FINAL Flashcards by Amy Harvey

When a facility wants to bill Medicare/Medicaid for services rendered, in order to apply to CMS to receive this funding the healthcare organization has to have met which guideline?

CoP

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What is the name of the CMS agencies that retrospectively review patient records to ensure that the level of care provided by practitioners meets the federal standards for medical necessity, level of care, and quality of care?

QIO’s

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Match the following definition to its proper term: “grants the healthcare organization legal authority to provide healthcare services within its scope of practice

Licensure

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All of the following serve as the basis of the review process except

Clinical practice guidelines and protocols

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Which of the following is the largest healthcare standards-setting body in the world?

TJC

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TJC’s accreditation process emphasizes __________ to evaluate continuous improvement in key safety and quality areas.

A Systems Approach

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The on-site survey process of TJC utilizes _______ that permits assessment of operational systems and processes in relation to the actual experiences of selected patients currently under the organization’s care.

tracer methodology

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The primary focus of TJC is to determine

If the healthcare organization is continually monitoring and improving quality of care

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When an organization is interested in becoming accredited by TJC, the application must include all of the following except:

Names of patients served

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TJC uses all of the following categories to report its decisions on accreditation except:

All of the above

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In the introduction pages of the textbook it spoke of the passage of Medicare in 1965. With the passage of Medicare (Title XVIII), which of the following functions became mandatory?

utilization review

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What process assists a healthcare facility in continuously looking at the ways that problems develop and seeking ways to prevent problems from happening in the future?

performance improvement

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In the introduction there is a discussion regarding TJC and mandated data sets needing reported on. Within this section it speaks of core measures. What is a core measure?

a set of patient care characteristics that TJC and CMS have determined to reflect the quality of care an organization can provide for important diagnoses.

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The process of comparing the outcomes of HIM abstracting functions at your facility with those of comparable departments of superior performance in other healthcare facilities to help improve accuracy and quality is referred to as

benchmarking

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There are four levels in most healthcare systems and all require changes. Which system is the most important one to consider in any healthcare facility?

Level A-the patient

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Performance measure is a tool that provides an indication of an organization’s performance in relation to a specific process or outcome. What type of tool is this?

quantitative

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What is another term for TQM in healthcare?

CQI

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Performance Improvement committes in today’s healthcare environment share the same type of structural characteristic. What is that characteristic?

cyclical

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What criteria is critical in selecting performance indicators for a health information management department?

the indicators must include the most important aspects of performance

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TJC requires that medical record review be performed to evaluate total average health record delinquency rate against monthly hospital discharges

quarterly

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All of the following are steps to consider when choosing a performance measure except:

collecting specific information

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Mercy Hospital is comparing their infant mortality rates for the month of January 2011 with their infant mortality rates for the month of January 2013. What is Mercy doing?

comparing its internal benchmark

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Variation is built into every system in some degree. The variation that is caused by factors outside of the system are called:

special-cause variations

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Which of the following is the BEST example of a performance measure?

95% of all surgery patients will receive prophylactic antibiotics within 1 hour of surgery

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Which QI toolbox technique organizes and prioritizes ideas into logical groupings?

affinity diagrams

Brainstorming, affinity grouping, and nominal group techniques are tools and techniques used during PI initiatives to facilitate ________ among employees?

communication

All of the following statements represent a fundamental principle of performance improvement except:

systems are static and do not demonstrate variation

A key feature of performance improvement is:

a continuous cycle of improvement

This type of performance measure focuses on a process that leads to a certain outcome, meaning that a scientific or experiential basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome.

process measure

Donabedian proposed three types of quality indicators: structure indicators, process indicators, and

outcome indicators

Which of the theorists listed below had the 14-Point model?

Deming

This PI models motto was used for monitoring, evaluating and solving problems in patient care. Which model was this?

10-step

In the “plan” phase of PDCA, which activity is not included?

test the solution with a trial run

DMAIC is part of which PI model?

Six Sigma

Which PI model was developed by Shewhart?

PDCA

What process assists a health care facility in continuously looking at the ways problems develop and seeking ways to prevent the problems from happening in the future?

performance improvement

In the health care setting today, what is the most common PI model used?

PDCA

Which theorist believed, “plan, control, improvement”? Was it

Juran

Which PI theorist believes that performance improvement starts at the top and works it way down?

Joiner

Which PI theorist believes that there are two thresholds in healthcare 100% and 0%?

Crosby

This tool is used to draw comparisons between component parts of the same data as shows how individual components relate to the whole. What type of tool are we talking about?

Pie chart

The local healthcare organization has contracted with ABC Labs, Inc. for all “after hours” lab services. This lab is located two blocks from the health care organization. The process is as follows: The samples are sent to the lab, via messenger. The ordering physician need the lab values back quickly in order to confirm CAP. At the off-site lab, the lab technician runs the tests, reviews the findings, and sends back a preliminary report to the ordering physician via the messenger. The desired turn-around time for this process is 4 hours or less. The data on this process is as follows: The number of after hours procedures performed per month and the average turn-around time per month Using this illustration above, which tool would best illustrate if a trend exists with regards to the timing of received reports over the course of 6 months?

run chart

Reporting the number of incomplete charts over a 6-month period using a run or line chart will prove valuable in which of the following two ways?

over time, the data can reveal trends and point out areas for improvement

The board of directors of a 400-bed women’s hospital receives a report of key quality indicator results on a periodic basis. The report always includes the quarterly cesarean section rate. This reporting period, they see a rise in the rate and want to know if it is a significant increase. What is the best QI tool for this purpose?

control chart

A histogram is a tool used for

displays data proportionally by identifying problems or changes in a system or process

When asked to compare staff member productivity, which tool will be the most effective data presentation to use?

bar chart

The health information reception desk is experiencing a huge influx of phone calls on Monday, Tuesday, and Wednesday mornings. This is creating a problem in getting requested patient information out within an acceptable time frame. The reception staff work group has agreed to start recording the reason for the phone calls for the next 4 weeks. They want to focus on solving the response-time problem by reducing the turnaround time for the largest category of phone calls. Which QI tool best supports this goal?

Pareto chart

All of the following are agencies and organizations that contribute benchmark frameworks for use in PI activities except:

HQO

In your reading assignment about comparative performance data, this reading lists two things TJC has categorized its performance measures into. They are

accountability and non-accountability

When a histogram reflects two peaks this means

incompatible data sets are being compared that need separate histograms

In your reading assignment, there was discussion made about performance data. All of the following are types of performance data except:

absolute frequency

According to the Pareto principle

20% of the sources of a problem are responsible for 80% of its effects.

The coding supervisor is responsible for reviewing a random sample of each coder’s work and reporting on the error rate for each coder. A check sheet is used to collect the number of charts reviewed, the number of errors for each coder, and the type of errors. What type (s) of graph(s) or chart(s) could be used to report the information gathered?

all of the above

Of the following tools listed below, which one is used to plot the points for two variables that may be related to each other in some way?

Scatter diagram

All of the following are part of a successful CQA program except:

the nursing department is not part of the CQA program

Which system is one of the most complex healthcare processes and also one fraught with the greatest possibilities for error?

medication usage system

With blood usage review, the committee must watch all of the following when blood products are ordered except:

how many blood/blood products are ordered

The Utilization Review Coordinator reviews inpatient records at regular intervals to justify necessity and appropriateness of care to warrant further hospitalization. Which of the following utilization review activities is being performed?

concurrent review

Surgical case review includes all of the following except

cases with elements missing in the preoperative anesthesia consultation

Physicians who are members of the Surgery Committee meet to review surgical cases referred for quality issues and deviations from standard care norms. This type of review in which a physician's record is reviewed by his or her professional colleagues is known as

peer review

As based in case law decisions and TJC standards, who is ultimately responsible to ensure quality and appropriateness of patient care in a health care facility?

governing body or board of trustees

In the abstract under medication usage review, all of the following are items that should be included in a drug usage review program in a hospital except

they should all be part of the program

Quality assessment monitoring relies on what primary source document to conduct medical care evaluations?

medical record

The quality review process of invasive and noninvasive procedures to ensure performance of appropriate procedure, preparation of patient, monitoring and postoperative care and education of patient describes which type of review?

surgical case review

The following organizations play a key role in the public-private partnership of the MBNQA except:

Board of Directors

How many steps are there to determine the starting point for assessing customer service quality?

When monitoring and improving customer satisfaction, an organization must know all of the following except:

what satisfies all customers

The Malcolm Baldrige National Quality Award has three sector-specific criteria. Which of the following is not one of the criteria?

all of them are included

Who was responsible for creating the HCAHPS survey?

AHRQ

In the HCAHPS Survey, which rating type did they ask customers to use to rate their overall stay at the hospital?

0-10 (zero being worst, 10 being best)

Which quality customer service award identifies organizations that will serve as role models for other organizations?

MBNQA

All of the following are types of vendors of patient satisfaction surveys except:

NitPicker

Customers receive products or services as a result of what type of process?

organizational

In the HCAHPS survey, the questions covered all of the topics except:

cleanliness of the staff topic

What is the name of the project management tool that is used in clinical process improvement to depict clinical guidelines or critical pathways in the treatment of common medical conditions?

Gantt chart

the UR Coordinator reviews IP records a regular intervals to justify necessity and appropriateness of care to warrant further hospitalizations. Which of following UR activities is being performed?

Continued stay review

The ongoing review of clinical care to ensure the necessity and effectiveness of the services being provided to the patient is the definition for

case management

According to your reading assignment, how many “Steps to Success” are there in Refining the Continuum of Care?

If the UR manager wanted to monitor and evaluate the prevention of inappropriate admissions, when would the manager need to collect the data?

prospectively

All of the following clinical finding represents SI indicators for the UR function for inpatient stay except

PO antibiotics for 10 days

What is the name of the QIO for the State of Missouri?

Primaris

Most health care facilities use this type of screening criteria for UR purposes to determine the need for IP (inpatient) services and justification for continued stay.

Severity of illness/intensity of service

This performance measure enables health care organizations to monitor a process to determine whether it is meeting requirements. What is the name of this performance measure?

Both A & B a. Indicator b. Criterion

All of the following approaches assist UR in determining the nature and extent of required care except:

TPP reviews

According to your textbook, when optimizing patient care, how many steps to success do they list?

NPSGs include all except

Over utilization of healthcare services

What does the abbreviation “P4P” mean?

Pay for Performance

Sentinel events

providers are rewarded for meeting pre-established targets for delivery of healthcare that improve quality and efficiency

What is ORYX?

All of the choices listed

All of the following are among Joint Commission’s initial core measure sets for hospitals EXCEPT

Diabetes

All of the following are core measures of ORYX we need to focus on except:

HEDIS gathers data in the following area(s):

All of the above

The following “sentinel events” must be available for Joint Commission review EXCEPT

Petechiae due to adverse drug reaction

In healthcare, risk includes

any occurrence or circumstance that might result in loss

Which of the following established legal liability for hospitals in 1965?

Darling v. Charleston

Sentinel events

must be reported to TJC along with a root-cause analysis.

Patient advocacy is usually

part of risk management

Risk management programs were introduced to reduce

malpractice suits against healthcare organizations and physicians

According to your reading, there are two documents important for managing risk exposure. One is the incident report, the other is the

patient’s health record

Considering what you now know about incident reporting, when should an incident report be analyzed?

concurrently

In order to assure complete documentation of any type of event in the healthcare setting, Occurrence Screenings, Incident Reports, Event Reports and Hazard Surveillance Reports should be documented and filed in the:

Risk Management Office

Patient safety must be integrated into a healthcare organization’s

all of the above

If TJC is made aware of a sentinel event that meets reportable criteria, how long does the healthcare organization have to prepare a root-cause analysis and action plan?

within 45 days of the event or becoming aware of the event

What is another tool used to help determine a root cause to a problem?

5 Why’s

When completing a RCA, how many steps must be completed?

In the fishbone diagram, what is documented on the “head” of the fishbone?

effect, problem, or quality characteristic

What is a fishbone diagram used for?

all of the above

Which accrediting body requires all accredited healthcare organizations to conduct RCA following any sentinel event?

TJC

In the fishbone diagram, what is shown on the “bones” of the fishbone diagram?

cause(s) of the effect

The medical transcription improvement team wants to identify the cause of poor transcription quality. Which of the following QI tools from the toolbox will best assist the team in identifying the root cause of the problem?

fishbone diagram

According to Mrs. Yu’s OB death we read about in this lesson, what was the proximate cause of her death?

inability of the OB nurses to assist in an emergency surgical procedure

When creating the fishbone diagram, what is the first step you should do?

document an outcome/goal on the right side of the diagram at the end of the horizontal causal line

What is another name for the fishbone diagram?

cause and effect diagram | Ishikawa diagram