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quality > FINAL > Flashcards

FINAL Flashcards

1
Q

Donabedian’s 4 perspectives

A
  • Structure- foundation of caregiving, which includes buildings, equipment, technology, professional staff, and policies
  • Process- The interrelated activities of healthcare organizations- including governance, managerial support, and clinical services- that affect patient outcomes across departments and disciplines within an integrated environment
  • Outcome- the results of care, treatment, and services in terms of the patients expectations, needs, and quality of life, which may be positive and appropriate or negative and diminishing
  • Cost- the amount of financial resources consumed in the provision of healthcare services
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2
Q

Hospital standardization

A

The minimum standard in the early 1900s is the professional organization is credited

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3
Q

TQM philosophy

A

Developed by W. Edward Deming based on the concept that processes, not people cause inferior products and outcomes

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4
Q

Six Sigma

A

Use statistics for measuring variation in a process with the intent of producing error-free results. 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

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5
Q

LEAN

A

quality improvement technique often seen in the manufacturing sector and has been implemented in many other industries with great success.

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6
Q

HRO

A

high reliability organization have learned to manage the unexpected. These organizations know that unexpected change can sometimes be prevented or at least anticipated or even prepared for.

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7
Q

Systems thinking

A

Viewing an organization as an open system of interdependencies and connectedness rather than a collection of individual parts and professional enclaves. Sees interrelatedness as a whole and looks for patterns rather than snapshots of organizational activities and processes

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8
Q

Performance measures

A

System-The foundations of care giving-Buildings, Equipment, Professional staff, appropriate policies
Process- interrelated activities in healthcare organizations, which promote effective and safe patient outcomes across services and disciplines within an integrated environment
Outcome-the final results of care, treatment, and services in terms of the patient’s expectations, needs, and quality of life, which may be positive and appropriate or negative and diminishing

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9
Q

Affinity diagram

A

are used to organize and prioritize ideas after the initial brainstorming session. (Large amount of info) Agrees on categories from brainstorming session.

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10
Q

Brainstorming

A

conducted in a structured or an unstructured way. In structured brainstorming, the leader solicits input from team members by going around the table or room.

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11
Q

Benchmarking

A

systematic comparison of the products, services, and outcomes of one organization with those of a similar organization

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12
Q

Mission

A
  • identifies the PI team, what it does, and whom it serves
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13
Q

Vision

A
  • A description of the ideal end-state

* A description of the way the process should function

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14
Q

Charter

A

Explain what issues the team was implemented to address
•Describe the goal or vision
•List the initial members of the team and their respective departments
•Helpful to keep the team’s objective in focus

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15
Q

Nominal

A

Also called categorical data, Include values assigned to name-specific categories, Male or female, usually displayed on bar graphs or pie charts

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16
Q

Ordinal

A

Also called ranked data, Expresses the comparative evaluation of various characteristics or entities, Likert scales, best displayed on bar graphs or pie charts

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17
Q

Discrete or count data

A

Numerical values that represent whole numbers, Number of children in a family, Number of non-billable patient accounts, Best displayed in bar graphs

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18
Q

Continuous data

A

Assume an infinite number of possible values, Weight, blood pressure, temperature, and so forth, Best displayed in histograms or line charts

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19
Q

Absolute Frequency

A

The number of times that a score or value occurs in the data set

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20
Q

Relative frequency

A

The percentage of the time that the characteristic or score appears in the data set

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21
Q

Bar graphs

A

Used to display discrete categories of data

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22
Q

Histogram

A

Bar graph that displays data proportionally, used to identify problems or changes in a system or process. Based on raw data and absolute frequencies

23
Q

Pareto Chart

A

Bar graph that uses data to determine priorities in problem solving, Help the PI team to focus on problems and their causes

24
Q

Pie Chart

A

Used to show the relationship of each part to the whole

25
Q

Line Chart

A
  • A simple, plotted chart of data that shows the progress of a process over time, PI Teams can identify trends, shifts, or changes in a process over time
26
Q

Control Charts

A

Used to measure key processes over time, Helps the PI team determine whether that variation is normal or a result of special circumstances

27
Q

Pivot tables

A

excel tool to summarize data according to categories

28
Q

What is a storyboard?

A

physical display presentation on a cardboard trifold

29
Q

Frequency of reports to PI Council

A

quarterly report is based on the documented meeting minutes and should include info about PI activities, such as summaries of data collection, conclusions, and recommendations.

30
Q

Format of PI minutes

A

written record of key events in a formal meeting

31
Q

Reference of customer to PI process-

A

internal and external

32
Q

Screening criteria

A

Utilization review- process of determining whether the medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified in the organizations utilization management plan, is an integral part of case management

33
Q

Discharge planning

A

case management plans continued care after the healthcare facility services end

34
Q

NPSGs

A

Identify patient correctly• Improve staff communication• Use medicines safely• Use alarms safely• Prevent mistakes in surgery• Prevent infection• Prevent patients from falling (long-term care) •Prevent bed sores (long-term care) •Identify patient safety risks

35
Q

JC core measures

A

are an example of criteria sets that healthcare organizations use for ongoing patient care monitoring. Acute myocardial infarction, heart failure, community acquired pneumonia, and pregnancy related conditions.

36
Q

Standard/universal precautions

A

can be defined as the use of infection prevention and control measures to protect against possible exposure to infectious agents.

37
Q

The risk manager’s principal tool for capturing the facts about PCEs

A

is the occurrence report, sometimes called the incident report.

38
Q

FMEA

A

failure mode and effects analysis. Technique that promotes systems thinking. FMEA includes defining high-risk processes using flow charts; identifying potential failure points in current processes; and scoring each potential failure by considering factors such as the frequency of failure proactive

39
Q

RCA

A

root cause analysis that determined process issues and new solutions to prevent sentinel events from occurring reactive

40
Q

Know about “clinical privileges”-

A

accordance of permission by a healthcare organization to a licensed independent practitioner to practice in a specific area of specialty within that organization

41
Q

Strategic plan mission vision and goals

A 
SWOT analysis
S—Strengths of the organization
W—Weaknesses of the organization
O—Opportunities that the organization may have
T—Threats to the organization
42
Q

Dashboard

A

the regular presentation of concise, appropriately displayed monitoring data for hospital boards of directors.

43
Q

Peer review

A

review by like professionals, or peers, established according to an organization’s medical staff bylaws, organizational policy and procedure, or the requirements of state law. The peer review system allows medical professionals to candidly critique and criticize the work of their colleagues without fear of reprisal

44
Q

Accreditation

A

The act of granting approval to a healthcare organization

45
Q

Licensure

A

The act of granting a healthcare organization or an individual healthcare provider permission to provide services of a defined scope in a limited geographical area

46
Q

Certification

A

Grants approval for a healthcare organization to provide services to a specific group of beneficiaries

47
Q

Deemed Status

A

term used for the assumption by the cms that an organization meets the Medicare and Medicaid cop as a result of prior accreditation by the accreditation association for ambulatory health care ( AAAHC) the American osteopathic association (AOA), the commission on Accreditation of rehabilitation facilities (CARF), or the joint commission.

48
Q

What is COP

A

a set of regulations published by the CMS to outline requirements of approved programs providing healthcare services to beneficiaries of Medicare and Medicaid programs

49
Q

Data repositories

A

provide PI activities with timely data and information that can be used to continuously monitor the quality of care

50
Q

Information warehouses

A

allow organizations to store reports, presentations, profiles, and graphics interpreted and developed from stores of data for reuse

51
Q

Project Life Cycle

A 
•Initiation- Identify a performance improvement opportunity 
oDetermine feasibility of the project
oDefine project objectives and scope 
oSelect team members 
oCreate vision and mission statements

•Planning
oIdentify the activities (tasks) the team will perform, and estimate the duration of activities
oDevelop final system requirements and criteria for standards of success
oDevelop a schedule and cost estimates
oPerform tasks and track progress

•Execution (Implementation) 
oPresent recommendations to leadership 
oExecute implementation plan
oBegin training 
oTrack and monitor progress
oRevise project as needed

•Closure
oCommunicate results in a final report
oCelebrate success
oContinue evaluation and control and identify new opportunities for improvement

52
Q

Change Management

A

-a group of interpersonal and communication techniques used to help people understand the process of change and accept improvements in the way they perform their work.
•Ending—characterized by grief and letting go
•Transition—characterized by confusion and creativity
•Beginning—characterized by acceptance and hope for the future

53
Q

Privilege

A

information is not admissible at trail unless the holder waives the privilege

54
Q

Protection

A

peer review protection means that the discussions, deliberations, records, and proceedings of medical staff committees having responsibility for the evaluation and improvement of quality are kept confidential and are not aubject to disclosure outside the medical staff process

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