Ch 1 Intro To QM

Question 1

What is the Medicare improvement for patients and providers act of 2008?

Answer 1

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

Question 2

What is the safe medical Device act of 1990?

Answer 2

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.

Question 3

What is the health insurance portability and accountability act of 1996?

Answer 3

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.

Question 4

Who is Det Norske Veritas healthcare?

Answer 4

DMV is equivalent to the joint commission. They a credit healthcare organizations and have deemed status with CMS.

Question 5

Define the following words supplier, input, action, output, customer.

Answer 5

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.

Question 6

Define process

Answer 6

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.

Question 7

Define system.

Answer 7

Group of related processes.

Question 8

Define internal customers.

Answer 8

Individuals or groups from within the organization examples referring physicians, hospital employees, departments, and department employees.

Question 9

Define external customers.

Answer 9

Individuals or groups from outside of the organization, examples patients and their families, third-party payers, and the community.

Question 10

Define Focus group

Answer 10

Small groups of focuses on a particular problem and then hopefully derives a solution, requires skilled facilitator to be successful

Question 11

Define quality improvement team

Answer 11

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.

Question 12

Define quality circles

Answer 12

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.

Question 13

Define multi voting

Answer 13

Used after brainstorming to dismiss nonessential or not realistic ideas helps discard on important issues and focus on important ones.

Question 14

What is consensus

Answer 14

After brainstorming this is a method used to get the group to agree on what they will focus on.

Question 15

Define workteams

Answer 15

Focus on solving complex problems or completing an entire task rather than focusing on one particular step in the process.

Question 16

Define problem-solving teams

Answer 16

Teams solve particular problems using root cause analysis. they may use the five whys and the thought process map.

Question 17

Identify the steps in the joint commissions 10 step process.

Answer 17

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

Question 18

Define indicator according to the joint commission

Answer 18

Valid and reliable quantitative process or outcome measure related to one or more dimensions of performance

Question 19

List the two important types of indicators and defined them.

Answer 19

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.

Question 20

Define aggregate data indicator

Answer 20

This indicator quantifies a process or outcome related to many cases, may occur frequently and may be desirable or undesirable.

Question 21

Identify and define healthcare performance indicators. (10)

Answer 21

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.

Question 22

Define SWOT Analysis

Answer 22

Analysis of internal strengths and weaknesses, and external opportunities and threats.

Question 23

Define focus – PDCA

Answer 23

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

Question 24

What is a failure mode and effects analysis FMEA

Answer 24

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

Question 25

What is six sigma

Answer 25

Management strategy seeks to identify and remove causes of errors in business processes.

Question 26

List the five steps used for six Sigma

Answer 26

Define, measure, analyze, improve, control

Question 27

Who is Frederick Winslow Taylor

Answer 27

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

Question 28

Who are W Edwards Deming and Joseph Juran?

Answer 28

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

Question 29

What are the three levels of testing in quality control and who is in charge of them?

Answer 29

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

Question 30

What are the reporting requirements to the Department of Health and Human Services for HIPAA violations?

Answer 30

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.

Question 31

What does HIPAA stand for where can it be found in the federal regulations?

Answer 31

Health Insurance portability and Accountability Act

CFR TITle 45, pART 160