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