TRENDS CH, 22

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Questions and Answers

The primary role of The Joint Commission (TJC) is

  • inspecting hospitals for compliance of infection control standards.
  • lobbying Congress on behalf of Medicare/Medicaid patients.
  • granting magnet status to excellent hospitals.
  • ensuring medical facilities meet patient safety guidelines. (correct)

The Joint Commission publishes a Sentinel Event Alert every month. Which of the following is the best example of a sentinel event?

  • Code pink is called after a newborn is discovered missing from the nursery. (correct)
  • After receiving the correct medication, the patient complains of itching all over, and a rash is noted on the patient's trunk.
  • Tylenol #3 is given to a patient when plain Tylenol was ordered.
  • During a blood transfusion, the patient's temperature increases to 100.4° F, and the patient complains of generalized pruritus.

A nurse is reviewing the technique used to identify the factors involved in an error. Which statement indicates the nurse has an adequate understanding?

  • "A root cause analysis is a process designed to investigate and categorize the root cause of the event." (correct)
  • "The rapid cycle test is a technique that is widely used."
  • "Define, measure, analyze, improve, control prevents events from occurring."
  • "A failure mode and effects analysis is a procedure to investigate the cause of the error."

A nurse is discussing the Pareto principle (80/20 rule), which leads to the idea of total quality management. Which statement [identifying the correct person] indicates an adequate understanding of this principle?

<p>Joseph Juran (B)</p> Signup and view all the answers

The nurse manager is educating a new hire on The Joint Commission (TJC). The manager tells the new hire that TJC mandates the use of continuous quality improvement and measurement of specific quality outcomes for patients with certain diagnoses. The teaching has been effective when the new hire states:

<p>&quot;Outcome measures are mandated for patients admitted with community-acquired pneumonia and congestive heart failure.&quot; (A)</p> Signup and view all the answers

A nurse manager is providing education to a new nurse on barriers to the implementation of quality improvement processes. The manager judges the teaching to be effective when the new nurse states:

<p>&quot;Expense is a primary barrier.&quot; (A)</p> Signup and view all the answers

The nurse manager has an adequate understanding of the continuous quality improvement process of Six Sigma when doing which of the following?

<p>Uses Six Sigma to increase profits (B)</p> Signup and view all the answers

A nurse is a team member assisting with the define-measure-analyze-improve-control (DMAIC) process. Which action would the nurse take during the define phase?

<p>Identify the stakeholders. (C)</p> Signup and view all the answers

A nurse is interested in becoming credentialed as a Certified Professional in Health Care Quality. Which action would the nurse take to achieve this?

<p>Take an exam. (D)</p> Signup and view all the answers

The continuous quality improvement (CQI) committee has performed a retrospective chart audit to investigate whether outcomes recorded in each nursing care plan are patient centered and written in behavioral terms. The expected standard is 98% compliance. The sample size was 200. Results showed that 180 charts met the standard. What assessment can be made?

<p>The standard was not met. An action plan should be developed. (C)</p> Signup and view all the answers

The nurse manager has an adequate understanding of root cause analysis when stating which of the following?

<p>&quot;Root cause analysis investigates the root causes of events that occur.&quot; (B)</p> Signup and view all the answers

A nurse is educating students on the history of quality improvement. The teaching has been effective when one of the students states that the historically, quality improvement focused on

<p>&quot;controlling process by inspection so that errors were prevented.&quot; (D)</p> Signup and view all the answers

A nurse is explaining to another nurse about the contributions of Edward Deming. The nurse judges that the explanation is effective when the nurse states:

<p>&quot;Quality is the responsibility of everyone within an organization.&quot; (C)</p> Signup and view all the answers

Which action takes place during the Define phase of the DMAIC process?

<p>A charter is developed. (C)</p> Signup and view all the answers

Which of the following statements by the nurse indicates an understanding of Quality and Safety for Nurses (QSEN)?

<p>&quot;QSEN helps prepare future nurses for improving patient safety.&quot; (A)</p> Signup and view all the answers

The nurse manager has an adequate understanding of Six Sigma when making which of the following statements?

<p>&quot;The primary goal of Six Sigma is to increase profits and reduce problems.&quot; (C)</p> Signup and view all the answers

A nurse manager is brainstorming quality improvement methods. Which action would help implement these methods on the assigned unit?

<p>Empower employees to carry out needed strategies for change. (C)</p> Signup and view all the answers

The nurse understands that the following statement is true about patient classification systems?

<p>&quot;The systems provide historical data of the usage of nursing time, which is helpful when developing the department budget.&quot; (C)</p> Signup and view all the answers

If the nurse had an adequate understanding of continuous quality improvement, which of the following statements would the nurse? (Select all that apply.)

<p>&quot;Systems within the hospital must be reviewed to determine how care can be enhanced.&quot; (B), &quot;The accountability for quality is vested in quality circles that function along service lines to improve patient care.&quot; (E), &quot;After quality standards are achieved, the nurse strives to maintain that standard of care.&quot; (F)</p> Signup and view all the answers

Which of the following are considered core measures and monitored by The Joint Commission? (Select all that apply.)

<p>Advance directives (B), Code arrests infection rates (C), Restraint use (D), Medication error rates (F)</p> Signup and view all the answers

A nurse manager is educating a group of nurses on common medication errors. The manager judges the teaching to be effective when one of the nurses states that common medication errors include (Select all that apply.)

<p>wrong-dose errors (C), rule violations (B), look-alike packaging (D), inadequate monitoring (E)</p> Signup and view all the answers

A nurse is listening to a pharmacist lecture about factors that contribute to medication errors. The teaching has been effective when the nurse states: (Select all that apply.)

<p>&quot;Problems within the system contribute to medication errors.&quot; (A), &quot;Work-design problems contribute to medication errors.&quot; (C), &quot;Environmental factors contribute to medication errors.&quot; (D), &quot;Human factors contribute to medication errors.&quot; (E)</p> Signup and view all the answers

A nurse is preparing a presentation on core measures. Which medical diagnosis should the nurse plan on presenting during the lecture? (Select all that apply.)

<p>Congestive heart failure (B), Deep vein thrombosis (C), Myocardial infarction (D), Pregnancy-related conditions (E)</p> Signup and view all the answers

A nurse manager is educating unit staff about HCAHPS. The manager judges the teaching to be effective when a staff nurse states that the HCAHPS survey contains rating about (Select all that apply.)

<p>communication. (A), discharge information. (B), pain management. (C), responsiveness. (E)</p> Signup and view all the answers

A nurse has an adequate understanding of barriers to quality improvement when stating which of the following? (Select all that apply.)

<p>&quot;Being unwilling to change is a barrier.&quot; (A), &quot;Cost is a barrier in quality improvement.&quot; (B), &quot;Failure to recognize that change is needed is a barrier.&quot; (C), &quot;Nurses' loyalty to old practices is a barrier.&quot; (E)</p> Signup and view all the answers

Which action by a group of nurses involves brainstorming? (Select all that apply.)

<p>Write a goal statement. (A), Identify stakeholders. (B), Think about solutions to the problem. (C), Write the problem statement. (E)</p> Signup and view all the answers

Which action would be occurring if a group of nurses were in the analyze phase of the DMAIC process? (Select all that apply.)

<p>Determine where to begin making a change. (B), Identify gaps between current performance and the goal. (C), Identify possible sources of variation. (D)</p> Signup and view all the answers

Which statement by the nurse indicates understanding of the control phase of the DMAIC process? (Select all that apply.)

<p>&quot;Standard operating procedures should be written.&quot; (A), &quot;In the control phase, steps in the new process should be standardized.&quot; (B), &quot;Changes should be monitored to ensure compliance.&quot; (D)</p> Signup and view all the answers

A nurse is discussing the Pareto principle (80/20 rule), which leads to the idea of total quality management. Which statement indicates an adequate understanding of this principle?

<p>Phillip Crosby (D)</p> Signup and view all the answers

Which quality initiative forefather stressed the meaning of the Pareto principle (80/20 rule) and its application to improving quality in organizations?

<p>Joseph Juran (C)</p> Signup and view all the answers

The nurse manager demonstrates an adequate understanding of the continuous quality improvement process of Six Sigma when stating which of the following?

<p>Uses Six Sigma to increase profits (C)</p> Signup and view all the answers

A nurse is interested in becoming credentialed as a Certified Professional in Health Care Quality (CPHQ). Which action would the nurse take to achieve this?

<p>Take an exam. (B)</p> Signup and view all the answers

A nurse is educating students on the history of quality improvement. The teaching has been effective when one of the students states that historically, quality improvement focused on which of the following?

<p>controlling process by inspection so that errors were prevented. (D)</p> Signup and view all the answers

Flashcards

The Joint Commission (TJC) primary role

Ensuring medical facilities meet patient safety guidelines.

Sentinel event

An unexpected occurrence involving death or loss of limb or function.

Root cause analysis

A process designed to investigate and categorize the root cause of the event.

Joseph Juran

Stressed the meaning of the Pareto principle and how it applies to improving quality in all organizations.

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TJC mandated outcome measures

Outcome measures are mandated for patients admitted with community-acquired pneumonia and congestive heart failure.

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Primary barrier to implementing QI

Expense is a primary barrier.

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Uses of Six Sigma

Uses Six Sigma to increase profits

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Action during the define phase of DMAIC

Identify the stakeholders.

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How to become a Certified Professional in Health Care Quality

Take an exam.

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Result of a retrospective chart audit

The standard was not met. An action plan should be developed.

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Nurse manager understanding of root cause analysis

Root cause analysis investigates the root causes of events that occur.

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Historically, quality improvement focused on

controlling process by inspection so that errors were prevented.

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Edward Deming philosophy

Quality is the responsibility of everyone within an organization.

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Action in DMAIC

A charter is developed.

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Nurses understanding of Quality and Safety for Nurses (QSEN)

QSEN helps prepare future nurses for improving patient safety.

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Nurse manager understanding of Six Stigma

The primary goal of Six Stigma is to increase profits and reduce problems.

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Quality improvement methods implementation on the assigned unit

Empower employees to carry out needed strategies for change.

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Nurse understanding of patient classification systems

The systems provide historical data of the usage of nursing time, which is helpful when developing the department budget.

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Understanding of continuous quality improvement

The accountability for quality is vested in quality circles that function along service lines to improve patient care.

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Core measures tracked by The Joint Commission

Code arrests infection rates

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Medication errors

look-alike packaging

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Why make medication errors

Problems within the system contribute to medication errors.

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Which diagnoses should fall under core measures?

Diabetes does not fall under these core measures.

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HCAHPS Survey

communication.

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Understand of barriers to quality improvement

Cost is a barrier in quality improvement.

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Brainstorming

Identify solutions and statements.

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DMAIC Process

Identify gaps and sources of variation.

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DMAIC process statements

Standardized and maintained!

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Study Notes

The Joint Commission (TJC)

  • The primary role is ensuring medical facilities meet patient safety guidelines.
  • Serves as the primary accrediting body for healthcare institutions, directly addressing patient safety through its standards.
  • Does not handle Medicare/Medicaid lobbying (which is done by other organizations), nor does it set infection control standards (which falls under the CDC).
  • Mandates continuous quality improvement and measurement of specific quality outcomes for patients with diagnoses like acute MI, congestive heart failure, community-acquired pneumonia, surgical infection prophylaxis, pregnancy-related conditions, and deep vein thrombosis.
  • Monitors certain core measures to track quality care, including advance directives, autopsy rates, leaving against medical advice (AMA) and elopement rates, blood product use rates, blood transfusion reaction rates, code blue rates, conscious sedation complication rates, fall rates, medication error rates, mortality rates, pain management effectiveness, restraint use, perinatal care, rates of deep vein thrombosis, and surgical-site infection rates.

Sentinel Events

  • Unexpected occurrences involving death or loss of limb or function.
  • Examples include serious medication errors, significant drug reactions, surgery performed on the wrong body site, blood transfusion reactions, and infant abductions.

Root Cause Analysis

  • It is a process to investigate and categorize the root cause of an event.
  • The purpose is to determine the primary causes of errors to develop effective solutions.
  • Involves investigating the root causes of events that occur.
  • It identifies all factors leading up to an error, and should be conducted effectively by trained professionals.

Quality Improvement Pioneers

  • Joseph Juran stressed the meaning of the Pareto principle and its application to improving quality in all organizations.
  • Edward Deming embraced the philosophy that quality is the responsibility of everyone within an organization.

Six Sigma

  • Increases profits, reduce problems and decreases misuse of the system by improving standard operating procedures and reducing errors.
  • Based on strategies that focus on continuous quality improvement (CQI) and reducing variation in practice through DMAIC (Define, Measure, Analyze, Improve, Control).
  • DMAIC is used primarily for improving existing processes that do not meet institutional goals or national norms.

DMAIC Phases

  • Define: Develop a charter; identify goals, team leaders, membership, team roles and responsibilities, and stakeholders affected by the process.
  • Measure: Agree on key performance indicators (time, costs, distance, numbers of incidents, or items).
  • Analyze: Identify gaps between current performance and goals; analyze baseline data to objectively pinpoint real problems. Identify possible sources of variation. Determine where to begin making a change.
  • Improve: Determine whether measures reflect true problems; revise problem and goal statements if needed based on findings.
  • Control: Establish controls to maintain improvements; develop, document, and implement an ongoing monitoring plan; standardize the new process; write standard operating procedures; monitor changes to ensure compliance.

Quality Improvement Barriers

  • The primary barrier to implementing effective quality improvement (QI) programs is the cost.
  • Other barriers include nurses' loyalty to old practices and failure to recognize that changes are needed.
  • Hospital administrators often oppose change of any kind because they value traditional practices, have an authoritative management style, or may not value innovators.

Factors Contributing to Medication Errors

  • Problems within the system.
  • Human factors.
  • Work-design problems.
  • Environmental factors.
  • Look-alike packaging.
  • Wrong-dose errors.
  • Inadequate monitoring.
  • Rule violations.
  • Poor communication.

Quality and Safety for Nurses (QSEN)

  • Helps prepare future nurses to improve patient safety in their healthcare environment.

Certified Professional in Healthcare Quality

  • Requires passing an exam.
  • Those who test should have worked in quality management for a minimum of 2 years.

Continuous Quality Improvement (CQI)

  • Involves quality circles that function along service lines to improve patient care.
  • Includes striving to maintain quality standards after they are achieved.
  • Requires systems within the hospital to be reviewed to determine how care can be enhanced.

Patient Classification Systems

  • They provide historical data on the usage of nursing time, which is helpful when developing the department budget.

Brainstorming

  • Identify stakeholders.
  • Think about solutions to the problem.
  • Write the problem statement.
  • Write a goal statement.

HCAHPS Survey

  • Contains ratings about communication.
  • Contains ratings about pain management.
  • Contains ratings about responsiveness.
  • Contains ratings about discharge information.

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