Quality IHI Exam 1 – Flashcards
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In regard to health disparities around the world, which of the following statements is most true? ***
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B and C The best answer is B and C. Where a child is born and raised can significantly change the life expectancy. The root causes of this and other health differences we see around the world are deeply complex and by no means begin or end in the clinical setting.
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Which of the following is a trend in modern health care across industrialized nations?
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A and C The best answer is A and C. As medical information and technology increases, demand for complicated procedures is increasing, and providers are becoming more and more specialized (and fragmented). The burden of disease is shifting toward chronic conditions.
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Which of the following countries has had a relatively inexpensive universal health insurance system for more than 50 years?
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Japan Japan has had a relatively inexpensive universal health insurance system for more than 50 years. Germany made health insurance mandatory for its entire population in 2009. Chile has given all Chileans access to a basic health care package since 2005.
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Which of the following statements is true: ***
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During the past 15 years, the cost of care has been a growing problem for many developed nations. The cost of care has been a growing problem throughout developed nations during the last 15 years. For example, across 34 nations that make up the Organization for Economic Cooperation and Development (OECD), the average per capita health care expenditure increased by more than 70 percent between 2000 and 2010. However, the biggest spenders — such as the US — don't necessarily have the highest quality in many areas. Today, countries around the world with vastly different political, economic, and cultural makeups are working toward the goals of improving quality and access in different ways.
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Which of the following statements is a reason for improving the US health care system?
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The US government and citizens alike are struggling to afford the cost of care. The US government and citizens alike are struggling to afford the cost of care. We've seen in this lesson the US has the means to measure health care quality — the results just often are not what one would hope! Although the US remains a leader in biomedical innovation, even the most advanced biomedical science and technology can't guarantee high-quality care.
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Why was it important for the Institute of Medicine (IOM) to develop its six aims for health care?
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So that health care organizations would have a better idea of what they needed to improve Just as defining dimensions of good performance helps employees, defining the aims (or dimensions of quality) of health care helped hospitals and other organizations understand what to focus on when improving their care.
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Which of the IOM aims has this hospital FAILED to meet?
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Timely Michael's care was not timely. He did not receive care when it was needed, without delays.
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The hospital where Michael is recovering reviews its patient satisfaction survey results in order to improve its care and patient outcomes. Leaders poring over the data note that 90 to 100 percent of patients rate staff as "excellent" in the following categories: listening, answering questions, being friendly and courteous, and giving good advice based on specific needs and preferences. Which aim is the hospital generally achieving?
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Patient-centered Patient-centered care is defined by the IOM as "care that is respectful of and responsive to individual patient preferences, needs, and values" and that ensures "patient values guide all clinical decisions." These high satisfaction rates are consistent with being patient-centered.
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Which of the following improvement efforts is the best example of increasing the effectiveness of care?
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Improving the percent of clinic patients achieving their goal blood pressure by instituting a series of reminders for providers about evidence-based processes Effective care is based on scientific evidence and avoids underuse and overuse. A reminder system allowing providers to more easily use evidence in a busy practice environment would best improve the effectiveness of care.
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Which of the following improvement efforts is the best example of increasing the equity of care? ***
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Through staff development and weekly feedback, equalizing the likelihood that a patient will receive pain medication regardless of race, ethnicity, or education The best answer is equalizing the likelihood that a patient will receive pain medication regardless of race, ethnicity, or education. Equity is about making sure that care does not vary based upon gender, race, ethnicity, socioeconomic status, geographic location, sexual orientation, and other individual characteristics.
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Which of the following is a basic principle of improvement?
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Every system is perfectly designed to get the results it gets. A basic principle of improvement is that every system is perfectly designed to get the results it gets. When an error occurs in a complex system — and health care is a complex system — one can reasonably conclude that the system is still perfectly designed for that error, or one like it, to occur again. To avoid that outcome, a conscious effort must be made to improve the system.
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Using Deming's System of Profound Knowledge is helpful in quality improvement because:
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It can help break down complex quality issues into smaller, more understandable parts. By breaking down a problem into its component parts, as in Deming's System of Profound Knowledge, you can better analyze it and design ways to improve it.
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Which component of Deming's System of Profound Knowledge is the team about to harness?
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Understanding variation They are working at understanding variation. By noting a unit that outperforms the others — a significant variation — the nursing home can now study that unit and attempt to spread its practices throughout the organization.
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After speaking with caregivers on Floor 3, the improvement team discovers that there is a particularly dedicated head nurse on the unit whose mother died after a catheter-associated UTI. This nurse orients all new providers and also provides feedback when she sees that catheters are being placed unnecessarily in patients. Which component of Deming's System of Profound Knowledge do this nurse's actions best represent?
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Psychology (human behavior) The answer is psychology (human behavior). This nurse is very particular about preventing UTIs because of the way this kind of infection has affected her life. This, in turn, has a strong effect on the way the entire unit works.
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Which of these is a question particularly associated with the "theory of knowledge" component in Deming's System of Profound Knowledge?
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What are your predictions about the system's performance? The answer is, "What are your predictions about the system's performance?" Deming believed knowledge is based on theory, and that theories need to be developed, applied, and tested in order to advance knowledge in a systematic fashion.
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The Model for Improvement begins with three questions designed to clarify the following concepts:
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Aims, measures, changes The Model for Improvement begins with three fundamental questions about any given improvement, designed to address the aim (what are we trying to accomplish?), the measures to be used (how will we know a change is an improvement?) and the changes to be used (what changes can we make that will result in an improvement?).
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Applying the Model for Improvement to the clinic's improvement goal, which of the following is the most reasonable aim statement?
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Increase the number of patients reporting they are "very satisfied" with the clinic's scheduling by 50 percent within six months. An aim statement must specify "how good, by when." Improving patient satisfaction with scheduling is a reasonable goal. Answer D is best described as an opportunity statement, as it contains no specifics about how much the clinic must improve, nor by when. Answer C is more of a "change" statement than an aim statement.
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What is the team's next step?
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Test their change plan using the PDSA cycle. Once you have worked through the first three questions of the Model for Improvement — the questions about aims, measures, and changes — it's time to do a small test of change using the PDSA cycle. The clinic should have already developed their measures, and now is not the time for a break — because the hard work of improvement is just beginning!
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The orthopedic clinic plans the change to improve scheduling, and then it carries out a small test of change with three patients on Tuesday morning. What's the next thing the clinic's improvement team should do?
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Measure to see if the change led to improvement. The team has planned a test of change and now they've done the test. The team must now study how the test went (the "S" part of the PDSA cycle). They can look at a mix of process measures (such as how often appointments started on time) and outcome measures (such as how satisfied the patients were with the new process).
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When trying to improve a process, one reason to use PDSA cycles rather than a more traditional version of the scientific method (such as a randomized, controlled trial) is that:
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Both C and D PDSA cycles allow for rapid and frequent review of data and then adjusting the test of change based upon those findings. For example, if a new guideline that's meant to improve pneumonia care isn't working, PDSA cycles allow you to change the guideline quickly and test its efficacy, rather than waiting until the end of a long study period.
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Having a clear aim statement is important in quality improvement work because:
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Aim statements provide a clear and specific goal for the organization to reach. Whether you're trying to reduce your commute time or cut down on the incidence of surgical-site infections, having a clear and specific aim statement makes your project more likely to succeed. Good aim statements include a specific, measurable goal, a deadline for achieving the goal, and information about which population will be affected: how good, by when, for whom. They do not, however, remove all obstacles from the process. And while many funding requests and leaders require strong aims, it's not always a requirement.
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An aim statement should include the following:
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Numeric goals, specific time frame, and the patient population or system affected Aim statements should specify measurable numeric goals, a time frame for attainment, and the group or system affected. Costs and team members, while important to the success of the quality improvement project, are not part of the aim statement itself.
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Which of the following is the most effective aim statement for this project?
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Within three months, the emergency department will administer all pain medications within 45 minutes of order time. Effective aim statements contain a time frame, a definition of the population to be affected, and specific, measurable goals. Answer B meets all three of these criteria. While answers A and C may be useful process changes to reduce the delay between the ordering and administration of medications, they are not aims in and of themselves. Option D is not specific enough, as it does not contain information about how much the department should improve.
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The charge nurse in the emergency room asks Brenda to assemble a team to improve the delivery of pain medication. As she considers who to place on the team, Brenda should:
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Review the aim statement to make sure the team includes representatives of all processes affected by the team's aim. Including the right people on the change team is crucial to a project's success. The team should include representatives of all processes affected by the team's aim, which is why Brenda should review the aim statement. Further, it should include people with enough authority in the system to remove barriers and implement changes; people with clinical or technical expertise; and people who can drive the project on a day-to-day basis. A team representing just one profession is rarely as effective as an interprofessional team.
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During Brenda's first group meeting, the members ask to review the aim statement to make sure they agree it addresses the current problem. With Brenda's approval, they all decide to rewrite it. However, when they meet to consider what would be a better aim statement, the group loses direction. In order to help them, Brenda might want to:
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Remind the team of the Institute of Medicine's dimensions of health care quality. Writing an effective aim, especially when it comes to being specific about the improvement desired, can be surprisingly difficult. The Institute of Medicine's six dimensions of health care quality can often provide guidance and direction when a team is struggling to formulate an effective aim statement. (Reminder: A handy way to remember the six dimensions is the mnemonic "STEEEP": safety, timeliness, effectiveness, equity, efficiency, and patient-centeredness.)
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What would you identify as the outcome measure for the project?
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Percentage of patients that are readmitted to the hospital Answer D—hospital readmissions—is the ultimate measure we're trying to move with the project. In other words, that's the main thing we're trying to improve. Answer A is a process measure, which tells us if we are consistently doing the things that are leading to improvement. Answers B and C are both balancing measures, meaning that we're keeping track of them to make sure the changes we're making are not having a negative effect on other parts of the system.
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Which of the following is an example of a process measure that you may collect as part of this improvement effort?
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The percentage of patients receiving a call within 48 hours of discharge Gathering data about process changes is important—otherwise you won't know if you are consistently doing the things that you predict will lead to improvement. Further, if your outcome measures show improvement over the course of your project, having good process measures allows you to make a reasonable conclusion about the efficacy of your new processes and their relation to the outcome. Answer A is an outcome measure for this project, and answer D is a balancing measure.
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Why might you consider collecting balancing measures?
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To make sure you did not unintentionally damage other aspects of the unit's work Sometimes changes in one part of a complex health care system will lead to unintended additional changes in a different part, like ripples in a pond. Balancing measures can help ensure you're aware of these significant negative consequences, so that you can address them.
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What else should you add to the graph to best explain the improvement work your unit has done?
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Annotations to show when specific changes were tested When you go through multiple linked PDSA cycles in the course of a project, it's important to note which changes were tested and when, so you can make sense of the results. The cost may be important, but this data point won't show whether the team's changes led to improvement. P-values showing statistical significance are more commonly used in quality research than in quality improvement.
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Gathering and reviewing data during an improvement project—that is, measuring—helps you answer which of the three questions of the Model for Improvement?
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How will we know that a change is an improvement? Measures (both qualitative and quantitative) provide a way to gather information on the effects of the change you are testing. Without measures, you have no real way of knowing whether your change led to an improvement. Having good measures is critical if you wish to improve care and spread change throughout a system.
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You're a medical assistant at a community health clinic. Sometimes, patients with unresolved problems need to come in for follow-up appointments. However, you notice that it's a real challenge to schedule these follow-ups within a week of the initial appointments. Which of the following techniques might be most useful as you search for a good idea for change?
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Review the process for scheduling these appointments with colleagues to identify opportunities for improvement. Coming up with a change that will address your problem is often one of the most difficult aspects of the change process. Brainstorming with colleagues may help, as can critical thinking and creative thinking about the problem at hand. In this case, simply moving to another clinic (answer B) might reduce your frustration but will not help the clinic. Improving the scheduling software (answer C) may be useful, but it's unclear at this point that technology is at the heart of the delays. Finally, the office staff very likely already know that patient follow-ups should be scheduled sooner, but some aspect of the process is making this difficult for them (answer D). Simply reminding them is unlikely to get results.
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What's the main benefit of using change concepts to come up with improvement ideas?
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Using change concepts can help you develop specific improvement ideas that might not have occurred to you initially. Change concepts can help you develop new, specific ideas for change that could lead to improvement. They don't necessarily improve the likelihood that implementation of these changes will go smoothly, however. Finally, testing the changes using PDSA cycles is still necessary!
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You notice that it's very easy to confuse medications at the community health center where you're working. They are lined up on the shelf and the labels are very similar. You decide that it's worth a try to highlight parts of drug names on certain labels to reduce confusion. Which change concept are you using?
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Design Systems to Prevent Errors By making it easier to identify the medications, you are making it harder for the people in your organization to make mistakes. Choices A, B, and D are all valuable types of change concepts, but they do not apply in this example.
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Which of the following changes falls under the heading of "eliminating waste"?
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Physicians type all consult responses directly into a computer rather than writing them in a patient's chart, thus saving paper. Waste is an activity or resource that does not add value. When a physician writes an order and someone else enters that order into the computer (answer A), two steps are required. Changing the process so it only requires one step reduces waste as well as potential for error. None of the other answers explicitly focuses on reducing waste.
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As you recall, the IHI staff member's change idea involves leaving work by 5:30 PM each workday. Which of the following is an example of using technology to help her do so?
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Scheduling a reminder into her work calendar that pops up daily at 5:15 PM with the message, "Leave!" The programmed reminder is an example of using technology to make it harder for people to "drift" into less-than-optimal behavior. Answer A is an example of benchmarking. Answer B is an example of the change concept "eliminate waste" (assuming those meetings were not necessary in the first place). Answer D simply shifts the work to home, rather than creating a more efficient work pattern.
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The care protocol was successful at the other hospital. Why would it be important to test this proven change at your hospital?
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Because this change may not be as effective in your hospital. Changes that work in one complex system may not be as effective, or effective at all, in another. The only way you will know for sure is to test the changes. Other reasons to test "proven" changes are to evaluate costs, minimize resistance and gain buy-in, and increase your own confidence that the change will lead to improvement in your setting.
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After several tests, you decide to try implementing a modified version of the protocol at your institution. Which of the following might you do within the "S" portion of your next PDSA cycle?
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Analyze information collected. "S" stands for Study. In this step you review the information collected during the "Do" step. Planning for implementation is part of the "Plan" step, and documentation of outcomes is part of the the "Do" step. Considering how to spread the change to another hospital is outside the scope of this PDSA cycle.
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Based on the recommendations in this lesson, what should you do next?
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Work on improving both the schedule and communication at the same time. You should start testing changes to both processes and run the tests concurrently. That way you can see how all the required changes work together. Remember, your goal is to bring knowledge into action—not to discover the single change that works best.
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Starting with small tests of change:
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Improves the likelihood of buy-in from opinion leaders Linking tests of change—with one test concluding and the next beginning at the same time, but this time on a larger scale or with a different scope—allows you to build support for your project. Each successive test is a way to demonstrate to key stakeholders that their input has value and that the project may actually lead to improvement. However, it's not necessary to seek consensus among stakeholders before testing changes.
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Which of the following statements is true?
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While not all changes lead to improvement, all improvement requires change. All improvement requires change—but unfortunately, not all changes lead to improvement. It is precisely for this reason that after you test a change, you should study the results to determine whether you're closer to accomplishing your goal.
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Which of the following might be an outcome measure for this effort?
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Average number of minutes between patient arrival at the clinic and completion of check-in Outcome measures tell you how the system is performing. In this case, the aim of the project is to decrease the time it takes to check in patients, so an appropriate outcome measure for this project could be "average number of minutes between patient arrival at the clinic and completion of check-in." The average number of patients seen by the clinic and the average number of students helping to check in patients might be useful to track as balancing and process measures, respectively.
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Which of the following is the best way to collect baseline data for this improvement project?
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Look at a few patients every day for a week. The best answer is to use a small sample and gather the data quickly. When measuring for improvement, it's often unnecessary (and may defeat the goal of rapid, iterative testing) to collect all available information over an extended period of time. Baseline data is important for knowing whether changes you are making are, in fact, leading to improvement.
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Which of the following is an example of an effective measurement technique for improvement?
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Use quantitative and qualitative data. The best answer is to use qualitative and quantitative data. Qualitative data, which is not so much about numbers as it is about the depth of the information collected, can be a rich source of knowledge in improvement projects. Interviews or focus groups are common sources of qualitative data. Measurement is not the goal; improvement is the goal. In order to move forward to the next step, a team needs just enough data to know whether changes are leading to improvement. ("Seek usefulness, not perfection" is a mantra at IHI.) To save time, integrate data collection into the daily routine as much as possible.
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Why should you consider collecting a family of measures when undertaking an improvement?
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A single measure may not be enough to determine the impact of a change on the system. Health care systems are extremely complex. A small change in a complex system can lead to many unexpected results, so using only one measure may not capture the effect of the change upon the system. Using more measures will not necessarily increase the likelihood of publication. Finally, it is health care that is complex, not necessarily the improvement project itself. The most successful projects are often the simplest ones.
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You're working on an improvement project at a community mental health center. Your project aim: "Within two months, 100 percent of our patients will wait less than 30 minutes to be seen by a physician." You decide to gather data on patient wait times over a week-long period in order to establish a baseline. What might be an important consideration as you plan your data collection strategy?
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What exactly you mean by "wait less than 30 minutes to be seen" — does this include the time the patient spends checking in, for instance? It is crucial to clearly define your measure before you begin gathering data, so that you and your team members measure the same thing each time — and so that others understand what you are measuring. It's not necessary to establish consensus at the outset about the value of the project; by doing small tests of change, you are likely to gain buy-in as you go. Finally, you are gathering data for improvement, not accountability, so for this project, it doesn't make sense to notify supervisors about the performance of individual caregivers.
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Which of the following methods would you recommend to display your improvement data?
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Draw a run chart. Run charts are an effective way to view changes over time. They are much easier to interpret visually than a list of numbers or a static display of data such as a bar chart.
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When designing the run chart, it is important to include:
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Units of time on the X axis The run chart should display units of time — whether it's days, weeks, or months — on the X axis. The Y axis is where you plot the key variable you are measuring, which in this case is the rate of UTIs.
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Which of the following is a problem with static data?
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It doesn't adequately portray variation. Summary statistics that are static in nature don't give you the appropriate picture of the variation that lives in your data. Although you can accurately display data such as the mean, median, or mode, it is not a good way to observe change over time.
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Which of the following statements is true about using data for improvement? ***
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All of the above. The best answer is all of the above.
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Which of the following describes data stratification?
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Classifying and separating data according to specific variables Classifying and separating data according to specific variables — a practice called stratification — is a helpful way to understand the story data is telling. The goal of stratification is to find patterns in data that will help you understand the causal factors at work. Stratification helps inform teams' decisions about what changes to make, where, and when.
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In a run chart, the variable being measured is typically placed on what axis?
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Y axis The measured value is usually represented on the Y axis of a run chart. The X axis is usually the time — minutes, hours, days, weeks, months, etc. — or a numerical sequence in cases where data doesn't correspond to units of time.
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Imagine you're a member of a newly formed improvement team that has taken up the challenge to reduce health care-associated infections at your hospital. You have an idea for a change to the room cleaning process that you want to test, but you're slightly nervous because improper cleaning and disinfection can carry a high risk for patients with compromised immune systems. You haven't run any PDSA cycles yet. Which of the following would be the best next step?
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Confirm the "face validity" of the new cleaning process by demonstrating it with a couple of housekeeping staff members and a supervisor. Based on your concern about patient safety, you'd likely first want to confirm the "face validity" of the new cleaning process by demonstrating it with a couple of housekeeping staff members and a supervisor. When testing changes that involve patients, it can be helpful to conduct an initial test using staff only. A simulation or practice session before going live is often a good way to uncover issues with high risk.
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When planning a sequence of PDSA cycles for a change that involves patients, which of the following is a true statement?
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We would expect the number of patients involved to grow rapidly from early cycles to later cycles. As improvement work progresses and the number of cycles increases, we would expect the scope and scale of the tests to increase, meaning both a rapidly growing number of patients involved in the tests as well as increasing diversity in the test population.
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When increasing the number of patients or events from one PDSA cycle to the next, it is usually helpful to multiply by what number?
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5 The 5X Rule recommends an increase by a factor of five whenever you finish one successful test and move on to the next.
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When determining sample size for the first test, it is most important to:
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Weigh the potential consequences of a test that does not lead to improvement against the belief in success. With improvement work, you should weigh the potential consequences of a test that does not lead to improvement against the belief in success. How small your first PDSA cycle should be rests on your degree of belief and the stakes involved.
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Let's say the hospital has an English-speaking nurse (Nurse Moss) assess one English-speaking patient with the new form. It is a successful test and the improvement team wants to increase the scale of the next test. What would they do?
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Increase the number of patients Nurse Moss assesses by a factor of 5. The best answer is to increase the number of patients Nurse Moss assesses by a factor of 5. Scale is the number of interactions within the test — in this case, the number of patients receiving the assessment, and the 5X Rules recommends an increase by a factor of five in each subsequent test. Changing the conditions of the test — such as the language involved or the staff involved — would be a change in scope, rather than scale.
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Which of the following methods would you recommend to display your improvement data?
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Draw a run chart. Run charts are an effective way to view changes over time. They are much easier to interpret visually than a list of numbers or a static display of data such as a bar chart.
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When designing the run chart, it is important to include:
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Units of time on the X axis The run chart should display units of time — whether it's days, weeks, or months — on the X axis. The Y axis is where you plot the key variable you are measuring, which in this case is the rate of UTIs.
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What is the minimum number of data points you should usually have to look for signs of improvement on a run chart?
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10 A run chart becomes more powerful as you add more data points because there will be more opportunities to identify patterns. If you're looking for signs of improvement, usually you need at least 10 data points.
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Which of the following is a problem with static data?
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It doesn't adequately portray variation. Summary statistics that are static in nature don't give you the appropriate picture of the variation that lives in your data. Although you can accurately display data such as the mean, median, or mode, it is not a good way to observe change over time.
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When you are graphing a proportion or a percent, what should you look at to help you understand the bigger picture?
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The denominator of the measured value By tracking the denominator of the measured value, you can confirm that your improvement effort is really showing signs of success, and there are not other factors at work.
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Within the following data set, what is the median? [2.5, 7.2, 2.5, 2.9, 4.7, 3.6, 4.7]
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3.6 You calculate the median by finding the midpoint of a set of numbers. In this case, the median is 3.6, because there are three values before and three values after 3.6, making it the midpoint.
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What aspect of the run chart helps you compare data before and after a PDSA cycle? ***
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B and C What aspect of the run chart helps you compare data before and after a PDSA cycle?
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Which of the following is a rule for determining non-random patterns?
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A and B The best answer is A and B. A run of six points or more and an astronomical point both indicate non-random patterns. A trend of three points or fewer does not. In order to indicate a non-random pattern, a trend must consist of five data points or more.
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In the above chart, how many useful observations are there?
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36 Counting all the points not on the median yields 36 useful observations.
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When did a PDSA cycle occur?
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March 5 The label on the chart shows a PDSA cycle occurred in March 2005
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How many runs are there?
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12 By counting the number of continuous points above or below the median, we get 12 runs.
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Using Rule 3, does this chart show non-random patterns?
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Yes, there are too few runs. There are 36 useful observations. For that number of observations, the table states that 13 or fewer runs show non-random patterns. We have 12 runs. Therefore, we can deduce that there is a non-random pattern in this chart.
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Which of the following traits do histograms, Pareto charts, and scatter plots have in common?
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They are all visual tools to display data. Answer: B. They are all visual displays of data. Histograms and Pareto charts are types of bar charts, but a scatter plot is not.
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What famous Italian economist is credited with the theory behind the 80/20 rule?
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Vilfredo Pareto The correct answer is Vilfredo Pareto. Pareto observed that 80 percent of the wealth of Italy was owned by 20 percent of the people. The Pareto chart was named after him by Joseph M. Juran.
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Which of the following BEST describes the purpose of a histogram? ***
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To show distribution of continuous data The best answer is that a histogram measures distribution of continuous data. A histogram is a special type of bar chart. It can be used to display variation in weight — but can also be used to look at other variables such as size, time, or temperature. A chart that shows the relationship between two variables is a scatter plot.
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When drawing a histogram, which is a good number of categories to include on your X axis?
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6-12 Six to 12 categories of equal width is usually a good number to help you understand the distribution of data.
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Which of the following charts would be best to justify focusing on a few large problems and ignoring many smaller ones? ***
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Pareto chart By separating the vital few from the trivial many, a Pareto diagram helps a team concentrate its efforts on the factors that have the greatest impact. It also helps a team communicate the rationale for focusing on certain areas.
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What are the four phases of an improvement project? ***
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Innovation-Pilot-Implementation-Spread The four phases of an improvement project are "Innovation-Pilot-Implementation-Spread." Plan-Do-Study-Act (PDSA) cycles are tests of change that improvers conduct during different phases of their improvement projects.
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How should Sandy and her improvement team try out the new process for improving pain control?
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Test the new process with one patient and closely review the results. The best answer is "test the new process with one patient on and closely review the results." Sandy and her team have an innovation and are ready to conduct a pilot. (Every organization is different, so just because the idea worked at another hospital does not mean it will work here.) Piloting involves starting small, such as with one patient, and carefully refining the change to make sure it works.
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After a successful pilot, which of the following should Sandy's improvement team undertake as a next step?
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A and B The best answer is "A and B." After a successful pilot, they should move on to the implementation phase. This phase includes actions to "hardwire" the change, such as making it standard policy and training new staff on it. In implementing the change, the team will continue to run PDSAs: making predictions, carrying out the test, collecting data, and refining the change based on results. (Note that compared to PDSAs in the pilot phase, these tests will require significantly more people, time, and resources.)
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What improvement project phase have Heather and her team just completed?
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Pilot The team has just completed the improvement stage that consists of early, rapid-cycle tests of change: the pilot phase
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Heather and her team continue to test the new idea. Assuming things continue to go well, what might they eventually do?
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All of the above. The best answer is "all of the above." After a successful pilot, the next steps are implementation and spread. IHI's Framework for Spread, which includes developing a communication and dissemination plan, is a helpful tool to use during the final phase of an improvement project.
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According to Herbert Kaufman, which of the following are reasons health care workers commonly resist change? ***
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All of the above The best answer is all of the above. In his book The Limits of Organizational Change, Herbert Kaufman identified all of these as potential barriers to implementing change in health care.
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In the example, which of the following is a process change?
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The planned nap The process change is the planned nap. It is the method by which the organization hopes to decrease worker fatigue.
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Which of the following represents a culture change?
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The belief that a planned nap can support patient safety The culture change is the fundamental belief that a planned nap can support patient safety and that napping is okay during a shift.
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What's the likeliest reason the program failed?
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The culture of the organization did not support napping during a shift. The program probably failed because the culture of the organization did not support napping on the job as a way to decrease worker fatigue and boost patient safety
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What would be a good way for the team to respond to the resistance to the change?
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Share data that shows the process change is associated with a decrease in adverse events. The best answer is to share data that shows the process change is associated with a decrease in adverse events. Many people find compelling data to be persuasive. Some people are more motivated by stories. However, the story needs to be directly related to the change in order to be persuasive.
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In designing a performance improvement team, it is helpful to: ***
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Have a mix of different types of people on the team A healthy mix of personality types helps ensure a team captures many perspectives on an issue.
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Personality and work style profile assessments can help to:
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Identify the personalities present and work to everyone's strengths. Personality and work style profile assessments help us understand how different people prefer to perceive the world and make decisions. This can be valuable — particularly if team leaders appreciate these differences and design the work to accommodate diverse preferences.
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Which of the following are strategies to help members of a QI team establish common goals?
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All of the above The best answer is all of the above. Some strategies to help get everyone on the same page include: Create a team roster so everyone knows who is on the team and how to reach each other, share stories to establish why the QI project is personally meaningful to people, and write out a work plan.
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What is the order of the four steps teams typically follow to get to a place where they are running smoothly? ***
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Forming, storming, norming, performing Mary Dolansky explained a four-step process by which teams to get to a place where they are running smoothly: forming, storming, norming, and — finally — performing
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You're on a team seeking to improve the process for treating patients with sepsis. (Sepsis occurs when chemicals released into the bloodstream to fight infection trigger inflammatory responses throughout the body). Which of the following is an example of "advocacy"?
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Stating your idea for updating the sepsis protocol. The best answer is stating your idea for updating the sepsis protocol. Advocacy is making your own views known (including why you feel or think the way you do). Inquiry is seeking the views of others. The key to being an effective team member is balancing advocacy and inquiry.
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When adapting to new change, most people fall into which of the following two categories?
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Early majority and late majority For any given change, the bulk of the population will fall into the early majority and late majority.
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Which of the following is a summary of Kurt Lewin's model of change?
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Unfreezing, changing, re-freezing Kurt Lewin wrote that successful change efforts involve preparing people for the change ("unfreezing"), helping them transition ("changing"), and ensuring that the new process becomes the norm ("re-freezing")
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In this scenario:
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Dave's behavior is normal; everyone has some challenges when adapting to new things. In this scenario Dave's behavior is perfectly normal. Everyone struggles with change to some extent.
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Using Everett Rogers' theory of adoption of innovation, which category of adopter best describes Rose?
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Innovator Rose is considered an innovator because she was involved and committed to the new process before it had even come to the hospital
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Using Rogers' theory of adoption of innovation, which category of adopter best describes Joan?
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Early adopter Joan is an early adopter because she wants her unit to be the first to pilot test the program.
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According to sociologist Everett Rogers' attributes of spreadable ideas, ideas that spread naturally are:
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Trialable One characteristic of ideas that spread naturally is trialability — that is, there is the opportunity for people to test the idea in a safe setting. The other four characteristics, according to Everett Rogers, are relative advantage, compatibility, simplicity, and observability
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Which of the following is an accurate statement about the spread of this innovation?
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The complexity of the change involved will likely slow the spread of this innovation. Implementing an entirely new clinic system is quite complex, making this a difficult innovation to spread. Improved outcomes may take time to appear and may not be easily observable, which could also slow spread. Finally, because this innovation involves a large-scale system change in most cases, it is difficult to test this easily and in a safe setting. This analysis does not imply that the medical home is not an improvement — only that it may be more difficult to spread than less complicated innovations
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ABC Medical Center's leadership team has implemented the medical home model in one pilot site. Now the team wants to spread the innovation to other sites, and it is using IHI's Framework for Spread. Which of the following should the spread team do?
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Ask staff to give daily feedback, to assess progress along the way. The best answer is to solicit daily feedback. One key factor in IHI's Framework for Spread is knowledge management, which includes gathering information about the spread process as it unfolds. Waiting a year to gather feedback is too long
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When attempting to spread a change that you feel is valuable but is not spreading naturally, if possible, it's a good idea to:
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B and C Changes that do not spread naturally might benefit from IHI's Framework for Spread and from brainstorming with the New Idea Scorecard. You could switch to a different innovation that's easier to spread, but it would be wiser to use the tools available to you before abandoning a potentially valuable innovation.
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The "setup" component of IHI's Framework for Spread is best defined as:
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Identifying the target population and the initial strategy to reach all sites in the target population with the new idea The best answer is "identifying the target population and the initial strategy to reach all sites in the target population with the new idea." Understanding the relationships within the system falls under the "social" component of IHI's Framework for Spread, and tracking and monitoring progress falls under "measurement and feedback." The identification and piloting of worthwhile innovations should occur before leaders attempt to spread those innovations throughout a system.
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What is the purpose of IHI's Framework for Spread?
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To spread improvements across health systems IHI's Framework for Spread is a useful way to think about the most important components to consider when developing and executing a strategy to spread improvements across health systems
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Which of the following is NOT one of the key components of the IHI Framework for Spread?
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Piloting innovation The pilot phase of an improvement project occurs before the spread effort, as a prerequisite. The improvement team will initiate a spread plan only if the pilot is successful.
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Regarding the Seton network goal for spread, which of the following is true?
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They surpassed it. The Seton Family of Hospitals set a spread goal to introduce 15 medical-surgical units to TCAB by June 2007. At project completion, they had exceeded the initial goal: 17 units were using the TCAB process within 18 months
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Which of the following communications strategies did the TCAB spread team use at Seton?
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All of the above The best answer is "all of the above." Because communication is at the heart of spread, the spread initiative needs an organized communication campaign. It's helpful to use many types of communication.
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Seton's Chief Nursing Officer was a key supporter of the TCAB spread effort. Which component of IHI's Framework for Spread does this fact best represent?
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Leadership The best answer is "leadership." Executive leaders in an organization play an important role in spread initiatives by supporting and facilitating the efforts. The ultimate success and sustainability of TCAB depended on leadership commitment at all levels: from the senior executives who set strategic priorities and ensured that good changes spread, to midlevel clinical leaders who empowered staff and orchestrated change, to local leaders and staff who redesigned care processes to achieve unprecedented patient outcomes
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With which of their following statements would you agree?
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Care has become more complex and specialized during the last 40 years. There is no question that health care has become, overall, more complex in the past four decades. Increased diagnostic technology, treatment options, and specialization have all added to the complexity (and costs) that patients see, but have also improved health outcomes for most conditions. In the case of breast cancer, and for many other acute and chronic illnesses, the number of individuals (and disciplines) involved in a single patient's care has increased dramatically. This has made communication and coordination among various physician and non-physician providers more critical than ever to providing safe and effective care. It should be noted that the number of specialists involved with a patient varies dramatically depending on where a patient lives, a patient's proximity to large medical centers, and the number of specialists who practice nearby. It is not always the case that more care is better care. Research shows that areas with relatively more medical specialists do not produce higher-quality care, higher patient satisfaction, or lower mortality.
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Compared to today, the treatment of breast cancer in the 1960s, typically:
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Required fewer individuals to participate in a single patient's care. The treatment of breast cancer in the 1960s was primarily surgical, and often involved more extensive surgery than is necessary today. Treatment has evolved to include surgical, radiation, and chemotherapy treatment that is more tailored to the size and location (spread) of the cancer at the time of diagnosis. Chemotherapy can be further tailored depending on characteristics (and predicted responsiveness) of the tumor cells themselves. Each of these aspects of care requires a range of professionals to plan, coordinate, and execute the treatment plan, all of which has resulted in a dramatic increase in survival rates for this condition. In England and Wales, for example, the five-year survival rate has jumped from 52% (in 1971-1975) to 82% (in 2001-2006) during the past three decades. And in the United States, the five-year survival rate has jumped from 75% (in 1975-1979) to 90% (in 2000-2002.)
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In your email back to the chief, what might you tell her?
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"Designing a complex system requires input from professionals with a range of expertise." A system that provides surgical care is a prime example of a complex system. Getting the right outcomes reliably, safely, and efficiently relies on the coordination of pre-operative, intra-operative, and post-operative components of care. Individuals with experience with one role in this process may believe that they have a bird's eye view of the entire process. This is almost never the case! Redesign of such a system requires a team representing all of the tasks and personnel that must contribute to the desired outcome. Graphically representing the process in a "flow diagram" is often a useful step in the design process. Finally, system redesign should not require pitting safety against efficiency; the system must be designed to simultaneously improve both.
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Which of the following should you keep in mind as your hospital redesigns the way it handles knee replacements?
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How system components are integrated with one another is as important as how well they function independently. Any complex design process should begin with excellent component processes and materials. But such components will not, by themselves, result in an excellent overall result. How components (and component processes) are integrated is a key to overall outcomes. This is as true for a medical care process as it is for an industrial design process. Even with a committed multidisciplinary team, it is very rarely, if ever, possible to get everything right on the first try. Finding flaws after initial implementation (and opportunities for further improvement) should be expected and embraced. While commitment to innovation, excellence, and continual improvement should be supported from the very top of an organization, the actual leadership of the design process should be at the level that will serve best to engage those who have the deepest knowledge of the workflows and component activities, and can engage the multidisciplinary design team.
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According to Steve Spear, as you design a better system for something like knee replacements, you should build in the capacity for innovation, which must be:
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Broad-based, non-stop, and high-speed. Steve Spear teaches us that part of daily work should include not only treating patients, but also identifying the workplace experiences that caused disruption and difficulty, and resolving those problems by identifying and addressing their root causes. Innovation must permeate an organization and not be the purview of only a segregated group of professionals. Innovation and improvement should not be only reactive to problems or leadership initiatives, but a part of the work of all team members. To thrive, an organization must have the capacity for "broad-based, non-stop, and high-speed innovation."
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If the knee replacement process still doesn't function as well as it should after the redesign, the hospital should:
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Consider this an expected outcome and focus on innovation and improvement. It would be highly unusual for a redesign process to result in a perfect system. The fact that there is still room to improve should also be an expected outcome. While convening the team would be helpful, small changes to the plan with continuous measurement are likely to result in the best process over time. There is occasionally a value to outside consultants, but the capacity for improvement and innovation really must be part of the culture and work of the organization itself
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Which of the following is typically true of "weak signals"?
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They can combine with other human or environmental factors to result in catastrophe. Weak signals that could be used to identify system deficiencies are common - and usually ignored. This is understandable since, by themselves, such signals do not result in direct harm. It is only when they combine with other factors that harm (and sometimes catastrophe) results. Examples in and out of health care abound, including NASA's Columbia Space Shuttle disaster, which, if the response to such signals had been more robust, could have been prevented. Since weak signals occur in daily work at all levels of an organization, each individual must see it as part of his or her job to identify and respond to such signals (or to "escalate" the problem up the hierarchy so that it can be fixed).
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One study following nurses through their work showed which of the following about operational failures on a nursing ward?
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Individuals worked around 90% of operational failures. An empirical study of nurses on a unit revealed just how common weak signals are in medical care. The operational failures were common across all nurses and not concentrated in a subset. In 90% of these failures, the nurses found ways to work around these problems so that patients still received needed care. While this is admirable in one way, such work-arounds do not allow for the opportunity to correct the underlying problems in the process and prevent them from causing harm in the future. Finally, only a very small number of these were reported up the chain so that corrective action could be taken.
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Which of the following might be an appropriate system-level response to that "weak signal"?
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B and C This represents a classic problem with a system, and is what is often called a "disaster waiting to happen." Exhorting personnel (nurses, doctors, or non-clinical staff) to "be careful" is almost never as effective as addressing the root cause with a system improvement. Changing the way medications are stored so that "look-alikes" cannot be easily confused is one very effective approach. Research on the contribution of human factors to medical errors suggests that developing work schedules that prevent excessive fatigue also has the potential to decrease the risk of error.
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It is estimated that for every death or injury caused by a medication error, there are how many medication errors with little or no potential for injury?
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100 Errors that actually cause harm are the "tip of the iceberg." Such errors are usually intercepted by someone else in the chain - a pharmacist, a nurse, or even a patient - before the mistake reaches the patient. Even some prescribing mistakes (such as too high or low a dose of a medication) reach the patient, but do not cause harm. It is for this reason that we must respond to weak signals related to medication errors in particular.
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The term "normalized deviance" refers to:
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Acceptance of events that are initially allowed because no catastrophic harm appears to result. Paradoxically, the fact that weak signals do not result in harm is what makes them most dangerous. When a weak signal is ignored (perhaps many times) and no harm results, workers integrate it into their conception of what is normal. Statements like "we always do it that way" may indicate underlying complacency. This acceptance of unsafe, ineffective, or inefficient routines is called normalized deviance.
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High-speed innovation in health care delivery systems can and should be used to:
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Improve access to care. The goal of innovation should be to simultaneously improve access, improve quality, and decrease costs. In fact, all organizations have the opportunity to improve their understanding of how to create value, incorporate that new-found understanding, and thereby enjoy better results across a broad range of measures. Innovation should not necessarily decrease contact time between clinicians and patients, but rather, it should make that time more effective.
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According to Steve Spear, the first step in building a system in which problems are routinely "seen and solved" is:
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Defining normal and helping workers to recognize abnormality. A system that is constantly improving requires all of its workers to be a part of the identification of ongoing problems. It also requires its workers to have the ability to escalate problems to an organizational level at which they can (quickly) be solved. The first step is to help all participants in the system to understand how the system is expected to work (what is "normal") and to identify abnormalities (when what is actually occurring is different from expectations). These abnormalities include micro- and macro-system failures, inconveniences, disruptions, disturbances, and the like, which require work-arounds, coping, fire fighting, and heroics to complete work successfully. By seeing abnormalities and solving for their root causes, organizations can identify sources of error and reduce (and eliminate) threats to system performance.
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What can we learn from the example of how Allegheny General Hospital reduced its central line infections?
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Dramatically improving safety and quality requires many small changes in a system. The example of Allegheny General Hospital shows that reducing (and eliminating) serious adverse outcomes is possible by identifying and fixing myriad system vulnerabilities. Eliminating central line infections was not accomplished in a single step (e.g., a "silver bullet solution"), or by a top-down directive from senior management. Rather, it required many small changes to processes of care, in response to many small "abnormalities," that could have been accomplished only with input from professionals actually doing the work. Root cause analysis (e.g., "system diagnosis") didn't lead to identification of a single causal factor; it revealed multiple factors that had to be addressed.
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When you raise this concern with one of the staff nurses on the unit, she says, "We've been doing this for three or four months, and it seems to be working fine." The nurses on this unit:
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Have changed their definition of what is "normal," and have adopted a routine that is a work-around. When a work-around for a problem (or just ignoring the problem) continues for a period of time, it is easy for workers to reset their conception of what is "normal" in their workplace. This can continue for a long period, since a problem may not result in harm immediately. Staff who develop such work-arounds are not intending to put patients at risk. On the contrary, they are doing their best to provide care in the moment within a flawed system. It is, however, their responsibility to observe and report problems so that they can be addressed. It is the responsibility of leaders to help diagnose why the inconveniences and disruptions are occurring and how they can be remediated.
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You feel that you must escalate this problem. In this context, "escalation" means:
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Communicating the problem, including when and where it is occurring, to the person who has the span of authority to fix system flaws. Often, the individual who has identified a problem does not have the perspective (across related processes or departments) or authority to solve it. The problem's root cause may be a poor assignment of responsibility or a broken handoff across a link between two professionals. Escalation is the process of calling out an abnormality or flaw in the system and making it known to individuals with a broader span of responsibility in the organization who can solve it. It isn't necessary to wait for many workers to report the same issue for a solution to be implemented. One disruption, inconvenience, or "operational failure" is proof that something is imperfect.
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You meet with the nurse administrator responsible for improvement when issues in the process of care are identified by those on the wards. She listens carefully to your concern, but in the end says she can only try to help improve nursing issues, and not those that extend to pharmacy or transport. The primary reason your meeting is unlikely to lead to an adequate solution is:
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The nurse administrator did not have the appropriate span of responsibility to engage the system components needed to solve the problem. Steve Spear identifies a number of steps needed to fix problems in a production system. They include recognizing abnormalities; having an identified person to call, with the knowledge, attitude, and responsibility necessary to find a solution; and giving workers the time and resources to solve the problem. In the case of health care, this means treating the "system" as well as the "patient." The challenge here is that even though someone is designated, and that person may have the time to fix how work is done, the nurse administrator may not have the perspective and authority to work across boundaries of specialty, function, and discipline.
