Chap 22

A nurse manager is providing education to a new nurse on barriers to the implementation of quality improvement processes. The manager judges the teaching to be effective when the new nurse states: a. "Expense is a primary barrier." b. "Resistance to change is a primary barrier." c. "One of the primary barriers is complacency with the status quo." d. "Not identifying the correct problem is a primary barrier."

ANS: A A primary barrier to implementing effective quality improvement (QI) programs is the cost. The cost of providing health care has greatly increased over the past few decades. However, through quality improvement measures, overall health care costs can be reduced. Other barriers (but not the primary one) to QI are nurses' loyalty to old practices and failure to recognize that changes are needed. Hospital administrators often oppose change of any kind because they may value traditional practices, have an authoritative management style, or may not value innovators. Nurses are often unaware or unwilling to change their practice from the way they have always done things—complacency with the status quo. Many practicing nurses remain resistant to change because it seems threatening and because it requires effort, retraining, and restructuring of habits, but cost still remains the primary barrier to implementing QI.

A nurse is interested in becoming credentialed as a Certified Professional in Health Care Quality. Which action would the nurse take to achieve this? a. Take an exam. b. Complete a 6-week internship. c. Have at least a bachelor's degree. d. Have at least 1 year of experience in quality management.

ANS: A Although there is no longer a minimum education requirement, those who test should have worked in quality management for a minimum of 2 years. Approximately 75% of those who apply to test actually achieve certification.

The primary role of The Joint Commission (TJC) is a. granting magnet status to excellent hospitals. b. lobbying Congress on behalf of Medicare/Medicaid patients. c. ensuring medical facilities meet patient safety guidelines. d. inspecting hospitals for compliance of infection control standards.

ANS: C The Joint Commission (TJC) is the primary accrediting body for health care institutions. Its standards directly address patient safety issues. Magnet status is approved by the American Nurses Association. TJC does not lobby Medicare/Medicaid issues. The CDC is the agency that maintains standards regarding infection control for hospital compliance.

Which action takes place during the design phase of the DMAIC process? a. A charter is developed. b. Key performance indicators are agreed upon. c. Analyze baseline data. d. Determine whether measures reflect the true problems.

ANS: A During the design phase of the DMAIC process, a charter is developed. Key performance indicators are agreed upon during the measure phase, baseline data are analyzed during the analyze phase, and it is determined whether measures reflect the true problems during the improve phase.

A nurse is explaining to another nurse about the contributions of Edward Deming. The nurse judges that the explanation is effective when the nurse states: a. "Quality is the responsibility of everyone within an organization." b. "Quality is the responsibility of the quality control inspector." c. "Quality is the responsibility of the CEO of the organization." d. "Quality is the responsibility of the manager of the organization."

ANS: A Edward Deming embraced the philosophy that quality is the responsibility of everyone within an organization.

A nurse is a team member assisting with the define-measure-analyze-improve-control (DMAIC) process. Which action would the nurse take during the define phase? a. Identify the stakeholders. b. Agree on the key performance indicators. c. Identify gaps between performance and goals. d. Identify those responsible for data collection.

ANS: A In the define phase, a charter is developed; goals, team leaders, membership, and team roles and responsibilities are identified; and the stakeholders affected by the process are identified. In the measurement phase, everyone within the team needs to agree on what is to be measured, which are called key performance indicators (time, costs, distance, numbers of incidents, or items). The analyze phase is usually a short phase, but it can be longer depending on the issue because analysis of baseline data is collected. It is important to be objective in identifying where the real problems exist during this phase. The improve phase is a good place to determine whether measures reflect the true problems. The problem statement and goal statement may need to be revised based on the findings. The data collected may have shown that no real problem exists or that the problem involves other issues. During the control phase, controls are established to keep things going in the right direction. Controlling and sustaining the improvement is not easy and requires the development, documentation, and implementation of an ongoing monitoring plan.

Which of the following statements by the nurse indicates an understanding of Quality and Safety for Nurses (QSEN)? a. "QSEN helps prepare future nurses for improving patient safety." b. "QSEN helps prepare future nurses for working mandatory overtime." c. "QSEN helps train nurses in the clinical setting." d. "QSEN provides nurses with strategies for passing the NCLEX exam."

ANS: A Quality and Safety for Nurses (QSEN) was developed to help prepare future nurses who will be needed in their health care environment to improve patient safety. QSEN does not prepare nurses to work mandatory overtime, train them in the clinical setting, or provide them with strategies to pass the NCLEX exam.

A nurse is educating students on the history of quality improvement. The teaching has been effective when one of the students states that the historically, quality improvement focused on a. "controlling process by inspection so that errors were prevented." b. "quality improvement did not begin until recently." c. "proactive approaches to lessen errors." d. "error prevention strategies."

ANS: A Teaching is effective when the student states that historically, quality improvement focused on controlling process by inspection so that errors were prevented. Later, the emphasis changed from inspection to proactive approaches to error prevention.

The nurse manager has an adequate understanding of Six Stigma when making which of the following statements? a. "The primary goal of Six Stigma is to increase profits and reduce problems." b. "The primary goal of Six Stigma is to attract physicians to an organization." c. "The primary goal of Six Stigma is advertisement of the organization." d. "The primary goal of Six Stigma is to attract nursing to an organization."

ANS: A The primary goal of Six Stigma is to increase profits and reduce problems. The primary goal is not to attract physicians or nurses to an organization or advertise.

A nurse is listening to a pharmacist lecture about factors that contribute to medication errors. The teaching has been effective when the nurse states: (Select all that apply.) a. "Problems within the system contribute to medication errors." b. "Human factors contribute to medication errors." c. "Work-design problems contribute to medication errors." d. "Environmental factors contribute to medication errors." e. "The nurse alone contributes to medication errors."

ANS: A, B, C, D The teaching has been effective when the nurse states that contributions to medication errors include problems within the system, human factors, work-design problems, and environmental factors.

A nurse manager is educating unit staff about HCAHPS. The manager judges the teaching to be effective when a staff nurse states that the HCAHPS survey contains rating about (Select all that apply.) a. communication. b. pain management. c. responsiveness. d. cost of hospital stay. e. discharge information.

ANS: A, B, C, E Teaching has been effective when the nurse states that HCAHPS survey contains rating about communication, pain management, responsiveness, and discharge information. HCAHPS does not include the cost of the hospital stay.

Which of the following are considered core measures and monitored by The Joint Commission? (Select all that apply.) a. Code arrests infection rates b. Advance directives c. Medication error rates d. Nurse staffing and vacation patterns e. Restraint use f. Numbers of hospital admissions

ANS: A, B, C, E The Joint Commission mandates that organizations continuously track certain core measures in order to monitor quality care. Some of these include advance directives, autopsy rates, leaving against medical advice (AMA) and elopement rates, blood product use rates, blood transfusion reaction rates, code blue rates, conscious sedation complication rates, fall rates, medication error rates, mortality rates, pain management effectiveness, restraint use, perinatal care, rates of deep vein thrombosis, and surgical-site infection rates. Nurse staffing and vacation patterns and tracking hospital admissions are not core measures.

If the nurse had an adequate understanding of continuous quality improvement, which of the following statements would the nurse? (Select all that apply.) a. "The accountability for quality is vested in quality circles that function along service lines to improve patient care." b. "After quality standards are achieved, the nurse strives to maintain that standard of care." c. "Quality standards must incorporate the expectations of patients and their families." d. "Systems within the hospital must be reviewed to determine how care can be enhanced." e. "Reducing costs to provide for substantial pay increases for nursing staff is an example of continuous quality improvement." f. "Computerized electronic documentation systems that provide continuous assessment of patient charges are an example of continuous quality improvement."

ANS: A, B, D Quality improvement (QI) refers to the process or activities that are used to measure, monitor, evaluate, and control services so that nurses can provide some measure of confidence to health care consumers. It includes reports that must be generated to track progress. This approach emphasizes continually looking for opportunities to improve. QI looks not only at what the nurse does in the pursuit of quality but also at how the systems of the units in the hospital can be improved to provide better care at lower cost. Reducing costs by providing for pay increases for nursing staff and computerized documentation systems are not examples of QI. Although quality improvement affects patients, their expectations and their family members' expectations are not necessarily incorporated into quality circles and the work that they do. Nurses must monitor quality care compliance; otherwise, people tend to go back to their old ways of doing things. The QI department is typically the department that receives data, analyzes trends, and recommends actions to facilitate improvement in the organization. However, there should also be a continuous quality improvement (CQI) council as a primary decision-making nursing team, as well as quality circles (QCs) that function along service lines, collaborating to improve care for a group of patient types.

A nurse is preparing a presentation on core measures. Which medical diagnosis should the nurse plan on presenting during the lecture? (Select all that apply.) a. Myocardial infarction b. Congestive heart failure c. Diabetes d. Pregnancy-related conditions e. Deep vein thrombosis

ANS: A, B, D, E Core measures include those for patients admitted with myocardial infarction, congestive heart failure, pregnancy-related conditions, and deep vein thrombosis. Diabetes does not fall under these core measures.

Which action would be occurring if a group of nurses were in the analyze phase of the DMAIC process? (Select all that apply.) a. Identify gaps between current performance and the goal. b. Identify possible sources of variation. c. Determine the goal. d. Write the problem statement. e. Determine where to begin making a change.

ANS: A, B, E If the nurses were in the analyze phase of the DMAIC process, they would identify gaps between current performance and the goal, identify possible sources of variation, and determine where to begin making a change. Determining the goal and writing the problem statement occur in the define phase.

A nurse has an adequate understanding of barriers to quality improvement when stating which of the following? (Select all that apply.) a. "Cost is a barrier in quality improvement." b. "There are no barriers to quality improvement." c. "Nurses' loyalty to old practices is a barrier." d. "Failure to recognize that change is needed is a barrier." e. "Being unwilling to change is a barrier."

ANS: A, C, D, E There are several barriers to quality improvement. These barriers include cost, loyalty to old practices, failure to recognize that change is needed, and being unwilling to change.

The nurse understands that the following statement is true about patient classification systems? a. "The systems measure all the needs of patients." b. "The systems provide an absolute formula for unit staffing." c. "The systems should not be used to make patient care assignments because acuity systems are more accurate." d. "The systems provide historical data of the usage of nursing time, which is helpful when developing the department budget."

ANS: D A patient classification or acuity system is used in many acute care hospitals to estimate the intensity of nursing care required to meet patient needs. It is helpful for developing a department budget. It is not a formula for unit staffing and does not measure all the needs of the patients.

The Joint Commission publishes a Sentinel Event Alert every month. Which of the following is the best example of a sentinel event? a. Tylenol #3 is given to a patient when plain Tylenol was ordered. b. Code pink is called after a newborn is discovered missing from the nursery. c. After receiving the correct medication, the patient complains of itching all over, and a rash is noted on the patient's trunk. d. During a blood transfusion, the patient's temperature increases to 100.4° F, and the patient complains of generalized pruritus.

ANS: B A sentinel event is an unexpected occurrence involving death or loss of limb or function. Examples of sentinel events include serious medication errors, significant drug reactions, surgery performed on the wrong body site, blood transfusion reactions, and infant abductions.

A nurse is discussing the Pareto principle (80/20 rule), which leads to the idea of total quality management. Which statement indicates an adequate understanding of this principle? a. Peter Pareto c. Phillip Crosby b. Joseph Juran d. Edward Deming

ANS: B Joseph Juran is one of the forefathers of quality initiatives. He stressed the meaning of the Pareto principle and how it applies to improving quality in all organizations.

The nurse manager has an adequate understanding of the continuous quality improvement process of Six Sigma when doing which of the following? a. "Uses Six Sigma to identify errors" b. "Uses Six Sigma to increase profits" c. "Uses Six Sigma to keep standard policies and procedures consistent" d. "Uses Six Sigma to improve patient-provider communication"

ANS: B The primary goal of Six Sigma is to increase profits and reduce problems by improving standard operating procedures, reducing errors (not just identifying them), and decreasing misuse of the system. Six Sigma methodology is based on strategies that focus on CQI and reducing variation in practice through the application of DMAIc. In other words, once a protocol is found to be effective, everyone is trained to do it the same way. The Six Sigma DMAIC process (define, measure, analyze, improve, control) is used primarily for improving existing processes that do not meet institutional goals or national norms. Although patient-provider communication is important, it is not the primary goal of Six Sigma.

A nurse is reviewing the technique used to identify the factors involved in an error. Which statement indicates the nurse has an adequate understanding? a. "The rapid cycle test is a technique that is widely used." b. "A root cause analysis is a process designed to investigate and categorize the root cause of the event." c. "A failure mode and effects analysis is a procedure to investigate the cause of the error." d. "Define, measure, analyze, improve, control prevents events from occurring."

ANS: B When an error is analyzed, the primary causes need to be determined so that a workable and effective solution can be developed. A root cause analysis is such a process designed to investigate and categorize the root cause of the event. The Six Sigma DMAIC process (define, measure, analyze, improve, control) is used primarily for improving existing processes that do not meet institutional goals or national norms. Rapid cycle tests are components of continuous quality improvement. A failure mode and effects analysis (FMEA) is a procedure in product development and operations management for analysis of potential failure modes within a system for classification by the severity and likelihood of the failures.

A nurse manager is educating a group of nurses on common medication errors. The manager judges the teaching to be effective when one of the nurses states that common medication errors include (Select all that apply.) a. good communication b. look-alike packaging c. wrong-dose errors d. inadequate monitoring e. rule violations

ANS: B, C, D, E The teaching has been effective when the nurse states that common medication errors include look-alike packaging, wrong-dose errors, inadequate monitoring, and rule violations. Common medication errors also include poor communication.

Which action by a group of nurses involves brainstorming? (Select all that apply.) a. List one solution to the problem. b. Identify stakeholders. c. Think about solutions to the problem. d. Write the problem statement. e. Write a goal statement.

ANS: B, C, D, E To brainstorm, the nurses should think about solutions to the problem, identify stakeholders, list solutions to the problem, and write the problem statement as well as the goal statement.

The continuous quality improvement (CQI) committee has performed a retrospective chart audit to investigate whether outcomes recorded in each nursing care plan are patient centered and written in behavioral terms. The expected standard is 98% compliance. The sample size was 200. Results showed that 180 charts met the standard. What assessment can be made? a. The standard was met. No action plan is necessary. b. The standard was not met, but no action plan is necessary because the rate of compliance was close to the standard. c. The standard was not met. An action plan should be developed. d. The standard was not met. An immediate re-audit is necessary.

ANS: C A threshold, or cutoff point, is determined for each indicator. This example represents a 90% compliance rate (180 divided by 200 = 0.9 or 90%), but the threshold or expected standard was set at 98%. Therefore, the standard was not met, and an action plan needs to be developed.

A nurse manager is brainstorming quality improvement methods. Which action would help implement these methods on the assigned unit? a. Continue without change. b. Resist change from upper management. c. Empower employees to carry out needed strategies for change. d. Agree to change what is directly beneficial.

ANS: C To implement and benefit from quality improvement methods, the nurse should encourage employees to carry out needed strategies for change. Continuing without change, resisting change, or only agreeing to change that is only directly beneficial would not be helpful.

Which statement by the nurse indicates understanding of the control phase of the DMAIC process? (Select all that apply.) a. "In the control phase, only the leader should be informed of changes." b. "Only those directly affected by the new process should be educated." c. "In the control phase, steps in the new process should be standardized." d. "Changes should be monitored to ensure compliance." e. "Standard operating procedures should be written."

ANS: C, D, E In the control phase of the DMAIC process, everyone should be kept informed of changes, standard operating procedures should be written, everyone should be educated about the new process, the steps in the new process should be standardized, and changes should be monitored to ensure compliance.

The nurse manager is educating a new hire on The Joint Commission (TJC). The manager tells the new hire that TJC mandates the use of continuous quality improvement and measurement of specific quality outcomes for patients with certain diagnoses. The teaching has been effective when the new hire states: a. "These mandates include patients admitted with Acute MI and COPD." b. "Outcomes measures are mandated for patients with a diagnosis of congestive heart failure and brain attack." c. "Acute renal failure and deep vein thrombosis have mandated outcomes by The Joint Commission." d. "Outcome measures are mandated for patients admitted with community-acquired pneumonia and congestive heart failure."

ANS: D TJC mandates outcome measures for patients admitted with a diagnosis of acute MI, congestive heart failure, community-acquired pneumonia, surgical infection prophylaxis, pregnancy-related conditions, and deep vein thrombosis. Keep in mind that each item in the option must be correct for the option to be correct, which is the reason acute MI and COPD as well as congestive heart failure and brain attack are incorrect.

The nurse manager has an adequate understanding of root cause analysis when stating which of the following? a. "Root cause analysis determines who to place the blame on." b. "Root cause analysis can identify some factors leading up to an error." c. "Root cause analysis is rarely conducted effectively." d. "Root cause analysis investigates the root causes of events that occur."

ANS: D The nurse manager has an adequate understanding of root cause analysis when they state it involves investigation of the root causes of events that occur. Root cause analysis does not determine who to blame, identifies all factors leading up to an error, and is conducted effectively by trained professionals.