QA #2 Flashcards
What are instruments or tools used to gather information
Measures
What is any type of measurement used to gauge a quantifiable component of performance.
Metric
What is the way in which an individual, a group, or an organization carries out or accomplishes its important functions and processes.
Performance
What is a tool that is usually used in the form of a number or statistic?
Measurement
The numbers are known as ________ or ________
performance measures or quality indicators
A measure expressed as a percentage is generally _____ useful than a measure expressed as an absolute number
More
What clearly communicates a measure’s prevalence in a population?
A percentage
What compares two things?
Ratio
What must have a denominator and numerator?
An average
Can averages be misleading?
Yes, because there could be outliers
T/F
You should exclude outliers when calculating an average.
True
Why should outliers be examined separately?
To figure out the root causes
What are four good characteristics of measurements?
Accuracy, usefulness, east to interpret, and consistently reported
What is used to judge the adequacy of the environment (physical and organizational resources) that supports healthcare delivery
Structure Measures
What is used to judge whether patient care and support functions are properly performed
Process Measures
What is used to judge the results of patient care and support functions
Outcome Measures
What is used to judge “whether something that should happen in a health care setting actually happened or how often it happened” (AHRQ 2016)
Patient Experience Measures
Healthcare organizations use two tiers of measures to evaluate performance. What are they?
- System level measure
- Activity level measure
What measures overall performance of processes and activities?
System Level
What measures individual process or activity performance
Activity Level
Using a combination of system and activity allows a healthcare organization to do what?
- Judge whether overall performance goals are being met
- Identify where frontline improvements may be needed
What two things guide the different level measures use by healthcare organizations for quality management?
External influence & Internal Influence
_________ is government regulations, accreditation standards, purchaser requirements
External Influence
_______ is the organization’s strategic priorities
Internal Influence
What is used to determine whether clinicians are making the right patient management choices?
Process Measures
What are used to evaluate the results of those choices
Outcome Measures
Outcome and Process Measures are used in decision-making processes by who?
Physicians and other clinicians
- Identify the topic
- Develop the measure
- Design the data collection system
What are these steps for?
The process for measure construction
Clinical decision-making measures are primarily ___________ process measures
Evidence-based
What are data that describes the extent to which current best evidence is used in making decisions about patient care.
Evidence-based measures
Determining what you want to know is known as what?
Identifying the topic of interest
Defining the measures that will be used to answer the questions is known as what?
Developing the measure
Ensuring that useful and accurate performance information is gathered, valid and reliable data sources must be identified is known as what?
Designing the data collection system
A _____ data source contains the correct information
Valid
A ______ data source consistently contains the information
Reliable
What is representative portion of a larger group (the population)?
Sample
What is a measure is free from random error and yields consistent results regardless of the individuals gathering the data?
Interrater Reliability
What are frameworks for displaying system-level performance measures
Balanced Scorecards
T/F
Components of structured performance management systems that align an organization’s vision and mission with operational objectives
True
What are the categories of scorecards?
- Financial
- Customer
- Internal business Process
- Learning and growing
The assessment phase involves what 3 activities?
- Displaying measurement data
- Comparing actual performance with expectations
- Determining whether action is needed
What is a measure of the middle or expected center value of a dataset. The most common measures of central tendency are the arithmetic mean, the median, and the mode
Central Tendency
T/F
Pareto charts allow organizations to prioritize improvement efforts on the “vital most” sources of problems and not be distracted by those of lesser importance.
False- vital few
_________ should be tied to a pre-defined goal or expectation.
Performance Measures
________ of measurement results should be associated with goals and expectation
Interpretation
_______ without defined performance expectations does not contribute to quality improvement.
Measurements
Performance targets may be established based on what three things?
- Opinion
- Criteria
- Performance comparison and Benchmarking
______ subjective belief regarding good performance
Opinion
______ appropriate standards, rules, or principles developed through clinical practice guidelines, consensus statements, and position papers
Criteria
What does SPC stand for?
Statistical Process Control
What allows the organizations to highlight performance variations and control performance.
Statistical Process Control
T/F
Statistical Process Control are primarily based on the importance of increasing process variation to consistently achieve desired results over time.
False- reducing
Performance stability is evaluated by determining the amount of variation is _____ or ______
Stable or Unstable
____ means in a state of statistical control
Stable
_____ means out of statistical control
Unstable
Method for analyzing performance problems and enacting improvements to ensure good performance.
PI
Analyzing the performance of various processes and improving them repeatedly to achieve quality objectives.
CI
Steady, incremental improvement in the organization’s overall performance
QI
Ongoing improvement of processes as a way to improve the quality of the outputs.
CQI
Performance improvment shuld be ______
Systematic
What does PDS(C)A stand for?
- Plan
- Do
- Study (Check)
- Act
What does FOCUS stand for?
- Find
- Organize
- Clarify
- Understand
- Select
Choose PDS(C)A \_\_\_\_\_ the change by studying the process and determine ways to measure success
Plan
Choose PDS(C)A \_\_\_\_ the change on a small scale
Do
Choose PDS(C)A \_\_\_\_\_ the data to determine whether the change produced the desired improvements
Check
Choose PDS(C)A \_\_\_\_ to maintain the gains
Act
Choose FOCUS
_____ a process that needs improvement
Find
Choose FOCUS
_____ a team of people knowledgeable about the process
Organize
Choose FOCUS
______ the current process and the changes needed to achieve the improvement
Clarify
Choose FOCUS
_____ the causes of variation by measuring performance at various steps in the process
Understand
Choose FOCUS
_____ actions needed to improve the process
Select
What is the average amount of weeks per improvement cycle?
Varies around 6 weeks
T/F
The rapid cycle improvement includes several big process changes and careful measurement of those changes to achieve an improvement goal
False- Small processes
T/F the rapid cycle improvement is an accelerated method of collecting and analyzing data and making changes based on that analysis
True
What does FADE stand for?
- Focus
- Analyze
- Develop
- Execute
Choose FADE
- Choose a problem
- Write a statement about the problem
Focus
Choose FADE
- Learn more about the problem
- Gather performance data
Analyze
Choose FADE
- Develop a solution for the problem
- Develop an implementation plan
Develop
Choose FADE
- Implement the plan
- Monitor results
- Adjust the plan as needed
Execute
What are the 8 wastes?
- Defects
- Overprocessing
- Waiting
- Non-utilized Talents
- Transportation
- Inventory
- Motion
- Extra Processing
What are the 5S?
Sort, Sustain, Scrub, Standardize, and Straighten
What is a special type of visual control used to indicate the need for movement of materials or patients?
Kanban
What are these steps an example of?
- Defining the mistake to be prevented
- Determining the root cause of the mistake
- Develop a device or method to prevent the mistake or make it easier to identify and correct
Mistake Proofing
What is a special type of process map that illustrates the system perspective of an activity
Value Stream Map
Value Stream Mapping identifies what?
Value-adding vs Non-value adding steps and related measurements
What is a simple and nonverbal way to relay information to others?
Visual Control
What does DMAIC stand for?
- Define
- Measure
- Analyze
- Improve
- Control
Define _______
Define the problem
Measure ______
Measure key aspect of the process
Analyze ____
Analyze the data
Improve _____
Improve the system
Control _____
Control and sustain the improvement