Leadership Midterm

In order to persuade the "logical" individuals in the room, what should you be sure to include in your presentation about improving care for patients with diabetes? (A) Average blood pressure and cholesterol levels (quality of care measures) of the clinic's patients with diabetes (B) A photograph of a patient who suffered unnecessarily from poorly controlled diabetes (C) A list of the providers in the clinic with the worst patient satisfaction measures (D) A reminder of the Board of Trustees' stated goal of improving chronic disease care

A "Logical" individuals are persuaded by data, so it would be a good idea to present the clinic's performance on quality of care measures (Answer A). A photograph of a patient (Answer B) would be more persuasive to "emotional" individuals, while a reminder of the Board of Trustees' goals (Answer D) would appeal to "formal" individuals, who are most persuaded by evidence that those with power and authority are on board with the proposed change.

Which of the following statements about astronomical data points is true? (A) They signal a non-random pattern (B) During a test of change, if you observe an astronomical data point in a positive direction, it proves your change has led to improvement. (C) Astronomical data points may be dramatically outside other data points or only slightly outside. (D) All of the above

A According to Rule 4, an astronomical data point signals a non-random pattern. This is not just highest or lowest data point, but one that is so dramatically outside the others that anyone looking at the chart would think it was unusual. One astronomical data point does not necessarily prove your change is an improvement.

Which of the following charts would be best to justify focusing on a few large problems and ignoring many smaller ones? (A) Pareto chart (B) Scatter plot (C) Histogram (D) Run chart

A By separating the vital few from the trivial many, a Pareto diagram helps a team concentrate its efforts on the factors that have the greatest impact. It also helps a team communicate the rationale for focusing on certain areas.

When you are graphing a proportion or a percent, what should you look at to help you understand the bigger picture? (A) The denominator of the measured value (B) The numerator of the measured value (D) The median of the denominator (E) The median of the numerator

A By tracking the denominator of the measured value, you can confirm that your improvement effort is really showing signs of success, and there are not other factors at work.

You're a medical assistant at a community health clinic. Sometimes, patients with unresolved problems need to come in for follow-up appointments. However, you notice that it's a real challenge to schedule these follow-ups within a week of the initial appointments. Which of the following techniques might be most useful as you search for a good idea for change? (A) Review the process for scheduling these appointments with colleagues to identify opportunities for improvement. (B) Quit and start working in a new clinic that functions more effectively. (C) Research possible upgrades to the appointment scheduling software. (D) Tell a member of the office staff that it would be great if follow-ups were scheduled more quickly.

A Coming up with a change that will address your problem is often one of the most difficult aspects of the change process. Brainstorming with colleagues may help, as can critical thinking and creative thinking about the problem at hand. In this case, simply moving to another clinic (answer B) might reduce your frustration but will not help the clinic. Improving the scheduling software (answer C) may be useful, but it's unclear at this point that technology is at the heart of the delays. Finally, the office staff very likely already know that patient follow-ups should be scheduled sooner, but some aspect of the process is making this difficult for them (answer D). Simply reminding them is unlikely to get results.

The charge nurse in the emergency room asks Brenda to assemble a team to improve the delivery of pain medication. As she considers who to place on the team, Brenda should: (A) Review the aim statement to make sure the team includes representatives of all processes affected by the team's aim. (B) Create a team of volunteers. (C) Create a team of managers and administrators. (D) Make sure only nurses are on the team, as they are the most likely to help her achieve her aim.

A Including the right people on the change team is crucial to a project's success. The team should include representatives of all processes affected by the team's aim, which is why Brenda should review the aim statement. Further, it should include people with enough authority in the system to remove barriers and implement changes; people with clinical or technical expertise; and people who can drive the project on a day-to-day basis. A team representing just one profession is rarely as effective as an interprofessional team.

Gathering and reviewing data during an improvement project—that is, measuring—helps you answer which of the three questions of the Model for Improvement? (A) How will we know that a change is an improvement? (B) What are we trying to accomplish? (C) What changes can we make that will result in improvement?

A Measures (both qualitative and quantitative) provide a way to gather information on the effects of the change you are testing. Without measures, you have no real way of knowing whether your change led to an improvement. Having good measures is critical if you wish to improve care and spread change throughout a system.

Reggie is a new pharmacist in a surgical intensive care unit. He notices that it is taking an average of three hours from the time an order is placed until a patient receives an antibiotic (the goal is one hour). What might Reggie do if he were to act like a leader? (A) Look into the cause of the problem and research how other ICUs have solved it. (B) Tell his supervisor about the data. (C) Transfer to a different ICU that has improved outcomes. (D) Make sure that patients during his shift get antibiotics faster by paying close attention to orders.

A One way to take a leadership stance is to seek out strong ideas for solving a problem. By looking at published articles by people who have overcome a similar challenge, Reggie is taking a leadership stance.

What aspect of the run chart helps you compare data before and after a PDSA cycle? (A) The average of the values (B) The baseline median (C) Annotations of when specific changes were tested (PDSA cycles) (D) B and C

D

Use the following scenario to answer the first two questions : You volunteer at a student-run clinic associated with your academic health center. As a member of the student board, you are constantly looking for ways to improve the clinic. One common complaint is that it takes too long to check patients in once they arrive, and you decide to tackle this problem. Which of the following might be an outcome measure for this effort? (A) Average number of minutes between patient arrival at the clinic and completion of check-in (B) Number of patients seen by the clinic (C) Average number of students helping to check a patient in (D) None of the above

A Outcome measures tell you how the system is performing. In this case, the aim of the project is to decrease the time it takes to check in patients, so an appropriate outcome measure for this project could be "average number of minutes between patient arrival at the clinic and completion of check-in." The average number of patients seen by the clinic and the average number of students helping to check in patients might be useful to track as balancing and process measures, respectively.

Which of the following is a problem with static data? (A) It doesn't adequately portray variation. (B) It is often inaccurate. (C) It can't display mean, median, or mode. (D) All of the above

A Summary statistics that are static in nature don't give you the appropriate picture of the variation that lives in your data. Although you can accurately display data such as the mean, median, or mode, it is not a good way to observe change over time.

Let's say the hospital has an English-speaking nurse (Nurse Moss) assess one English-speaking patient with the new form. It is a successful test and the improvement team wants to increase the scope of the next test. What would they do? (A) Have a Spanish-speaking nurse give the assessment to one of her Spanish-speaking patients. (B) Have a different English-speaking nurse give the assessment to one of her English-speaking patients. (C) Increase the number of patients Nurse Moss assesses by a factor of 5. (D) Increase the number of patients Nurse Moss assesses by a factor of 10.

A The best answer is to have a Spanish-speaking nurse give the assessment to one of her Spanish-speaking patients. Changing the conditions of the test — such as the language involved — would be a change in scope. A change in scale would be a change in the number of interactions within the test.

Which of the following is the best way to collect baseline data for this improvement project? (A) Look at a few patients every day for a week. (B) Look at 10 percent of patients for a year. (C) Look at 100 percent of patients for a month. (D) There is no reason to collect baseline data.

A The best answer is to use a small sample and gather the data quickly. When measuring for improvement, it's often unnecessary (and may defeat the goal of rapid, iterative testing) to collect all available information over an extended period of time. Baseline data is important for knowing whether changes you are making are, in fact, leading to improvement.

What famous Italian economist is credited with the theory behind the 80/20 rule? (A) Vilfredo Pareto (B) Benedetto Cotrugli (C) Joseph M. Juran (D) Michelangelo Histogram

A The correct answer is Vilfredo Pareto. Pareto observed that 80 percent of the wealth of Italy was owned by 20 percent of the people. The Pareto chart was named after him by Joseph M. Juran.

Which of the following statements is true: (A) During the past 15 years, the cost of care has been a growing problem for many developed nations. (B) During the past 15 years, most countries around the world have used similar approaches to improve health care quality and access. (C) Among industrialized nations, there is a perfect correlation between quality rankings and the number of dollars spent on health care. (D) All of the above

A The cost of care has been a growing problem throughout developed nations during the last 15 years. For example, across 34 nations that make up the Organization for Economic Cooperation and Development (OECD), the average per capita health care expenditure increased by more than 70 percent between 2000 and 2010. However, the biggest spenders — such as the US — don't necessarily have the highest quality in many areas. Today, countries around the world with vastly different political, economic, and cultural makeups are working toward the goals of improving quality and access in different ways.

Which of the following changes falls under the heading of "eliminating waste"? (A) Physicians type all consult responses directly into a computer rather than writing them in a patient's chart, thus saving paper. (B) Dispensers full of hand sanitizer are placed throughout a floor, thus improving compliance with hand hygiene protocols. (C) A clinic starts tracking the number of foot exams that diabetic patients receive each year, thus ensuring they receive evidence-based care (D) A hospital invites patients to participate in the redesign of one of its centers, thus making them feel like valued members of a care team

A Waste is an activity or resource that does not add value. When a physician writes an order and someone else enters that order into the computer (answer A), two steps are required. Changing the process so it only requires one step reduces waste as well as potential for error. None of the other answers explicitly focuses on reducing waste.

Having a clear aim statement is important in quality improvement work because: (A) Aim statements provide a clear and specific goal for the organization to reach. (B) All grant agencies require clear aim statements when they are considering funding requests. (C) Aim statements remove all obstacles from quality improvement projects. (D) The leaders of all organizations expect to see these types of goals.

A Whether you're trying to reduce your commute time or cut down on the incidence of surgical-site infections, having a clear and specific aim statement makes your project more likely to succeed. Good aim statements include a specific, measurable goal, a deadline for achieving the goal, and information about which population will be affected: how good, by when, for whom. They do not, however, remove all obstacles from the process. And while many funding requests and leaders require strong aims, it's not always a requirement.

Which of the following is a basic principle of improvement? (A) Improvement must come from the bottom up — not the top down. (B) Every system is perfectly designed to get the results it gets. (C) Data should always drive improvement. (D) When examining a complex system, consider all the parts separately.

B A basic principle of improvement is that every system is perfectly designed to get the results it gets. When an error occurs in a complex system — and health care is a complex system — one can reasonably conclude that the system is still perfectly designed for that error, or one like it, to occur again. To avoid that outcome, a conscious effort must be made to improve the system.

What is the minimum number of data points you should usually have to look for signs of improvement on a run chart? (A) 6 (B) 10 (C) 15 (D) 25

B A run chart becomes more powerful as you add more data points because there will be more opportunities to identify patterns. If you're looking for signs of improvement, usually you need at least 10 data points.

An aim statement should include the following: (A) Specific time frame, team membership, and numeric goals (B) Numeric goals, specific time frame, and the patient population or system affected (C) Patient population or system affected, estimated cost of improvement, and numeric goals (D) All of the above

B Aim statements should specify measurable numeric goals, a time frame for attainment, and the group or system affected. Costs and team members, while important to the success of the quality improvement project, are not part of the aim statement itself.

Which of the following statements is true? (A) All changes lead to improvement; therefore, all improvement requires change. (B) While not all changes lead to improvement, all improvement requires change. (C) The changes that are known to lead to improvement should be implemented before testing.

B All improvement requires change—but unfortunately, not all changes lead to improvement. It is precisely for this reason that after you test a change, you should study the results to determine whether you're closer to accomplishing your goal.

Use the following scenarios to answer questions 2-4: An orthopedic clinic in a busy metropolitan area would like to improve its patient scheduling process. More specifically, the clinic wants to improve its efficiency and the satisfaction of its patients. Applying the Model for Improvement to the clinic's improvement goal, which of the following is the most reasonable aim statement? (A) Implement two PDSA cycles within six months of beginning the project. (B) Increase the number of patients reporting they are "very satisfied" with the clinic's scheduling by 50 percent within six months. (C) Modify the scheduling process to allow both front desk staff AND nurses to directly schedule appointments. (D) Create an efficient process for scheduling return appointments at the time of checkout.

B An aim statement must specify "how good, by when." Improving patient satisfaction with scheduling is a reasonable goal. Answer D is best described as an opportunity statement, as it contains no specifics about how much the clinic must improve, nor by when. Answer C is more of a "change" statement than an aim statement.

Using Deming's System of Profound Knowledge is helpful in quality improvement because: (A) It's a systematic set of procedures for implementing improvement. (B) It can help break down complex quality issues into smaller, more understandable parts. (C) It can help figure out who is to blame after an error. (D) It's a helpful way to secure funding from external sources for planned improvements.

B By breaking down a problem into its component parts, as in Deming's System of Profound Knowledge, you can better analyze it and design ways to improve it.

Which of the following describes data stratification? (A) Plotting observations to show the relationship between two sets of data (B) Classifying and separating data according to specific variables (C) Plotting data over time (D) Illustrating the relative frequency of occurrence

B Classifying and separating data according to specific variables — a practice called stratification — is a helpful way to understand the story data is telling. The goal of stratification is to find patterns in data that will help you understand the causal factors at work. Stratification helps inform teams' decisions about what changes to make, where, and when.

Use the following chart to answer questions 9-12. Note that one data point is on the median: In the above chart, how many useful observations are there? (A) 27 (B) 36 (C) 37 (D) 40

B Counting all the points not on the median yields 36 useful observations.

Which of the following is an example of an effective measurement technique for improvement? (A) Always strive for perfection. (B) Use quantitative and qualitative data. (C) Always set aside designated time for data collection. (D) All of the above

B The best answer is to use qualitative and quantitative data. Qualitative data, which is not so much about numbers as it is about the depth of the information collected, can be a rich source of knowledge in improvement projects. Interviews or focus groups are common sources of qualitative data. Measurement is not the goal; improvement is the goal. In order to move forward to the next step, a team needs just enough data to know whether changes are leading to improvement. ("Seek usefulness, not perfection" is a mantra at IHI.) To save time, integrate data collection into the daily routine as much as possible.

Use the following scenario to answer the next 3 questions: Brenda, an emergency room nurse, notes that there seems to be a significant delay between the ordering and the administration of pain medications in her department. She decides to conduct a small improvement project to reduce this delay and obtains the support of the charge nurse (head nurse). Which of the following is the most effective aim statement for this project? (A) Within one month, 95 percent of physicians will tell nurses when a pain medication is ordered on emergency room patients. (B) Within three months, the emergency department will administer all pain medications within 45 minutes of order time. (C) Within two months, improve the timeliness of pain medication delivery by allowing nurses to stock the most commonly used medications in the emergency unit (D) Within three months, the emergency department will improve the timeliness of pain medication delivery to 100 percent of patients.

B Effective aim statements contain a time frame, a definition of the population to be affected, and specific, measurable goals. Answer B meets all three of these criteria. While answers A and C may be useful process changes to reduce the delay between the ordering and administration of medications, they are not aims in and of themselves. Option D is not specific enough, as it does not contain information about how much the department should improve.

Why should you consider collecting a family of measures when undertaking an improvement? (A) It makes the project more publishable. (B) A single measure may not be enough to determine the impact of a change on the system. (C) All improvement projects are so complex that they require multiple measures. (D) All of the above

B Health care systems are extremely complex. A small change in a complex system can lead to many unexpected results, so using only one measure may not capture the effect of the change upon the system. Using more measures will not necessarily increase the likelihood of publication. Finally, it is health care that is complex, not necessarily the improvement project itself. The most successful projects are often the simplest ones.

You're working on an improvement project at a community mental health center. Your project aim: "Within two months, 100 percent of our patients will wait less than 30 minutes to be seen by a physician." You decide to gather data on patient wait times over a week-long period in order to establish a baseline. What might be an important consideration as you plan your data collection strategy? (A) Whether you'll provide food for the patients who wait more than 30 minutes. (B) What exactly you mean by "wait less than 30 minutes to be seen" — does this include the time the patient spends checking in, for instance? (C) How to establish consensus among the clinic's caregivers about the value of the project before gathering data. (D) How to inform the supervisors of individual physicians quickly when those physicians' patients wait more than 30 minutes.

B It is crucial to clearly define your measure before you begin gathering data, so that you and your team members measure the same thing each time — and so that others understand what you are measuring. It's not necessary to establish consensus at the outset about the value of the project; by doing small tests of change, you are likely to gain buy-in as you go. Finally, you are gathering data for improvement, not accountability, so for this project, it doesn't make sense to notify supervisors about the performance of individual caregivers.

Why was it important for the Institute of Medicine (IOM) to develop its six aims for health care? (A) So that accreditation organizations would be better able to evaluate hospitals (B) So that health care organizations would have a better idea of what they needed to improve (C) So that lawmakers could focus their attention upon specific areas when working on health care reform (D) All of the above

B Just as defining dimensions of good performance helps employees, defining the aims (or dimensions of quality) of health care helped hospitals and other organizations understand what to focus on when improving their care.

When effective leaders hear others complaining about a problem, which action would they most likely take? (A) Change the subject to talk about something interesting. (B) Try to learn how big the problem really is. (C) Add their own complaints to the chorus. (D) All of the above

B Leaders don't ignore problems or complain about them. They try to learn how big a problem really is. Then they work with others to figure out what to do about it.

You are working on decreasing adverse events related to medication errors, a serious problem on your pediatrics unit. After gathering some data, you present it to your colleagues on the unit. The result is several days of heated discussion among various caregivers. As a leader, at this point you should: (A) Meet with the hospital's chief executive and ask her to mandate the changes you have in mind. (B) Work to engage as many individuals on the unit as possible, investigating the source of their worries and responding to their concerns. (C) Recognize the level of anxiety this topic has provoked and back off for a while to allow people to digest the information. (D) Consider trying out your ideas on another unit to avoid causing more anxiety on this one.

B Leadership is about action. It's not about making everyone happy. It's also not about formal authority. It is essential for leaders to recognize that people will respond in a variety of ways when faced with a problem or change; it's also essential to move forward the improvement despite those reactions. Working to engage as many individuals on the unit as possible will help achieve a "workable level of unity."

Starting with small tests of change: (A) Allows you to start testing on live patients right away (B) Improves the likelihood of buy-in from opinion leaders (C) Means you don't need to do any planning before each test (D) Should be done only with the consent of opinion leaders

B Linking tests of change—with one test concluding and the next beginning at the same time, but this time on a larger scale or with a different scope—allows you to build support for your project. Each successive test is a way to demonstrate to key stakeholders that their input has value and that the project may actually lead to improvement. However, it's not necessary to seek consensus among stakeholders before testing changes.

When drawing a histogram, which is a good number of categories to include on your X axis? (A) 1-5 (B) 6-12 (C) 13-24 (D) >24

B Six to 12 categories of equal width is usually a good number to help you understand the distribution of data.

When increasing the number of patients or events from one PDSA cycle to the next, it is usually helpful to multiply by what number? (A) 2 (B) 5 (C) 10 (D) 20

B The 5X Rule recommends an increase by a factor of five whenever you finish one successful test and move on to the next.

Which of the following is a rule for determining non-random patterns? (A) A run of three points or more (B) Too many or too few runs (C) A trend of three points or fewer (D) A and B

B The best answer is too many or too few runs. A run of six (not three) points or more and an astronomical point both indicate non-random patterns. A trend of 3 points or less does not. In order to indicate a non-random pattern, a trend must consist of 5 data points or more.

Which statement about persuasion is most accurate? (A) It is essentially manipulative, and leaders shouldn't manipulate others. (B) It is one of the important tasks of leadership. (C) It doesn't really work, since people don't make changes unless you require them to do so. (D) It requires leaders to be charismatic and eloquent.

B The first step in many leadership challenges is to persuade the group that there is a problem and a possible solution.

When did a PDSA cycle occur? (A) February 05 (B) March 05 (C) June 06 (D) July 07

B The label on the chart shows a PDSA cycle occurred in March 2005

You are working to improve the care of diabetics in your community health clinic, and today you're giving a presentation to the clinic's leadership. You begin by telling the story of Kevin, a diabetic in the clinic who underwent a below-the-knee amputation after years of poorly controlled diabetes. What is the reason for telling this story? (A) Motivate by guilt. (B) Engage the largest possible number of people in the room. (C) Demonstrate that the data that you collected is valid. (D) Expose a possible legal liability.

B The majority of people — in any room — tend to be influenced most powerfully not by logic or formal authority, but by their emotions. Telling the story of a real patient is a way to engage their interest in solving the problem you hope to address.

In a run chart, the variable being measured is typically placed on what axis? (A) X axis (B) Y axis (C) Either axis (D) Neither axis; the run chart does not compare variables.

B The measured value is usually represented on the Y axis of a run chart. The X axis is usually the time — minutes, hours, days, weeks, months, etc. — or a numerical sequence in cases where data doesn't correspond to units of time.

The orthopedic clinic plans the change to improve scheduling, and then it carries out a small test of change with three patients on Tuesday morning. What's the next thing the clinic's improvement team should do? (A) Change their measures. (B) Measure to see if the change led to improvement. (C) Report their results to the clinic leadership and prepare a poster for a national meeting. (D) Implement the new scheduling process based upon their initial impressions of how everything is working.

B The team has planned a test of change and now they've done the test. The team must now study how the test went (the "S" part of the PDSA cycle). They can look at a mix of process measures (such as how often appointments started on time) and outcome measures (such as how satisfied the patients were with the new process).

Here's a table to help you apply Rule 3 to the chart: Using Rule 3, does this chart show non-random patterns? (A) Yes, there are too many runs. (B) Yes, there are too few runs. (C) No. (D) It is impossible to tell.

B There are 36 useful observations. For that number of observations, the table states that 13 or fewer runs show non-random patterns. We have 12 runs. Therefore, we can deduce that there is a non-random pattern in this chart.

Which of the following traits do histograms, Pareto charts, and scatter plots have in common? (A) They are all bar charts. (B) They are all visual tools to display data. (C) They all show change over time. (D) All of the above.

B They are all visual displays of data. Histograms and Pareto charts are types of bar charts, but a scatter plot is not.

Use the following scenario to answer the next 2 questions: Transcendental Nursing Home is working on decreasing its rates of catheter-associated urinary tract infections (UTIs) among its residents. While reviewing data, the improvement team notices that the UTI rate on Floor 3 is half that of the rest of the floors. They decide to visit the unit and find out what it is doing differently. Which component of Deming's System of Profound Knowledge is the team about to harness? (A) Appreciation of a system (B) Understanding variation (C) Theory of knowledge (D) Psychology (human behavior)

B They are working at understanding variation. By noting a unit that outperforms the others — a significant variation — the nursing home can now study that unit and attempt to spread its practices throughout the organization.

After six months of data collection and four linked PDSA cycles, you are preparing to present the results of your unit's readmissions project to the hospital board. The graph looks like this so far: (progressive decline) What else should you add to the graph to best explain the improvement work your unit has done? (A) The cost of the improvement effort (B) Annotations to show when specific changes were tested (C) Explanation of what a PDSA cycle is (D) P-values showing statistical significance

B When you go through multiple linked PDSA cycles in the course of a project, it's important to note which changes were tested and when, so you can make sense of the results. The cost may be important, but this data point won't show whether the team's changes led to improvement. P-values showing statistical significance are more commonly used in quality research than in quality improvement.

Use the following scenario to answer the next three questions. A hospital is trying to implement a new patient assessment form. They want to first test the usability and efficacy of the form. When determining sample size for the first test, it is most important to: (A) Look at similar research to see what sample size other organizations use. (B) Weigh the potential consequences of a test that does not lead to improvement against the belief in success. (C) Use a random sampling technique, so results can be extrapolated. (D) Ask all staff members what sample size they think should be used.

B With improvement work, you should weigh the potential consequences of a test that does not lead to improvement against the belief in success. How small your first PDSA cycle should be rests on your degree of belief and the stakes involved.

Within the following data set, what is the median? [2.5, 7.2, 2.5, 2.9, 4.7, 3.6, 4.7] (A) 2.5 (B) 3.6 (C) 4.0 (D) 4.7

B You calculate the median by finding the midpoint of a set of numbers. In this case, the median is 3.6, because there are three values before and three values after 3.6, making it the midpoint.

After several tests, you decide to try implementing a modified version of the protocol at your institution. Which of the following might you do within the "S" portion of your next PDSA cycle? (A) Develop the final plan for the protocol implementation. (B) Document unexpected observations. (C) Analyze information collected. (D) Strategize how to move this to another hospital in the system.

C "S" stands for Study. In this step you review the information collected during the "Do" step. Planning for implementation is part of the "Plan" step, and documentation of outcomes is part of the the "Do" step. Considering how to spread the change to another hospital is outside the scope of this PDSA cycle.

Which of the following descriptions best describes "leadership"? (A) A firm, unyielding position on what should be done to solve a problem (B) A set of beliefs based upon principle (C) A positive, "let's do something about it" attitude toward problems (D) A posture of resistance to those in authority

C A leadership stance is a positive, can-do approach to solving problems. It is not an opinion, a belief, or a reflexive opposition to people in power.

When a leader aims to achieve something and initially fails, what is his or her most likely response? (A) You should give a really good explanation. (B) You should make sure that people know how hard you worked. (C) You should find a new way to work with people to get it done. (D) You make sure that everyone knows whose fault it is.

C An effective leader takes a leadership stance — that is, takes responsibility for solving a problem and initiates action. He or she also achieves a "workable level of unity" — just enough agreement among his or her followers to move forward. Good leaders do not point the finger at others or complain when things go wrong.

When planning a sequence of PDSA cycles for a change that involves patients, which of the following is a true statement? (A) Patient characteristics in each PDSA cycle should be as uniform as possible to allow valid comparisons. (B) The number of patients in each cycle should stay fixed, to allow valid comparisons. (C) We would expect the number of patients involved to grow rapidly from early cycles to later cycles. (D) None of the above

C As improvement work progresses and the number of cycles increases, we would expect the scope and scale of the tests to increase, meaning both a rapidly growing number of patients involved in the tests as well as increasing diversity in the test population.

You notice that it's very easy to confuse medications at the community health center where you're working. They are lined up on the shelf and the labels are very similar. You decide that it's worth a try to highlight parts of drug names on certain labels to reduce confusion. Which change concept are you using? (A) Manage Time (B) Optimize Inventory (C) Design Systems to Prevent Errors (D) Improve Work Flow

C By making it easier to identify the medications, you are making it harder for the people in your organization to make mistakes. Choices A, B, and D are all valuable types of change concepts, but they do not apply in this example.

Use the following scenario to answer the next 3 questions: You are working on shortening the time it takes patients with chest pain to get to the cardiac catheterization lab in your hospital. Your aim is to have 90 percent of patients brought to the lab within 45 minutes of arrival to the hospital. You decide to try a care protocol that another hospital in the area implemented with great success. The care protocol was successful at the other hospital. Why would it be important to test this proven change at your hospital? (A) Because the last success may have been a fluke. (B) So that you can publish your results. (C) Because this change may not be as effective in your hospital. (D) In order to demonstrate the ability of this protocol to improve care in other hospitals for those that created it.

C Changes that work in one complex system may not be as effective, or effective at all, in another. The only way you will know for sure is to test the changes. Other reasons to test "proven" changes are to evaluate costs, minimize resistance and gain buy-in, and increase your own confidence that the change will lead to improvement in your setting.

You work on a surgical unit that receives 87 new patients per week. In your spare time, you are trying to improve pain control across the unit. As you prepare to collect your baseline data before testing your change, you consider your plan to gather this information. Which of the following would be the best data collection plan for this project, and why? (A) Collect data on the pain level of every patient for at least a year. (B) Collect data for at least a year, focusing only on patients who have undergone especially painful surgeries. (C) Collect data on a representative selection of patients for two weeks. (D) There is no reason to collect baseline data.

C Collecting data on a representative portion of your population — that is, sampling — allows you to collect baseline data and start making improvements faster, using fewer resources, than would be possible if you tried to look at every patient. Baseline data is important so that you can see if the changes you are testing are leading to improvement. Collecting data about a nonrepresentative sample of your population, such as by looking only at patients with the most severe pain, won't show the broad impact of your project on your unit.

Which of the following improvement efforts is the best example of increasing the effectiveness of care? (A) Decreasing adverse drug events by having a pharmacist on rounds in the intensive care unit (B) Shortening wait times at a clinic by allowing patients to self-register on a computer in the waiting room (C) Improving the percent of clinic patients achieving their goal blood pressure by instituting a series of reminders for providers about evidence-based processes (D) Instituting quarterly focus groups of patients seen in the emergency department to better identify patient concerns

C Effective care is based on scientific evidence and avoids underuse and overuse. A reminder system allowing providers to more easily use evidence in a busy practice environment would best improve the effectiveness of care.

Which of the following is an example of a process measure that you may collect as part of this improvement effort? (A) The rate of patients being readmitted within 30 days (B) The reasons for readmission to the hospital (C) The percentage of patients receiving a call within 48 hours of discharge (D) The cost of the labor associated with the calls

C Gathering data about process changes is important—otherwise you won't know if you are consistently doing the things that you predict will lead to improvement. Further, if your outcome measures show improvement over the course of your project, having good process measures allows you to make a reasonable conclusion about the efficacy of your new processes and their relation to the outcome. Answer A is an outcome measure for this project, and answer D is a balancing measure.

You're working on an improvement project at a community mental health center. Your project aim: "Within two months, 100 percent of our patients will wait less than 30 minutes to be seen by a physician." You decide to gather data on patient wait times over a week-long period in order to establish a baseline. What might be an important consideration as you plan your data collection strategy? (A) How to establish consensus among all the clinic's caregivers about the value of the project before gathering data. (B) How to inform the supervisors of individual physicians quickly when those physicians' patients wait more than 30 minutes. (C) Who will collect the data and what method he or she will use for collecting it. (D) All of the above.

C It is crucial to clearly define not just what the data is that you want to collect, but how you will collect it. You are gathering data for improvement, not accountability, so for this project, it doesn't make sense to notify supervisors about the performance of individual caregivers. It's not necessary to establish consensus at the outset about the value of the project; by doing small tests of change, you are likely to gain buy-in as you go.

Which of the following countries has had a relatively inexpensive universal health insurance system for more than 50 years? (A) Chile (B) Germany (C) Japan (D) The US

C Japan has had a relatively inexpensive universal health insurance system for more than 50 years. Germany made health insurance mandatory for its entire population in 2009. Chile has given all Chileans access to a basic health care package since 2005.

Which statement about storytelling is most accurate? (A) It persuades a few people in the room, but is difficult to do. (B) It is anecdotal, and therefore should not be used as a tactic for persuasion. (C) It can put a human face on otherwise abstract data. (D) All of the above

C Most people are influenced most powerfully by their emotions, rather than by logic or formal authority. For these emotional people, a leader must connect his or her issue to their hearts—and storytelling is often a good way to do that.

After assembling a team and working through the three questions of the Model for Improvement, the orthopedic clinic decides to implement an automated reminder phone call 24 hours prior to each clinical appointment. The clinic's improvement team hopes that this small change will improve scheduling. What is the team's next step? (A) Take a well-deserved break. (B) Develop their project-level measures. (C) Test their change plan using the PDSA cycle. (D) Report their results to clinic leadership and prepare a poster for a national meeting.

C Once you have worked through the first three questions of the Model for Improvement — the questions about aims, measures, and changes — it's time to do a small test of change using the PDSA cycle. The clinic should have already developed their measures, and now is not the time for a break — because the hard work of improvement is just beginning!

Reggie takes a look at the time between antibiotic order and administration in the other ICUs in his hospital. He discovers that most of the ICUs have the same problem. This is an example of which of the following actions of leaders discussed in this lesson? (A) Reframing the issue (B) Connecting to a powerful ally (C) Forming a clearer picture of the problem (D) Proving his case

C Reggie gathered some data and realized that this problem affects nearly all the ICU patients in his hospital. Having formed a clearer picture of the problem, he now is in an excellent position to engage the hospital's leadership

You are a radiology resident, and you're working to decrease the time it takes to get chest x-rays read in the hospital. You've gathered some data, and you're now discussing your results with the residency director and the chief of radiology. Thus far, you have presented the data to them and reviewed a case of a patient who had a negative outcome because of a delay in the reading of his chest x-rays. During this meeting, it would be a good idea to also: (A) List the reasons a resident might be the best type of leader to address this problem. (B) Ask for this effort to be noted in your evaluation form for the rotation. (C) Relate your goal to national radiology standards. (D) Relate the effort to your personal career goals.

C Some members of any group are "formal"—that is, they're more likely to try a new idea if they see that people with power and authority are on board. Connecting the change you want to make to the interests of higher authorities is a key tactic in persuading these types of people.

The Model for Improvement begins with three questions designed to clarify the following concepts: (A) Plan, do, act (B) Mission, goal, strategy (C) Aims, measures, changes (D) Will, ideas, and execution

C The Model for Improvement begins with three fundamental questions about any given improvement, designed to address the aim (what are we trying to accomplish?), the measures to be used (how will we know a change is an improvement?) and the changes to be used (what changes can we make that will result in an improvement?).

Which of the following statements is a reason for improving the US health care system? (A) The US has fallen behind in biomedical innovation. (B) The US lacks the means to measure health care quality and access. (C) The US government and citizens alike are struggling to afford the cost of care. (D) All of the above

C The US government and citizens alike are struggling to afford the cost of care. We've seen in this lesson the US has the means to measure health care quality — the results just often are not what one would hope! Although the US remains a leader in biomedical innovation, even the most advanced biomedical science and technology can't guarantee high-quality care.

What can quality improvement teams learn from Renoir, Monet, and Cezanne? (A) Improvement, like artistic work, should be a solo journey. (B) Your personal compass always points the way. (C) Teamwork can lead to creative ideas. (D) All of the above

C The answer is teamwork can lead to creative ideas. Renoir, Monet, and Cezanne, who were all artists in the French Impressionist movement, fed off each other's ideas and energy to create masterpieces. Similarly, members of quality improvement teams should work together to understand systems and make changes to improve patient care. The other choices are incorrect because improvement is not a solo journey and everyone's compass may go off course from time to time.

Which of these is a question particularly associated with the "theory of knowledge" component in Deming's System of Profound Knowledge? (A) What motivates people to act as they do? (B) What is the variation in results trying to tell you about the system? (C) What are your predictions about the system's performance? (D) What is the whole system that you're trying to manage?

C The answer is, "What are your predictions about the system's performance?" Deming believed knowledge is based on theory, and that theories need to be developed, applied, and tested in order to advance knowledge in a systematic fashion.

Michael Pugh talks about the distinction between management and leadership. Which of the following is most indicative of leadership? (A) Commanding people (B) Hiring people (C) Influencing people (D) Problem solving

C The best answer is influencing people. Michael Pugh says in management, you have to have resources and staff, and you have to problem solve. But ultimately to achieve something bigger than daily operations, you have to actually lead people, which is about influence more than authority.

You're trying to improve patient satisfaction scores in your hospital's emergency department. You decide to poll 40 patients a day for three weeks. Your charge nurse says that the quality of service really fluctuates depending on the time of day. So your daily sample consists of 10 patients polled at 8 AM, another 10 at noon, another 10 at 5 PM, and the final 10 at 9 PM. This is an example of what kind of sampling? (A) Simple random (B) Proportional stratified random (C) Judgment (D) None of the above

C The best answer is judgment sampling. Judgment sampling chooses samples based on subject matter expertise.

Which of the following BEST describes the purpose of a histogram? (A) To show the relationship between two variables (B) To show variation in weight over time (C) To show distribution of continuous data (D) None of the above

C The best answer is that a histogram measures distribution of continuous data. A histogram is a special type of bar chart. It can be used to display variation in weight — but can also be used to look at other variables such as size, time, or temperature. A chart that shows the relationship between two variables is a scatter plot.

Let's say the hospital has an English-speaking nurse (Nurse Moss) assess one English-speaking patient with the new form. It is a successful test and the improvement team wants to increase the scale of the next test. What would they do? (A) Have a Spanish-speaking nurse give the assessment to one of her Spanish-speaking patients. (B) Have a different English-speaking nurse give the assessment to one of her English-speaking patients. (C) Increase the number of patients Nurse Moss assesses by a factor of 5. (D) Increase the number of patients Nurse Moss assesses by a factor of 10.

C The best answer is to increase the number of patients Nurse Moss assesses by a factor of 5. Scale is the number of interactions within the test — in this case, the number of patients receiving the assessment, and the 5X Rules recommends an increase by a factor of five in each subsequent test. Changing the conditions of the test — such as the language involved or the staff involved — would be a change in scope, rather than scale.

When will the organization know the assessment form has been implemented on Unit Y? (A) When Nurse Moss uses the form for all her patients (B) When nurses on Unit Y use the form when they remember to (C) When nurses on Unit Y automatically use the form to assess all their patients (D) When the organization has tested the form on all its patients for a month

C The best answer is when nurses on Unit Y automatically use the form to assess all their patients. Implementation occurs when a change is embedded into daily practice.

As you recall, the IHI staff member's change idea involves leaving work by 5:30 PM each workday. Which of the following is an example of using technology to help her do so? (A) Comparing the time she leaves to that of the person who seems to go home earliest each day. (B) Cancelling two meetings every day. (C) Scheduling a reminder into her work calendar that pops up daily at 5:15 PM with the message, "Leave!" (D) Taking work home each night on a laptop computer.

C The programmed reminder is an example of using technology to make it harder for people to "drift" into less-than-optimal behavior. Answer A is an example of benchmarking. Answer B is an example of the change concept "eliminate waste" (assuming those meetings were not necessary in the first place). Answer D simply shifts the work to home, rather than creating a more efficient work pattern.

When designing the run chart, it is important to include: (A) Units of time on the Y axis (B) The rate of UTIs on the X axis (C) Units of time on the X axis (D) A and B

C The run chart should display units of time — whether it's days, weeks, or months — on the X axis. The Y axis is where you plot the key variable you are measuring, which in this case is the rate of UTIs.

In the above chart, which of the following data points would you skip in your count of "useful observations"? (A) Feb 2005 (B) March 2005 (C) May 2006 (D) None of the above

C Useful observations do not include data points that fall directly on the median, so you would skip May 2006 and conclude there are 36 useful data points.

Which of the following best describes a workable level of unity? (A) When everyone on a team is unanimously in favor of a proposal (B) When a team is unable to reach a consensus and cannot move forward. (C) When a group is willing to try an action together, even if there isn't complete agreement on what to do (D) When an authority figure makes a rule that everyone must follow

C Whatever a leader does is highly unlikely to be applauded by every single one of his or her colleagues — but that shouldn't stop a leader from moving forward. The idea is to create some sort of workable level of unity that allows the group to move beyond dueling opinions and into action.

Imagine you're a member of a newly formed improvement team that has taken up the challenge to reduce health care-associated infections at your hospital. You have an idea for a change to the room cleaning process that you want to test, but you're slightly nervous because improper cleaning and disinfection can carry a high risk for patients with compromised immune systems. Which of the following is most important to determine the best size for your initial PDSA test? (A) Apply the 5X rule. (B) Apply the 1-2-3 rule. (C) Weigh the potential consequences of a test that does not lead to improvement against the degree of belief in success. (D) Weigh the potential consequences of a test that does not lead to improvement against the possible benefit of a test that does lead to improvement.

C With improvement work, you should weigh the potential consequences of a test that does not lead to improvement against the belief in success. How small your first PDSA cycle should be rests on your degree of belief and the stakes involved.

Use the following scenario to answer the next 4 questions: As a nurse manager of a medicine unit in an academic hospital, you're aware that your unit has a high rate of patient readmissions. In fact, 36 percent of the patients discharged from your unit are readmitted to the hospital within 30 days. After reviewing the literature, you become aware that this rate is quite high compared to national standards. Working with other members of your unit, you develop a plan to call patients on the phone within 48 hours of discharge, with the aim of cutting readmission rates to 18 percent. What would you identify as the outcome measure for the project? (A) Average length of stay (B) The cost of labor associated with the calls (C) Rate of job satisfaction of those on the unit making the calls (D) Percentage of patients that are readmitted to the hospital

D Answer D—hospital readmissions—is the ultimate measure we're trying to move with the project. In other words, that's the main thing we're trying to improve. Answer A is a process measure, which tells us if we are consistently doing the things that are leading to improvement. Answers B and C are both balancing measures, meaning that we're keeping track of them to make sure the changes we're making are not having a negative effect on other parts of the system.

When planning a sequence of PDSA cycles for a change that involves patients, which of the following is a true statement? (A) Patient characteristics in each PDSA cycle should be as uniform as possible to allow valid comparisons. (B) The number of patients in each cycle should stay fixed, to allow valid comparisons. (C) We would expect the number of patients involved to very slowly grow from early cycles to later cycles. (D) None of the above

D As improvement work progresses and the number of cycles increases, we would expect the scope and scale of the tests to increase, meaning both a rapidly growing number of patients involved in the tests as well as increasing diversity in the test population.

Imagine you're a member of a newly formed improvement team that has taken up the challenge to reduce health care-associated infections at your hospital. You have an idea for a change to the room cleaning process that you want to test, but you're slightly nervous because improper cleaning and disinfection can carry a high risk for patients with compromised immune systems. You haven't run any PDSA cycles yet. Which of the following would be the best next step? (A) Have one housekeeper use the process with one room cleaning. (B) Have all housekeepers use the process for a week. (C) Have one housekeeper use the process on five room cleanings. (D) Confirm the "face validity" of the new cleaning process by demonstrating it with a couple of housekeeping staff members and a supervisor.

D Based on your concern about patient safety, you'd likely first want to confirm the "face validity" of the new cleaning process by demonstrating it with a couple of housekeeping staff members and a supervisor. When testing changes that involve patients, it can be helpful to conduct an initial test using staff only. A simulation or practice session before going live is often a good way to uncover issues with high risk.

How many runs are there? (A) 9 (B) 10 (C) 11 (D) 12

D By counting the number of continuous points above or below the median, we get 12 runs.

You and a fellow medical student have learned that in many countries, doctors avoid wearing long-sleeved coats at work because the coats can carry harmful bacteria such as methicillin-resistant Staphylococcus aureus (MRSA). You and your friend would love to see providers in the US stop wearing the coats. A conference of hospital and clinic leaders is coming up. How might you pique their interest in this issue of wearing long-sleeved coats? (A) Tell them the story of one patient who became sick with a health care-acquired infection. (B) Tell them how much money could be saved if long-sleeved coats were banned. (C) Show them data about how American MRSA rates compare with those of other countries. (D) All of the above

D By telling the story of a patient and talking about cost savings, you are connecting the problems of the powerless to both the hearts and the business interests of the powerful. By using data, you are forming a clearer picture of the problem. These are leadership behaviors.

What's the main benefit of using change concepts to come up with improvement ideas? (A) Using change concepts makes PDSA cycles unnecessary. (B) Using change concepts makes it much more likely that the implementation will go smoothly. (C) Using change concepts will lead you to focus on quantifiable technological improvements. (D) Using change concepts can help you develop specific improvement ideas that might not have occurred to you initially.

D Change concepts can help you develop new, specific ideas for change that could lead to improvement. They don't necessarily improve the likelihood that implementation of these changes will go smoothly, however. Finally, testing the changes using PDSA cycles is still necessary!

Which of the following improvement efforts is the best example of increasing the equity of care? (A) Decreasing adverse drug events by having a pharmacist on rounds in the intensive care unit (B) Shortening wait times at a clinic by allowing patients to self-register on a computer in the waiting room (C) Instituting quarterly focus groups of patients seen in the emergency department to better identify patient concerns (D) Through staff development and weekly feedback, equalizing the likelihood that a patient will receive the appropriate amount of pain medication regardless of their race

D The best answer is equalizing the likelihood that a patient will receive pain medication as indicated regardless of race, ethnicity, or education. Equity is about making sure patients receive appropriate, high-quality care regardless of gender, race, ethnicity, socioeconomic status, geographic location, sexual orientation, and other individual characteristics.

Your hospital has recently begun using the World Health Organization (WHO) Surgical Safety Checklist in all of its operating rooms. As chief of surgery, you have been hearing different reports about the use of the checklist; apparently, some surgeons are all for it, while others remain skeptical. You are curious about finding out how well and often the checklist is actually being used. Which of the following might be a good first step to take? (A) Request that an assistant be assigned to the administrative details, so that you can focus on the true work of leadership. (B) Go to the operating rooms and observe the checklist being used a few times. Collect some data about the use of the checklist (C) Talk to surgical nurses about their experience with the checklist. (D) B and C

D Leadership is an action, not a formal position of authority. One of the first actions of leaders is to get a clear picture of the real situation, often by gathering data and finding out what people are experiencing on the front lines of care.

Use the following scenario to answer questions 1-2: During a clinical rotation on the medical-surgical floor of a hospital, you notice several patients have developed urinary tract infections (UTIs) associated with their Foley catheters (tubes inserted into the bladder to drain urine). Your staff physician agrees that this is a problem and offers to help with an improvement project. Together, you work through several PDSA cycles to reduce the rate of UTIs on your floor. Which of the following methods would you recommend to display your improvement data? (A) Draw a bar chart. (B) Write a list of numbers. (C) Create a two-column table. (D) Draw a run chart.

D Run charts are an effective way to view changes over time. They are much easier to interpret visually than a list of numbers or a static display of data such as a bar chart.

Use the following scenario to answer the following two questions: During a clinical rotation on the medical-surgical floor of a hospital, you notice several patients have developed urinary tract infections (UTIs) associated with their Foley catheters (tubes inserted into the bladder to drain urine). Your staff physician agrees that this is a problem and offers to help with an improvement project. Together, you work through several PDSA cycles to reduce the rate of UTIs on your floor. Which of the following methods would you recommend to display your improvement data? (A) Draw a bar chart. (B) Write a list of numbers. (C) Create a two-column table. (D) Draw a run chart.

D Run charts are an effective way to view changes over time. They are much easier to interpret visually than a list of numbers or a static display of data such as a bar chart.

Why might you consider collecting balancing measures? (A) To show that you met your aim (B) To make sure you are able to publish your study (C) To demonstrate to your hospital board that you were justified in using resources for this project (D) To make sure you did not unintentionally damage other aspects of the unit's work

D Sometimes changes in one part of a complex health care system will lead to unintended additional changes in a different part, like ripples in a pond. Balancing measures can help ensure you're aware of these significant negative consequences, so that you can address them.

Which of the following is an example of a personality or work style profile assessment? (A) Myers-Briggs Type Indicator (B) Strength Deployment Inventory (C) DiSC Profile (D) All of the above

D The Myers-Briggs Type Indicator, the Strength Deployment Inventory, the DiSC Profile, and the Riso-Hudson Enneagram Type Indicator (RHETI) are all examples of personality or work style profile assessments.

In the lesson, IHI fellow Jana Deen explained that she went back to her roots and focused on patients to start making changes in health care. What other resources might be helpful as you seek to improve health care? (A) Social networking sites like Facebook and Twitter (B) National conferences (C) Listservs (D) All of the above

D The answer is All of the above. Social networks, conferences, and listservs can all be useful tools to stay in touch with colleagues around the world. If you're using the websites for professional purposes, make sure to avoid sharing any patient information.

After speaking with caregivers on Floor 3, the improvement team discovers that there is a particularly dedicated head nurse on the unit whose mother died after a catheter-associated UTI. This nurse orients all new providers and also provides feedback when she sees that catheters are being placed unnecessarily in patients. Which component of Deming's System of Profound Knowledge do this nurse's actions best represent? (A) Appreciation of a system (B) Understanding variation (C) Theory of knowledge (D) Psychology (human behavior)

D The answer is psychology (human behavior). This nurse is very particular about preventing UTIs because of the way this kind of infection has affected her life. This, in turn, has a strong effect on the way the entire unit works.

Which of the following is a rule for determining non-random patterns? (A) A run of six points or more (B) An astronomical point (C) A trend of three points or fewer (D) A and B

D The best answer is A and B. A run of six points or more and an astronomical point both indicate non-random patterns. A trend of three points or fewer does not. In order to indicate a non-random pattern, a trend must consist of five data points or more.

Which of the following is a trend in modern health care across industrialized nations? (A) Providers are becoming more specialized. (B) The disease burden is shifting toward acute conditions. (C) There is growing demand for complicated procedures. (D) A and C

D The best answer is A and C. As medical information and technology increases, demand for complicated procedures is increasing, and providers are becoming more and more specialized (and fragmented). The burden of disease is shifting toward chronic conditions.

In regard to health disparities around the world, which of the following statements is most true? (A) Inequitable medical care is the primary driver of health disparities. (B) Where a child is born significantly affects his or her life expectancy. (C) The root causes of health disparities are complex. (D) B and C

D The best answer is B and C. Where a child is born and raised can significantly change the life expectancy. The root causes of this and other health differences we see around the world are deeply complex and by no means begin or end in the clinical setting.

Which of the following statements is true about using data for improvement? (A) Both quantitative and qualitative data can be useful. (B) The data should tell a story. (C) A run chart is one of the most helpful tools for displaying data. (D) All of the above.

D The best answer is all of the above.

During Brenda's first group meeting, the members ask to review the aim statement to make sure they agree it addresses the current problem. With Brenda's approval, they all decide to rewrite it. However, when they meet to consider what would be a better aim statement, the group loses direction. In order to help them, Brenda might want to: (A) Reconsider who should be on the improvement team. (B) Move the meeting to a later date, so that she can come better prepared. (C) Explain to the group that the aim is set, as both she and the charge nurse have already agreed on the wording. (D) Remind the team of the Institute of Medicine's dimensions of health care quality.

D Writing an effective aim, especially when it comes to being specific about the improvement desired, can be surprisingly difficult. The Institute of Medicine's six dimensions of health care quality can often provide guidance and direction when a team is struggling to formulate an effective aim statement. (Reminder: A handy way to remember the six dimensions is the mnemonic "STEEEP": safety, timeliness, effectiveness, equity, efficiency, and patient-centeredness.)

After implementing the new protocol, you observe that patients are getting to the lab more quickly than before, but not as quickly as you had predicted. You examine the data and realize that there are really multiple issues delaying patients' arrival to the catheterization lab. Specifically, the emergency department needs to notify the lab staff in advance, but this communication rarely happens. Further, the schedule that the emergency department uses to contact the lab staff is riddled with errors. Based on the recommendations in this lesson, what should you do next? (A) Focus on fixing the schedule. (B) Discipline the emergency department staff who have failed to contact the catheterization lab in the past. (C) Focus on improving the communication between the emergency staff and the catheterization staff. (D) Work on improving both the schedule and communication at the same time.

D You should start testing changes to both processes and run the tests concurrently. That way you can see how all the required changes work together. Remember, your goal is to bring knowledge into action—not to discover the single change that works best.

Use the following scenario to answer the next 2 questions: Michael S., a 49-year-old factory worker, is brought to the hospital after developing chest pain at work. He is quickly diagnosed with an acute myocardial infarction (heart attack). However, he waits almost two hours to get to the catheterization lab and have his blocked coronary artery opened. Ultimately, he suffers permanent damage to his heart. Which of the IOM aims has this hospital FAILED to meet? (A) Equitable (B) Safe (C) Effective (D) Efficient (E) Timely (F) Patient-centered

E Michael's care was not timely. He did not receive care when it was needed, without delays.

When trying to improve a process, one reason to use PDSA cycles rather than a more traditional version of the scientific method (such as a randomized, controlled trial) is that: (A) PDSA cycles are easier to run with a large team of people. (B) The results of PDSA cycles are more generalizable than other methods. (C) PDSA cycles are simpler to use than other methods. (D) PDSA cycles provide a mechanism to adjust improvement ideas as the project progresses. (E) Both C and D

E PDSA cycles allow for rapid and frequent review of data and then adjusting the test of change based upon those findings. For example, if a new guideline that's meant to improve pneumonia care isn't working, PDSA cycles allow you to change the guideline quickly and test its efficacy, rather than waiting until the end of a long study period.

The hospital where Michael is recovering reviews its patient satisfaction survey results in order to improve its care and patient outcomes. Leaders poring over the data note that 90 to 100 percent of patients rate staff as "excellent" in the following categories: listening, answering questions, being friendly and courteous, and giving good advice based on specific needs and preferences. Which aim is the hospital generally achieving? (A) Equitable (B) Safe (C) Effective (D) Efficient (E) Timely (F) Patient-centered

F Patient-centered care is defined by the IOM as "care that is respectful of and responsive to individual patient preferences, needs, and values" and that ensures "patient values guide all clinical decisions." These high satisfaction rates are consistent with being patient-centered.

You volunteer at a student-run clinic associated with your academic health center. As a member of the student board, you are constantly looking for ways to improve the clinic. One common complaint is that it takes too long to check patients in once they arrive, and you decide to tackle this problem. Which of the following might be a process measure for this effort?

Number of students helping to check a patient in In this case, you're trying to decrease wait times by increasing the number of staff members on duty, so an appropriate process measure for this project would be number of students helping to check a patient in. Keeping track of costs associated with a new process could be a balancing measure. The average number of minutes between patient arrival at the clinic and completion of check-in may be a useful outcome measure.