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Questions and Answers
The primary role of The Joint Commission (TJC) is
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?
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 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?
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?
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:
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:
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:
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:
The nurse manager has an adequate understanding of the continuous quality improvement process of Six Sigma when doing which of the following?
The nurse manager has an adequate understanding of the continuous quality improvement process of Six Sigma when doing which of the following?
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?
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?
A nurse is interested in becoming credentialed as a Certified Professional in Health Care Quality. Which action would the nurse take to achieve this?
A nurse is interested in becoming credentialed as a Certified Professional in Health Care Quality. Which action would the nurse take to achieve this?
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?
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?
The nurse manager has an adequate understanding of root cause analysis when stating which of the following?
The nurse manager has an adequate understanding of root cause analysis when stating which of the following?
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
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
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:
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:
Which action takes place during the Define phase of the DMAIC process?
Which action takes place during the Define phase of the DMAIC process?
Which of the following statements by the nurse indicates an understanding of Quality and Safety for Nurses (QSEN)?
Which of the following statements by the nurse indicates an understanding of Quality and Safety for Nurses (QSEN)?
The nurse manager has an adequate understanding of Six Sigma when making which of the following statements?
The nurse manager has an adequate understanding of Six Sigma when making which of the following statements?
A nurse manager is brainstorming quality improvement methods. Which action would help implement these methods on the assigned unit?
A nurse manager is brainstorming quality improvement methods. Which action would help implement these methods on the assigned unit?
The nurse understands that the following statement is true about patient classification systems?
The nurse understands that the following statement is true about patient classification systems?
If the nurse had an adequate understanding of continuous quality improvement, which of the following statements would the nurse? (Select all that apply.)
If the nurse had an adequate understanding of continuous quality improvement, which of the following statements would the nurse? (Select all that apply.)
Which of the following are considered core measures and monitored by The Joint Commission? (Select all that apply.)
Which of the following are considered core measures and monitored by The Joint Commission? (Select all that apply.)
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.)
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.)
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.)
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.)
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.)
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.)
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.)
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.)
A nurse has an adequate understanding of barriers to quality improvement when stating which of the following? (Select all that apply.)
A nurse has an adequate understanding of barriers to quality improvement when stating which of the following? (Select all that apply.)
Which action by a group of nurses involves brainstorming? (Select all that apply.)
Which action by a group of nurses involves brainstorming? (Select all that apply.)
Which action would be occurring if a group of nurses were in the analyze phase of the DMAIC process? (Select all that apply.)
Which action would be occurring if a group of nurses were in the analyze phase of the DMAIC process? (Select all that apply.)
Which statement by the nurse indicates understanding of the control phase of the DMAIC process? (Select all that apply.)
Which statement by the nurse indicates understanding of the control phase of the DMAIC process? (Select all that apply.)
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?
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?
Which quality initiative forefather stressed the meaning of the Pareto principle (80/20 rule) and its application to improving quality in organizations?
Which quality initiative forefather stressed the meaning of the Pareto principle (80/20 rule) and its application to improving quality in organizations?
The nurse manager demonstrates an adequate understanding of the continuous quality improvement process of Six Sigma when stating which of the following?
The nurse manager demonstrates an adequate understanding of the continuous quality improvement process of Six Sigma when stating which of the following?
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?
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?
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?
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?
Flashcards
The Joint Commission (TJC) primary role
The Joint Commission (TJC) primary role
Ensuring medical facilities meet patient safety guidelines.
Sentinel event
Sentinel event
An unexpected occurrence involving death or loss of limb or function.
Root cause analysis
Root cause analysis
A process designed to investigate and categorize the root cause of the event.
Joseph Juran
Joseph Juran
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TJC mandated outcome measures
TJC mandated outcome measures
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Primary barrier to implementing QI
Primary barrier to implementing QI
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Uses of Six Sigma
Uses of Six Sigma
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Action during the define phase of DMAIC
Action during the define phase of DMAIC
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How to become a Certified Professional in Health Care Quality
How to become a Certified Professional in Health Care Quality
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Result of a retrospective chart audit
Result of a retrospective chart audit
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Nurse manager understanding of root cause analysis
Nurse manager understanding of root cause analysis
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Historically, quality improvement focused on
Historically, quality improvement focused on
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Edward Deming philosophy
Edward Deming philosophy
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Action in DMAIC
Action in DMAIC
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Nurses understanding of Quality and Safety for Nurses (QSEN)
Nurses understanding of Quality and Safety for Nurses (QSEN)
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Nurse manager understanding of Six Stigma
Nurse manager understanding of Six Stigma
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Quality improvement methods implementation on the assigned unit
Quality improvement methods implementation on the assigned unit
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Nurse understanding of patient classification systems
Nurse understanding of patient classification systems
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Understanding of continuous quality improvement
Understanding of continuous quality improvement
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Core measures tracked by The Joint Commission
Core measures tracked by The Joint Commission
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Medication errors
Medication errors
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Why make medication errors
Why make medication errors
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Which diagnoses should fall under core measures?
Which diagnoses should fall under core measures?
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HCAHPS Survey
HCAHPS Survey
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Understand of barriers to quality improvement
Understand of barriers to quality improvement
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Brainstorming
Brainstorming
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DMAIC Process
DMAIC Process
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DMAIC process statements
DMAIC process statements
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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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