QA #2 Flashcards by Abigail Colvin

What are instruments or tools used to gather information

Measures

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What is any type of measurement used to gauge a quantifiable component of performance.

Metric

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What is the way in which an individual, a group, or an organization carries out or accomplishes its important functions and processes.

Performance

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What is a tool that is usually used in the form of a number or statistic?

Measurement

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The numbers are known as ________ or ________

performance measures or quality indicators

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A measure expressed as a percentage is generally _____ useful than a measure expressed as an absolute number

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What clearly communicates a measure’s prevalence in a population?

A percentage

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What compares two things?

Ratio

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What must have a denominator and numerator?

An average

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Can averages be misleading?

Yes, because there could be outliers

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T/F

You should exclude outliers when calculating an average.

True

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Why should outliers be examined separately?

To figure out the root causes

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What are four good characteristics of measurements?

Accuracy, usefulness, east to interpret, and consistently reported

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What is used to judge the adequacy of the environment (physical and organizational resources) that supports healthcare delivery

Structure Measures

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What is used to judge whether patient care and support functions are properly performed

Process Measures

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What is used to judge the results of patient care and support functions

Outcome Measures

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What is used to judge “whether something that should happen in a health care setting actually happened or how often it happened” (AHRQ 2016)

Patient Experience Measures

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Healthcare organizations use two tiers of measures to evaluate performance. What are they?

System level measure

- Activity level measure

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What measures overall performance of processes and activities?

System Level

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What measures individual process or activity performance

Activity Level

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Using a combination of system and activity allows a healthcare organization to do what?

Judge whether overall performance goals are being met

- Identify where frontline improvements may be needed

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What two things guide the different level measures use by healthcare organizations for quality management?

External influence & Internal Influence

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_________ is government regulations, accreditation standards, purchaser requirements

External Influence

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_______ is the organization’s strategic priorities

Internal Influence

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What is used to determine whether clinicians are making the right patient management choices?

Process Measures

What are used to evaluate the results of those choices

Outcome Measures

Outcome and Process Measures are used in decision-making processes by who?

Physicians and other clinicians

1. Identify the topic 2. Develop the measure 3. Design the data collection system What are these steps for?

The process for measure construction

Clinical decision-making measures are primarily ___________ process measures

Evidence-based

What are data that describes the extent to which current best evidence is used in making decisions about patient care.

Evidence-based measures

Determining what you want to know is known as what?

Identifying the topic of interest

Defining the measures that will be used to answer the questions is known as what?

Developing the measure

Ensuring that useful and accurate performance information is gathered, valid and reliable data sources must be identified is known as what?

Designing the data collection system

A _____ data source contains the correct information

Valid

A ______ data source consistently contains the information

Reliable

What is representative portion of a larger group (the population)?

Sample

What is a measure is free from random error and yields consistent results regardless of the individuals gathering the data?

Interrater Reliability

What are frameworks for displaying system-level performance measures

Balanced Scorecards

T/F Components of structured performance management systems that align an organization’s vision and mission with operational objectives

True

What are the categories of scorecards?

- Financial - Customer - Internal business Process - Learning and growing

The assessment phase involves what 3 activities?

- Displaying measurement data - Comparing actual performance with expectations - Determining whether action is needed

What is a measure of the middle or expected center value of a dataset. The most common measures of central tendency are the arithmetic mean, the median, and the mode

Central Tendency

T/F Pareto charts allow organizations to prioritize improvement efforts on the “vital most” sources of problems and not be distracted by those of lesser importance.

False- vital few

_________ should be tied to a pre-defined goal or expectation.

Performance Measures

________ of measurement results should be associated with goals and expectation

Interpretation

_______ without defined performance expectations does not contribute to quality improvement.

Measurements

Performance targets may be established based on what three things?

1. Opinion 2. Criteria 3. Performance comparison and Benchmarking

______ subjective belief regarding good performance

Opinion

______ appropriate standards, rules, or principles developed through clinical practice guidelines, consensus statements, and position papers

Criteria

What does SPC stand for?

Statistical Process Control

What allows the organizations to highlight performance variations and control performance.

Statistical Process Control

T/F Statistical Process Control are primarily based on the importance of increasing process variation to consistently achieve desired results over time.

False- reducing

Performance stability is evaluated by determining the amount of variation is _____ or ______

Stable or Unstable

____ means in a state of statistical control

Stable

_____ means out of statistical control

Unstable

Method for analyzing performance problems and enacting improvements to ensure good performance.

Analyzing the performance of various processes and improving them repeatedly to achieve quality objectives.

Steady, incremental improvement in the organization’s overall performance

Ongoing improvement of processes as a way to improve the quality of the outputs.

CQI

Performance improvment shuld be ______

Systematic

What does PDS(C)A stand for?

- Plan - Do - Study (Check) - Act

What does FOCUS stand for?

- Find - Organize - Clarify - Understand - Select

``` Choose PDS(C)A _____ the change by studying the process and determine ways to measure success ```

Plan

``` Choose PDS(C)A ____ the change on a small scale ```

``` Choose PDS(C)A _____ the data to determine whether the change produced the desired improvements ```

Check

``` Choose PDS(C)A ____ to maintain the gains ```

Act

Choose FOCUS | _____ a process that needs improvement

Find

Choose FOCUS | _____ a team of people knowledgeable about the process

Organize

Choose FOCUS | ______ the current process and the changes needed to achieve the improvement

Clarify

Choose FOCUS | _____ the causes of variation by measuring performance at various steps in the process

Understand

Choose FOCUS | _____ actions needed to improve the process

Select

What is the average amount of weeks per improvement cycle?

Varies around 6 weeks

T/F The rapid cycle improvement includes several big process changes and careful measurement of those changes to achieve an improvement goal

False- Small processes

T/F the rapid cycle improvement is an accelerated method of collecting and analyzing data and making changes based on that analysis

True

What does FADE stand for?

- Focus - Analyze - Develop - Execute

# Choose FADE - Choose a problem | - Write a statement about the problem

Focus

# Choose FADE - Learn more about the problem | - Gather performance data

Analyze

# Choose FADE - Develop a solution for the problem | - Develop an implementation plan

Develop

# Choose FADE - Implement the plan - Monitor results - Adjust the plan as needed

Execute

What are the 8 wastes?

1. Defects 2. Overprocessing 3. Waiting 4. Non-utilized Talents 5. Transportation 6. Inventory 7. Motion 8. Extra Processing

What are the 5S?

Sort, Sustain, Scrub, Standardize, and Straighten

What is a special type of visual control used to indicate the need for movement of materials or patients?

Kanban

What are these steps an example of? 1. Defining the mistake to be prevented 2. Determining the root cause of the mistake 3. Develop a device or method to prevent the mistake or make it easier to identify and correct

Mistake Proofing

What is a special type of process map that illustrates the system perspective of an activity

Value Stream Map

Value Stream Mapping identifies what?

Value-adding vs Non-value adding steps and related measurements

What is a simple and nonverbal way to relay information to others?

Visual Control

What does DMAIC stand for?

- Define - Measure - Analyze - Improve - Control

Define _______

Define the problem

Measure ______

Measure key aspect of the process

Analyze ____

Analyze the data

Improve _____

Improve the system

Control _____

Control and sustain the improvement