from a. external sources. b. internal sources. c. both internal and external sources d. neither internal or external sources.

c. both internal and external sources

Practices used to ensure the smooth transition of patients from acute care to another setting is known as a. case management. b. clinical practice guidelines. c. discharge planning. d. retrospective review.

c. discharge planning.

The main focus of utilization management is a. avoidance of adverse events. b. delivery of quality care. c. effective use of resources. d. patient safety.

c. effective use of resources.

Two improvement tools that connect performance variables to outcomes are a cause and effect diagram and a. brainstorming. b. control charts. c. force field analysis. d. Pareto chart

c. force field analysis.

The earliest manifestation of quality management is a. continuous quality improvement. b. performance improvement c. quality assurance. d. total quality management.

c. quality assurance.

Fifty percent of the HIM staff possess the CHIM credential within the health care institution. This is an example of which type of indicator? a. Outcome b. Performance c. Process d. Structure

d. Structure

Performance indicators a. are qualitative measures. b. are relatively easy to calculate and maintain. c. cannot be institution specific. d. measure and monitor whether standards are met.

d. measure and monitor whether standards are met.

Clinical practice guidelines are a. billing regulations for the provincial health insurance. b. recommendations from Health Canada. c. standards for accredited hospitals. d. statements of optimal interventions for specific diagnoses.

d. statements of optimal interventions for specific diagnoses.

The focus of quality assurance is best described as a. continuous quality improvement. b. doing more with less. c. improvement of a system. d. to find problems and fix them.

d. to find problems and fix them.