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Quality in HC

An indicator (performance measure) about the placement and number of fire extinguishers would be which type? structure (systems). There are systems, processes, or outcomes
Continuous quality improvement is best described by the following statements EXCEPT corrective action targets clinicians more so than processes
an indicator (performance measure) about the institution's death rate would be which type? outcome. There are systems, processes, or outcomes
In quality review activities, departments are directed to focus on clinical processes that are all of the above
The process of comparing the outcomes of HIM abstracting functions at your facility with those of comparable departments of superior performance in other healthcare facilities to help improve accuracy and quality is referred to as benchmarking
The quality improvement team for the HIM department meets to generate ideas to address physician complaints about missing dictation reports. What QI tool would prove useful in discussing various recommendations for solving this problem? brainstorming
Joint Commission and other accrediting bodies require that medical record review be performed to evaluate adequacy, accuracy, completeness, and quality documentation on an ongoing (continuous) basis
Which performance tool is used to provide structure by classifying infomation into smaller groups (categories or grouping) after a brainstorming session? affinity diagram
What process assists a health care facility in continuously looking at the ways that problems develop and seeking ways to prevent problems from happening in the future? performance improvement
What feature distinguishes the Nominal Group Technique (NGT) from brainstorming? NGT determines the importance of responses through a rating system.
The board of directors of a 400 bed women's hospital receives a report of key quality indicator results on a periodic basis. The report always includes the quarterly cesarean section rate and has for many years. This recent period they have seen a rise control chart
Pie charts: show the relationship of each part to the whole
The outpatient coding staff has been working to improve coding accuracy. The standard for the number of cases that must be coded has been raised four times in the past year. The staff states: "The more cases which must be coded the greater the error rat scatter diagram
What is the best tool for differentiating between common cause variation and special cause variation? control chart
The primary source document used in quality assessment monitoring is the: medical record
The coding supervisor is responsible for reviewing a random sample of each coders work and reporting on the error rate for each coder. A checksheet is used to collect the number of charts reviewed, the number of errors for each coder and the type of erro all of the above
A histogram is a valuable tool for representing: a frequency distribution with continuous interval data
The manager of the quality department is listing various sources of data. Which of the following data sources would be an example of an external source? Quality Improvement Organizations information (benchmarking)
The health information reception desk is experiencing a huge influx of phone calls on Monday, Tuesday, and Wednesday mornings. This is creating a problem in getting requested patient information out within an acceptable time frame. The reception staff w pareto chart
Which of the following is incorrect about the use of control charts? the upper control limits are always + or - 1.8 standard deviations
A Team Facilitator is a voting member of the team. False
The team leader has many responsibilites. These include preparing and scheduling meetings and helping the group to stay focused. Of the following responsibilities, which IS NOT a responsibility of the team leader? Creating charts and diagrams
A PI team is instituted to: research, plan, and implement improvement
"evaluate the HIM lab in regard to accessibility, resources, library access, Internet access, quality equipment, and adequacy of equipment while maintaining 95% HIM student satisfaction with these services." mission statement
A list of tasks to be accomplished during a meeting is termed a(an): agenda
"The HIM lab provides access to a variety of application software resources, library knowledge bases, and the Internet. A convenient, comfortable work environment exists." vision statement
Keeping track of the committees progress and activities is usually called the: minutes
The abbreviation CRAF stands for: conclusions, recommendations, actions, and follow up
The definition of the storyboard: graphic display tool used to communicate details of PI activities
The following represent keys to successful storytelling:organization, structure, timeliness, frequency, connection, celebration, and feedback. True
What quality indicator would prove useful in tracking customer satisfaction in the correespondence/release of information function? the turnaround time from the date of the request is received to the date the information is provided to the requester
Most healthcare facilities use this type of screening criteria for utilization review purposes to determine the need for inpatient services and justification for continued stay: severity of illness/ intensity of service criteria (SI/ IS)
Patient mortality, infection and complication rates, adherence to living will requirements, adequate pain control and other documentation that describe end results of care or a measurable change in the patients health are examples of: outcome measures
What action (s) would assist the manager of a medical record department in improving customer perception on the quality of services provided by the department? identify specific customer needs in order to design value added services
Customers that are outside the organization who receive products or services from within the organization are called: external customers
Individuals within the organization that receive products and services from an organizational unit or department are called: internal customers
In order to monitor and improve customer satisfaction the organization must know: all of the above
Continuum of care is defined as: totality of healthcare services provided in all settings from the least to the most extensive
The process by which an organization optimizes the care for the patient is called: case management
A project management tool used to schedule important activities is called a/an: Gantt chart
The use of flowcharts allows the performance improvement team to examine the process under investigation from all directions: True
The application of a set of procedures specifically designed to minimize or eliminate the passage of infectious disease agents from one individual to another is termed: universal precautions
A nosocomial infection is: acquired from the hospital after the patient was admitted
The Blood Usage Review Committee has a quality monitor established to review all blood transfusion reaction cases. The HIM Director will be working with the committee to identify and abstract patient outcome information for committee evaluation. What da all of the above
In compiling statistics to report the specific cause of death for all open heart surgery cases, the quality coordinator assists in documenting: patient care outcomes
A surgeon left a clamp in a patient resulting in a return to the operating room. In an integrated(cross-functional) organizational quality management model, all of the following entities would receive data about the investigation except: pharmacy and therapeutics committee
All of the following are among JCAHO's initial core measure sets for hospitals except: diabetes
As a HIM coding supervisor, you are asked to compare the current coding process with a proposed concurrent coding process. What visual tool would be the best to identify all the logical steps and sequence of each procedure? flow chart
In optimizing patient care, which of the following is NOT one of the Steps to Success covered in our text? evaluate the cost effectiveness of high risk procedures
Management of infectious disease includes these steps:1. Use of standard precautions 2. Infection surveillance 3. Education and screening programs True
RCA is a retrospective tool. True
Major responsibilities of the Risk Manager generally include: all of the above
A sentinel event is always considered a PCE, but not all PCEs are sentinel events. True
Needle sticks, patient or employee falls, medication erros or any event not consistent with routine patient care activities would require risk reporting documentation in the form of a/an: incident report
The policy and procedure manual no longer refects current practices. This situation is a risk management issue because: the manual represents the normal course of business
The best protection aganist injuries and ensuing financial liability is: risk prevention
FMEA is a retroactive tool used to analyze potential problems. False
Occurrences involving injury or property loss are called: potentially compensable events
Which of the following IS NOT included as a step to builiding a safe and effective medication management system, as outlined in our text? Cost savings include always using generic medications
Learning the underlying causes of a sentinel event by starting with a proximate cause and continuing to ask WHY is using what technique? root cause analysis
SWOT Strength, Weaknesses, Opportunities, Threats
FMEA Failure mode and effects analysis – defines high risk processes with flowcharts, identifies potential failure points and scores them.
Criteria for priorities High risk and high volume
PI models are based on continuous monitoring and performance assessment
Success of PI Program dependent on collection of data and information it gives.
3 types of data collection patient specific, aggregated, comparative
Data repositories Gives timely data for continuous monitoring
Intranet based comms keeps everyone appraised of status of projects
Standardization tools organizations must standardize data collection across all PI activities
Info warehouses allows storage of reports
Comparative performance data internal and external benchmarking, JCAHO Core Measures
JCAHO standards infomation management, record of care treatment and services, performance improvement
Establishing database determine content, laws regs standards, data dictionary
Aggregate data primary or secondary? secondary usually
Secondary data sources purposes quality performance and safety, research, population health, administration
Users internal – in org and external – outside of org (state data banks, etc)
Types of Sec Data Sources MPI, physician, diagnosis and operation indexes
MPI contains name, address, dob, admission/disch dates, dr name, record number
Disease and operation index ordered by code, includes record number, dr name, discharge date
Registries vs Index registries have more information
Disease registries secondary data related to dx, condition, or proc – case definition and case finding
Cancer registries facility and population based
Cancer registries amendment act of 1972 mandated pop. Based registries in each state
Reporting and follow up to Cx Registry Annual report, data used in QA/Research, patient follow up.
Standards and approval for Cx Registries ACS Commision on Cancer, NAACCS (North American Assoc Central Cx Registries) for state, CDC nationally
Education for Cx Registries NCRA, CTR – certified cancer registrar
Trauma Registries similar to Cx, trauma registry required for level 1 trauma center
Education for Trauma Registry RHIT, etc or Certified Spec. in Trauma Registry
PI Model – Organization wide 1. ID performance measures, 2.Measure performance, 3. Analyze/compare internal/external data, 4. ID improvement opportunity, 5. perform ongoing monitoring.
PI Model – Team based 1. research and define expectations, 2. Design/redesign process/ed, 3. implement process/ed, 4. document and communicate findings.
Created by: dbmurph22
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