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HCM 450 Final Exam (All quizzes) Study online at quizlet.com/_6win8d According to Dr. Avedis Donabedian, what is the most important prerequisite to ensuring a healthcare organization will be high performing?

All individuals are truly committed to quality.

According to the Health Research & Educational Trust (HRET) of the American Hospital Association, which of the following is a provider initiative that will advance population health?

Improve care quality and patient safety.

According to The Joint Commission, if a mistake occurs that harms a patient, what must be told to the patient or their representative?

Unanticipated patient outcomes

According to The Joint Commission in 2015, which of the following was one of the most common root causes of sentinel events in healthcare organizations?

?? Inadequate communication between care providers??

According to The Joint Commission, which of the following situations represents a sentinel event?

Patient has a stroke after being given an incorrect medication.

Achieving near-perfect quality is the primary goal of which performance improvement model?

Six Sigma

7.

At what level of reliability do most US hospitals now function?

90 percent

8.

The clinic medical director wants to know Scatter if there is a correlation between the diagram number of minutes patients must wait to see a physician and the time of day. Which graph would you use to display the data to help determine if a relationship exists between the two variables?

1.

2.

3.

4.

5.

6.

13.

For a healthcare process to achieve Six Sigma, what level of quality is expected?

Minimal waste?

Free of defects Meets expectations (INCORRECT) No variation Minimal waste

9.

Doctors often practice defensive medicine for the purpose of avoiding malpractice liability. True False

10.

During what stage of team development Storming do team members often exhibit dissension, irritation over lack of progress, and general impatience?

14.

For a population health care measure, the entire population, not just those receiving care, is being evaluated. True False

True

15.

For what purpose would a cause and effect diagram be used during a root cause analysis?

Brainstorm reasons for the event

16.

Healthcare quality can never be achieved without reliability. True False

True

17.

The healthcare quality Triple Aim framework was developed by the National Academy of Medicine. True False

False

18.

A healthcare service is considered underused when the added benefits are less than the added costs of that service. True False

False

19.

A health maintenance organization conducted a study on outpatient treatment of patients with asthma. The need for a new asthma management protocol was identified, and it was developed. Now the protocol is being piloted by physicians at two primary care clinics. This project is in which phase of the Plan-Do-Study-Act improvement cycle?

Do

20.

The hospital has collected patient satisfaction Pareto data for more than one year. It is now time for chart strategic planning, and you've been asked to summarize the satisfaction data so senior leaders can establish two or three strategic objectives related to improving patient satisfaction. They want to focus on the vital few issues that cause the most problems. What type of graph would you use to provide senior leaders with the information they need?

True

11.

During what type of improvement project does the team brainstorm what could go wrong in each step of a process.

Failure mode and effects analysis

12.

Eliminating wasteful inefficiencies in a process is the primary goal of which performance improvement model?

Lean

21.

A hospital improvement team has brainstormed several potential solutions to the problem of high nursing staff turnover. What tool could the team use to select the solutions most likely to be successful?

Decision matrix

29.

The Joint Commission requires accredited healthcare organizations to have a quality management plan. True False

False

22.

The hospital team charged with reducing Planning the incidence of patient falls has selected matrix four different patient care process changes that need to be implemented. What tool would the team use to document the tasks necessary for making these process changes?

30.

The likelihood of human errors causing patient harm can be greatly reduced by disciplining staff for making mistakes. True False

False

31.

The Medicare program's quality management requirements for healthcare facilities are found in what regulations?

Conditions of Participation

32.

Most providers now have real-time access to measurement data that allow them to effectively manage the health of a population. True False

True

33.

The number of actions that achieve intended results divided by the total number of actions is measuring what aspect of performance?

Reliability

34.

One reason healthcare organizations seek accreditation is to stimulate internal quality improvement efforts. True False

True

35.

Process standardization improves patient safety. True False

True

36.

Six Sigma projects commonly involve which of these steps?

DefineMeasureAnalyzeImproveControl

37.

Staff in an ambulatory surgery center want to streamline the patient admission process. What performance improvement tool would they use to get a better understanding of how patients are currently admitted?

Flowchart

38.

Affinity Staff members in the physical therapy department gather information about the diagram reasons why patient treatments do not start at the scheduled time. They want to group the reasons for late treatment starts into related categories to identify commonalities. What performance improvement tool could be used to sort the reasons into similar categories?

23.

24.

How long after an improvement project has ended should measurement data be gathered to determine the project's success?

Until the project sponsor is confident improvements are permanent

An improvement team in a home health Force field agency wants to streamline the process of analysis discharging patients. The team identifies all the factors that will hinder the success of their improvement plans, as well as those factors that will increase the likelihood of success. The team is using what improvement tool? An improvement team in the emergency department brainstorms all factors that have an effect on how long patients wait before being seen by a physician. What performance improvement tool would be useful for categorizing the factors identified through this brainstorming activity?

Cause and effect diagram

In a high-performing organization, conflict and disagreement are dealt with openly. True False

True

27.

In a high-reliability organization, there are fewer accidents than would be expected. True False

True

28.

In regard to team development, what is the Recognize role of the improvement team leader? development as a natural team progression

25.

26.

39.

Statistical process control techniques can be applied to which type of graph?

Line graph

50.

Response rate is low

40.

The study of interactions between people, technology, and policy for the purpose of improving work reliability is called what?

Human factors engineering

What can cause data gathered through the use of patient satisfaction surveys to be unreliable?

51.

Tax-exempt, nonprofit hospitals are required to provide community benefits to maintain their tax-exempt status. True False

True

What component of the organization's quality management (QM) activities is often documented in the QM plan?

Performance improvement model used in the organization

52.

What diagram is used to illustrate the start and finish times for an improvement project.

Gantt chart

A team in the hospital registration department is conducting a Lean project to reduce wasteful steps in the process of preregistering elective admissions. What qualitative improvement tool could the team use to better understand the movement of preadmission paperwork throughout the department?

Workflow diagram

53.

What does an organization use benchmarking for?

To compare current performance to an exemplary organization

54.

What factor makes an improvement team work most effectively?

Operates under an agreed-upon set of ground rules

The timekeeper keeps the team on track during improvement project meetings.

True

55.

What factors unique to healthcare delivery inhibit adoption of some industrial quality improvement techniques?

Variable conditions and behaviors of patients

56.

What federally recognized group maintains a database of adverse patient events?

Patient Safety Organization

57.

What framework is used by an organization to categorize systemlevel performance measures?

Balanced scorecard

58.

What group acts on the behalf of consumers to keep healthcare costs down?

Insurance industry

59.

What group is responsible for allocating resources necessary to support quality management activities in the organization?

Administrative leaders

41.

42.

43.

True False 44.

45.

To be successful as project team members, what characteristic should individuals possess?

People committed to achieving project goals

To improve productivity in the hospital Stakeholder operating room, the manager wants to start analysis scheduling elective surgeries on Saturday. What tool can the manager use to identify strategies for gaining support from individuals who may resist this change?

46.

Until the 1970s, healthcare quality activities were primarily based on which management system?

Pre-Industrial Revolution craft model

47.

What activity is done to achieve compliance with minimum quality standards in a healthcare organization?

Quality assurance

60.

What group is ultimately responsible for the quality of patient care and services in a healthcare organization?

Board of trustees

48.

What activity-level measure is related to the system-level measure "percentage of hospital patients who are very satisfied with the overall quality of care"?

Percentage of patients reporting that nurses treated them with respect

61.

What group requires managed care organizations to have a written utilization management plan?

National Committee for Quality Assurance

62.

What group sponsors the National Guidelines Clearinghouse?

What are the three primary quality management activities?

Measurement, assessment, and improvement

Agency for Healthcare Research and Quality

63.

What healthcare reimbursement system rewards care providers for achieving cost performance expectations?

Pay for performance

49.

64.

What improvement model involves small process changes and careful measurement of the effect of the changes?

Rapid cycle improvement

65.

What individual assists the leader in managing discussions during improvement project team meetings?

Facilitator

66.

What individual or group creates the written charter for an improvement project?

Sponsor

What is a basic responsibility of the quality department in a healthcare organization?

Help other departments identify potential quality problems

What is a common cause of performance improvements being unsustainable?

People lapse into the old way of doing things.

67.

68.

69.

What is a component of an organization's quality management infrastructure?

Committees

70.

What is a measure of the health status of people in a population?

Percentage of population that is insured

71.

What is a measure of the performance potential of a process?

Capability

72.

What is an example of a quantitative improvement tool?

Scatter diagram

73.

What is an example of overuse of healthcare resources?

Physician prescribes antibiotics for a patient with a cold

74.

75.

76.

What is an improvement action considered to be strong— meaning it is more likely to achieve patient safety improvement goals than weak or intermediate actions?

Tangible involvement by leadership

What is a process measure of staff performance in a nursing home?

Number of records lacking documentation of resident's allergies

What is a publicly available source of comparative healthcare performance data?

Healthcare Cost and Utilization Project

77.

What is a quality-related support position in a hospital?

Infection control coordinator

78.

What is a step common to all performance improvement models?

Identify customer expectations

79.

What is a visual representation of the flow of process steps?

Process diagram

80.

What is one of the core values found in the Baldrige healthcare criteria for performance excellence?

Management by fact

81.

What is the denominator for the performance measure "percentage of home health patients admitted to the hospital"?

Total number of home health patients

82.

What is the first question asked during a FOCUS-PDCA project?

What process do we want to improve?

83.

What is the first step an organization Find out the should take when transforming the quality prevailing core culture? values and beliefs.

84.

What is the first step for providers seeking to implement population health?

Define the challenge and target population.

85.

What is the first step in constructing a performance measurement?

Identify topic of interest

86.

What is the first step of a population health care improvement project?

Define the improvement goal

87.

What is the first step of a root cause analysis?

Understand what happened

88.

What is the ideal number of members on an improvement project team.

Five to ten

89.

What is the primary purpose of risk management activities in a healthcare organization?

Protect the organization from financial losses

90.

What is the primary purpose of root cause Improve analysis and failure mode and effect patient safety analysis?

91.

What is the primary purpose of utilization management?

Eliminate under- and overuse of health services

92.

What is the primary reason for analyzing patient incident data?

To identify unsafe patient care situations

93.

What is the primary reason for measuring the effectiveness of improvement actions?

Confirm actions are successful

94.

What is the purpose of population health care?

To maximize the health and wellbeing of persons in a defined population

95.

What job aid can be used to remind Clinical path physicians and other caregivers of key interventions on each day of a patient's hospitalization?

96.

What legislation first introduced incentives for providers to adopt population health care strategies?

The Health Maintenance Organization Act of 1973

97.

What national performance measurement project contains many measures applicable to population health care?

Healthcare Effectiveness Data and Information Set (HEDIS)

98.

What organization published Crossing the Quality Chasm: A New Health System for the 21st Century?

Institute of Medicine

99.

What organization sponsored the first program to improve quality in US hospitals?

American College of Surgeons

100.

What qualitative tool would be used by an improvement team to undercover the root cause of a performance problem?

Five Whys

101.

What quality program is managed by the National Institute of Standards and Technology in the US Commerce Department?

Baldrige National Quality Program

102.

What reporting format is used to Quality summarize the steps of a performance storyboard improvement project?

103.

What situation puts data accuracy at risk when more than two people are independently gathering data for the same performance measure?

104.

105.

106.

107.

What terms are used to describe what could go wrong during a process step?

Failure mode

108.

What traits common to an improvement project team in the norming stage?

A lot of feedback, limited agenda items, members focused on success

109.

What type of data display uses symbols or colors to draw people's attention to performance concerns?

Dashboard

110.

What type of form is used by hospital caregivers to document potential or actual patient safety concerns?

Incident report

111.

What type of healthcare organization has an organized medical staff?

Hospital

112.

What type of healthcare organization uses measures found in the Healthcare Effectiveness Data and Information Set (HEDIS)?

Health insurance plan

113.

When a data point on a control chart falls above the upper control limit, the process being measured is exhibiting what type of characteristic?

Special cause variation

114.

When an IT system alerts the physician Making failures to a potential incompatibility when a visible new drug is prescribed for a patient, how is the system helping to prevent...