HIMS 5635 Exam 2

Scatter Plot

chart displays values for two continuous variables (on the X and Y axes) to find patterns.

Line Chart

displays information as a series of data points connected by straight line segments. It is an extension of a scatter graph, and is created by connecting a series of points that represent individual measurements with line segments. A line chart is often used to visualize a trend in data over intervals of time - a time series - thus the line is often drawn chronologically.

Ask "Why" five times to ......

get to the "root cause"

Run Chart

graph that displays observed data for a Key Output Variable (KOV) (on the Y axis) in a time sequence (on the X axis); usually, the data represent some aspect of the output or performance of a process. The mean line is the average of all the KOV points plotted on the graph.

Key Input Variable

is a process input that provides a significant impact on the output variation of a process or a system or on the key output variable.

Pareto Chart

is a specialized bar chart where data are plotted in order, from the category with the greatest frequency to the least and the cumulative percentage is plotted. The Break Point is defined at 80% cumulative percent.

Determining whether a target change in KOV is met

is calculated using the 'post' average and the 'pre' average as variables, but not any measure of variation/standard deviation (and therefore is not done with control charts)

An indicator of a low quality RCA

is identifying lack of training or non-adherence to policy as the root cause and a corrective or preventive action that is low on the Safety Precedence Sequence (recommend that a person have training)

Key Output Variable

is the factor that results as output from a process or some objects such as parts, assemblies or entire systems.

X-Bar chart

plots the mean of the Key Output Variable from the subgroup on the Y axis

Fishbone diagrams can be used to

represent findings from an RCA.

Control Chart

run chart that plots averages of subgroups with upper and lower control limits that are 3 standard deviations above and below the centerline (which is the mean)

Safety precedence sequence

sequence identifies individual training as the least effective corrective action for a system.

When do you remove Special Cause Variation?

should be removed from control charts (remove only the data point, not the subgroup, unless the entire subgroup is due to a special cause). Removing special cause variation brings in UCL and LCL.

6M Branch Categories of the Fishbone Diagram

-Measurement: Data quality issues for measures that are used to evaluate process quality. -Materials: Intended (materials) and unintended (contaminants) inputs to the process. -Method: How the process is performed and the specific requirements for doing it, such as policies and procedures, rules, regulations and laws. -Environment (Mother Nature): The conditions, such as culture and physical environment in which the process operates. -Manpower: Training, knowledge, experience for anyone involved with the process. -Equipment (Machines): Equipment used or potentially available to use in the process.

ASQ Critique of Healthcare RCAs

-Only does "Five Whys" recommended by TJC. -Distinct from other QI work. -Ends with proximate cause (RC should not be lack of training or non-adherence to policy). -Ignores IC part of DMAIC. -Only done for sentinel events (not near misses or suspected vulnerabilities). -Inadequately trained RCA teams. -Organization does not have a just culture (name, blame, and shame mindset). -Few meta-analyses across RCAs.

How histograms are different than bar graph?

-There is no space between adjacent columns -The columns are positioned over a label that represents a grouped interval for a continuous variable -Grouped intervals are placed in ascending order

What are some questions asked during Root Cause Analysis?

-What happened? (reportable incident or near miss) -What happened that day? -What usually happens? -What should have happened? (per policy) -Why did it happen? (root and contributing causes) -What are we going to do to prevent it from happening again? (preventive actions) -How will we know that our actions improved patient safety? (measures/tracking)

Four Important uses for Control Chart

1) distinguish common cause and special cause variation 2) determining whether a process is 'in control' or 'out of control' 3) identify process trends, 4) determine whether a process improvement made a statistically significant change

Sentinel event

unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

On a control chart, what separates common from assignable causes of variation? a. x-bar lines b. Control limits c. Specification limits d. Production limits e. Mean divided by standard deviation

B. Control Limit

An Ishikawa diagram helps to a. Put information in its order of priority b. Explore past outcomes c. Show team responsibilities d. Show functional responsibilities

B. Explore past outcomes

The X Bar R Chart uses two control charts to monitor a process. What are they? A. Mean and Standard Deviation B. Mean and Range C. Mean and Variance D. Grand Average and Variance

B. Mean and Range

A process is out-of-control. Describe the type of variation that exists in the process. A. Random Variation B. Special Cause Variation C. Common Cause Variation D. Inherent Variation

B. Special Cause Variation

What is the difference between a histogram and a Pareto chart? A. A histogram is a less accurate version of a Pareto chart. B. A histogram is a type of Pareto chart. C. A Pareto chart is a type of histogram. D. A histogram and a Pareto chart simply different terms for the same technique.

C. A Pareto chart is a type of histogram.

A type of bar chart displaying the frequency of occurrence is called a _______________. A. X bar R Control Chart B. Pareto Chart C. Histogram D. Cumulative Frequency Graph

C. Histogram

Your control chart shows seven consecutive points on one side of the mean. What does this indicate? A. The process is in-control (within the UCL and LCL) B. The process appears to be too table and should be questioned C. The process needs to be checked for special causes D. The wrong control chart has been selected

C. The process needs to be checked for special causes

Bar Chart

Chart that displays the Frequency of groups of categorical variables, made up of columns plotted on a graph, where the height of the columns indicated the size of the group defined by the column label.

A project manager used a control chart to determine whether a process was stable or not, and to determine if its performance was predictable. He determined the upper and lower specification limits based on the contractual requirements. A set of eighteen data points were taken. Of these, 8 consecutive data points were above the mean. What can you say about such a process? A. A process is considered as out of control if five consecutive data points are above or below the mean. Hence the process is out of control. B. A process is considered as out of control if six consecutive data points are above or below the mean. Hence the process is within control. C. A process is considered as being within control if less than half the data points are above or below the mean. Hence the process is within control. D. A process is considered as out of control if seven consecutive data points are above or below the mean. Hence the process is out of control.

D. A process is considered as out of control if seven consecutive data points are above or below the mean. Hence the process is out of control.

On a control chart, if six consecutive plot points are above the mean, then what can be established about the process? A. The process is out of control B. The process will be out of control after plotting the seventh point. C. The process is in control D. Nothing can be established

D. Nothing can be established

What is a control chart that monitors changes in the dispersion or variability of a process? a. x-bar chart b. c-chart c. p-chart d. R-chart e. OC chart

D. R-chart

Which Steps should you take when you notice special causes in a control chart? A. Do nothing B. Continue taking data measurements to confirm your belief C. Stop and identify the Special Causes D. Stop, identify the special Causes and eliminate them

D. Stop, identify the special Causes and eliminate them

Control charts can only be used if the data aren't normally distributed. True or False?

False

TJC does not requires that sentinel events be reported and investigated with a root cause analysis (RCA) True or False

False

Upper and lower control limits are usually set at +/- 6 standard deviations from the mean. True or False?

False

What is the Pareto Principle?

Roughly 80% of the effects come from 20% of the causes (also known as the 80-20 rule, created by Joseph Juran and named after Vilifredo Pareto, who found that 80% of pea pods grew from 20% of the plants)

The Joint Commission vs. FDA in Patient Safety Goals and Risk Management

The Joint Commission: -Sentinel Events. -National Patient Safety Goals (NPSG). -Risk management. FDA: -"New Look" approach to risk management. -CAPA process. -FMEA analysis.

Fishbone Diagram

a type of cause and effect diagram that provides users with a tool for visualising the causes and drivers of an outcome, or the head of the fish.

RCAs are required by TJC for .....

all sentinel events.

A project Manager has been overwhelmed with problems on his project. He would like to identify the root cause of the problem in order to determine where to focus his attention. Which of the following tools would be BEST for the project manager to use? a. Pareto Chart b. Conflict resolution techniques c. Fishbone diagram d. Trend Analysis

c. Fishbone diagram

TJC: National Patient Safety Goals (NPSG)

- Improve the Accuracy of patient/resident/client identification. -Improve the effectiveness of Communication among caregivers. -Implement a listing of do-not-use abbreviations. Report all values defines as critical by the laboratory to a responsible caregiver within the time frames. -Standardize an approach to "hand off" communications that includes an opportunity to ask and respond to question. -Improves the safety of using medications. -Eliminate wrong-site, wrong-patient, and wrong-procedure surgery. -Improve the effectiveness of clinical alarm systems. -Reduce the risk of healthcare-associated infections. -Reduce the risk of patient harm resulting from falls. -Reduce the risk of surgical fires. Prevent Healthcare-associated pressure ulcers.

What are the significant of Failure Modes and Effects Analysis?

- List failure modes, causes, and effects in a proactive manner. -Assign 1-10 score for likelihood of occurrence, likelihood of detection, and severity. -Calculate Risk Profile Number (RPN). -Recommend preventive actions.

Risk mitigation strategies

-Avoiding the risk by deciding not to continue with the activity that gives rise to the risk. -Removing the risk source. -Changing the likelihood. -Changing the consequences.

What are the uses of a Fishbone Diagram?

-Compact visual representation of possible causes for a problem. -Identify many possible causes for a bad outcome (e.g., sentinel event) or for not meeting a quality improvement target (e.g., 20% MRSA rate reduction in 6 months). -Quickly sort related ideas into standardized categories. -Can encourage thinking of more causes by identifying underexplored categories from a brainstorming session.

Why use a Pareto Chart?

-Data-based prioritization of QI effort -Uses categorized data to identify the most frequently reported factors -Applies the Pareto principle for the threshold for diminishing returns on investment

Best Practice Incident Analysis: Five Whys

-First why: Focus on what the person did that was "wrong" (usually the nurse). -Second why: Focus on procedures that were not followed by that nurse. -Third why: Focuses on someone in a different role (pharmacist, physician, nurse manager, etc) who did not follow a procedure/policy or detect a problem. -Fourth why: Something at the level of the system that could be better designed to protect against this type of problem. -Fifth why: Organizational incentives not aligned

Corrective Actions: Safety Precedence Sequence In order of reliability for achieving safety:

1. Design the system for minimum hazard. 2. Install safety devices. 3. Use cautions and warnings. 4. Control through administrative means - procedures, instructions, etc. 5. Rely on personnel actions from training, knowledge or awareness. 6.Take no action; accept the risk of recurrence.

Corrective and Preventive Action (CAPA) Process

1. Identify issues or sentinel event. 2. Classify and prioritize reported issues/events. 3. Assign responsibility for the investigation. 4. Investigate/Analyze root and contributing causes. 5. Identify corrective and preventive actions. 6. Implement actions. 7. Monitor effectiveness of actions. 8.Disseminate lessons learned.

Risk Management

A defined process for examining risks and their potential consequences, determining mitigating factors, and whether safeguards are needed to prevent or lessen identified risks.

Select 3 types of Analysis tools to identify root causes/data relationships commonly used in the Six Sigma methodology. A. Control Charts, Pareto Charts, Fish-Bone Diagrams B. Pareto Charts, Capability Indices, Control Charts C. Pareto Charts, Fish-Bone Diagrams, Scatter Plot Diagrams D. Scatter Plot Diagrams, Pareto Charts, Correlation

A. Control Charts, Pareto Charts, Fish-Bone Diagrams

Which one of the characteristics below does not reflect common cause variation: A. Trend B. In-Control C. Predictable D. Stable

A. Trend

Five Whys analysis (Recommended by who?)

Is a best practice recommended by TJC that encourages finding root causes that are less 'proximate' and thus have a better chance of improving the overall system

An Intervention involves a change to a

KIV (Key Input Variable)

Who created the Fishbone Diagram?

Kaoru Ishikawa (also called Ishikawa Diagram)

Target change in KOV is met is calculated using the _____ average and the ____ average as variables, but not any measure of variation/standard deviation (and therefore is not done with control charts)

Post, Pre

Which chart plots the range of the Key Output Variable from the subgroup on the Y axis?

R chart

The data is displayed as a collection of points, each having the value of one variable determining the position on the horizontal axis and the value of the other variable determining the position on the vertical axis on which chart?

Scatter plot

Histogram

Specialized bar chart that displays data proportionally in order to show the relative frequency of occurrence of categories with heights of bars

How to determining Statistically Significant Changes in KOV from an Intervention from an intervention (Change to KIV) using Control Charts?

Statistically significant change if any data in post-intervention Xbar Chart is above original UCL or below LCL

Check sheet

Structured Data collection form used to gather data based on sample observation in order to detect patterns.

Root Cause Analysis

Structured retrospective analysis approach to identify a root cause and contributing causes to an unfortunate outcome.

Frequency distribution

Tabulation of the frequencies of each category defined by a range of values (usually for a continuous variable) Note: a frequency distribution is usually graphically represented by a histogram by means of rectangles whose widths represent class intervals and whose areas are proportional to the corresponding frequencies

Traditional Risk Management vs. "New Look"

Traditional: -Punitive. -To err is human. -Individual performance. -Distance from possibility of failures. -Never let this happen again. -Human error is the cause of accidents. -Compartmentalized flows of information Report and count errors. New Look: -Non-punitive. -To fail is systemic. -Team performance. -Celebrate possibility of failures. -Reduce these sources of vulnerabilities. -Human error is the starting point for inquiry. -Open flows of information. -Analyze/model contributors to failures.

Corrective and Preventive Action (CAPA) Process is used primarily for medical devices in order to satisfy FDA requirements; Corrective and preventive actions are taken in response to specific events and predicted vulnerabilities True or False

True

RCAs conducted in hospitals tend to be lower quality than for medical devices or regulated industries True or false?

True

Failure Modes and Effects (FMEA) Analysis

Use during redesign, when applying process in a new way, or after a failure to prevent problems

Special Cause Variation

When a special circumstance or unexpected event occurs in the process. Outlier data are investigated to see if they are: -Evidence of some inherent change in the system; -New, unanticipated, emergent or previously neglected phenomena within the system; -Variation inherently unpredictable (Also called assignable cause, unnatural pattern)

Common Cause Variation

When an outlier results from expected variation in a process due to the fact that the process cannot be performed in exactly the same manner every time (Also called normal variation, chance variation)