Week 1

Question 1

What are the characteristics of a health care quality professional?

Answer 1

Align quality with organizational strategy
Passionate
Honest
Patient
Positive
Participatory
Forward thinking

Question 2

What is the role of the healthcare quality professional?

Answer 2

Builds a patient safety culture
Secures qualify and safety engagement
Aligns quality with organizational strategy
Incorporates patient safety, risk management, ip, reg, VIP, customer sat, clinical qualify measures, and med staff services
Uses data to drive improvement
Ensures quality becomes a core competency for all staff

Question 3

What are the seven pillars of healthcare quality?

Answer 3

Humanistic outcomes ( patient preference): efficacy (controlled environment, establishes ideal state); effectiveness (intended outcome, impacted by multiple factors); efficiency; acceptability (usefulness, improve quality of life).

Society outcomes (social preferences): optimality (cost effectiveness, ROI); equity (equal treatment, ability to pay); legitimacy (evidence based).

Question 4

Important historical studies

Answer 4

1999: Building a safer Health system (to err is human), IOM. Direct relationship between quality of care and patient outcomes. Proved that people die from hospital care.

2013: A new, evidence-based estimate of patient harms, journal of patient safety. 200,000+ deaths per year, serious harm more common than lethal harm.

Question 5

What is the triple aim? Quintuple?

Answer 5

1. Improved patient experience
2. Improve out comes for populations.
3. Reduce costs.
4. Improve clinician/ healthcare team experience
5. Equity & inclusion

Question 6

How does the AHA recommend to implement the triple aim?

Answer 6

1. Design patient centered care.
2. Empower people & the system with information, technology, and transparency.
3. Build care management and coordination systems.
4. Integrate behavioral social and physical health.
5. Develop collaborative leadership.
6. Integrate care delivery into the community.
7. Create safe and highly reliable organizations.

Question 7

Define and differentiate: QA, QC, PI

Answer 7

QA: measures compliance with standards. Planned, systemic, review, audits. Focuses on individuals, processes, before product is finished.
QC: process of ensuring products and services meet customer expectations.reactive testing. Focus on product defects after it is finished.
PI: continuously improve processes to meet standards. Proactive prevention, planning. Focus is on processes and systems ongoing.

Question 8

Define and differentiate: underuse, overuse, misuse.

Answer 8

Underuse: failing to provide medically necessary care or follow EBP.
Overuse: providing a dray treat ment without medical justification.
Misuse: medical errors in the provision of care.

Question 9

Define and differentiate: vision, mission, goal, objective

Answer 9

Vision: future Goal, commitment, short, patient-centered.
Mission reflects current state describes organizational purpose in broad terms. Goals: intangible, hard to measure
Objectives: specific, measurable tasks taken to achieve goal

Question 10

SWOT analysis stands for _____________ and is an important part of _________?

Answer 10

Strengths, weaknesses, opportunities, threats; strategic planning

Question 11

Organizational strategic planning key components.

Answer 11

1. Examine organization, customer, community.
2. Develop goals, short and long term.
3. Perform assessments, internal and external
4. Design products and services, market them.

Question 12

An important part of the integrative Hoshin approach is the

Answer 12

Plan do study Act model.

Question 13

4 key ways to integrate qualify findings

Answer 13

1. strategic goals - use pi measures for business planning and resource allocation.
2. By-laws - establish priorities with physicians.
3. Management roles - empower staff and evaluate compliance.
4. Regulatory-root cause analysis, action plans.

Question 14

What is the role of the governing body or board?

Answer 14

The governing body carries the legal authority and responsibility for all care provided in an organization. They are responsible to oversee and govern all affairs of the hospital.

Question 15

Define and differentiate: credentialing and privileging

Answer 15

Credentialing; a background check to verify licensure, diplomas, references, etc.
Privileging: grants authority to practice as determined by professional standards, accreditation and regulatory guidelines, etc.

Question 16

Define and differentiate: FPPE and OPPE

Answer 16

Focused professional practice evaluation: consistently implemented,clearly defined monitoring process, includes qualitative and quantitative data. For the newly privileged.
Ongoing professional practice evaluation: on going, re-privileging process that supports early detection and response to performance issues.

Question 17

Define and differentiate: complaint, grievance, appeal

Answer 17

Complaint: oral or written, dissatisfied with qualify or processes of care.
Grievance: formal written complaint (associated with union members).
Appeal: impartial review of decision on grievance by third party.

Question 18

What are the four types of leaders?

Answer 18

Charismatic ( charming, only relates to small group of people).
Autocratic ( makes decisions independently, difficulty with staff commitment).
Bureaucratic (follows rules exactly, not conducive to change t may engender respect).
Consultative ( presents decisions to staff, gains staff commitment).

Question 19

What are some barriers to system change?

Answer 19

Autocratic views, Failure to adapt, weak consensus, feelings of victimization, identification with role over purpose, relying too heavily on past

Question 20

Tips for facilitating change

Answer 20

Create collaborative teams trainings
Common vision for care
Include all levels of staff
Build consensus through discussion, diverse viewpoints coverage