Chap 8: External QI

Question 1

What is a generic screen?

Answer 1

A monitor, or routine and on the ration of a process. May be combined with or triggered by Sentinel events.

Question 2

What is the ACCME?

Answer 2

Created by the enemy, it is the accreditation Council for continuing medical education, to accredit providers of AMA certified CME credits.

Question 3

What is the NCQA?

Answer 3

National committee for Quality assurance. A private, nonprofit organization dedicated to improving health care quality since 1990.

Includes accreditation, certification and physician recognition programs. Survey teams and managed-care experts conduct accreditation survey process, along with recording data on key clinical measures.

Question 4

What committee was formed to create accountability of healthcare organizations that use utilization review programs?

Answer 4

The utilization review accreditation commission (URAC), the largest accrediting body for healthcare.

Question 5

What does the joint commission accredit, and how often?

Answer 5

National accrediting body for most hospitals, and some other types of healthcare delivery organizations. Hospital requesting accreditation are charged a fee, and a full accreditation survey is required at least every 3 years.

Question 6

Who establishes national patient safety goals, and how often?

Answer 6

The joint commission, annually.

The joint commission also requires investigation of Sentinel events.

Question 7

As opposed to a focused a valuation, and ongoing evaluation must occur at least once every?

Answer 7

2 years

Question 8

Who created the concept of Never events?

Answer 8

The leapfrog group, the conglomerate of large employers and public purchasers found it it to trigger giant leaps forward in safety, quality and affordability of healthcare.

Question 9

What is the international organization for standardization?

Answer 9

Worlds largest developer and publisher of international standards. ISO 9001 is specific for quality. ISO certification does not replace joint commission certification, but helps improve documentation and records, making certification cheaper and less time-consuming.

Question 10

Many point of service plans, HMOs and PPOs a reporting quality data according to HEDIS. What does HEDIS stand for, and what is the motivation behind this reporting?

Answer 10

Healthcare effectiveness data and information set. NCQA called for reporting of this data in 2005.

HEDIS address a broad range of important health issues, including management of asthma, cardiovascular disease, hypertension, antidepressant medication management, breast, cervical and colorectal cancer, and comprehensive diabetes care.

Question 11

Besides measuring health issues, what else is included in HEDIS?

Answer 11

CAHPS: consumer assessment of healthcare providers and systems, and measure of consumer experience.

Consumers rate claims processing, getting care quickly, getting needed care, Dr. communication, rating of healthcare, health plans, personal doctors and specialists.

Question 12

Name the four parts of the clinical value compass developed by Batalden and Nelson.

Answer 12

1. Functional health status
2. Satisfaction
3. Clinical outcomes
4. Cost

Question 13

What is Baldridge?

Answer 13

The Baldrige national quality program was established in 1987, with healthcare added in 1999

Question 14

What are the Baldrigde performance excellence goals for healthcare?

Answer 14

Quality, sustainability, effectiveness, capabilities, and learning.

Question 15

What do many organizations use Baldridge for?

Answer 15

Use Baldridge to develop an overall performance map to identify areas that need improvement, then use six Sigma, lean or both to improve those areas.

Question 16

What are the Baldrige healthcare criteria for performance excellence, according to the item listing?

Answer 16

1. Leadership
2. Strategic planning
3. Focus on patients, customers and markets
4. Analysis and knowledge management
5. Workforce focus
6. Process management
7. Results.

For the Baldrige national quality award.

Question 17

When does the joint commission initiate the focused evaluation?

Answer 17

2007

Question 18

When was the first board certification?

Answer 18

1917 by ophtho. Used to be voluntary.

Most boardss have 10 years till recertification. Agreed-upon sets of guidelines for all 24 members of the American board of medical specialties in 2002.

Question 19

When was to err is human published?
When was crossing the quality chasm published?
Who published them?

Answer 19

1. 1999
2. 2001
3. The Institute of medicine

Question 20

What was the AAMC’s response to the Institute of medicine reports?

Answer 20

Creates the medical school objectives project, MSOP.

Question 21

What are the three main goals of the MSOP?

Answer 21

1. Critically evaluate the knowledge base supporting good patient care
2. Understand the gap between prevailing and best practices
3. Participate in closing the gap.

Question 22

The IHI works to incorporate the teaching of quality improvement into health professional educational curriculum with 8 knowledge domains. What are they?

Answer 22

1. Healthcare as a process, system
2. Variation and measurement
3. Customer-beneficiary knowledge
4. Leading, following and making changes in healthcare.
5. Collaboration
6. Social context and accountability.
7. Developing new locally useful knowledge
8. Professional subject matter.

Question 23

Which two of the six ACGME core competencies most directly relate to quality improvement?

Answer 23

Practice-based learning: demonstrate the ability to investigate and evaluate patient care practices, to appraise and assimilate scientific evidence, and to improve pt care practices

Systems-based practice: demonstrate an awareness of any responsiveness to the larger context and system of healthcare and the ability to effectively call on the system resources to provide care of optimal value.

Question 24

Can you get CME credit for a quality improvement project?

Answer 24

Apparently since 2005 you can get up to 20 credits, when working through an approved CME provider.

Question 25

List the largest accreditation bodies

Answer 25

NCQA: National committee for quality assurance
URAC: utilization review accreditation commission: largest buddy for healthcare
Joint commission: establishes national patient safety goals, OPPD, so put evaluations, and review of sentinel event.
The leapfrog group
International organization for standardization.