Quality and Performance Improvement in Healthcare Ch 1-14

This type of data assumes an infinite number of possible values in measurements that have decimal values as possibilities: nominal data ordinal data discrete data continuous data

continuous data

The regular and frequent assessment of healthcare processes and their outcomes and related costs is considered ____________. continuous monitoring continuous data continuum of care continuum of data

continuous monitoring

A PI team that involves staff from more than one department, service area, or discipline is called a ________. blitz team functional team cross-functional team TQM team

cross-functional team

A staff member is assigned to sit in the waiting room of the physician's office to collect data on patient waiting times. The staff member records the time in which the patient comes in the door and when the patient is called back to the examining room. This is an example of what type of data collection? survey interview direct observation qork imaging

direct observation

These types of data are numerical values that represent whole numbers: nominal data ordinal data discrete data continuous data

discrete data

When a recommendation for continuing privileges is not made, or a restriction is privileges is requested, the physician must be provided means by which their application and supporting materials will be reviewed by an impartial panel to ensure objective assessment. This procedure is called _______. Question options: amendment due process root-cause analysis occurrence report

due process

Which is not a primary tool used in the recruitment process: Question options: position requisitions job descriptions education employment applications

education

A _______ interview uses specific questions to determine how the interviewee responds under pressure. Question options: structured unstructured stress none of the above

stress

In this type of interview, a predetermined list of questions is used: structured interview unstructured interview planned interview unplanned interviewed

structured interview

This association was established in 1840 to represent the interests of physicians across the United States. American College of Surgeons American College of Physicians American Medical Association American Association of Physicians

American Medical Association

Examples of this type of data include: weight, time, and temperature: nominal data ordinal data discrete data continuous data

continuous data

Internal customers are individuals from outside the organization who receive products or services from within the organization. True False

False

OSHA requires healthcare organizations to conduct an annual hazard vulnerability analysis (HVA) to identify potential hazards, threats, and adverse events and then assess their impact on care, treatment, and services. Question options: True False

False

Organizational leadership does not use indicators to identify cases in which a patient did not receive the best care. Indicators are not helpful in monitoring care processes. True False

False

Risk management only involves the process of working through a malpractice suit. True False

False. It often spends more time trying to identify organizational condition that increase risk exposure before occurrences of injury happen.

The Joint Commission manages the National Nosocomial Infections Surveillance System (NNIS). True False

False. The CDC's Division of Healthcare Quality Promotion manages it.

A PI team that involves staff from more than one department, service area, or discipline is called: Blitz team Functional team Cross-functional team TQM team

Cross-functional team

A type of PI team that constructs relatively simple and quick "fixes" to improve work process without going through the complete PI cycle is called: Blitz team Functional team Cross-functional team TQM team

Blitz team

The investigational technique that facilitates the identification of the various factors that contribute to a problem known as a fishbone diagram is also called a/an: Pareto chart Cause-and-effect diagram Flowchart Affinity diagram

Cause-and-effect diagram

Which of the following is not one of the 7 keys to successful storytelling? Organization Structure Frequency Condition

Condition

A PI team that involves staff from a single department or service area is called: Blitz team Functional team Cross-functional team TQM team

Functional team

This analysis assists a healthcare organization to determine the types of disasters that they may face. Hazard vulnerability Material vulnerability Material safety data sheets Hazard safety data sheets

Hazard vulnerability

Which of the following individuals volunteered to sponsor the first review of medical college curriculum and educational processes leading to more rigorous academic standards for medical schools? Dr. Thomas Bond Benjamin Franklin Dr. Samuel Gross Henry Pritchett

Henry Pritchett

A person who represents the rights and interests of another individual as though they were the person's own is referred to as a patient: advocate friend advisor manager

advocate

This organization developed a set of National Patient Safety Goals (NPSGs) that all institutions participating in accreditation must promote and train their staffs providing care to adhere to? Joint Commission American Hospital Association Institute of Medicine American College of Surgeons

Joint Commission

Which of the following is the first rule of creating effective storyboards? Prepare clean boards for group presentation and display. Plan the presentation to fit the size of the storyboard and the general size of the panels. Map the board in advance with labels for each section. Keep detailed information in a team record binder for reference.

Map the board in advance with labels for each section.

These documents give detailed information about a material, including any hazards associated with the material. Hazard vulnerability plan Material vulnerability plan Material safety data sheets Hazard safety data sheets

Material safety data sheets

Which of the following agencies provide organizations guidance on the required components of a fire prevention program? Question options: OSHA NIMS NFPA FEMA

NFPA

Which of the following is a system that provides guidelines for common functions and terminology to support clear communication and effective collaboration in emergency situations? Question options: OSHA NIMS NFPA FEMA

NIMS

Which state was the first to pass legislation that required nurses to be registered? Massachusetts North Carolina New York Pennsylvania

North Carolina

A graphic tool used to organize and prioritize ideas after a brainstorming session is called: affinity diagram cause-and-effect diagram brainstorming diagram sentinel diagram

affinity diagram

This acronym is used to train healthcare staff on the proper steps to use a fire extinguisher. RACE PASS FATHOM RATS

PASS

This acronym is used to train healthcare staff on the proper steps to use a fire extinguisher: RACE PASS FATHOM RATS

PASS

Which of the following terms does the textbook use to identify a variety of methods PI teams can use to accomplish their goals? PI processes QI toolbox techniques QI actions PI skills

QI toolbox techniques

This acronym is used to train healthcare staff the proper methods for fire responses. RACE PASS FATHOM RATS

RACE

Which of the following is an example of a certification rather than a license? Question options: RN LCSW LPN RHIA

RHIA

A patient can bring their own and take their own medications to the hospital during a hospitalization. True False

True. This is true but they can only be administered in response to orders that permit their administration, and only after the medication has been evaluated and identified as the correct medication.

A benefit from storytelling is that it documents team accomplishments over an extended period of time in an organized and succinct way. True False

True

Data from a community needs assessment expands the body of knowledge related to behavior changes that promote healthier lifestyles and have the potential to promote wellness in at-risk populations. True False

True

Most performance improvement models are cyclical in nature. True False

True

Postprogram assessments are the most common method used to evaluate employee knowledge of care environment and safety area issues. Question options: True False

True

Proper handwashing has been identified by the CDC as one of the single most important methods for preventing the spread of infection. True False

True

Quality and performance monitoring is a data-driven process. True False

True

The customer is the receiver of a product or service as a result of an organizational process. True False

True

The five rights of medication administration include: right patient, right drug, right dose, right route and right time. True False

True

Various regulatory and accreditation agencies require evidence of PI activities by healthcare organizations to prove their compliance? True False

True

The diamond decision icon symbol is used in flowcharting to indicate: a process when actions are being performed by humans a point in the process at which participants must evaluate the status of the process formal procedures that participants are expected to carry out the same way every time a point in the process where the participants must record data in paper-based or computer-based formats

a point in the process at which participants must evaluate the status of the process

This manual input icon (trapezoid) is used in flowcharting to indicate: a process when actions are being performed by humans a point in the process at which participants must evaluate the status of the process formal procedures that participants are expected to carry out the same way every time a point in the process where the participants must record data in paper-based or computer-based formats

a point in the process where the participants must record data in paper-based or computer-based formats

The rectangle process icon symbol is used in flowcharting to indicate: a process when actions are being performed by humans a point in the process at which participants must evaluate the status of the process formal procedures that participants are expected to carry out the same way every time a point in the process where the participants must record data in paper-based or computer-based formats

a process when actions are being performed by humans

Which section of the CRAF minutes documents who was assigned to accomplish which activities during the next work period? conclusions recommendations actions follow-up

actions

Inappropriate timing of dose, transcription errors, missed doses, extra doses given are all examples of this type of medication error. administration pharmacy discharge prescribing

administration

A patient injury resulting from a medication, either because of a pharmacological reaction to a normal does, or because of a preventable adverse reaction to a drug resulting from an error is called: adverse drug event adverse pharmacological drug error medication error

adverse drug event

Which of the following is often used as a powerful tool for teaching and learning? lecture reports display storytelling

storytelling

This type of data display tool is used to display discrete categories: bar graph histogram pie chart line chart

bar graph

A standard of performance or best practice for a particular process or outcome is called a/an _____. performance measure benchmark improvement opportunity data measure

benchmark

A standard of performance or best practice for a particular process or outcome is called a/an: performance measure benchmark improvement opportunity data measure

benchmark

The systematic comparison of the products, services, and outcomes of one organization with those of a similar organization is called: process comparison outcome comparison comparing benchmarking

benchmarking

A type of PI team that constructs relatively simple and quick "fixes" to improve work process without going through the complete PI cycle is called a ________. blitz team functional team cross-functional team TQM team

blitz team

An idea-generation technique in which a team leader solicits creative input from team members is called: benchmarking systematic input brainstorming team input

brainstorming

A patent for a new drug that gives its manufacturer an exclusive right to market the drug for a specific period of time under this name: brand generic specific patent

brand

The principal process by which organizations optimize the continuum of care for their patients is _________. utilization management services management case management resource management

case management

This data collection tool is used when one needs to gather data on sample observations in order to detect patterns. check sheet ordinal data tool balance sheet nominal data tool

check sheet

Monitoring incidents of patient's falls can be used to measure effectiveness of hospital staff. This type of indicator would be considered a(n) ______. Question options: clinical measure human resource measure process measure employee measure

clinical measure

Which of the following is one of the tools utilized to help HMOs address their specific members' needs? admission planning post-discharge assessment community needs assessment discharge planning

community needs assessment

The symbol in flowcharting that is used to mark the point in the process where the analysis skips to another common point of the process is called: terminator icon line connector icon connector icon process icon

connector icon

A Joint Commission accredited organization must review their formulary annually to ensure a medication's continued: safety and dose efficiency and efficacy efficacy and safety dose and efficiency

efficacy and safety

Healthcare customers expect that staff and providers will understand their emotional reactions to their illness and will help them cope with their circumstances. responsiveness perceived quality empathy assurance

empathy

How often does the reappraisal and reappointment process generally occur? Question options: every year every two years every three years never

every two years

Which section of the CRAF minutes documents whether the actions were accomplished and whether the group is ready to make decisions and recommendations for further activities? conclusions recommendations actions follow-up

follow-up

The predefined process icon (rectangle with vertical lines on the left and right) is used in flowcharting to indicate: a process when actions are being performed by humans a point in the process at which participants must evaluate the status of the process formal procedures that participants are expected to carry out the same way every time a point in the process where the participants must record data in paper-based or computer-based formats

formal procedures that participants are expected to carry out the same way every time

A team organized in the HIM department to look at errors in the release of information process would be considered a: blitz team functional team cross-functional team multi-disciplinary team

functional team

Which of the following techniques, used in unstructured interviews, helps the interviewer establish trust with the respondent and address the pertinent quality issues by moving questions from a broad theme to a narrow theme? funneling skewing nominal group brainstorming

funneling

Criteria that have been developed by many of the same agencies for use across the continuum of care and in various regions of the country are referred to as _________. internal generic external basic

generic

Once a patent for a brand drug expires, other manufacturers may copy the drug and release it under its pharmaceutical or: specific name generic name patent name brand name

generic name

Which of the following includes the management of toxic materials and wastes through the identification of chemicals and materials that need special handling and disposal. Question options: safety management plan security management plan hazardous materials and waste management plan emergency management plan

hazardous materials and waste management plan

An infection defined as occurring in a patient in a hospital or healthcare setting in whom it was not present or incubating at the time of the admission is: healthcare associated infection hospital sickness community-acquired infection community sickness

healthcare associated infection

Which of the following would be considered an indirect caregiver? Question options: registered nurse physical therapist chaplain housekeeper

housekeeper

Any individual permitted by law to provide healthcare services without direction or supervision, within the scope of the individual's license as conferred by state regulatory agencies and consistent with individually granted clinical privileges is referred to as _____. Question options: administrator facilitator licensed independent practitioner service oriented contractor

licensed independent practitioner

In a patient satisfaction survey the patient is asked to rate their level of satisfaction with the healthcare organization, from 1 to 5. This type of method is called? continuous data count data likert scale sliding scale

likert scale

This type of data display tool is a plotted chart of data that shows the progress of a process over time: bar graph histogram pie chart line chart

line chart

This program provides safe and reliable equipment to patients, train care providers in the safe and effective use of the equipment, and ensure that the equipment is maintained by qualified individuals. safety management security management medical equipment management emergency management

medical equipment management

This program provides safe and reliable equipment to patients, trains care providers in the safe and effective use of the equipment, and ensures that the equipment is maintained by qualified individuals: safety management security management medical equipment management emergency management

medical equipment management

Events that occur in a healthcare organization that do not necessarily affect an outcome, but if was to recur, carry significant change of being a serious adverse event is called: time-out serious events sentinel events near-misses

near-misses

A QI technique that allows groups to narrow the focus of discussion or to make decisions without becoming involved in extended circular discussions is called: brainstorming benchmarking decision making technique nominal group technique

nominal group technique

Which of the following techniques is commonly used by the PI team after completing a brainstorming session to rank the ideas generated from least to most important? benchmarking brainstorming decision making technique nominal group technique

nominal group technique

The risk manager's principal tool for capturing the facts about potentially compensable events is the: accident report RM report occurrence report event report

occurrence report

An important strategy in survey design involves the use of terms, phrases, and words that are known to both the PI team and respondents. This clarity of terminology is called _______. assurance responsiveness operational definition direct observation

operational definition

This type of data is also called ranked data and expresses the comparative evaluation of various characteristics or entities, and relative assignment of each, to a class according to a set of criteria: nominal data ordinal data discrete data continuous data

ordinal data

New staff members are required to receive an overview of the organization as well as the details about their specific job responsibilities. This process is called? Question options: on-the-job training orientation job shadowing continuing education

orientation

This type of performance measure indicates the result of the performance or non-performance of a function or process. outcome measure data measure process measure system measure

outcome measure

This type of performance measure indicates the result of the performance or non-performance of a function or process: outcome measure data measure process measure system measure

outcome measure

The final results of care, treatment, and services in terms of the patient's expectations, needs, and quality of life, which may be positive and appropriate or negative and diminishing are included in what area of performance measurement? outcomes processes systems benchmarks

outcomes

This type of chart can help the PI team focus on problems and their causes, and demonstrate which are most responsible for the problem. bar graph pareto chart pie chart line graph

pareto chart

During the mid-1700s, the citizens of Philadelphia, PA, recognized the need to sequester newly arrived immigrants, who often contracted diseases during their long voyages to America. This procedure is an example of early __________. infection control utilization management performance improvement life safety

performance improvement

A quantitative tool that provides an indication of an organization's performance in relation to a specified process or outcome is a/an: performance measure improvement opportunity team-based process data measure

performance measure

This tool provides significant data about a physician's performance to the credentials committee to make decisions about reappointment to the medical staff. Question options: physician profile summary National Practitioners Data Bank medical staff bylaws post-training assessment

physician profile summary

This type of data display tool is used to show the relationship of each part to the whole: bar graph histogram pie chart line chart

pie chart

Which of the following tools may be used to summarize charges from a department? plot table pareto chart pie chart pivot table

pivot table

Follow-up on a patient after discharge to ensure that the transition has gone smoothly and that the patient is receiving all of the services required is considered this case management step: care planning at the time of admission review the progress of care postdischarge planning discharge planning

postdischarge planning

Occurrences involving liability for injury or property loss are call: potentially compensable events risk management risk occurrences potentially harmful occurrences

potentially compensable events

Inappropriate dose, non-formulary agent, medication errors to transfer are all examples of this type of medication error. administration pharmacy discharge prescribing

prescribing

This type of performance measure focuses on a process that leads to a certain outcome, meaning that a scientific or experiential basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome. outcome measure data measure process measure system measure

process measure

This type of performance measure focuses on a process that leads to a certain outcome, meaning that a scientific or experiential basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome: outcome measure data measure process measure system measure

process measure

The interrelated activities in healthcare organizations, which promote effective and safe patient outcomes across services and disciplines within an integrated environment are included in what area of performance measurement? outcomes processes systems benchmarks

processes

This type of report is based on the documented meeting minutes and should include information about PI activities such as: summaries of data collection, conclusions, and recommendations. annual report dashboard storyboard quarterly report

quarterly report

Which section of the CRAF minutes captures the teams plan for putting its decision in effect, with justification points if necessary? conclusions recommendations actions follow-up

recommendations

The level at which an organization can provide an offered product or service when requested and as advertised is called _________. responsiveness reliability assurance empathy

reliability

When the customer (patient) has judged that the healthcare worker is continuously monitoring both the customer's condition and his or her satisfaction with services, what aspect of quality of care or meeting the customer requirement is being met? assurance empathy reliability responsiveness

responsiveness

Monitoring the patient throughout the entire episode of care is considered this case management step; preadmission care planning care planning at the time of admission review progress of care discharge planning

review progress of care

In risk management terminology, an exposure to the chance of injury or financial loss and their associated liability is: incident occurrence rights risk

risk

Analysis of a sentinel event from all aspects to identify how each contributed to the occurrence of the event and to develop new systems that will prevent recurrence is called: flowcharting statistical analysis root-cause analysis nominal group technique

root-cause analysis

This plan demonstrates the master planning and outlines the design of the safety functions for the organization. safety management plan security management plan hazardous materials and waste management plan emergency management plan

safety management plan

This plan demonstrates the master planning and outlines the design of the safety functions for the organization: safety management plan security management plan hazardous materials and waste management plan emergency management plan

safety management plan

This program is designed to manage the physical and personal safeguard of the patients served, staff and individuals coming to the organization. safety management security management hazardous materials and waste management emergency management

security management

Healthcare organizations often use color coded systems (such as Code Green) to alert employees about potential problems in and around the healthcare facility. Some examples of these potential problems are: suspicious vehicles, disruptive visitors, and issuing of trespass notices. Which emergency management program would generate this alert? Question options: safety management plan security management plan hazardous materials and waste management plan emergency management plan

security management plan

An unexpected occurrence involving death or serious physical or psychological injury, or risk thereof is called: unusual event sentinel event unexpected event serious event

sentinel event

The use of infection prevention and control measures to protect against possible exposure to infectious agents is called: infectious deterrents standard measures standard precautions infectious measures

standard precautions

When developing a survey the use of structured questions to limit the number of possible responses helps to: standardize the data collected generate more responses elicit more information maximize the number of write-in responses

standardize the data collected

A graphic display tool used to communicate the details of performance improvement activities is called _________. storyboard minutes report follow-up report

storyboard

The foundations of care giving, which include buildings, equipment, professional staff and appropriate policies are included in what area of performance measurement? outcomes processes systems benchmarks

systems

A document that explains the issues the team was implemented to improve, describes the goals and objectives and desired end state (vision), and lists the initial members of the team and their respective departments is called: team charter team mission team charge team vision

team charter

A PI team role primarily responsible for ensuring that an effective performance improvement process occurs by serving as advisor and consultant to the PI team; remaining neutral, nonvoting member; suggesting alternative PI methods and techniques to keep the team on target and moving forward; maintaining group dynamics; acting as coach and motivator for the team; assisting in consensus building when necessary; and recognizing team and individual achievements is the: team leader team member team recorder/scribe team facilitator

team facilitator

A PI team role responsible for championing the effectiveness of PI activities in meeting customers' needs and for the content of a team's work is the: team leader team member team recorder/scribe team facilitator

team leader

A PI team role responsible for participating in team activities, identifying opportunities for improvement, gathering and analyzing data, sharing knowledge, and planning improvements is a: team leader team member team recorder/scribe team facilitator

team member

A broad statement describing what a healthcare organization does; or a statement of the goals and purpose of a performance improvement initiative is called: team charter team mission team charge team vision

team mission

A PI team role responsible for maintaining the records of a team's work during meetings, including any documentation required by the organization, is the ________. team leader team member team recorder or scribe team facilitator

team recorder or scribe

A PI team role responsible for maintaining the records of a team's work during meetings, including any documentation required by the organization is the: team leader team member team recorder/scribe team facilitator

team recorder/scribe

A description of the ideal end state or a description of the best way a process should function is called: team charter team mission team charge team vision

team vision

How often are healthcare facilities required to practice their emergency preparedness plan? once twice three times never

twice

How often are healthcare facilities required to practice their emergency preparedness plan? annually twice a year three times a year never

twice a year

Which of the following is an integral component of case management that helps to improve patient outcomes, lower healthcare spending, while still providing appropriate care to patients at the appropriate time? clinical practice standards continuum of care review value-based purchasing utilization review

utilization review