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Includes all the factors which affect the context in which healthcare is delivered; examples
include physical facility, equipment, Human Resources, staff training, and payment methods; it
controls how providers and patients in healthcare systems act. ✔Correct Answer-Structure
The term used for the sum of all actions making up healthcare (diagnosis, treatment, preventive
care, patient education, actions taken by patients/families). Also includes how care is delivered
(technical actions), manner in which care is delivered (interpersonal actions). ✔Correct
Answer-Process
Effects of healthcare on patients or populations (changes to health status, behavior, knowledge,
patient satisfaction, health related quality of life); sometimes is seen as most important
indicators of quality because improving patient health status is the primary goal of healthcare.
✔Correct Answer-Outcome
Donabedian's Framework classifies Professionals, Facilities, Technologies, Resources, and
Organizations as ___________ ✔Correct Answer-Structures
Donabedian's Framework classifies Leadership, Management, Interaction, Diagnosis, and
Therapy as _____________ ✔Correct Answer-Processes
Donabedian's Framework classifies _______________ as Clinical, Functional, Experience, and
Engagement ✔Correct Answer-Outcomes
__________ = (quality of service + outcome)/Cost ✔Correct Answer-Value
Using outcome information without monitoring the ___________ of care is inefficient; cost and
quality are inseparable issues, you cannot address one without the other ✔Correct Answer-
Process
Most quality ________ are useful to identify potential problems, but not as a definitive measure
of quality. Multiple measures of quality need to be integrated to provide a clear picture of the
quality of care. ✔Correct Answer-Indicators
Assessment Tool used based on criteria considering service, patient safety and cost to identify
which improvement activities to focus on or prioritize; should include weighted values assigned
to each quality function in hierarchy of importance to compare all issues identified; should
,document results in minutes or other written documents. ✔Correct Answer-Prioritization
Matrix
___________ and ______________ should include Goals, Objectives, Structure, Design, Roles,
Responsibilities, Methodology and Evaluation ✔Correct Answer-Performance and process
improvement plans
____________ and __________ should include deficiencies or requirements for improvements
and action plans developed and monitored. ✔Correct Answer-Assessment Surveys and
continue our readiness activities
A conscientious, explicit, and judicious use of current best evidence to make patient care
decisions ✔Correct Answer-Evidence Based Medicine
The Integration of clinical expertise, patient values, and the best research evidence into the
decision making process for patient care; Promotes patient safety through provision of effective
and efficient healthcare and results in less variation in care and fewer unnecessary procedures
✔Correct Answer-Evidence Based Practice
EBP (evidence Based practices) complements principles of _________ and _________.
✔Correct Answer-Performance and Process Improvement
EBP is based on improving ________ and _________ ✔Correct Answer-Patient experiences
and outcomes
_________ are formed when one organization or group works with another to make changes
and improvements; examples include two healthcare systems working together; can be
developed through other like facilities within a healthcare system, other facilities outside the
system, or even regional and national groups. ✔Correct Answer-Collaboratives
___________ are teams of people who work regularly together ✔Correct Answer-Natural
Work Teams
employees from about the same hierarchical level, but from different work areas, who come
together to accomplish a task ✔Correct Answer-Cross Functional Teams
teams that consist of employees who have similar or complementary skills and are located in
the same unit of a functional structure ✔Correct Answer-Departmental Teams
Responsible for
Recommending an approach to leadership
Determining how to reward employees
Determining the policy of safety programs
Develop and approve quality program
, Lend legitimacy to efforts
Maintain focus
Foster teamwrok
Provide resources ✔Correct Answer-Steering Committee/Quality Council
___________ ensure the team is focused and organized by including
Clearly defined scope, Description of team tasks: why and who; people or departments
represented on the team; Timeline for meetings and resources; structure of leadership;
expected communication of progress and results; ground rules ✔Correct Answer-Team
Charters
Formal leader of a performance and process improvement project; responsible for overall
project; aligns resources and monitors progress; holds others accountable for change; inspires
team members; serves as a coach or consultant. ✔Correct Answer-Sponsor
Moves team along; not vested in outcome; promotes effective group team dynamics; is
concerned with how decisions are made. Not a team member; serves as a coach or consultant;
focuses on meeting and improvement processes. Keeps team on track. Has expertise regarding
use of performance and process improvement tools ✔Correct Answer-Facilitator
Vested in outcome of improvement efforts; guides team to achieve successful outcomes and
reach established goals. Specific responsibility for guiding team through meeting process to
achieve objectives; involved in meeting content and process; provides direction and support for
the team. ✔Correct Answer-Team Leader
Opinion leaders who provide project credibility and are integral to the social structure.
Respected clinicians or staff with influence through reputation or leadership qualities; support
the change and work for its implementation ✔Correct Answer-Champion
Vested in outcome; shares knowledge and expertise of process or issues addressed by team;
responsible for both content and process of team meetings; shares responsibilities for focusing
on objective, contributing information, analyzing data, staying on track and making decisions
that continually impact and improve the team ✔Correct Answer-Member
Created the PDSA cycle ✔Correct Answer-W. Edwards Deming
Set aims, established measures, and selected changes for the PDSA Model for Improvement
✔Correct Answer-IHI
______ uses statistical analysis to measure and improve performance;
Focuses on elimination of errors (defects) in processes; based on normal distribution of data
(bell shaped curve); six standard deviations from the mean (only 3.4 defects per million
opportunities; uses DMAIC model (define, measure, analyze, improve, control); philosophy is
customer focused and data driven. ✔Correct Answer-Six Sigma