Test 2

Question 1

What are 5 function an HCO’s clinical organization must perform?

Answer 1

Ensure an accurate diagnosis, 
ensure excellent care (safe, effective, patient-centered, timely, effective, equitable), 
individualize patient care, 
improve community health, 
improve clinical performance.

Question 2

What are patient management protocols?

Answer 2

Formally established expectations that define the normal steps or processes in the care of a clinically related group of patients at a specific institution. (e.g., diagnosing and treating chest pain at a specific facility)

Question 3

What are functional protocols?

Answer 3

Procedures and sets of activities to carry out elements of care. (e.g., the process of prescribing medication)

Question 4

Patient management protocols should be flexible and adaptable. What are some ways to do that?

Answer 4

Protocols should be reviewed regularly, they should emphasize conditional expectations, and they should include provisions for exceptions.

Question 5

Patient management protocols improve:

Answer 5

Individual caregiver performance in four ways. 1. provides evidence-based guidelines. 2. Several professions can usee it to anticipate and coordinate care events. 3. Caregivers can use it as an outline to guide decisions 4. Measures performance and information collection.

Question 6

Functional protocols improve:

Answer 6

Processes by: eliminating unnecessary tasks, looking for overlooked tasks, standardizing supplies, reducing errors, finding ways to lower costs, and re-engineering the care process

Question 7

IOM Six dimensions of quality

Answer 7

Safety
Timeliness
Effectiveness
Efficiency
Equity
Patient-centeredness

Question 8

3 methods for process improvement

Answer 8

CQI, Lean, Six sigma

Question 9

Donabedian’s definition of quality

Answer 9

Healthcare delivered using:
the right structure
the right processes
that produces good outcomes

Question 10

What are clinical support services

Answer 10

Non-nursing, non-clinical services. 
Radiology 
clinical laboratory
ED
OR
Pharmacy
PT/OT
cardio-respiratory therapy
GI lab
cardio diagnostics

Question 11

Who manages the clinical services departments?

Answer 11

Each department has a manger that reports to the chief of patient care office, the COO, the CMO, or the VP of professional services.

Question 12

Toughest job of the hospital:

Answer 12

Nursing manager of the OR

Question 13

Who works in the OR

Answer 13

Anesthesia (MDA or CRNA) 
Surgical staff (Surgeon, PA/NP/SA, circulating nurse, surgical tech)

Question 14

Pereoperative:

Answer 14

Pre, during, post

Question 15

HCAHPS

Answer 15

Hospital Consumer Assessment of Healthcare Providers and Systems

Question 16

Stoplight

Answer 16

Green - completed it
Yellow - working on it
Red - unable to be completed. Post it somewhere visible.

Question 17

AIDET

Answer 17

Acknowledge, 
introduce yourself, 
Duration, 
Explanation, 
Thank

Question 18

Studer execution framework

Answer 18

Align goals, behavior, and processes

Question 19

Goals for high performers:

Answer 19

Re-recruit, recognize, retrain

Question 20

Goals for middle performers

Answer 20

Reassure, re-recruit, develop

Question 21

Goals for low performers

Answer 21

Improve or de-select

Question 22

Barriers to change:

Answer 22

Denial, 
rationalization, 
blame, 
uniqueness, 
unwillingness, 
not skilled

Question 23

Getting over the wall

Answer 23

You have to deselect low performers to get over the wall

Question 24

Examples of social Determinants of Health

Answer 24

Health Care
Education
Housing
Employment
Income
Food Access
Transportation
Physical and Built Environment
Culture
Literacy

Question 25

WHO definition of health

Answer 25

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

Question 26

Equity

Answer 26

“Fair opportunity for everyone to attain their full health potential regardless of demographic, social, economic or geographic strata.”

Question 27

Triple aim of Health Equity

Answer 27

Implement health in all policies,
strengthen community capacity,
expand understanding of health

Question 28

Social Determinants of Equity

Answer 28

Systems of power that determine the range of social contexts and the distribution of populations into those social contexts.

Question 29

How often do you need to do a community health needs assessment?

Answer 29

Every 3 years

Question 30

What is Community Benefit

Answer 30

Programs, services, and activities that non-profit health care organizations provide in response to community needs to improve community health or increase access to health care

Question 31

How did the Clinic overhaul the patient experience?

Answer 31

Using in-system physician champions

Question 32

(NPSGs)

Answer 32

National patient safety goals:

led by the Joint Commission to create a safer and more therapeutic environment for healthcare.

Question 33

(PSO)

Answer 33

Patient Safety Organizations: collect, aggregate, and analyze reports of errors and near misses in a confidential database so that measures can be identified to promote safety.

Question 34

IHI

Answer 34

Institute of Health Initiatives

Question 35

ISMP

Answer 35

Institute of Safe Medical Practices

Question 36

HIPAA

Answer 36

Health Insurance Portability and Accountability Act

Question 37

OIG

Answer 37

Office of the Inspector General

Question 38

CLIA

Answer 38

Clinical Laboratory Improvements Act. passed in response to several incidents in which Papanicolaou (pap) smears were misread or mixed up resulting in the misdiagnosis of many patients. Established minimum educational and experience requirements for all clinical laboratory personnel. Defined testing categories according to their level of complexity.

Question 39

ALARA

Answer 39

As Low as Reasonably Achievable. measures should be taken to deliver the lowest level of exposure to radiation to the patient while still gaining the intended result.