exam 1: quality management in healthcare

Question 1

continuous quality improvement (CQI)

Answer 1

PROCESS used to improve quality and performance

Question 2

what are the 3 key processes for improvement

Answer 2

1. system: is there something creating the errors
2. clinical: nurses at bedside
3. managerial: evals, cost benefits

Question 3

total quality management (TQM)

Answer 3

management PHILOSOPHY that emphasizes a commitment to excellence throughout the organization
- pursue excellence

Question 4

what does DMAIC stand for and what process is it part of

Answer 4

define, measure, analyze, improve, control
- it is part of the Six Sigma process in determining how far we deviate from perfection

Question 5

hospital consumer assessment of healthcare and systems (HCAHPS)

Answer 5

survey to patients

Question 6

incident reports

Answer 6

used to analyze the severity, freq, and causes of occurrences within the five risk categories

Question 7

indicator
- retrospective indicator
- concurrent indicator

Answer 7

too used to measure performance of structure, process, and outcome standards
- retrospective: look at pt chart at discharge and pull data

• concurrent: looking at pt chart while they’re there

Question 8

what is the difference between indicator and benchmarking?

Answer 8

indicator: looking at a specific hospitals standards

benchmarking: compare to other locations

Question 9

just culture

Answer 9

fairness in approaches, look at root problem, not immediate blame, look at big picture
- Differentiate between human errors, at risk behaviors, and reckless behaviors

Question 10

what should a nurse manager be and what should they foster?

Answer 10

• Mediator and encourager
• Foster good communication
• Keep unit informed when mistakes occur

Question 11

six sigma

Answer 11

quality management program that uses qualitative data to monitor progress; how much does performance deviate from the standard

Question 12

lean six sigma

Answer 12

improve process flow and eliminating waste, decrease variation to improve efficiency

Question 13

outcome standard

Answer 13

all effects of healthcare on patients and populations, changes to health status, behavior, knowledge, satisfaction

Question 14

what is the most important indicator of quality

Answer 14

outcome standard

Question 15

process standards

Answer 15

sum of all actions that make up healthcare, connected with actual delivery of care

Question 16

quality management

Answer 16

philosophy that defines a corporate culture emphasizing customer satisfaction, innovation, and employee involvement –> seeks to prevent problems or improve care

Question 17

reportable incident

Answer 17

includes any unplanned occurrence that affects or could potentially affect a patient, family member, or staff

Question 18

risk management (and risk management program)

Answer 18

purpose is to ID, analyze, and eval risk and then dev a plan for reducing the freq and severity of accidents and injuries

Question 19

root-cause analysis

Answer 19

working backwards and seeing what lead to that event

Question 20

spaghetti diagram

Answer 20

drawing of actual work flow in specified area at a point in time

Question 21

structure standards

Answer 21

all factors that relate to physical environment, organization and management of an organization and affect the context in which care is delivered

Question 22

quality improvement

Answer 22

ew ways to prevent errors from happening
- Ongoing process of innovation, prevention of error, and staff involvement

Question 23

explain the 3 different types of standards:
- outcome standard
- process standard
- structure standard

Answer 23

• outcome standard: all effects of healthcare on patients and populations, changes to health status, behavior, knowledge, satisfaction
• process standard: sum of all actions that make up healthcare, connected with actual delivery of care
• structure standard: all factors that relate to physical environment, organization and management of an organization and affect the context in which care is delivered

Question 24

what are the six themes of six sigma

Answer 24

1. patient focus
2. data drive
3. process emphasis
4. proactive management
5. boundaryless collab
6. aim for perfection, but tolerate failure