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CIC Exam > Leadership > Flashcards

Leadership Flashcards

0
Q

What is an outcome measure

A

Measure that indicates the result of the performance of a process or function
Typically undesirable outcome- SSI rates

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1
Q

What are the types of measurement?

A

Outcome measure

Process measure

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2
Q

What is process measure?

A

Focuses in a process or the steps in a process that lead to specific outcomes
Used to evaluate quality if linked to an outcome. Example use of sterile barriers to reduce CLABSI
Hand hygiene compliance

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3
Q

Methods of calculation

What is a Numerator

A

The event being measured.

Falls, VAP, UTI, etc

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4
Q

What is the denominator?

A

Population at risk

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5
Q

What are the 3 ways performance measures are calculated?

A

Rate
Continuous variable
Ratio

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6
Q

What is prevalence rate?

A

Calculation includes existing cases during a time period.

All pts with CAUTI, both new & existing cases on day one in an LTAC

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7
Q

What is continuous variable?

A

Calculated when many results are possible. Days in the hospital, minutes to treatment, wait time

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8
Q

What is ratio- based measure

A

Depends on the relationship btwn 2 counted sets of data and may not have a value of zero or greater

SIR - dividing the number of observed SSI by expected SSI a

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9
Q

What is risk adjusted data or stratified?

A

Stratifying SSI data by pt status, duration, or wound class

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10
Q

What is a PI team?

A

Tool to deploy quality focus culture or process

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11
Q

Gap analysis

A

Technique to determine the steps necessary to take a move from s currant state to a desired state.
Identified gaps in process

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12
Q

Root cause analysis

A

Retrospective look at adverse outcomes and determines what happened, why it happened and what can be done to prevent it again
Investigate major incidence sentinel events and errors

Avoids blames, considers human factors, redesign for a safer system
Uses tree design for responsibility
Team summarizes, identifies causes, strategies about process redesign

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13
Q

Failure mode effect analysis FMEA

A 
Determine a process to study, carries a risk of harm
Content experts
Flow diagram identify steps
Brainstorm possible reasons for failure
Determine actions to eliminate
Redesign the process 
Identify outcome measures
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14
Q

FMEA

A

Failure- lack of success
Mode-process or way things are done
Effects- consequences of an action
Analysis- detailed examination of a process

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15
Q

SWOT analysis

A

Investigate public health issues
Improve healthcare outcomes
Points out what an organization should plan for
How to use resources to guide efforts

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16
Q

Six sigma

A

Precision and accuracy

Eliminates waste.

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17
Q

Six Sigma (DMAIC)

A

Define the customer, project boundaries, improve processes
Measure performance of the process involved
Analyze data collected
Map the process to determine root causes &improvement opportunities
Improve the target process by designing creative solutions to fix problems
Keep the process on the new course

18
Q

List the functions of an IP program

A

Obtain & manage critical data and information (surveillance)
Develop and recommend policies and procedures
Intervene directly to prevent the transmission of infectious disease
Educate and train HCW, patients, and caregivers

19
Q

What is the goal of an IP program?

A

Protect the patient
Protect the HCW, visitor, & others in the health care environment
Accomplish the previous two goals in a cost effective manner when possible

20
Q

Areas to access the quality of the IP program

A 
Customer satisfaction
Appropriateness
Efficacy
Timeliness
Availability
Effectiveness
Efficiency
21
Q

How to determine IP surveillance plan

A

Mandated reporting requirements
Procedures, service lines, surgeries
New equipment, instruments, procedures
Patient demographics - diseases common to a patient population or risk factors

22
Q

What is included in the mission statement

A

Defines purpose, focus, and context for all department activities
Sets boundaries for their activities
Supports the overall institutional mission
Why the program exists

23
Q

What is a vision statement

A

Picture of where the IP program wants the organization to go
Focus on strategic advantages
Add value to others

24
Q

What are topics of communication for nursing

A 
Changing regulations
Surveillance rates
ER situations - outbreaks
Employee practices that need improvement
Education about emerging pathogens
Product recall info
Recommendations to change practice 
Assist in root cause analysis
25
Q

Topics for medical staff

A 
Surveillance rates & ICP minutes
Procedural issues involving physicians
ER situations
Changing legislation & regulations
Recommendations to change practice
26
Q

What is PDSA

A

Plan- identify responsibilities of the person, resources, risks and goals
Do-implement strategies specified in the plan to achieve goals
Study- collect and display data about goal achievement
Act- continual change I order to achieve goals and stay abreast of new developments

27
Q

What is a run chart?

A

Graph that displays observed data in a time sequence

28
Q

What is a histograms

A

Graphical representations visual impression of the distribution of data

29
Q

Fishbone diagram

A

Show the cause of a certain event

Commonly used to identify potential factor causing an overall effect

30
Q

What is a Pareto chart

A

Contains both bars and line graph with individual values represented in descending order by bars.

31
Q

Communication with risk management

A

Product recalls
Pt names from exposure risks/incidents
Notification of inappropriate actions that place pts at risk of infection
Follow up results from pts with infection exp risk
Notifying them of a need for root cause because if death or disability

32
Q

What is a strategic plan

A

Direction the organization will go in the future to meet mission, vision goals
Analysis of the organization
Conclusions about what an organization must do as a result of issues
Action planning

33
Q

TJC a requirements for strategic plan

A

Prioritize the identified risk for acquiring infection
Set goals - unprotected exposures, transmission r/t procedures, equipment, devices, supplies
Describe activities for surveillance
Describe process for evaluation

34
Q

When is a Case control study used?

A

The outcome is known and have to find the risk factors

35
Q

What is a cohort study?

A

Risk factors are known and want to determine the outcome.

36
Q

What is a randomized control study

A

Want to alter the risk or outcome

37
Q

Human factors

A

Environmental, organizational, and job factors and human individual characteristics which influence behavior at work in a way that affects health and safety.

38
Q

What human factors contribute to errors?

A

Limited memory capacity (5-7 pieces in short term memory)
Negative effects of stress & associated cognitive tunnel vision used to compensate and focus in highly intense situations.
Negative influence of fatigue and sensory overload
Overdependence on multi tasking skills if staff in complex work environments

39
Q

What is a functional manger?

A

Most common type spin an organization, person who had authority over an organizational unit. Functional managers have ongoing responsibilities and are not usually directly affiliated with project teams, other than ensuring that goals and objectives are aligned with the organization also overall strategies and vision.

40
Q

Vision statement

A

Answers the WHAT

A picture of the future of the IP program.
Long term
Focus on strategic advantages
Add value to others

41
Q

Mission statement

A

Why does the program exist?
Mission is more concrete and tangible
Common purpose

42
Q

Core values

A

How does the program function on a day to day basis

43
Q

Six sigma DMAIC

A 
Define
Measure
Analyze
Improve
Control

CIC Exam (9 decks)

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