HCM 450- Section 1

Question 1

Meaning of quality management

Answer 1

Quality management is a broad term encompassing all activities in a healthcare organization used to direct, control and improve quality. Quality management is the means by which patient care is maintained and improved at all levels of the system- individual, department and organizational.

Question 2

What is the primary reason for quality management?
A. Blueprint of patient care
B. Patient Care
C. Continuous improvement
D. All the Above

Answer 2

C. Continuous improvement

Question 3

Identify the primary activities of quality management

Answer 3

Measurement, assessment, and improvement

Question 4

Define Measurement

Answer 4

Collection of information for the purpose of understanding current performance and seeing how performance changes or improves over time.

Question 5

Define Assessment

Answer 5

Use of performance information to determine whether an acceptable level of quality has been achieved.

Question 6

Define Improvement

Answer 6

Planning and making changes to current practices to achieve better performance.

Question 7

Describe the common components of the quality management system in a healthcare organization.

Answer 7

Quality infrastructure (routine meetings with cross departmental representations), leadership oversight and accountability, performance measurement in key clinical and service, use of measurement data to improve performance in key clinical and service categories, involvement of major stakeholders including sharing of performance data with front line staff

Question 8

Groups involved in quality management system

Answer 8

governing body or board of trustees, senior leaders, second tier groups, third tier groups (multi-disciplinary, interdepartmental committees)

Question 9

In quality management, the governing body or board of trustees are responsible for

Answer 9

ultimately responsible for the quality of patient care in a hospital

Question 10

In quality management, the senior leaders are responsible for

Answer 10

ensuring continuous quality improvement and for establishing and cultivating a culture of safety.

Question 11

In quality management, second tier groups are responsible for

Answer 11

coordinating the quality management activities and evaluating performance of physicians and licensed independent practitioners

Question 12

In quality management, third tier groups are charged with

Answer 12

conducting quality management activities in a particular service or function

Question 13

Describe the purpose of quality management plan

Answer 13

The primary purpose of quality management plan is to provide a blueprint for measuring and improving performance. A properly documented and implemented plan provides reasonable assurance that the organization is in compliance with regulatory requirements and accreditation standards. The Medicare conditions of participation require participating providers to have a written plan.

Question 14

Elements of a basic quality plan

Answer 14

• An outline of the program structure
• Designation of the committee responsible for overseeing the program
• Role, structure, function, and frequency of meetings of the program oversight committee and other relevant committees

Question 15

Describe performance assessment techniques

Answer 15

look up

Question 16

Structure measures

Answer 16

• measures of health care performance are used to assess the adequacy of the environment in which health care takes place.
• The results of a structure measure are generally binary; either the structure is acceptable or it is not acceptable. A limitation of structure measurement is that an acceptable structure may not be sufficient to assure high quality health care.

Question 17

Process measures

Answer 17

measures of health care performance are used to assess the completion of required tasks. The measure is used to evaluate whether the task was performed (or not performed) as expected.

Question 18

Outcome Performance

Answer 18

measures are used to assess the end results of health care services.

Question 19

Outcome Performance

Answer 19

measures are used to assess the end results of health care services. (physiologic, psycho social, or biological)

Question 20

Patient experience measure

Answer 20

Some end results are experiential- meaning the results pertain to or derived from experiences of health service recipients

Question 21

Measure that could be used by rehabilitation facility to evaluate the STRUCTURAL aspects…
A. Number of certified nursing assistants on each shift
B. Percent of patients able to ambulate 20 ft without assistance
C. Number of patients who develop a UTI
D. Percent of patients who are readmitted to the hospital

Answer 21

A. Number of certified nursing assistants on each shift

Question 22

Percentage of patients who develop deep vein thrombosis following a surgical procedure

Answer 22

Outcome measure

Question 23

A PROCESS measure of performance for a hospital emergency department

Answer 23

Percent of time staff confirm patient AD beoire giving medication

Question 24

For the performance measure’ “Percent of staff who comply with hand hygiene requirements” what population would be included in the numerator?
A. Number of staff observed in compliance with hand hygiene requirements
B. Number of staff who are acknowledgeable of hand hygiene requirements
C. Number of staff observed caring for patients
D. Number of staff on duty during observation period

Answer 24

A. Number of staff observed in compliance with hand hygiene requirements

Question 25

A PATIENT EXPERIENCE measure A. Percent of patients that report their pain was adequately controlled postop B. Percent of patients assessed for fall risk at the tie of hospital admission C. Percent of phone calls answered by admission clerks within 90 seconds D. Average time between carpal tunnel surgery and return to work

Answer 25

A. Percent of patients that report their pain was adequately controlled postoperatively

Question 26

A PROCESS measure that could be used by a family practice clinic to evaluate the quality of care provided to adults with asthma A. Percent of patients with an exacerbation requiring hospitalization B. percent of patients that receive instructions on the use of their medications C. Percent of patients satisfied with the clinic's asthma educational sessions D. Percent of patients with asthma who have health insurance

Answer 26

B. percent of patients that receive instructions on the use of their medications

Question 27

Demonstrate an understanding of methods used to collect measurement data, particularly determining sample size

Answer 27

•Now we know what we want to measure... •Design strategy for gathering data for the measures •Goal: Obtain accurate data that matches the measurement data specifications

Question 28

Recognize performance improvement methods

Answer 28

1. Finding the cause of information gaps 2. Select interventions 3. Implement Interventions

Question 29

Demonstrate an understanding of the relationship between quality management, patient safety, and risk management

Answer 29

ch 7

Question 30

3 primary risk management functions include:

Answer 30

risk identification, evaluation and control

Question 31

Describe RCA (root cause analysis)

Answer 31

performance improvement project done following a significant patient incident or sentinel event. JC require accredited orgs to conduct a RCA following occurrence of any serious patient incident considered to be sentinel event. When event occurs, project team is appointed to do the RCA and it is normally a multi-disciplinary, inter-department project.

Question 32

RCA (root cause analysis) | Steps

Answer 32

* Understand what happened * Identify the root causes of the event * Design, Implement and evaluate the effectiveness of risk reduction strategies (action plans). * Make risk reduction strategies permanent or revise and re-test strategies

Question 33

What are the two types of variation in quality management?

Answer 33

Common Cause Variation | Special Cause Variation

Question 34

Describe common cause variation

Answer 34

(also cause normal, chance or random variation) is predictable; process is in control and stable

Question 35

Describe special cause variation

Answer 35

(also called abnormal or assignable cause variation) is not predictable; process is out of control and unstable