Chapter 15

Question 1

what elements does strategic planning take into account?

Answer 1

Assessment of the community it serves, its scope of services, the available technologies, and staff expertise

Question 2

It validates the mission, vision, goals, and values for the organization.

It is the process of determining the major goals of the organization and the policies and strategies for obtaining and using resources to achieve those goals

Answer 2

Strategic Planning

Question 3

What does the S in the acronym SWOT stand for?

Answer 3

Strengths of organization

Question 4

What does the W in the acronym SWOT stand for?

Answer 4

Weaknesses of organization

Question 5

What does the O in the acronym SWOT stand for?

Answer 5

Opportunities that organization may have

Question 6

What does the T in the acronym SWOT stand for?

Answer 6

Threats to the organization

Question 7

High risk, high volume, or problem prone processes

the degree of adverse impact on patient care that can be expected if an improvement opportunity remains unsolved

the degree to which patient safety is improved

Answer 7

Criteria for setting performance improvement priorities

Question 8

Formal document stating any recurring performances issues along with goals that an employee needs to achieve in order to regain good standing

Answer 8

PI plan

Question 9

What group ultimately has the responsibility for delegating the PI plan implementation?

Answer 9

Board of directors

Question 10

What elements of the Performance Improvement (PI) Plan are evaluated annually?

Answer 10

The executive summary section of the PI review summarizes the main points of the annual report.

Question 11

Provides minute-to-minute data on the myriad functions its various systems perform.

provides valuable information that is in an easily readable format and can be used as a guide for making management decisions.

often times the method used to communicate findings of the benchmarking process and ongoing performance

Answer 11

Dashboards roles in upper committees

Question 12

Findings from peer reviews are aggregated and reported to the executive committee of the medical staff as well as to clinician’s professional files for consideration o=in the re-credentialing process

Answer 12

Peer Review Assessing physician performance

Question 13

Committee made up of individuals who are involved in a patient’s care, including health care practitioners, family members, clergy, and others, with the purpose of reviewing ethical issues in difficult cases

Answer 13

Ethics Committee

Question 14

Makes the final decision regarding credentialing in a managed care organization

Answer 14

Credentialing committee

Question 15

Medical staff composed of physicians and pharmacists who provide necessary information and advice on whether a drug should be added to a formulary

Answer 15

Pharmacy and Therapeutics committee

Question 16

Evaluate and assess existing conditions, operations, and practices to determine the impact of and general compliance with the Joint Commission EOC Standards. Identify and generate improvement opportunities and process change to facilitate the safety, security, and comfort of patients and their social

Answer 16

Environmental safety committee

Question 17

The committee makes recommendations on matters that affect quality of care, including staffing, equipment, space planning, credentialing, medical staff appointment and reappointment, and clinical privileges.

Answer 17

Departmental committee

Question 18

When would peer review take place?

Answer 18

At Departmental Committees (Medicine & Surgery)

Question 19

Review by like professionals, or peers, established according to an organizations medical staff by laws, organizational policy and procedures, or the requirements of the state.

Answer 19

Peer review