Quality Management in Healthcare Midterm
repeat the project starting at the Plan phase
During the act phase of the PDSA project, what is the next step if changes made to improve performance are found to be unsuccessful?
Data analysis
During which phase of quality management are raw data examined to draw conclusions about performance?
Lean
Eliminating wasteful inefficiencies in a process is the primary goal of which performance improvement model?
Compare current performance to an exemplary organization
For what purpose does an organization use benchmarking?
Pre-industrial revolution craft model
Until the 1970s healthcare quality activities were primarily based on which management system?
Quality Assurance
What activity is done to achieve compliance with minimum quality standards in a healthcare organization?
Percentage of patients reporting nurses treat them with respect
What activity-level measure is related to the facility-level measure "Percentage of rehab facility patients who are very satisfied with the overall quality of care"?
measurement, assessment, and improvement
What are the three primary quality management activities?
response rate is low
What can cause data gathered through the use of patient satisfaction surveys to re unreliable?
Variable conditions and behaviors of patients
What factors unique to healthcare delivery hinder adoption of some industrial quality improvement techniques?
Health Information Technology for Economic and Clinical Health
What federal act created incentives for hospitals and providers to adopt electronic health records?
Balanced scorecard
What framework is used by an organization to categorize facility-level performance measures?
Insurance Industry
What group acts on the behalf of consumers to keep healthcare costs down?
rapid cycle improvement
What improvement model involves small process changes and careful measurement of the effect of the changes?
Lean
What improvement model originated in the toyota automobile production system?
Consistently performs as intended
What is a characteristic of a reliable healthcare service?
Number of records lacking documentation of residents allergies
What is a process measure of staff performance in a nursing home?
Healthcare Cost and Utilization Project
What is a publicly available source of comparative healthcare performance data?
Kaizen event
What is a short-term lean project?
quality circle
What is a small group of employees organized to solve work-related problems?
measure success
What is a step common to all performance improvement models?
Consistent with current professional knowledge
What is one aspect of healthcare quality?
Affordable care
What is one of the aims of the National Quality Strategy?
Better Care
What is one of the aims of the Triple Aim Framework?
Systems perspective
What is one of the core values underlying the Baldrige health care criteria for performance excellence?
performance gap
What is revealed by evaluating the difference between a departments actual and expected performance?
Electronic database
What is the data source for an e-measure?
Total number of home health patients
What is the denominator for the performance measure "percentage of home health patients admitted to the hospital"?
What process do we want to improve?
What is the first question asked during a FOCUS-PDCA project?
Identify topic of interest
What is the first step in constructing a performance measurement?
Quality planning
What is the first step of the Juran Quality Trilogy?
kanban
What lean technique makes it easier for staff to quickly recognize when an inventory item needs to be restocked?
Institute of Medicine
What organization published "Crossing the Quality Chasm: A New Health System for the 21st Century"?
American College of Surgeons
What organization sponsored the first program to improve quality in US hospitals?
five whys
What qualitative tool would be used by an improvement team to undercover the root cause of a performance problem?
Cost-effective
What quality characteristic describes a healthcare service in which the desired results are achieved with minimal expenditure of resources?
Baldridge National Quality Program
What quality program is managed by the National Institute of Standards and Technology in the U.S. Commerce Department?
quality storyboard
What reporting format is used to summarize the steps of a performance improvement project?
poor interrater reliability
What situation puts data accuracy at risk when more than two people are independently gathering data for the same performance measure?
licensing requirements
What state regulations contains quality-related responsibilities for healthcare organizations?
Ratio
What statistic is used to report a measurement that is comparing two things, for instance the actual number of hospital deaths as compared to the expected deaths?
Line graph
What type of data display is commonly used to report performance measurement data over time?
Health insurance plan
What type of healthcare organization uses measures found in the healthcare effectiveness data and information set (HEDIS)?
Special cause variation
When a data point on a control chart falls above the upper control limit, the process being measured is exhibiting what type of characteristic?
High-Value
When healthcare produces good outcomes at a reasonable cost it is considered to be:
Continue to monitor performance
When measurement data show that a departments performance of a key process is meeting expectations, what action should the manager take?
National Quality Forum
Which external group does NOT establish performance measurement requirements for healthcare organizations?
Histogram
Which graph is used to display the frequency distribution of measurement data?
Histogram
Which graph shows the frequency distribution of data in a dataset
Tabular report
Which of the following data displays can be used to show data from different time periods?
Need for improvement
Which of the following factors is not considered when selecting a format for displaying measurement data?
Convenience
Which of the following healthcare quality dimensions was NOT mentioned by the Committee on Quality of Health Care in America as needing improvement?
Check sheet
Which of the following is a data-gathering tool used to collect performance measurement data?
percentage of patients reporting pain was well-controlled
Which of the following is a patient experience measure for an ambulatory surgery center?
Percentage of staff using hand cleaner when entering patient room
Which of the following is a process measure of performance in a hospital intensive care unit?
Number of disaster drills conducted annually
Which of the following is a structure measure used to evaluate hospital performance?
The majority of quality defects are caused by a small percentage of identifiable problems
Which of the following statements best represents the philosophy employed by the Pareto principle?
time-series data are plotted on a control chart
Which of the following statements regarding control charts is true?
Walter Shewhart
Who is considered the father of statistical quality control?
Affinity diagram
Staff members in the physical therapy department gather information about the reasons why patient treatments do not start at the scheduled time. They want to group the reasons for late treatment starts into related categories to identify commonalities. What performance improvement tool could be used to sort the reasons into similar categories?
line grpah
Statistical process control techniques can be applied to which type of graph listed below?
True
T/F: A control chart can be used to distinguish between common cause and special cause variations in performance.
False
T/F: A healthcare service is considered underused when the added benefits are less than the added costs of that service
True
T/F: A performance measure is considered evidence-based if it derived from nationally recognized practice guidelines
True
T/F: Doctors often practice defensive medicine for the purpose of avoiding malpractice liability
False
T/F: Healthcare organizations DO NOT use performance comparisons with other organizations to set performance targets
True
T/F: Healthcare quality can never be achieved without reliability
True
T/F: In a high-reliability organization there are fewer accidents that would be expected.
False
T/F: Measures of clinical decision-making often originate from medical license requirements
True
T/F: Nurses are part of the provider healthcare stakeholder group
no more than five
According to Kaplan and Norton, how many measures should be included in a balanced scorecard category?
Six Sigma
Achieving near-perfect quality is the primary goal of which performance improvement model?
force field analysis
An improvement team in a home health agency wants to streamline the process of discharging patients. The team identifies all the factors that will hinder the success of their improvement plans, as well as those factors that will increase the likelihood of success. The team is using what improvement tool?
cause and effect diagram
An improvement team in the emergency department brainstorms all factors that have an effect on how long patients wait before being seen by a physician. What performance improvement tool would be useful for categorizing the factors identified through this brainstorming activity?
True
T/F: One reason healthcare organizations seek accreditation is to stimulate internal quality improvement efforts.
False
T/F: Performance targets are set at 100% for aspects of healthcare that affect patient satisfaction
True
T/F: Process improvement teams use analytic tools to evaluate where changes are needed to improve performance
True
T/F: Purchaser requirements influence the quality management activities of a healthcare organization
True
T/F: Tampering can occur when a manager reacts to performance measurement results without knowing how much natural performance variance occurs in the process.
False
T/F: The National Quality Strategy is published by the National Academy of Medicine
False
T/F: The healthcare quality triple aim framework was developed by the National Academy of Medicine
True
T/F: The percent of patients receiving home health services who develop a pressure ulcer is a measure of potentially avoidable events.
False
T/F: Visual controls are used in a Lean project to make process waste easier to identify
Conditions of participation
The Medicare program quality management requirements for healthcare facilities are found in what regulations?
scatter diagram
The clinic medical director wants to know if there is a correlation between the number of minutes patients must wait to see a physician and the time of day. Which graph would you use to display the data to help determine if a relationship exists between these two variables?
Pareto chart
The hospital has collected a patient satisfaction data for more than one year. It is now time for strategic planning and you've been asked to summarize the satisfaction data so senior leaders can establish two or three strategic objectives related to improving patient satisfaction. They want to focus on the vital few issues that cause the most problems. What type of graph would you use to provide senior leaders with the information they need?
Interview patients who fail to show up for appointments
The manager of a primary care clinic wants to determine what is causing patients not to show up for their appointment. How would the clinic determine the cause of no-show appointments?
free of defects
for a healthcare process to achieve six sigma, what level of quality is expected?
define-measure-analyze-improve-control
six sigma projects commonly involve which of these steps?
flowchart
staff in an ambulatory surgery center want to streamline the patient admission process. What performance improvement tool would they use to get a better understand of how patients are currently admitted?
capability
what is a measure of the performance potential of a process?
process diagram
what is a visual representation of the flow of process steps?
improvement
which step follows the assessment phase in the quality management cycle?
Do
A health maintenance organization conducted a study on outpatient treatment of patients with asthma. The need for a new asthma management protocol was identified and it was developed. Now the protocol is being piloted by physicians at two primary care clinics. This project is in which phase of the PDSA improvement cycle?
decision matrix
A hospital improvement team has brainstormed several different potential solutions to the problem of high nursing staff turnover. What tool could the team use to select the solutions most likely to be successful?
National no-show rate at similar clinics
A primary care clinic is conducting an improvement project aimed at reducing no-shows to medical appointments. What information would be used by the clinic to set a quantitative improvement foal for this project?
Benchmark data from similar clinics
Patients in an urgent care clinic have expressed concerns about long wait times to see a physician. The clinic manager initiates an improvement project and starts by setting a performance goal What information should the manager use to set this goal?
False
Qualitative tools provide numeric information for an improvement project team
planning matric
a hospital team charged with reducing the incidence of patient falls has selected four different patient care process changes that need to be implemented. What tool would the team use to document the tasks necessary for making these process changes?
