CPHQ Composite

I-43 Systems Thinking

Language and tool-kit for problems solving analyzing interrelationships and forces.

21-In evaluating long waiting times, a healthcare quality professional can best demonstrate components related to staffing, methods, measures, materials, and equipment by utilizing A. a run chart. B. a histogram. C. a pie chart. D. an Ishikawa diagram.

D. an Ishikawa diagram.***********

37-The most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staff is by A. developing professional relationships. B. inviting medical staff to an inservice on quality tools. C. evaluating physician participation on quality teams. D. providing outcome data at medical staff meetings

D. providing outcome data at medical staff meetings.********

K26 Principles of Management

Management is the sum of the activities of: {planning, organizing, staffing, directing, coordinating, and working to improve human and material resources} to achieve stated goals.

Which of the statistical techniques are least susceptible to outliers?

Median

I-37 Random - Common Cause Variation

Noise - intrinsic to process

Customer Focus

Organizational plan considers customer perspective -Identify customer -Assess customer needs Helps organization refine mission, vision, and core values

Vision

Organizations statement of its goals for the future -Organizations direction is built on mission and guided by vision

What are the 4 main roles of quality personnel?

1. Give input into each process 2. Track oversight activities 3. Ensure work is completed 4. Manage quality files for review and appointment

How long does significant change take to anchor in practice and culture?

10 years

Negotiation

The art of conferring, discussing, or bargaining to reach agreement.

Construct Validity

The degree to which an instrument measures the theoretical construct or trait that it was designed to measure (e.g., severity adjustment scales are tools for measuring staffing needs)

Strategic Planning.

The development and codification of a major direction for an organization's future.

How many points in a up or down direction does there need to be for a trend in a control chart?

6 points

87. How should qu#lity m#n#gement within # he#lthc#re org#niz#tion be viewed? #. As #n event b. As # burden c. As # continuum d. As # finite process

87. C: Qu#lity m#n#gement of # he#lthc#re org#niz#tion should be viewed #s # continuum th#t is #lw#ys progressing tow#rd the best possible outcomes.

I Mnemonic

A contraction or abbreviation used to represent the full expression.

Interrelationship Diagram

A drawing that organizes numerous complex problems, issues, or ideas by sorting and displaying their interrelations. Requires multidirectional thinking when a straight-line, cause-and-effect relationship does not exist.

Plan, Do, Check, Act (PDCA).

A four-step process designed to continuously improve quality, originally conceived by Shewhart.

team.

A group of people who are interdependent with respect to information, resources, and skills and who seek to combine their efforts to achieve a common goal.

Value Statements

A listing of organizational values that support the mission and vision statements and guide strategic planning, decision-making, and the provision of all services.

The range

A measure of variability; how measures spread out and the degree to which values differ.

H Integrated Delivery System - Vertical

A network of entities that provide and coordinate healthcare to a defined population across the entire continuum of care: prevention, ambulatory, subacute, acute, and long term.

H Ethic

A set of principles of right conduct.

Misuse of Care

A situation in which appropriate medical services are provided to patients poorly, exposing them to added risk of preventable complications.

Overuse of treatment.

A situation in which patients undergo treatment or procedures from which they do not benefit

Organization Leaders

The group of individuals that sets expectations, develops plans, and implements procedures to assess and improve the quality of the organization's governance, management, clinical, and support functions and processes.

Measurement

The planned, systemic process of quantifiable data collection, at a single point in time or repeated over time.

Readiness.

The state of being prepared mentally or physically for some experience or action; being immediately available or ready for immediate use.

Act

The step in the Plan-Do-Check-Act cycle at which one implements changes on a broad scale.

Check

The step in the Plan-Do-Check-Act cycle at which one measures outcomes compared to predicted outcomes

Plan.

The step in the Plan-Do-Check-Act cycle in which one questions the capacity or capability of a process and poses theories on how to improve the process and predict measurable outcomes.

Managed Care Reimbursement

Third party payers mange cost of healthcare and episodes of care

Improve

To take actions that result in a desired measurable change.

Preventable Event

Unintended injury to patients not caused by an error.

In what direction does a positive correlation follow?

Upwards

Active Hospital Privileges

Able to perform under their contract privileges

I-37 ADL

Activities of daily living

Rapid Cycle Improvement

Utilizing traditional quality tools but expediting the change and the results

I-42 ADE

Adverse Drug Events

H Medicare

Age 65+, permanent kidney failure, and disabled. Managed by CMS.

Administrative (non-clinical) support systems

Aid the day-to-day operations

I Accountability

All information is attributable to its source. [TJC]

The clinical competency of a physician is determined by

a committee of peers.

Which of the following is used to summarize a characteristic in a population?

frequency distribution

work group

more general term for a group of individuals who work together on a project

Core Measures

protocols based on evidence-based research for given types of disease processed -Report to: CMS and TJC

Participatory leadership style

Each individual has a voice in decisions, but top management retains the ultimate decision-making authority.

What does EMR stand for?

Electronic Medical Record

Benchmarking

Examine processes and results that represent best practices for similar activities inside or outside the healthcare industry. -Enables organization to set targets or goals for process improvement activities

I-41 GWTG

Get with the Guidelines - American Heart Association

Responsibilities of an outside consultant when leading employees?

Group dynamics and facilitation

In managed care, the most widely used performance measures are

HEDIS

K32 Risk Management/Liability Early Warning System

Identification of: 1) Adverse Patient Occurrence {APO} 2) Potentially Compensable Event {PCE}

Nominal Data.

In statistical process control, these are known as attributes data. Also called count, discrete, or qualitative data. Binary data are categorical data with only two possibilities (e.g., gender).

With what type of data do you use a Pareto diagram?

Categorical data

Appraisal

Initial evaluation by peers of a practitioner's competency to provide care and services to patients in or for a healthcare organization. May include credentialing, privileging, and appointment.

Decision Making

Choosing from among alternatives to determine a course of action. There must be at least two options, or there is no decision, only forced choice.

Delphi-method

Combination of the brainstorming, multi-voting, and nominal group techniques. Used when group members are not in one location and often is conducted by e-mail when a meeting is not feasible.

The clinical competency of a physician is determined by

Committee of Peers

Norms of Behavior.

Common or pervasive ways of acting that are found in a group.

Compliance

Conformity in fulfilling official requirements

k21 Special Case Rules

Control Chart 1) Any value at or beyond 3SD Control & Run Chart 1) 6 consecutive up or down 2) 8 consecutive above or below mean

Major benefit of rapid-cycle improvement

Collaborating organizations share their experiences and improvements spread quickly

Kaizen

Continuous Improvement -lean methodology

Qualitative

(QDA) is the range of processes and procedures whereby we move from the qualitative data that have been collected, into some form of explanation, understanding or interpretation of the people and situations we are investigating. Most powerful information Words

performance management plan should include

-list of priorities among the performance improvement activities, -a clear definition of the performance improvement problem that needs to be addressed, -an established list of standards to be met during performance improvement

Forming

-team members are positive and polite. As leader, you play a dominant role at this stage, because team members' roles and responsibilities aren't clear.

83. Wh#t is the rel#tionship between peer review #nd root c#use #n#lysis? #. They #re unrel#ted b. Peer review sp#rks root c#use #n#lysis c. They work together in f#ilure #n#lysis d. They were both designed by the Joint Commission

83. C: Peer review #nd root c#use #n#lysis #re both tools th#t #re used h#nd-in-h#nd #s p#rt of f#ilure #n#lysis.

Which of the following is most useful in performing a morbidity/mortality review? A.autopsy results B. physician profiling C. do-not-resuscitate policy D. length of stay

A.√ autopsy results*******************

Convenience Sampling

An approach that allows the use of any available group of subjects (e.g., all patients at an organization who are undergoing a certain procedure over a 12-month period).

Patient-centered care

Defined as involving patients and their families in the design of new care models and in decision making about individual options for treatment.

H Disease Management

Disease management is a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant.

36- Benchmarking is based on identifying which of the following? A. best practices B. competition C. deficiencies D. statistical control

EXPLANATIONS: A. Benchmarking is the comparison of results against a reference point, which is a best practice. B. See explanation A. C. See explanation A. D. See explanation A.

2011 MOQ 1- In evaluating "long waiting times," a healthcare quality professional best demonstrates components related to staffing, methods, measures, materials, and equipment utilizing A. a run chart. B. a histogram. C. a pie chart. D. an Ishikawa diagram.

EXPLANATIONS: A. Run charts are used to track data over time. B. Histograms and bar charts are used to show distribution. C. Pie charts are used to compare parts of a whole. D. An Ishikawa (cause and effect) diagram helps to analyze potential causes.

Nominal group technique

Group-decision-making process for generating a large number of ideas in which each member works by himself or herself.

Shared Values.

Important concerns and goals shared by most of the people in a group; they tend to shape group behavior and often persist over time even when group membership changes.

The Joint Commission (TJC)

Improves safety of care using accreditation and certification as risk reduction activities -deemed status from CMS

Hoshin Planning

Japanese term for policy deployment; a component of the total quality management/quality improvement system used to ensure that the vision set forth by top management is being translated into planning objectives. Also includes the actions that both management and employees will take to accomplish long-term organizational strategic goals.

Negligence

Lack of proper care, as judged by peers.

Empowering Leader

Leader shares power and decision making with employees, enabling others by providing the necessary resources and support.

Tort

Legal cases that result from civil wrongs including invasion of privacy, lack of consent, defamation of character, fraud and deceit, assault and battery, negligence/malpractice.

trend analysis

Reveal any changes in wait times over a set period of time as well as any new or worsening problems

A serious event has occurred related to the timely notification of critical test results. The root cause was traced to nursing difficulty with following the organizational policy. To prevent a similar event from reoccurring, which of the following should be done next?

Review the policy with nursing representatives to identify ambiguities.

Utilization Management Processes

Reviews: Pre-admission Concurrent Retrospective Authorizations Length of Stay Variances

I-32 The Paradigm

Structure leads to Process Process leads to Outcome {understand causal relationships}

SIPOC

Suppliers, Inputs, Process, Outputs, and Customers Used to identify internal and external customer needs a process and to use with other lean tools for process improvement

A large acute care facility has fostered a culture of patient safety through staff education, support of process improvements at the departmental level, and implementation of a non-punitive approach to error reporting. Compliance with patient safety goals in departments range from 75—100%.How should the organization assess its culture of patient safety?

Survey employees and physicians

H Scope of Care or Services

The activities performed by governance, managerial, clinical, or support staff. [TJC] A delineation of the important functions of the organization is necessary in order to then identify the associated processes performed. This definition is a significant expansion from the past focus on clinical activities.

Quality Planning.

The activity of developing the products and processes required to meet customer needs by determining who the customers are and what needs they have; developing product features and processes that respond to needs and produce desired product features; and transferring the resulting plans to the operating forces.

Range.

The difference between the highest and lowest values in a distribution of scores; usually expressed as a maximum and minimum.

uncertainty.

The fear and discomfort associated with the implementation of an innovation.

Guiding Principles

The organization's attitudes and policies for employees that help to direct the vision.

H Vision Statement

The organization's intent and aspirations for the future (what the organization strives to be). It should espouse forward thanking goals for quality and customer service.

Resilience.

The process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant sources of stress—such as family and relationship problems, serious health problems, or workplace and financial stressors.

Sample.

The selection of cases from the accessible population to provide a logical way of making statements about a larger group based on a smaller group and to permit researchers to make inferences or generalize from the sample to the population.

Norming

This is when people start to resolve their differences, appreciate colleagues' strengths, and respect your authority as a leader. -develop a stronger commitment to the team goal, and you start to see good progress towards it.

Focused Professional Practice Evaluation (FPPE)

Time limited process for organization to evaluate and confirm current competence for initially requested privileges -Required by TJC and HFAP -for initial appointment and new privileges

Deemed status refers to

accreditation equivalency with a CMS survey

Convenience Sampling

any available group of subjects is used -lack of randomization

A facility is becoming part of a healthcare network. Which of the following employee education programs is most important?

consumer expectations

bureaucratic leader

does not trust self or others to make decisions and instead relies on the organization's rules, policies, and procedures to direct the group's work efforts; rule-oriented

A policy for "time-outs" in an operating room was initiated in the first quarter. The second quarter data has demonstrated only 40% compliance with all elements of the process. The first step the Quality Council should take is to

examine if the policy is clear and user friendly.

When examining the relationship between staff and patient outcomes, which of the following would be most appropriate to assess?

patient safety data and overtime data

Conclusions in a statistical study are generalized to the

population

Team building exercises for the first meeting should include all of the following EXCEPT

reviewing the improvement plan.

Minimizing the chances of an adverse event reoccurring includes determining the primary contributing factor by using

root cause analysis.

Patient Safety

"Freedom from accidental injury caused by medical care"

Accreditation Association for Ambulatory Health Care (AAAHC)

-Exclusively focused on ambulatory health care -Peer based accreditation program

k9 Standard Deviation

1 = 68.2 2 = 95.4 3 = 99.7

K53 Specific Department Reviews

1) Pathology 2) Radiology 3) Pharmacy 4) Nursing (a) National Database for Nursing Quality Indicators {NDNQI}

Credentialing

1. Appointment/Reappointment to medical staff 2. Granting/Renewing/Revising clinical privileges

What are the 7 steps to interpreting and using information?

1. Plan and organize 2. Verify and correct 3. Identify and present findings 4. Study and develop recommendations 5. Take action 6. Monitor performance 7. Communicate results

101. The p#thology dep#rtment of Hospit#l A is up for # service-specific review. Wh#t documents should be considered #s p#rt of this review? #. Gener#l policies #nd procedures for the hospit#l b. Employee work history #nd perform#nce st#tistics c. Specific policies #nd procedures for p#thology d. All of the #bove

101. C: A service-specific review of the p#thology dep#rtment would cover specific policies #nd procedures for p#thology.

82. Who c#n initi#te # peer review? #. A p#tient b. A physici#n c. An insur#nce c#rrier d. All of the #bove

82. D: A peer review m#y be initi#ted by # p#tient, # physici#n, or #n insur#nce c#rrier.

99. Which of the following is defined #s correction of f#ulty processes to improve the qu#lity of outcomes? #. Six Sigm# b. Peer review c. Qu#lity improvement d. None of the #bove

99. C: Qu#lity improvement is defined #s correction of f#ulty processes to improve the qu#lity of outcomes.

Delphi Method.

A combination of brainstorming, multivoting, and nominal group techniques. This technique is utilized when group members are not in one location and frequently is conducted by mail and or e-mail when a meeting is not feasible.

Nominal Group technique.

A group decision-making process for generating a large number of ideas in which each member works by himself or herself.

Stratification.

A process that breaks down single numbers into meaningful categories or classification to focus corrective action; used to isolate and illuminate improvement opportunities.

Rapid Cycle Improvement.

A strategy whereby organizations collaborate to identify and prioritize aims for improvement and gain access to methods, tools, and materials that will enable them to conduct sophisticated, evidence-based quality improvement activities that they could not conduct individually.

29-An emergency department trends wait times from patient arrival to physician assessment. Data are reported using a run chart. Which of the following demonstrates a true statistical increase in treatment delays? A. 6 consecutive ascending data points B. 7 consecutive descending data points C. a zigzag pattern of 10 data points D. data points close to the mean line

A. 6 consecutive ascending data points

Which of the following is NOT a function of the facilitator on a quality improvement team? A. Keep minutes and records of the team's efforts. B. Keep the group focused on a central issue. C. Tactfully prevent anyone from dominating the discussion. D. Manage time.

A.√ Keep minutes and records of the team's efforts.*****************

Healthcare Facility Accreditation Program (HFAP)

Accreditation agency with deemed status that accredits hospitals and other types of healthcare facilities.

Join Commission International (JCI)

Accreditation agency with deemed status that accredits international hospitals and other types of healthcare facilities.

I-41 AHRQ

Agency for Healthcare Research and Quality

Optimality

Allocation of resources is achieved to the benefits derived from the services provided.

I-41 AHIP

America's Health Insurance Plans

total Quality Management.

An approach to organizational development and change that ensures that the organization meets or exceeds customer expectations; a strategic, integrated management system that involves all managers and employees and uses quantitative methods to continuously improve an organization's processes to meet and exceed customer needs, wants, and expectations.

Balanced Scorecard (BSC).

An approach to performance management developed by Norton and Vaplan. The basic idea of the BSC is that per formance measures should provide a comprehensive view of organizational performance and not be overly dependent on a few choice indicators. The BSC helps organizations better link long-term strategy with short-term activities.

Multivoting.

An easy, quick method for determining the most popular or important items from a list. This method utilizes a series of votes to cut the list in half each time, thus reducing the number of items to be considered

Multivoting

An easy, quick method for determining the most popular or important items from a list. This method utilizes a series of votes to cut the list in half each time, thus reducing the number of items to be considered -use after brainstorming to identify the key items on which the group will focus

Quality Control.

An evaluation of actual quality performance in which actual performance is compared to quality goals and the differences are addressed.

Innovation

An idea, practice, or object that is perceived as new by those who adopt it

I Client

Any computer that is hooked up to a computer network.

Healthcare Safety

Any improvement effort focused on eliminating medical errors; the degree to which the healthcare environment is free from hazards or dangers.

Patient Safety.

Any improvement effort focused on eliminating medical errors; the degree to which the healthcare environment is free from hazards or dangers.

Licensed Independent Practitioner (LIP)

Any individual who is professionally licensed by the state and permitted by the organization to provide patient care services without direction or supervision, which the scope of that license.

Patient Safety Solutions.

Any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of healthcare.

K56 FMEA Detection

Assign "1-10" for the capability of DETECTION of the failure mode. With "1" being detectable every time, "10" being impossible to detect.

25-Which of the following sampling techniques involves selecting the medical record of every fifth patient undergoing cardiovascular bypass? A. convenience B. systematic C. stratified D. simple random

B. systematic*************

Health information can assist the organization to?

Base the selection of quality improvement projects and develop new process to fill gaps

Which of the following is the most appropriate question to ask when reviewing an organization's performance improvement (PI) plan? A. "Are there sufficient organizational resources to support the PI plan?" B. "Does the PI plan include statistical methods for monitoring change?" C."Is the PI plan consistent with the organization's mission and strategic priorities?" D. "Has the organization been successful in communicating the intent and message of the PI plan to employees?"

C.√ "Is the PI plan consistent with the organization's mission and strategic priorities?"******************

Ratio Continuous Data

CMeasured on scares that theoretically have no gaps; considered variables data; has a true zero -equal distance between each point -no value goes below zero

Consulting Hospital Privileges

Cannot perform only consult

Efficient Care

Care provided in ways that avoid waste, including waste of equipment, supplies, ideas, and energy (IOM Six Aims)

I CHIN

Community Health Information Network: Networks forming to exchange data electronically among computer systems of various healthcare financing and delivery organizations in a defined geographic region.

Heroes

Company role models whose ideals, character, and support of the organizational culture highlight the values and norms a company wishes to reinforce. Heroes provide a role model for success.

The following data on falls were obtained from a facility with units that have similar average daily censuses. Unit A—9% Unit B—4% Unit C—6% Unit D—8% What other information is needed to help determine the cause of the falls?

Compliance with the fall prevention protocol

The perception of how an organization operates, including how employees relate to internal and external customers, is the organizational

Culture

When developing a strategic plan that integrates patient safety, which of the following factors is most critical

Culture of performance improvement

When introducing continuous quality improvement (CQI) into an organization, a chief executive officer must first A. reach consensus with the staff. B. educate supervisors in CQI principles. C. obtain funding from the governing body. D.assess the organization's readiness for change.

D.√ assess the organization's readiness for change.***********

Ordinal Categorical Data

Data in which characteristics are put into categories and rank-ordered. -Assignment to the categories is not arbitrary. EX: education- AD, BS, MS, PhD

Interval Data

Data in which the distance between each data point is equal (e.g., the values on a Fahrenheit thermometer).

I DRIP

Data rich, Information poor.

Decision Support Systems

Deal with strategic planning functions

CPHQ activities

Develop data collection and measurement procedures in order to evaluate outcomes. Provide education. Coordinate activities related to licensure, accreditation, standards and regulation. Identify organization needs and opportunities for improvement. Prepare organization wide plans. Document activities and provide summary reports to leadership and GB. Facilitate interdisciplinary teams. Differentiate a variety of organization needs.

H Proctoring

Direct observation and/or a review of medical records by peers to validate competency to perform requested privileges (initial or new), usually for a specified number of cases or for a period of time.

In what direction does a negative correlation follow?

Downwards

Simple Random Sampling

Each individual in population has an equal chance to be chosen

I-32 Focus on Process

Four Factors influence outcomes 1) Disease process and severity 2) Processes of care 3) Patient compliance 4) Random unidentified variables

H Standard of Practice

Generally formulated by practitioner organizations. Standards of care and practice are the building blocks of practice guidelines, critical/clinical paths, patient care policies and procedures, and indicators for quality management activities.

K22 Governance

Governing Board is responsible for everything.

Based on the principles from the Institute for Healthcare Improvement (IHI), who has the ultimate responsibility for the effectiveness of quality improvement and patient safety within an organization?

Governing Body

Strategic Leadership

Guidance or direction that is essential to meeting intended objectives or successfully implementing a plan of action.

In managed care, the most widely used performance measures are

HEDIS Healthcare Effectiveness Data and Information Set

What does a control chart do?

Identifies common cause and special cause variation possibly using six-sigma limits.

Medication reconciliation is used to do what?

Identify and resolve discrepancies

Tree Diagram.

Identify the overall goal that can be broken down into the steps necessary to achieve it

Common Cause

In statistical process control (SPC), a term that applies to problems rooted in basic processes and systems.

Pay for Performance.

Incentives that drive breakthrough performance to improve the quality of care and service rendered by healthcare providers. Typically includes performance metrics, public report cards, and payment differential for providing better quality care and service.

Treatment error

Is a mistake related to the resolution of a condition

autocratic leadership

Leader is directive and controlling; employees have little discretionary power in their work.

Central limit Therem

Means that the administrator will assume that a sample is respresentative of the dept. as a whole

A quality improvement team has brainstormed a list of many ideas. Which tool should the team use to identify which ideas to test first?

Multi-voting

Community Health Information Networks (CHINs)

Networks forming to exchange data electronically among computer systems of various healthcare financing and delivery organizations in a defined geographic region.

Quality improvements team development stages?

Norming, forming, performance,

The best way to evaluate the effectiveness of performance improvement training is through

Observed behavioral changes

Communication error

Occurs between two service providers or between a service provider and a patient.

H Profiling

Ongoing documentation, tracking, and compilation of practitioner clinical activities and services (e.g. performance measure and peer review data and information), as well as QI/PI activities (e.g., teams, committees, leadership) for reappraisal.

Society Outcomes

Optimality, Equity, Legitimacy

The evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to the performance of the

Organization's system

I-36 PI vs Re-Engineering

PI is incremental Re-Engineering is big and basic

Centers for Medicare and Medicaid Services (CMS)

Part of the department of health and human services Administers the following programs -medicare -medicaid -CHIP -Federally facilitated health insurance market place

Misuse of Care

Patients receive appropriate but poorly provided service, exposing them to added risk of preventable complications

Which of the following statements about patient falls in a long term care facility is TRUE?

Patients who climb over raised side rails are more seriously injured if they fall than those who fall from a bed without side rails raised.

Prospective Payment System

Payment rates established in advance for a specific time period; predetermined rates based on average levels of resource use (DRG's)

"85/15" Theory

Philosophy by Edward Deming stating that 85% of problems detected are process-or system-related and 15% are traceable to individuals.

PDSA

Plan, do, study, act

Provider Networks

Plans contact with venders (providers, labs etc) to provide services -HMO -PPO -EPO

How do you demostrate PDSA?

Prioritize, Pilot, Compare, Rollout

Root-Cause analysis

Required for sentinel events. When variation is inherent in the process and a reduction of the variance is desired, the root cause of the variation must be identified to eliminate tampering with the effective components of the process.

Conditions for Coverage (CfCs) or Conditions of Participation (CoPs)

Requirements established by CMS that healthcare organizations must meet to participate in the Medicare and Medicaid programs.

What is the result of a generic screening?

Risk of identification

Minimizing the chances of an adverse event reoccurring includes determining the primary contributing factor by using

Root Cause Analysis

H Ethics

Rules or standards governing conduct.

Appointment

Selection for membership in a medical/professional staff (e.g. hospital or medical group) to to a practitioner panel.

Histogram

Specialized bar chart used to summarize groups of data that are similar.

Objectives.

Specific statements that detail how goals will be achieved through specific measurable actions; -relatively narrow and concrete

Checklist

Standard way to ensure completion of critical tasks for a process or activity

Snowball Sampling

Subjects suggests other subjects

Two most essential functions of an infection control program?

Survellance and prevention

P value

The __________ , or calculated probability, is the probability of finding the observed, or more extreme, results when the null hypothesis (H 0) of a study question is true - the definition of 'extreme' depends on how the hypothesis is being tested.

H Systems Thinking

The belief that the behavior of all systems follows certain common principles, the nature of which can be discovered, articulated, understood, and used to make change. [Peter Senge]

Validity.

The degree to which an instrument measures what it is intended to measure. Validity usually is more difficult to establish than reliability.

Availability

The degree to which appropriate care is accessible and obtainable to meet a patient's needs.

Reliability.

The extent to which an experiment, test, or measuring procedure yields the same results on repeated trials.

Information.

The knowledge obtained when data are translated into results and statements that are useful for decision making. To be meaningful, data must be considered within the context of how they were obtained and how they are to be used.

Efficacy

The potential, capacity, or capability to produce the desired effect or outcome, as already shown, e.g., through scientific research (evidence-based) findings.

H Reliability Rating

The probability of the success of a process; calculated bin healthcare by measuring compliance with performance measures.

Diffusion

The process by which an innovation or new idea is communicated through certain channels over time among members of a social system (dissemination can be synonymous with diffusion).

Capital Budgeting

The process by which an organization evaluates and selects which long-term investments (or capital expenditures) it will make. Typically this is an annual activity, but it also may be triggered by events such as requests for new programs or equipment.

Process of Care.

The steps in which healthcare is delivered (how patients were diagnosed and treated; the activities involved in prevention, diagnosis, and treatment).

Mean

The sum of all scores or values divided by the total number of scores. Also known as the average, it is the most widely used measure of central tendency in statistical tests of significance.

H Mission

The written expression of the origination's overall, broad purpose and role (what/who the organization is). In a quality improvement environment it is expected that the statement of mission will express a high-priority, comprehensive commitment to patient care, to quality in all activities, and to service to the community. The mission statement is the basis for the formation of organizational vision, values, goals, and objectives.

Evaluation

To determine the worth of or to appraise. In performance improvement, evaluation is included in the analysis process.

What is the purpose of the a risk management trend analysis?

To identify opportunities

I-9 IOM

U.S. Institute of Medicine: 1999 "To Err is Human: Building a Safer Health System" 44,000 to 98,000 people die from preventable medical errors. Asked for 50% reduction in 5 years. Inspired Institute for Healthcare Improvement "100,00 Lives Campaign" 2001 "Crossing the Quality Chasm"

H UM

Utilization Management: The examination, evaluation, and appropriate use of organization resources; an organization wide, interdisciplinary, approach to balancing cost, quality, and risk concerns in the provision of patient care.

URAC

Utilization Review Accreditation Commission. Also known as the American Accreditation Healthcare Commission

What does 'value added' mean?

When customers recognize the value in something

On what axis does the follower/dependent variable go?

X-axis

On what axis does the leader/independent variable go?

Y-axis

In profiling length-of-stay data for benchmarking, it is important that data be

adjusted for severity

Systematic Sampling

after the first case is randomly selected, draw every n-th case from a population

Episode of Care

all the care a patient receives in the course of treatment for a specific illness, condition, or medical event

A process indicator is one that measures

an activity to provide care or service.

Mean

average. - most widely used measure of central tendency

The rate of Cesarean section performed at a facility over the past 5 years is best presented in a

control chart because data collected over time.

Categorical variable

count -nominal data

Core Values

define organizations attitudes and help direct vision

During quality management data analysis activities, Pareto charts are most appropriately used for

determining priorities among contributing factors.

-In the process of strategic planning, an organization makes decisions about the future. A basic component of the planning process is to

examine both internal and external environments.

Medical Error

failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim.

-Which of the following topics are discussed at a morbidity and mortality conference?

healthcare-acquired infections and perioperative mortality

-When conducting a sentinel event review, a root cause analysis

identifies gaps in patient care processes.

When conducting a sentinel event review, a root cause analysis

identifies gaps in patient care processes.

The primary purpose of integrating financial and quality management information is to

identify problems in resource management.

Adverse Event

injury caused by something that happened in the delivery of medical care rather then by underlying disease or patient condition

What are the types of benchmarking projects?

internal, external. zero-incidence

Prevention Error

is a mistaken approach to avoid a condition

To introduce performance improvement concepts throughout the organization, a healthcare quality professional should consider implementing all of the following steps EXCEPT

mandating staff participation in self-study activities related to quality.

Interpercentile Measure

measure of variability -interquartile range (most common) -measures lined up in order of size and divided into quarters. Only middle 50% of cases are used -EX: growth chart

Structural Measures are?

measures of infrastructure, capacity, systems, and process (nursing staff ratios)

Median.

middle

poke-yoke

mistake proofing -lean methodology

Sustain improvement by?

monitoring

Clinical Pathways

multidisciplinary management tool proactively depicting all inclusive important events that should take place in a sequence goal- to achieve optimal quality of care while minimizing delays and efficient resource utilization

Administrative Support Information System

non-clinical support systems that aid day-to-day operations -including financial information systems, human resources information systems

The best way to evaluate the effectiveness of performance improvement training is through

observed behavioral changes.

An operating room circulating nurse reported that the instrument count indicated a missing clamp. X-ray findings were negative, and the patient showed no adverse effects. This occurrence is an example of which of the following?

potentially compensable event

An acute care facility has had an increase in the rate of patient falls in the past six months. The healthcare quality professional should recommend

sharing the data with staff to provide feedback

Use a histogram to

show spread of distribution show whether data are systematic or skewed show whether there are extreme data values for data analysis and outcome variation

Failure Mode and Effects Analysis (FMEA)

systematic and proactive method of identifying and preventing failures before they occur -used for new systems/process, redesign of system/process in early stages, and existing systems/processes -analysis completed for each failure identified (known or potential)

According to the 80/20 rule, 80% of an organization's problems are related to

systems

The prevalence of a disease depends on the

the incidence and duration of the disease

A team approach to quality improvement activities is preferred when

the process has many owners

Situation-Background-Assessment-Recommendation (SBAR) is a

tool to improve communication between caregivers.

Handoffs

transfer and acceptance of patient care responsibility achieved through effective communication -should include patient history, infections/complications, need for restraints

t-test

used to analyze the difference between two means -used when determining whether difference between two groups means is statistically significant

Which of the following best demonstrates use of the Plan-Do-Check-Act performance improvement model? A. Review current practice, form a multidisciplinary committee, schedule a meeting to develop a plan, and determine actions to be taken. B. Identify a problem, implement change, educate staff about the change, and rewrite policies and procedures to augment the change. C.Prioritize opportunities for improvement, pilot the improvement, compare pre- and post-implementation data, and rollout to the entire organization. D. Collect baseline data, form a committee to develop the plan, validate audit data, and formalize the change.

C.√ Prioritize opportunities for improvement, pilot the improvement, compare pre- and post-implementation data, and rollout to the entire organization.*************

64. The best approach for training staff about quality and patient safety is to A. require staff to complete mandatory online training at convenient times. B. develop posters and brochures that explain key quality concepts and place them strategically throughout the workplace. C.conduct multidisciplinary interactive sessions consistent with adult-learning principles. D. have the CEO meet with each department to explain the department's role in quality and safety.

C.√ conduct multidisciplinary interactive sessions consistent with adult-learning principles. **************

An organization's data demonstrate an increase in the number of patient falls. A healthcare quality professional should recommend A. revising the fall-risk assessment tool. B. convening a focus group of medical staff to discuss fall risks. C. increasing staffing on weekends and nights. D.sharing the data with the staff to provide feedback.

D.√ sharing the data with the staff to provide feedback.*************

Ordinal Data

Data in which characteristics are put into categories and rank-ordered. Assignment to the categories is not arbitrary. Examples of ordinal scale data are nursing staff rank (nurse level 1, nurse level 2), educational level (BS, MS, MD), or attitude toward research scale (strongly agree, agree, neutral, disagree, strongly disagree).

42- Which of the following tools should be used to record patient and practitioner-specific data? A. flowchart B. graphs C. histogram D. spreadsheet

EXPLANATIONS: A. A flowchart shows a process. B. There is not enough information provided to determine whether graphs could be used. C. There is not enough information provided to determine whether a histogram could be used. D. A spreadsheet allows for individualized data to be represented.

58- Replacing retrospective review with concurrent review is an example of A. a paradigm shift. B. a process improvement. C. an empowerment process. D. productivity enhancement.

EXPLANATIONS: A. A paradigm shift is a change in method or perspective. B. Switching from a retrospective to concurrent review represents a change that may or may not result in a process improvement. C. Empowerment typically gives the people involved the power to make decisions and is not related to the review process. D. Switching to a concurrent review may or may not result in an increase in productivity.

24- A root cause analysis revealed a patient in an acute psychiatric unit committed suicide by hanging himself with his shoelaces. To prevent this from occurring again, the most appropriate action is to institute A. patient checks every 15 minutes. B. a policy allowing only non-laced shoes. C. a 24-hour video monitoring system. D. a buddy system for the patients.

EXPLANATIONS: A. Checking patients every 15 minutes may not prevent suicide. B. This policy eliminates the object that was used to commit suicide and creates a safer environment. C. A monitoring system may not prevent suicide. D. A buddy system may not prevent suicide.

5- Which of the following is an essential component in a performance improvement report? A. governing body approval B. data analysis and display C. individual performance review D. team composition and attendance

EXPLANATIONS: A. The governing body is accountable for the performance improvement program, but their approval is not a component of a performance improvement report. B. The report has no value without having the data displayed and analyzed. C. An individual performance review is not an essential part of a performance improvement report. D. Team composition and attendance are not usually included in a performance improvement report.

Accountable Care Organization (ACO)

Groups of doctors, hospitals and other healthcare providers, who work together to give coordinated high quality care to their patients, at lower costs

Quality Improvement teams.

Groups of people assigned to focus on a desired improvement; can be natural work teams, such as teams whose members work each day to complete a task; cross-functional teams, such as an operating-room team; or intact teams, such as a team of nurses in a particular unit.

Which of the following questions should be asked first when reviewing an organization's performance improvement (PI) plan?

Is the PI plan consistent with the organization's mission and strategic priorities?

H LIP

Licensed Independent Practitioner: Any individual who is professionally licensed by the state (US) and permitted by the organization to provide patient care services without direction or supervision, within the scope of that license.

Adjourning

Many teams will reach this stage eventually. For example, project teams exist for only a fixed period, and even permanent teams may be disbanded through organizational restructuring.

Peer Review

Medical staff involved in measuring, assessing, and improving performance to licensed practitioners Effective Peer Review Process should be: consistent, defensible, and balanced

I-10 PPS

Medicare Prospective Payment System: reimbursement based on a predetermined, fixed amount for a particular service depending on the classification system of that service (for example, diagnosis-related groups (DRG) for inpatient hospital services). CMS uses separate PPSs for reimbursement to acute inpatient hospitals, home health agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities.

Levels of significance

(p) gives the probability of observing a difference as large as the one found in the study when there is no true difference (when null hypothesis is true) -based on probability, when p , results are statistically significant

Baldrige Performance Excellence Program

-provides organizational assessment tools and criteria -educates leaders and practices of best-in-class organizations -recognizes national role models with Presidential Award for performance excellence -7 criteria (leadership, strategy, measurement, customer focus, work force focus, operational focus, results)

Population (N).

. The total aggregate or group (e.g., all cases that meet a designated set of criteria for practitioners, all patients who have died at a particular hospital, all registered nurses with a tenure of 10 years or more).

I-38 Reliability Rating

1 Measure = {# patents passing}/Total patients Composite Measures = {Total # passing}/{# measures x # patients} Patient Encounters = {# patents passing all}/ Total patients

K46 PI Process

1) Identify team 2) Use systematic approaches 3) Formulate an action plan 4) Test action as appropriate 5) Commit to implementation 6) Implement 7) Improvement sustainment 8) Evaluate effectiveness 9) Document improvement plan & result 10) Communication/disseminate information across organization

K9 QM Basic Principles 1-3

1) Productive work is accomplished through Processes. 2) Sound Customer-Supplier relationships are absolutely necessary for sound QM. 3) The main source of Quality Defects is problems in the Process.

I-13 Traditional Clinical Review Departments

1) Quality Management {QM} 2) Utilization Management {UM} 3) Risk Management {RM} 4) Infection Control {IC} 5) Case Management/Discharge Planning {CM/DP} 6) Practitioner credentialing, privileging, and competency appraisal 7) Continuing medical/clinical education

I-30 Juran Trilogy

1) Quality Planning 2) Quality Control 3) Quality Improvement

I-31 Quality Management Cycle (The Model)

1) Quality Planning 2) Quality Control / Measurement 3) Quality Improvement

105. Wh#t is d#t# inventory listing? #. Prep#ring # list of #ll reports currently produced b. Cre#ting # spre#dsheet th#t holds #ll #v#il#ble d#t# c. Determining wh#t inform#tion is #v#il#ble from which sources d. T#king inventory of #ll historic#l #nd org#niz#tion#l d#t#

105. C: D#t# inventory listing c#n be defined #s determining wh#t inform#tion is #v#il#ble from which sources, thereby m#king #n inventory of #v#il#ble d#t# sources.

123. How does perform#nce improvement rel#te to risk m#n#gement #ssessment? #. Perform#nce improvement #nd risk m#n#gement #ssessment #re unrel#ted. b. Perform#nce improvement is # p#rt of risk m#n#gement #ssessment. c. Risk m#n#gement #ssessment is # p#rt of perform#nce improvement. d. Perform#nce improvement corrects issues identified in risk m#n#gement #ssessment.

123. D: Perform#nce improvement is rel#ted to risk m#n#gement bec#use it is # tool to correct the issues th#t #re uncovered during # risk m#n#gement #ssessment.

At least how many points of data do you need for a control chart?

20 points

3. St. Josephʼs Hospit#l w#s recently r#nked l#st in the region in the #re# of efficiency in tr#nsferring p#tients to inp#tient beds. When working on process improvements, wh#t type of d#t# is likely to prove most helpful? #. Intern#l d#t# b. Historic#l d#t# c. Qu#lity control d#t# d. Comp#r#tive d#t#

3. D: Comp#r#tive d#t# would prove most helpful in improving the processes #t St. Josephʼs Hospit#l. By comp#ring their d#t# #nd processes with those of higherr #nked medic#l f#cilities, process improvement solutions could be derived. A #nd B #re incorrect bec#use intern#l d#t#, whether historic#l or contempor#ry, will not help identify the re#sons for the l#st pl#ce r#nking #nd will not help improve processes. C is wrong bec#use qu#lity control d#t# is #nother intern#l me#sure th#t will only comp#re the existing processes with est#blished intern#l st#nd#rds.

63. Wh#t effect will #n extreme org#niz#tion#l focus on fin#nci#l report results likely h#ve on p#tient s#fety? #. It will h#ve no effect on p#tient s#fety b. It will h#ve # positive effect on p#tient s#fety c. It will h#ve # neg#tive effect on p#tient s#fety d. It will complic#te p#tient s#fety policies

63. C: A strong org#niz#tion#l focus on fin#nci#l report results, the so-c#lled "bottom line," will likely h#ve # neg#tive effect on p#tient s#fety #s efforts #re m#de to lower costs of service.

70. It h#s recently been brought to your #ttention th#t there is # disp#rity in #dmission r#tes between insured #nd uninsured p#tients with the s#me conditions. How could you best express this disp#rity st#tistic#lly? #. Through use of # P#reto ch#rt b. By using benchm#rk d#t# c. Through comp#r#tive #n#lysis d. By ev#lu#ting st#nd#rd devi#tion

70. C: The best w#y to st#tistic#lly express # disp#rity between two c#tegories of d#t# is through comp#r#tive #n#lysis. A, B, #nd D #re incorrect bec#use, while they st#tistic#lly express d#t#, they do not show disp#rities within # d#t# set #nd they do not comp#re numbers #s cle#rly #s comp#r#tive #n#lysis does.

77. It is confirmed th#t # p#tient who s#t for 30 minutes in the w#iting room of your clinic w#s di#gnosed with me#sles. Wh#t necess#ry infection-control step should be t#ken? #. Educ#te the p#tient on possible effects of the me#sles b. Document the c#se in your #nnu#l clinic st#tistics c. Tr#in front-desk employees to recognize signs of me#sles d. Cont#ct #ll p#tients who m#y h#ve been in the w#iting room th#t d#y

77. D: The most import#nt infection-control step in this situ#tion would be to cont#ct #ll p#tients who m#y h#ve been in the w#iting room th#t d#y.

88. As # dep#rtment m#n#ger, you #re trying to est#blish provider response time benchm#rks. The d#t# th#t you receive is #ggreg#ted d#t# outlining #ll provider #ctivities for your dep#rtment. Wh#t should your first step be in working tow#rd est#blishing benchm#rks? #. Ask for # re-mining of d#t# b. De-#ggreg#te #nd cl#ssify d#t# c. Est#blish only bro#d benchm#rks d. Distribute d#t# to employees

88. B: De-#ggreg#ting #nd cl#ssifying d#t# is the best first step in bre#king down the #ggreg#ted d#t# to determine specific d#t# on provider response time.

Strategic Goal.

A broadly stated or long-term outcome written as an overall statement that relates to a philosophy, a purpose, or a desired outcome.

Cultural Screen

A change management tool focusing on the cultural aspect of change and identifying those factors associated with the culture of the organization that should be assessed to achieve successful change.

H Benchmark

A comparative "best" as baseline for improvement.

Flowchart or Process Flowchart

A graphical display of a process outlining the sequence and relationship of the pieces of the process

Force Field Analysis

A method to systematically identify both the various forces that facilitate or increase the likelihood of success and the opposite factors, those that decrease or restrain the likelihood of success or improvement in the process

Patient safety is promoted in an organization through A.encouragement of error reporting, staff education, and reliable systems. B. reliable systems, open communication, and performance reviews. C. performance reviews, encouragement of error reporting, and willingness to pay overtime. D. willingness to pay overtime, open communication, and staff education.

A.√ encouragement of error reporting, staff education, and reliable systems.*******

40. Team building goals for a first meeting should include all of the following EXCEPT A.evaluating the project. B. learning to work as a team. C. getting to know one another. D. setting meeting ground rules.

A.√ evaluating the project.**********

Nominal Data.

Also called count, discrete, or qualitative; considered attributes data with no quantitative value -Binary data-data with only two possibilities (e.g., gender).

utilization Management.

An organized, comprehensive approach to analyze, direct, and conserve organizational resources, so as to provide care that is both high in quality and cost-effective (e.g., medical necessity appropriateness review; discharge planning and monitoring; overutilization and underutilization surveillance; and identification of overutilization and underutilization).

45-A team approach to problem solving is most useful when A. the organization's goals are unclear. B. diverse areas of expertise are required. C. communication challenges exist. D. required by a regulatory body.

B. diverse areas of expertise are required.*************

9-The primary reason healthcare organizations use benchmarking is to A. comply with accreditation standards. B. improve performance. C. decrease risk to the organization. D. provide risk adjustment.

B. improve performance.**********

Complex Adaptive Systems (CAS

Systems of interdependent things (e.g., agents that can be people, departments) wherein there are a great number of connections between a wide variety of elements in addition to the ability to learn from experience.

Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization's quality improvement program?

have quantifiable objectives

-Medication reconciliation is a process intended to

identify and resolve discrepancies.

Medication reconciliation is a process intended to

identify and resolve discrepancies.

central tendency

statistical indexes that describe where a set of scores/values of a distribution cluster -mean, median, mode

International Organization for Standardization (ISO)

-Developer of voluntary international standards -in healthcare focus is on quality management program

RCI

-Identifies and prioritizes aims for improvement -gains access to methods, tools, and materials for evidence-based quality improvement -moves quickly

Health Maintenance Organization (HMO)

-Members need to receive most/all care from network provider -PCP responsible for managing and coordinating all healthcare -Members pay for using providers outside the network

Population Health Management Payment

-New models for healthcare payment being designed to support PHM -Payment shifts under accountable care arrangement -Fee for service reimbursement reward providers for efficient, effective, and appropriate care for fee-for-value approached -Value-based approach demonstrates improved outcomes for a population under management

K56 FMEA 5-7

1) Calculate the Risk Priority Number for each effect (a) Severity x Frequency /Occurrence x Detection (b) Highest RPNs are tackled first 2) Take action to eliminate or reduce the high risk failure modes 3) Identify performance measures to monitor the effectiveness of the redesigned process

I-14 Services vs Products

1) Most services are "performances" - intangible 2) Services are heterogeneous 3) Production of the services is often inseparable for its consumption 4) Services are perishable

I-47 STEEEP (Systems)

1) Safety 2) Timeliness 3) Effectiveness 4) Efficiency 5) Equity 6) Patient-Centeredness

K43 QI Team Process

1) Selecting the Team 2) Relating to the Quality Council 3) Stages of Team Development (a) Forming (b) Storming (c) Norming (d) Performing {Conforming}

Leadership Support of Safety

1. Allocate resources (staff, equipment, time) 2. Analyzed processes with failures and risks driving change 3. Communicate and implement changes 4. Support non-punitive error reporting

To interpret and use information

1. Plan and organize 2. Verify and correct 3. Identify and present findings 4. Study and develop recommendations 5. Take action 6. Monitor performance 7. Communicate the results

Five steps for leadership Improvement Framwork

1. Set direction:mission, vision, and strategy 2. Establish the foundation 3. Build will 4. Generate ideas 5. Execute change

23. Which of the following c#n be defined #s, "A set of me#sures #nd d#t# th#t give m#n#gers #nd #dministr#tors # quick yet comprehensive overview of perform#nce?" #. Process me#surement b. B#l#nced scorec#rd c. D#shbo#rd d. Six Sigm#

23. B: A b#l#nced scorec#rd is # set of d#t# th#t give # quick #nd comprehensive overview of perform#nce. Process me#surement is lengthy #nd gener#lly focused on # single process #re#, not quick #nd #llencomp #ssing. D#shbo#rd scoring is not #s quick or comprehensive #s # b#l#nced scorec#rd. Six Sigm# de#ls with qu#lity me#surement, not perform#nce d#t#.

29. Which of the following is # good w#y to #ssess customer needs #nd expect#tions? #. Surveys b. Focus groups c. Inform#l discussions d. All of the #bove

29. D: Surveys, focus groups, #nd inform#l discussions #re #ll excellent w#ys to #ssess customer needs #nd expect#tions.

66. Using Don#bedi#nʼs model, which of the following #re#s most needs to be #ddressed in # clinic with elev#ted levels of post-tre#tment infection? #. Structure me#sures b. Process me#sures c. Outcome me#sures d. None of the #bove

66. C: Outcome me#sures de#l with the effects of tre#tment #fter the f#ct, so they #re the most #pplic#ble portion of Don#bedi#nʼs model to this p#rticul#r situ#tion. A #nd B #re wrong bec#use structure #nd process me#sures do not #pply to this situ#tion. D is incorrect bec#use Don#bedi#nʼs outcome me#sures do #pply to this c#se.

K10 QM Basic Principles 7-9

7 Total employee involvement is critical. 8 New organizational structures can help achieve QI. 9 QM employs: (a) Quality Planning (b) Quality Control - measurement (c) Quality Improvement

k1 Information Management Process 7-11

7) Analyze Data 8) Interpret Data / Information 9) Act on Information 10) Report Data / Information / knowledge / Decision 11) Collect more Data to Monitor / Analyze the Decision

Variation

A "change of deviation in form, condition, appearance, extent, etc., from a former or usual state, or from an assumed standard."

Goal

A broad, general statement specifying a purpose or desired outcome; may be more abstract than an objective (one goal can have several objectives). Establishing a goal is the initial step in the strategic planning process and sets the direction for the activities to follow.

First-order Change

A change that comprises small, relatively easy steps. It requires minimal effort to achieve and rarely has a significant effect on complex systems or organizations

Patient Safety Practice.

A type of process or structure whose application reduces the probability of adverse events resulting from a patient's exposure to the healthcare system across a range of diseases and procedures.

Expert Sampling

A type of purposive sampling that involves selecting experts in a given area because of their access to the information relevant to the study.

24-Which of the following are the primary reasons for developing drug formularies? A. manage pharmacy costs and promote patient safety B. reduce medication errors and educate physicians C. encourage the appropriate use of medications and educate physicians D. decrease food and drug interactions and promote patient safety

A. manage pharmacy costs and promote patient safety*******

Study the effects of change and make a decision by?

Adopting, adapting, or abandoning the specific change

H Iatrogenic

An infection or other complication of treatment induced in a patient by a physician's or other licensed independent practitioner's activity, manner, or therapy.

Parametric tests.

Statistical tests used with data measured on a continuous scale (i.e., interval or ratio data, also known as variables data).

What occurs in the 'norming' stage of team development?

Team cohesion is established

Communicability.

The ability to clearly communicate a description and value of the innovation to stakeholders.

Leadership

The ability to influence an individual or group toward achievement of goals.

trialability.

The degree to which an innovation can be tested on a small scale.

Certified Professional in Healthcare Quality (CPHQ

The designation received by a person after passing the written examination and adhering to standards established by the Healthcare Quality Certification Board (HQCB) and continuing to maintain those standards through the recertification process.

Outcomes.

The results of care processes (e.g., patients' progress, satisfaction, length of life, and quality of life following treatment).

What are Pareto charts used for?

To identify priorities among contributing factors using represented valued

A curriculum for staff education in organizational change should include all of the following

budgeting techniques.

Case Management

collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet individuals health needs -focuses on improvement of patients goals within a defined timeframe, integrating efforts of team members

-When using cost-benefit analysis in decision making, it is important to remember that

consideration of the benefit is more important than cost.

I-44 Four levels in Systems

1) Events 2) Patterns of Behavior 3) Systemic Structure {decisions...} 4) Mental Models

K56 Benchmarking 2

1)Finding best practice and trying to look more like that practice 2) Identify Benchmarking Needs 3) Benchmarking System / Steps 4) Using Benchmark Data

Performance Monitoring.

A plan for monitoring the impact and effectiveness of a quality improvement action and collecting additional data.

Teatment error

Mistake related to the resolution of a condition

What should be used to identify immediate attention after brain-storming

Multi-voting

H Structure

Structure leads to process and process leads to outcome.

Organizational learning.

A pattern of learning carried out in organizations skilled at creating, acquiring, and transferring knowledge and at modifying behavior to reflect new knowledge and insights.

H Flowchart

A pictorial representation displaying the actual-sequence of steps and their inter-relationships in a specific process in order to identify hand-offs, inefficiencies, redundancies, inspections, and waiting steps and/or the ideal-sequence of steps, once the actual process is known.

I-18 QM/Improvement definition

A planned, systematic, organization-wide (or network) approach to the monitoring, analysis, and improvement of organization performance, thereby continually improving the quality of patient care and services provided and the likelihood of desired patient outcomes.

Simple Process.

A process that allows people to follow a prescribed procedure. It has been tested and ensures replicability without particular expertise.

H Negligent Conduct

Doing what a reasonable person would not do: failure to do what a reasonable person would do (based on set standards and under like circumstances and training) Gross Negligence: is failure to act if there is known or suspected risk resulting in adverse impact or death.

Which of the following are attributes of a culture of safety?

increased patient acuity level and error-proof environment

Which of the following actions should the facilitator make the highest priority during the customer focus group process?

establishing rapport with the group

H Reappointment

Selection for continued membership in a medical/professional staff or to a practitioner panel, based on reappraisal.

What does PPE stand for?

Personal Protective Equipment

Nonparametric tests.

Statistical tests that are used with categorical (attributes) data and should be used with ordinal data, especially if the ordinal categories have a small range of possible values or a nonnormal distribution.

the most effective way to integrate performance improvement concepts throughout an organization

quality teams

K39 Cost-Effectiveness Analysis (CEA)

1) Comparison of costs with outcomes in quantitative, but non-monetary units 2) Each alternative is compared against the same outcome measure or measures 3) Measures: Effectiveness, Operational Use, Personal & Equipment, Cost Factors

21. A sm#ll city h#s two hospit#ls. The Hospit#l Consumer Assessment of He#lthc#re He#lthc#re Providers #nd Systems (HCAHPS) reports show Hospit#l A is performing f#r below Hospit#l B in customer service. The #dministr#tors #t Hospit#l A decide to set #n org#niz#tion#l go#l of r#nking higher th#n Hospit#l B in customer service in one ye#r. Wh#t is the most logic#l first step in the go#l-setting process? #. Develop #n over#ll picture of the p#rti#l go#ls to be #chieved. b. Identify # specific #nd singul#r go#l to be initi#lly pursued. c. Require immedi#te tr#ining for #ll members of e#ch dep#rtment. d. Bring in customer service experts to ev#lu#te #nd improve processes.

21. A: When undert#king # go#l-setting process, the best first step is to develop #n over#ll picture of the sm#ller p#rti#l go#ls to be #chieved. B is wrong bec#use it disreg#rds the over#ll go#l for the s#ke of # single sm#ller go#l. C #nd D #re incorrect bec#use they #re re#ctive steps, not pro#ctive steps.

Which of the following principles applies to continuous quality improvement in an organization?

Systems, not poor job performance, are responsible for most problems

Successful Collaboratives

Identify champion -individuals within organization who are ready and willing to move forward -individuals already implementing best practices -engage leaders and physicians to be champions

Lean approach

Identifying new ways to get things done and making changes in a short period of time. Basically, identifying more effective ways by eliminating wastes.

K51 Clinical Pathway

Multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare). Outcomes are tied to specific interventions.

Forecasting

The process of predicting what will happen in the future. The ability to forecast accurately and timely will prove to be a highly valued step in ensuring the strategies are set with clarity of purpose.

Compliance

To act in accordance with another's command, request, rule, or wish. In healthcare, this translates to providing, billing, reimbursing and monitoring services according to the laws, regulations, administrative rules and guidelines governing the organization.

What is a cohort study?

Used to analyze groups of people with specific characteristics

Spaghetti Diagram

Used to demonstrate the flow or movement a process -identify excess or wasted travel or movement

Risk-management for healthcare entities can be defined as an organized effort to.....

identify, assess, and reduce, where appropriate, risk to patients, visitors, staff and organizational assets.

-Which of the following action plans is the first step in correcting inappropriate blood usage in an emergency department?

improvements in documentation

Which of the following actions would have the greatest impact in reducing harm?

improving interdisciplinary communication

For health information technology to be most effective in reducing harm, the technology needs to be

integrated with clinical workflow.

A federally certified electronic health record (EHR) with the capacity for e-prescribing, electronic exchange of health information, and submission of healthcare quality measures meets

meaningful use requirements.

Which of the following is the most effective way to integrate performance improvement concepts throughout an organization?

quality teams

Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization's quality improvement program?

quantifiable objectives

When a team evaluating the use of restraints starts to discuss a liability claim related to a patient, the facilitator should

review team ground rules.

74. When does the credenti#ling process gener#lly t#ke pl#ce? #. Prior to employment b. Prior to termin#tion c. Every ye#r of employment d. Every five ye#rs of employment

74. A: Credenti#ling gener#lly t#kes pl#ce prior to employment.

I-38 Pareto Principle

80% of a problem is caused by 20% of the causes

9. Which of the following is not considered # principle of tot#l qu#lity? #. Competent m#n#gement b. Customer focus c. Continuous improvement d. Te#mwork

9. A: Competent m#n#gement is not considered # principle of tot#l qu#lity. Customer focus, continuous improvement, #nd te#mwork #re the three principles of tot#l qu#lity.

H Outcomes Management

A "technology of patient experience designed to help patients, payers, and providers make rational medical care-related choices based on better insight into the effect of these choices on the patient's life."

Commission of office laboratory Accreditation (ColA).

A body that accredits physician office laboratories in compliance with Clinical Laboratory Improvement Amendments (CLIA), hospitals, and independent laboratories.

Baldrige Award

A competitive award that is given to organizations demonstrating a commitment to quality excellence based on successfully meeting the Baldrige National Health Care Criteria for Performance Excellence.

Function

A key area of responsibility and activity of healthcare organizations, such as leadership or performance improvement.

H Standard of Care

A level of performance the patient can expect. That is predefined and accepted within the community of professionals, based upon the best scientific knowledge, current outcome data, and clinical expertise.

Root Cause Analysis (RCA)

A systematic process aimed at finding the basic problem (root cause) and taking action to correct the problem after it has occurred -Requirement for several accrediting organizations in response to a sentinel event

I Storyboard

A visual display of the team and pertinent data/information, analyses, and decisions made during the improvement process.

Systems Theory

A way of looking at an organization holistically and breaking it down into a series of individual elements that interact with each other.

Standard of Practice

An acceptable level of performance or an expectation for professional intervention or behavior

Accreditation

An external "seal of approval" indicating that a facility or service has passed a standardized objective review process (usually an on-site survey) conducted by an impartial organization and that it meets guidelines or nationally/ internationally recognized performance standards. Usually a voluntary process.

26-A chief quality officer has the responsibility for education and implementation of a quality improvement process. To affect cultural change, the chief quality officer must A. believe the costs are justified by the benefits. B. be a visible participant in the process C. receive quarterly reports. D. limit training to managers and supervisors.

B. be a visible participant in the process.************

20-When a healthcare organization is contracting with an outside provider for services, the subcontractor must A. provide a representative to the Quality Council. B. meet all regulatory requirements. C. have an active risk management program. D. have a competitively priced service.

B. meet all regulatory requirements.********************

What type of data is used in a control chart?

Continuous data

With what type of data do you use a Run chart?

Continuous data

What is the difference between categorical and continuous data?

Continuous data can be measured over time, or on a scale. Categorical data is a discrete number is specific.

I Integrity

Data has not been altered or destroyed in an unauthorized manner.

Abduction/Elopement Security System

Designed with different alarms (e.g. bands for babies and parents, electronic locked or sensored doors at elevators)

Negligent conduct

Doing what a reasonable person would not do; failure to do what a reasonable person would do (based on set standards and under like circumstances and training). GROSS negligence is a failure to act if there is known of suspected risk resulting in adverse impact or death.

25- Patient satisfaction scores for a community hospital demonstrate multiple areas for improvement including a need to improve attractiveness of the facility, responsiveness to patient needs, and physician and nursing communication. Based on these results, which of the following should the healthcare quality professional also expect to find? A. administration prioritizing and leading units to achieve organizational goals B. unit managers who openly discuss patient satisfaction scores C. units operating independently with little communication between units D. employee satisfaction scores in the 80th percentile compared to other peer organizations

EXPLANATIONS: A. Based on the information provided, leadership may not have prioritized these issues to achieve organizational goals. B. There is not enough information provided to determine if managers are discussing patient satisfaction scores. C. Responsiveness to patient needs requires effective communication between multiple units as well as staff. D. Employee satisfaction does not necessarily correlate with these patient satisfaction scores.

56- Standards of care based on the knowledge and research of recognized experts are known as A. benchmark data. B. generic screens. C. pre-established criteria. D. evidence-based guidelines.

EXPLANATIONS: A. Benchmark data are included in establishing standards of care. B. Generic screens are used as triggers to identify potential problem areas. C. Pre-established criteria may not be based on research. D. Evidence-based guidelines are consensus driven and based on research or literature.

54- Which of the following is the best way to determine if a quality improvement initiative is successful? A. Present findings to the Quality Council. B. Conduct an employee survey. C. Compare outcomes with pre-established goals. D. Survey patients and customers.

EXPLANATIONS: A. Presenting findings to a Quality Council does not help determine whether an initiative is successful. B. A survey of employees may not help determine if goals have been met. C. Outcomes are evidence of having accomplished pre-established goals. D. Surveying patients and customers may not determine whether an initiative is successful.

12- The most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staff is by A. developing professional relationships. B. inviting medical staff to an inservice on quality tools. C. evaluating physician participation on quality teams. D. providing outcome data at medical staff meetings.

EXPLANATIONS: A. Relationships are needed, but they are not the most effective way to communicate quality improvement activities. B. Inviting medical staff to an inservice does not ensure attendance. C. Evaluating participation is not a communication tool. D. Outcome data communicates objective feedback to medical staff.

3- Management using quality improvement principles should emphasize the importance of A. staff orientation. B. customers' expectations. C. quarterly statistical reports. D. team selection.

EXPLANATIONS: A. Staff orientation is only one component of quality improvement principles. B. The basis of quality improvement is knowing what the customer needs and wants. C. Quarterly statistical reports are only one component of quality improvement principles. D. Team selection is only one component of quality improvement principles.

11- Which of the following best describes an organizational vision statement? A. It is used as a marketing strategy. B. It defines the structure of the institution. C. It describes the organization's strategic plan. D. It reflects the organization's aspirations.

EXPLANATIONS: A. The vision statement may be used for marketing purposes, but it does not define marketing strategies. B. The structure of the institution is not defined in the vision statement. C. The strategic plan is not part of an organization's vision statement. D. Vision is the image or description of what the organization desires to become.

I EDI

Electronic Data Interchange: The computer-to-computer transmission of business data in a standard format, which replaces a traditional paper business document.

when developing dept specific measures the manager should?

Ensure that the numberator and denominator are clearly defined

What are t-tests used for?

Evaluate the effects of two different treatments

Efficiency

Examines the extent to which scarce resources are used to derive the greatest benefits with the least waste.

Brainstorming

Free-flowing generation of ideas. No censoring or discussion of ideas at this point. Everything is acknowledged

immediate jeopardy

IJ is a mechanism to escalate crisis survey issues immediately within both state and federal agencies and with the healthcare provider.

Special-Cause.

In statistical process control, a term describing problems that stem from isolated occurrences that are outside the system.

Why is benchmarking important?

It enables organizations to set targets or goals for process improvement activities.

H Medicaid

Low-income, managed by each state.

Interval Continuous Data

Measured on scales that theoretically have no gaps; considered variables data; no true zero -equal distance between each data point EX:the values on a Fahrenheit thermometer

K23 Mission, Vision, Values

Mission: explains the company's reason for existence. Vision: describes the company as it would appear in a future successful state. Values: describes what the company believes in and how it will behave.

Risk Management.

Organized effort to identify, assess, and reduce risks to patients, visitors, staff, and organizational assets Goal of risk is to protect the organization from financial losses that may arise because of the risks -regulatory compliance -safety management -client-provider relations -publicity and media coverage -patient care

PDCA

Plan, do, check, act

Common Cause

Process is stable and predictable with random distribution of plotted points within limits

k21 Common Cause Variation

Random / Common Cause - intrinsic to process

Outcome Measures

Results of overall process or system performance (mortality)

Complex Adaptive Systems (CAS)

Systems of interdependent things (e.g., agents that can be people, departments) wherein there are a great number of connections between a wide variety of elements in addition to the ability to learn from experience.

H Demand Management

Term from economics; in project management it refers to meeting customer expectations; in managed care it refers to influencing access to medical care.

Test

Testing

I Auditability

The ability to do a methodical examination and verification of all information activities such as entering and accessing.

Content Validity

The degree to which the instrument adequately represents the universe of content; includes judgments by experts about the degree to which the test appears to measure what it is suppose to measure

Content Validity

The degree to which the instrument adequately represents the universe of content; includes judgments by experts or respondents about the degree to which the test appears to measure the relevant construct.

Validity

The degree to which the instrument measures what it is intended to measure

Variability.

The degree to which values on a set of scores differ.

Risk

The possibility of loss or injury; peril; a dangerous element of factor.

Do

The step in the Plan-Do-Check-Act cycle in which one makes changes on an experimental basis.

I Timeliness

The time between the occurrence of an event and the availability of data about the event. Timeliness is related to the use of the data. [TJC]

What is the purpose of a cause and effect diagram?

To analyze potential causes of a problem or a source of variation.

Prioritization Matrix

Tool organizes tasks, issues, or actions and prioritizes them based on agreed-upon criteria. The tool combines the tree diagram and the L-shaped matrix diagram, displaying the best possible effect.

Special Cause Variation

Variation due to specific circumstances and the process is not stable or predictable.

Special-Cause variation

Variation that arises from sources that are not inherent in the process is unpredictable. On a control chart, this type of variation is exhibited as points that fall outside the control limits.

refine the differences between an organization's objectives and the stakeholder needs. Which of the following tools is most appropriate?

gap analysis

Culture

shared values and behavioral norms -provides a sense of identity -enhances cooperation -creates system of informal rules -creates distinctions between organizations, allowing competitive edge

The target for performance improvement should be

systems.

Patient Safety Program

-Led by Patient Safety Officer -Linked to strategic plan, quality, management, information management, and infection control -includes safety education (staff and patients) -includes safety data collection and analysis -Conducts proactive risk reduction -Identifies high risk processes -Identifies, manages, and reports sentinel events

Steering Committee/Quality Council

-Responsible for oversight for all quality performance activities -permanent team -clearinghouse for QI clinical/non clinical information -Sustain, facilitate, and explain initiatives -Connects to strategic plan -Top leaders, medical staff, quality department, board, and community

Cause-and-Effect, Ishikawa, or Fishbone Diagram

-displays possible causes and effects identified through brainstorming -used to organize ideas from brainstorming -used during RCA to identify root causes -look for topics generating the most ideas as a potential area to start improvement

Examples of human engineering

-eliminating waste thru reduction in motion

Fair and Just Culture

-every one makes mistakes and implements workarounds -emphasize the importance of learning from mistakes and near misses -individuals are accountable to the system -greatest error is to not report a mistake, preventing the system/others from learning -culture of patient safety is created when everyone advocates for safety

Characteristics of Structure that Supports Quality

-focus on process -recognition of internal customers -reduction of hierarchy -creation of team based organization -use of councils and steering committees -development of agile organization

Characteristics of Organizations that Support Quality

-involvement of leaders -allocation of resources -reward for quality improvement activities -involvement in quality improvement actives -time and discussion spent on quality improvement activities -prevailing quality focused attitude

Prioritization Matrix

-issues are identified and options must be narrowed down -options all need to be done, but prioritization of sequencing is needed Use to organize: tasks, issues, and actions

Agency for Healthcare Research and Quality (AHRQ)

-lead federal agency charged with improving quality and safety of US healthcare system -invests in and develops the knowledge and tools -creates materials to teach and train healthcare systems and professionals to put results od research into practice -generates measures and data used by providers and policymakers

Exclusive Provider Organization (EPO)

-network of individual medical care providers, or groups of medical care providers, who have entered into written agreements with an insurer to provide health insurance to subscribers. -Must receive care exclusively from healthcare providers with EPO contracts or EPO won't pay -Services limited to medically necessary or preventive care

Run Chart Rules

-used to identify nonrandom signals of change 1. Shift (6 or more consecutive points either above or below center line) 2. Trend (5 or more points going up or down) 3. Too many or too few runs crossing center line 4. Astronomical data point

Six Sigma.

-uses statistical analysis to measures and improve performance -focus on elimination of error in process -based on normal distribution -DMAIC -customer focused Strategy: identification, characterization, optimization, institutionalization

K27 Integration of Quality Functions UM, QM, RM

1) All three functions: (a) Measure & assess processes and outcomes (b) Have reporting requirements and responsibilities (c) Have similar organizational obstacles. 2) Align with strategic facility goals.

K55 FMEA 1-4

1) Brainstorm potential failure modes (a) Consecutively number each potential failure point 2) Identify the potential causes of each failure mode 3) List potential effects (adverse outcomes) of each failure mode 4) Assign rating for each effect - Scale of 1-10 (a) Severity (b) Frequency/occurrence (c) Detection

K27 Building Effective Quality Structure

1) Clarify leadership roles 2) Determine the Quality Language 3) Create Accountability Structure 4) Develop Information Flow Chart 5) Integrate Organization Policies and Guiding Statements e.g patient safety, quality of care, service, PI.

K51 Clinical Standards Development and Use

1) Clinical Pathways & Practice Guideline Development (a) Statements to assist practitioner and patient decisions about applicable healthcare for specific clinical circumstances 2) Evidence-Based Medicine/Practice (EMB) (a) Integration of individual experience with best available external clinical evidence from systematic research.

I-13 Quality Functions {QM, UM, RM, IC}

1) Data collection, summarization, aggregation 2) Information analysis, display, presentation 3) Information interpretation, sharing, use 4) Ongoing communications within organization 5) Effectiveness oversight

I-12 HHS - Value-based health care improvement

1) Develop interoperable health information technology (HIT) 2) Measure and publish quality information 3) Measure and publish price information 4) Promote Quality and efficiency of care

Crisis Management

1) Forecasting potential crises and planning how to deal with them (proactive) and 2)When a crisis occurs, identifying its full nature, intervening to minimize damage, and recovering (reactive)

H Crisis Management

1) Forecasting potential crisis and planning how to deal with them (proactive) and 2) When a crisis occurs, identifying its full nature, intervening to minimize damage, and recovering (reactive).

k1 Information Management Process 1-6

1) Identify Current Available Data Sources 2) Identify Critical Information Needs 3) Define Data Elements 4) Determine Data Collection Plan 5) Acquire / Collect / Capture Data 6) Aggregate & Display Data

K27 Effective Quality Structures

1) Identify Important Functions 2) Determine organization-wide methodology 3) Establish reporting routines 4) Determine and implement Teams 5) Prepare written plan 6) Identify leadership education needs 7) Train Teams

K32 Risk Analysis & Evaluation

1) Identify the risks with adverse impact (a) Disclosure & Apology (b) RCA 2) Identify risk with potential for, but without current adverse impact (a) FMEA 3) Analytical skills & decision making methods 4) Prioritize by frequency, severity, & potential for reduction 5) Risk mitigation

K32 Risk Prevention

1) PI methods 2) Risk financing 3) Risk control 4) Risk avoidance 5) Risk shifting 6) Risk prevention Risk Control: {Avoidance, Prevention, Loss Reduction, Segregation of Exposure} Risk Financing: {Retention, Transfer (shifting)}

I-36 Three types of Healthcare Processes

1) Patient flow (moving people) 2) Information flow 3) Material flow

I-43 Systems Thinking - 5 Learning Disciplines

1) Personal Mastery 2) Mental Models 3) Shared Vision 4) Team Learning 5) Systems Thinking

K45 Quality Management & Performance Improvement

1) Quality Management Trilogy (a) Quality Planning (b) Quality Control/Measurement (c) Quality Improvement 2) QM/PI Function (a) Design (b) Monitor (c) Analysis (d) Improve

K46 Juran Model

1) Quality Planning (Strategic Leadership) 2) Quality Control/Measurement (Performance Improvement Process) 3) Quality Improvement

FMEA Steps

1. Define topic and process to be studied 2. Convene interdisciplinary team with content and process experts 3. Develop flow diagram of process and subprocess 4. List all possible failure modes of each sub-process including severity and probability of failure mode 5. After analyzing the failure modes, determine action for each failure mode to eliminate, controls, or accept 6. Identify corresponding outcome measures to test the redesign process

Use a scatter diagram to

1. Determine whether there is a relationship between the two variables 2. Identify the strength of the relationship whether tight, loose, or outliers, 3. Determine the type of relationship whether positive, negative, or no relationship.

Use a control chart to

1. Distinguish between common and special cause variations 2. Assist in eliminating special cause variation 3. Observe the effects of a process improvement 4. Identify problems, analyze data, and evaluate outcome.

Medical Error Investigation

1. Focus on issue or error.near miss 2. Collect information from practitioners involved 3. Review information 4. Interpret error (intentional or unintentional) 5. Identify contributing factors (i.e. process issues) 6. Conduct a full analysis (may need to analysis the root cause depending on the medical error) 7. Determine next steps needed such as coaching or training

Four stages of team development

1. Forming 2. Storming 3. Norming 4. Performing

4 Goals of EHR

1. Guide clinic practice 2. Interconnect clinicians 3. Personalize care 4. Improve population health

What are the four goals of an EMR?

1. Guide clinical practice. 2. Interconnect clinicians 3. Personalize care 4. Improve population health

Create a Safety Culture

1. Have a clear vision of what is required 2.Assess where organization is compared to its stated values and goals 3. Recognize that leadership owns the culture 4. Create tools to reinforce the behaviors and culture desired 5. Link culture and annual performance review

Six aims for healthcare improvements by IOM

1. Safety 2. Effectiveness 3. patient-centeredness 4. timeliness 5. efficiency 6. equity

What are the 4 rules to help you identify signals of change in a run chart?

1. Shift 2. Trend 3. Number of runs 4. Astronomical

What are the 4 types of probability sampling?

1. Simple random sampling 2. Systematic sampling 3. Stratified random sampling 4. Convenience sampling

Special Cause Rules

1. Single point outside limits 2. Shift (8 or more points in a row above/below center line) 3. Trend (6 or more points increasing or decreasing) 4. 2 of 3 points in outer 1/3 5. 15 or more points in inner 3rd

What are the 4 types of nonprobability sampling?

1. Snowball sampling 2. Expert sampling 3. Purposive or judgement sampling 4. Quota sampling

10. He#lthc#re org#niz#tions #re often cl#ssified #s systems. Wh#t is the prim#ry re#son for this design#tion? #. They sp#n sever#l st#tes with # network of providers. b. They #re dyn#mic#lly complex #nd h#ve multiple levels of m#n#gement. c. They #re # collection of p#rts th#t function #s #n interdependent whole. d. They employ # bro#d cross-section of the popul#tion in v#rious positions.

10. C: He#lthc#re org#niz#tions #re often cl#ssified #s systems bec#use they #re # collection of p#rts th#t function #s #n interdependent whole.

100. As #n #dministr#tor f#ced with mounting surgic#l errors #nd complic#tions, you #re determined to improve the situ#tion. Which of the following would be the most #ppropri#te step tow#rd oper#ting room qu#lity improvement? #. Enforcing pre-surgic#l fullte #m briefings b. Punishing surgeons involved in errors c. Scheduling surgeries l#ter in the d#y d. Merging surgic#l #nd #nesthesi# te#ms

100. A: Enforcing pre-surgic#l full-te#m briefings would be the most #ppropri#te step tow#rd improving oper#ting room qu#lity in this situ#tion.

102. Wh#t #re some of the pitf#lls f#ced when ev#lu#ting te#m perform#nce? #. It is time-consuming #nd l#cks objectivity. b. It is pointless #nd nonspecific. c. It is discrimin#tory #nd stressful. d. It is leg#lly complex #nd doesnʼt improve productivity.

102. A: Some of the m#jor pitf#lls of te#m perform#nce ev#lu#tions #re the time they t#ke #nd the l#ck of objectivity #s te#m members ev#lu#te one #nother.

103. Wh#t tool is most effective in ev#lu#ting te#m perform#nce? #. Focus groups b. D#t# mining c. Dep#rtment meetings d. Anonymous surveys

103. D: Anonymous surveys #re the most effective tool in ev#lu#ting te#m perform#nce bec#use they remove the fe#r of retribution for low r#nkings #nd # sense of oblig#tion for high r#nkings.

104. When # hospit#l is f#cing low customer s#tisf#ction r#tings, wh#t is the best initi#l go#l in #n#lyzing the d#t#? #. Bring in experts to help #n#lyze b. Identify the underlying problem c. Require m#nd#tory tr#ining d. Re-survey diss#tisfied customers

104. B: When # hospit#l is f#cing low customer s#tisf#ction r#tings, the best first step is identifying the underlying problem, #fter which perform#nce improvement c#n be coordin#ted. A, C, #nd D #re incorrect bec#use, while bringing in experts, requiring tr#ining, #nd re-surveying customers m#y h#ppen l#ter in the process, they #re not good first steps.

106. Which of the following ch#rt types would be most effective in showing reduction of influenz# incidence over time #s # result of # v#ccin#tion progr#m? #. P#reto ch#rt b. Run ch#rt c. Fishbone di#gr#m d. Flow ch#rt

106. B: A run ch#rt is designed to show trending outcomes #g#inst p#ssing time, which is perfect for the influenz# incidence reduction presented in this question. A, C, #nd D #re incorrect bec#use even though P#reto ch#rts, fishbone di#gr#ms, #nd flow ch#rts #re #ccur#te w#ys to visu#lly displ#y inform#tion, they do not fit the p#r#meters of the given situ#tion.

107. P#tient-s#fety incident reports #t Hospit#l A h#ve incre#sed over the p#st two ye#rs by #lmost 20 percent #ccording to recent d#t#. P#tient compl#ints h#ve not incre#sed signific#ntly over this period. Wh#t is the most likely expl#n#tion for this trend? #. P#tients #re not noticing the incidents b. Incidents h#ve #ctu#lly incre#sed by 20 percent c. C#re providers #re selfreporting incidents more d. None of the #bove

107. C: Incre#sed provider selfreporting is the most likely c#use of the incre#sed incident reporting in light of the #bsence of #n incre#se in customer compl#ints.

108. When dissemin#ting he#lth inform#tion to minority popul#tions, which of the following consider#tions is most vit#l in ensuring effic#cy? #. Timeliness b. Cultur#l #ppropri#teness c. Entert#inment v#lue d. Educ#tion#l content

108. B: When dissemin#ting he#lth inform#tion to minority popul#tions, cultur#l #ppropri#teness is the most import#nt consider#tion for effic#cy bec#use cultur#lly in#ppropri#te present#tions of inform#tion will likely be ignored.

109. Perform#nce improvement results should be dissemin#ted to employees prim#rily for the purpose of... #. Positive reinforcement. b. Dep#rtment#l br#gging rights. c. Educ#tion#l motiv#tion. d. Punishment of low performers.

109. A: The m#in effect of perform#nce improvement results #mong employees is #n over#ll sense of positive reinforcement th#t encour#ges them to m#int#in the good work. B, C, #nd D #re incorrect bec#use, while they represent possible effects of perform#nce improvement results, they #re not the prim#ry purpose of dissemin#tion of results to employees.

11. M#ry h#s # f#mily history of he#rt dise#se #nd type II di#betes. She #lso h#s pre-hypertension. M#ryʼs doctor recently put her on # diet #nd exercise progr#m. This is #n ex#mple of system thinking c#lled... #. Qu#lity control. b. Preemptive medicine. c. Continuous improvement. d. History dependency.

11. B: System thinking th#t prescribes prevent#tive #ctions to help prevent #n impending problem is c#lled preemptive medicine.

110. Wh#t type of ch#rt is most effective in demonstr#ting c#use #nd effect? #. Flowch#rt b. Run ch#rt c. Fishbone di#gr#m d. P#reto ch#rt

110. C: A fishbone di#gr#m is the best type of visu#l represent#tion to show c#use #nd effect bec#use it demonstr#tes how v#rious effects br#nch from the s#me c#use.

111. Which of the following is not likely to be included in # pr#ctitioner profile? #. Educ#tion #nd tr#ining b. Li#bility cl#ims filed c. St#ff/f#culty privileges d. Pr#ctitioner #ge

111. D: Pr#ctitioner #ge h#s no pl#ce in # pr#ctitioner profile, #s it is irrelev#nt to competence levels, skills, #nd #bilities. The other #nswer choices #ll represent inform#tion th#t belongs in # pr#ctitioner profile.

112. The m#ternity w#rd of Hospit#l A h#s just #dded four FTE nursing st#ff members members. After 60 d#ys, productivity numbers do not seem to be incre#sing #s expected. Wh#t is the most likely c#use of this phenomenon? #. The le#rning curve for new employees b. An incre#se in p#tient needs c. A d#t# reporting error d. Resentment of new st#ff by older employees

112. A: Productivity gener#lly t#kes # brief dip #fter the #ddition of new employees due to the le#rning curve #nd their need for #ssist#nce from est#blished st#ff members.

113. Clinic A h#s just completed six months of customer s#tisf#ction surveys. Excellence in perform#nce h#s been #ppropri#tely recognized. Now compl#ints must be #n#lyzed #nd somehow qu#ntified. Wh#t method would be most effective in the compl#int #n#lysis process? #. Sort surveys into sep#r#te folders b. Cre#te # t#xonomy for coding compl#ints c. Address compl#ints one #t # time d. M#tch compl#ints with perform#nce issues

113. B: The most effective w#y to #n#lyze l#rge numbers of compl#ints is through the cre#tion of # t#xonomy for coding compl#ints bec#use it helps cl#ssify #nd org#nize compl#ints in # logic#l w#y th#t lends itself well to #n#lysis.

114. As dep#rtment m#n#ger, it is your job to conduct #n #nnu#l perform#nce #ppr#is#l for e#ch employee in your dep#rtment. One of your employees is exhibiting signific#nt issues in response times for p#tient requests. How c#n you best incorpor#te perform#nce improvement into the employeeʼs perform#nce #ppr#is#l? #. Incorpor#te punitive me#sures into the ev#lu#tion b. Use encour#ging words to help the employee improve c. Set specific perform#nce go#ls #nd # re-#ppr#is#l d#te d. Perform#nce improvement is not p#rt of perform#nce #ppr#is#l

114. C: The best w#y to incorpor#te perform#nce improvement concepts into #n employee #ppr#is#l is through specific perform#nce go#ls #nd # set re- #ppr#is#l d#te. A #nd B #re incorrect bec#use they #re not concrete perform#nce improvement techniques.

115. Which of the following #re import#nt elements of # written p#tient s#fety pl#n? #. Scope b. Purpose c. Guidelines d. All of the #bove

115. D: A written p#tient s#fety pl#n includes # scope, # purpose, #nd guidelines.

116. A seven-ye#r-old girl receiving tre#tment for pneumoni# #t Hospit#l B h#s just been #bducted by her noncustodi #l p#rent. Under st#nd#rd p#tient s#fety guidelines, how would this event be cl#ssified? #. As #n #dverse incident b. As # sentinel event c. As # B#ldrige occurrence d. As # risk m#n#gement #nom#ly

116. B: Abduction qu#lifies #s # sentinel event under Joint Commission guidelines #nd st#nd#rd pr#ctices.

117. Wh#t is the prim#ry purpose of # p#tient s#fety progr#m? #. To reduce medic#l errors #nd h#z#rds b. To comply with loc#l #nd n#tion#l st#nd#rds c. To reduce li#bility #nd tort cl#ims d. To meet #ccredit#tion requirements

117. A: The prim#ry purpose of # p#tient s#fety progr#m is to reduce medic#l errors #nd h#z#rds.

118. Your clinic h#s h#d three recent inst#nces of ch#rt mixups. In e#ch c#se, doctors m#de initi#l p#tient cont#ct with the wrong ch#rt in h#nd #nd incorrect inform#tion. Wh#t technology would be most helpful in this situ#tion? #. Medic#tion b#rcode sc#nners b. T#blet computers or sm#rt phones c. Electronic he#lth record softw#re d. Individu#l record RFID t#gs

118. C: Electronic he#lth record softw#re is the best choice for preventing p#per ch#rt mix-ups #nd to ensure th#t doctors meet the p#tient with the most #ccur#te #nd up-to-d#te inform#tion possible.

119. To ensure proper identific#tion of tr#nsfusion p#tients, your org#niz#tion h#s recently #dopted # twoperson bedside/ch#ir-side verific#tion process. Wh#t is this #n ex#mple of? #. Requirements for #ccredit#tion b. N#tion#l p#tient s#fety go#ls c. Joint Commission best pr#ctices d. Loc#l #nd region#l he#lthc#re l#ws

119. B: Two-person bedside/ ch#ir-side verific#tion of tr#nsfusion p#tients is # cle#r ex#mple of n#tion#l p#tient s#fety go#ls being put into pl#ce.

12. How does the World He#lth Org#niz#tion Surgic#l S#fety Checklist le#d to tight coupling in the oper#ting room? #. It est#blishes univers#lity for p#tients. b. It comp#rtment#lizes the procedures. c. It est#blishes # cle#r oper#ting room hier#rchy. d. It closely #ligns the v#rious individu#ls involved in the process.

12. D: The World He#lth Org#niz#tion Surgic#l S#fety Checklist le#ds to tight coupling in the oper#ting room by closely #ligning the v#rious individu#ls involved in the surgic#l process.

120. After experiencing # sentinel event, Hospit#l A is required to perform # root c#use #n#lysis. Which of the following is not # requirement of # root c#use #n#lysis? #. It must be conducted #s soon #s possible #fter the event. b. All personnel involved in the event must be present. c. Leg#l #ffid#vits must be t#ken before questioning. d. Bl#me #nd li#bility should not be discussed or #ssigned.

120. C: During # root c#use #n#lysis, leg#l #ffid#vits #re not required before questioning. All of the other #nswer choices #re elements th#t #re required #s p#rt of # root c#use #n#lysis.

122. A recent risk m#n#gement #ssessment h#s demonstr#ted th#t sever#l frequently-used pieces of medic#l equipment h#ve not been serviced recently, posing # thre#t to proper p#tient c#re. Wh#t perform#nce improvement process should be undert#ken to correct this issue? #. Post/publish equipment m#inten#nce guidelines b. Post/publish # set equipment m#inten#nce schedule c. Design#te # specific employee/group to oversee m#inten#nce d. All of the #bove

122. D: As p#rt of perform#nce improvement on the equipment m#inten#nce, guidelines should be published or posted, # m#inten#nce schedule should be published or posted, #nd # specific employee or group should be design#ted to h#ndle m#inten#nce.

124. Hospit#l A recently implemented shorter inp#tient st#ys for most surgic#l procedures. A utiliz#tion m#n#gement #ssessment h#s reve#led, however, th#t more p#tients #re returning to the emergency room for post-surgic#l tre#tment. Wh#t perform#nce improvement me#sure would be most likely to reduce the incidence of post-surgic#l p#tient returns? #. Implement better predisch #rge ev#lu#tions b. Reverse the shorter-st#y policies c. Provide more p#inkillers #t disch#rge d. C#refully #n#lyze the p#tient return d#t#

124. A: Implementing better pre-disch#rge ev#lu#tions is the most likely option for reducing post-surgic#l p#tient returns.

125. Which of the following is #n extern#l qu#lity review th#t me#sures compli#nce #g#inst #n industry st#nd#rd for he#lthc#re org#niz#tions? #. Peer review b. Accredit#tion c. Root c#use #n#lysis d. Credenti#ling

125. B: Accredit#tion is #n extern#l qu#lity review th#t me#sures compli#nce #g#inst industry st#nd#rds.

13. Who cre#ted the hospit#l inform#tion m#n#gement st#nd#rd th#t st#tes, "The hospit#l m#int#ins the security #nd integrity of he#lth inform#tion?" #. The B#ldrige Committee b. The Joint Commission c. The N#tion#l Institutes of He#lth d. The ORYX Initi#tive

13. B: The Joint Commission set the st#nd#rd th#t hospit#ls #re responsible for he#lth inform#tion security #nd integrity.

14. The r#te of sick d#ys #mong employees in the intensive c#re unit (ICU) f#lls well within the hospit#l st#nd#rd, but the CNAs cl#im the RNs t#ke too m#ny sick d#ys, #nd this prevents consistent c#re rel#tionships between RNs #nd CNAs. Wh#t should m#n#gement do to investig#te this situ#tion? #. Set up surveill#nce of the dep#rtment b. Distribute p#tient surveys throughout the ICU c. Distribute employee surveys throughout the ICU d. Unbundle/dis#ggreg#te the d#t# #nd re#n#lyze it

14. D: The best w#y to underst#nd ex#ctly wh#t is h#ppening in the intensive c#re unit (ICU) is to unbundle or dis#ggreg#te the d#t# #nd #n#lyze it #g#in, looking for specific ch#llenges with RN sick d#ys.

15. The new #dministr#tor of Hospit#l A implements # topdown h#nd w#shing policy for #ll employees #nd visitors to the hospit#l. As # result, previously high infection r#tes drop below n#tion#l st#nd#rd levels for the first time. This new policy is #n ex#mple of... #. Perform#nce me#sures. b. Qu#lity #ssur#nce. c. Risk m#n#gement. d. Inform#tion m#n#gement.

15. C: Risk m#n#gement is defined #s t#king steps to #void #nd control risks within #n environment to #ccomplish # desired outcome, #nd the h#nd w#shing policy helps m#n#ge the risk of infection.

16. The B#ldrige Perform#nce Excellence Progr#m He#lth C#re Criteri# rem#rk on the import#nce of me#surement #nd #n#lysis of d#t#. Wh#t c#n be the downside of # he#vy perform#nce d#t# focus? #. M#n#gers c#n get tunnel vision #nd overlook nonme #sured errors #nd issues. b. D#t# f#r #bove the n#tion#l st#nd#rd c#n result in infl#ted self-opinion. c. D#t# f#r below the n#tion#l st#nd#rd c#n result in depression #nd despondency. d. Hospit#ls with high d#t# scores #re held to impossibly high st#nd#rds.

16. A: The downside of # he#vy d#t# focus c#n be tunnel vision by m#n#gers, which c#n le#d to oversight of non-me#sured errors. 17.

17. A position h#s recently opened for # dep#rtment he#d in hum#n resources (HR). It is your job to select the best intern#l c#ndid#te to interview for the position. Which of the following c#ndid#tes possesses the strongest le#dership potenti#l? #. An HR supervisor who h#s been with the org#niz#tion for 10 ye#rs. b. An #ccounting supervisor who h#s # perfect qu#lity record. c. An HR employee who mentors new hires #nd frequently #ttends volunt#ry tr#ining. d. A supervisor in the m#inten#nce dep#rtment who w#nts to try something new.

17. C: An employee with experience in the field who h#s emotion#l intelligence (demonstr#ted by mentoring new hires) #nd # quest for new knowledge shows excellent le#dership potenti#l.

20. Wh#t h#ppens right #fter # Joint Commission-#ccredited hospit#l experiences # sentinel event? #. An #w#rd is presented to #dministr#tors. b. A root c#use #n#lysis is performed. c. Immedi#te re-#ccredit#tion is gr#nted. d. Perform#nce improvement me#sures #re implemented.

20. B: When # Joint Commission-#ccredited hospit#l experiences # sentinel event, # root c#use #n#lysis is performed.

22. The process improvement te#m h#s recently est#blished # go#l th#t #ll p#tients be tri#ged within 20 minutes of #rriv#l in the emergency room (ER). Wh#t might be # neg#tive outcome of this go#l? #. ER nurses will be overstressed. b. Mist#kes #re likely to be m#de. c. Tri#ge will be less thorough. d. All of the #bove

22. D: If # strict time limit is est#blished, #ll of these will occur - ER nurses will be overstressed, mist#kes #re likely to be m#de, #nd tri#ge will be less thorough.

24. Within the l#st four d#ys, three post-surgic#l p#tients h#ve died of pneumoni# complic#tions #t # l#rge hospit#l. None of the p#tients presented #s symptom#tic for pneumoni# #t the time of surgery. Wh#t ev#lu#tion tool should be used to help identify #nd resolve this issue? #. Epidemiologic#l theory b. Perform#nce m#n#gement me#sures c. St#tistic#l #n#lysis d. Improvement me#sures

24. A: Epidemiologic#l theory is used to identify the source #nd c#use of #n issue or #nom#ly, which is perfect for the surgic#l complic#tions represented in this question.

25. Wh#t is the prim#ry purpose of the Consumer Assessment of He#lth Providers #nd Systems (CAHPS)? #. To relieve d#t# collection efforts by #dministr#tors b. To offer p#tients #n #nonymous outlet for he#lthc#re compl#ints c. To c#pture p#tient s#tisf#ction d#t# in # univers#l m#nner d. To provide # forum for more effective communic#tion between p#tients #nd providers

25. C: The prim#ry purpose of the Consumer Assessment of He#lth Providers #nd Systems (CAHPS) is to c#pture p#tient s#tisf#ction d#t# in # univers#l w#y th#t c#n be comp#red #mong #ll hospit#ls. A, B, #nd D represent second#ry or terti#ry purposes of CAHPS; they do not represent its prim#ry purpose.

26. When Hospit#l Aʼs neon#t#l infection r#tes rise unexpectedly, the qu#lity council est#blishes # new set of perform#nce me#sures. They b#se their me#sures on intern#l st#nd#rds, customer survey d#t#, #nd employee survey d#t#. Wh#t import#nt element #re the qu#lity council members disreg#rding? #. Epidemiologic#l st#nd#rds b. Customer s#tisf#ction d#t# c. Employment records d. Extern#l st#nd#rds

26. D: It is vit#l th#t qu#lity council members t#ke extern#l st#nd#rds (such #s n#tion#l go#ls #nd requirements) into #ccount when #ddressing the rising infection r#tes.

28. As # qu#lity profession#l, you #re #bout to #ddress #dministr#tors reg#rding # recent decre#se in customer s#tisf#ction with postp#rtum c#re. In prep#r#tion, you w#nt to cre#te # report to present #t the meeting. Which of the following would be most import#nt to consider #s you prep#re your report? #. Properly form#tting the report to industry st#nd#rds b. Identifying the d#t# most relev#nt to the situ#tion c. Expounding on historic#l d#t# on postp#rtum c#re d. Reviewing postp#rtum s#tisf#ction #t other org#niz#tions

28. B: When prep#ring the report on postp#rtum c#re to be presented to #dministr#tors, the most import#nt go#l is identifying which d#t# #re most relev#nt to the situ#tion. A, C, #nd D #re incorrect bec#use while they m#y offer some items of interest, they do not best help you describe the situ#tion #t h#nd to the #dministr#tion.

30. Which of the following is the most import#nt w#y th#t tr#nsp#rency of he#lthc#re d#t# serves #s # regul#tor for the industry? #. It encour#ges perform#nce improvement to cre#te more positive d#t#. b. It tends to drive poorlyperforming org#niz#tions out of business. c. It cre#tes # culture of sh#me #nd fe#r #mong employees. d. It does not serve #ny regul#tory purpose.

30. A: When he#lthc#re d#t# is tr#nsp#rent #nd visible to # number of popul#tions, it encour#ges perform#nce improvement to cre#te more positive d#t#, thereby improving the im#ge of the org#niz#tion. B #nd C #re incorrect bec#use while they m#y be true for some org#niz#tions, they do not represent the most import#nt regul#tory function of he#lthc#re tr#nsp#rency.

31. Which of the following is the logic#l first priority in process improvement? #. Tr#ining employees on improvements b. Me#suring process improvement c. Identifying process issues d. Cre#ting #n improvement pl#n

31. C: The first priority in process improvement should be identifying the existing process issues. A, B, #nd D #re incorrect bec#use while they #re good steps in the process improvement journey, they #re not the first priority in the process.

32. As # m#n#ger, you #re working with # new employee who h#s ch#llenges with #ppropri#te customer service processes. Together you #re est#blishing # perform#nce improvement pl#n. Which of the following should not be # p#rt of the pl#n? #. Rese#rch into the c#uses of the employeeʼs ch#llenges b. A cle#r st#tement of the problems to be #ddressed c. Specific #ction steps to be t#ken #s p#rt of the pl#n d. A desired outcome or go#l beh#vior #nd # timeline

32. A: Rese#rching the c#uses of #n employeeʼs ch#llenges h#s no pl#ce in the perform#nce improvement pl#n process. A cle#r problem st#tement, specific #ction steps, #nd # go#l beh#vior #re #ll import#nt elements in cre#ting # perform#nce improvement pl#n.

33. Wh#t role do clinic#l guidelines pl#y in est#blishing process requirements for #n org#niz#tion? #. They conflict with one #nother. b. Clinic#l guidelines dict#te process requirements. c. Process requirements dict#te clinic#l guidelines. d. They #re unrel#ted.

33. B: Clinic#l guidelines dict#te process requirements for #n org#niz#tion, #s new processes must f#ll into line with the guidelines of #n org#niz#tion #nd industry pr#ctices. A #nd D #re incorrect bec#use they minimize the rel#tionship between clinic#l guidelines #nd process requirements. C is wrong bec#use process requirements #re governed by clinic#l guidelines, not the other w#y #round.

34. Recent HCAHPS d#t# for Hospit#l A indic#te th#t doctors #re not providing #dequ#te expl#n#tions to p#tients. In improving the p#tient s#fety culture with reg#rds to this issue, wh#t two elements must be #ddressed? #. P#tient perceptions #nd clinic#l qu#lity b. P#tient perceptions #nd physici#n educ#tion c. Physici#n educ#tion #nd time constr#ints d. Qu#lity st#nd#rds #nd time constr#ints

34. A: When improving the p#tient s#fety culture, both p#tient perceptions #nd clinic#l qu#lity must be t#ken into #ccount #nd b#l#nced.

35. Which of the following is # p#tient s#fety go#l identified by the Joint Commission? #. Cut service times in emergency dep#rtments b. Apply Six Sigm# principles to sentinel events c. Improve the effectiveness of c#regiver communic#tions d. Est#blish strong customer service numbers #mong p#tients

35. C: Improving the effectiveness of c#regiver communic#tion is # p#tient s#fety go#l th#t h#s been est#blished by the Joint Commission. A, B, #nd D m#y be good go#ls, but they h#ve not been est#blished #s specific p#tient s#fety go#ls by the Joint Commission.

36. How might #n implicit org#niz#tion#l go#l of service time reduction be #n #ccident#l #dvers#ry to p#tient s#fety go#ls? #. They could not be #ccident#l #dvers#ries. b. A rush to meet service times might impede #dequ#te communic#tion. c. Improved service times m#y neg#tively imp#ct service levels. d. Customer s#tisf#ction levels might be f#lsely elev#ted.

36. B: An implicit go#l of service time reduction is # potenti#l #dvers#ry to p#tient s#fety bec#use providers who #re hurrying m#y not communic#te effectively with p#tients.

38. At # business lunch, # colle#gue from # hospit#l #cross town encour#ges you to try implementing Six Sigm# to improve your org#niz#tion. After discussing it #t length with your colle#gue, you feel the biggest benefit of Six Sigm# for your hospit#l would be, #. The go#l of driving errors to zero. b. The long-st#nding tr#dition of use. c. The origins in m#nuf#cturing. d. The view th#t #ll work is # process.

38. A: The biggest benefit of Six Sigm# is the go#l of driving errors to zero, thereby dr#m#tic#lly improving the qu#lity of c#re.

39. Two hospit#ls in your region h#ve recently #dopted computerized physici#n order entry (CPOE). You h#ve #ssembled #n ev#lu#tion te#m to determine if CPOE is right for your org#niz#tion. Which of the following f#ctors would likely h#ve the strongest imp#ct on your decision? #. It is import#nt for your org#niz#tion to be technologic#lly competitive. b. Sever#l p#tients #nd he#lthc#re providers h#ve endorsed the system. c. The system is shown to reduce prescribing errors by 50 percent or more. d. M#jor st#keholders #re pressuring for #doption of the system.

39. C: The most influenti#l re#son for implementing CPOE is the f#ct th#t it h#s been shown to reduce prescribing errors by 50 percent or more, thereby improving qu#lity of c#re. A, B, #nd D m#y #ll be influencing re#sons for #dopting CPOE, but they should not be the deciding f#ctor, #s they #re much less import#nt th#n reducing prescribing errors.

How many categories of causes do you need for a cause and effect diagram?

4 categories of causes

K10 QM Basic Principles 4-6

4) Understanding the variability of the Processes is key to improving quality. 5) Quality Control should focus on the most vital Processes. 6) The modern approach to quality it thoroughly grounded in scientific and statistical thinking.

4. Which of the following is # structure designed to help f#cilit#te te#m or group pursuit of specific go#ls #nd objectives? #. M#n#gement b. Org#niz#tion c. Intelligent design d. Deleg#tion

4. B: An org#niz#tion is # structure th#t is designed to bring # group together for the pursuit of specific go#ls #nd objectives. While m#n#gement #nd deleg#tion #re both import#nt, they #re not centr#l to the unific#tion of # te#m or group for go#l pursuit. They #re #spects of the structure, but not the structure itself.

40. The intensive c#re unit (ICU) is f#cing # problem with excessive sick d#ys being t#ken by the CNA st#ff. After surveying ICU employees, you identify sever#l potenti#l c#uses for this issue. When you present this inform#tion to the m#n#gement te#m, wh#t type of visu#l represent#tion would be most effective? #. A flowch#rt or deployment ch#rt b. A pie ch#rt or run ch#rt c. A fishbone di#gr#m or P#reto ch#rt d. None of the #bove

40. C: Either # fishbone di#gr#m or P#reto ch#rt is the best w#y to visu#lly represent # specific problem #nd # list of contributory c#uses. A #nd B #re not correct bec#use flowch#rts, deployment ch#rts, pie ch#rts, #nd run ch#rts #re designed to present # v#riety of d#t#, not just to illustr#te # specific problem #nd its c#uses.

41. Wh#t type of d#t# #n#lysis is most #ppropri#te #fter #n org#niz#tion experiences # signific#nt neg#tive event? #. Prospective #n#lysis b. Root c#use #n#lysis c. F#ilure mode #nd effects #n#lysis d. Introspective #n#lysis

41. B: A root c#use #n#lysis is designed to investig#te #nd pose possible remedies for # signific#nt neg#tive effect in # he#lthc#re setting. A #nd C #re not correct bec#use they #re both forw#rd-looking ev#lu#tions inste#d of b#ckw#rd-looking investig#tions. D is wrong bec#use it is not # relev#nt type of d#t# #n#lysis.

42. An issue with response time to p#tient requests h#s been identified in the post-surgic#l w#rd of Hospit#l A. The #dministr#tors desire to improve perform#nce in this #re#. Wh#t element of process perform#nce will most help determine the best course of #ction? #. Process beh#vior b. Process me#surement c. Process c#p#bility d. Process requirements

42. D: Process requirements #re the element of process perform#nce th#t represents the voice of the customer, outlining the ch#nge or #ction th#t is needed. A, B, #nd C #re incorrect bec#use #lthough they #re #ll elements of process perform#nce, they #re not the elements th#t help define the needed ch#nge or best course of #ction.

43. In wh#t w#y #re benchm#rk d#t# v#lu#ble to the perform#nce improvement process? #. They provide # comp#rison st#nd#rd for beh#vior. b. They c#n be used to punish underperformers. c. They c#n be used to rew#rd high performers. d. They #ssist in #chieving dep#rtment-specific #ccredit#tion.

43. A: Benchm#rk d#t# #re v#lu#ble to the perform#nce improvement process bec#use they provide # comp#rison st#nd#rd for beh#vior. B, C, #nd D #re not the best choices bec#use they do not demonstr#te the w#y benchm#rk d#t# c#n be used to help perform#nce improvement.

44. Which of the following is #bsolutely essenti#l for the le#der of #n effective perform#nce improvement te#m? #. "Type A" person#lity b. Ch#rism# #nd persu#sion c. Modeling t#rget beh#viors d. Extended tenure with the org#niz#tion

44. C: The le#der of # perform#nce improvement te#m must model t#rget beh#viors #bove #ll else in order to set the ex#mple for te#m members.

46. Over the p#st ye#r, Hospit#l A h#s become much busier, #nd there h#ve been sever#l signific#nt medic#tion #dministr#tion errors. M#n#gement is determined to rectify this issue #s quickly #nd efficiently #s possible. Which of the following would be the best solution for p#tient s#fety? #. Retr#ining nursing st#ff on medic#tion #dministr#tion b. Implementing b#rcode medic#tion #dministr#tion technology c. Shortening nursing shifts to incre#se #lertness d. Requiring two-person te#ms to #dministr#te medic#tions

46. B: Implementing b#rcode medic#tion #dministr#tion technology is the most effective #nd efficient w#y to reduce errors in medic#tion #dministr#tion, #s it uses technology to double-check work performed by nursing st#ff before the medic#tion is #ctu#lly #dministered. A, C, #nd D #re incorrect bec#use, while they m#y help correct the issue, they would t#ke longer #nd be less reli#ble th#n b#rcode medic#tion #dministr#tion technology.

47. Hospit#l B implemented # perform#nce improvement #nd tot#l qu#lity overh#ul just over # ye#r #go. Upon #n#lysis of fin#nci#l d#t# for this ye#r, Hospit#l B discovers incre#sed profits in spite of tr#ining costs for the progr#m. Wh#t is the most likely re#son for this profit#bility? #. There w#s #n #ccounting error. b. All hospit#ls in the #re# s#w profits. c. Incre#sed qu#lity drew new customers. d. Most of the st#ff took # p#y cut.

47. C: New customers often result from perform#nce improvement initi#tives, boosting #n org#niz#tionʼs bottom line.

48. As # dep#rtment m#n#ger, you notice incre#sing #bsences #nd decre#sing perform#nce levels #mong CNAs in your dep#rtment. Wh#t could you do to help identify the c#use of these issues? #. Distribute employee s#tisf#ction surveys b. Org#nize employee feedb#ck forums c. Aggreg#te #nd c#refully ev#lu#te relev#nt st#tistic#l d#t# d. All of the #bove

48. D: A good m#n#ger will use s#tisf#ction surveys, feedb#ck forums, #nd c#reful d#t# #n#lysis to help identify the c#use of the CNA issues #nd help reest#blish the st#tus quo.

49. How does use of #n electronic medic#l record (EMR) improve p#tient s#fety? #. Any use of technology reduces errors in he#lthc#re. b. EMR brings #n org#niz#tion up to n#tion#l st#nd#rds. c. EMR provides #ll p#tient inform#tion in # centr#lized pl#ce. d. Using EMR does not improve p#tient s#fety.

49. C: Using #n electronic medic#l record (EMR) keeps #ll p#tient inform#tion in # centr#lized loc#tion, m#king it e#sy to #ccess #nd #n#lyze.

k26 Cause & Effect Diagram Groups

5 M's 5 P's 1) Manpower 1) People 2) Materials 2) Provisions (supplies) 3) Machines 3) Policies # 4) Methods 4) Procedures 5) Management 5) Place (environment) #

5. Mrs. Jones w#its more th#n #n hour p#st her scheduled #ppointment time. She fin#lly le#ves in # huff, c#lling the doctorʼs office # joke #nd s#ying she h#s better things to do. Mrs. Jonesʼ perception of qu#lity in this inst#nce is b#sed on... #. Medic#l c#re. b. St#tistic#l #nom#lies. c. Provider norms. d. P#tient c#re.

5. D: Mrs. Jonesʼ ev#lu#tion of the medic#l office w#s b#sed entirely on her p#tient c#re experience, not the #ctu#l qu#lity of the office or st#ff.

50. As # m#n#ger, you see # need to strengthen p#tient s#fety within your org#niz#tion. Wh#t is the most effective w#y to introduce new p#tient s#fety me#sures into your org#niz#tion#l culture? #. Integr#te p#tient s#fety me#sures into existing str#tegic go#ls b. Provide extensive m#nd#tory tr#ining on p#tient s#fety c. Assemble m#n#gers #nd require them to roll policies down to employees d. Cre#te # new set of org#niz#tion#l go#ls solely b#sed on p#tient s#fety

50. A: Integr#ting new p#tient s#fety me#sures into existing str#tegic go#ls m#kes them e#sier to implement bec#use of the level of f#mili#rity with the current str#tegic str#tegic go#ls.

51. As m#n#ger of inform#tion technology, you feel your responsibility for risk m#n#gement is minim#l. Wh#t risk m#n#gement responsibilities in your clinic would be most likely to f#ll under your #uspices? #. Post-surgic#l p#tient s#fety b. Medic#l equipment m#inten#nce c. He#lth record integrity d. Fin#nci#l #sset security

51. C: The inform#tion technology dep#rtment p#rticip#tes in risk m#n#gement, with their #re# of expertise being he#lth record integrity.

52. P#tient s#tisf#ction surveys h#ve recently reve#led customer service ch#llenges #t Hospit#l A #cross multiple dep#rtments. Wh#t import#nt element should be considered when building # perform#nce improvement te#m to h#ndle this issue? #. The te#m should c#refully ev#lu#te p#tient feedb#ck on customer service. b. The te#m should be #ssembled with members from every #ffected dep#rtment. c. The te#m should est#blish cle#r go#ls #nd benchm#rks for future feedb#ck. d. All of the #bove

52. D: C#refully ev#lu#ting feedb#ck, dr#wing members from multiple dep#rtments, #nd est#blishing cle#r future go#ls #re #ll import#nt elements of building # perform#nce improvement te#m to resolve customer service issues.

53. As # new #dministr#tor, you #re e#ger to #ddress some issues you h#ve seen #nd improve the efficiency of v#rious dep#rtments. But #s you begin to implement ch#nges, you encounter # gre#t de#l of resist#nce from st#ff members. Wh#t would be the best first step in underst#nding this resist#nce #nd m#king #ppropri#te #nd effective ch#nges? #. Underst#nding the history #nd culture of the org#niz#tion b. Providing tr#ining cl#sses #nd semin#rs #bout the ch#nges c. Implementing punishment for those uncooper#tive with the ch#nges d. Refr#ining from m#king #ny ch#nges for #t le#st # ye#r

53. A: The most import#nt first step for # new #dministr#tor who w#nts to m#ke ch#nges is to underst#nd the org#niz#tion#l history #nd culture #nd m#ke ch#nges #ppropri#tely.

54. Which of the following is #n ex#mple of qu#lit#tive d#t# collection? #. Reviewing post-surgic#l infection st#tistics b. Surveying p#tients for s#tisf#ction levels c. An#lyzing employee #ttend#nce r#tes d. Collecting emergency room w#it-time d#t#

54. B: Surveying p#tients is the only #nswer th#t results in qu#lit#tive feedb#ck bec#use the #nswers #re more subjective #nd perspectivedependent th#n qu#ntit#tive d#t#. A, C, #nd D #re incorrect bec#use they produce qu#ntit#tive d#t# th#t is objective #nd not qu#lit#tive in n#ture.

55. As p#rt of #n initi#tive for #dministr#tors to be more involved in d#y-to-d#y business, you h#ve been spending # gre#t de#l of time in the w#rds of Hospit#l B. You notice there seem to be unre#son#bly long w#it times between p#tient requests #nd nurse responses. Wh#t st#tistic#l process could you use to determine if this is # new or worsening problem? #. R#ndom v#ri#tion b. Qu#lit#tive d#t# collection c. Trend #n#lysis d. Speci#l c#use v#ri#tion

55. C: Performing # trend #n#lysis will reve#l #ny ch#nges in w#it times over # set period of time, #s well #s #ny new or worsening problems. A, B, #nd D #re wrong bec#use, while they offer st#tistic#l #n#lysis, they do not demonstr#te long-term trends or ch#nges in service levels.

56. When ev#lu#ting d#t# for length of st#y #fter cholecystectomy, you discover # very l#rge st#nd#rd devi#tion in the d#t#. Wh#t could #ccount for this? #. Diverse provider preferences for post-surgic#l length of st#y b. Diverse post-surgic#l needs of cholecystectomy p#tients c. An error in c#lcul#tion of the me#n d. A #nd B

56. D: Both diverse provider preferences #nd diverse p#tient needs could result in the dr#m#tic st#nd#rd devi#tion in the st#tistics. C is incorrect bec#use # c#lcul#tion error in determining the me#n is not gener#lly # re#son for # signific#nt st#nd#rd devi#tion.

57. You #re the #dministr#tor of # growing hospit#l, #nd you #re considering #pplying for the M#lcolm B#ldrige N#tion#l Qu#lity Aw#rd for your org#niz#tion. As you weigh the costs in time #nd money #g#inst the benefits of #pplic#tion, which benefit would most likely be the strongest encour#gement for #pplic#tion? #. The notoriety of the #w#rd b. The rigors of self- #ssessment c. The v#lue of site-visit feedb#ck d. The government ties to the progr#m

57. C: The potenti#l v#lue of site-visit feedb#ck th#t c#n come #s # result of #pplying for # B#ldrige Aw#rd is the most encour#ging f#ctor for #pplic#tion.

58. As # perform#nce improvement te#m f#cilit#tor, wh#t #re your most import#nt functions? #. Motiv#ting #nd communic#ting effectively b. Alloc#ting resources #nd mining d#t# c. Instructing #nd redirecting employees d. Dict#ting duties #nd reprim#nding offenders

58. A: The most import#nt functions of # perform#nce improvement te#m f#cilit#tor #re motiv#tion #nd communic#tion. B, C, #nd D #re not the best choices bec#use, while # te#m f#cilit#tor m#y perform these duties, they #re not the most import#nt or even necess#ry functions of the te#m f#cilit#tor.

59. Which of the following is # v#lid role on # perform#nce improvement te#m? #. Te#m le#der b. Te#m member c. Te#m f#cilit#tor d. All of the #bove

59. D: A perform#nce improvement te#m is m#de up of # te#m le#der, # te#m f#cilit#tor, #nd te#m members.

I-19 QM Principles 6-10

6) Quality control should focus on the most vital process 7) The modern approach to quality is thoroughly grounded in scientific and statistical thinking 8) Total employee involvement is critical 9) New organizational structures can help achieve quality improvement 10) Quality management employs 3 basic, closely interrelated activates: (a) Quality Planning (b) Quality Control [QM ](c) Quality Improvement

6. If m#n#gers f#il to m#ke org#niz#tion#l decisions consciously, wh#t gener#lly serves #s the b#sis for outcomes? #. Circumst#nces b. Org#niz#tion#l policy c. St#tistic#l norms d. Feder#l regul#tions

6. A: When m#n#gers do not m#ke conscious org#niz#tion#l decisions, those decisions #re m#de by def#ult #ccording to circumst#nces. Decision m#king becomes re#ctive inste#d of pro-#ctive, #nd more #nd more resources #re devoted to m#n#ging current problems which could h#ve been prevented, inste#d of pl#nning for the future. This c#n le#d to the beginning of # neg#tive feedb#ck loop which c#n be very destructive to #n org#niz#tion.

60. Wh#t is the most import#nt first step of #n effective perform#nce improvement te#m? #. M#ke ch#nges to org#niz#tion#l pr#ctices b. Ev#lu#te the effectiveness of implemented ch#nge c. Identify # specific process th#t needs improvement d. Educ#te employees on ch#nges to be m#de

60. C: The most import#nt first step for # perform#nce improvement te#m is identifying # specific process th#t needs improvement.

62. Although p#tient s#fety events #re occurring with un#ccept#ble frequency within your org#niz#tion, st#ff members #re reluct#nt to report these events bec#use they fe#r retribution. Wh#t c#n be done to improve st#ff reporting? #. Nothing will improve st#ff reporting b. Implement # non-punitive reporting policy c. Incre#se punishments for reporting d. Implement punishment for not reporting

62. B: Implementing # nonpunitive reporting policy is the best option to help encour#ge employees to report potenti#l p#tient s#fety events. A is not the best choice bec#use it represents c#pitul#tion to the problem inste#d of resolution. C #nd D #re incorrect bec#use incre#sing the punishments for volunt#ry reporters will discour#ge employees from reporting issues.

67. A recent #rticle from # prestigious he#lth r#nking org#niz#tion h#s pl#ced Hospit#l A #t the very bottom of # list of region#l hospit#ls. In order to move up in the r#nkings, wh#t should Hospit#l A do first? #. Est#blish # steering committee to pinpoint problems #nd identify solutions b. Repl#ce individu#ls #t the #dministr#tive level with new hires c. Est#blish # qu#lity council to enforce qu#lity st#nd#rds d. L#unch #n extensive public rel#tions c#mp#ign to improve im#ge

67. A: To fix the low pl#cement in r#nkings, Hospit#l A needs to est#blish # steering committee to pinpoint problem #re#s #nd identify potenti#l solutions.

68. N#tion#l mort#lity r#tes for he#rt #tt#ck victims h#ve recently come #cross your desk. If you w#nt to conduct # one-s#mple t-test comp#ring mort#lity r#tes #t your hospit#l with n#tion#l r#tes, wh#t should your first step be? #. Find the st#nd#rd devi#tion for the n#tion#l he#rt #tt#ck mort#lity r#tes b. G#ther mort#lity r#tes for # r#ndom s#mple of he#rt #tt#ck p#tients #t your hospit#l c. Do # direct comp#rison of he#rt #tt#ck mort#lity v#ri#nce r#tes #t your hospit#l d. Collect qu#lit#tive d#t# on he#rt #tt#ck mort#lity

68. B: A one-s#mple t-test requires # r#ndom s#mple of #pplic#ble d#t#, so g#thering the r#ndom s#mple would be the first step in conducting the t-test. A, C, #nd D #re incorrect bec#use they do not fit into the fr#mework of # one-s#mple t-test.

69. You h#ve est#blished # p#tient s#tisf#ction benchm#rk of 90 percent for e#ch individu#l provider in your dep#rtment. One provider consistently h#s scores between 87 #nd 89 percent over the course of # ye#r. How would you describe his perform#nce #g#inst the benchm#rk? #. Slightly subst#nd#rd b. Dr#m#tic#lly subst#nd#rd c. St#nd#rd d. Above st#nd#rd

69. A: When # benchm#rk of 90 percent p#tient s#tisf#ction h#s been set, # provider who consistently scored between 87 #nd 89 percent would h#ve perform#nce th#t w#s considered slightly subst#nd#rd.

7. During # surgic#l procedure, # sm#ll medic#l implement w#s left inside # p#tient. The follow-up surgery to remove the implement is #n ex#mple of... #. Qu#lity improvement. b. Qu#lity control. c. Qu#lity #ssur#nce. d. Tot#l qu#lity.

7. C: Qu#lity #ssur#nce is # focus on outputs or qu#lity #fter the point of production, including #ny corrective #ctions necess#ry to optimize post-production qu#lity, #s in the surgery performed to remove the implement left in the p#tient. A, B, #nd D #re incorrect bec#use they refer to qu#lity processes th#t t#ke pl#ce on different levels #nd #re not corrective in the w#y th#t qu#lity #ssur#nce is.

71. After three ye#rs of rising influenz# r#tes, Clinic A institutes #n extensive v#ccin#tion c#mp#ign. Wh#t outcome d#t# would be expected #s # result of this c#mp#ign? #. More clinic visitors b. Higher he#lthc#re costs c. Reduced clinic visits d. Decre#sed influenz# incidence

71. D: The expected result of the v#ccin#tion c#mp#ign by Clinic A would be decre#sed influenz# incidence.

72. Which of the following #re import#nt #re#s to consider when ev#lu#ting # public he#lth surveill#nce system for d#t# collection? #. D#t# qu#lity b. System experience c. V#lidity of #cquired d#t# d. All of the #bove

72. D: D#t# qu#lity, system experience, #nd v#lidity of #cquired d#t# #re #ll import#nt #re#s to consider when ev#lu#ting # public he#lth surveill#nce system for d#t# collection. A, B, #nd C #re not correct bec#use none of those options #lone is the best #nswer, #lthough they #re #ll import#nt elements of #n effective system #s # whole.

73. Hospit#l A h#s just implemented # new electronic he#lth record system. As #n #dministr#tor, it is your job to get everyone comfort#ble using this new system. Wh#t would be the best first step in this process? #. Presenting system benefits to st#keholders b. Requiring m#nd#tory tr#ining for #ll employees c. Requiring m#nd#tory us#ge by #ll employees d. Distributing # list of other org#niz#tions using the technology

73. A: When implementing # new system #nd trying to get employees comfort#ble with it, one of the best first steps is presenting #ctu#l system benefits to st#keholders who c#n get others excited #bout the technology. B, C, #nd D #re incorrect bec#use #lthough they #re #ll possible t#ctics to get employees to use the new system, they #re not effective #s # first step.

75. As # member of # qu#lity improvement te#m, you #re p#rticip#ting in # medic#tion us#ge review. Who else must p#rticip#te in this process? #. The p#tient b. A c#re provider c. A #nd B d. None of the #bove

75. C: Both # p#tient #nd provider should be involved in # medic#tion us#ge review to improve effic#cy.

76. P#tients on the postsurgic #l w#rd h#ve been compl#ining #bout # l#ck of priv#cy when nurses #re performing wound c#re. Wh#t process is most #ppropri#te to initi#te for resolution of this issue? #. Qu#lity control b. P#tient #dvoc#cy c. Qu#lity #ssur#nce d. Peer review

76. B: A l#ck of priv#cy during wound c#re should be resolved through the support of # p#tient #dvoc#te.

78. You h#ve been t#sked with cre#ting p#tient s#fety tr#ining for the nursing st#ff. Wh#t is your first step in prep#ring tr#ining m#teri#ls? #. Determine le#rning objectives b. Write lessons for present#tion c. Cre#te supplement#l m#teri#ls d. Schedule tr#ining times/ loc#tions

78. A: The first step in cre#ting p#tient s#fety tr#ining (or #ny other kind of tr#ining tr#ining) should be determining the le#rning objectives. B, C, #nd D #re incorrect bec#use, #lthough they #re v#lid steps in cre#ting tr#ining, they do not represent the first step of the process.

79. Which of the following #re efficient w#ys to ev#lu#te the effectiveness of perform#nce improvement tr#ining? #. Exit surveys for p#rticip#nts b. An#lysis of post-tr#ining perform#nce c. Post-tr#ining focus groups with p#rticip#nts d. All of the #bove

79. D: Exit surveys for p#rticip#nts, #n#lysis of posttr #ining perform#nce, #nd posttr #ining focus groups #re #ll effective w#ys to ev#lu#te the effectiveness of perform#nce improvement tr#ining.

8. Which of the following st#tements #bout qu#lity in he#lthc#re is true? #. Qu#lity is # conglomer#te of lessons, methods, #nd knowledge. b. Qu#lity directly correl#tes to p#tient s#fety. c. Qu#lity is multif#ceted #nd multidimension#l in n#ture. d. All of the #bove

8. D: All of the st#tements presented in A, B, #nd C #re true st#tements #bout qu#lity in he#lthc#re.

80. When providing customer service tr#ining to employees from multiple dep#rtments, wh#t is the most import#nt concept to keep in mind? #. Diverse scheduling needs b. L#ck of f#mili#rity #mong tr#inees c. How differences m#y #ffect le#rning d. Some employees m#y not need tr#ining

80. C: The most import#nt thing to keep in mind when providing customer service tr#ining for employees from multiple dep#rtments is how differences m#y #ffect le#rning.

81. Wh#t is the prim#ry purpose #nd ultim#te go#l of perform#nce improvement tr#ining? #. To improve perform#nce in # specific #re# b. To improve perform#nce throughout #n org#niz#tion c. To introduce new ide#s to employees d. To cre#te uniformity #cross #n org#niz#tion

81. A: The prim#ry purpose #nd ultim#te go#l of perform#nce improvement tr#ining is to improve perform#nce in # specific #re#. B is incorrect bec#use perform#nce improvement should be t#rgeted #t # specific beh#vior to be improved. C #nd D wrong bec#use, while they #re both desir#ble go#ls, neither one represents the prim#ry purpose #nd ultim#te go#l of perform#nce improvement tr#ining.

84. You #re deeply involved in prep#ring #n #w#rd #pplic#tion, #nd you need to survey intern#l subject m#tter experts to #nswer the questions needed for the #pplic#tion. Wh#t question would be #ppropri#te for #ny survey, reg#rdless of the dep#rtment or subject? #. Describe your dep#rtment#l #ppro#ch to p#tient c#re b. Describe your dep#rtment#l #ppro#ch to customer service c. Describe your dep#rtment#l #ppro#ch to fin#nci#l m#n#gement d. All of the #bove

84. B: Every dep#rtment c#n #nd should #nswer survey questions describing their #ppro#ch to customer service.

85. Which regul#tory body is responsible for the Hospit#l Consumer Assessment of He#lthc#re Providers #nd Systems (HCAHPS) currently in use in more th#n 98 percent of #cute c#re hospit#ls? #. The Joint Commission b. The Centers for Medic#re #nd Medic#id Services (CMS) c. The Agency for He#lthc#re Rese#rch #nd Qu#lity (AHRQ) d. B #nd C

85. D: The Hospit#l Consumer Assessment of He#lthc#re Providers #nd Systems (HCAHPS) w#s designed jointly by the Centers for Medic#re #nd Medic#id Services (CMS) #nd the Agency for He#lthc#re Rese#rch #nd Qu#lity (AHRQ).

86. Which of the following methods would be most #ppropri#te for discussing individu#l p#tient m#n#gement issues with # c#re provider? #. One-on-one discussion b. Focus group c. C#re provider survey d. All of the #bove

86. A: One-on-one discussion is the best #nd most #ppropri#te form of communic#tion when discussing the m#n#gement of #n individu#l p#tient with # c#re provider.

89. Which of the following might h#ve # pl#ce on #n individu#l perform#nce improvement report? #. Time on job b. Gender c. Age d. None of the #bove

89. A: Time on job might h#ve # pl#ce on #n individu#l perform#nce improvement report bec#use # new employee would not be expected to improve #s quickly #s #n est#blished employee, #nd #n est#blished employee should show improvement over their time on job.

90. As #n #dministr#tor, you #re pl#nning to implement # process ch#nge th#t will improve p#tient s#fety throughout your org#niz#tion. Who will likely pl#y the biggest role in getting employees motiv#ted to ch#nge? #. Ch#mpions b. Administr#tors c. New hires d. Te#m f#cilit#tors

90. A: Ch#mpions #re respected "key pl#yers" in the org#niz#tion #nd will therefore be most likely to pl#y # big role in getting employees motiv#ted to ch#nge.

91. While reviewing ye#r-end st#tistics, you notice your hospit#l performs m#ny more tonsillectomies th#n other hospit#ls in the #re#. Wh#t response would be most #ppropri#te to determine the c#use of this st#tistic#l #nom#ly? #. Peer review b. Aw#rds to providers c. P#tient #dvoc#cy d. Medic#l record review

91. D: In # st#tistic#l #nom#ly situ#tion involving medic#l procedures, # medic#l record review would be w#rr#nted to determine why tonsillectomies were being performed more often th#n #t other region#l hospit#ls.

92. Despite repe#ted tr#ining, the emergency room st#ff still exceeds suggested org#niz#tion#l w#it times for incoming p#tients. Wh#t f#ctor should be considered before future tr#ining to ensure ch#nge will occur? #. Mis#lignment of dep#rtment#l #nd org#niz#tion#l str#tegic go#ls b. Age #nd gener#tion#l differences of dep#rtment employees c. Gender-b#sed bi#s of tre#tment times for incoming p#tients d. St#nd#rd devi#tion of st#ffing levels #g#inst p#tient influx levels

92. A: Before pursuing further tr#ining for the emergency room st#ff, it is import#nt to ex#mine if there is # mis#lignment of dep#rtment#l go#ls (qu#lity c#re) #nd org#niz#tion#l str#tegic go#ls (reduced w#it times).

93. Wh#t provides the found#tion for # perform#nce improvement project? #. The budget b. The personnel involved c. The desired outcome d. The process for improvement

93. C: A specific desired outcome provides the found#tion for # perform#nce improvement project, serving #s the t#rget to be re#ched with improvements m#de.

94. Hospit#l B h#s seen # recent incre#se in post-surgic#l wound infections. Investig#tion of the problem reve#ls # recurring issue with proper wound c#re by sever#l members of the nursing st#ff. Wh#t would be the best dep#rtment#l #ppro#ch to this issue? #. Root c#use #n#lysis b. Punishment of involved st#ff members c. Implement#tion of # perform#nce improvement te#m d. Utiliz#tion m#n#gement #ssessment

94. C: When f#ced with recurring st#ff issues with wound c#re, implementing # perform#nce improvement te#m is the best option, #s it cre#tes both # process #nd #n incentive for improvement.

95. Which of the following is the best definition of "ch#mpions"? #. High performers from v#rious dep#rtments b. Credible #nd influenti#l st#ff members c. Well-educ#ted #nd highlytr #ined profession#ls d. Employees with long tenure #t the org#niz#tion

95. B: Ch#mpions #re credible #nd influenti#l st#ff members who c#n be very motiv#tion#l in cre#ting ch#nge.

96. Employees #re reducing your productivity by continu#lly coming into your office with compl#ints #nd questions. As # m#n#ger, you w#nt employees to #ddress these issues with their direct supervisors. Then the supervisors c#n come to you with #ny questions. How c#n you best est#blish this structure? #. Reduce your office hours b. Reverse your open-door policy c. Tr#in supervisors in #ssertiveness d. Cle#rly define lines of #uthority

96. D: As # m#n#ger, you must cle#rly define lines of #uthority to direct #ccount#bility where it belongs in the ch#in of comm#nd.

97. You #re p#rt of # cost- #n#lysis te#m ev#lu#ting # proposed inp#tient nutrition progr#m. Wh#t is the first step your te#m should t#ke in the cost #n#lysis process? #. Study fr#ming b. Report form#tting c. Audience defining d. P#tient polling

97. A: The first step in # st#nd#rd cost #n#lysis process is study fr#ming. B #nd C #re wrong bec#use, #lthough they #re v#lid p#rts of cost #n#lysis, they come l#ter in the process, not #s the first step. D is not correct bec#use p#tient polling is not p#rt of # st#nd#rd cost #n#lysis.

98. Hospit#l A is prep#ring for intern#tion#l #ccredit#tion. As #n #dministr#tor, wh#t should you do to help prep#re for the #ccredit#tion process? #. Prep#re st#ff for the procedures of the process b. Compile #ll documents necess#ry for #ccredit#tion c. Ensure e#ch dep#rtment meets current st#nd#rds d. All of the #bove

98. D: In prep#r#tion for intern#tion#l #ccredit#tion, #dministr#tors should prep#re st#ff for the survey process, #ssist in compiling necess#ry documents, #nd ensure dep#rtments #re meeting current st#nd#rds.

Total Quality Management (TQM)

A broad management philosophy, espousing quality and leadership commitment that provides the energy and the rationale for implementation of the process of Continuous Quality Improvement (CQI) within the organization wide Quality Management Strategy.

H Force Field Analysis

A change management tool. Looks at forces for and against a change; 1) to decide if the change should be attempted or 2) used to create strategies to increase support and decrease opposition.

Process Decision Program Chart.

A chart that maps out the identified events and contingencies that can occur from a problem statement to its solution and attempts to identify potential deviations from the desired process, thus allowing the team to anticipate and prevent the deviation.

Deployment Chart

A chart used to project schedules for complex tasks and their associated subtasks. It usually is used with a task for which the time for completion is known and may be used to determine who has responsibility for the parts of a plan or project. Also called a planning grid

Control Chart.

A chart used to statistically illustrate upper and lower limits of a process and the variation of an organization's process within those limits.

Corrective Action Plan (CAP).

A collection of documents that organize improvements needed for organizations to be in full compliance with standards or regulations. These plans often are written in response to a survey, inspection, or gap analyses from assessments that define observations as well as recommendations for actions to achieve compliance for a given standard. Also known as a plan of correction, improvement plan, and action plan.

I Knowledge-Based Information

A collection of stored facts, models, and information that can be used for designing and redesigning processes and for problem solving... found in the clinical, scientific, and management literature... [TJC]

Second-order Change.

A complex change that requires a significant alteration in behavior to achieve desired new ways of performing or new processes.

I Multi-Level Filing System (hierarchical)

A computer filing system that allows user defined directories, creating a structure with many levels.

Fair and Just Culture

A culture in which everyone throughout the organization is aware that medical errors are inevitable, but in which all errors and unintended events are reported, even when the events may not cause patient injury. These efforts can make the system safer.

Dashboard

A data __________ is an information management tool that visually tracks, analyzes and displays key performance indicators (KPI), metrics and key data points to monitor the health of a business, department or specific process. They are customizable to meet the specific needs of a department and company.

K51 Practice Guidelines

A detailed description of a process of maintenance of health status or to slow the decline in health status in certain chronic clinical conditions. They are established to assist in the delivery of effective and efficient health care that preserves the resources of the provider, the patient, and the funding entity.

Matrix Diagram

A diagram that displays the connection between each idea or issue in one group to those in another group or groups. Can show the relationship between two items as well as the strength of the relationship.

Cause-and-Effect, Ishikawa, or Fishbone Diagram

A diagram used to analyze and display the potential causes of a problem or the source of variation. In general, there are at least four categories in the diagram, such as the four Ms (manpower, methods, machines, and materials) or the five Ps: patron (users of the system), people (workers), provisions (supplies), places to work (work environment), and procedures (methods and rules).

Budgeting

A formal annual or periodic process through which financial performance goals and actual results are evaluated for the current and previous fiscal years, allowing for the development of formal goals for the next fiscal year.

Brainstorming

A free-flowing generation of ideas with the potential to create excitement, equalize involvement, and result in original solutions to the problem

Information Managment

A function (set of processes) focused on meeting the organization's needs for information about decision-making.

H Practice Guideline

A generally accepted principle for patient management, with care specifications based on the most current scientific findings (evidence of effectiveness, hence, "evidence-based"), clinical expertise, and community standards of practice. "Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."

What is a run chart?

A graph of the same variable over time.

Run Chart.

A graphic display of data points over time; also called a trend chart. Run charts are control charts without the control limits.

Nominal Group technique

A group decision-making process for generating a large number of ideas in which each member works by himself or herself. -use when team members are new to each other or dealing with a controversial topic

Quality Circle.

A group of employees who perform similar duties and meet regularly, with or without management, to discuss quality and productivity problems and propose solutions or suggestions for improvement.

Team

A group of people who are interdependent with respect to information, resources, and skills, and who seek to combine their efforts to achieve a common goal

Plan, Do, Study, Act (PDSA).

A later adaptation by Deming of the Plan-Do-Check-Act cycle; also referred to as the Deming Cycle or the Deming Wheel.

H Risk Register

A listing of identified risks and its components, usually in table format, that supports the governing body, leadership, management, and teams seeking to develop, organize, implement, and/or maintain ERM or another new strategic initiative, function, process, or project. It is a tool for documenting priorities; summarizing and succinctly describing risks to be managed, based on probability and impact scores, by category; listing prevention or mitigation strategies; responsibility; timeline.

H Value Statement

A listing of organizational values that support the mission and vision statements and guide strategic planning, decision making, and the provision of all services.

Value-Stream mapping

A map of the process in which only value-added steps for the customer are retained and other waster removed.

Quality Improvement (QI).

A means by which quality performance is achieved at unprecedented levels by establishing the infrastructure needed to secure annual quality improvement; identifying the specific areas for improvement; establishing clear accountability for bringing QI projects to a successful conclusion; and providing the resources, motivation, and training needed by the teams (e.g., to diagnose the causes, stimulate establishment of a remedy, and establish controls to hold the gains).

Black Belt

A member of an organization who has been extensively trained in Six Sigma methods. A Black Belt also is experienced in statistical analysis and interested in teaching others

Purposive Sampling or Judgment Sampling.

A method in which a particular group or groups are selected on the basis of certain criteria. It is subjective, because the researcher uses his or her judgment to decide who is representative of the population.

Stratified Random Sampling.

A method in which a population is divided into strata, or subpopulations (e.g., people of the same gender or ethnicity, patients with particular diseases, patients living in certain parts of the country), and each member of a stratum has an equal probability of being selected.

Stratified Random Sampling.

A method in which a population is divided into strata, or subpopulations, and each member of a stratum has an equal probability of being selected.

Simple Random Sampling.

A method in which each individual in the sampling frame (all subjects in the population) has an equal chance of being chosen (e.g., pulling a name out of a hat containing all possible names).

Quota Sampling.

A method in which the researcher makes a judgment about the best type of sample for the investigation and prespecifies characteristics of the sample to increase its representativeness.

Systematic Sampling.

A method in which, after the first case is randomly selected, every n-th element from a population is selected (e.g., picking every third name from a list of possible names).

Process Analysis.

A method of analyzing data using industrial quality improvement techniques to improve clinical or administrative outcomes. Process analysis occurs whenever a group of individuals diagrams a healthcare process.

Cluster Sampling

A method requiring that the population be divided into groups or clusters.

Threshold

A numerical point, below which the data should not fall, or the point or level at which something begins or changes.

Purposive Sampling or Judgment Sampling.

A particular group is subjectively selected based on criteria

K25 Balanced Scorecard

A performance measurement summary based on and organized around the organization's strategic plan, a translation of mission, vision, and strategy into a balanced set of top-level-approved financial and non-financial measures that drive organizational change and improvement. [spider} Reflects the priorities of both the organization & its customers. A group of Scorecards. {aka: Strategic Scorecard, Dashboard}

Near Miss Event

A potential medical error, caught prior to administration of use.

Standard of Care

A predefined outcome of patient care that the patient can expect from the encounter and that is accepted within the community of professionals, based upon the best scientific knowledge, current outcome data, and clinical expertise.

Failure Mode and Effect Analysis

A preventive approach to identify failures and opportunities for error and can be used for process as well as equipment.

Failure Mode and Effects Analysis (FMEA)

A preventive approach to identify failures and opportunities for error; can be used for processes as well as equipment. An FMEA is a systematic method of identifying and preventing failures before they occur.

When is a control process considered stable?

A process is stable if it is within its control limits and doesn't have any common cause or special cause variation.

Simple Process.

A process that allows people to follow a prescribed procedure (e.g., running preprogrammed or automated reports) to get the same results every time; for example, cooking with a recipe that has been tested ensures replicability without particular expertise.

Complex Process

A process that has uncertain outcomes even when formulas or prescriptive procedures have been developed and expertise is available (e.g., successful staffing of a nursing unit for one shift does not necessarily ensure the success of the next).

Complicated Process

A process that requires a high level of expertise in many specialized fields and coordination to achieve a high degree of certainty of the outcome (e.g., launching a moon rocket where the formulas are critical and necessary, and one successful launch increases the likelihood that the next launch will occur as planned)

Clinical Risk Management

A process used to indicate the concern and interest taken in clinical care provided to patients, clients, and other customers.

Healthcare Facilities Accreditation Program (HFAP)

A program of the American Osteopathic Association that accredits acute-care hospitals, hospital laboratories, and ambu latory care, surgery, mental health, substance abuse, and physical rehabilitation facilities.

H Clinical Path

A prospective, detailed, strategic treatment regimen, or daily/intermittent protocol for patient care, designed to identify and integrate key activities, interventions, and services for certain patient conditions. Clinical paths are applicable across the continuum of care, e.g., in acute care form pre-admission and pre-operative treatment through the hospital stay to discharge and post-discharge phases of care, including home care. Clinical/critical paths are designed to include clinical performance criteria for specified time periods of intervals, organized by categories of care needs, e.g., diagnostics, treatments, activity, medications, psychosocial, etc. They are useful tools for measuring actual performance.

Performance Measure

A quantifiable process and outcome indicator used to monitor performance.

An acute care facility plans to use a survey to evaluate its level of customer satisfaction. The facility has an urgent care center, dialysis unit, operating room, cardiac catheterization lab, and six Medical/Surgical inpatient units.Which of the following methods provides the most reliable data?

A random sample of 20% of all annual discharges/visits per unit

Confidence Interval (CI

A range of possible values around a sample estimate (e.g., a mean, proportion, ratio) that is calculated from data; commonly is used when comparing groups but also has other applications.

Confidence Interval (CI)

A range of that describe how much a sample statistic (such as a mean) deviated from the population statistic -most commonly 95% or 90%

System.

A regularly interacting or interdependent group of items forming a unified whole; a framework for seeing interrelationships rather than things, for seeing patterns of change rather than static "snapshots."

Appeal

A request to change a previous decision made by the organization

Focused or Intensive Review

A review of processes or outcomes using preestablished criteria or indicators

Six Sigma.

A rigorous methodology that uses data and statistical analysis to measure and improve performance. Quality is improved by eliminating errors in production and service-related processes. Six Sigma is based on the concept of the normal distribution or curve and the belief that there is a point, six standard deviations from the mean, at which there should be almost zero defects. Therefore, error rates should not exceed 3.4 defects per million opportunities (dpmo).

underuse of Care

A situation in which patients do not receive beneficial health services

underuse of Care.

A situation in which patients do not receive beneficial health services (e.g., 50% of heart attack victims fail to receive beta-blockers).

Overuse of treatment.

A situation in which patients undergo treatment or procedures from which they do not benefit (e.g., 50% of X-rays in back pain patients are unnecessary).

Strategic objective.

A specific statement written in measurable and observable terms using quantitative and qualitative measurement criteria. Written as an action-oriented statement, it indicates the minimum acceptable level of performance and specific time limit or degree of accuracy.

Common Cause Variation

A stable process which affects everyone working in the process and all process outcomes. Variation is due to the process or system design.

Strategic Quality Initiative

A statement of intent and a strategy to improve care and services in a specific way; a high-level, leadership driven, organization wide decision, resulting from, or incorporated into, the strategic planning process.

Control Chart.

A statistical used to distinguish between variation due to -common cause -special cause -Statistical tool to demonstrate if a process os stable (and predictable)

H Dephi Technique

A structured communication technique, a systematic, interactive forecasting method which relies on a panel of experts. The experts answer questionnaires in two or more rounds. After each round, a facilitator provides an anonymous summary of the experts' forecasts from the previous round as well as the reasons they provided for their judgments. Thus, experts are encouraged to revise their earlier answers in light of the replies of other members of their panel. It is believed that during this process the range of the answers will decrease and the group will converge towards the "correct" answer. Finally, the process is stopped after a pre-defined stop criterion (e.g. number of rounds, achievement of consensus, stability of results) and the mean or median scores of the final rounds determine the results.

Brainstorming

A structured group process used to create as many ideas as possible in a short a time as possible (i.e. one session) and to elicit both individual and group creativity. -use when a list of possible ideas is needed -Technique works well to generate ideas for cause/effect diagram and tree diagram

Snowball Sampling.

A subtype of convenience sampling that allows subjects to suggest other subjects for inclusion in the study, so that the sampling process gains momentum. This type of sampling process gains subjects who are difficult to identify but are known to others because of an informal network.

Decision Support System

A system dealing with functions including strategic planning and marketing, resource allocation, performance evaluation and monitoring, product evaluation and services, and medical management (e.g., evidence-based practice, clinical pathways)

learning Healthcare System

A system designed to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in healthcare

Clinical Information System

A system designed to support direct patient care processes; includes: medical records, laboratory/radiology results etc

Clinical Information System

A system designed to support direct patient care processes; automated clinical information systems have great potential for analyzing and improving the quality of patient care. Expanded clinical information systems in use include medical records and their retrieval systems, computer-assisted medical decision making for history and physicals and antibiotic selection, and clinical application programs for health risk programs and health maintenance organization encounter data.

Managed Healthcare

A system of healthcare delivery that tries to manage the cost, quality and access of healthcare -variety of systems ranging from managed indemnity, preferred provider organization (PPO), and health maintenance organizations (HMO) -techniques used to manage healthcare costs by influencing patient costs through influencing patient care decision making with assessments of appropriateness and provisions of care

Management Information System (MIS).

A system that can contain both manual and automated methods to provide information for decision making. Also called data-processing structure, clinical information system, medical information system, hospital information system, or decision support system.

Lean Enterprise

A system that uses value stream analysis (a tool for exposing waste), root cause analysis (a method for pursuing perfection) and new technologies to facilitate more efficient practices. The major focus in a lean enterprise is to eliminate waste in the following areas: production, waiting time, inappropriate processing, inventory, transporting, and defects.

H Root Cause Analysis

A systematic process for identifying the most basic or causal factor(s) underlying variation in performance, including the occurrence of possible occurrence of adverse events that might be precursors to a sentinel event; the intensive, in-depth analysis of a problem event, e.g., s sentinel event, to learn the most basic reason(s) for the problem, which, if corrected, will minimize recurrence of that event.

H Nominal Group Process

A technique used to give everyone on the team/group an equal voice in brainstorming, problem selection, or resolution. -Highly structured process to obtain primary data -Few representatives from the priority population respond to questions based on specific needs. -Small groups of 5 to 7 -Rank proposed ideas privately and share the rankings with the group

Risk Adjustment.

A technique used to take into account or to control the fact that different patients with the same diagnosis might have additional conditions or characteristics that could affect how well they respond to treatment.

Continuous Quality Improvement

A term used interchangeably with "Quality Improvement" to mean a management approach to the ongoing study and improvement of the processes of providing health care services to meet the needs and expectations of patients and others.

Chi-square (χ2) test.

A test that measures the statistical significance of a difference in proportions and is the most commonly reported statistical test in the medical literature.

Expectancy theory

A theory concerned with how individuals decide which behaviors to engage in and how much effort they should give to that behavior; focuses on the individual's perception of effort-to-performance and performance-to-outcomes links.

Activity Network Diagram

A tool also known as an arrow diagram, program evaluation and review technique (PERT), or a critical path method (CPM) chart. Through the use of the arrow diagram, a sequence of events is depicted. It is useful when several simultaneous paths must be coordinated.

Stratification Chart.

A tool designed to show where a problem does and does not occur or to demonstrate underlying patterns.

Scatter Diagram.

A tool for learning about associations or relationships between two variables - Identifies causes and effects relationships between variables -positive correlation: data goes from lower left to upper right

Interrelationship Diagram

A tool that allows a team to analyze all the interrelated cause-and-effect relationships and factors involved in a complex problem;

H Interrelationship Diagram

A tool that allows a team to analyze all the interrelated cause-and-effect relationships and factors involved in a complex problem; distinguish between issues that serve as drivers and those that are outcomes; and describe desired outcomes.

Statistical Process Control (SPC).

A tool that allows management to determine a range of random variation that always occurs in a process. SPC describes two types of causes of random variation: common-cause and special-cause variation.

tree Diagram.

A tool that maps out the full range of paths and tasks that are involved in a process and must be accomplished in order to achieve a goal; resembles an organizational chart.

Affinity Diagram

A tool that organizes numerous ideas or issues into groupings based on their natural relationships within the groupings. Typically used to analyze or chart a process and to structure and organize issues to provide a new perspective.

Prioritization Matrix.

A tool that organizes tasks, issues, or actions and prioritizes them based on agreed-upon criteria. The tool combines the tree diagram and the L-shaped matrix diagram, displaying the best possible effect.

I Lotus Diagram

A tool to expand thinking around a broad topic. The expansion may include types categories, details, or questions around a theme. Start with a topic in the center. List 8 components (or causes) around the topic. Then for each of these 8 components, list 8 sub-components...

Force Field Analysis Tool

A tool used by the team when a proposed solution to a problem will require significant change, an dit is important to analyze the potential impact and chances of success.

Brainwriting

A tool used to aid in sharing ideas in which people who have ideas can make them anonymously. It reduces the sense that one has to compete with others to be heard and often results in generation of more ideas than brainstorming.

Scatter Diagram.

A tool used to display possible causes and effects. Can determine the extent to which two variables (quality effects or process causes) relate to one another. Often used in combination with fishbone or Pareto diagrams or charts.

Lotus Diagram

A tool used to expand thinking around a single topic. The expansion may include types, categories, details, or questions around a theme.

Variation Analysis.

A tool used to explain statistically significant differences in data. These differences may be due to clinical factors, patient characteristics, data collection methods (e.g., sampling characteristics), or organizational characteristics (e.g., staffing).

Pareto Diagram or Pareto Chart.

A tool used to prioritize a series of problems or possible causes of problems. Displays a series of bars in which the the varying height of the bars clearly displays the priority for problem solving.

Delphi Technique

A tool used to reach team consensus concerning a particular goal or task

Dashboards

A tool used to represent key management and performance indicators. Can be used as a data-mining tool to synchronize and synthesize vast amounts of data into visual representations. Can be used for analyzing and forecasting various organizational systems

H Prioritization Matrix

A tool used to select one option from a group of alternatives, be they problems or solutions, or to put the options into priority order if all need to be done, to promote objective decision making. Tool used to organize info that can be compared on a variety of characteristics in order to make a comparison, selection or choice

Patient Safety Practice

A type of process or structure whose application reduces the probability of adverse events resulting from a patient's exposure to the healthcare system across a range of diseases and procedures.

Special-Cause Variation.

A variation that occurs when an activity falls outside the control limits or when an obvious nonrandom pattern occurs around the central line. This type of variation should be interpreted as a trend and investigated.

32- The concept of "patient safety" applies most appropriately to A. environmental safety measures. B. serious physical injuries. C. patient complaint management. D. risk prevention.

A. According to The Joint Commission and others, the physical environment is only one aspect of patient safety; therefore, this is an incomplete answer. B. According to The Joint Commission and others, patient safety encompasses not only prevention of serious physical injury, but also the identification of risks in the performance of tasks or the physical environment; therefore, this answer is incomplete. C. Complaint review and management may help to identify potential patient safety issues, but is not a reliable method to improve patient safety. D. The Joint Commission defines safety as the degree to which the risk of an intervention (e.g., use of drugs, procedures) in the care environment is reduced for a patient and other persons, including healthcare practitioners. Safety risks may arise from the performance of tasks, the structure of the physical environment, or situations beyond the organization's control, such as weather. Therefore, risk prevention is the correct answer because it best encompasses all areas of safety, while the other responses are limited to one area of patient safety.

28- A facility has identified a trend of increased falls for patients aged 60 to 85 years. An effective fall prevention program should include A. a fall protocol, restraint criteria, and a family sitter program. B. restraint criteria, staff education, and a sedation protocol. C. a patient assessment process, a family sitter program, and a sedation protocol. D. a patient assessment process, a fall protocol, and staff education.

A. See explanation B. B. According to the CMS Conditions of Participation for hospitals and long-term care, patients or residents have the right to be free of restraints of any form (physical or drug) that are not medically necessary. Restraints should only be used when other less restrictive forms of management have failed and there is a need to ensure the safety or well-being of the patient/resident. Restraints should not be used as part of a routine falls prevention program. C. According to the CMS Conditions of Participation for hospitals and long-term care, patients or residents have the right to be free of restraints of any form (physical or drug) that are not medically necessary. Medications used to restrict the freedom of movement of a patient are considered a restraint when not used as medically necessary for their condition. Therefore, any sedation protocol used as part of the falls prevention program would be considered a restraint. D. The proper steps to reducing patient falls include assessing the risk for fall regularly during a patient stay, putting in place protocols to reduce falls based on the results of the assessment, then conducting staff education to ensure these steps are implemented.

53- A healthcare quality professional is developing a policy regarding access to physician quality files. In addition to the date and name of the person requesting the information, which of the following should be included in the policy? A. requestor's contact information B. purpose of the request C. the credentialing application D. the practitioner privilege form

A. The requestor's contact information is not an essential element to include as a requirement in this policy. B. The high degree of sensitivity related to the evaluation of practitioner experience and outcomes dictates the need to answer questions about who (to ascertain authority), when (to establish timing), why (to determine whether the access was valid and credible), and what (to establish the relevancy of the request to the stated reason for access). C. The credentialing application is not an essential element to include as a requirement in this policy. D. The practitioner privilege form is not an essential element to include as a requirement in this policy.

28-A Quality Council has chartered a performance improvement team to reduce medication errors. The team has been meeting for several months and progress has been very slow. Which of the following is the most important factor for the Quality Council to assess with the team leader? A. composition of the team B. number of medication errors since team was chartered C. team members' ability to interpret graphs D. length of team meetings

A. composition of the team****************

8-The Joint Commission (TJC) Standards and Elements of Performance are used A. to define expectations for safety and quality care. B. in place of Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. C. to determine compliance with the Department of Health and Human Services (HHS). D. to calculate pay-for-performance incentives or penalties.

A. to define expectations for safety and quality care.*********

small, rural hospital wishes to evaluate customer satisfaction using a survey. The organization has four patient care units, an emergency department, and an ambulatory unit. Which of the following survey methods provides the most reliable information? A.a random sample of 20% of annual discharges/visits per unit B. a random sample of 5% of all annual discharges/visits C. all discharges/visits in January and July D. all discharges/visits of customers with a last name beginning with the letters A-E

A.√ a random sample of 20% of annual discharges/visits per unit*******

A process indicator is defined as one that measures A. an activity carried out to provide care or service. B. significant events that require further investigation. C. unexpected or negative variations. D. the appropriateness of procedure or treatment.

A.√ an activity carried out to provide care or service.*********

In continuous quality improvement programs, surveys are essential to determine which of the following? A.customer needs B. performance standards C. effective management D. population demographics

A.√ customer needs ****************

An organization has established a culture of patient safety when A.fear of retaliation is eliminated. B. reports of potential errors have decreased. C. patient safety goals are implemented. D. employee education is completed.

A.√ fear of retaliation is eliminated. ****************

A performance improvement team has been created to examine infection rates following surgery. Which of the following is the best reference for the team to use? A.hospital infection rates following surgery among similar facilities B. individual infection rates for each surgeon C. postoperative antibiotic use among surgeons D. number of surgeries performed among similar facilities

A.√ hospital infection rates following surgery among similar facilities***********

Situation-Background-Assessment-Recommendation (SBAR) is a A. tool to improve communication among caregivers. B. Six Sigma methodology. C. method that measures process variation. D. software package used in quality improvement.

A.√ tool to improve communication among caregivers.*************

Det Norske Vertis (DNV)

Accreditation program CMS-approved (called NIAHO) to accredit hospitals and critical access hospitals and acquire IOS 9001 certification by the 4th year -annual deemed status surveys and quality improvement

Commission for Accreditation of Rehabilitation Facilities (CARF)

Accreditation services include aging services, behavioral health, child and youth services, employment and community services, medical rehabilitation, and opioid treatment programs -includes an internal examination, onsite survey, a quality improvement plan, and evidence of conformance to standards.

EHR-based and Code-based systems

Allow healthcare providers to identify positive and negative outcomes so appropriate action can be taken. Both systems serve to focus users on areas of concern regarding outcomes performance. Cost savings occur because energy can be focuses on analyzing and controlling deviations from the baseline.

The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare organizations).

An accreditation commission that aims to improve the safety of care using accreditation and certification as risk-reduction activities; compliance with standards is intended to reduce the risk of adverse outcomes

uRAC (formerly the utilization Review Accreditation Commission)

An accreditation organization for case management, claims processing, consumer-directed healthcare, core accreditation, credentials verification organization, disease management, health call center, health network, health plan, health provider credentialing, health utilization management, health Web site, Health Insurance Portability and Accountability Act (HIPAA) privacy and security, independent review, workers' compensation, and utilization management.

National Committee for Quality Assurance (NCQA).

An accrediting body that evaluates the quality of care and service provided by healthcare organizations. NCQA assesses organization performance against standards for care and service delivery, including the Healthcare Effectiveness Data and Information Set (HEDIS).

Commission on Accreditation of Rehabilitation Facilities (CARF).

An accrediting body that promotes the quality, value, and optimal outcomes of services through a consultative accreditation process.

Medical Error

An adverse event that could be prevented given the current state of medical knowledge, the failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems or a preventable adverse event.

Cost-Benefit Analysis (CBA)

An analysis performed to determine the viability and broader benefits of proposed capital expenditures. This tool helps organizations better utilize financial and human resources and includes a time frame that demonstrates the costs and benefits of the project over specific periods of time.

Fail Forward

An approach in which one faces failure rather than avoids failure

Case Management

An approach to care that consists of intake and assessment, development of care plan, case coordination, discharge planning, and quality management.

H Risk Assessment (Proactive)

An assessment that examines a process in detail, including sequencing of events; assesses actual and potential risk, failure, or point of vulnerability; and, through a logical process, prioritizes areas for improvement, based on the actual or potential client care impact of care, treatment, or services provided.

Total Quality

An attitude or orientation that permeates an entire organization and the way in which an organization performs its internal and external business.

Standard Deviation.

An average of the deviations from the mean, it is the most frequently used statistic for measuring the degree of variability in a set of scores. Standard refers to the fact that the deviation indicates a group's average spread of scores or values around their mean; deviation indicates how much each score is scattered from the mean.

Never Event

An event that should never happen and if it does, immediate investigation and remediation is required. (also called a sentinel event)

Multiple Regression Analysis

An exercise that estimates the effects of two or more independent variables (x) on a dependent measure (y).

Code-Based System

An information system based on retrospective administrative data, such as data in the Uniform Bill document 1992 (UB-92) or claims data,

Code-Based System

An information system based on retrospective administrative data, such as data in the Uniform Bill document 1992 (UB-92) or claims data, including clinical information spanning the patient's entire stay but not identifying the specific timing of certain conditions

Administrative Support Information System

An information system that aids dayto-day operations in healthcare organizations, including financial information systems, human resources information systems, and office automation systems.

H Event

An occurrence that is either deemed to be, or results in a significant problem. e.g., sentinel event, adverse event, near miss event.

learning organization

An organization in which people continually expand their capacity to create the results they truly desire, new and expansive patterns of thinking are nurtured, collective aspiration is set free, and people are continually learning to see the whole together.

Green Belt

An organization member who is knowledgeable about Six Sigma methods but has received less training than a Black Belt and usually carries out projects.

College of American Pathologists (CAP

An organization that provides general laboratory accreditation, along with specialty programs for reproductive laboratories and forensic urine drug testing programs.

Patient Safety Organization (PSO)

An organization that receives deidentified patient health information for use in population health and in improving patient outcomes.

Goals Strategic Planning

An organization wide/systemwide, ongoing look into the future. Steps 1. Create a framework for operations 2. Create a fit with external environment 3. Establish process for coping with change and renewal 4. Foster anticipation, innovation, and excellence 5. Facilitate constant decision making 6. Create an organizational focus

Vision.

An organization's statement of its goals for the future, described in measurable terms that clarify the direction for everyone in the organization. An organization's direction is built upon its mission and is guided, through leadership, by its vision.

H Professional Liability Early Warning System

An organization-wide system to screen all patients for real or potential adverse incidents, issues, and occurrences (adverse patient occurrences or APOs) that might result in increased risk to the organization or corporation and/or less than optimal quality of care. Potentially compensable events are APOs that might become claims, based on the actual or potential negative impact on the patient

Confidentiality

An organizational (facility/staff) and/or patient right, to the fullest extent of the law, to personal and informational privacy, including all identifiable health information and all identifiable quality management information.

Affinity Diagram

An organizational tool most often used at the beginning of a team's work to organize large volumes of ideas or issues into major categories.

H Practice Parameter

An overall patient management strategy that outlines a range of appropriate services for a given clinical condition or identifies a range of clinical conditions for which a given service may be appropriate, incorporation acceptable practice guidelines, clinical criteria, protocols, or standards of care [Includes AMA descriptions of practice parameters].

H Sentinel Event

An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. The phrase "of the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. [TJC]

Continuous.

An uninterrupted extension in a sequence or an uninterrupted flow

Regression Analysis.

Analysis based on statistical correlations or associations among variables.

Outcome and Assessment Information Set (OASIS)

Assessment of patients in home health care settings, which also provides a set of performance improvement measures.

3-Which of the following accrediting bodies have deemed status with the Centers for Medicare and Medicaid Services (CMS)? A. ISO Certification and The Joint Commission (TJC) B. Det Norske Veritas (DNV) and the Healthcare Facility Accreditation Program (HFAP) C. The American Osteopathic Association (AOA) and the National Quality Forum (NQF) D. The American Medical Association (AMA) and Commission Accreditation of Rehabilitation Facilities (CARF)

B. Det Norske Veritas (DNV) and the Healthcare Facility Accreditation Program (HFAP)****

23-A former patient emails an organization's chief executive officer complimenting the friendliness of the nurses while complaining that her pain was not well-managed. To comply with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, what actions are needed? A. Interview staff involved, track performance over time, and report to the Quality Council. B. Investigate the complaint, write the patient, and report to the governing board C. Call the patient, put compliments in the nurses' personnel records, and report to the Quality Council. D. Review the medical record, put compliments and complaints in the appropriate staff personnel records, and report to the governing board.

B. Investigate the complaint, write the patient, and report to the governing board.*******

23-A former patient emails an organization's chief executive officer complimenting the friendliness of the nurses while complaining that her pain was not well-managed. To comply with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, what actions are needed? A. Interview staff involved, track performance over time, and report to the Quality Council. B. Investigate the complaint, write the patient, and report to the governing board. C. Call the patient, put compliments in the nurses' personnel records, and report to the Quality Council. D. Review the medical record, put compliments and complaints in the appropriate staff personnel records, and report to the governing board.

B. Investigate the complaint, write the patient, and report to the governing board.*******

30-A facility decided to implement Standard Precautions 1 year ago, but compliance has been poor. In addition to assessing the causes for poor compliance, the most effective way for the organization to improve compliance is to A. stock personal protective equipment (PPE) in the clean utility room. B. have employees demonstrate the use of personal protective equipment (PPE) as a part of staff competency. ************** C. show a videotape on Standard Precautions quarterly. D. review and revise handwashing policies and procedures.

B. have employees demonstrate the use of personal protective equipment (PPE) as a part of staff competency. **************

11. A quality improvement manager received the results from the most recent customer survey. Sixty percent of the residents in a nursing home have rated the temperature of foods served as poor. Which of the following actions should be taken first? A. Call the dietitian and ask for an explanation. B.Review previous results and assess trends. C. Set up a continuous monitor for review. D. Ignore the results and assess next quarter.

B.√ Review previous results and assess trends.*************

The following information about patient falls is obtained from a facility with units that have a similar average daily census: Unit A: 6% Unit B: 4% Unit C: 9% Unit D: 8% Which of the following additional information is most important to evaluate the cause of the falls? A. number of falls B. compliance with fall protocol C. medication education D. time of day

B.√ compliance with fall protocol *************

56. When developing department-specific performance measures and indicators, the quality manager as a consultant should A. conduct a literature search and select quality indicators. B.ensure that the numerator and denominator are clearly defined. C. prioritize the quality indicators for selection by the department leader. D. review the mission statement and seek physician input.

B.√ ensure that the numerator and denominator are clearly defined. ************

Evidence-based Research

Basis for sound clinical practice guidelines and recommendations

unfreezing.

Beliefs, expectations, and norms that can be remolded into new beliefs and behaviors. Through a process of learning new information, attitudes, and processes, people are able to redefine their current beliefs and "refreeze" these new concepts into their behaviors.

What is the difference between benchmarking and comparison data sources?

Benchmarking is typically external while comparison is usually internal but can be external.

total Quality.

Best defined as an attitude or an orientation that permeates an entire organization, and the way that an organization performs its internal and external business. Total quality integrates fundamental management techniques, existing improvement efforts, and the use of technical tools utilizing a disciplined statistical quality control (SQC).

Who bears the ultimate responsibility for quality of care?

Board of directors

6-The concept of organizational responsibility is most important to the field of healthcare quality because it holds the organization responsible for A. maintaining confidentiality of all documents. B. requiring physicians to carry adequate malpractice insurance. C. maintaining a process to identify deficiencies in the provision of care. D. ensuring that peer review physicians have no conflict of interest in cases being reviewed.

C. maintaining a process to identify deficiencies in the provision of care.

44-To be useful in preventing future error, a root cause analysis (RCA) should be performed A. at least 45 days after the event. B. using practitioners who were not involved in the event. C. utilizing a multidisciplinary team. D. documenting opinion as well as facts.

C. utilizing a multidisciplinary team.********

Organizational leaders can best demonstrate commitment to a new quality improvement initiative by A. reviewing the quality improvement plan. B. offering solutions to identified problems. C.allocating resources for the process. D. maintaining performance appraisals for staff.

C.√ allocating resources for the process.*************

The responsibility for providing organizational direction for a facility's continuous quality improvement program frequently rests with the quality A. teams. B. leader. C. council. D. facilitator.

C.√ council.************

16. The prevalence rate of a disease depends on the A. incidence rate and duration of the disease. B. number of new cases and the population at risk. C.total number of cases and the population at risk. D. incidence and change in the balance of etiological factors.

C.√ total number of cases and the population at risk.****************

Healthcare Facilities Accreditation Program (HFAP)

CMS deemed applicable to organizations such as -hospitals and their clinical labs -ambulatory care/surgical facilities -mental health and substance abuse facilities -physical rehabilitation facilities

K51 Practice Guidelines vs. Clinical Pathway

CPG: clinical practice guideline is more general and proposed by IOM in 1990. {Building blocks required to create a successful pathway? Or interchangeable with CP?} AKA: Care Maps, Care Pathways, Collaborative Care Pathways, Critical Pathways, Integrated Care Pathways, Multidisciplinary Pathways Of Care, Pathways Of Care, Protocols.

timely Care.

Care in which wait times and harmful delays for those who receive and provide care are eliminated (IOM Six Aims).

Effective Care

Care provided based on scientific knowledge about who will likely benefit and on a philosophy of restraint from providing care when it is not likely to benefit the patient (Institute of Medicine [IOM] Six Aims).

Safe Care.

Care that avoids injuring patients in the process of giving care that is intended to help them (IOM Six Aims).

Equitable Care

Care that does not vary in quality because of patients' personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status (IOM Six Aims).

Patient-Centered Care.

Care that is respectful and responsive to patient preferences, needs, and values (IOM Six Aims).

What are the two types of data?

Categorical and Continuous Data

I-44 CAS

Complex Adaptive Systems

Which of the following is the major responsibility of senior management regarding continuous quality improvement?

Conduct periodic reviews of the program.

a major responsibility of senior management regarding continuous quality improvement?

Conduct periodic reviews of the program.

Which type of data has more statistical power?

Continuous data has more statistical power and needs fewer data points.

; 27-The concept of "patient safety" applies most appropriately to A. environmental safety measures. B. serious patient injuries. C. patient complaint management. D. risk prevention.

D. risk prevention.*************

An ambulatory/outpatient care facility identifies an opportunity to improve the turnaround time for reports of x-rays performed at a local hospital. Which of the following groups should be involved in the team to improve the process? A. administrative representatives from both facilities B. primary care physician, clinic nurse, and clinic administrator C. radiologist, primary care physician, and clinic medical records D.clerical, clinical, and administrative staff from both facilities

D.√ clerical, clinical, and administrative staff from both facilities**************

The best tool to display stability of nosocomial infection rates over time is a A. run chart. B. histogram. C. Pareto chart. D.control chart.

D.√ control chart.****************

A trend analysis of incidents occurring in a healthcare facility should focus on which of the following areas? A. timeliness of reporting and data accuracy B. case mix index and staffing patterns C. practitioner profile and diagnostic codes D.severity level and occurrence types

D.√ severity level and occurrence types ***********

Ratio Data.

Data in which the distance between each point is equal and there is a true zero (e.g., weight and height).

Information

Data transformed through analysis and interpretation into a form useful for decision-making.

DMAIC

Define, measure, analyze, improve and control

Validity

Degree to which instrument measures what it is intended to measure

Automated Clinical Support Systems

Designed to support direct care processes.

Special-Cause Variation.

Distribution or pattern of points is not random, process is unstable

Beneficiary and Family Centered Care (BFCC)

Division of the QIO that performs statutory review functions, including complaints and quality of care reviews for people with medicare

When evaluating the program success to prevent fall data elements froman incident report are important?

Documentation of nursing assessment

2- Which of the following are the primary reasons for developing drug formularies? A. manage pharmacy costs, promote patient safety B. reduce medication errors, educate physicians C. encourage the appropriate use of medications, educate physicians D. decrease food and drug interactions, promote patient safety

EXPLANATIONS: A. A drug formulary is an approved list of medications, clinical indications, and doses that helps manage pharmacy costs and patient safety. B. Reduced medication errors may result from having a drug formulary, but is not the primary reason for having one. It is also not intended to educate physicians. C. A formulary may encourage the appropriate use of medications, but it is not intended to educate physicians. D. A formulary is intended to promote patient safety, but the primary purpose is not intended to decrease food and drug interactions.

19- Based on identified issues, a healthcare quality professional examines 100% of one physician's admissions and only 20% of all other physicians' admissions. This is best described as a A. focused review. B. prospective review. C. retrospective review. D. concurrent review.

EXPLANATIONS: A. A focused review is performed for a predetermined reason and is concentrated on a select sample of cases or data elements. Case or data element selection is usually based on internally identified problem areas or on external demands. Since the quality professional examined 100% of one physician's admission based on identified issues, a focused review is the best description of this case. B. A prospective review is performed prior to care or practice. It is evident in the case above that the review was based on identified issues related to a physician's practice patterns. C. The case above can be described as a retrospective review; however, a focused review is a more accurate answer since the quality professional reviewed 100% of a physician's admissions compared to 20% or all other physician's admissions. D. A concurrent review is performed at the onset of and during care; there is no evidence in the case above that the review was performed at that time.

9- For a quality improvement team to deal effectively with conflict, it is important to appoint which of the following to its membership? A. risk manager B. human resources representative C. facilitator D. senior leader

EXPLANATIONS: A. A risk manager's role would not necessarily deal with conflict within a quality improvement team. B. A human resources representative handles staffing issues, but not necessarily conflict, within a team. C. A facilitator is an unbiased party that may help groups deal with conflict. D. A senior leader's role would not necessarily deal with conflict within a quality improvement team.

20- An emergency department tracks wait times from patient arrival to physician assessment. Data are reported using a run chart. Which of the following demonstrates a true statistical increase in treatment delays? A. 6 consecutive ascending data points B. 7 consecutive descending data points C. a zigzag pattern of 10 data points D. data points close to the mean line

EXPLANATIONS: A. A true statistical increase is indicated by 6 consecutive ascending data points. B. Descending data points do not indicate an increase in this particular case. C. A zigzag pattern of data points demonstrates variability in the data. D. Data points close to the mean demonstrate minimal variation in the data.

48- The following data are being analyzed based on 6 months of incident reports for falls in a facility with 10 ICU beds and 40 Med/Surg beds: Which of the following is the next step for the healthcare quality professional to pursue? A. Continue to track and trend incident reports. B. Educate Med/Surg units on fall prevention. C. Form a team to change the ICU fall protocol. D. Conduct further analysis of fall data.

EXPLANATIONS: A. Action needs to be taken to investigate fall patterns because not enough information is provided from the above data. B. Education should be targeted toward identified issues after further analyzing the data. C. Revision may be necessary, but the first step is to determine the cause of the falls. D. The data need to be analyzed further to determine the significance and/or incidence.

23- The concept of organizational liability is most important to the field of healthcare quality because it holds the organization responsible for A. maintaining confidentiality of all documents. B. requiring physicians to carry adequate malpractice insurance. C. maintaining a process to identify deficiencies in the provision of care. D. ensuring that peer review physicians have no conflict of interest in cases being reviewed.

EXPLANATIONS: A. Confidentiality of all documents is not the most important part of organizational liability. B. Carrying adequate malpractice insurance is usually required, but is not the most important aspect. C. Maintaining quality of care is the ultimate responsibility of the governing body of an organization. D. Conducting unbiased peer reviews is a process that helps identify deficiencies in care.

37- Which of the following sampling techniques involves selecting the medical record of every fifth patient undergoing cardiovascular bypass? A. convenience B. systematic C. stratified D. simple random

EXPLANATIONS: A. Convenience sampling allows the use of any arbitrarily selected medical record and while selecting every fifth record may be convenient, systematic sampling is the best answer. B. Systematic sampling is the selection of every nth element from a population. C. Stratified sampling allows for two or more populations, which is not appropriate in this situation. D. Simple random sampling allows every record an equal chance of being selected.

46- Meaningful quality process measures must be A. relevant and valid. B. feasible and explainable. C. relevant and explainable. D. valid and feasible.

EXPLANATIONS: A. Data must be reproducible to be valid. For data to be reproduced, it should be relevant. Relevance of data is important because the data must relate to the quality process being measured. B. See explanation A. C. While the data must be relevant; if it is not valid, it is not meaningful. D. While the data must be valid, feasibility is not one of the typical characteristics used to determine whether a quality process is meaningful.

18- A Quality Council has chartered a Failure Mode and Effects Analysis (FMEA) team to examine the best method of preventing medication errors after the installation of a new medication dispensing system. The team's first major task should be to A. identify ways to detect the likelihood of the equipment breaking down. B. brainstorm on potential failure modes of the equipment. C. multi-vote on the severity of the potential equipment breakdowns. D. develop a flow chart of how the equipment will be installed.

EXPLANATIONS: A. Detecting a specific failure mode, such as equipment failure, is a step in an FMEA, but it is not the first major step. B. In an FMEA, brainstorming potential failures is the first major step. C. Multi-voting on the severity of a failure mode, such a as equipment breakdown, is a step in the FMEA process; but it is not the first major step. D. Developing a flow chart of how equipment will be installed is not a step in an FMEA.

61- Healthcare quality professionals can best communicate organizational values and commitment through A. establishing a multidisciplinary task force. B. disseminating monthly newsletters. C. creating a mission statement. D. leading by example.

EXPLANATIONS: A. Establishing a task force does not communicate organizational values and is not ongoing. B. Newsletters may be one way of communicating, but are a passive form of communication. C. A mission statement is a passive form of communication. Leading by example is the best way to communicate values stated in the mission. D. Demonstrating and practicing expected values are the best ways to communicate organizational values.

52- The most effective tool to improve communication between caregivers is known as A. FMEA. B. PDCA. C. PDSA. D. SBAR.

EXPLANATIONS: A. Failure Mode and Effect Analysis (FMEA) is a prospective analysis tool. B. Plan, Do, Check, Act (PDCA) is a performance improvement methodology. C. Plan, Do, Study, Act (PDSA) is a performance improvement methodology. D. Situation, Background, Assessment, Recommendation (SBAR) creates a shared model for effective information transfer by providing a standardized structure for concise factual communication among clinicians.

44- A chief quality officer has the responsibility for education and implementation of a quality improvement process. To affect cultural change, the chief quality officer must A. believe the costs are justified by the benefits. B. be a visible participant in the process. C. receive quarterly reports. D. limit training to managers and supervisors

EXPLANATIONS: A. For administration support and resources to be provided, administration must believe the costs are justified in order to affect culture change. B. Administration and organization leaders, such as the chief quality officer, must be part of the effort to affect cultural change. C. Receiving quarterly reports does not affect culture change. D. Limiting training to certain staff members does not affect culture change.

39- Which of the following patient safety goals is applicable to everyone in a healthcare facility? A. hand-off communication B. medication safety C. hand hygiene D. prevention of falls

EXPLANATIONS: A. Hand-off communication is about communication among caregivers, not all healthcare workers. B. Medication safety primarily affects pharmacy and nursing units. C. Good hand hygiene is appropriate for everyone, whether in direct contact with patients or not. D. Prevention of falls primarily affects caregivers, housekeeping, and maintenance.

6- Which of the following is the primary goal of risk management? A. Identify and manage risks to promote patient safety. B. Maintain an effective incident reporting system. C. Perform failure mode and effects analyses. D. Eliminate financial loss associated with legal actions.

EXPLANATIONS: A. Improving patient safety is the primary goal of risk management. B. Incident reporting is a tool that may be used in risk management, but is not the primary goal. C. A failure mode and effects analysis is a proactive method used to help identify problems. D. Risk management programs help protect an organization from financial loss, but it is not the primary goal. 7-

26- A team approach to problem solving is most useful when A. the organization's goals are unclear. B. diverse areas of expertise are required. C. communication challenges exist. D. there are ample resources within the organization.

EXPLANATIONS: A. It is leadership's responsibility, not the team's responsibility, to clearly define organizational goals. B. The make-up of a team that varies in perspective and experience provides a variety of skill sets that will help solve problems. C. Communication challenges may make working within a team more difficult. D. A team approach to problem solving should not be dependent on the amount of resources.

17- Which of the following is essential to an effective quality council? A. involvement of leadership B. consultation of the legal advisor C. participation of the strategic planning committee D. direction from the organization's quality department

EXPLANATIONS: A. Leadership involvement promotes an effective quality council through resource and support allocation to achieve objectives. B. A legal advisor is not commonly a member of a quality council. C. A strategic planning committee is not commonly a component of a quality council. D. The quality department may provide input, but not necessarily direction, to a quality council.

63- Measuring the time it takes a nurse to perform a procedure addresses which of the following aspects of care? A. monitoring B. process C. outcome D. structure

EXPLANATIONS: A. Monitoring is an observance of the process, outcome, or structure. B. Process is the systematic approach to the delivery of medical care. C. Outcome is the result of the medical care provided to patients. D. Structure involves the resources available for medical care delivery.

59- Which of the following is an example of a "never event" or sentinel event? A. missed dose of an antibiotic B. patient fall that results in a bruised tailbone C. fever of 101.2 °F after a blood transfusion D. patient suicide in the psychiatric ward

EXPLANATIONS: A. One missed dose of an antibiotic is not usually considered a sentinel event. B. A bruised tailbone is usually not a sentinel event. C. A fever alone is not a serious side effect of a blood transfusion. D. A suicide in a healthcare facility is serious, preventable, and of concern to all.

47- Clinical decision support systems can best support medication safety by alerting prescribers to A. patient compliance and allergies. B. the need for dose adjustments and patient weight changes. C. drug interactions and patient weight changes. D. allergies and drug interactions.

EXPLANATIONS: A. Patient compliance is not part of a support system. B. Dose adjustment and weight change alerts may be programmed, but are not the primary purpose of the system. C. Patient weight change alerts may be programmed, but are not the primary purpose of the system. D. A clinical decision support system involves a computerized medication management system that allows medication alerts to be programmed (including allergies and drug interactions).

40- A Quality Council is preparing a Patient Safety Plan. A key factor that needs to be considered for the long-term success of the patient safety program is to A. determine which patient safety goals need to be monitored. B. involve the entire organization in the program. C. review incident reports to identify what disciplinary action should occur. D. research how technology can be used to prevent errors.

EXPLANATIONS: A. Patient safety goals may be monitored as part of the program, but are not essential to the program's success. B. The program must be organization-wide to be successful. It must include all members of the healthcare team. C. Reviewing incident reports to identify what disciplinary action should occur would not be part of a patient safety program that aims for a non-threatening environment. D. Technology may be very useful to the program, but it is not essential to its success.

41- Which of the following steps occurs first in facilitating change in an organization? A. Identify problems to be addressed in the organization. B. Get feedback from management. C. Identify key people in the organization who should be involved. D. Develop a performance improvement plan.

EXPLANATIONS: A. Performance improvement methodology includes identifying issues and/or problems before taking action. B. Management feedback may be useful, but the problems should be identified first and feedback should be sought from all stakeholders. C. Identifying key people who should be involved is important, but those people cannot be selected until the problems have been identified. D. A performance improvement plan cannot be developed until the problems have been identified.

57- Physician profiles should be reviewed at time of reappointment to A. assess practitioner competency. B. compare the practitioner to their peers. C. review the number of complaints. D. facilitate reappointment approval.

EXPLANATIONS: A. Physician profiles demonstrate knowledge and skills through outcomes for individual practitioners. B. Comparisons are a component of physician profiles, but are not the main reason they are reviewed for reappointment. C. The number of complaints may be included in physician profiles, but this is not the main reason to review profiles. D. Physician profiles can help facilitate the reappointment process, but demonstrating physician competency is the reason for reviewing profiles.

34- A hospital is working to reduce readmissions. Which of the following is the best approach to accomplish this goal? A. giving an education sheet on patient medication to the patient and family B. having the patient provide return demonstration of the knowledge provided C. showing a video to a patient and their family D. requesting the home health nurse provide patient instruction EXPLANATIONS:

EXPLANATIONS: A. Providing an education sheet without an opportunity for dialogue is not sufficient. B. Return demonstration is an evidence-based approach for learning. C. Showing a video does not ensure that learning has occurred. D. Delaying instruction until the patient reaches homecare is not appropriate.

60- A facility decided to implement Standard Precautions 1 year ago, but compliance has been poor. In addition to assessing the causes for poor compliance, the most effective way for the organization to improve compliance is to A. stock personal protective equipment (PPE) in the clean utility room. B. initiate return demonstration as a part of staff competency. C. show a videotape on Standard Precautions quarterly. D. review and revise handwashing policies and procedures.

EXPLANATIONS: A. Providing equipment does not necessarily improve compliance. B. Including return demonstration in competency testing ensures that staff understand proper technique. C. Showing a videotape does not necessarily improve compliance. D. Reviewing and revising handwashing policies and procedures does not necessarily improve compliance.

4- Quality improvement teams are beneficial because they A. improve managerial control. B. promote competition and pride among members. C. maximize expertise and perspectives. D. authorize solutions to problems.

EXPLANATIONS: A. Quality improvement teams do not affect managerial control. B. Promoting competition is not a function of quality improvement teams. C. A diverse team, including members with different experience and backgrounds, provides a broader knowledge base and outcomes. D. Authorizing solutions to problems is a function of management.

31- Evaluating medication administration to reduce medical errors is an example of A. quality management. B. utilization management. C. risk management. D. financial management.

EXPLANATIONS: A. Quality management involves the process of achieving organizational performance improvement goals. B. Utilization management relates to utilization of resources. C. Improving patient safety, including error reduction, is the primary goal of risk management. D. Financial management involves the process of achieving organizational financial goals.

21- Which of the following are essential functions of an infection control program? A. risk management and surveillance B. prevention and education C. surveillance and prevention D. patient safety and risk management

EXPLANATIONS: A. Risk management is not an essential function of an infection control program. B. Education is a component of prevention, but is not an essential function of an infection control program by itself. C. Two principal functions of infection control are surveillance and prevention. D. Patient safety and risk management are not essential functions of an infection control program.

62- A critically ill patient is admitted and requires a specialized procedure; however, the surgeon does not have privileges at the facility. Which of the following documents will be most helpful in identifying the course of action the hospital should take? A. patient safety manual B. risk management plan C. medical staff bylaws D. surgical policies and procedures

EXPLANATIONS: A. See explanation C. B. See explanation C. C. Medical staff privilege rules are defined in the medical staff bylaws. D. See explanation C.

30- A number of specialty and primary care clinicians have participated in several meetings to develop clinical practice guidelines for the management of diabetes. The team leader has moved the team through the actual guideline development, and is now concentrating on the "evaluation of quality-of-care" phase. Which of the following sequences of steps should the team consider in developing the evaluation phase? A. identify medical review criteria, identify sampling methods to be used, define objectives of the performance review, pilot test B. develop data collection form, identify populations covered by the guideline, identify the data sources, conduct the review C. define objectives of the performance review, identify populations covered by the guideline, develop data collection form, pilot test D. consider costs of the review, identify clinicians and sites of care, define objectives of the performance review, develop data collection form

EXPLANATIONS: A. See explanation C. B. See explanation C. C. Objectives must be defined first. D. See explanation C.

7- The relationship between patient satisfaction and hours per patient day on a medical unit was found to be (r = 0.60, p < 0.05). What is the correlation between these two values? A. 0.05 B. 0.36 C. 0.55 D. 0.60

EXPLANATIONS: A. See explanation D. B. See explanation D. C. See explanation D. D. The correlation coefficient (r) is an index that ranges from -1.0 to 1.0 and reflects the extent of a linear relationship between two data sets. The correlation coefficient is 0.60.

22- A surgery department's monthly case review revealed 10 records meeting criteria and six additional records that did not meet the criteria. In calculating the incidence rate, the denominator is A. 4. B. 6. C. 10. D. 16.

EXPLANATIONS: A. See explanation D. B. See explanation D. C. See explanation D. D. The denominator is the total of all of the medical records, which equals 16.

45- A Quality Council has created a Patient Safety Council. The council is concerned that staff may see this as another program that has been added to their busy schedules that will eventually go away. The best way for the organization to establish patient safety as an ongoing part of the organization's culture is to A. display the number of incident reports monthly with lessons learned. B. identify the patient safety goals and how they will be monitored. C. make patient safety a part of the employees' job descriptions. D. include a presentation on patient safety in employee orientation.

EXPLANATIONS: A. Sharing risk data may help develop a patient safety program, but it will not change the culture of an organization. B. Identifying and monitoring goals is a necessary part of a patient safety program, but will not change the culture of an organization. C. Including patient safety in the job description provides a mechanism to hold employees accountable. D. Providing presentations on patient safety may be helpful, but is not the best way to change the culture of an organization

51- A patient is transferred to a neighboring hospital for a magnetic resonance imaging (MRI) exam. Due to a misinterpretation of orders, the procedure is performed on the wrong part of the body. Which of the following should the healthcare quality professional do? A. Report this as a sentinel event to the transferring hospital. B. Do nothing since it happened at another facility. C. Conduct an analysis to reduce future occurrences. D. Recommend disciplinary action for the offenders.

EXPLANATIONS: A. Simply reporting the event to the transferring hospital does not constitute an investigation. B. Performing a procedure on the wrong part of a patient's body is, by The Joint Commission definition, a sentinel event. Therefore, doing nothing is not the correct response, regardless of whether or not it occurred at another facility due to the fact the patient originated at the quality professional's facility. C. According to The Joint Commission definition, performing a procedure on the wrong patient or the wrong body part is a sentinel event. Any sentinel event that occurs, regardless if another facility is involved, must be investigated in an attempt to reduce further occurrences. D. Recommending disciplinary action would not be appropriate until the completion of the investigation determines its necessity.

29- A Quality Council has chartered a performance improvement team to reduce medication errors. The team has been meeting for several months and progress has been very slow. Which of the following is the most important factor for the Quality Council to assess with the team leader? A. composition of the team B. number of medication errors since team was chartered C. team members' ability to interpret graphs D. frequency of team meetings

EXPLANATIONS: A. The composition of the team is the most important factor and is often the main cause of team failure. Having the right team in place is essential. B. The number of medication errors is not relevant to the team's functionality. C. Interpreting graphs is a skill the team needs, but it is not as important as having the right team members. D. The frequency of meetings may need to be examined, but is not the most important factor

43- Two surveys were completed in a healthcare facility that showed conflicting results concerning patient satisfaction with food services. The two surveys were independently designed and distributed by different departments within the facility. The healthcare quality professional should first A. set up a quality improvement team to improve food service. B. distribute the surveys to obtain a larger sample size. C. design, distribute, and analyze a new survey instrument. D. meet with the departments to review the survey processes.

EXPLANATIONS: A. The data must be analyzed before action steps can be taken. B. A larger sample size may not be necessary. C. The current surveys should be investigated before creating a new survey. D. Reviewing the survey processes with the departments will help the understanding of the survey tools and the processes used

15- A team has identified a process for improvement, selected examples of best practice performers, visited those sites, gathered all necessary data, and compiled the results. The most effective next step for the team is to A. identify the next process to benchmark. B. implement change at the team's site. C. compare results to historical data. D. make the results public for others to use for benchmarking.

EXPLANATIONS: A. The first issue has not been resolved. It needs to be addressed before moving on to the next process. B. Implementation is the next step in the performance improvement cycle. C. All necessary data have already been compiled. D. The process has not been completed, so there is nothing to share at this point.

35- The evaluation of the quality and appropriateness of patient care in the radiology department is the responsibility of the A. medical director of radiology. B. chief medical officer. C. medical director of the quality department. D. administrator of clinical services.

EXPLANATIONS: A. The medical director of a department has the ultimate responsibility for everything within that department (care, quality, technology, etc.). B. The chief medical officer is responsible for facility-wide medical staff operations. C. The medical director of the quality department is responsible for activities within the quality department. D. The administrator of clinical services is responsible for facility-wide clinical activities.

27- A performance improvement training program has been conducted. The healthcare quality professional has determined that improvement has not occurred. The most likely cause for the lack of improvement would be that A. organizational systems are inhibiting changes. B. employees practice what they are trained to do. C. staff members thought the program was too long. D. the facilitator did not prepare agenda materials.

EXPLANATIONS: A. The most common failure of training programs is system challenges within the organization. There must be a culture that fosters safety as a priority for everyone within the organization. B. Employees practicing what they are trained for would lead to improvement and is one of the intended outcomes of a training program. C. While the employees' perception about the program may be that it was too long, it would not be the sole reason that improvement did not occur. This information could help to improve future training programs within the organization. D. The lack of agenda materials could have contributed to the lack of improvement, but would not be the sole cause.

33- The use of clinical pathways and guidelines in hospitals should A. minimize variation in patient care. B. reduce length of stay. C. improve patient satisfaction. D. identify errors in patient care.

EXPLANATIONS: A. The purpose of a clinical pathway and guideline is to standardize best practices. B. Reduced length of stay may occur as a result of minimizing variation in patient care. C. Improved patient satisfaction may occur as a result of minimizing variation in patient care. D. Identifying errors may occur as a result of minimizing variation in patient care.

16- A continuous quality improvement organization promotes vigorous education and training/retraining in order to A. restructure internal jobs. B. reduce the need for competency testing. C. promote harmony within the organization. D. acquire new knowledge and new skills.

EXPLANATIONS: A. The purpose of continuous quality improvement within an organization is to reduce risks and improve the quality of care and patient safety. Restructuring internal jobs would not be a result of a highly reliable organization with a continuous quality improvement program and processes. B. Continuous Quality Improvement (CQI) is a process of creating an environment in which management and workers strive to create constantly improving quality. A successful quality improvement program is one that inspires people to learn, but still requires competency testing. C. Promoting harmony is not a goal of continuous quality improvement. D. As the stem of the question identifies a component of continuous quality improvement as one that promotes education and training, this will yield new knowledge and skills.

38- An effective facilitator should be skilled in process evaluation and the tools of performance evaluation, and must A. not have a vested interest in the content. B. be in a salaried position. C. not speak unless directed by the team leader. D. be a front-line employee.

EXPLANATIONS: A. The role of the facilitator is to be the process expert and remain objective. B. See explanation A. C. See explanation A. D. See explanation A.

50- Which of the following is the first step in the strategic planning process? A. setting goals and objectives B. defining organizational structure C. determining productivity indicators D. establishing and controlling a budget

EXPLANATIONS: A. The strategic planning process is based on what the organization wants to achieve (i.e., goals and objectives). The quality professional might consider other possibilities as first steps, but those were not presented in the options. B. Organizational structure may not be a component of a strategic plan. C. Productivity indicators are measures of the progress made toward the goals and objectives. D. Budget determinations are made based on the goals and objectives.

13- Quality improvement team progress is best evaluated by which of the following? A. team leader B. senior leadership C. PDCA process D. nominal group technique

EXPLANATIONS: A. The team leader may be biased and is not the best source for team evaluations. B. Senior leadership is not usually involved in evaluating a team. C. The Plan, Do, Check, Act process is a comprehensive methodology used to conduct performance improvement activities, including the analysis of progress. D. The nominal group technique is a group decision-making process for generating a large number of ideas where each member works individually. This technique would not be helpful in evaluating team progress.

8- Hospital A has recently merged with Hospital B. After 6 months, it is noted that Hospital A has successfully transitioned their staff to new organizational values, while Hospital B still struggles. Hospital A's success can best be attributed to A. requiring adoption of new values by all staff. B. support of both hospitals' mission statements. C. acceptance of the new mission and vision statements. D. integrating technology and databases.

EXPLANATIONS: A. There is not enough information provided to show that the values were adopted by all staff. B. Support of two mission statements could be confusing to staff and would not lead to an integrated organization. C. Acceptance of the new mission and vision statements demonstrates integration of the two facilities. D. Values are not dependent on the integration of technology and databases.

55- A re-engineering effort occurred at a facility. The activities, particularly those regarding staff layoffs, were carefully planned, communicated, and implemented according to the plan. One year later, the business is stable but staff morale is very low. A healthcare quality professional has been asked to consult in determining where the effort went wrong. Based on the concepts of change theory, the cause is most likely A. that the re-engineering decision was a mistake. B. a failure to address the needs of the staff who were retained. C. leadership was not properly trained in the change process. D. a few disgruntled staff are instigating dissension in the ranks.

EXPLANATIONS: A. There is not enough information to determine whether the re- engineering was a mistake. B. Addressing the needs of the retained staff is important for staff morale, "buy-in," or ownership of the change. C. Improperly trained leadership may be a component of the issues, but not necessarily the cause of low staff morale. D. Having disgruntled staff may be a component of the issues, but there is not enough information to determine whether this has occurred.

14- To reduce the incidence of ventilator-associated pneumonia (VAP) in a critical care unit, who should be included on a quality improvement team? A. intensivist, ICU nurse, and respiratory therapist B. primary care physician, infection control nurse, and surgeon C. ICU manager, respiratory therapist, and pharmacist D. pharmacist, intensivist, and infection control nurse

EXPLANATIONS: A. Intensive-care medicine or critical-care medicine is concerned with the provision of life support or organ support systems in patients who are critically ill and who usually require intensive monitoring. In this scenario, the healthcare quality professional would involve staff that would most commonly be related to the care of a patient with VAP. The involvement of the intensivist, ICU nurse, and respiratory therapist would be considered common, and would comprise the ideal and appropriate team to care for a patient with VAP. B. While the primary care physician may be involved, it is not common practice for the infection control nurse/preventionist to be involved in the daily care of a patient with VAP. C. While the ICU manager and pharmacist could be involved in the care of a patient with VAP, they would not be ideal members of a quality improvement team. D. While the pharmacist, intensivist, and infection control nurse/practitioner could be part of the VAP quality improvement team, this response is not ideal as it does not include the respiratory therapist or ICU nurse.

Multivoting

Easy, quick method for determining the most popular or important items from a list. Method uses a series of votes to cut down items to be considereded

-Which of the following is most appropriate in preparation for an external survey of a healthcare facility?

Educate staff about the types of questions they may be asked.

Humanistic Outcomes

Efficacy, Effectiveness, Efficiency and Acceptability

What are the seven Pillars of Quality?

Efficacy, Effectiveness, Efficiency, Acceptability, Optimality, Equity,Equity, Legitimacy Legitimacy

Reengineering.

Efforts focused on work force redesign or on the restructuring of systems and departments into more efficient processes.

Lean

Emphasizes reducing waste and housing on actives that add value for the customer -applies value stream mapping and root cause analysis -uses cross functional teams -eliminates waste in area such as production, waiting time, transporting, and processing -customer defines value

Occupational Safety and Health Administration (OSHA)

Establishes requirements for environmental safety programs such as: -management of blood borne pathogens -prevention of TB transmission -keeping patient areas clear of food/drink -annual posting of staff injury logs

H E&CF Chart

Events and Causal Factors: Used to find root causes. Combines a flowchart and affinity diagram to identify both the sequence of events and relevant conditions affecting each event.

K51 EMB

Evidence-based medicine (EBM), also called evidence-based health care (EBHC) or Evidence-based practice (EBP) to broaden its application to allied health care professionals, has been defined as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

K64 Evaluation of QM/PI

Evolution of PI, Processes and Outcomes 1) At least annually, but ongoing evaluation is better 2) Process effectiveness 3) Outcome effectiveness 4) Component process effectiveness 5) Other methods & Tools

I-37 Special Cause Variation

Extrinsic to usual process Can be tracked (assigned) to root causes Sentinel event, or unique Produce a majority of "outliers" Respond: Case-specific focused review and root cause analysis Eliminate bad, make good "best practice"

Which of the following team members is responsible for keeping meetings focused?

Facilitator

K55 FMEA

Failure Mode Effectiveness Analysis: aka HFMEA 1) Proactive 2) Identifies and improves steps in a process to reasonable ensure a safe can clinically desirable outcome 3) Steps (a) Describe and understand the process - flowchart current process (macro)

H FMEA

Failure Mode and Effects Analysis: A team-based quality improvement tool hat prospectively assesses, identifies, and improves steps in a process to reasonably ensure a safe and clinically desirable outcome [NCPS]: A systematic mechanism to identify and prevent product and process failures before they occur.

FMEA

Failure modes and effects analysis is a step-by-step approach for identifying all possible failures in a design, a manufacturing or assembly process, or a product or service. "Failure modes" means the ways, or modes, in which something might fail. (PROACTIVE/high risk process, creating or revising)

Patient Safety and Quality Improvement Act of 2005 (PSQIA)

Federal law that provides privilege and confidential protections for patient safety work products.

I-38 Statistical Process Control {SPC}

First remove assignable/special cause variation. Then perform in-depth analysis / Graphic comparisons.

k26 Ishikawa Diagram

Fishbone | Cause and Effect | Herringbone Diagram | Causes are usually grouped into major categories to identify the sources of variation. e.g. people, methods, machines, materials, measurements, environment.

I GIGO

Garbage in, Garbage out. The quality of the output is a function of the quality of the input.

Empowerment

Giving employees the authority and information they need to make wise recommendations or decisions and solve problems.

Flowchart or Process Flowchart

Graphic display of a process as it is known to the authors -outlines a sequence and relationships of the pieces and processes -use as part of an RCA or FMEA

Run Chart

Graphical display of data plotted in some type of order, generally time -also known as a trend chart or time series chart -tool for understanding variation -can display more then one measure on chart

I-42 NCQI

Health Care Quality Indicators Project (NCQI): 2003 Organization for Economic Cooperation and Development (OECD) - 23 counties - 86 indicators

I Protected Health Information

Health information that contains information such that an individual person can be identified as the subject of that information. [TJC]

I-42 HEDIS 2011

Healthcare Effectiveness Data and Information Set - required by NCQA for accreditation score.

H Quality Healthcare

Healthcare that is "...accessible, effective, safe, accountable, and fair..." AHRQ

H HAI

Healthcare-Associated Infection: Replaces "nosocomial infection" (hospital-acquired) because it implies all health care and is not limited to hospitals. {More general Healthcare-Acquired Conditions {HAC}}

H Monitoring and Evaluation

Historically a data collection process that focused on high-priority quality-of-care issues and was designed to facilitate problem solving and the identification of opportunities to improve.

Just-in-time training

Historically been a tool used in readiness programs. This education is timed to be provided not too far in advance of an anticipated survey, so as not to run the risk of staff or leaders forgetting the information prior to survey, and not too close to the survey, when staff and leaders may become overwhelmed with information.

I-42 HCAHPS

Hospital Consumer Assessment of Healthcare Providers and Systems Survey - 27 patient experience of care measures.

Define nosocomial

Hospital acquired infection

Global Trigger Tool

IHI developed tool that uses triggers (clues) to identify adverse events through retrospective review of patients' medical records.

Triple Aim

Improve care, Improve population health, and reduce costs

Florence Nightingale and quality

In 1863, she noticed that patients seemed to fare better in some London hospitals than others. She was the first to call for systematic inquiry into the nature of care processes that could be related to outcome variability.

Severity of Harm.

In a failure mode and effects analysis, an estimation of how serious the effects or harm would be if a given failure did occur.

I-10 IPA

Independent Practice Association: HMO contracts with IPA. The IPA contracts with individual doctors. Allows doctors to remain "independent" in their practice, but to negotiate with payers as a group (like a union).

Institute for Healthcare Improvement (IHI)

Independent organization that partners to improve the health of individuals and populations 5 Key Areas 1. Improvement capability 2. Person and Family Centered care 3. Patient safety 4. Quality, Cost, and Value 5. Triple aim for populations

Transformational Leader

Leader is able to inspire others to change expectations and motivations to work toward common goals.

Transactional Leader

Leader views the leader-follower relationship as a process of exchange where compliance or performance is achieved through the process of giving rewards and punishment.

What is benchmarking?

Looking at data from different sources and making comparisons.

Standard Deviation.

Measure of variability-average of devotions from the mean -standard: average spread of scores around the mean -deviation: how much each score is scattered from the mean

Diagnostic error

Mistake occurs when a condition is misidentified or and indicated test is not performed.

Balanced Scorecard (BSC).

Must reflect organizations strategic goals and objectives and provide status of progress towards goal attainment The BSC helps organizations better link long-term strategy with short-term activities.

I-41 NCQA

Nation Committee for Quality Assurance has contract with CMS to oversee the Health Outcomes Survey {HOS}. Medicare Advantage plans contract with NCQA-certified vendor to perform HOS component Of Healthcare Effectiveness Data and Information Set {HEDIS}

What is NCQA? and it what 3 ways does it evaluate healthcare?

National Committee for Quality Assurance -Accredits, certifies and recognizes healthcare organizations, services and providers

I-42 NQMC

National Quality Measures Clearing House is sponsored by Agency for Healthcare Research and Quality {AHRQ}. Can search for National Quality Forum {NQF}-Endorsed measures among others.

What is not the responsibility of a CPHQ in regards to patient safety program

Not responsible for enforcing any rules for the patient safety program

National Committee for Quality Assurance (NCQA)

Offers 6 accreditation, 5 certification, and 5 physical recognition programs Organizations pass a rigorous, comprehensive review and annually report on their performance -reports HEDIS

Healthcare accreditation

Official authorization or approval, or recognition for conforming to standards, or to recognize as outstanding.

Common-Cause variation

On a control chart, this type of variation is exhibited as points between the control limits in no particular pattern.

A facility is becoming part of a healthcare network. Which of the following employee education programs is most important?

Organizational Change

Learning Organization

Organizations that are continually learning through the use of personal mastery, shared vision, mental models, team learning, and systems thinking.

Utilization Managment

Organized, comprehensive approach to analyzing, directing, and conserving organization resources -goal to facilitate delivery of high-quality, low-cost, efficient, and effective care to patients -response to changing needs/expectations of customers, healthcare changes, and technology advances

In medical staff credentialing, which of the following sources is NOT appropriate for primary source verification?

Original medical school diploma provided by the practitioner

Statistical Quality Control (SQC)

Originated in the 1940's secondary to manufactures attempting to meet deadlines in lieu of quality

Rapid Cycle Improvement goal

Participating organizations can learn from other organizations successes and failures.

Traditional Retrospective Payment

Pays providers after services have been provided

H Reappraisal

Periodic reevaluation by peers of a practitioner's competency to provide care and services to patients in or for a healthcare organization. Reappraisal may include re-credentialing, re-privileging, proctoring for a new privilege, profiling, peer review, and reappointment.

Privileging

Permission to provide specific medical al of other patient care services in the granting organization, within well-defined limits, based on the individual's professional license and his or her experience, competence, ability, and judgement and on the organization's ability to provide and support the service.

Plan-Do-Check-Act

Plan- Question the capacity or capability of a process. Pose theories on how to improve the process and predict measurable outcomes. Do- Make changes on a experimental, pilot basis Check- Measure outcomes compare to predicted outcomes Act- Implement the changes on a broad scale

A performance improvement team aims to reduce the rate of post-surgical infection rates in a small rural acute care facility. Which of the following should the team use as a reference? The post-surgical infection rates among individual surgeons. Postoperative antibiotic use among the surgeons. National benchmark post-surgical infection rates based on the most recent research. Post-surgical infection rates in similar facilities.

Post-surgical infection rates in similar facilities.

Capitation

Prepayment for services with a fixed number of dollars per month (PMPM) on a per-person rather than a per-procedure basis, regardless of the amount of care the member/patient receives.

What are the two types of sampling?

Probability and Nonproability sampling

H Gantt Chart

Project planning tool for developing schedules; a graphic display of individual parts of a quality improvement process as bars on a horizontal time scale.

Episodes of Care Reimbursement

Providers receive one lump sum for all services related to a condition/disease

fee-for-service

Providers receive payment for each service provided

Bar Code Medication Administration (BCMA)

Purpose is to eliminate wrong medication to wrong patient

K46 QM - Juran - PI {crosswalk}

QP - Planning - Design QC - Measure before - Monitor + "Analyze" QI - Measure before - "Analyze" QI - Implement - Improve (QC+QI - Measure after - Monitor + Analyze)

Resistance (in regard to change)

Really an attraction to factors in the current system that we might not fully understand or appreciate. Resistance is a natural, potentially changeable, reaction of a system attracted to something else.

Healthcare certification

Recognition for meeting special qualifications within a field.

I Privacy

Referring to information, the right of an individual to limit the disclosure of personal information. [TJC]

Effective Performance and Process Improvement

Requires: -involvement of top-down leadership -value of every associate -continuous improvement -customer focus

health plan is required to have a mechanism for members to submit complaints. Which of the following actions must be included in the complaint analysis to ensure the plan makes full use of this type of information?

Review complaints to find system problems that can be improved.

Six-Sigma

Rigorous methodology that uses data and statistical analysis to measure and improve performance. Six-sigma is based on the concept of the normal distribution or curve and the belief that there is 0.6 standard deviations from the mean at which there should be almost zero defects. Error rates should not exceed 3.4 defects per million opportunities

Probability Sampling.

Sampling that requires every element in the population to have an equal or random chance of being selected for inclusion in the sample.

Probability Sampling

Sampling that requires every element in the population to have an equal or random chance of being selected for inclusion in the sample. -simple random sampling -systematic random sampling -stratified random sampling

Reappointment

Selection for continued membership in a medical/professional staff (e.g. hospital or medical group) or to a practitioner panel (e.g. preferred provider organization), based on reappraisal.

H Appointment

Selection for membership in a medical professional staff or to a practitioner panel.

On which of the following areas should a trend analysis of incidents at an acute care facility focus?

Severity level and occurrence types

I SMTP

Simple Mail Transfer Protocol: An internet protocol used for transferring electronic messages.

Objectives.

Specific statements that detail how goals will be achieved; they therefore are relatively narrow and concrete. Objectives represent the organization's commitment to achieving specific outcomes.

H CQI

System that seeks to improve services with an emphasis on future results. Like total quality management, CQI uses a set of statistical tools to understand subsystems and uncover problems, but its emphasis is on maintaining quality in the future, not just controlling a process. Once a process that needs improvement is identified, a team of knowledgeable individuals is gathered to research and document each step of that process. Once specific expectations and the means to measure them have been established, implementation aims at preventing future failures and involves the setting of goals, education, and the measurement of results.

I-9 TJC

The Joint Commission: In 2002 changed from What & Who to How & Results (process & outcomes)

Mission

The organization's purpose or reason for existing.

Customer

The person or entity that receives the process, product, or service and therefore defines the quality of products or services received. Customer focus is a value central to any improvement initiative.

Strategy.

The plans and activities developed by an organization in pursuit of its goals and objectives, particularly in regard to positioning itself to meet external demands relative to its competition.

Knowledge Management

The process of collecting information about the spread with the measurement and feedback component for modifying the spread process as necessary; focuses on the knowledge that people need to do their work, improve services, remain current with changing needs, and develop innovative solutions.

Cost-Benefit Analysis

The process of placing monetary values (dollars) on all costs associated with outputs (actual and predicted) and on all benefits (to patient/member and organization) to assist in comparing different interventions and selecting which programs or services to provide.

Work Motivation.

The psychological forces that determine the direction of a person's behavior in an organization, a person's level of effort, and a person's level of persistence.

Structure.

The resources available for care delivery (e.g., the qualifications of practitioners and the facilities and technology available to them).

Outcome

The result(s) or effect(s) of the performance or non-performance of one or more functions or processes. Represents the cumulative effect of one or more processes on a patient at a defined point in time.

Credentialing and Quality Oversight

The role of quality is to: -give input into each process -track oversight activities -ensure work is completed -manage quality files for review and reappointment

Culture

The set of shared attitudes, values, goals, and practices that characterizes a company or corporation. A system of beliefs and actions that characterize a particular group. Culture also refers to norms of behavior and shared values among a group of people. The social "glue" that holds people together. At the heart of culture is the notion of shared values (what is important) and behavioral "norms" (the way things are done). Cultures are described as strong when the core values are intensely held and widely shared.

H Management

The sum of the activities of: planning, organizing, staffing, directing, coordinating, and working to improve human and material resources toward the achievement of stated goals.

Integration

The systematic coordination of key management functions concerned with the planning and design of quality processes, as well as the measurement, analysis, and improvement of patient care and services provided by the organization.

Performing

The team reaches the performing stage, when hard work leads, without friction, to the achievement of the team's goal. The structures and processes that you have set up support this well. As leader, you can delegate much of your work, and you can concentrate on developing team members. It feels easy to be part of the team at this stage, and people who join or leave won't disrupt performance.

I Authentication

The validation of correctness for both the information itself and the person who is the author or user of information. [TJC]

H Failure Mode

The way a process can fail to function or fail to provide the desired result; an undesirable variation in a process.

Failure Mode

The way that a process or sub-process can fail to function or fail to provide the desired result; an undesirable variation in a process.

H Plan

The written document describing a particular program and all associated structures, processes, and activities. e.g. Quality Management (III), Utilization Management (III), Risk Management (III), Information Management (V), Organizational Plan for Patient Care Services (II), Corporate Compliance Plan (III).

Symbols.

Things that represent an idea. The purpose of symbols is to reflect the culture, trigger values and norms, and help people make sense of their organization.

Capitation

Third party payer reimburses providers a fixed per capita amount for a period (PMPM or Per Member Per Month)

What is the role of quality personnel?

To provide consultative support to the governing body and medical staff regarding their roles and responsibilities in quality oversight.

H TQM

Total Quality Management: A broad management philosophy, espousing quality and leadership commitment, that provides the energy and the rationale for implementation of the process of Continuous Quality Improvement (CQI) within the organization wide Quality Management Strategy.

Routine self-assessment

The ability to evaluate compliance of key regulatory and accreditation requirements and a cornerstone of a continuous readiness program

Leadership

The ability to influence an individual or group toward achievement of goals. -Leaders cope with change by developing a vision and aligning subsystems

Reversibility.

The ability to stop the adoption or use of the innovation and return to a normal or "safe" position if the innovation is not effective.

Data

The abstract representation of things, facts, concepts, and instructions that are stored in a defined format and structure on a passive medium (e.g., paper, computer, microfilm).

Values.

The beliefs and philosophy within an organization that establish the basis for the operation and provide guidelines for daily behavior.

Evidence-based

The best external evidence available, i.e., scientific research findings

Benchmarking

The comparison of an organization's or an individual practitioner's results against a reference point. Ideally, the reference point is a demonstrated best practice

Evidence-Based Medicine and Practice

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

Evidence-based medicine

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

Coaching

The consultative, collaborative interaction of at least two people, characterized by advocacy and encouragement

K56 Benchmarking 3

The continual process of measuring practices and services against the performance of recognized leaders at a particular function, regardless of "industry standard". [Brown]

Continuity of Care

The coordination of needed healthcare services for a patient or specified population among all practitioners and across all involved provider organizations over time.

Effectiveness

The degree to which a desired outcome is reached; the degree to which care is provided in the correct manner, given the current state of knowledge, to meet the expected outcome.

Compatibility

The degree to which an innovation is perceived as being consistent with the existing values, experiences, beliefs, and needs of potential adopters.

Relative Advantage.

The degree to which an innovation is perceived as better than the idea it supersedes.

Simplicity.

The degree to which an innovation is perceived as simple to understand and use.

Appropriateness

The degree to which care is "correct" and relevant to the patient's clinical needs, given the current state of knowledge.

Safety

The degree to which the healthcare environment is free from danger of hazard; the degree to which the healthcare intervention minimizes risks of adverse outcome for both patient and provider.

Observability or Visibility

The degree to which the use of an innovation and the results it produces are visible to those who should consider it.

Interrater Reliability

The degree to which two raters, operating independently, assign the same ratings

Interrater Reliability

The degree to which two raters, operating independently, assign the same ratings in the context of observational research or in coding qualitative materials

Range

The difference between the highest and lowest values in a distribution of scores; usually expressed as a maximum and minimum. -provides quick estimate of variability

Performance

The effective execution or accomplishment of important functions and processes, with particular focus on those that increase the probability of desired outcomes; what is done and how well it is done to provide healthcare.

Reliability

The extent to which an instrument yields the same result on repeated trials.

Reliability

The extent to which an instrument yields the same results on repeated trials.

The Institute of Medicine (IOM) defines healthcare quality as

The extent to which health services provided to individuals and patient populations improve desired health outcomes. Care should be based on the strongest clinical evidence and provided in a technically and culturally competent manner characterized by good communication and shared decision making.

Criterion-Related Validity

The extent to which the score on the instrument can be related to a criterion (the behavior that the instrument is supposed to predict). Can be either predictive or concurrent.

Criterion-Related Validity

The extent to which the score on the instrument can be related to a criterion (the behavior that the instrument is supposed to predict). Can be either predictive or concurrent. -EX: risk adjustment scales are tool used to measure morbidity and mortality

Nonparametric test

Used with categorical or count data includes: chi-square

Acceptability

Usefulness of the service to the patient and its perceived impact on his/her quality.

k8 Value

Value = {Quality + Outcome} / Cost

Centers for Medicare and Medicaid Services (CMS

The federal government agency within the U.S. Department of Health and Human Services that is accountable for Medicare, Medicaid, and state Children's Health Improvement Programs (CHIPs); formerly the Health Care Financing Administration (HCFA).

Risk identification

The first step to determine what risks can affect the achievement of organizational goals.

Empowerment.

The giving away of power traditionally held by the manager. It typically involves a higher level of information sharing, decision making, and problem solving at the level closest to the situation, and shared recognition

H Organization Leaders

The group of individuals that sets expectations, develops plans and implements procedures to assess and improve the quality of the organization's governance, management, clinical, and support functions and processes.

I Nonrepudiation

The inability to dispute a document's content or authorship. The handshake includes acknowledgement that the data was received... The ability to ensure that e-commerce participants do not deny (i.e. repudiate) their online actions.

Competency

The individual's ability to produce both the health and satisfaction of patients, as applicable, and meet the needs and expectations of other customers; performance related to stated requirements and to professional standards of care and practice.

Management accountability for compliance

The management team provides operational oversight within an organization and is key to ensuring continuous compliance within its areas of compliance.

Median.

The measure of central tendency that corresponds to the middle score; that is, the point on a numerical scale above which and below which 50 percent of the cases fall

Effectiveness

What extent does the service achieve its intended outcomes in a real world environment.

When do you use a scatter diagram?

When you want to determine if there is a relationship between two variables.

force field analysis

_________ analysis is a development in social science. It provides a framework for looking at the factors that influence a situation, originally social situations. It looks at forces that are either driving movement toward a goal or blocking movement toward a goal.

Continuous variable

__________ variables are numeric variables that have an infinite number of values between any two values. A continuous variable can be numeric or date/time. For example, the length of a part or the date and time a payment is received.

Consecutive Sampling

___________ sampling is very similar to convenience sampling except that it seeks to include ALL accessible subjects as part of the sample. This non-probability sampling technique can be considered as the best of all non-probability samples because it includes all subjects that are available that makes the sample a better representation of the entire population.

laissez-faire leader

a hands-off leader who allows members of the group to make their own decisions; little guidance or control

Quota Sampling.

a judgement is made about the most representative sample

autocratic leader

a leader who has control and makes decisions with little or no consultation with others; independently

Democratic leadership style

a leadership style in which managers work with employees to make decisions

reliability coefficient

also known as correlation coefficient. -numerical index of comparison's reliability -greater than 0.70 acceptable r=

-A physician complains to the healthcare quality professional that the nursing staff did not strictly follow orders for a patient. The physician requests that the healthcare quality professional speak with the nurse manager. To facilitate improved communication, the healthcare quality professional should

arrange a meeting with the physician and nurse manager.

Regression analysis

based on statistical correlations, associated among variables -one variable (x) used to predict second variable (y) -similar to a scatter diagram -hight the correlation, the more accurate the degree of prediction r=__________

self-directed team

best for a project that requires a measure of autonomy and can complete tasks with limited oversight

In the development of department-specific performance indicators, the healthcare quality professional in her role as a consultant should

conduct a literature search and select appropriate quality indicators

Facility A is investigating its medication administration time for a specific diagnosis. Evidence-based guidelines indicate that administration of a particular drug within 30 minutes significantly improves patient outcomes. The national average is 32 minutes. The average for Facility B is 28 minutes. If the average for Facility A is 35 minutes, Facility A should

contact Facility B to determine its practices

When developing a strategic plan that integrates patient safety, which of the following factors is most critical?

culture of performance improvement

The success of a performance improvement program will be most influenced by the

culture of the organization.

-The perception of how an organization operates, including how employees relate to internal and external customers, is the organizational

culture.

A valid data collection tool should incorporate

definition of data elements

Medical staff By-laws

delineate how medical staff will organize and govern

Pareto charts are most appropriately used for

determining priorities among contributing factors.

consultative leader

discuss issues with workers but retain the final authority for decision making; presents a decision and then welcomes input and discussion from staff

Computerized Physician Order Entry (CPOE)

electronic entry process for physicians or practitioners to create patient treatment instructions -Purpose: designed to eliminate handwriting issues and control medication selection choices by providers

Provisional Hospital Privileges

enables someone to practice as a provider with certain restrictions imposed. Applies to individuals who do not meet requirements for full credentialing

A monitoring system is being designed in which data will be collected and compared to criteria. Which of the following will best enhance the validity and reliability of the data?

establishing criteria that are based on the most recent changes in medical science and technology

Quality improvement teams are responsible for all of the following EXCEPT

establishing the need for the team

A hospital has recently moved to a paperless system. It is noted that some data is missing from the obstetrics delivery record. A healthcare quality professional should recommend

evaluating the computerized data entry process.

comparison

examine processes and results against a reference point either internally or externally with competitors and other organizations providing similar services

Models of Reimbursement

fee-for-service, traditional retrospective payment, managed care reimbursement, episode of care reimbursement, capitation, prospective payment

following three categories are normally used to calculate a criticality index

frequency, severity, and ease of detection

A major drawback of using raw data to present the results of quality monitoring is that they

lack proper reference points for interpretation.

The utilization management committee is reviewing length-of-stay data for a particular procedure. In comparing data by physician, which of the following statistics would be most useful?

mean

A federally certified electronic health record (EHR) with the capacity for e-prescribing, electronic exchange of health information, and submission of healthcare quality measures meets

meaningful use requirements

Process Measures

measures of process improvement. They tell whether the parts or steps in the system are performing as planned. (timely administration of prophylactic surgical antibiotics)

Chi-square (χ2) test.

measures the significance of a difference in proportions -conceptually same as t-test(analyzes difference in 2 means) -most commonly reported statistical test in the medical literature.

Center for Improvement in Healthcare Quality (CIHQ)

membership based organization comprised of acute care and critical access hospitals CMS deemed for acute care hospitals

Histogram Chart

or frequency plot. -presents information about one measured variable in 6-12 groups that are equal and mutually exclusive (no overlap) -continuous data -shows the distribution of data collected -does NOT tell you if process is stable

Informed consent for hip surgery was obtained and documented for an elderly patient. In the recovery room, a nurse discovered the wrong hip had been replaced. A healthcare quality professional should

perform a root cause analysis.

a nurse discovered the wrong hip had been replaced. A healthcare quality professional should

perform a root cause analysis.

An annual evaluation of a laboratory's quality program identified no opportunities for improvement. Which of the following elements of the program should be reviewed?

performance indicators

A healthcare entity initiating re-structuring must consider the impact on staff to ensure the greatest opportunity for success by

planning carefully, communicating openly, and leading effectively.

A healthcare quality professional wants to develop a continuous survey readiness model. The initial step should be

planning education for the entire team.

Which of the following obstetrical outcomes would result in a morbidity review?

post-delivery septicemia

Human Factors Engineering

practice of designing products, systems, or processes to take proper account of the interaction between them and the people that use them -attempts to design systems to optimize safety and minimize risk of error in complex environments

A healthcare quality professional is conducting a study to determine how many patients contracted influenza after receiving flu shots. This study is evaluating

prevalence.

Balanced scorecards are useful because they

put strategy and vision at the center of an organization's effort

Magnet Designation

recognizes excellence in nursing. 5 model components transformational leadership, empowerment, exemplary professional practice, innovation, and empirical quality results)

corporate compliance

requires adherence to state and federal regulations, and legal and ethical standards. provided by the Officer of Inspector general of HHS

-In profiling length-of-stay data for benchmarking, it is important that data be

severity adjusted.

Data Collection plans

should identify the who, what, when, where, how, and why. Internal data sources are just-in-time and external data sources can be dated

Risk adjustment

technique used to take into account or to control the fact that different patients with the same diagnosis may have additional conditions or characteristics that can affect how well they respond to treatment. Risk-increasing variables reflect that a patient has a high probability of dying.

Benchmarking

the comparison of an organizations or an individual practitioners results against a reference point. Benchmarking enables the organization to set a target or goal for its performance improvement activities.

Human factors engineering is defined as the study of humans and their interaction with

the tools they use and the environment.

Leaders enhance employee commitment to organizational values by fostering which of the following types of communication?

timely, open, two-way

Ongoing Professional Practice Evaluation (OPPE)

to demonstrate ongoing competency in delivering safe, effective care -used to determine whether to continue, limit, or revoke existing privileges

The phrase "reaching consensus" is often used in performance improvement. The term consensus refers to

unanimous agreement

Satisfaction surveys, focus groups, and complaint tracking are tools used to

understand customers' expectations.

Pareto Diagram or Pareto Chart.

used to focus improvement efforts -display the 80/20 rule -categories ordered from most frequently occurring to least frequently occurring on x axis

Parametric test

used with data measured on a continuous scale includes: T-test and regression analysis

Transitions of Care

when a patient moves from one health care provider or setting to another

H Performance Improvement

"The continuous study and adaptation of a healthcare organization's functions and processes to increase the probability of achieving desired outcomes and to better meet the needs of individuals and other users of services." "Data collection and analysis for the purpose of providing an indication of the organization's performance on a specified process of outcome."

Patient-Centered Medical Home (PCMH)

"a model of the organization of primary care that delivers the core functions of primary health care"-patient centered, comprehensive, coordinated, accessible, continuously improved.

Sentinel Event

-Adverse outcome identified that involves death, or serious physical or psychological injury -Patient safety event that reaches a patient and results in death, permanent harm, severe temporary harm, and/or intervention required to sustain life

Steering Committee/Quality Council Responsibilities

-Develop and approve quality program and plan -Maintain organizational focus on goals/priorities -foster teamwork for improvements -provide necessary resources -formulate policies -look at processes, not individuals

Preferred Provider Organization (PPO)

-Health plan contracts with a network of preferred providers to provide services at a reduced fee -Do not need PCP

Storming

-people start to push against the boundaries Storming often starts where there is a conflict between team members' natural working styles. Some may question the worth of the team's goal, and they may resist taking on tasks.

National Qualify Forum (NQF)

-voluntary consensus standards-setting organization

K53 Clinical Process Reviews

1) Indication / Appropriateness (physicians) 2) Preparation / Dispensing 3) Administration / Performance 4) Monitor Effects 5) Patient education (with procedures) 6) Sample Size (a) 5% or 30 whichever is greater

I-13 QM use of Information

1) Integration of Data/Information 2) Coordination of improvement efforts 3) Timely effective communication

K56 Benchmarking 1

1) Locate a peer organization with good results that you can communicate with and emulate 2) Learn what steps your peer implemented to improve performance 3) Decide what steps to implement in your organization

H Quality

1) Measurable: Compliance with, or adherence to, standards (or performance measures). 2) Appreciative: The comprehension and appraisal of excellence beyond minimal standards and criteria, based on training and expertise. 3) Perceptive: The degree of excellence that is perceived by the recipient or observer of care rather than by the provider. 4) An organizational definition: "Quality is meeting or exceeding expectations at a cost that represents value to the customer."

k3 Committee Meeting Organization

1) Meeting Date 2) Agenda 3) Packets 4) Meeting 5) Minutes 6) Reminders

I-18 Integrated QM

1) Organized around "important organization functions" 2) All processes: (a)Governance (b)) Managerial (c) Support Activities (d) Clinical Activities 3) Cost, Quality, Risk 4) All caregivers in CP/PG involved in improvement

H Quality Management

1) Quality Planning: Identifying, measuring, and prioritizing customer needs and expectations concerning the process and its outcomes: setting quality improvement goals. As needed; designing, defining, and developing the function/service/process capable of producing the desired outcome. 2) Quality Control/Measurement: Measuring the current performance and its variance form expected or intended performance; measuring key processes and outcomes, prerequisite to prioritizing for quality improvement and/or quality planning; describing variability in processes. 3) Quality Improvement: Using collaborative efforts and teams to study and improve specific existing processes at all levels in the organization.

K35 Medical Errors - Commission v Omission

1) Unintentional preventable mistakes in provision of care which may or may not harm the patient 2) Act of Commission (doing something wrong) or Omission (failing to do something) 3) IOM Report: "To Err is Human: Building a Safer Healthcare System"

K39 Financial Management

1)Financial planning 2) Financial Monitoring to execute budget 3) Analysis & Reporting 4) Definition of Financial Management (a) Operation Budget (b) Analysis/Variance reports 5) Definition of Financial Planning (a) Capital Budget Planning involves creating both the Operating and Capital budgets. Monitoring is analyzing the money spent to see if matches the planned budget.

I-19 QM Principles 1-5

1)Productive work is accomplished through processes 2) Sound customer-supplier relationships are necessary for quality management 3) The main source of quality defects is problems in the process 4) Poor quality is costly 5) Understanding the variability of processes is key to improving quality

1. Which of the following is the best definition of "vision" in regards to creating an organizational vision statement? a. The ability to see the future b. An ideal future state c. A realistic action plan for future performance d. An outline of future organizational purpose

1. B: In the creation of an organizational vision statement, vision is a description—realistic or not—of an ideal future state. This description of an ideal future state gives shape to the goals of an organization. A vision statement does not involve detailed descriptions about the specific actions necessary for bringing the vision to fruition.

What 5 criteria should be met in order to consider a condition for a condition to be assessed in a quality assessment?

1. Be common condition or have significant effect on morbidity or mortality. 2. Scientific evidence for treating effects or preventing the condition. 3. The improvement in the quality of treatment for the condition will improve overall health. 4. Have cost-effective interventions. 5. The interventions for the condition should be susceptible to significant influence by health care providers.

Triple Aim for healthcare delivery

1. Ensure the quality of care for the individual 2. improve the health of the population 3. Control costs.

Quality information management process

1. Identify current available data sources 2. Identify critical information needs 3. Define data elements 4. Determine data collection plan 5. Acquire/collect data 6. Aggregate and display data 7. Analyze data 8. Interpret data/information 9. Act on informatin 10. Report data 11. Collect more data to monitor and analyze decision

In the information management process what are the critical steps in a data plan?

1. Identify current available data sources. 2. Interpret critical information needs. 3. Define data elements. 4. Determine data collection plan. 5. Acquire/collect data 6. Aggregate and display data. 7. Analyze data 8. Interpret data/information 9. Act on information 10. Report data/information/knowledge/decision 11. Collect more data to monitor/analyze the decision.

Quality Role in Patient Safety

1. Incident Report Review (record of facilities unusual occurrences) 2. Sentinel/Unexpected Event Review 3. Patient Safety Goals (Review and measure adherence to accreditation and regulatory bodies and own internal goals) 4. Patient Safety Improvement Team (Facilitate patient safety improvement teams to analyze safety issues and recommend improvements)

Use a Pareto diagram when

1. It is important to know where to focus improvement efforts 2.It is important to focus on problems or causes of variation 3. You need to identify the most frequent or most important factors contributing to cost, problems, etc.

Use a run chart to

1. display variation over time 2. Detect presence or absence of special cause variation 3. Observe effects of process improvement 4. Identify problems 5. Analyze data and evaluate outcomes

121. Wh#t role does perform#nce improvement d#t# pl#y in the #ppointment/privilege deline#tion process? #. Perform#nce improvement #nd #ppointment/privilege deline#tion #re unrel#ted. b. Perform#nce improvement should be required for #ppointment/privilege eligibility. c. Perform#nce improvement should t#ke pl#ce #fter #ppointment/privilege deline#tion. d. Perform#nce improvement oversight should be the job of # newly-#dv#nced employee.

121. B: Perform#nce improvement, #s demonstr#ted over time with #n org#niz#tion, should be # required element for #ppointment/privilege deline#tion bec#use it gives #n ide# of # providerʼs commitment to #n org#niz#tion #nd to qu#lity.

How long does significant change take to implement?

18-24 months

19. Who should be considered when developing process requirements within # he#lthc#re org#niz#tion? #. P#tients b. Intern#l customers c. St#keholders d. All of the #bove

19. D: P#tients, intern#l customers, #nd st#keholders should #ll be considered when developing process requirements within # he#lthc#re org#niz#tion.

2. A patient care team is in disagreement over new admissions procedures. What decision-making model should management use? a. Decision criteria b. Consensus c. Invocation d. Tenure influence

2. A: Decision criteria is a decision-making model th#t explores all options equ#lly and gives unorthodox or unpopul#r options a fair ch#nce, even when they #re under dispute. Consensus is not the best choice bec#use this #ppro#ch often reduces decisions to options th#t everyone likes #nd discounts the unorthodox or unpopul#r options th#t could be #ppropri#te #nd vi#ble.

27. Wh#t ch#llenge often occurs with the use of #ggreg#ted d#t#? #. The numbers become too l#rge to comprehend. b. Context is lost #nd solutions #re not identified. c. Imperson#lity #nd v#gueness #re not eng#ging. d. Speci#l interpreters #re needed for underst#nding.

27. B: When d#t# #re #ggreg#ted, one of the biggest ch#llenges is the loss of context, which m#kes specific solutions h#rd to identify.

37. In # quest to improve p#tient s#tisf#ction d#t#, Clinic A is cre#ting # p#tient survey. Which of the following #re#s should be the focus of the survey? #. Physic#l needs b. Emotion#l needs c. Soci#l needs d. All of the #bove

37. D: A good p#tient survey will #ddress the physic#l, emotion#l, #nd soci#l needs of the p#tient to give # provider # complete picture of how the p#tientʼs needs c#n best be met.

45. Who developed the N#tion#l P#tient S#fety Go#ls (NPSGs)? #. The Le#pfrog Group b. HCAHPS c. Centers for Dise#se Control (CDC) d. The Joint Commission

45. D: The Joint Commission cre#ted the N#tion#l P#tient S#fety Go#ls (NPSGs) to improve p#tient s#fety n#tionwide.

How many points in a up or down direction does there need to be for a trend in a run chart?

5 points

65. Wh#t is the m#n#gement term for # comprehensive expression of #n org#niz#tionʼs identity #nd purpose? #. Vision st#tement b. Mission st#tement c. Cultur#l st#tement d. Org#niz#tion#l st#tement

65. B: A mission st#tement is # comprehensive expression of #n org#niz#tionʼs identity #nd purpose.

Spaghetti Diagram

Also called a layout diagram, is a graphic representation of the flow of traffic or movement

Management

Doing the correct things to stay on the path towards goal achievement -managers cope with complexity through planning and budgeting

-The primary purpose of integrating financial and quality management information is to

identify problems in resource management.

H Leadership Group

"Individuals in senior positions with clearly defined, unique responsibilities." Possible groups include governance, management, medical staff, nursing, other clinical staff. An individual may be a member of more than one group.

H Indicator

"Performance Measure": Includes data definitions, as well as numerator and denominator statements, to accurately specify what is being measured.

nonprobability sampling

-It is not possible to estimate the probability that every element is included -Convenience sampling -Snowball sampling -purposive/judgement sampling

18. In # l#rge hospit#l setting, which of the following represents #n intern#l customer? #. An #dmitted p#tient b. A physic#l ther#py dep#rtment #ssist#nt c. A medic#l equipment supplier d. A p#tientʼs f#mily

18. B: A physic#l ther#py dep#rtment #ssist#nt is #n intern#l customer bec#use he or she works within the org#niz#tion#l structure. The other choices #ll represent extern#l customers.

61. After three wrong-site surgeries in one ye#r, Hospit#l A determined # need to ch#nge preoper#tive pr#ctices to help elimin#te this issue. Their best response would be... #. Suggesting surgeons double check p#tient ch#rts prior to surgery. b. Firing #nd repl#cing #ll involved surgic#l st#ff #nd support personnel. c. Cre#ting written procedures m#nd#ting better preoper#tive communic#tion. d. Highlighting surgic#l notes in p#tient ch#rts for e#sier #ccess.

61. C: Cre#ting written policies m#nd#ting better pre-surgic#l communic#tion would be the best response to the errors.

64. Who is responsible for p#tient s#fety in # he#lthc#re org#niz#tion? #. The p#tient s#fety officer b. Administr#tors #nd m#n#gers c. A #nd B d. All members of #n org#niz#tion

64. D: All members of #n org#niz#tion, no m#tter their title or job duties, #re responsible for p#tient s#fety.

Goal

A broad, general statement specifying a purpose or desired outcome; -may be more abstract than an objective -one goal can have several objectives Establishing a goal is the initial step in the strategic planning process and sets the direction for the activities to follow.

t test.

A test used to analyze the difference between two means to determine whether the difference between them is significant; a distinction must be made regarding the two groups.

Procedural Justice.

A theory of motivation that focuses on fairness with respect to processes or procedures used to allocate outcomes.

What does a 'deemed' status mean?

Accreditation equivalency with CMS

Instruments

Devices that healthcare quality professionals and researchers use to obtain and record the data received from the subjects (e.g., questionnaires, rating scales, and interview transcripts)

Test

Did you get this

I-37 Common Cause Variation

Contribute to "normal variation" Find chronic problems Find persistent "best practices"

Which of the following is an example of a leadership strategy to integrate the patient safety program into the organization's overall performance improvement system?

Apply failure mode and effects analysis (FMEA) in the healthcare system

Fitness for use

As explained in the Juran Triology, the cost of quality accounting means that there is a break-even point of less than 100%. Beyond a certain point, the cost of providing quality exceeds the value of the incremental improvement in quality.

Quality Improvement Organization (QIO)

As part of the DHHS national Quality Strategy, replaced the PROs and is dedicated to improving health quality for Medicare beneficences.

k21 Special Cause Variation

Assignable/ Special Cause - Extrinsic {Sentinel Event are always "Special Cause"} 1) Investigate (a) if good then make standard (b) if bad then change process to eliminate

What should not be included in a curriculm for organizational change?

Budgeting Techniques

10- A Failure Mode and Effects Analysis (FMEA) is performed A. to immediately investigate an incident that occurred. B. as a preventative measure before an incident occurs. C. if the severity of an incident led to a patient death. D. when there is a chance of an incident reoccurring.

EXPLANATIONS: A. The FMEA process is performed before an incident occurs. B. The FMEA process is a proactive, systematic method of identifying and preventing incidents from occurring. C. The FMEA process examines severity, but before an incident or a death occurs. D. The FMEA process examines the likelihood of occurrence, but before an incident occurs.

Lean methodology

Includes the application of value-stream analysis (a tool for exposing wastes), and root-cause analysis (method for pursuing perfection). Major focus is to eliminate wastes in the following ares, production, waiting time, inappropriate processing, inventory, transporting, and defects.

H Appraisal

Initial evaluation by peers of a practitioner's competency to provide care and services to patients in or for a healthcare origination. Appraisal may include credentialing, privileging, proctoring and appointment.

H Negligence

Lack of proper care, as judged by peers. A person who alleges negligent medical malpractice must prove four elements: (1) a duty of care was owed by the physician; (2) the physician violated the applicable standard of care; (3) the person suffered a compensable injury; and (4) the injury was caused in fact and proximately caused by the substandard conduct. The burden of proving these elements is on the plaintiff in a malpractice lawsuit.

Participative leader

Leader allows employees some degree of autonomy in completing their work while maintaining some control of the group and the decision-making process; leader seeks input from employees and serves as facilitator

H Organizational Ethics

Management of relationships with patients and the public under a set of principles of right conduct; conduct of business with patients and the public with respect, honesty, and integrity; and recognition and acceptance of responsibilities under law.

H Integrated Delivery System - Horizontal

Multi-institutional entity with coordinated functions, activities, or operating units that are at the same stage or segment of the continuum of care, e.g., hospital system.

I-41 NGC

National Guidelines Clearinghouse AHRQ, AMA, AHIP >2,300 evidence based clinical practice guidelines

Pay for Performance.

Provides bonus to health care providers if they meet or exceed agreed upon quality or performance measures -may also reward improvement over time

Who is responsible for the effectiveness of quality improvement and patient safety?

The governing body (board of directors)

Risk Management.

Strategies deployed to protect the organization from financial losses that may arise because of the risks to which it is exposed.

I-19 Basic QM Principles

TQM: Total Quality Management CQI: Continuous Quality Improvement

Process Decision Program Charts (PDPC)

The PDPC is used to understand a goal in relation to the steps for getting to the goal.

Mission

The or ganization's purpose or reason for existing. A mission statement answers such questions as "Why are we here?" "Whom do we serve?" and "What do we do?"

Mode

The score or value that occurs most frequently in a distribution of scores.

Performance Management.

The use of performance management information to effect positive change in organizational culture, systems, and processes by helping to set agreed-upon performance goals, allocating and prioritizing resources, informing managers to either confirm or change current policy or program direction to meet those goals, and sharing results of performance in pursuing those goals.

Activity Network Diagram

Through the use of the arrow diagram, a sequence of events is depicted from start to finish. It is useful when several simultaneous paths must be coordinated. -determine the time duration of each task -calculate the shortest possible time to complete the next project

Temporary hospital Privileges

Time limited (no more then 120 day) granted by CEO

Discrete variable

_________ variables are numeric variables that have a countable number of values between any two values. A discrete variable is always numeric. For example, the number of customer complaints or the number of flaws or defects.

Non-probability sampling

__________ sampling is a sampling technique where the samples are gathered in a process that does not give all the individuals in the population equal chances of being selected.

Hoshin Planning

a component of the total quality management/quality improvement system used to ensure that the vision set forth by top management is being translated into planning objectives. -Deployment or roll down to departments to develop plans including targets and means- Heart of Hoshin Planning

Effective peer review process will include the following

consistency, defensibly, balance,

-One aspect of a quality process that integrates with risk management is the review and evaluation of

adverse drug events.

Quantitative

data is information about quantities; that is, information that can be measured and written down with numbers ________variables can be classified as discrete or continuous Numbers

Decision Support System

deal with strategic planning -marketing, resource allocation, performance evaluation and monitoring, product evaluation and services

A consulting firm has been selected by a facility's quality professional to assess the quality improvement program. Before starting the assessment, the quality professional should

define expectations and outcomes.