Module 5

Question 1

What is HCAHPS?

Answer 1

Nationally standardized publicly reported patient satisfaction

Question 2

Is there a penalty for not reporting?

Answer 2

Yes!

Question 3

What are the goals of HCAHPS?

Answer 3

• Comparable date across hospitals
• Increased transparency
• Creates incentive for hospitals to improve quality of care

Question 4

What are the 10 domains of HCAHPS?

Answer 4

1. Communication w/ nurses
2. Communication w/ doctors
3. Responsiveness of hospital staff
4. Communication about meds
5. Discharge instructions
6. Care transition
7. Cleanliness of hospital
8. Quietness of hospital
9. Overall rating
10. Recommendation of hospital

Question 5

What is the purpose of NDNQI?

Answer 5

To understand the link between nursing staff and patient outcomes; similar to HCAHPS but specific to NURSE SENSITIVE INDICATORS!

Question 6

NDNQI Clinical Indicators: Structure?

Answer 6

Nurse turnover
ED throughput
Patient volume and flow
Staffing and skill mix

Question 7

Process Clinical Indicators (NDNQI)?

Answer 7

Pressure Ulcers
Patient Falls
Care Coordination
Restraints
Device Utilization

Question 8

NDNQI Clinical Indicators: Outcomes?

Answer 8

CAUDIs
CLABSIs
Hospital Readmissions
C-Diff
MRSA
Ventilator Acquired Pneumonia
Pediatric Peripheral IV Infiltration

Question 9

What is meaningful use?

Answer 9

minimum US government standards for electronic health records

Question 10

What does HITECH do?

Answer 10

Promote the use of electronic health records in the US and support technology in healthcare

Question 11

What are the PRIORITIES of meaningful use?

Answer 11

• Improve quality, safety, efficiency, and reduce health disparities
• Improve care coordination
• Improve public/population health
• Ensure privacy and security

Question 12

What are the MAIN COMPONENTS of meaningful use?

Answer 12

• Electronic Health Record
• Barcode Scanning
• Computerized Provider Order Entry (CPOE)

Question 13

What is the PURPOSE of risk management?

Answer 13

• Prevent patient injury
• Minimize financial loss
• Preserve the organization’s reputation

Question 14

What is the law to protect against patient dumping?

Answer 14

EMTALA

Question 15

What does EMTALA make you do?

Answer 15

give people a medical screening exam BEFORE you can ask for insurance or payment source

Question 16

What is the role of the risk manager?

Answer 16

Mandatory reporting of abuse & neglect, nosocomial infections (hospital-acquired), and death within 24 hr of
admission

Question 17

What are reportable events for risk managers?

Answer 17

• Unexpected occurrences or accidents that lead to death
• EMTALA Violations
• Retained surgical objects
• Infant deaths, births, and reportable fetal deaths
• Infants d/c to wrong family
• Pt suicides/attempts
• Sexual assault of patient
• Sentinel events

Question 18

What should you know about Unusual Occurrence Reports (Incidence Reports)?

Answer 18

They should be objective and confidential; should NEVER be found in a patient’s chart.

Question 19

What is a sentinel event?

Answer 19

An event that leads to death, permanent harm, or severe temporary harm

Question 20

Example of Sentinel Events?

Answer 20

Amputating the wrong leg
or
Administering the wrong medication leading to death of the patient

Question 21

What is a Never Event?

Answer 21

Seriously preventable complication that could have reasonably been avoided

Question 22

Example of a Never Event?

Answer 22

Development of Stage 3/4 Pressure Ulcer
or
CLABSI
or
CAUTI (CAUDI)

Question 23

What’s an example of a never event leading to a sentinel event?

Answer 23

RN hangs the wrong blood, patient becomes anaphylactic, and dies.
or
Pt gets CAUTI and becomes septic and dies.

Question 24

T/F: All never events become sentinel events.

Answer 24

False.

Question 25

What does a license do?

Answer 25

Protect the public

Question 26

What is assault?

Answer 26

Making a threat to harm someone

Question 27

What is battery?

Answer 27

Touching someone without consent or justification

Question 28

What should you do if a patient decides to leave AMA?

Answer 28

tell the patient the risks and document what happened

Question 29

T/F: Nurse can make a patient stay that wants to leave.

Answer 29

False, you cannot detain a person wanting to leave the hospital against medical advice.

Question 30

What can you do as a nurse to avoid risk management issues?

Answer 30

• follow 5 rights to med administration
• be competent in skills you’re performing
• thoroughly document everything

Question 31

If you have an order you’re unsure about, what should you do?

Answer 31

• Call DR and have them verify
• Know what your job description is
• Be familiar with policies & procedures

Question 32

What is a high-risk area in healthcare related to diagnosis errors?

Answer 32

Physicians misinterpreting x-rays
or
Residents examining the wrong patient

Question 33

What are high risk areas related to healthcare-acquired infections?

Answer 33

CAUTI
CLABSI
Surgical site infection

Question 34

What is a “fall”?

Answer 34

an unplanned decent to the ground with or without injury

Question 35

What should you know about falls?

Answer 35

They’re preventable!

Question 36

Falls are what kind of issue?

Answer 36

Multidisciplinary b/c pts can fall anywhere in the hospital & Complicated b/c it can involve meds, disease or aging process, mental cognition, ambulation, and noncompliance.

Question 37

20-30% suffer moderate to severe injuries related to falls such as…

Answer 37

Bruises
Hip fractures
Head trauma

Question 38

What is a key factor of falls?

Answer 38

Age!
- Toddlers b/c they’re very wobbly when they walk.
- Old folks due to physical, sensory, and cognitive changes.