Exam 2 (Practice Questions)

Piloting innovation The pilot phase of an improvement project occurs before the spread effort, as a prerequisite. The improvement team will initiate a spread plan only if the pilot is successful.

Which of the following is NOT one of the key components of the IHI Framework for Spread? (A) Piloting innovation (B) Better ideas (C) Setup (D) Social system

Unfreezing, changing, re-freezing Kurt Lewin wrote that successful change efforts involve preparing people for the change ("unfreezing"), helping them transition ("changing"), and ensuring that the new process becomes the norm ("re-freezing").

Which of the following is a summary of Kurt Lewin's model of change? (A) Introduction, testing, implementation (B) Research, communication, measurement (C) Unfreezing, changing, re-freezing (D) Collaboration, integration, standardization

3. No mention of the nursing position authority It is critical that job descriptions for nursing positions provide information relative to the nurse's authority, responsibility, and accountability for delegation. Delineation of roles and responsibilities, a listing of tasks that the nurse can complete, and a listing of minimum qualifications for the nursing position could be included in a job description.

A group of nurse managers are reviewing a new job description for a staff nurse on a medical-surgical unit. Which observation if found would indicate that the job description needs revision with regard to delegation? 1. Delineation of roles and responsibilities 2. A listing of tasks that the nurse can complete 3. No mention of the nursing position authority 4. Listing of minimum qualifications for the nursing position

1. "Individuals become eligible for Medicare at 65 years of age." 3. "The individual must have paid into the Medicare Trust Fund while employed." Currently, individuals must be 65 to be eligible for Medicare and must have paid into the Medicare Trust Fund to be eligible to receive it. A person must work 10 years, not 5 years, to be eligible for Medicare, and Medicaid is available to disabled children and low income individuals below the age of 65.

A nondisabled client who will turn 65 years of age in 6 months asks the nurse about Medicare. Which statements by the nurse are true concerning Medicare eligibility? Select all that apply. 1. "Individuals become eligible for Medicare at 65 years of age." 2. "To be eligible for Medicare, an individual must have worked a minimum of 5 years." 3. "The individual must have paid into the Medicare Trust Fund while employed." 4. "Children who are disabled are eligible for Medicare." 5. "Medicare is available for all persons who have low income."

4. Inability for health insurers to deny service due to pre-existing conditions The ability of young people to remain on their parent's health insurance has increased the number of young people who are able to continue to have health care, but after the age of 26 it does not increase these individuals' access to health insurance. The inclusion of preventative services has increased access to specific services but has not led to an overall increase in access to health insurance. The imposition of tax has not been shown to increase access to health care because currently the tax is still less than the yearly premiums needed for health insurance in many cases.

A nurse educator is discussing the implementation of the Patient Protection and Affordable Care Act and shares with the students which aspect of the law that has had a major impact on access to health insurance? 1. Individuals may remain on a parent's health insurance until the age of 26. 2. Inclusion of preventative services such as mammograms 3. Imposition of a tax on persons without health insurance 4. Inability for health insurers to deny service due to pre-existing conditions

1. Once a task has been delegated, the nurse is absolved of responsibility. Inherent in the delegation of tasks with regard to right supervision or evaluation, the nurse who has delegated the tasks remains responsible and accountable for completion. If this statement was made, it clearly indicates that the staff nurse requires additional training in this area. The other statements referring to providing feedback, giving clear directions, and monitoring performance of the delegated tasks demonstrate the concept is understood.

A nurse manager is educating a staff nurse with regard to the five rights of delegation. Which statement by the staff nurse indicates that additional training is needed with regard to right supervision or evaluation? 1. Once a task has been delegated, the nurse is absolved of responsibility. 2. Nurses should provide feedback relative to task completion. 3. It is important to provide clear directions relative to task delegation. 4. Performance of the delegated task should be monitored.

1. The clinic is staffed primarily by volunteers. 3. The clinic will need to rely on contributions or grants for funding. Clinics that operate as free or reduced cost for the uninsured and the underinsured are very limited in scope and location and, for the most part, are also uncompensated. Funding comes most of the time from personal contributions or grants. It is usually staffed by volunteers and will have very limited hours because of this. The clinic will not be subject to the EMTALA Act (Emergency Medical Treatment and Labor Act) because the clinic would not be receiving Medicare funds.

A parish nurse is working with a local faith community to open a reduced-cost/free clinic for patients with limited or no insurance coverage. The nurse explains to the group that this type of health-care organization has which characteristics? Select all that apply. 1. The clinic is staffed primarily by volunteers. 2. The clinic will be able to offer many services. 3. The clinic will need to rely on contributions or grants for funding. 4. The clinic is subject to the EMTALA Act. 5. The clinic can expect to be open 7 days/week.

2. Possibility of a delegate-related barrier Refusal by a delegate to perform a task may represent that the delegate is uncomfortable with the procedure, or is feeling overworked, or may be unable to perform the task physically. Underdelegation is when the delegator assumes all or most of the tasks remaining to be the sole one responsible for providing care. Overdelegation is when a delegator delegates most or all tasks to a delegate. There is no information provided here in this scenario that indicates multiple tasks have been provided. Possibility of a delegator-related barrier is not supported in this scenario for the RN has elected to delegate a task.

A physician has ordered a rectal suppository to be administered to a 25-year-old male patient. The registered nurse (RN) delegates this task to the licensed practical nurse (LPN). The LPN would prefer not to complete this task. The RN tells the nurse manager about this issue. How would the nurse manager interpret this refusal by the LPN to perform a delegated task? 1. Underdelegation 2. Possibility of a delegate-related barrier 3. Overdelegation 4. Possibility of a delegator-related barrier

3. The UAP told the RN that she was going to obtain the specimen from the patient after lunch. Right communication refers to providing clear and concise information between both delegator and the delegate. The RN following up by checking the patient's chart and monitoring the task completion process is an example of right supervision. The RN delegating the task itself to the UAP is an example of the delegation process.

A registered nurse (RN) delegated specimen collection to an unlicensed assistive personnel (UAP) for a patient who had a urine analysis ordered by the physician. The UAP did not obtain the specimen. When checking the patient's chart later in the shift, the RN noticed that there was no documentation that a urine specimen was collected. The RN asked the UAP to provide an explanation for why the specimen was not obtained. The UAP told the RN that she was going to obtain the specimen from the patient after lunch. Which stated action would correlate with the delegation right of right communication? 1. The RN followed up later in the shift checking the patient's chart for documentation of the specimen collection. 2. The RN delegated the task to the UAP. 3. The UAP told the RN that she was going to obtain the specimen from the patient after lunch. 4. The RN monitored the task completion process.

2. Performing a pain assessment In terms of delegation, the registered nurse can use delegation to improve delivery of care to patients by allowing some patient care tasks to be provided by other licensed or nonlicensed personnel. In this care, the RN is delegating aspects of patient care to a CNA. As this individual is a nonlicensed person, the RN should never delegate patient assessment as that remains within the role and responsibility of the RN. Positioning the patient for comfort, assisting the patient with transfers, and offering the patient hydration can be performed by the CNA.

A registered nurse (RN) is working on a medical-surgical unit functioning as a team leader for five patients with a licensed practical nurse (LPN) and a certified nurse's aide (CNA). Which action should not be delegated to the CNA? 1. Positioning the patient for comfort by raising the head of the bed 2. Performing a pain assessment 3. Assisting the patient with transfer from bed to chair 4. Offering the patient fluids

1. Underdelegation This is an example of underdelegation, whereby the nurse may feel that she represents the best individual to accomplish and provide patient care. Effective delegation would require appropriate use of task delegation based on the five rights of delegation—right task, right person, right circumstance, right direction or communication, and right supervision. Overdelegation is when all tasks are delegated to others. Right person is one of the five rights of delegation, and while the RN in question may well feel that she is the best person to do the job, the process of delegation implies that tasks will be delegated to others.

A registered nurse (RN) refuses to delegate any patient care tasks to other members of the nursing unit staff preferring to complete all tasks herself. What type of delegation practice would this demonstrate? 1. Underdelegation 2. Effective delegation 3. Overdelegation 4. Recognition of right person

Innovator Because she needs to be the first to use the technology, even before the distributor has had a chance to work out all the kinks, your neighbor is showing characteristics of an innovator.

A well-known tech company is releasing a new phone/computer/printer/food processor combo, and your neighbor has already signed up to beta test the device. Nothing like it is on the market, and the media hype about the product is huge — although the news is the product still has some problems. What type of adopter is your neighbor? (A) Innovator (B) Early majority (C) Late majority (D) Laggard

All of the above The best answer is all of the above. In his book The Limits of Organizational Change, Herbert Kaufman identified all of these as potential barriers to implementing change in health care.

According to Herbert Kaufman, which of the following are reasons health care workers commonly resist change? (A) The expected autonomy of health care workers (B) A real or perceived limit on resources (C) An accumulation of policies, procedures, regulations (D) All of the above

Compatible One characteristic of ideas that spread naturally is compatibility — that is, they are consistent with the existing values, experiences, beliefs, and needs of potential adopters. The other four characteristics, according to Everett Rogers, are relative advantage, trialability, simplicity, and observability.

According to sociologist Everett Rogers' attributes of spreadable ideas, ideas that spread naturally are: (A) Complex (B) Comprehensive (C) Compatible (D) Conceivable

Trialable One characteristic of ideas that spread naturally is trialability — that is, there is the opportunity for people to test the idea in a safe setting. The other four characteristics, according to Everett Rogers, are relative advantage, compatibility, simplicity, and observability.

According to sociologist Everett Rogers' attributes of spreadable ideas, ideas that spread naturally are: (A) Trialable (B) Complex (C) Intriguing (D) Groundbreaking

Ask staff to give daily feedback, to assess progress along the way. The best answer is to solicit daily feedback. One key factor in IHI's Framework for Spread is knowledge management, which includes gathering information about the spread process as it unfolds. Waiting a year to gather feedback is too long.

An innovation in the United States that is spreading is the concept of a "medical home." Medical homes are meant to be a comprehensive, integrated approach to primary care. The people developing medical homes believe that providing care this way will improve access, patient satisfaction, and patient-centeredness — and improve clinical outcomes. Implementing a medical home involves redesigning the clinic system on a large scale and changing many behaviors of the staff and providers. As of yet, there is limited and conflicting data about whether medical homes lead to improved clinical outcomes. ABC Medical Center's leadership team has implemented the medical home model in one pilot site. Now the team wants to spread the innovation to other sites, and it is using IHI's Framework for Spread. Which of the following should the spread team do? (A) Ask staff to give daily feedback, to assess progress along the way. (B) Avoid asking staff for feedback at any point, to convey that the new system is mandatory. (C) Ask staff for feedback on the idea prior to implementation only, to encourage and then enforce staff buy-in. (D) Ask staff to try the new system for a year before giving feedback, so they have time to adjust to the new system before critiquing it.

None of the above The best answer is "none of the above." Implementing an entirely new clinic system is quite complex, making this a difficult innovation to spread. Improved outcomes may take time to appear and may not be easily observable, which could also slow spread. Finally, because this innovation involves a large-scale system change in most cases, it is difficult to test this easily and in a safe setting. This analysis does not imply that the medical home is not an improvement — only that it may be more difficult to spread than less complicated innovations.

An innovation in the United States that is spreading is the concept of a "medical home." Medical homes are meant to be a comprehensive, integrated approach to primary care. The people developing medical homes believe that providing care this way will improve access, patient satisfaction, and patient-centeredness — and improve clinical outcomes. Implementing a medical home involves redesigning the clinic system on a large scale and changing many behaviors of the staff and providers. As of yet, there is limited and conflicting data about whether medical homes lead to improved clinical outcomes. Which of the following is an accurate statement about the spread of this innovation? (A) This innovation has a high degree of simplicity, so it is likely to spread quickly. (B) Because the relative advantage of this new care model is highly apparent, it is likely to spread quickly. (C) There are obvious and low-cost ways to make this innovation more "observable," which might help it spread more quickly. (D) None of the above

The complexity of the change involved will likely slow the spread of this innovation. Implementing an entirely new clinic system is quite complex, making this a difficult innovation to spread. Improved outcomes may take time to appear and may not be easily observable, which could also slow spread. Finally, because this innovation involves a large-scale system change in most cases, it is difficult to test this easily and in a safe setting. This analysis does not imply that the medical home is not an improvement — only that it may be more difficult to spread than less complicated innovations.

An innovation in the United States that is spreading is the concept of a "medical home." Medical homes are meant to be a comprehensive, integrated approach to primary care. The people developing medical homes believe that providing care this way will improve access, patient satisfaction, and patient-centeredness — and improve clinical outcomes. Implementing a medical home involves redesigning the clinic system on a large scale and changing many behaviors of the staff and providers. As of yet, there is limited and conflicting data about whether medical homes lead to improved clinical outcomes. Which of the following is an accurate statement about the spread of this innovation? (A) This innovation has a high degree of simplicity, so it is likely to spread quickly. (B) Because the relative advantage of this new care model is highly apparent, it is likely to spread quickly. (D) The complexity of the change involved will likely slow the spread of this innovation. (E) There are obvious and low-cost ways to make this innovation more "trialable," which might help it spread more quickly.

(D) 80 percent According to The Joint Commission, an estimated 80 percent of serious medical errors can be linked to miscommunication between caregivers when patients are transferred or "handed-over."

Approximately what percentage of serious adverse events in health care can be linked to miscommunication between caregivers when patients are transferred or "handed-over"? (A) 5 percent (B) 20 percent (C) 50 percent (D) 80 percent

(C) The team routinely takes a moment to discuss the plan and voice concerns before doing a procedure. One of the main characteristics of strong health care teams is effective and frequent communication. The absence of unprofessional behavior (Answer A) does not necessarily mean the team is effective. And the failure to share information during shift changes is risky for patients (Answer B).

As a nurse practitioner in a small, rural urgent care clinic, you believe that your clinic team works well together. Which of the following facts would best support your belief? (A) Not a single complaint about unprofessional behavior has been filed by clinic members over the past year. (B) The providers work in rotating shifts and rarely need to transmit information from one shift to the next. (C) The team routinely takes a moment to discuss the plan and voice concerns before doing a procedure. (D) All of the above.

All of the above. The best answer is "all of the above." After a successful pilot, the next steps are implementation and spread. IHI's Framework for Spread, which includes developing a communication and dissemination plan, is a helpful tool to use during the final phase of an improvement project.

Dr. Gonsalvez, the medical director of the medicine ward, wants to lower the 30-day readmission rate of the patients on her unit (i.e., the percentage of patients readmitted to the hospital within 30 days of discharge). She meets with the nurse manager and other stakeholders, and, together, they develop a process to improve the way the ward discharges patients and transfers care back to each patient's primary care provider. The team tests the change on the ward and runs multiple PDSA cycles to improve the process. The data look promising.

Pilot The team has just completed the improvement stage that consists of early, rapid-cycle tests of change: the pilot phase.

Dr. Gonsalvez, the medical director of the medicine ward, wants to lower the 30-day readmission rate of the patients on her unit (i.e., the percentage of patients readmitted to the hospital within 30 days of discharge). She meets with the nurse manager and other stakeholders, and, together, they develop a process to improve the way the ward discharges patients and transfers care back to each patient's primary care provider. The team tests the change on the ward and runs multiple PDSA cycles to improve the process. The data look promising. What improvement project phase have Dr. Gonsalvez and her team just completed? (A) Spread (B) Pilot (C) Implementation (D) Planning

(D) A and C The best answer is A and C. Effective health care teams have a shared goal and effective two-way communication. The membership of the team may change frequently (Answer B), and it's quite possible for a health care team to consist of people who have never worked together before.

Effective health care teams have several important characteristics, including: (A) Common goals, like a choir or a sports team (B) Stable membership; that is, they have the same people on the team from day-to-day. (C) Effective communication techniques. (D) A and C

(C) Effective communication techniques Effective health care teams have a shared goal and effective two-way communication. The membership of the team may change frequently (Answer B), and it's quite possible for a health care team to consist of people who have never worked together before (Answer A). That makes strong, two-way communication a critical part of delivering safe care.

Effective health care teams have several important characteristics, including: (A) The ability to rehearse procedures together, like a choir or a sports team. (B) Stable membership; that is, they have the same people on the team from day-to-day. (C) Effective communication techniques. (D) The ability to achieve good results without strong communication.

Includes SBAR, briefings, and debriefings. Effective structured communication, such as SBAR, briefings, and debriefings, can help teams develop clear and appropriate care plans. These tools can keep important information from getting lost or disregarded in the decision making process. Everyone on the team can benefit from these tools — and anyone on the team can initiate their use.

Effective structured communication: (A) Must be initiated by the team leader. (B) Includes SBAR, briefings, and debriefings. (C) Is more important for nurses than for physicians. (D) Includes email, text messaging, and debriefings.

(C) Seek input from all members of the team. Effective team leaders are not necessarily the ones with the most training, the most degrees, or the highest salary. And they don't always have all the answers. They do, however, seek feedback from all team members, recognizing that one person can't provide safe care alone.

Effective team leaders: (A) Have multiple degrees. (B) Are usually physicians. (C) Seek input from all members of the team. (D) Know the correct answer in any given situation.

Human behavior Although technology and funding may be necessary for some people to accept change, human behavior is present in any change effort and must be addressed for the change to be effective.

For people to accept change, you MUST address which of the following in change efforts? (A) Technology (B) Funding (C) Human behavior (D) A, B (E) B, C

The handoff was too brief and failed to include important information. This short, recorded handoff was brief and did not include important information about the patient's background, such as her stroke and her communication challenges. The use of SBAR — with its explicit inclusion of background information — might have made this handoff more effective. Verbal repeat back, while very useful, would not necessarily have helped you uncover the key information you needed in this case.

How might the transition between providers ("hand-over") have contributed to this situation? (A) The handoff was too brief and failed to include important information. (B) The handoff was hard to understand. (C) You weren't paying close attention to the information you were being given. (D) You had no opportunity for verbal repeat back

Is not meant to be prescriptive, but a guide IHI's Framework for Spread, which identifies seven key steps to help an innovation spread through a social system, is not meant to be prescriptive, but a guide. It does not focus specifically on the financial implications of the change.

IHI's Framework for Spread: (A) Identifies 12 components to consider when developing a spread strategy (B) Helps you assess the financial implications of spreading change (C) Is not meant to be prescriptive, but a guide (D) A and B

The planned nap The process change is the planned nap. It is the method by which the organization hopes to decrease worker fatigue.

Imagine that your health care organization is trying to reduce worker fatigue. Your improvement team is working on a planned nap program in which you offer the opportunity for staff members working a shift of more than 12 hours to take a planned nap. You have identified a designated room for the nap, and you have communicated with the staff about the importance of rest in ensuring patient safety. Unfortunately, data reveal that workers are not taking advantage of the program. Your team is frustrated, because this program worked at another hospital in a neighboring town. In the example, which of the following is a process change? (A) The planned nap (B) The data that show whether staff members are taking a planned nap (C) The belief that a planned nap can support patient safety (D) None of the above

Share data that shows the process change is associated with a decrease in adverse events. The best answer is to share data that shows the process change is associated with a decrease in adverse events. Many people find compelling data to be persuasive. Some people are more motivated by stories. However, the story needs to be directly related to the change in order to be persuasive.

Imagine that your health care organization is trying to reduce worker fatigue. Your improvement team is working on a planned nap program in which you offer the opportunity for staff members working a shift of more than 12 hours to take a planned nap. You have identified a designated room for the nap, and you have communicated with the staff about the importance of rest in ensuring patient safety. Unfortunately, data reveal that workers are not taking advantage of the program. Your team is frustrated, because this program worked at another hospital in a neighboring town. What would be a good way for the team to respond to the resistance to the change? (A) Share data that shows the process change is associated with a decrease in adverse events. (B) Abandon the idea. (C) Tell a story about a patient whom medical science was able to save. (D) A, B

The culture of the organization did not support napping during a shift. The program probably failed because the culture of the organization did not support napping on the job as a way to decrease worker fatigue and boost patient safety.

Imagine that your health care organization is trying to reduce worker fatigue. Your improvement team is working on a planned nap program in which you offer the opportunity for staff members working a shift of more than 12 hours to take a planned nap. You have identified a designated room for the nap, and you have communicated with the staff about the importance of rest in ensuring patient safety. Unfortunately, data reveal that workers are not taking advantage of the program. Your team is frustrated, because this program worked at another hospital in a neighboring town. What's the likeliest reason the program failed? (A) The nap wasn't long enough. (B) The room for the nap was too noisy. (C) The culture of the organization did not support napping during a shift. (D) Workers weren't as tired as managers thought they were.

The belief that a planned nap can support patient safety The culture change is the fundamental belief that a planned nap can support patient safety and that napping is okay during a shift.

Imagine that your health care organization is trying to reduce worker fatigue. Your improvement team is working on a planned nap program in which you offer the opportunity for staff members working a shift of more than 12 hours to take a planned nap. You have identified a designated room for the nap, and you have communicated with the staff about the importance of rest in ensuring patient safety. Unfortunately, data reveal that workers are not taking advantage of the program. Your team is frustrated, because this program worked at another hospital in a neighboring town. Which of the following represents a culture change? (A) The planned nap (B) The designated room for the nap (C) The staff education about the nap (D) The belief that a planned nap can support patient safety

Have a mix of different types of people on the team A healthy mix of personality types helps ensure a team captures many perspectives on an issue.

In designing a performance improvement team, it is helpful to: (A) Choose people who are unlikely to disagree with one another (B) Have a mix of different types of people on the team (C) Have everyone on the team exhibit similar personality preferences (D) All of the above

Are a type of structured communication. Briefings are short, structured meetings in which the entire team comes together to talk about a patient, procedure, or situation that the team is about to encounter. Briefings are a very effective way to ensure that everyone knows what should happen next for a patient. In many organizations, briefings include many members of the care team beyond doctors and nurses — such as social workers, respiratory therapists, and other clinicians. Briefings take place before an event, while debriefings take place after an event.

In health care, briefings: (A) Are of limited effectiveness. (B) Are a type of structured communication. (C) Involve only doctors and nurses. (D) Need to take place as soon after an event as possible, to maximize learning for the entire group.

(A) Ineffective teams can contribute to unsafe events and situations. Ineffective teams can contribute to unsafe events and situations as much as having no team at all. Conversely, effective teams — teams whose members communicate often and reciprocally — act as a kind of "safety net" that can help prevent errors resulting from one member's fatigue or distraction, for instance. Effective teams may still use technology often, and it's likely that patients and families will encounter many members of the team.

One reason it's critical for caregivers to improve their teams' effectiveness is: (A) Ineffective teams can contribute to unsafe events and situations. (B) Effective teams limit the number of caregivers patients have to speak with, reducing confusion among patients and families. (C) Teams rely less on technology and more on human capabilities, thus leading to better care. (D) All of the above

1. "The RN told me that I couldn't obtain a urine specimen from a patient." With regard to delegation by an RN to an UAP, UAPs are allowed to obtain specimen collection. Therefore, the nursing staff would require additional instruction in what can and cannot be delegated. The other options are within the scope of practice for the UAP and do not reflect any inconsistency with delegation of tasks.

Nonlicensed staff members (unlicensed assistive personnel [UAP]) have asked for a meeting with the nurse manager as they are unhappy with how some of the nursing staff (Registered Nurse [RN]) has been delegating tasks with regard to patient care. Which statement if made by a nonlicensed staff member would indicate that additional instruction is needed for the nursing staff with regard to effective delegation principles? 1. "The RN told me that I couldn't obtain a urine specimen from a patient." 2. "I was told by the RN that I had to wait until the order was written in the patient's chart before I could act on it." 3. "The RN told me that I should wait until after lunch before I gave the patient AM care as the patient had just been medicated for pain." 4. "The RN told me that I had to change all of the bed linen for the patients before I went home at the end of the shift."

3. Interprofessional Interprofessional refers to members with specific disciplinary training and diverse perspectives working collaboratively in planning and implementing patient-centered care. It is thought to be more inclusive of all members of the health-care team. Multidisciplinary describes a team in which members function independently and then share information with each other. QSEN calls for team members to be collaborative in planning and implementation. Interdisciplinary refers to teams that cooperate, collaborate, communicate, and integrate care, but QSEN calls for team members to be collaborative in the planning and implementation. Customized care refers to the type of care that should be provided to patients, not the way in which the team should function to provide that care.

Nurses are aware that the Quality and Safety Education in Nursing (QSEN) competency, Teamwork and Collaboration, requires what specific type of collaboration? 1. Multidisciplinary 2. Interdisciplinary 3. Interprofessional 4. Customized care

(A) Effective teams reduce the risk of errors by providing a "safety net" for individual caregivers. Effective teams — teams whose members communicate often and reciprocally — act as a kind of "safety net" that can help prevent errors resulting from one member's fatigue or distraction, for instance. Effective teams may still use technology often, and it's likely that patients and families will encounter many members of the team.

One reason it's critical for caregivers to improve their teams' effectiveness is: (A) Effective teams reduce the risk of errors by providing a "safety net" for individual caregivers. (B) Effective teams limit the number of caregivers patients have to speak with, reducing confusion among patients and families. (C) Teams rely less on technology and more on human capabilities, thus leading to better care. (D) All of the above

Identify the personalities present and work to everyone's strengths. Personality and work style profile assessments help us understand how different people prefer to perceive the world and make decisions. This can be valuable — particularly if team leaders appreciate these differences and design the work to accommodate diverse preferences.

Personality and work style profile assessments can help to: (A) Identify the personalities present and work to everyone's strengths. (B) Identify why some people will never respond well to change. (C) Determine who has the right expertise to be on an improvement team. (D) A and C

All of the above The best answer is "all of the above." The Seton Family of Hospitals set an overall spread aim to introduce 15 medical-surgical units to TCAB by June 2007. They tracked their progress in terms of both coverage and completion, and they also tracked clinical outcome measures related to quality and safety.

Regarding Seton's plan for measurement in the TCAB spread initiative, which of the following is true? (A) The spread team tracked their progress in terms of both coverage and completeness. (B) The spread team had a goal to reach a certain number of units by a certain time. (C) The spread team tracked outcomes measures related to quality and safety. (D) All of the above

They surpassed it. The Seton Family of Hospitals set a spread goal to introduce 15 medical-surgical units to TCAB by June 2007. At project completion, they had exceeded the initial goal: 17 units were using the TCAB process within 18 months.

Regarding the Seton network goal for spread, which of the following is true? (A) They surpassed it. (B) They met it exactly. (C) They failed to meet it. (D) The goal was unclear, so it was unclear whether they met it.

A and B The best answer is "A and B." After a successful pilot, they should move on to the implementation phase. This phase includes actions to "hardwire" the change, such as making it standard policy and training new staff on it. In implementing the change, the team will continue to run PDSAs: making predictions, carrying out the test, collecting data, and refining the change based on results. (Note that compared to PDSAs in the pilot phase, these tests will require significantly more people, time, and resources.)

Sandy Liu, a cardiac care unit nurse, notices that a few of her patients are suffering from inadequate pain control. Currently, a patient who needs pain medication must call the front desk, which then calls the nurse, who then goes to the patient's room to find out what he or she needs. Sandy finds out that a hospital in the next county has a simpler process: Patients can send a text message directly to the nurse to request pain medication. Sandy goes to her manager and suggests that they form a team to work on improving pain control and test this change in the cardiac care unit. After a successful pilot, which of the following should Sandy's improvement team undertake as a next step? (A) Work on seeing that the change is widely adopted by the unit, such as by making it a formal policy and training new staff on it. (B) Continue to run PDSA cycles. (C) Spread the change to other hospitals in the network. (D) A and B

Test the new process with one patient and closely review the results. The best answer is "test the new process with one patient on and closely review the results." Sandy and her team have an innovation and are ready to conduct a pilot. (Every organization is different, so just because the idea worked at another hospital does not mean it will work here.) Piloting involves starting small, such as with one patient, and carefully refining the change to make sure it works.

Sandy Liu, a cardiac care unit nurse, notices that a few of her patients are suffering from inadequate pain control. Currently, a patient who needs pain medication must call the front desk, which then calls the nurse, who then goes to the patient's room to find out what he or she needs. Sandy finds out that a hospital in the next county has a simpler process: Patients can send a text message directly to the nurse to request pain medication. Sandy goes to her manager and suggests that they form a team to work on improving pain control and test this change in the cardiac care unit. How should Sandy and her improvement team try out the new process for improving pain control? (A) Test the new process with one patient and closely review the results. (B) Bring together a group of stakeholders to develop an implementation plan. (C) Test the new process throughout the hospital to build a pool of data. (D) None of the above: There is no need to test this process because another hospital has already proved it to be effective.

Leadership The best answer is "leadership." Executive leaders in an organization play an important role in spread initiatives by supporting and facilitating the efforts. The ultimate success and sustainability of TCAB depended on leadership commitment at all levels: from the senior executives who set strategic priorities and ensured that good changes spread, to midlevel clinical leaders who empowered staff and orchestrated change, to local leaders and staff who redesigned care processes to achieve unprecedented patient outcomes.

Seton's Chief Nursing Officer was a key supporter of the TCAB spread effort. Which component of IHI's Framework for Spread does this fact best represent? (A) Communication (B) Leadership (C) Setup (D) Measurement

Understanding the relationships within the system The best answer is "understanding the relationships within the system." When leaders of a spread project understand the relationships within their social system, they can identify people who can help persuade others to adopt a change. Identifying a target population falls into the "setup" component of IHI's Framework for Spread, and tracking and monitoring progress falls under "measurement and feedback." The identification and piloting of worthwhile innovations should occur before leaders attempt to spread those innovations throughout a system.

The "Social System" component of IHI's Framework for Spread is best defined as: (A) Understanding the relationships within the system (B) Identifying a target population for the spread project (C) Assessing and identifying worthwhile innovations (D) A method of tracking and monitoring progress

Identifying the target population and the initial strategy to reach all sites in the target population with the new idea The best answer is "identifying the target population and the initial strategy to reach all sites in the target population with the new idea." Understanding the relationships within the system falls under the "social" component of IHI's Framework for Spread, and tracking and monitoring progress falls under "measurement and feedback." The identification and piloting of worthwhile innovations should occur before leaders attempt to spread those innovations throughout a system.

The "setup" component of IHI's Framework for Spread is best defined as: (A) Tracking and monitoring spread progress (B) Identifying the target population and the initial strategy to reach all sites in the target population with the new idea (C) Understanding the relationships within the system (D) Assessing innovations and identifying those that are of value

Communication The best answer is "communication." Because communication is at the heart of spread, the spread initiative needs an organized communication campaign. It's helpful to use many types of communication.

The TCAB spread team use at Seton relied on regular meetings, one-to-one calls, and a website to support their spread effort. Which component of IHI's Framework for Spread does this best represent? (A) Communication (B) Leadership (C) Setup (D) Measurement

1. Have experience in working with interdisciplinary teams 4. Have experience in performing self-assessment 5. Have experience in designing and testing interventions to change a care process Skills that are necessary to be competent in quality improvement include having been a member of an interdisciplinary team and improving the quality of one's own performance through self-assessment and personal change. It is also important to have had experience in designing and testing interventions to change the process of care with the objective of improving quality. The nurse who works on quality improvement should be able to identify errors and hazards in care and to assess current practices and compare them with relevant better practices, not provide efficient care.

The director of nursing has decided to begin a quality improvement program, and staff members with what skills should be included on the initial committee to ensure the success of this program? Select all that apply. 1. Have experience in working with interdisciplinary teams 2. Have experience in error justification 3. Have experience in providing efficient care 4. Have experience in performing self-assessment 5. Have experience in designing and testing interventions to change a care process

1. Decrease errors in nursing care. Human factors engineering looks at environmental issues, but its main goal is to ultimately decrease errors in nursing care. Human factors engineering studies human capabilities and limitations to determine ways in which errors in nursing care can be decreased. Human factors engineering may look at staffing to determine if there are adequate caregivers to provide safe care, but this is not the goal. Human factors engineering looks at efficiency of actions, but its main goal is to ultimately decrease errors in nursing care.

The nurse is aware that human factors engineering is utilized to accomplish what goal? 1. Decrease errors in nursing care. 2. Ensure that there is adequate staffing on a nursing unit. 3. Determine if the nursing unit is an optimal healing environment. 4. Design more efficient ways for nurses to provide patient care.

3. Helps the patient heal himself or herself The definition of the optimal healing environment is one that enables the body's capacity to heal itself. Providing sufficient room for family members is an element of the optimal healing environment, but it is not the main goal. Provision of privacy is mandated for all patients and is an implied element but is not the main goal. A pleasant hospital experience is not the goal of the optimal healing environment, because the patient experience while leading to healing may not be pleasant.

The nurse is aware that the optimal healing environment, which is a component of the Patient-Centered Care Quality and Safety Education in Nursing (QSEN) competency, is designed to assist the patient in what way? 1. Has enough room for family members 2. Provides for privacy 3. Helps the patient heal himself or herself 4. Ensures a pleasant hospital experience

2. County health department Public health departments often provide primary care to indigent populations and underserved populations. Vaccination services and sexually transmitted disease clinics are frequently operated by health departments at a reduced fee or free for qualified individuals. A possible sexually transmitted disease is not considered an emergency, and both an urgent clinic and a physician's office would require some type of payment.

The nurse is counseling a 20-year-old male who is unemployed and has no health insurance and is concerned that he may have contracted a sexually transmitted disease. What facility or agency would be the most appropriate place for the nurse to refer this patient? 1. Emergency department of the local hospital 2. County health department 3. 24-hour urgent clinic 4. Private physician's office

3. Individuals with Medicare pay approximately 65% of actual provider costs. Individuals with Medicare pay approximately 65% of actual provider costs. Individuals without insurance pay approximately 90% of the actual cost. Individuals with private insurance pay approximately 65% to 75% of the actual charges. Individuals with Medicaid pay less than what Medicare pays for actual provider costs.

The nurse is discussing health-care reimbursement with a group of student nurses. Which statement by a student nurse indicates an understanding of the reimbursement system? 1. Individuals without insurance pay approximately 50% of the actual provider costs. 2. Individuals with private insurance pay approximately 90% of the actual provider costs. 3. Individuals with Medicare pay approximately 65% of actual provider costs. 4. Individuals with Medicaid pay approximately 75% of actual provider costs.

2. The patient is covered, Part A covers hospital benefits. Part A of Medicare is also known as hospital insurance and covers inpatient care in a hospital, skilled nursing facility, or hospice. Part B is known as medical insurance and covers doctor visits, outpatient care, and durable medical equipment. Part C is known as Medicare Advantage, and individuals pay a premium that decides how much is charged for covered services. Part D is the prescription benefit.

The nurse is talking with a patient who was just admitted to an acute care health facility and just recently enrolled in Medicare Parts A, B. The patient is concerned that Medicare benefits will not cover hospitalization, and the nurse knows that which statement is true concerning this individual. 1. The patient is not covered because Part C is necessary for hospital benefits. 2. The patient is covered, Part A covers hospital benefits. 3. The patient is covered, Part B covers hospital benefits. 4. The patient is not covered because Part D is necessary for hospital benefits.

2. Employers must provide health insurance if the company has more than 50 employees. 3. Children may stay on their parent's health plans until age 26. 5. Insurance coverage cannot be denied because of preexisting conditions. Employers are mandated to provide health insurance if the company has at least 50 full-time employees. Dependents may stay on a parent's health-care plan until the age of 26. No one may be denied health insurance because of a preexisting condition. The ACA provides for no annual limits on coverage. Annual cost sharing is limited to the maximum allowed for health saving accounts.

The nurse is trying to explain the requirements of the Patient Protection and Affordable Care Act (ACA) and knows that which provisions are required of the act? Select all that apply. 1. There is a $500,000 annual limit on coverage. 2. Employers must provide health insurance if the company has more than 50 employees. 3. Children may stay on their parent's health plans until age 26. 4. Cost sharing is eliminated. 5. Insurance coverage cannot be denied because of preexisting conditions.

4. Patients state that the nursing staff knew about their desires and allowed them to make their own decisions. Advocacy in nursing is defined as a process of analyzing, counseling, and responding to patients' care and self-determination preferences. Empowerment is where patients believe they have access to information, support, and resources that give them opportunities to learn and grow about their own health conditions. Self-management recognizes the patient as the source of control and that the necessary tools and system supports are available for the patient to self-manage his or her own disease. Health literacy is the patients' ability to read, understand, and act on health-care information.

The nurse leader as a part of the patient-centered care Quality Safety Education in Nursing (QSEN) competency has encouraged all nurses to be advocates for their patients. The nurse leader knows that this concept is understood when the nurses demonstrate which action? 1. Patients state they believe they have access to information and resources and have the opportunity to learn and grow. 2. Patients state that they have all the supports necessary to manage their own disease. 3. Patients state they have the ability to read, understand, and act on information about their diseases. 4. Patients state that the nursing staff knew about their desires and allowed them to make their own decisions.

3. Meet the expectations of the patient. According to the IOM report, To Err Is Human, there are three domains of quality that must be implemented, and these include patient safety, practice consistent with current medical knowledge, and meeting customer-specific values and expectations. Working with both interdisciplinary and intradisciplinary teams are components to be included in the health profession as education and is also a part of the QSEN competency of Teamwork and Collaboration. Meeting the expectations of the nurses is also a part of the Teamwork and Collaboration QSEN competency.

The nurse manager has decided to use the strategies of the Institute of Medicine (IOM), To Err Is Human, to improve health care on the nursing unit. The nurse has identified that patient safety, practice consistent with current medical knowledge, and what other strategy must be implemented in this endeavor? 1. Work in interdisciplinary teams. 2. Work in intradisciplinary teams. 3. Meet the expectations of the patient. 4. Meet the expectations of the nurses.

All of the above The best answer is "all of the above." Because communication is at the heart of spread, the spread initiative needs an organized communication campaign. It's helpful to use many types of communication.

Which of the following communications strategies did the TCAB spread team use at Seton? (A) Regular meetings (B) One-to-one calls (C) A website (D) All of the above

1. Efficient The nurse manager is being efficient, which means to avoid waste, in particular, equipment, supplies, energy, and ideas. To be equitable is to not vary in quality because of personal characteristics. Patient-centered is providing care that is respectful of and responds to the unique needs of each patient. Effective is providing services to those for whom it would be beneficial and avoiding provision of services to those not likely to benefit from them.

The nurse manager has encouraged the nurses to provide patients on the unit any toiletries that are needed but to determine if the patient needs these supplies before providing them. Which one of the Institute of Medicine's Six Aims for Health Care in the 21st Century is the nurse manager using? 1. Efficient 2. Equitable 3. Patient-centered 4. Effective

1. Nurses identify the clinical question. 2. Nurses collect the best evidence relevant to the identified question. 3. Nurses evaluate relevant studies to determine their validity, reliability, and applicability. 4. Nurses incorporate evidence using their expertise and the patient's preferences to implement care. 5. Nurses evaluate the practice decision. The PICOT (population/patient problem, intervention, comparison, outcome, time) technique begins with the identification of the clinical question. Nurses then collect the best evidence relevant to the question. Third, nurses critically appraise the evidence before using it by evaluating the studies for validity, reliability, and applicability. Fourth, nurses incorporate the evidence using their expertise and the patient's preferences to implement care. The last step is that nurses evaluate their practice decisions or change to determine whether they affected the patient's outcome.

The nurse manager is beginning the process of integrating evidence into a clinical skill and plans to use the PICOT approach. Place in order the steps of the PICOT technique. Nurses evaluate the practice decision. Nurses identify the clinical question. Nurses incorporate evidence using their expertise and the patient's preferences to implement care. Nurses evaluate relevant studies to determine their validity, reliability, and applicability. Nurses collect the best evidence relevant to the identified question.

2. Work processes are to be simplified. 3. Train all members of the nursing unit to work as a team. 4. Redesign work processes to prevent accidents. Unit jobs are to be designed for safety, and work processes are to be simplified and standardized. All members of the nursing unit are to be trained to work in interprofessional teams. The nursing unit should identify threats to safety before an accident occurs and redesign processes to prevent accidents. Patient safety is to be the responsibility of all team members, not just leadership. Simulations should be used whenever possible to discover possible errors before actually caring for patients.

The nurse manager is responsible for designing a new pediatric oncology unit and plans to ensure that it is designed with a culture of safety. The nurse manager is aware that this culture of safety requires what necessary principles to accomplish this task? Select all that apply. 1. Patient safety must be the responsibility of the unit leadership team. 2. Work processes are to be simplified. 3. Train all members of the nursing unit to work as a team. 4. Redesign work processes to prevent accidents. 5. Discourage the use of simulation and focus on actual patient care.

4. Care affordability Person-centered care, care coordination, and healthy living all showed improvement, but care affordability worsened from 2002 through 2010 and then leveled off.

The nurse manager is studying the 2014 National Healthcare Quality and Disparities report and notes that improvements have been made in all but which priority? 1. Person-centered care 2. Care coordination 3. Healthy living 4. Care affordability

1. Sensitivity to operations 3. Preoccupation with failure 5. Resilience Sensitivity to operations is a fundamental characteristic to high-reliability organizations because it states that leaders and staff must be constantly aware of risks to patient safety and reduce them. Preoccupation with failure is a fundamental characteristic of high-reliability organizations and states that leaders and staff must view near-misses as evidence that systems should be improved, rather than as proof that the system is working effectively. Resilience is a fundamental characteristic of high-reliability organizations and states that leaders and staff must be educated and prepared to respond when systems failures occur. Reluctance to simplify, not desire to simplify, is the fundamental characteristic. It states that avoiding overly simple explanations of failure is essential to understand the true reasons that patient safety is in jeopardy. Deference rather than creation of expertise is the fundamental characteristic of high-reliability organizations and states that leaders and managers must listen and respond to the insights of frontline staff.

The nurse manager is working to create a culture of safety and is aware that which characteristics are fundamental to designing processes for high-reliability organizations? Select all that apply. 1. Sensitivity to operations 2. Desire to simplify 3. Preoccupation with failure 4. Creation of expertise 5. Resilience

2. Health-care professionals are to be transparent in all activities. 4. The patient is the source of control over his or her own care. 5. Health-care professionals anticipate needs of the patient. Health-care professionals are to be transparent, not operate in secrecy. The patient is the source of control over care, rather than health-care professionals. Health-care professionals are to predict and anticipate needs, rather than react to problems. The patient is to have access to information without restriction, delay, or the need to request permission. Waste is to be continually decreased rather than resorting to budget cuts and rationing services.

The nurse manager is working to ensure that the Institute of Medicine's Ten Rules for Health-care Delivery in the 21st Century are in place on the medical-surgical unit by using which rules? Select all that apply. 1. The patient may gain information after asking permission for records. 2. Health-care professionals are to be transparent in all activities. 3. Waste is controlled by budget cuts and rationing of services. 4. The patient is the source of control over his or her own care. 5. Health-care professionals anticipate needs of the patient.

3. Chronic disorders such as diabetes and chronic obstructive pulmonary disease (COPD) The U.S. health system is not performing well in avoiding hospital admissions for people with chronic conditions. Childhood communicable disorders, traumatic sports injuries, and dementia do not regularly cause repeat hospital admissions.

The nurse manager knows that more effort needs to be made to increase attention to what type of disorders to help avoid repeated hospital admissions? 1. Childhood communicable disorders 2. Traumatic injuries caused by sports 3. Chronic disorders such as diabetes and chronic obstructive pulmonary disease (COPD) 4. Dementia in the geriatric population

2. Health-care organizations did not have sufficient infrastructure. Health-care organizations have been slow to adopt quality improvement because of a lack of infrastructure and the absence of leadership among health-care providers. Prior to quality improvement programs, health-care organizations did not have comparable programs that effectively reduced errors. Health-care organizations produce a product that is the outcome of the patients, and health-care organizations can be considered high-risk organizations.

The nurse manager recognizes that health-care organizations have been slow to accept the principles of quality improvement for what reason? 1. Health-care organizations had programs comparable to quality improvement. 2. Health-care organizations did not have sufficient infrastructure. 3. Health-care organizations do not produce a product and therefore do not require quality improvement. 4. Health-care organizations are considered low-risk organizations and have little need of quality improvement.

2. Research concerning best practices According to the IOM's Ten Rules for Health-care Delivery in the 21st Century, decision making is evidence based, rather than based on the education and experience of the health-care professional.

The nurse manager, using the Institute of Medicine's Ten Rules for Health-care Delivery in the 21st Century, knows that the policies and procedures should be based on what? 1. Education of the staff nurses 2. Research concerning best practices 3. Education of the nurse manager 4. Collective years of experience of the staff nurses

4. Standardized protocols According to the Agency for Healthcare Research and Quality (AHRQ) (2005), evidence-based practice and standardized tools are critical aspects of patient safety improvement. Resilience refers to nurses being educated and prepared to respond to system failure, while important safety improvement is not dependent on it. Human factors engineering helps to determine what environmental factors influence the commission of errors. While very helpful, safety improvement is not dependent on it. High-reliability organizations refers to consistent performance of high levels of safety over time. It is evidence of safety improvement.

The nurse understands that improvement of safety in nursing is dependent on evidence-based practice and which element of the safety competency? 1. Resilience 2. Human factors engineering 3. High-reliability organizations 4. Standardized protocols

3. United States The United States, due to its political and cultural systems, does not have universal health care and is not likely to acquire it in the near future. France, Australia, Canada, and the United Kingdom all have this form of health care.

The nursing student correctly identifies which country that does not offer universal health care to its citizens? 1. France 2. United Kingdom 3. United States 4. Australia

(A) Fairness, transparency, and psychological safety A culture of safety rewards transparency - the willingness to report and share information learned from mistakes. A culture of safety is also fair to those who make mistakes, holding individuals accountable only if it's clear that a system failure was not the source of the errors. Psychological safety - a sense that individual concerns will be received openly and treated with respect - is a critical aspect of a culture of safety. However, deference to expertise - placing strong emphasis on rank within the health care hierarchy - is not a part of the culture of safety, as it would make errors more likely to occur. Finally, while emotional intelligence is important, it is not a core characteristic of a culture of safety.

What are some of the characteristics of a culture of safety? (A) Fairness, transparency, and psychological safety (B) Fairness, equitable pay, and emotional intelligence (C) Deference to expertise, transparency, and emotional intelligence (D) Deference to expertise, equitable pay, and psychological safety

Innovation-Pilot-Implementation-Spread The four phases of an improvement project are "Innovation-Pilot-Implementation-Spread." Plan-Do-Study-Act (PDSA) cycles are tests of change that improvers conduct during different phases of their improvement projects.

What are the four phases of an improvement project? (A) Plan-Do-Study-Act (B) Innovation-Pilot-Study-Act (C) Plan-Implement-Pilot-Spread (D) Innovation-Pilot-Implementation-Spread

(C) A place where all staff can talk freely about safety problems without fear Humans, even humans using technology, are fallible. In health care, there will always be errors and near-misses. In a culture of safety, however, people feel comfortable discussing errors and are rewarded for their focus on patient safety. Although an anonymous reporting system may be useful, the fact that it needs to be anonymous may indicate that people don't feel comfortable discussing errors openly.

What is a culture of safety? (A) A place where errors never happen (B) A place where errors are always caught (C) A place where all staff can talk freely about safety problems without fear (D) A place where all staff feel comfortable reporting errors only if they're guaranteed anonymity

4. Determine which clinical problem is to be researched. Determining the clinical problem to be researched is the first step of integration of evidence into practice. Research is the second step in the integration of evidence into practice. Ensuring relevance is the third step in the integration of evidence into practice. Evaluating the effectiveness is the last step in the integration of evidence into practice.

What is the first step that nurses should take in integrating evidence-based practice on a nursing unit? 1. Research how other nursing units have implemented evidence-based nursing. 2. Ensure that the evidence is relevant to the specific nursing unit. 3. Evaluate the effectiveness of the evidence to patient care. 4. Determine which clinical problem is to be researched.

Forming, storming, norming, performing Mary Dolansky explained a four-step process by which teams to get to a place where they are running smoothly: forming, storming, norming, and — finally — performing.

What is the order of the four steps teams typically follow to get to a place where they are running smoothly? (A) Forming, storming, norming, performing (B) Norming, performing, forming, storming (C) Storming, forming, norming, performing (D) Performing, storming, forming, norming

To spread improvements across health systems IHI's Framework for Spread is a useful way to think about the most important components to consider when developing and executing a strategy to spread improvements across health systems.

What is the purpose of IHI's Framework for Spread? (A) To spread health education to underserved communities (B) To spread improvements across health systems (C) To eliminate the spread of disease (D) To ensure accurate spread of information

Early majority and late majority For any given change, the bulk of the population will fall into the early majority and late majority.

When adapting to new change, most people fall into which of the following two categories? (A) Innovators and early majority (B) Early adopters and innovators (C) Early majority and early adopters (D) Early majority and late majority

Make the change an organizational priority. Changes that do not spread naturally might benefit from IHI's Framework for Spread; the "leadership" component of this framework states that changes spread more easily when they are key strategic initiatives. While you could switch to a different innovation that's easier to spread, it would be wiser to try to use the Framework for Spread before abandoning a potentially valuable innovation. Remember that every location is different, so you must monitor feedback and adapt as necessary.

When attempting to spread a change that you feel is valuable but is not spreading naturally, if possible, it's a good idea to: (A) Move on to something else that does spread naturally (B) Make the change an organizational priority. (C) Implement the change in each new location exactly the same way as in the previous location. (D) None of the above

B and C Changes that do not spread naturally might benefit from IHI's Framework for Spread and from brainstorming with the New Idea Scorecard. You could switch to a different innovation that's easier to spread, but it would be wiser to use the tools available to you before abandoning a potentially valuable innovation.

When attempting to spread a change that you feel is valuable but is not spreading naturally, if possible, it's a good idea to: (A) Move on to something else that does spread naturally. (B) Use IHI's Framework for Spread. (C) Use the New Idea Scorecard. (D) B and C

Testing a change concept The testing phase of an improvement project occurs before the spread effort, as a prerequisite. Only if the pilot is successful will the improvement team initiate a spread plan.

Which of the following is NOT one of the key components of IHI's Framework for Spread? (A) Leadership (B) Communication (C) Testing a change concept (D) Social system

(A) No matter what profession you belong to, you will be a member of the team and must work intentionally toward making that team effective. If you're entering any field in which you'll be caring for patients, it's a certainty that you will be a member of a team; in fact, you may be a member of multiple teams. As such, you'll have the responsibility to communicate effectively, value the contributions of other members, and keep building your team's ability to provide excellent care. Teamwork skills don't come naturally to everyone (Answer C), but anyone can learn and practice them.

When considering your role within a health care team, it is important to keep in mind that: (A) No matter what profession you belong to, you will be a member of the team and must work intentionally toward making that team effective. (B) You may be part of a team, but will likely be able to work autonomously without much input or help from others. (C) Teamwork skills will come naturally to you, because we all learn them in other settings. (D) You will need to be a good team member until you become an expert in your field, at which point you probably won't need teamwork skills.

(C) No matter what profession you belong to, you will be a member of the team and must work intentionally toward making that team effective If you're entering any field in which you'll be caring for patients, it's a certainty that you will be a member of a team; in fact, you may be a member of multiple teams. As such, you'll have the responsibility to communicate effectively, value the contributions of other members, and keep building your team's ability to provide excellent care. Teamwork skills don't come naturally to everyone, but anyone can learn and practice them.

When considering your role within a health care team, it is important to keep in mind that: (A) You may be part of a team, but will likely be able to work autonomously without much input or help from others. (B) Teamwork skills will come naturally to you, because we all learn them in other settings. (C) No matter what profession you belong to, you will be a member of the team and must work intentionally toward making that team effective (D) You will need to be a good team member until you become an expert in your field, at which point you probably won't need teamwork skills.

1. Initiating a blood transfusion 3. Administering chemotherapy infusion 4. Completing initial admission assessment Certain tasks cannot be delegated by an RN to a LVN, such as but not limited to initiation of a blood transfusion, administration of chemotherapy infusions, and completion of an initial admission assessment. The LVN can perform as a delegated task insertion of a urinary catheter along with changing of a post-operative dressing.

Which actions should not be delegated to a licensed vocational nurse (LPN) on a medical unit in a hospital setting by a registered nurse (RN)? Select all that apply. 1. Initiating a blood transfusion 2. Inserting a urinary catheter 3. Administering chemotherapy infusion 4. Completing initial admission assessment 5. Performing post-operative dressing changes

1. Academic experience 2. Use of experience to help form an opinion 3. Analysis of information to help arrive at a decision Nursing judgment represents a clinical decision process based on analysis of information supported by education and experience that are used to form an opinion. One's leadership style and/or the level of administrative experience is not uniquely attached to the formation of nursing judgment, as nursing judgment rests with the individual nurse rather than being ascribed to the roles that are performed. Nurses exhibit nursing judgment independent of their leadership style or the level of their administrative experience.

Which aspects are included in how nurses develop nursing judgment? Select all that apply. 1. Academic experience 2. Use of experience to help form an opinion 3. Analysis of information to help arrive at a decision 4. Leadership style 5. Level of administrative experience as opposed to being a staff nurse

1. UAP delegating a task to a LPN 3. LPN delegating a task to a RN 5. UAP delegating a task to a RN In terms of delegation, a RN can delegate tasks to another RN, LPN, or UAP. LPNs may not delegate to a RN but can delegate to a UAP. UAPs cannot delegate tasks.

Which examples represent improper use of delegation in the clinical setting by a registered nurse (RN), licensed practical nurse (LPN), or unlicensed assistive personnel (UAP)? Select all that apply. 1. UAP delegating a task to a LPN 2. RN delegating a task to a UAP or a LPN 3. LPN delegating a task to a RN 4. RN delegating a task to a RN 5. UAP delegating a task to a RN

4. UAP was providing information to a patient who was just placed on isolation relative to neutropenic precautions Client teaching remains under the direction of the RN. Client teaching can be reinforced by LPN as licensed individuals once the initial health information has been provided. The UAP can assist with transfers for the 2-day postoperative patient. The LPN can administer oral pain medication following performing a pain assessment, and the LPN can monitor ongoing blood transfusions.

Which observation if made by a registered nurse (RN) who is working with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) would require immediate intervention based on the delegation process? 1. UAP was transferring a patient out of bed who was 2 days postoperative laparoscopic surgery 2. LPN was administering oral pain medication following performing a pain assessment 3. LPN was monitoring a blood transfusion 4. UAP was providing information to a patient who was just placed on isolation relative to neutropenic precautions

The receiver repeats to the sender what he has heard. Verbal repeat back, or closed-loop communication, is a tool that allows both the sender and the receiver to verify that information has been communicated correctly. It involves four steps: the sender concisely states information, the receiver repeats what he has heard, the sender acknowledges that the repeat-back was correct or makes a correction, and the process continues until both people verify their shared understanding. This tool makes it possible to identify and clear up confusion immediately.

Which of the following actions is essential for closed-loop communication? (A) The sender gives a great deal of detailed information to the receiver, making sure not to leave anything out. (B) The receiver responds to all information, even if it is only with an "okay" or "uh-huh," to acknowledge that he has heard the sender. (C) The receiver repeats to the sender what he has heard. (D) None of the above is essential.

All of the above The best answer is all of the above. Some strategies to help get everyone on the same page include: Create a team roster so everyone knows who is on the team and how to reach each other, share stories to establish why the QI project is personally meaningful to people, and write out a work plan.

Which of the following are strategies to help members of a QI team establish common goals? (A) Create a team roster. (B) Share stories. (C) Write down a shared work plan. (D) All of the above

(B) Safer care The best answer is that care will be safer. For example, according to The Joint Commission, an estimated 80 percent of serious medical errors can be linked to miscommunication between caregivers when patients are transferred or "handed-over." One of the hallmarks of effective health care teams is frequent, two-way communication — a characteristic that would likely have an immediate and positive effect on care transitions and safety. While better teamwork can lead to fewer delays, elimination of waste, and even less costly care, these results would likely be secondary to an increase in safety.

Which of the following is likely to be the most immediate result of building an effective health care team? (A) Less costly health care (B) Safer care (C) Fewer delays in care (D) Elimination of waste in the system

2. Tracheostomy care Tracheostomy care can be performed by either a RN or LPN. The task could also be delegated by the RN to the LPN. Initiation of a blood transfusion should be performed by a RN. Assisting a patient with feeding can be performed by a UAP. Obtaining a daily weight can be performed by a UAP. The RN could delegate assisting the patient with feeding and obtaining a daily weight to the UAP.

Which patient activity could be performed by either a registered nurse (RN) or a licensed practical nurse (LPN) or delegated as a task even if there is an unlicensed assistive personnel (UAP) present on the unit? 1. Initiation of blood transfusion 2. Tracheostomy care 3. Assisting a patient with feeding 4. Obtaining daily weight

2. Assessing needs of the population in the context of available resources A nurse considers available resources based on the assessment of needs of the population in determining the right circumstances of delegation. The fact that completion of the task does not require nursing judgment refers to the right task. Identifying competency level refers to the right person. Providing correct information to a patient refers to the right direction or communication.

Which situation provides an example of the right circumstances as defined by the five Rights of Delegation? 1. Completion of the task does not require nursing judgment 2. Assessing needs of the population in the context of available resources 3. Identifying competency level 4. Providing correct information to a patient

2. Accountability exists at both nursing and organizational levels. Accountability is defined as being held responsible for direct or indirect actions provided in the context of delegation. Accountability exists both at nursing and organizational levels. Nurses are accountable for their actions, and the organization is responsible for providing sufficient resources for nurses to deliver care. Nursing state practice acts address roles and responsibilities of nurses in terms of accountability to provide safe, prudent practice to the public. Adequate nurse staffing contributes to being able to maintain accountability by having resources that allow for delivery of care. Nursing competency provides a framework for helping to support the concept of accountability.

Which statement best reflects the concept of accountability with regard to delegation of tasks? 1. Nursing state practice acts do not require nurses to be held accountable for their actions. 2. Accountability exists at both nursing and organizational levels. 3. An organization's obligation to accountability is based on its ability to offer quality care regardless of nurse staffing. 4. The competency of the nurse is not considered as being relevant to accountability.

3. Transferring a patient from the bed to a chair In terms of delegation, effective use of both licensed and nonlicensed personnel is the mainstay of establishing effective delegation of tasks. Transferring a patient from the bed to a chair should not be delegated to the LVN as it would be more applicable to the role function of the UAP. The other options: performing oral hygiene for a patient who has oral ulcerations, feeding a patient with dysphagia, and monitoring a blood transfusion can be performed by the LVN.

Which task should not be delegated to a licensed vocational nurse (LVN) by a registered nurse (RN) who is working with a LVN and unlicensed assistive personal (UAP) as part of the team? 1. Performing oral hygiene for a patient who has oral ulcerations 2. Feeding a patient with dysphagia 3. Transferring a patient from the bed to a chair 4. Monitoring a blood transfusion

(A) "Thanks! I'll tell your supervisor that you helped me today." In a culture of safety, all individuals value safety. Those who help prevent errors should be rewarded, not punished or told not to repeat their behavior. If this were an especially strong culture of safety, the pharmacist would also suggest sharing his error with the rest of the staff and changing the system to make medication mix-ups less likely. Answer B is threatening and Answer C is likely to be confusing to the learner. Answer D shows that although this pharmacist may value safety, the rest of the group does not.

You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. After you speak up, which of the following responses by the pharmacist would best indicate that this pharmacy has a culture of safety? (A) "Thanks! I'll tell your supervisor that you helped me today." (B) "If you know what's good for you, you won't tell anyone about this." (C) "Thanks! But in the future, please correct me in private, when others aren't around." (D) "Thanks! I appreciate that. But don't ever say something like that to the other pharmacist here. He's got quite a temper."

(D) A and B The best answer is A and B. While challenging authority figures requires courage in any field, the hierarchical nature of health care can make speaking up particularly difficult. This is especially true when senior practitioners get upset with junior staff who voice concerns about safety. Other reasons it may be hard to say something in this case include your respect for the pharmacist, concern that you are mistaken, and fear of being yelled at or mistreated. For learners, there's the additional worry that your evaluations and grades may be affected. However, it is always your place to speak up where safety is concerned, even if you're not certain you're right.

You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. Which of the following is a factor that might make it difficult for you to say something to this pharmacist? (A) You're just a student, and health care is hierarchical by design. (B) The pharmacist got annoyed when someone corrected him earlier. (C) You do not have time to say anything today. (D) A and B

(C) So that the patient does not experience an adverse event Speaking up about safety concerns should be a patient-centered act. Your goal in voicing your concern is simply to ensure the patient receives safe and effective care — in this case, the correct medication. Voicing your concern should not be about displaying your knowledge, currying favor, or getting someone in trouble.

You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. Why should you tell the pharmacist about your concern? (A) So that the pharmacist will think well of you when completing your evaluation at the end of the rotation (B) So that you can make your knowledge and eye for details apparent (C) So that the patient does not experience an adverse event (D) So that the pharmacist gets some extra training

(B) "I am concerned there is a safety issue here." When speaking up, it is important to use clear, direct language. Words like "safety" or "concerned" can get people's attention. Hinting at a problem, such as in Answer A, is not sufficient. Likewise, using threats, as in Answer C, is not professional behavior. Answer B is the vaguest option, and it's least likely to result in a solution to the problem.

You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills. You decide to speak with the pharmacist while he is filling the order. What would be the most appropriate thing to say? (A) "Did you check the bottle from which you're dispensing that medication?" (B) "I am concerned there is a safety issue here." (C) "What are you doing? Can I help?" (D) "Stop filling that prescription right now or I will be forced to call the manager."

Stating your idea for updating the sepsis protocol. The best answer is stating your idea for updating the sepsis protocol. Advocacy is making your own views known (including why you feel or think the way you do). Inquiry is seeking the views of others. The key to being an effective team member is balancing advocacy and inquiry.

You're on a team seeking to improve the process for treating patients with sepsis. (Sepsis occurs when chemicals released into the bloodstream to fight infection trigger inflammatory responses throughout the body). Which of the following is an example of "advocacy"? (A) Listening to your teammate's idea to improve screening for sepsis. (B) Stating your idea for updating the sepsis protocol. (C) Adapting your idea for the sepsis protocol based on your teammate's input. (D) A and C

Dave's behavior is normal; everyone has some challenges when adapting to new things. In this scenario Dave's behavior is perfectly normal. Everyone struggles with change to some extent.

Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient's earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult. In this scenario: (A) Rose is right; Dave is just being difficult. (B) Dave is probably too busy and that is why he is throwing up roadblocks. (C) Dave's behavior is normal; everyone has some challenges when adapting to new things.

Innovator Rose is considered an innovator because she was involved and committed to the new process before it had even come to the hospital.

Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient's earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult. Using Everett Rogers' theory of adoption of innovation, which category of adopter best describes Rose? (A) Innovator (B) Early adopter (C) Early majority (D) Late majority (E) Laggard (F) Not enough information to tell

Early adopter Joan is an early adopter because she wants her unit to be the first to pilot test the program.

Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient's earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult. Using Rogers' theory of adoption of innovation, which category of adopter best describes Joan? (A) Innovator (B) Early adopter (C) Early majority (D) Late majority (E) Laggard (F) Not enough information to tell