Quality and Performance Management

Transcription

1 Quality and Performance Management Bernard J. Horak, Ph.D., FACHE, CPHQ The MITRE Corporation 1 Quality and Performance Management Knowledge Areas Percentage and Number of Exam Questions in Each Knowledge Area Knowledge Area Percentage Number of Questions Healthcare 17% 34 Management and Leadership 15% 30 Human Resources 11% 22 Finance 11% 22 Quality and Performance Management 10% 20 Business 9% 18 Professionalism and Ethics 8% 16 Laws and Regulations 7% 14 Governance and Organizational Structure 6% 12 Healthcare Technology & Information Management Knowledge 6% % 200 2

2 Knowledge Areas 1. Benchmarking 2. Medical staff & peer review 3. Risk management 4. Patient safety 5. Performance/process improvement 6. Patient satisfaction 7. Clinical performance improvement 8. Utilization review & case management 9. Quality/performance measurement & strategic quality planning 3 Benchmarking An improvement process used to discover and incorporate best practices into your operation. 4

3 Benchmarking Aspects Process Practice/element Metric Enablers: Tool: protocol, checklist Training Information system (e.g., a data base) 5 Benchmarking Analysis 1. Identify best practices: Identify and quantify the unique contribution or impact of each practice/element 2. Determine gaps: Clearly show and explain differences between your process and others 3. Implement changes: Ask, What would we have to do to our process to incorporate this practice/element? 6

4 Sources of Data & Practices AHRQ: CMS: Agency for Healthcare Research & Quality Clinical guidelines CAHPS: Consumer Assessment of Health Providers and Systems Patient Safety Culture Survey Centers of Medicare & Medicaid Services Hospital Compare Website NCQA: National Committee on Quality Assurance (accreditor of health plans) HEDIS: Healthcare Effectiveness Data and Information Set NQF: National Quality Forum (NQF) Quality measures 7 Sources of Data & Practices (cont.) The Joint Commission: Quality Check Website Center for Transforming Healthcare Baldrige Healthcare Criteria for Performance Excellence National Academy of Medicine or NAM, Health & Medicine Division Note: Formerly the Institute of Medicine (IOM) Collaborative networks; e.g., through the Institute for Healthcare Improvement (IHI) Internal benchmarking comparisons (e.g., with other units in your organization or facilities in your system)

5 Practice Question 1. You are designing a new benchmarking initiative for your organization. What would be the first step to undertake? a) Identify high performing organizations b) Identify your poor or low performing units c) Create a comparative data base d) Seek out collaborative networks/alliances 9 Practice Question 2. Which organization accredits healthcare plans and provides measure of health plan effectiveness? a) AHRQ b) CMS c) NCQA d) NQF 10

6 Medical Staff & Peer Review 11 Governing Body The hospital s governing body has the ultimate authority and responsibility for the oversight and delivery of healthcare. CAMH, MS-1

7 Medical Staff: Bylaws The organized medical staff must create and maintain a set of bylaws that define its role within the context of a hospital setting. CAMH, MS-1 13 Medical Staff: Executive Committee The medical staff executive committee makes recommendations, as defined in the medical staff bylaws, directly to the governing body on: 1. Medical staff membership 2. Medical staff s structure 3. Credentialing and privileging process 4. Delineation of privileges 5. Actions on reports of medical staff committees, departments, and other assigned activity groups CAMH, MS-14a 14

8 Medical Staff: Credentialing Definition: The process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care in or for a healthcare organization. Purpose: Grant membership in a medical staff. CAMH, GL-9 15 Medical Staff: Privileging Definition: The process whereby the specific scope of patient care services are authorized based the individual s credentials and performance. Purpose: Permits the practitioner to conduct specific procedures. CAMH. GL-32 16

9 Medical Staff: Adverse Actions Termination or suspension of medical staff membership Termination, suspension, or reduction of clinical privileges By laws must outline the process for hearings and appeals as well as the composition of the hearing committee Report to National Practitioner Data Bank (NPDB) and state licensing agency CAMH, MS-39 & 40 Peer Review Definition: The process by which a professional review body considers whether a practitioner s clinical privileges or membership will be adversely affected by a physician s competence or professional conduct. Purpose: Promotion of the highest quality of medical care as well as patient safety. 18

10 Practice Question 3. In hospitals, the medical staff is accountable to the: a) Medical Staff President b) Chief Executive Officer c) Governing Body d) The State Medical Board 19 Practice Question 4. What process results in the delineation of specific procedures allowed for a healthcare practitioner? a) Credentialing b) Privileging c) Peer review d) Accreditation 20

11 Risk Management (RM) 21 Risk Management Overview Should identify, evaluate, and reduce exposure to injury or risk to patients, staff, visitors, and the organization Risk financing now usually through outside party (e.g., commercial insurance) 22

12 Risk Management: Elements of Performance (Joint Commission) 1. Proactive risk assessment of a process 2. Use of results of risk assessment and information about system or process failures 3. Dissemination of lessons learned 4. Annual report to board on: System/process failures Sentinel events Disclosure to patients and families Actions to improve patient safety CAMH, LD-38 & FMEA: Failure Modes Effects Analysis 1. Steps (What are the steps in the process?) 2. Failure modes (What could go wrong?) 3. Failure causes (Why/how could the failure happen?) 4. Failure effects (What would be the consequences?) Joshi, et al., The Healthcare Quality Book 24

13 Risk Management: Areas of High Risk Hospital acquired infections (HAIs) Medication administration Falls Medical equipment (preventive maintenance) Cyber security Care transitions, hand off communication 25 Injury Management (Sentinel Events) Definition: A patient safety event that reaches a patient and results in death, permanent harm, or severe temporary harm. CAMH, SE-1 26

14 Injury Management (Sentinel Events) 1. Comprehensive system analysis (e.g., root cause analysis, asking of why multiple times) 2. Action plan 3. Report w/in 45 days 4. Disclosure to injured patient/family 5. Support to 2 nd victim CAMH, SE Patient s Right to Complain Statement of Patient s Rights & Responsibilities Inform the patient about the complaint resolution process Review/resolve complaint Follow up if can t be immediately resolved (process must be explained to the patient) Allow for free voicing of complaints and recommendations without coercion, discrimination, reprisal, or unreasonable interruption of care CAMH, RI-16 & 17 28

15 Practice Question 5. In designing a risk management program for your organization, what approach would have the most impact on reducing risk? a) Developing a reporting system for medical errors b) Require assessments of all high risk areas or processes c) Use task forces to address key Joint Commission standards d) Educate the staff on potential risks and patient safety practices 29 Practice Question 6. In conducting a risk assessment, what would be the first action to take? a) Identify the steps in the process of concern b) Identify what could fail in the process c) Identify causes of failure in the process d) Identify priorities for action 30

16 Patient Safety 31 Management Action 90% Worker Action 10% Patient Safety: Leadership Standard The hospital has an organizationwide, integrated patient safety program within its performance improvement activities. CAMH, LD-38 32

17 NAM/IOM Aims for Improvement Safe: Avoiding injuries to patients (no medical errors) Effective: Providing services that are based on scientific, evidence based knowledge avoiding underuse and overuse using Evidence Based Medicine (EBM) Patient centered: Delivering care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions (e.g., through patient engagement/partnership) IOM, Crossing the Quality Chasm 33 NAM/IOM Aims for Improvement Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care Efficient: Avoiding waste, in particular waste of equipment, supplies, ideas, and energy Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio economic status (no health disparities) IOM, Crossing the Quality Chasm 34

18 Patient Safety: Universal Protocol 1. Pre procedure verification: Needed documentation, test results, blood products devices, implants, equipment, etc. Patient identification; i.e., name & date of birth 2. Site marking 3. Time out immediately before the procedure Note: Culture is key (e.g., anyone can stop the line or throw a challenge flag ) CAMH, NPSG National Patient Safety Goals (Examples & Implications) Patient Safety Goal 1. Patient identifiers 2. Staff communication 3. Medication safety Implication Red rules (pt. identification) Critical test reporting & informing pt. Medication reconciliation 36

19 Patient Safety: A Comprehensive Approach Prevention (e.g. yellow socks) Detection (e.g., bed alarm) Mitigation (e.g., rubber mat) Joshi, et al., The Healthcare Quality Book 37 Design for Safety 1. Identify where errors could occur a preoccupation for reliability and safety 2. Build in prevention, detection, and mitigation 3. Focus on the system involve staff and patients -- Reduce complexity (e.g., steps in process) -- Standardize processes, materials, and technology/equipment Every system is perfectly designed to get the results it gets. Paul Batalden Joshi,, et al., The Healthcare Quality Book 38

20 Practice Question 7. What is the most effective way to prevent medical errors? a) Systems design b) Education c) Error reporting d) Policies and procedures 39 Practice Question 8. What two questions should be asked to ensure the correct patient identification? a) Name and last four of the person s social security number b) Name and mother s maiden name c) Name and date of birth d) Name and purpose of the visit or encounter 40

21 Performance & Process Improvement 41 Key Terms Process Improvement: find and fix faulty processes or create a new process Quality: meet desired outcomes Quality Assurance: find and discard faulty outputs Lean: eliminate waste Six Sigma: reduce variability and defects (3.4 per million) ISO 9001: follow internationally recognized quality standards Performance Excellence: use an integrated, systems approach to improve organizational performance (e.g., Baldrige framework) Quality Improvement: all of the above 42

22 Six Sigma: DMAIC DEFINE: Identify the customers, their problems, and areas critical to quality (CTQ). MEASURE: ANALYZE: Categorize key characteristics, verify measurement systems, collect data, and assess current level of performance. Convert raw data into information that provides insights into the process, find root causes, and determine which problems are most important. IMPROVE: Address root causes, develop solutions, run a pilot, and make final changes to the process. CONTROL: Monitor effectiveness of the changes and continuously improve. 43 Lean Management & Six Sigma Approaches Attribute Lean Six Sigma Purpose To reduce waste To improve performance and reduce errors Relevance to business Cut costs Reduce cost of poor quality Implementation Identification of non-value added steps and use of process of 5S (sort, simplify, scrub, standardize, and sustain) Extensive use of training, statistics, and process of DMAIC (define, measure, analyze, improve, and control) Outcomes Efficiency (e.g., cycle-time reduction) Effectiveness (e.g., error reduction) 44

23 Process Improvement Model (FOCUS PDSA) Find a Process to Improve Organize a Team that Knows the Process Clarify Current Knowledge of the Process Understand Sources of Process Variation Select the Process Improvement 45 ACT To hold gain To continue improvement Improvement Data collection plan PLAN Data analysis: Customer view Worker view Lessons learned Improvement Data collection STUDY DO

24 Process Improvement Team Guidelines Champion Charter 5 8 members Interdisciplinary Close to the process Needed expertise Measures of success Rewards/incentives 47 Process Improvement Tools Data Collection Tool, Protocol or Checklist 1. Pilot/test the instrument 2. Train on use 3. Standardize administration 4. Verify use 5. Constantly improve 48

25 Flowchart Diagram the process from start to end 49 Fishbone Diagram (Cause and Effect) Diagram 50

26 Cause Effect Diagram: Major Areas to Brainstorm Communication People Processes Materials 51 Pareto Chart principle: 80% of the problems come from 20% of the causes 52

27 Run Chart 53 Structured communication; e.g., SBAR (Situation Background Assessment Recommendation) Team simulations/training; keys are communication providing feedback Crew Resource Management (CRM) TeamSTEPPS (Team Strategies & Tools to Enhance Performance and Patient Safety) 54

28 Practice Question 9. Your medical staff on the general medicine unit has been complaining about the delays in the administration of medications. You study the processing times on other units and indeed find that the general medical unit times are considerably longer. What would be your first step to take? a) Implement best practices from other units b) Have the manager from the highest performing unit assist the unit in its improvement efforts c) Emphasize responsiveness in administering medications d) Organize a process improvement team on the unit 55 Practice Question 10. What tool is most appropriate in identifying priorities for action? a) Flowchart b) Cause effect diagram c) Pareto chart d) Run chart 56

29 Practice Question 11. What approach focuses on reducing waste in a healthcare process or system? a) Six Sigma a) Lean management b) SBAR c) ISO Patient Satisfaction AKA: Service Excellence AKA: Patient Experience 58

30 Definition: Customers Customer: anyone who has expectations regarding a process s operation or outputs: Patients Family Staff Community Payers 59 Integrating Customer Requirements 1. Know your customers, stakeholders, markets 2. Identify their expectations, needs, requirements 3. Design or improve services 4. Measure how your doing and continuously improve Kelly in Continuous Quality Improvement in Healthcare by McLaughlin and Kaluzny, 60

31 Patient Engagement 1. Education (key is understanding) 2. Full involvement in their care 3. Input on facility design, care processes 4. Interactions via web portal 5. Listening posts 61 Listening Posts 1. Observations/MBWA What s getting in way of patient care? How might we harm patients today? What can I do for you? 2. Secret shoppers (when, what, how felt) 3. Surveys/questionnaires 4. Focus groups 5. Walk throughs, shadowing 62

32 6. Patient/family advisory councils 7. Complaints & compliments 8. Patient diaries & progress notes 9. White boards (1 5 scale) 10. Scan boards, computer kiosks 63 Service Excellence: Some Best Practices 1. Organizational support to the micro unit 2. Measures on scorecard and dashboard 3. Review of the entire patient experience (from the parking lot to the bill ) 4. Competency based training of staff 5. No pass zones 64 64

33 CAHPS Hospital Survey (Consumer Assessment of Healthcare Providers & Systems) Nurse Communication Doctor Communication Explanation of Medicines Timely Help from Staff Information About Recovery Pain Control Cleanliness Overall Rating of Hospital (Scale: 1 10) Would Recommend Hospital (Scale: Definitely No, Probably No, Probably Yes, Definitely Yes) 65 Other Patient Satisfaction Surveys PRC (Professional Research Consultants) Survey Calls and on line results within 24 hours Similar questions to CAHPS, but tailored Net Promoter Scores Focus on loyalty and growth (new & return patients) One question: How likely to recommend? (0 10 scale) Promoters (9 10) Passives (7 8) Detractors (0 6) 66

34 Practice Question 12. You are the administrator of a family practice group that has high patient satisfaction scores. You want your patients not only to be satisfied, but to be advocates for your practice to the point of going out their way to tell others about your group. What would have the most impact? a) Provide patients with the patient satisfaction results b) Provide patients with examples of how best practices have been implemented c) Reward and recognize staff for their role in improving patient satisfaction d) Involve patients through advisory councils and other mechanisms to provide input to improve service 67 Practice Question 13. What approach will best expand or clarify the results of patient surveys? a) Observations b) Shadowing c) Walk throughs d) Focus groups 68

35 Clinical Performance Improvement Evidence Based Medicine (EBM) Clinical Practice Guidelines Clinical Pathways Disease Management Population Health 69 Evidence Based Medicine (EBM) The conscientious, explicit and judicious use of current best evidence from systematic research in making decisions about the care of individual patients. Usually based on clinical trials or consensus opinion of experts. Oxford Centre for Evidence-Based Medicine 70

36 Clinical Practice Guidelines Based on evidence-based research Tools (e.g., list of tests of procedures) that describe the care for patients with a specific condition Also called: practice parameter, protocol, clinical practice recommendations, preferred practice pattern, or guideline National Guidelines Clearinghouse (AHRQ): CAMH, GL-7 71 Clinical Pathways / Care Pathways The specific sequencing of activities to care for patients in the organization Based on clinical guidelines, best practices, and patient expectations Used in utilization reviews 72

37 EBM to Pathways Evidence based Medicine (EMB) Studies Clinical Practice Guidelines (CPGs) Clinical Pathways 73 Disease Management Coordinated healthcare for those with conditions in which patient self care efforts are significant Particularly relevant for chronic conditions (e.g., diabetes, arthritis, asthma, high blood pressure) Care Continuum Alliance (formerly the Disease Management Association of America) 74

38 Population Health: WHO Definition of Health Health is a state of complete physical, social, and mental well being, not merely the absence of disease or infirmity. 75 Population Health Defined as the health outcomes of a group of individuals Key is attention to the multiple determinants of health, particularly social determinants, the physical environment, and individual behavior Kindig and Stoddart,

39 Practice Question 14. You are doing a review of a measures report that shows the results from care for heart attack patients. In analyzing this information with the Chief of Cardiology, it was determined that much variability exists in how care is being provided by the staff cardiologists. What action would you first take? a) Recommend the use of clinical practice guidelines b) Develop clinical pathways c) Institute a disease management program d) Refer the issue to the utilization review committee 77 Practice Question 15. What action should you take to ensure that all critical activities associated with care of a patient are being carried out in the right sequence in your organization? a) Institute clinical practice guidelines b) Develop clinical pathways c) Institute a disease management program d) Refer the issue to the utilization review committee 78

40 Practice Question 16. What intervention has the greatest impact on population or community health? a) Health screenings b) Additional clinic in the community c) Education on life style changes d) Community recreational programs 79 Utilization Review & Case Management 80

41 Utilization and Quality Underuse. The failure to provide a necessary/recommended care which can lead to additional complications, higher costs, and premature deaths. Overuse. Unnecessary services that can add costs and endanger the health of patients. Misuse. Medical errors causing injury, complications, or death as well as additional costs. Variation. Differences in way care is delivered (not using evidencebased practices). errors-safety/improving-quality/improving-health-care-quality.pdf 81 Medical Necessity Health care services that a prudent physician would provide that is: Generally accepted standards of practice Clinically appropriate Not primarily for economic benefit or convenience American Medical Association 82

42 Utilization Review (UR) What: A comprehensive evaluation of the medical necessity and efficiency of care Why: To contain and lower costs by reducing unnecessary medical care How: Services are compared to an established norm usually using clinical guidelines and pathways Saunier B, The Devil is in the Details: Unforeseen Costs of Utilization Review as a Cost Containment Mechanism. Issues in Law & Medicine 27(1): Types of Reviews Prospective review (e.g., pre approvals, 2 nd opinions) Concurrent review (e.g., while in hospital) Retrospective review (e.g., post discharge) Saunier B, The Devil is in the Details: Unforeseen Costs of Utilization Review as a Cost Containment Mechanism. Issues in Law & Medicine 27 (1):

43 Case Management What: Care coordination and advocacy for options and services to meet an individual s and family s comprehensive health needs. How: Identification of appropriate providers and facilities throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner. Note: A key tool is discharge planning. abid/224/default.aspx 85 UR vs. Case Management Utilization Review Fiscally based Case Management Needs based Birmingham J. (2007). Case Management: Two Regulations with Coexisting Functions. Professional Case Management. 86

44 Practice Question 17. The hospital s Utilization Review (UR) Committee usually addresses all of the following, except? a) Necessity of tests and procedures b) Length of stay c) Revenue per patient d) Cost per patient 87 Practice Question 18. What approach addresses the comprehensive needs of the patient and their family? a) Medical necessity determination b) Utilization review c) Case management d) Population health 88

45 Performance Measurement & Strategic Quality Planning 89 IHI Triple Aim Better Health Better Care Lower Costs 90

46 Structure Process Outcome (Donabedian Model) S+P = O Structure: Based on organizational features or participant characteristics (e.g., % MDs board certified) Process: Activities in carrying out work (e.g., # of patients seen, # vaccinations) Outcome: Evidence of degree that ultimate objective is met (e.g., health status, mortality, infection rates) 91 Accountability/Core Measures Examples Outcomes measures Mortality & readmissions from acute myocardial infarction (AMI), heart failure (HF), and pneumonia Catheter associated urinary tract infections (CAUTIs) Central line association bloodstream infections (CLABSI) Process measures HF patients given an ACE inhibitor Antibiotics given within one hour before surgery Patients given pneumonia & influenza vaccinations 92

47 Key Agencies & Roles NQF: National Quality Forum endorse measures NCQA: National Committee on Quality Assurance Health plan report using measures in the Healthcare Effectiveness Data and Information Set (HEDIS) AHRQ: Agency for Healthcare Research & Quality National Guidelines Clearinghouse, CAPHS, Patient Safety Survey CMS: Hospital Compare, Value Based Purchasing (VBP), and Quality Improvement Organizations (QIOs) Joint Commission: Quality Report, Quality Check Website 93 CMS: Hospital Compare Patient Experience Timely and Effective Care Use of Medical Imaging Complications Readmissions & Deaths Payment & Value of Care 94

48 CMS: Value Based Purchasing Holds health care providers accountable for both the cost and quality of care they provide. (value-based incentives) Attempts to reduce inappropriate care and to identify and reward the best-performing providers 95 CMS: Quality Improvement Organizations (QIOs) Mission: Improve the effectiveness, efficiency, economy, and quality of care to Medicare beneficiaries. Core functions: Improve quality of care for beneficiaries Review medical necessity/utilization Address individual complaints 96

49 The Joint Commission: Quality Report Accreditation decision Special quality awards National Patient Safety Goals (NPSG) compliance Quality indicators (accountability/core measures) Note: Report on the Quality Check Website CAMH, QR Impacts of Quality Initiatives Operations: Documentation, coding Data collection & IT support for measures Quality is everyone s job Staffing: Medical staff hours, particularly residents Nursing ratios, vacancy rates, turnover rates Financing/Cost: Reimbursement Cost savings 98

50 Practice Question 19. What organization has as its mission to study and recommend accountability/core measures for CMS and the Joint Commission? a) AHRQ b) NCQA c) NAM/IOM d) NQF 99 Practice Question 20. What area would you focus on to most effectively respond to current and future national quality initiatives? a) Accreditation standards b) National patient safety goals c) Staff education and training d) Data to support accountability measures 100

51 Take Aways 1. Preoccupation with patient safety & quality 2. Focus on the system 3. Data driven 4. Staff & patient involvement 5. Continuously improve using QI tools 101 Key Quality Tools Run Chart Pareto Chart FMEA (Failure Modes Effects Analysis) FOCUS PDSA (Plan Do Study Act) Lean & Six Sigma 102

52 Web Sites Agency for Healthcare Research and Quality. Institute for Healthcare Improvement (IHI). Joint Commission: National Patient Safety Foundation Lucian Leape Institute & ACHE: Leading a Culture of Safety: A Blueprint for Success Publications Brassard & Ritter. The Memory Jogger II Health Care Edition: A Pocket Guide of Tools for Continuous Improvement & Effective Planning, Salem, NH: QOAL/QPC, Institute of Medicine, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. DC: National Academy Press, Joshi, et al., The Healthcare Quality Book, Chicago: Health Administration Press, Shaffie & Shahabazi. Lean Six Sigma: The McGraw Hill 36 Hour Course. New York: McGraw Hill,

53 Question #1 Explanation 1. You are designing a new benchmarking initiative for your organization. What would be the first step to undertake? a) Identify high performing organizations b) Identify your poor or low performing units c) Create a comparative data base d) Seek out collaborative networks/alliances Answer c). A comparative data base should first be established since this will identify high and low performing units as well as promising collaborative networks or alliances. 105 Question #2 Explanation 2. Which organization accredits healthcare plans and provides measure of health plan effectiveness? a) AHRQ b) CMS c) NCQA d) NQF Answer: c). NCQA accredits healthcare plans. AHRQ conducts studies in quality improvement and patient safety. CMS focuses on care provided to the elderly, poor, and disabled. NQF studies and recommends quality measures. 106

54 Question #3 Explanation 3. In hospitals, the medical staff is accountable to the: a) Medical Staff President b) Chief Executive Officer c) Governing Body d) The State Medical Board Answer: c). The medical staff is directly accountable to the governing body. The CEO provides support and general guidance to the medical staff. The Medical Staff President has the managerial responsibility with respect to he medical staff. The state medical board is independent of the facility's medical staff. 107 Question #4 Explanation 4. What process results in the delineation of specific procedures allowed for a healthcare practitioner? a) Credentialing b) Privileging c) Peer review d) Accreditation Answer: b). Privileging outlines specifically what a practitioner can do. It follows credentialing which is membership in the medical staff. Peer review is a process in which privileges are determined. Accreditation usually involves recognition of a healthcare organization such as by The Joint Commission. Kelly

55 Question #5 Explanation 5. In designing a risk management program for your organization, what approach would have the most impact on reducing risk? a) Developing a reporting system for medical errors b) Require assessments of high risk areas c) Use task forces to address key Joint Commission standards d) Educate the staff on potential risks and patient safety practices Answer: b). Assessments of risk risk areas would have the most impact since it would identify critical processes or activities which need improvement to prevent future adverse events. All other alternatives are appropriate but would not have as much impact on reducing risk. 109 Question #6 Explanation 6. In conducting a risk assessment, what would be the first action to take? a) Identify the steps in the process of concern b) Identify what could fail in the process c) Identify causes of failure in the process d) Identify priorities for action Answer a). The first step in any FMEA (Failure Modes and Effects Analysis) is delineating all the steps in the existing process of concern. This would be followed, in order, by identifying what could fail, the possible causes of the potential failures, and priorities for taking action. 110

56 Question #7 Explanation 7. What is the most effective way to prevent medical errors? a) Systems design b) Education c) Error reporting d) Policies and procedures Answer a). Systems design is most effective since approximately 90% of errors can be traced to systems issues. All others are helpful and should be implemented, but they would not have as much impact. 111 Question #8 Explanation 8. What two questions should be asked to ensure the correct patient identification? a) Name and last four of the person s social security number b) Name and mother s maiden name c) Name and date of birth d) Name and purpose of the visit or encounter Answer c). Two most appropriate identifiers are the patient s name and date of birth. Social security numbers SSN or parts of the SSN should be avoided. The mother s maiden name may not be known to some patients. The purpose of the visit/encounter may not be clearly known and visits/encounters tend to be similar for patients arriving at the same location or time. 112

57 Question #9 Explanation 9. Your medical staff on the general medicine unit has been complaining about the delays in the administration of medications. You study the processing times on other units and indeed find that the general medical unit times are considerably longer. What would be your first step to take? a) Implement best practices from other units b) Have the manager from the highest performing unit assist the unit c) Emphasize responsiveness to your staff in administering medications d) Organize a process improvement team on the unit Answer d). A team should first be chartered to determine specific system s issues. Implementing best practices or having another manager assist should only be done after the issues have been identified by the team. Emphasizing responsiveness will not address systems issues. 113 Question #10 Explanation 10. What tool is most appropriate in identifying priorities for action? a) Flowchart b) Cause effect diagram c) Pareto chart d) Run chart Answer c). The Pareto chart displays areas in priority order, usually through bar graphs. The flowchart is best used to identify problems (duplication, gaps, etc.) in a process. The cause effect diagram is used to identify root causes of a problem. The run chart is usually used to show changes over time (e.g., errors per month). 114

58 Question #11 Explanation 11. What approach primarily focuses on reducing waste in a healthcare process or system? a) Six Sigma b) Lean management c) SBAR d) ISO 9001 Answer b). Lean management focuses on reducing waste. Six Sigma mainly looks at reducing defects in a system or process. SBAR (Situation Background Assessment Recommendation) is a tool for hand off communication among providers. ISO 9001 provides international quality standards. 115 Question #12 Explanation 12. You are the administrator of a family practice group that has high patient satisfaction scores. You want your patients not only to be satisfied, but to be advocates for your practice to the point of going out their way to tell others about your group. What would have the most impact? a) Provide patients with the patient satisfaction results b) Provide patients with examples of how best practices have been implemented c) Reward and recognize staff for their role in improving patient satisfaction d) Involve patients through advisory councils and other mechanisms to provide input to improve service Answer d). Patient engagement through such means as education, web portals, and advisory councils best increases loyalty to and advocacy for your organization. The other alternatives would have far less impact. 116

59 Question #13 Explanation 13. What approach will best expand or clarify the results of patient surveys? a) Observations b) Shadowing c) Walk throughs d) Focus groups Answer: d). Focus groups best allow you to expand, clarity, or understand the patients reasons for scores they provided on surveys. Shadowing is simply following the patient through the system. Walk throughs is when you simulate walking through the system as though you were the patient. 117 Question #14 Explanation 14. You are doing a review of a core measures report that shows the results from care for heart attack patients. In analyzing this information with the Chief of Cardiology, it was determined that much variability exists in how care is being provided by the staff cardiologists. What action would you first take? a) Recommend the use of clinical practice guidelines b) Develop clinical pathways c) Institute a disease management program d) Refer the issue to the utilization review committee Answer: a). Clinical practice guidelines will provide a standard approach to treating patients (e.g., proper tests and procedures). Clinical pathways then take these guidelines and apply them to a particularly sequence of care in your organization. Disease management focuses on chronic care. The utilization review committee addresses the necessity and cost of care. 118

60 Question #15 Explanation 15. What action should you take to ensure that all critical activities associated with care of a patient are being carried out in the right sequence in your organization? a) Use clinical practice guidelines b) Develop clinical pathways c) Institute a disease management program d) Refer the issue to the utilization review committee Answer b). Clinical pathways take clinical guidelines and apply them to a specific sequence of care in your organization. Clinical practice guidelines provide you a general approach to treating patients (e.g., proper tests and procedures). Disease management focuses on chronic care. The utilization review committee addresses the necessity and cost of care. 119 Question #16 Explanation 16. What intervention has the greatest impact on population or community health? a) Health screenings b) Additional primary care clinics c) Education on life style changes d) Community recreation programs Answer: c). Health education in such areas as exercise, nutrition, smoking and alcohol cessation, and avoidance of risky behaviors will have far more impact and lasting effect that the other alternatives. 120

61 Question #17 Explanation 17. The hospital s Utilization Review (UR) Committee usually addresses all of the following, except: a) Necessity of tests and procedures b) Length of stay c) Revenue d) Cost per patient Answer c). Revenue (which deals with volume and price) is mainly addressed by the administrators and finance staff. The UR Committee addresses the necessity of tests/procedures, length of stay, and cost per patient. 121 Question #18 Explanation 18. What approach addresses the comprehensive needs of the patient and their family: a) Medical necessity determination b) Utilization review c) Case management d) Population health Answer c). Case management attempts to address both the medical and social needs of the patients and families. Medical necessity examines the appropriateness of care. Utilization review looks at reducing the costs of care. Population health focused on the health outcomes of groups of individuals with the intent of keeping people healthy. 122

62 Question #19 Explanation 19. What organization has as its mission to study and recommend accountability/core measures for CMS and the Joint Commission? a) AHRQ b) NCQA c) NAM/IOM d) NQF Answer: d) National Quality Forum (NQF) has the mission to study and recommend accountability measures. AHRQ and NAM/IOM mainly conduct studies in quality improvement and patient safety. NCQA accredits healthcare plans. 123 Question #20 Explanation 20. What area would you focus on to most effectively respond to current and future national quality initiatives? a) Accreditation standards b) National patient safety goals c) Staff education and training d) Data to support accountability measures Answer: d) Data Is most needed since quality or accountability measures will be increasingly demanded by payers in pay for performance and value based purchasing initiatives as well by patients as they seek out healthcare. All other alternatives are important, but they would not have as much impact. 124

63 Key Terms Process Improvement: find and fix faulty processes or create a new process Quality: meet desired outcomes Quality Assurance: find and discard faulty outputs Lean: eliminate waste Six Sigma: reduce variability and defects (3.4 per million) ISO 9001: follow internationally recognized quality standards Performance Excellence: use an integrated, systems approach to improve organizational performance (e.g., Baldrige framework) Quality Improvement: all of the above 125 Contact Bernard J. Horak, Ph.D., FACHE, CPHQ Quality Improvement & Organizational Effectiveness Principal, The MITRE Corporation bhorak@mitre.org 126