Chapter 10 Health Information Technology: An Applied Approach – Flashcards

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accoutable care organization (ACO)
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an organization of healthcare providers accountable for the quality, cost, and overall care of Medicare beneficiaries who are assigned and enrolled in teh traditional fee-for service program
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admission utilization review
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a review of planned services (intensity of service) and/or a patient's conditions (severity of illness) to determine whether care msut be delivered inan acute care setting
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affinity group
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a technique for organizing similar ideas together in natural groupings
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agency for healthcare research and quality (AHRQ)
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the branch of the United States Public Health Service that supports general health reserach and distributes research findings and treatment guidelines with the goal of improving the quality, appropriateness, and effectiveness of healthcare services
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bar graph
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a graphic technique used to display frequency distributiosn of nominal or ordinal data that fall into categories
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benchmark
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an analysis process that is based on comparison
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brainstorming
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a group problem solving technique that invovles the spontaneous contribution of ideas form all members of the group
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case manaegment
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the ongoing, concurrent review performed by clincial professionals to ensure the necessity and effectiveness fo the clinical services being provided to a patient.
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cause and effect diagram
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an investigational technique that facilitates the identification of the variosu factors that contribute to a problem
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checksheet
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a tool that permits the systematic recording of observations of a particular phenomenon so that trends or patterns can be identified
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claims management
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a functional related to risk manaegment that enables an organization to track descriptive claims information (incidents, claimants, insurance, demands, cates, and so on) along with data on investigation, litigation, settlement, defendants, and subrogation
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clinical practice guidelines
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a detailed, step by step guide used by healthcar epractitioners to make knowledge based decisions related to patient care and issued by an authoritative organization such as a medical society or government agency
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clinical protocols
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specific instructions for performing clinical procedures established by authoritative bodies such as medical staff committees, and intended to be applied literally and universally
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common cause variation
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the source of varaition in a process that is inherent within the process
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continued stay (or concurent) utilization review
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a periodic review conducted durign a hosptial stay to determine whether the patient continues to need acute care serivces
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continuous improvement
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a management philosophy that emphasizes the importance of knowing and meeting customer expectations, reducing variation within processes, and relying on data to build knowledge for process improvement 2. a continuouis cylce of planing, measuring, and monitoring performance and making knowledgebased improvements
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customer
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...an internal or external recipient of services, products, or information
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dashboards
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...reports fo process measures to help leaders know what is currently going on so that they can plan strategically where they want to go nex
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discharge planning
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...the process of coordinating the activities related to the release of a patient when inpaient hospital care is no longer needed
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discharge utilization review
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...a process for assessing a patient's readiness to leave the hospital
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external customers
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...individuals from outside the organization who receive products or services from within the organization
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financial indicators
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...a set of measures designed to routinely monitor the current financial status of a healthcare organization or of one of its constituent parts
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flowcharts
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...a graphic tool that uses standard symbols to visually display detailed information, including time and distance, of the sequential flow of work of an individual or a product as it progresses through a process
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force field analysis
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...a performance improvement tool used to identify specific drivers of, and barriers to, an organizational change so that positive factors can be reinforced and negative factors reduced
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ground rules
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...an agreement concerning attendance, time management, participation, communication, decision making, documentation, room arrangements and cleanup, and so forth, that has been developed by PI team members at the initiation of the team's work
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histogram
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...a graphic technique used to display the frequency distribution of continuous data (interval or ratio data) as either numbers or percetnages in a series of bars
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incident/occurrence report
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...a quality/performance management tool used to collect data and information about potentially compensable events (events that may result in death or serious injury)
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intensity of service screening criteria
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...preestablished standards used to determine the most efficient healthcare settinginwhich to safely provide needed services
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internal customers
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...individuals within the organiztion who receive products or services from an organizational unit or department
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ISO 9000 certification
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...an internationally agreed upon set of generic standards for quality management systems established by the International Standards Organization
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the Joint Commission
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...a private, nto for profit organization that evaluates and accredits hospitals and other healthcare organziations on the basis of predefined performance standards
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mission
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...the defined purpose for which a group of people or an organization joins forces to accomplish specific goals
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multivoting technique
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...a decision making method for determining group to handle data organizaed into a data structure with numerous dimensions
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national patient safety goals (NPSGs)
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...goals issued by the Joint commission on Accreditation of Healthcare Organizations to improve patient safety inhealthcare organizations nationwide
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nominal group technique
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...a group process technique that involves the steps of silent listing, recording each participant';s list, discussing, and rank ordering the priority or importance of items
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opportunity for improvement
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...a healthcare structure, product, service, process, or outcome that does not meet its customers' expectations, and , therefore, could be improved
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outcome indicators
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type of quality indicators
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outcome measures
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documents the results of care for individual patients as well as for specific types of patients grouped by diagnostic category
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outputs
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...the outcomes of inputs into a system (for example, the output of the admitting process is the patient's admsision to the hospital
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pareto chart
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...a bar graph that includes bars arranged in order of descending size to show how decisions on the prioritization of issues, problems or solutions
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patient advocacy
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...the function performed by patient representatives (sometimes called ombudsmen) who respond personally to complaints from patients and/or their families
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performance improvement (PI)
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...the continuous study and adaptation of a healthcare organization's functions and processes to increase the likelihood of achieving desired otucomes
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performance indicators
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...measures used by heatlhcare facilities to assess teh qualtiy, effectiveness and efficiency of their services
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potentially compensable event
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...an event that may result in financial liability for a healthcare organization, for example, an injury, accident, or medical error
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preadmission utilization review
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...a type of review conducted before a patient's admission to an acute care facility to determine whether the planned service warrants care in an inpatient setting
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process indicators
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...specific measures that enable the assessment of the steps taken in rendering a service
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processes
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the day to day tasks and methods utilized in a standardized procedure to accomplish teh provision by an individual or organiztion of products and services to its customers
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productivity indicators
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...a set of measures desigend to routinely monitor the output and quality of products and/or services provided by an individual, an organization or one of its constituent parts
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prospecitvie utilization review
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...a review of a patient's health records before admission to determine the necessity of admission to an acute care facility and to determine or satisfy benefit coverage requirements
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quality indicators
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...a standard against which actual care may be measured to identify a level of performance for that standard
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retrospectvie utilization review
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...a review of records some time after the patient's discharge to determine any of several issues, including the quality or appropriateness of the care provided
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risk
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the probable amount of loss foreseen by an insurer in issuing a contract
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risk management program
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...a comprehensive progam of activities intended to minimize the potential for injuries to occur in a facility
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root cause analysis
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...a technique used inperformance improvemetn initiatives to discover teh underlying causes of a problem
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run chart
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...a type of graph that shows data points collected over time and identifies emerging trends or patterns
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scatter diagrams
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...a visual representation of data points on an interval or ratio level used to depict reltionships between two variables
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scorecards
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...reports of outcomes measures to help leaders know what they have accomplished
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severity of illness screening criteria
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...standards used to detrermine the most appropriate setting of care based on teh level of clinical signs and symptoms that a patient shows upon presentation to a healthcare facility
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six sigma
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...disciplined and data driven methodology for getting rid of defects in any process
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special cause variation
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...an unusual source of variation that occurs outside a process but affects it
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standard
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a model or example established by authority, custom, or general consent or a rule established by an authority as a measure of quality
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statistical process control chart
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...a type of run chart that includes both upper and lwoer control limits and indicates whether a process is stable or unstable
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structure indicators
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...quality indicators that measure the attributes of an organizational setting, such as number and qualifications of staff, adequacy of equipment and facilities, and adequacy of organizational policies and procedures
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structured brainstorming
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...a group problem solving technique wherein the team leader asks each participant to generate a lsit of ideas for the topic under discussion and then report them to the group in a nonjudgmental manner
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unstructured brainstorming method
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...a group problem solving technique wherein the team leader solicits spontaneous ideas for the topic under discussion frm members of the team in a free flowing and nonjudgmental manner
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utilization review
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...the process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria
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virtuoso teams
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group of experts brought toghether to address an issue or situation
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Which of the following is the goal of clinical practice guidelines?
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To standardize clinical decision making
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Which one of the following is the largest healthcare standards-setting body in the world?
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Joint Commission
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Which of the following is not a responsibility of a healthcare organization's quality management department?
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Using medical peer review to identify patterns of care
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Problems in patient care and other areas of the healthcare organization are usually symptoms inherent in a(n) _____.
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system
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Which of the following statements best defines utilization management?
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It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care.
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Which of the following is not a type of utilization review?
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Documentation utilization review
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What is the role of the case manager?
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To coordinate medical care and ensure the necessity of the services provided to beneficiaries
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What is role is not representative of the ombudsmen in patient advocacy?
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Judge
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A hospital's C section rate is an example of a:
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clinical performance measure
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The process that involves ongoing surveillance and prevention of infections so as to ensure the quality and safety of healthcare for patients and employees is known as:
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Infection Control
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The traditional approach to assuring quality was study a process only when there was failure to__.
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Meet established standards
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Donabedian proposed three types of quality indicators: structure indicators, process indicators, and __.
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Outcome indicators
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Problems in patient care and other areas of the healthcare organization are usually symptoms inherent in a(n)__.
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system
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Many organizations and quality experts define quality as meeting or exceeding __.
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Customer expectations
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Which of the following is a technique used to generate a large number of creative ideas from a group?
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Brainstorming
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Which of the following is a data collection tool that records and compiles observations or occurrences?
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Checksheet
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Which of the following is used to plot the points for two variables that may be related to each other in some way?
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Scatter diagram
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The leader of the coding performance improvement team wants all of her team members to clearly understand the coding process. Which of the following would be the best tool for accomplishing this objective?
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Flowchart
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The medical transcription improvement team wants to identify the cause of poor transcription quality. Which of the following tools would best aid the team in identifying the root cause of the problem?
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Fishbone diagram
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According to the Pareto principle, ___.
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. 20 percent of the sources of a problem are responsible for 80 percent of its actual effects.
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Data collected during the process of providing patient services are the best source of information on the effectiveness of care.
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True
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Sentinel events are events that showcases the good quality of care provided by a healthcare facility.
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False
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The National Committee on Quality Assurance (NCQA) has issued specific national patient safety goals in response to its identification of patient safety as its top priority in accrediting managed healthcare organizations.
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False
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Joint Commission's methodology for accessing quality of healthcare during its survey process is to follow specific patients through their entire admission and to identify non-compliance with standards as reflected in the experience of patients.
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True
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Clinical practice guidelines are developed with the goal of standardizing clinical decision and therefore must be followed in every case.
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False
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An incident report would be completed when a patient has an adverse reaction to a medication properly administered.
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False
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Thanks to technology and scientific advances, infection has disappeared in the beginning of the 21st century as a significant problem impacting healthcare.
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False
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NCQA has loose standards for managing utilization of healthcare resources but very rigorous standards for managing quality and reimbursement.
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False
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Because of their importance to patient care, incident reports are always filed in the patient's medical record.
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False
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One of the Joint Commission's national patient safety goals in the area of communications requires healthcare organizations to implement a Joint Commission defined list of unacceptable medical abbreviations to be used in the patient's medical record.
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True
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data abstracts
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data abstracts ...a defined and standardized set of data points or elements common to a patient population that can be regularly identified in teh health records of the population and coded for use and analysis in database management systems
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discharge abstract system
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..a data repository (usually electronic) used for collecting information on demographics, clinical conditions, and services in which data are condensed from hospital health records into coded data for the purpose of producing summary statistics about discharged patients
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health care quality improvement program (HCQIP)
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...a quality initiative begun in 1992 by the Health Care Financing Administration and implemented by peer review organiztions that uses patterns of care analysis and collaboration with practitioners, beneficiaries, providers, plans, and other purchasers of healthcare services to develop scientifically based quality indicators and to identify and implement opportunities for healthcare improvement
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inputs
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...data entered into a hospital system (for example, teh patient's knowledge fo hsi or her condition, the admitting clerk's knowledge of the admission process, and the computer with its admitting template are all inputs for the hospital's admitting system
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outcome indicators
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measure the actual results of care for patients and populations, including patient and family satisfaction
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fishbone diagram
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A performance improvement tool used to identify or classify the root causes of a problem or condition and to disp[lay the root causes graphically; also called cause and effect diagram
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time ladders
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support the collection of data that must be oriented by time. Very simply they are usually paper based with the intervals of time necessary to address the problems under consideration listed down the right side of one, two, or three columns on a sheet of paper
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True or False: Performance monitoring is outcomes driven
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False
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True or False: Performance improvement is something that is done periodically
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False
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True or False: An outcome indicator measures results of care provided to the patient
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True
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Which of the following provide process measure metrics in a precise format?
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Dashboard
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The focus of performance improvement should be on:
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Customers
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Fifty percent of our HIM staff have a nationally recognized credential. This is an example of what type of indicator?
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Structured
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Which tool is used to display performance data over time?
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Run Chart
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The nosocomial infection rate for our hospital is 0.2% while the rate at a similar hospital across town is 0.3%. This is an example of:
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Benchmark
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The type of variation that is caused by factors outside a system is called:
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special-cause variation
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True or False: Goals should be measurable
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True
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True or False: Effective communication is the responsibility of administration only.
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False
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True or False: A checksheet is used to record and complete observations and occurrences
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True
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Team based performance improvement processes - success depends on 7 elements:
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1 establishing ground rules 2 Stating the team's purpose or mission 3 Identifying customers and their requirements 4 Documenting current processes and identifying barriers 5 Collecting and analyzing data 6 Identifying possible solutions by brainstorming or using other PI techniques 7 Making recommendations for changes in the process
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Establishing ground rules (5)
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1 to arrive on time for meetings 2 To complete and present the results of assignments from the previous meeting 3. to respect the opinions of all team members 4 to listen to other team members' points of view without criticism 5 to abide by decisions made by the team
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Staff members adapt to change more readily when:
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They have been a part of the decision
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Which of the following documents the current process?
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Flowchart
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What technique would be the best to display rankings?
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Pareto chart
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true or false: Affinity grouping helps to determine what issue is the most important.
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False
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true or false: Establishing ground rules and identifying customers and their requirements are part of team-based performance improvement processes
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True
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true or false: Brainstorming tries to identify a large number of ideas in a short amount of time.
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True
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What type of leadership helps to increase employee motivation and empowerment?
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Shared leadership because every employee is a vital part. Shared leadership framework is essential for implementing PI
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QIOs use peer review, data analysis, and other tools to:
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Evaluate whether or not a healthcare facility is meeting standards for accreditation and licensing.
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Shared leadership means:
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Employees are participants in the performance improvement program
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The NPSG scores organizations on areas that:
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commonly lead to patient injury
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true or false: Accreditation standards were developed to standardize clinical decision making.
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false
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true or false: The Conditions of Participation are used to monitor hospitals and other healthcare organizations in becoming licensed by the state
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False
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true or false: The mission of AHRQ is to improve quality, safety, efficiency, and effectiveness for all Americans
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True
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3 important functions of utilization management
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-Utilization review -case management -discharge planning
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3 basic functions of risk management
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1 risk identification and analysis 2. Loss prevention and reduction 3. claims management
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A group of processes that determine the appropriateness of medical services is:
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Utilization management
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A patient has been discharged prior to an administrative utilization review being conducted. Which of the following should be performed?
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Retrospective utilization review
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A patient fell out of bed. What should be done?
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Complete an incidence occurrence report
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A patient is dissatisfied with his or her care. Who should the patient contact at the hospital?
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Patient representative/advocate
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A woman dies in labor and delivery. The Joint Commission would call this type of outcome an:
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Sentinel event
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To share in savings, ACOs would meet quality standards in five key areas:
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1 Care coordination 2 Patient/caregiver care experiences 3 Patient safety 4 Preventive health 5. At risk population/frail elderly health
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According to the Joint Commission a Sentinel Event is:
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-An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. - An outcome of such magnitude that each event requires an investigation and response. examples: medical errors, explosions, and fires and acts of violence
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Regulatory and Accreditation Requirements for Risk Management In Acute Care Hospitals
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Anything that undermines patient safety is a risk issue. According to (JC) all hospital activities must be evaluated as to the potential risk to the patient or to the organization. Leadership is responsible for ensuring adequate resources for patient safety.
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Ombudsperson model
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According to the healthcare ombudsperson model, all parties benefit because the ombudsperson: -Intervenes at the earliest possible opportunity at the lowest possible level -Maintains informality, confidentiality, and independence -Resolves potentially compensable events through timely communication -Is a professional trained in communicating adverse outcomes and mediation skills - Has the time built into his or her job to spend with patients and providers - Is sanctioned by top leadership to move fluidly horizontally and vertically within the existing organizational structure
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Patient Advocacy Programs
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a patient rep (aka ombudsperson) responds personally to complaints from patients and their families. Patient reps are trained to handle minor complaints and to seek remedies on behalf of patients. Also trained to recognize serious problems that need to be forwarded to performance improvement and/or risk management personnel.
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4 general steps in claims management process
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1. Reporting of claims: written or formal legal notification - risk mgr notifies the proper authority:administration, vendor or corporate counsel. Risk mgr also reports and investigates potentially compensable events for which no claims have been filed. 2. Initial Investigation of claims: gathers all info of relevant claim or the potentially compensable event, interviews and copies of witness statements, etc. 3. Protection of primary and secondary health records: After completion of records upon discharge, they should be kept in a lock storage place. 4. Negotiation of settlements: Risk mgr, insurance rep, admin, and or legal counsel decide whether to offer a monetary settlement.
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Loss prevention and Reduction
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risk mgr responsible for developing systems to prevent injuries and other losses within the organization. Education also is an invaluable tool in risk management and sometimes is the only activity required to prevent potential safety problems.
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Who has the ultimate responsibility for ensuring the quality of the medical care provided by the organization?
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in hospitals and healthcare organizations, the board of directors has ultimate responsibility. Also responsible for fiscal stability. staff training is critical to success and orientation should include training in quality management.
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Governing Board of Directors (GBOD)
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has overall responsibility and accountability for the successful operation of the organization's quality and PI activities and should include membership form the communities of interest. Regular review current status of quality and PI initiatives and approve all strategic decisions and organization all expenditures of resources concerning them.
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Quality management board (QMB)
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has responsibility for the PI program across all subunits of the organization and should include membership from top administration, medical staff officers, top quality management staff. Should be facilitating all proposals for quality and PI initiatives, making recommendations to the governing board regarding strategic quality direction. Monitor the progress of all initiatives, providing assistance and advisement as necessary to keep initiatives moving along to completion.
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Quality management liaison group (QMLG)
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responsibility for disseminating information about the organization's quality and PI initiatives throughout the middle management of the organization, for educating managers regarding their roles and the roles of their organizational units in quality and PI initiatives and for developing cross-functional coordination and communication across organizational units in order to accomplish quality and PI initiatives. Also responsible for maintaining the organization in continuous readiness for accreditation and/or licensure survey
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Quality Management Department
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-Helping departments or groups of departments with similar issues to identify potential quality problems -Assisting determination of the best methods for studying potential problems (for ex: survey, chart review, or interview with staff) -Participating in regular meetings across the organization, as appropriate, and training organization members on quality and performance improvement methodology, tools, and techniques. -tracks progress on specific quality studies; distributes study results and recommendations to the appropriate bodies (departments, committees, administration, board of directors or trustees); facilitates implementation of educational or structural changes that flow from the recommendations;p and ensures that follow-up studies are performed in a timely manner
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4 basic ground rules for creative solution brainstorming
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1 Welcome all ideas - no judgments, no wrong ideas or ridiculous proposals 2 Be creative in contributions - think out side the box! every point of view is valuable. Far fetched ideas may trigger more practical ones and/or present valid solutions 3 Attempt to contribute a large quantity of ideas in a short amount of time. 5 - 15 minutes at most 4. Piggyback on one another's ideas - add or build on the ideas of others to create combinations, improvements or variations. In all cases a member's own words are used to record the ideas. To reduce to a set that is manageable and effective for the problem, use a grouping technique
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Process Redesign
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After reviewing data, policies, procedures, interviews, etc it is decision time. either leaving the situation as it is with minor adjustments or to develop major restructuring of the process to make it meet customers' expectations. If restructuring is required include the next 5 steps: 1 Incorporate findings or changes identified in the research phase of the improvement process 2 If necessary, collect focused data from the prioritized problem areas to further clarify process failure or variation 3. Create a flowchart of the redesigned process 4 Develop policies and procedures that support the redesigned process 5 Educate involved staff about the new process. Brainstorming for solutions!
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Brainstorm Problem areas
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technique used to generate a large number of creative ideas from a group. Thinking out of the box for original ideas. Technique can be structured or unstructured
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Collecting current process data
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Create a flow chart of the current process - Flowcharts help all the team members understand the process in the same way. Will identify redundancies and complex and problematic areas.
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Document current processes and identifying barriers
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-What is the current process? -Where are the start and end points of the process? -What are the barriers to the process?
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Identifying customers/requirements
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internal and external customers and their requirements - then modify process to meet the requirements
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Variations within the system: common-cause variation
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ex: when a nurse takes a patient's blood pressure, she may believe that she is performing the procedure in exactly the same way every time, but she will get slightly different readings each time.
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Variations caused outside the system: special-cause variation
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If the special cause produces a negative effect, we will want to identify the special cause and eliminate it. If a positive effect we will reinforce it. ex: before blood pressure test, patient is upset about phone call resulting in his blood pressure being too high
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Nothing can happen or improve without:
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effective communication
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Data must support PI activities and decisions:
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best method for obtaining timely, accurate, and relevant data.
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The problem is usually?
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the system. problems in patient care and other areas of the healthcare organization are usually symptoms of shortcomings inherent in a system or a process.
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Fundamental Principles of Continuous Performance Improvement: (9
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1. The structure of a system determines its performance. Therefore, problems are more often within systems than within individual people. 2. All systems demonstrate variation. Some variation occurs because of common causes and some because of special causes. 3.Improvements rely on the collection and analysis of data that increase knowledge. 4. PI requires the commitment and support of top administration 5. PI works best when leaders and employees know and share the organization's mission, vision, and values 6. PI efforts take time and require a big investment in people 7. Excellent teamwork is essential 8. Communication must be open, honest, and multidirectional 9. Success must be celebrated to encourage more success.
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Outcome required to be continuously monitored by hospitals:
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monthly delinquent health record rate. To determine rate: # of incomplete health records that exceed the medical staff-established time frame for record completion/Average monthly discharges
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The Joint Commission - delinquent health records:
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will cite the healthcare organization with a requirement for improvement if the total average health record delinquency exceeds 50 percent of the average monthly discharges in any one quarter.
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Donabedian proposed 3 types of quality indicators
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1 Structure indicators: measure the attributes of the setting, such as number and qualifications of the staff, adequacy of equipment and facilities, and adequacy of organizational policies and procedures. 2 Process indicators: measures the actions by which services are provided, the things people or devices do, from conducting appropriate tests, to making a diagnosis, to actually carrying out a treatment. 3 Outcome indicators: measure the actual results of care for patients and populations, including patient and family satisfaction
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Identification of performance measures:
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for each service, process, or outcome determined important to track.
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Performance improvement process
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1 Identify performance measures 2 Measure performance 3. Analyze and compare internal/external data 4. Identify improvement opportunity 5. Perform ongoing monitoring
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Identifying areas to monitor
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includes important organizational functions, particularly those that are high-risk, high-volume, or problem-prone. Outcomes of care, customer feedback and the requirements of regulatory agencies are additional areas that organizations consider when prioritizing performance measures.
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What is the key to improvement
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measurement - the key to improvement lay in the measurement of the important characteristics of their practice
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How is performance measured?
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Using one or more performance indicators. Ex: performance can be measured against financial indicators, such as the average cost per laboratory test, or productivity indicators, such as the number of patients seen per physician per day. What is IMPORTANT is to measure the aspects of performance that really reflect quality and that point conclusively to the aspects of performance that require improvement.
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What is the key feature of performance improvement in today's healthcare organizations?
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it is a continuous cycle of measurement, analysis, monitoring, planning, designing, and evaluating. Performance monitoring is data driven.
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