Ch 1 Intro To QM Flashcards
What is the Medicare improvement for patients and providers act of 2008?
This mandates any non-hospital institution performing advanced diagnostic services must be accredited as of January 1, 2012 in order to receive federal funding.
Three options for accreditation:
1. American College of radiology
2. joint commission
3. Intersocietal accreditation commission
What is the safe medical Device act of 1990?
This act provides required communication between FDA And manufactures when there problems with medical devices.
The Facility must report to the FDA and the manufacture any medical devices that are caused the death or serious injury of a patient or employee. If the manufacturer is unknown report must be sent to the FDA.
Form 3500 is used for volunteer reporting.
Form 3500 A is used for mandatory reporting - must be submitted within 10 working days.
What is the health insurance portability and accountability act of 1996?
This act simplified healthcare standards and protected patient security and confidentiality.
Security requirements for the electronic patient records, standard electronic formats for insurance transactions, patient information and confidentiality privacy rules.
Who is Det Norske Veritas healthcare?
DMV is equivalent to the joint commission. They a credit healthcare organizations and have deemed status with CMS.
Define the following words supplier, input, action, output, customer.
Supplier is an individual or entity that furnishes input to a process or provides institutions with goods and services.
Input is information or knowledge necessary to achieve the desired outcome.
Action is the means or activity used to achieve the desired outcome.
Customer - person, department or organization that needs or wants desired outcome.
Define process
Ordered series of steps to help achieve a desired outcome or all of the tasks directed at accomplishing one particular outcome grouped in a sequence.
Define system.
Group of related processes.
Define internal customers.
Individuals or groups from within the organization examples referring physicians, hospital employees, departments, and department employees.
Define external customers.
Individuals or groups from outside of the organization, examples patients and their families, third-party payers, and the community.
Define Focus group
Small groups of focuses on a particular problem and then hopefully derives a solution, requires skilled facilitator to be successful
Define quality improvement team
Group of individuals who implement the solutions that were derived by the focus group, ideally six or seven individuals that are key customers or suppliers of the steps in the process, avoid team managers.
Define quality circles
Group composed of supervisors and workers who are from the same department or may have same function, meet regularly and identify potential problems within department processes and formulate solutions.
Define multi voting
Used after brainstorming to dismiss nonessential or not realistic ideas helps discard on important issues and focus on important ones.
What is consensus
After brainstorming this is a method used to get the group to agree on what they will focus on.
Define workteams
Focus on solving complex problems or completing an entire task rather than focusing on one particular step in the process.
Define problem-solving teams
Teams solve particular problems using root cause analysis. they may use the five whys and the thought process map.
Identify the steps in the joint commissions 10 step process.
Step one assign responsibility
Step two delineate the scope of care and service
Step three identify important aspects of care and service
Step four identify indicators and performance measures
Step 5 establish a means to trigger evaluation
Step 6 collect and organize data
Step 7 initiate evaluation
Step 8 take actions to improve care and service
Step 9 assess affectedness of actions and maintain improvements
Step 10 communicate results to affected individuals and groups
Define indicator according to the joint commission
Valid and reliable quantitative process or outcome measure related to one or more dimensions of performance
List the two important types of indicators and defined them.
Adverse event indicator: this is an undesirable and usually unanticipated event caused by medical management rather than by the underlying disease or condition of the patient. This type of event typically prolongs the hospitalization of the patient.
Sentinel event indicator: this is an unexpected occurrence involving death or serious physical or psychological injury, or the risk there of. This is called a sentinel event because it signals the need for immediate investigation and response. Examples would be wrong site surgery, patient suicide, incorrect medication or blood product administration.
Define aggregate data indicator
This indicator quantifies a process or outcome related to many cases, may occur frequently and may be desirable or undesirable.
Identify and define healthcare performance indicators. (10)
Appropriateness of care – how necessary was the care
Continuity of care – coordination of care amongst practitioners or organizations over time
Effectiveness of care – level of benefit rendered under ordinary circumstances, degree care is provided in the correct manner
Efficacy of care – level of benefit expected, the degree to which the care has been shown to accomplish the desired outcome
Efficiency of care – outcome obtain with the highest quality of care is delivered in the shortest amount of time, least amount of expense, positive outcome for the patient condition.
Respect and caring – Autonomy, sensitivity, respect for patients needs, how will patient is treated
Safety in the care environment – degree to which the risk of an intervention and the risk in the care environment are reduced for the patient and others.
Timeliness of care – degree to which the care or intervention is provided to the patient at the most beneficial or necessary time.
Cost of care – delivery of care that is reasonable for the current marketplace.
Availability of care – if the facility is able to provide the care needed by the patient.
Define SWOT Analysis
Analysis of internal strengths and weaknesses, and external opportunities and threats.
Define focus – PDCA
F – find a process to improve or problem to solve
O- organize a team that knows the process and work on improvement.
C – clarify the problem and current knowledge of the process.
U - understand a problem and the causes of process variation.
S – select the method to improve the process
P – plan to implement a new method to improve the process
D – do the implementation and measure the change
C – check the results of the change
A – act to hold improvements and continue further improvements
What is a failure mode and effects analysis FMEA
Procedure for analysis of potential failure within a system, classifying the severity or determining the effects of failures upon the system and helping determine corrective action to overcome the failure.
Done in three steps, severity, occurrence, detection
What is six sigma
Management strategy seeks to identify and remove causes of errors in business processes.
List the five steps used for six Sigma
Define, measure, analyze, improve, control
Who is Frederick Winslow Taylor
Father of scientific management, instituted the idea of classifying each step of the process to avoid errors and to make a specific individual focus on the low-level details this can be seen in manufacturing plants and any other assembly line system
Who are W Edwards Deming and Joseph Juran?
Both use quality improvement and management strategies to reduce errors and to help the Japanese economy after World War II. PDCA is accredited to Deming
What are the three levels of testing in quality control and who is in charge of them?
Level one noninvasive and simple Any technologist can do level one basic QC testing Level two noninvasive and complex Done by a QC technologist Level III invasive and complex Done by physicist and engineers
What are the reporting requirements to the Department of Health and Human Services for HIPAA violations?
If a breach of unsecured protected health information affects 500 or more individuals, a covered entity must notify the Secretary of the breach without unreasonable delay and in no case later than 60 calendar days from the discovery of the breach.
If a breach of unsecured protected health information affects fewer than 500 individuals, a covered entity must notify the Secretary of the breach within 60 days of the end of the calendar year in which the breach was discovered.
What does HIPAA stand for where can it be found in the federal regulations?
Health Insurance portability and Accountability Act
CFR TITle 45, pART 160
