FINAL

Question 1

Donabedian’s 4 perspectives

Answer 1

• Structure- foundation of caregiving, which includes buildings, equipment, technology, professional staff, and policies
• Process- The interrelated activities of healthcare organizations- including governance, managerial support, and clinical services- that affect patient outcomes across departments and disciplines within an integrated environment
• Outcome- the results of care, treatment, and services in terms of the patients expectations, needs, and quality of life, which may be positive and appropriate or negative and diminishing
• Cost- the amount of financial resources consumed in the provision of healthcare services

Question 2

Hospital standardization

Answer 2

The minimum standard in the early 1900s is the professional organization is credited

Question 3

TQM philosophy

Answer 3

Developed by W. Edward Deming based on the concept that processes, not people cause inferior products and outcomes

Question 4

Six Sigma

Answer 4

Use statistics for measuring variation in a process with the intent of producing error-free results. Refers to the standard deviation used in descriptive statistics to determine how much an event or observation varies from the estimated average of the population sample

Question 5

LEAN

Answer 5

quality improvement technique often seen in the manufacturing sector and has been implemented in many other industries with great success.

Question 6

HRO

Answer 6

high reliability organization have learned to manage the unexpected. These organizations know that unexpected change can sometimes be prevented or at least anticipated or even prepared for.

Question 7

Systems thinking

Answer 7

Viewing an organization as an open system of interdependencies and connectedness rather than a collection of individual parts and professional enclaves. Sees interrelatedness as a whole and looks for patterns rather than snapshots of organizational activities and processes

Question 8

Performance measures

Answer 8

System-The foundations of care giving-Buildings, Equipment, Professional staff, appropriate policies
Process- interrelated activities in healthcare organizations, which promote effective and safe patient outcomes across services and disciplines within an integrated environment
Outcome-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

Question 9

Affinity diagram

Answer 9

are used to organize and prioritize ideas after the initial brainstorming session. (Large amount of info) Agrees on categories from brainstorming session.

Question 10

Brainstorming

Answer 10

conducted in a structured or an unstructured way. In structured brainstorming, the leader solicits input from team members by going around the table or room.

Question 11

Benchmarking

Answer 11

systematic comparison of the products, services, and outcomes of one organization with those of a similar organization

Question 12

Mission

Answer 12

• identifies the PI team, what it does, and whom it serves

Question 13

Vision

Answer 13

• A description of the ideal end-state

* A description of the way the process should function

Question 14

Charter

Answer 14

Explain what issues the team was implemented to address
•Describe the goal or vision
•List the initial members of the team and their respective departments
•Helpful to keep the team’s objective in focus

Question 15

Nominal

Answer 15

Also called categorical data, Include values assigned to name-specific categories, Male or female, usually displayed on bar graphs or pie charts

Question 16

Ordinal

Answer 16

Also called ranked data, Expresses the comparative evaluation of various characteristics or entities, Likert scales, best displayed on bar graphs or pie charts

Question 17

Discrete or count data

Answer 17

Numerical values that represent whole numbers, Number of children in a family, Number of non-billable patient accounts, Best displayed in bar graphs

Question 18

Continuous data

Answer 18

Assume an infinite number of possible values, Weight, blood pressure, temperature, and so forth, Best displayed in histograms or line charts

Question 19

Absolute Frequency

Answer 19

The number of times that a score or value occurs in the data set

Question 20

Relative frequency

Answer 20

The percentage of the time that the characteristic or score appears in the data set

Question 21

Bar graphs

Answer 21

Used to display discrete categories of data

Question 22

Histogram

Answer 22

Bar graph that displays data proportionally, used to identify problems or changes in a system or process. Based on raw data and absolute frequencies

Question 23

Pareto Chart

Answer 23

Bar graph that uses data to determine priorities in problem solving, Help the PI team to focus on problems and their causes

Question 24

Pie Chart

Answer 24

Used to show the relationship of each part to the whole

Question 25

Line Chart

Answer 25

- A simple, plotted chart of data that shows the progress of a process over time, PI Teams can identify trends, shifts, or changes in a process over time

Question 26

Control Charts

Answer 26

Used to measure key processes over time, Helps the PI team determine whether that variation is normal or a result of special circumstances

Question 27

Pivot tables

Answer 27

excel tool to summarize data according to categories

Question 28

What is a storyboard?

Answer 28

physical display presentation on a cardboard trifold

Question 29

Frequency of reports to PI Council

Answer 29

quarterly report is based on the documented meeting minutes and should include info about PI activities, such as summaries of data collection, conclusions, and recommendations.

Question 30

Format of PI minutes

Answer 30

written record of key events in a formal meeting

Question 31

Reference of customer to PI process-

Answer 31

internal and external

Question 32

Screening criteria

Answer 32

Utilization review- process of determining whether the medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified in the organizations utilization management plan, is an integral part of case management

Question 33

Discharge planning

Answer 33

case management plans continued care after the healthcare facility services end

Question 34

NPSGs

Answer 34

Identify patient correctly• Improve staff communication• Use medicines safely• Use alarms safely• Prevent mistakes in surgery• Prevent infection• Prevent patients from falling (long-term care) •Prevent bed sores (long-term care) •Identify patient safety risks

Question 35

JC core measures

Answer 35

are an example of criteria sets that healthcare organizations use for ongoing patient care monitoring. Acute myocardial infarction, heart failure, community acquired pneumonia, and pregnancy related conditions.

Question 36

Standard/universal precautions

Answer 36

can be defined as the use of infection prevention and control measures to protect against possible exposure to infectious agents.

Question 37

The risk manager’s principal tool for capturing the facts about PCEs

Answer 37

is the occurrence report, sometimes called the incident report.

Question 38

FMEA

Answer 38

failure mode and effects analysis. Technique that promotes systems thinking. FMEA includes defining high-risk processes using flow charts; identifying potential failure points in current processes; and scoring each potential failure by considering factors such as the frequency of failure proactive

Question 39

RCA

Answer 39

root cause analysis that determined process issues and new solutions to prevent sentinel events from occurring reactive

Question 40

Know about “clinical privileges”-

Answer 40

accordance of permission by a healthcare organization to a licensed independent practitioner to practice in a specific area of specialty within that organization

Question 41

Strategic plan mission vision and goals

Answer 41

``` SWOT analysis S—Strengths of the organization W—Weaknesses of the organization O—Opportunities that the organization may have T—Threats to the organization ```

Question 42

Dashboard

Answer 42

the regular presentation of concise, appropriately displayed monitoring data for hospital boards of directors.

Question 43

Peer review

Answer 43

review by like professionals, or peers, established according to an organization’s medical staff bylaws, organizational policy and procedure, or the requirements of state law. The peer review system allows medical professionals to candidly critique and criticize the work of their colleagues without fear of reprisal

Question 44

Accreditation

Answer 44

The act of granting approval to a healthcare organization

Question 45

Licensure

Answer 45

The act of granting a healthcare organization or an individual healthcare provider permission to provide services of a defined scope in a limited geographical area

Question 46

Certification

Answer 46

Grants approval for a healthcare organization to provide services to a specific group of beneficiaries

Question 47

Deemed Status

Answer 47

term used for the assumption by the cms that an organization meets the Medicare and Medicaid cop as a result of prior accreditation by the accreditation association for ambulatory health care ( AAAHC) the American osteopathic association (AOA), the commission on Accreditation of rehabilitation facilities (CARF), or the joint commission.

Question 48

What is COP

Answer 48

a set of regulations published by the CMS to outline requirements of approved programs providing healthcare services to beneficiaries of Medicare and Medicaid programs

Question 49

Data repositories

Answer 49

provide PI activities with timely data and information that can be used to continuously monitor the quality of care

Question 50

Information warehouses

Answer 50

allow organizations to store reports, presentations, profiles, and graphics interpreted and developed from stores of data for reuse

Question 51

Project Life Cycle

Answer 51

``` •Initiation- Identify a performance improvement opportunity oDetermine feasibility of the project oDefine project objectives and scope oSelect team members oCreate vision and mission statements ``` •Planning oIdentify the activities (tasks) the team will perform, and estimate the duration of activities oDevelop final system requirements and criteria for standards of success oDevelop a schedule and cost estimates oPerform tasks and track progress ``` •Execution (Implementation) oPresent recommendations to leadership oExecute implementation plan oBegin training oTrack and monitor progress oRevise project as needed ``` •Closure oCommunicate results in a final report oCelebrate success oContinue evaluation and control and identify new opportunities for improvement

Question 52

Change Management

Answer 52

-a group of interpersonal and communication techniques used to help people understand the process of change and accept improvements in the way they perform their work. •Ending—characterized by grief and letting go •Transition—characterized by confusion and creativity •Beginning—characterized by acceptance and hope for the future

Question 53

Privilege

Answer 53

information is not admissible at trail unless the holder waives the privilege

Question 54

Protection

Answer 54

peer review protection means that the discussions, deliberations, records, and proceedings of medical staff committees having responsibility for the evaluation and improvement of quality are kept confidential and are not aubject to disclosure outside the medical staff process