IHI QI 101, IHI QI 102, QI 103: Testing and Measuring Changes with PDSA Cycles :O, QI 104, NUR 455 IHI QI 105: Leading Quality Improvement

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. Which of the following is the best example of a process measure that the team may collect as part of this improvement effort?

The percentage of patients receiving a call within 48 hours of discharge

In the example, which of the following is a process change?

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

Why might an improvement team consider collecting balancing measures?

To make sure they didn't unintentionally introduce undesired changes

Brenda, the office manager at a dental practice, noticed many patients were missing their appointments. With the support of her colleagues, she decided to conduct a small improvement project to improve the process for reminding patients of upcoming visits, with the goal of having fewer "no shows." During a team meeting, Brenda's team members review her aim statement. Which of the following comments from a team member would most strongly suggest Brenda has selected an appropriate aim?

"It feels like a very meaningful project for both the patients and the practice."

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

10

How many useful observations are on this chart? (Note that one data point is on the median.) 27 36 37 40

36

The team from the example on the previous page has started to draw a histogram for its 32 data points: How high (i.e., to what numbers on the vertical axis) should the team draw the bars in the remaining three categories? 8, 2, 4 4, 3, 2 0, 5, 3 4, 0, 2

4,3,2

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

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

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

6-12

An operating room (OR) team identified eight categories of factors that contributed to errors during surgical setup. They tracked and calculated the following data in relation to those categories: Can you calculate the missing data point for the table above? (Hint: Start by adding the three largest values in the 'frequency' column. Then divide that number by the 'total frequency.') 70 75 80 85

75

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 run chart. B. Create a two-column table. C. Write a list of numbers. D. Draw a bar chart.

A

Once again, here's the run chart of ED "walk aways" over time from the previous lesson; practice applying the four run chart rules. Which of the following do you see? (Note that there is one data point on the median, which is February 7.) A. At least one shift (based on Rule 1) B. At least one trend (based on Rule 2) C. At least one shift AND at least one trend D. Neither a shift nor a trend

A

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 c) The median of the denominator d) The median of the numerator

A

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

Which of the following is the best interpretation of the run chart below based on Rule 3? Hint: There are 24 data points, and two of them fall directly on the median. A. There are too many runs for the pattern to appear random. B. The pattern appears to be random. C. There is insufficient data to judge whether the pattern appears to be random or not. D. There are too few runs for the pattern to appear random.

A

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

After a successful pilot, which of the following should Sandy's improvement team undertake as a next step?

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

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

A single measure may not be enough to determine the impact of a change on the system. 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.

Having a clear aim statement is important in quality improvement work because:

Aim statements provide a clear and specific goal for the team or organization to reach.

The Model for Improvement begins with three questions designed to clarify the following concepts:

Aims, measures, changes

According to Herbert Kaufman, which of the following are reasons health care workers commonly resist change?

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

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.

All of the above.

Heather and her team continue to test the new idea. Assuming things continue to go well, what might they eventually do?

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

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. 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?

Analyze information collected.

After six months of data collection and four linked PDSA cycles, a team is preparing to present the results of its improvement project. The graph looks like this so far. What additional information is most important for them to add to the graph to best explain the work they've done?

Annotations to show when specific changes were tested

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

Average number of minutes between patient arrival at the clinic and completion of check-in 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.

According to Rule 3, does the chart show non-random patterns? Use the the table below to help you. (Note that one data point is on the median.) A. Yes, there are too many runs. B. Yes, there are too few runs. C. No. D. It is impossible to tell.

B

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

B

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

Measure: Percentage of staff reporting they're satisfied at work and total staffing costs

Balancing measure

Measure: Readmission of ventilated patients to the ICU who then require mechanical ventilation

Balancing measure

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?

Because this change may not be as effective in your hospital

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. 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. Units of time on the Y axis AND the rate of UTIs on the X axis

C

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

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

Classifying and separating data according to specific variables 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.

At Clinic A, the plan is to meet as a team and start with 10 patients. The team will note how many clinicians washed their hands before and after each patient encounter to learn what might be the barriers to hand washing. The team will continue to track 10 patients per week as various interventions are tested and then will determine if hand hygiene compliance gets better over time. At Clinic B, the plan is to meet as a team and choose a test to implement. The team will randomly assign patients to two groups, making sure both have similar attributes. The team will then develop a database, and over the next six months, measure how many clinicians in each group washed their hands before and after each patient encounter. After that, the team will implement the chosen intervention with one of the groups and reassess hand hygiene compliance as compared to the control group. Which of the clinics is measuring for improve

Clinic A

Which of the following changes falls under the heading of "eliminating waste"?

Clinicians type all notes directly into a computer rather than writing them in a patient's chart, thus saving paper.

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.

Confirm the "face validity" of the new cleaning process by demonstrating it with a couple of housekeeping staff members and a supervisor. 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.

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. The baseline median AND annotations of when specific changes were tested (PDSA cycles)

D

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

D

As an office manager, you notice there's a high rate of "no shows" for appointments at your practice. People often tell you they scheduled the appointment far in advance, and simply forgot to go. You decide it's worth a try to improve this problem by sending reminders via text message. Which change concept are you using?

Design Systems to Prevent Errors

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.

Draw a run chart. 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.

You are undertaking a project to improve hand hygiene on your unit, and you have some ideas for changes that might work in the categories of "Enhance the Producer-Customer Relationship" and "Design Systems to Avoid Mistakes." Match your ideas to the change concepts they represent.

Educate staff about how washing hands helps keep patients safe.Change concepts #36: Emphasize Natural and Logical Consequences.CorrectAsk staff which type of soap or hand sanitzer they prefer to use.Change Concept #38: Listen to Customers.CorrectProvide training on proper hand washing technique.Change Concept #39: Coach the Customer to Use a Product or Service.CorrectEncourage patients to ask providers if they have washed their hands.Change Concept #55: Develop Contingency Plans.CorrectPost signs on the unit to remind staff about the importance of washing hands.Change Concept #59: Use Reminders.Correct

Defining a family of measures helps you answer which of the three questions of the Model for Improvement?

How will we know that a change is an improvement?

Starting with small tests of change:

Improves the likelihood of buy-in from opinion leaders

A hospital is trying to implement a new patient assessment form. They want to first test the usability and efficacy of the form. 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.

Increase the number of patients Nurse Moss assesses by a factor of 5. 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.

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?

Increase the number of patients reporting they are "very satisfied" with the clinic's scheduling by 50 percent within six months.

What are the four phases of an improvement project?

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

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

It doesn't adequately portray variation. 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.

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 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.

Look at a few patients every day for a week. 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.

According to the chart, when did a PDSA cycle occur? February 05 March 05 June 06 July 07

MARCH 5

Let's return to the hand hygiene example. Matching: Can you select one possible cause of poor hand hygiene compliance that could play a role in each category on the cause and effect diagram?

MaterialsHand sanitizer availabilityCorrectMethodsProper hand-washing techniqueCorrectEnvironmentReminder signsCorrectEquipmentHand sanitizer dispensersCorrectPeopleStaff knowledge

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.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?

Measure to see if the change led to improvement.

An aim statement should include the following

Numeric goals, specific time frame, patient population or system affected

Based on the aim of the project, indicate whether each of the following project measures is an outcome measure, process measure, or balancing measure. Aim #1: Reduce the incidence of ventilator-associated pneumonia (VAP) by reducing the number of ventilator days in the intensive care unit (ICU) by 20 percent within five months. Measure: Percentage of patients with ventilator-associated pneumonia

Outcome measure

Measure: Average number of minutes spent in the waiting room per patient

Outcome measure

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:

PDSA cycles provide a mechanism to adjust improvement ideas as the project progresses.

Medical staff at a community health center were concerned about the oral health of many of their patients. To improve patients' oral and overall health, they wanted to improve the coordination between medical and dental services, with medical providers more reliably providing appropriate referrals for dental care based on patients' age and risk factors. What would you identify as the best outcome measure for the project?

Patients' oral health, as measured by caries risk assessment

What improvement project phase have Heather and her team just completed?

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

Based on the aim of the project, indicate whether each of the following project measures is an outcome measure, process measure, or balancing measure. Aim #2: Reduce the average waiting time for all patients to under 20 minutes by next August. Measure: Patient cycle times (e.g., time to registration, time from arrival to triage, time from triage to bed placement) and the percentage of time staff arrive for their shifts on time

Process measure

Measure: Average number of days on mechanical ventilation

Process measure

You're a dental assistant at a small clinic. Sometimes patients with unresolved problems need to come in for recall appointments. However, you notice that it's a real challenge to schedule these recalls 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?

Review the process for scheduling these appointments with colleagues to identify opportunities for improvement.

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?

Scheduling a reminder into her work calendar that pops up daily at 5:15 PM with the message, "Leave!"

By June of 2025, we will reduce the incidence of pressure ulcers in the critical care unit by 50 percent.

Strong

Our most recent data reveal that, on average, we reconcile the medications of only 35 percent of our discharged inpatients. We intend to increase this average system-wide to 50 percent by April 1, 2027, and to 75 percent by August 31, 2027.

Strong

How should Sandy and her improvement team try out the new process for improving pain control?

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

Which of the following statements is true?

The Model for Improvement is appropriate for many types of clinical improvement efforts. The Model for Improvement is one of multiple improvement models applicable to health care. Lean is a helpful methodology for improving value and reducing waste in health care.

Which of the following represents a culture change?

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

What's the likeliest reason the program failed?

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

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. 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

Units of time on the X axis 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.

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

Use quantitative and qualitative data. 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.

What's the main benefit of using change concepts to come up with improvement ideas?

Using change concepts can help you develop specific improvement ideas that might not have occurred to you initially.

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

We would expect the number of patients involved to grow rapidly from early cycles to later cycles. 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.

We aim to reduce harm and improve patient safety for all of our internal and external customers.

Weak

We will reduce all types of hospital-acquired infections.

Weak

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.

Weigh the potential consequences of a test that does not lead to improvement against the belief in success. 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.

A good aim statement helps improvement teams answer which question from the Model for Improvement?

What are we trying to accomplish?

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.

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? 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.

Which of the following statements is true?

While not all changes lead to improvement, all improvement requires change.

Brenda, the office manager at a dental practice, noticed many patients were missing their appointments. With the support of her colleagues, she decided to conduct a small improvement project to improve the process for reminding patients of upcoming visits, with the goal of having fewer "no shows." Which of the following is the most effective aim statement for this project?

Within three months, 90 percent of patients will show up for their appointments.

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.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?

Work on improving both the schedule and communication at the same time.

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.

Y axis 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.

You're working on trying to reduce waiting times for patients. Your formal aim is to reduce the average waiting time for all patients to less than 20 minutes by next November. For a few months, you have tried different changes and dutifully gathered data on several process measures and your outcome measure, which is the average number of minutes in the waiting room per patient. You're meeting with your office team to review this graph. Upon studying it, would you say the changes the team is testing are leading to improvement?

Yes

4) 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) During the past 15 years, the cost of care has been a growing problem for many developed nations.

1) 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) Every system is perfectly designed to get the results it gets.

2) 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) It can help break down complex quality issues into smaller, more understandable parts.

1) 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) So that health care organizations would have a better idea of what they needed to improve

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. 3) 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) Understanding variation

4) 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) Improving the percent of clinic patients achieving their goal blood pressure by instituting a series of reminders for providers about evidence-based processes

3) 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

5) 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.

5) 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) What are your predictions about the system's performance?

2) 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) A and C

1) 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) B and C

4) 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) Psychology (human behavior)

5) 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 pain medication regardless of race, ethnicity, or education

d) Through staff development and weekly feedback, equalizing the likelihood that a patient will receive pain medication regardless of race, ethnicity, or education

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. 2) 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) timely

3) 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