Chapter 18 - Performance

Question 1

performance improvement (PI)

Answer 1

the continuous study and adaptation of a healthcare organization’s functions and processes to increase the likelihood of achieving desired outcomes

Question 2

performance measurement

Answer 2

the process of comparing the outcomes of an organization, work unit, or employee against pre-established performance plans and standards

Question 3

performance indicators

Answer 3

a measure used by healthcare organizations to assess the quality, effectiveness, and efficiency of their services

Question 4

financial indicators

Answer 4

A set of measures designed to routinely monitor the current financial status of a healthcare organization or one of its constituent parts. An example of a financial indicator would be the average cost per radiology exam compared to the average insurance reimbursement amount received.

Question 5

productivity indicators

Answer 5

A set of measures designed to routinely monitor the output and quality of products or services provided to an individual, a healthcare organization, or one of its constituent parts. An example of a productivity indicator would be the number of patients seen per physician per day.

Question 6

PDSA cycle

Answer 6

A cycle used to achieve the goal of constant and never-ending improvement. It is:

1. Plan it
2. Do it
3. Study it
4. Act on its results

Sometimes this is called continuous quality improvement (CQI) or total quality management (TQM).

Question 7

opportunity for improvement

Answer 7

A healthcare structure, product, service, process, or outcome that does not meet its customers’ expectations and, therefore, could be improved.

Question 8

quality indicator

Answer 8

A standard against which actual care may be measured to identify a level of performance for that standard.

Question 9

structure indicators

Answer 9

Something that measures the attributes of the healthcare setting, such as number and qualifications of the staff, adequacy of equipment and facilities, and adequacy of organizational policies and procedures.

Question 10

process indicators

Answer 10

a measure of the steps in a process and the tasks people or devices do (e.g. conducting appropriate tests, making a diagnosis, carrying out a treatment)

Question 11

outcome indicators

Answer 11

a measure of the actual results of care for patients and populations, including patient and family satisfaction

Question 12

external customers vs. internal customers

Answer 12

External customers are those people outside the organization for whom it provides services. For example, the external customers of a hospital would include patients, third-party payers, and the department of health. Organizations also have internal customers such as employees and shareholders.

Question 13

stakeholder

Answer 13

1. a person entrusted with the stakes of bettors
2. one who is involved in or affected by a course of action
3. people or groups without whose support the organization would cease to exist

Question 14

systems thinking

Answer 14

A way of helping a person to view systems from a broad perspective that includes seeing overall structures, patterns and cycles in systems, rather than
seeing only specific events in the system. This broad view can help you to quickly identify the real causes of issues in organizations and know just where to work to address them.

Question 15

common-cause variation

Answer 15

Variation that is inherent within the system is common-cause variation.

For example, when a nurse takes a patient’s blood pressure, she may believe she is performing the procedure in exactly the same way every time, but in practice she will get slightly different readings each time. Although the blood pressure cuff, patient, and nurse are all the same inputs into the system, variations can occur.

For example, the cuff may be applied to a different place on the patient’s arm. The patient may have a slightly different emotional or physiological status at the time of the measurement. The nurse may have a different level of focus or concentration. Any one of these (or other) factors can affect the values obtained. However, they are potentially present in every single episode of blood pressure measurement in every single patient.

It is important to recognize not every variation is a defect. The variation may just be an example of common-cause variation.

Question 16

special-cause variation

Answer 16

An unusual source of variation that occurs outside a process but affects it.

If the special cause produces a negative effect, identify the special cause and eliminate it, if possible. If the special cause produces a positive effect, reinforce it so this positive effect will continue and perhaps be expanded into the processes of others in the organization.

An example: a patient is upset about a phone call he received just before the nurse came in to take his vitals, his blood pressure may register exceptionally high. The change in values occurred due to a special cause (phone call) and resulted in a blood pressure reading much higher than ­expected.

Question 17

conflate

Answer 17

1. to bring together: BLEND
2. to confuse
3. to combine (things, such as two versions of a text) into a composite whole

Question 18

Answer 18

A checksheet is a data collection tool that records and compiles observations or occurrences. The checksheet consists of a simple list of categories, issues, or observations on the left side of the health record and a place on the right to record incidences by placing a checkmark. When the data collection is finished, the checkmarks are counted to reveal any patterns or trends. A checksheet is a simple way to obtain a clear picture of the basic facts.

Question 19

data abstracts

Answer 19

A defined and standardized set of data points or elements common to a patient population that can be regularly identified in the health records of the population and coded for use and analysis in a database management system.

Not to be confused with data abstraction, which is the reduction of a particular body of data to a simplified representation of the whole.

Question 20

Answer 20

Time ladders support the collection of data that must be oriented by time; they specify intervals of time necessary to address the problem under consideration listed down the right side of one, two, or three columns. Then, as the data collector observes, he or she records events next to the time of occurrence.

For example, a receptionist could record on a time ladder when a patient arrives at his or her workstation and then record again on the same time ladder when the patient goes to an exam room. To visualize how the receptionist’s other duties have an impact on his or her interactions with patients, he or she could also be asked to record timing of phone calls, provider requests for assistance, and other competing tasks.

Collecting time ladder data over an appropriate period develops a detailed, clear picture of the workflow or process. Another example is a time ladder created from computer-based data. For example, the EHR could be used to generate a report documenting the time of arrival for patients without appointments. Using this data from a substantial period of a month or more, clinic management could anticipate the need to keep a specific number of appointment slots available for walk-ins.

Question 21

Answer 21

A run chart displays data points for a specific time frame to provide information about performance. In a run chart, the measured points of a process are plotted on a graph at regular time intervals to help team members identify whether there are substantial changes in the numbers over time.

Question 22

Answer 22

A statistical process control chart looks like a run chart except that it has reference lines indicating the upper control limit (UCL) and lower control limit (LCL) drawn horizontally at the top and bottom of the chart. The upper line represents the UCL, and the lower line represents the LCL.

The middle line represents the mean and the line above represents two standard deviations above the mean. The line below the mean represents two standard deviations below the mean. Remember, two standard deviations from the mean statistically include 95 percent of the observations of a process and three standard deviations include 99 percent. Like the run chart, the statistical process control chart plots points to show how a process is performing over time. However, the two control limit lines permit the evaluator to use the rules of probability to interpret whether the process is stable (in other words, predictable and within the bounds of probability) or out of control (many points of data outside the second or third standard deviations).

The statistical process control chart makes it possible to see whether the variation within a process is the result of a common cause or a special cause. It lets the PI team know whether the team needs to try to reduce the ordinary variation occurring through common cause or to seek out a special cause of the variation and try to eliminate it. Removing the variation will bring the upper and lower control limit lines closer together. Common-cause variation would produce patterns that would stay within the two or three standard deviations of the mean, whereas a special-cause variation is more likely to produce patterns that will exceed the limits of chance of the two or three standard deviations.

Question 23

Answer 23

A flow chart is a graphic tool that uses standard symbols to visually display detailed information, including time and distance of the sequential flow of work of an individual or a product as it progresses through a process. A flow chart should be created to illustrate the current process used because the team must first examine and understand the current process before making improvements.

There are different types of flowcharts: each type has its own set of boxes and notations. The four most common types of boxes/symbols in a flowchart are:

A start or end point, represented by an oval.
A processing step, usually called activity, and denoted as a rectangular box.
A decision, usually denoted as a diamond.
A line is a connector that shows the relationship between different shapes.

Question 24

nominal group technique

Answer 24

A process used to reach consensus about an issue or an idea that the team considers most important. Each team member ranks each idea according to importance.

For example, if there were six ideas, the most important idea is ranked with the number six (giving it six points); the second most important idea is ranked the number five, and so on. After each individual team member has had a chance to rank the list of ideas, the scores for each idea are totaled. The nominal group technique demonstrates where the team’s priorities lie.

Question 25

multivoting technique

Answer 25

A variation of the nominal group technique and serves the same purpose. Instead of ranking each issue or idea, team members rate issues by marking them with a distribution of points. In weighted multivoting, a team member distributes his or her allotment of points among as few or as many issues as he or she wants.

For example, the team member might give 13 out of 25 points to one issue of importance, 3 points each to four other issues, and no points to the remaining issues. After the voting, the sum of the numbers given to each issue determines the issue with the highest priority. Thus, the team will be able to see which issue emerged as particularly important to the entire team.

Question 26

affinity grouping

Answer 26

The practice of gathering and grouping together pieces of qualitative (non-numeric) data, based on shared similarities.

Question 27

Answer 27

One of the common quality improvement tools used for risk management purposes is the cause-and-effect diagram.

A cause-and-effect diagram, also known as fishbone diagram because of its characteristic fish shape, is an investigational technique that facilitates the identification of the various factors that contribute to a problem. It facilitates root-cause analysis, or the analysis of an event from all aspects (human, procedural, machinery, material), to identify how each contributed to the occurrence of the event and to develop new systems that will prevent recurrence.

The problem or reason for the quality improvement exercise is written clearly in a box on the right side of the diagram. A horizontal line is drawn and diagonal lines resembling ribs ­connect the boxes above and below the main horizontal line (or backbone). Each box contains a different category of information.

This type of diagram was created by Kaoru Ishikawa.

Question 28

Answer 28

Force-field analysis is another tool used to display data generated through brainstorming. Force-field analysis identifies specific drivers of and barriers to an organizational change, so that positive factors can be reinforced and negative factors reduced. Team members brainstorm the reasons or factors that would encourage a change for improvement and those that might create barriers. The team leader places the factors in the appropriate column on the chart.

Question 29

potentially compensable event

Answer 29

An event (for example, an injury, accident, or medical error) that may result in financial liability for a healthcare organization

Question 30

Lean methodology

Answer 30

Lean is a process improvement methodology focused on eliminating waste and improving the flow of work processes. Healthcare organizations have found ways to apply the Lean methodology, such as eliminating waste in processes by streamlining workflow and tasks to remove time-consuming and unnecessary steps. Healthcare has a growing burden to improve the quality of patient care while also decreasing and controlling costs.

The eight basic principles of lean are:

Improve safety
Increase productivity
Pull scheduling
Reduce inventory
Reduce costs
Minimize waste
Minimize time and effort
Eliminate re-work

Question 31

pull scheduling

Answer 31

a system of production scheduling that pulls product through the value-stream in a continuous flow rather than pushing it through in batches

Question 32

value stream

Answer 32

the set of actions that take place to add value for customers from the initial request through realization of value by the customers

Question 33

pull system vs push system

Answer 33

A pull system is a lean manufacturing strategy used to reduce waste in the production process. In this type of system, components used in the manufacturing process are only replaced once they have been consumed so companies only make enough products to meet customer demand. This means all of the company’s resources are used for producing goods that will immediately be sold and return a profit.

Essentially, a pull system works backwards, starting with the customer’s order then using visual signals to prompt action in each previous step in the process. The product is pulled through the manufacturing process by the consumer’s demand.

Another system used in supply chains is a push system, which sharply contrasts with a pull system. In a push system, units are produced based on forecasted demand and then pushed into the market, whereas a pull system uses actual demand. Companies using a push system must predict what the customer will want to purchase and in what quantity, which is difficult as sales can be unpredictable and vary from previous years.

In a pull system, the quantity produced is just enough to meet current demand. However, in a push system, products are mass produced for estimated future demand. These products must remain in inventory until they are needed, which could take months, years or may not happen at all.

Question 34

Answer 34

Value-stream mapping, also known as “material- and information-flow mapping”, is a lean-management method for analyzing the current state and designing a future state for the series of events that take a product or service from the beginning of the specific process until it reaches the customer.

A value stream map is a visual tool that displays all critical steps in a specific process and easily quantifies the time and volume taken at each stage. Value stream maps show the flow of both materials and information as they progress through the process.

Question 35

value chain

Answer 35

a set of activities that a firm operating in a specific industry performs in order to deliver a valuable product (i.e., good and/or service) for the market

Question 36

Answer 36

A value chain diagram (value chain analysis) is a means of evaluating each of the activities in a company’s value chain to understand where opportunities for improvement lie.

(The term margin refers to the profit margin the company makes out of the activities of its value chain.)

Question 37

Six Sigma

Answer 37

A set of techniques and tools for process improvement. A six sigma process is one in which 99.99966% of all opportunities to produce some feature of a part are statistically expected to be free of defects.

Six Sigma strategies seek to improve manufacturing quality by identifying and removing the causes of defects and minimizing variability in manufacturing and business processes. It does this by using empirical and statistical quality management methods and by hiring people who serve as Six Sigma experts. Each Six Sigma project follows a defined methodology and has specific value targets, such as reducing pollution or increasing customer satisfaction.

(sigma = standard deviation)
Sigma refers to the standard deviation used in descriptive statistics to determine how much an event or observation varies from the estimated average of the population sample. Six Sigma was chosen as a target statistic because even two or three standard deviations would not be acceptable in certain scenarios. A 2.5 percent error rate for making correct change at a movie theater may be acceptable, but that error rate in healthcare can be catastrophic. Even one preventable adverse event or death should not occur. Therefore, it is important to keep this PI (performance improvement) approach in proper perspective when applying it to healthcare. The Six Sigma measure indicates no more than 3.4 errors per 1 million encounters.

Question 38

Lean Six Sigma

Answer 38

Lean Six Sigma methodology utilizes elements of elimination of waste from Lean and critical process quality characteristics from Six Sigma.

Question 39

high reliability organizations (HROs)

Answer 39

Organizations that focus on creating an environment that eliminates or minimizes error.

HRO methodology comes from the airline, wildland firefighting, and nuclear power industries and is now being used in healthcare. HROs are concerned with noticing weak signals in order to prevent a potential negative outcome, and these weak signals receive a substantial response within this model. A weak signal is an early sign of failure.

In healthcare, as with other types of industries, there are often small signals that are ignored. Healthcare organizations can become HROs by paying attention to these small signals.

For example, a housekeeper may notice a problem with a patient. Within an HRO organization, that housekeeper would be empowered and motivated to report this concern to a clinician. An important part of this model and one way that HROs notice weak signals is mindfulness—a keen awareness and a necessary characteristic for all employees of an HRO. When employees are mindful and focused on their duties, there is less room for error. (For example, a distracted physician may be more prone to error.)

Organizational reliability is improved, and errors are reduced when sources of distraction are eliminated and mindfulness is emphasized within a healthcare organization. HROs are preoccupied with failure and use these failures as learning experiences to improve processes and quality in order to eliminate error

Question 40

quality management system (QMS)

ISO 9001

Answer 40

A quality management system (QMS) is a collection of business processes focused on consistently meeting customer requirements and enhancing their satisfaction. It is aligned with an organization’s purpose and strategic direction. It is expressed as the organizational goals and aspirations, policies, processes, documented information and resources needed to implement and maintain it.

ISO 9001 is defined as the international standard that specifies requirements for a quality management system (QMS).