World Health Organization

1) According to the World Health Organization (WHO), how could at least half a million deaths due to surgical error be prevented every year? Your Answer:b) By implementing systemic changes in operating rooms Correct Answer:b) By implementing systemic changes in operating rooms At least half a million deaths per year could be prevented with effective implementation of systemic improvements in operating rooms. Specifically, multiple studies have found implementing the use of the WHO Surgical Safety Checklist would significantly reduce surgical morbidity and mortality due to surgical errors.

2) According to Paul Levy, which of the following were factors that led to the wrong-site surgery at Beth Israel Deaconess Medical Center in June 2008? Your Answer:d) A and B
Correct Answer:d) A and B
The best answer is A and B. According to Levy, multiple factors led to the wrong-site surgery (which occurred even though the surgical team marked the correct site), one of which was that the team did not conduct a “time out” safety check, another of which was a broader systems issue, in that the hospital did not have adequate mechanisms in place to prevent such an error in an extremely hectic operating room environment.

3) What did Paul Levy do after handling the immediate fallout from the wrong-site surgery? Your Answer:d) All of the above
Correct Answer:d) All of the above
The best answer is all of the above. Paul Levy employed a multi-pronged approach to spread awareness of the error and the hospital’s response to it, as well as collect feedback from the public. It’s critical to communicate effectively after a preventable mistake, as patients often want to know what steps are being taken to prevent similar mistakes from occurring again. Further, being transparent about errors allows the entire organization — and even other organizations — to learn from them.

4) Which of the following opinions did Dr. Robert Wachter express in his response to Paul Levy’s blog about the wrong-site surgery of June 2008? Your Answer:d) Circumstances could exist where the providers were to blame for the error. Correct Answer:d) Circumstances could exist where the providers were to blame for the error. Wachter felt that if the providers were routinely and knowingly negligent — in an environment where good systems did exist to prevent errors — they could be to blame and punishment might be warranted. However, it would still be a controversial topic and a tough balancing act of “no blame” versus accountability. Overall, Wachter praised Levy and commended in particular his public disclosure of the case.

5) Ben, a 36-year-old patient with Type I diabetes mellitus and kidney failure, comes to the hospital to have a special arteriovenous fistula placed in his arm to allow him to begin dialysis in a few weeks. The fistula was supposed to be placed on the left arm, but the surgical team accidentally operates on the opposite arm, not realizing until the procedure is finished. When Ben wakes up from anesthesia, he sees a bandage on his right arm and is confused. What should happen right away? Your Answer:a) The mistake should be communicated to Ben and the hospital’s administrators Correct Answer:a) The mistake should be communicated to Ben and the hospital’s administrators The hospital should communicate right away with Ben and his family about the mistake, and administrators also need to know about it, so they can start investigating what happened and changing processes to avoid such an event in the future. It is likely that punishing those involved should be avoided. Although posting information publically may be a good idea, the patient and his family must be attended to first. Post-Lesson Assessment

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1) In the US, which group is most likely to be uninsured?
Your Answer:a) Hispanics
Correct Answer:a) Hispanics
According to the latest available data, Hispanics are most likely to be uninsured. In 2010, more than half of the Hispanic population reported having experienced uninsurance at some point in the past year.

2) Which of the following is a trend in modern health care across industrialized nations? Your Answer:d) A and C
Correct Answer:d) A and C
The best answer is A and C. As medical information and technology increases, demand for complicated procedures is increasing, and providers are becoming more and more specialized (and fragmented). The burden of disease is shifting toward chronic conditions.

3) Which of the following countries has had a relatively inexpensive universal health insurance system for more than 50 years? Your Answer:c) Japan
Correct Answer:c) Japan
Japan has had a relatively inexpensive universal health insurance system for more than 50 years. Germany made health insurance mandatory for its entire population in 2009. Chile has given all Chileans access to a basic health care package since 2005.

4) Which of the following statements is true:
Your Answer:a) During the past 15 years, the cost of care has been a growing problem for many developed nations. Correct Answer:a) During the past 15 years, the cost of care has been a growing problem for many developed nations. The cost of care has been a growing problem throughout developed nations during the last 15 years. For example, across 34 nations that make up the Organization for Economic Cooperation and Development (OECD), the average per capita health care expenditure increased by more than 70 percent between 2000 and 2010. However, the biggest spenders — such as the US — don’t necessarily have the highest quality in many areas. Today, countries around the world with vastly different political, economic, and cultural makeups are working toward the goals of improving quality and access in different ways.

5) Which of the following statements is a reason for improving the US health care system? Your Answer:c) The US government and citizens alike are struggling to afford the cost of care. Correct Answer:c) The US government and citizens alike are struggling to afford the cost of care. The US government and citizens alike are struggling to afford the cost of care. The US has improved its mortality amenable to health care, but it remains high compared to other nations. We’ve seen in this lesson the US has the means to measure health care quality — the results just often are not what one would hope! Post-Lesson Assessment

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1) Why was it important for the Institute of Medicine (IOM) to develop its six aims for health care? Your Answer:b) So that health care organizations would have a better idea of what they needed to improve Correct Answer:b) So that health care organizations would have a better idea of what they needed to improve Just as defining dimensions of good performance helps employees, defining the aims (or dimensions of quality) of health care helped hospitals and other organizations understand what to focus on when improving their care.

2) Which of the IOM aims has this hospital FAILED to meet?
Your Answer:e) Timely
Correct Answer:e) Timely
Michael’s care was not timely. He did not receive care when it was needed, without delays.

3) The hospital where Michael is recovering reviews its patient satisfaction survey results in order to improve its care and patient outcomes. Leaders poring over the data note that 90 to 100 percent of patients rate staff as “excellent” in the following categories: listening, answering questions, being friendly and courteous, and giving good advice based on specific needs and preferences. Which aim is the hospital generally achieving? Your Answer:f) Patient-centered

Correct Answer:f) Patient-centered
Patient-centered care is defined by the IOM as “care that is respectful of and responsive to individual patient preferences, needs, and values” and that ensures “patient values guide all clinical decisions.” These high satisfaction rates are consistent with being patient-centered.

4) Which of the following improvement efforts is the best example of increasing the effectiveness of care? Your Answer:c) Improving the percent of clinic patients achieving their goal blood pressure by instituting a series of reminders for providers about evidence-based processes Correct Answer:c) Improving the percent of clinic patients achieving their goal blood pressure by instituting a series of reminders for providers about evidence-based processes Effective care is based on scientific evidence and avoids underuse and overuse.A reminder system allowing providers to more easily use evidence in a busy practice environment would best improve the effectiveness of care.

5) Which of the following improvement efforts is the best example of increasing the equity of care? Your Answer:e) Equalizing rates of cardiac workups between men and women presenting to the Emergency Department with chest pain through staff development and weekly feedback about workup rate Correct Answer:e) Equalizing rates of cardiac workups between men and women presenting to the Emergency Department with chest pain through staff development and weekly feedback about workup rate The best answer is equalizing rates of cardiac workups between men and women presenting to the Emergency Department with chest pain through staff development and weekly feedback about workup rate. Equity is about making sure that care does not vary based upon gender, race, ethnicity, socioeconomic status, geographic location, sexual orientation, and other individual characteristics. Post-Lesson Assessment

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1) Which of the following is a basic principle of improvement? Your Answer:b) Every system is perfectly designed to get the results it gets. Correct Answer:b) Every system is perfectly designed to get the results it gets. A basic principle of improvement is that every system is perfectly designed to get the results it gets. When an error occurs in a complex system — and health care is a complex system — one can reasonably conclude that the system is still perfectly designed for that error, or one like it, to occur again. To avoid that outcome, a conscious effort must be made to improve the system.

2) Using Deming’s System of Profound Knowledge is helpful in quality improvement because: Your Answer:b) It can help break down complex quality issues into smaller, more understandable parts. Correct Answer:b) It can help break down complex quality issues into smaller, more understandable parts. By breaking down a problem into its component parts, as in Deming’s System of Profound Knowledge, you can better analyze it and design ways to improve it.

3) Which component of Deming’s System of Profound Knowledge is the team about to harness? Your Answer:b) Understanding variation
Correct Answer:b) Understanding variation

They are working at understanding variation. By noting a unit that outperforms the others — a significant variation — the nursing home can now study that unit and attempt to spread its practices throughout the organization.

4) After speaking with caregivers on Floor 3, the improvement team discovers that there is a particularly dedicated head nurse on the unit whose mother died after a catheter-associated UTI. This nurse orients all new providers and also provides feedback when she sees that catheters are being placed unnecessarily in patients. Which component of Deming’s System of Profound Knowledge do this nurse’s actions best represent? Your Answer:d) Psychology (human behavior)

Correct Answer:d) Psychology (human behavior)
The answer is psychology (human behavior). This nurse is very particular about preventing UTIs because of the way this kind of infection has affected her life. This, in turn, has a strong effect on the way the entire unit works.

5) In their review of data, the Transcendental improvement team notices that one unit has infection rates that are sky-high. Frustrated, the leadership decides to replace all the providers on that unit except the three with the highest seniority. What is the likely outcome, and why? Your Answer:a) Infection rates will not change because the leaders have not changed the system of care. Correct Answer:a) Infection rates will not change because the leaders have not changed the system of care. The most likely answer is that infection rates will not change because the leaders have not changed the system of care. Removing individual “offenders” from a system should not be expected to magically make infection rates will go down. The best way to implement improvement is to change the system of care itself.

6) Which of these is a question particularly associated with the “theory of knowledge” component in Deming’s System of Profound Knowledge? Your Answer:c) What are your predictions about the system’s performance? Correct Answer:c) What are your predictions about the system’s performance? The answer is, “What are your predictions about the system’s performance?” Deming believed knowledge is based on theory, and that theories need to be developed, applied, and tested in order to advance knowledge in a systematic fashion. Post-Lesson Assessment

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1) The Model for Improvement begins with three questions designed to clarify the following concepts: Your Answer:c) Aims, measures, changes
Correct Answer:c) Aims, measures, changes
The Model for Improvement begins with three fundamental questions about any given improvement, designed to address the aim (what are we trying to accomplish?), the measures to be used (how will we know a change is an improvement?) and the changes to be used (what changes can we make that will result in an improvement?).

2) Applying the Model for Improvement to the clinic’s improvement goal, which of the following is the most reasonable aim statement? Your Answer:b) Increase the number of patients reporting they are “very satisfied” with the clinic’s scheduling by 50 percent within six months. Correct Answer:b) Increase the number of patients reporting they are “very satisfied” with the clinic’s scheduling by 50 percent within six months. An aim statement must specify “how good, by when.” Improving patient satisfaction with scheduling is a reasonable goal. Answer D is best described as an opportunity statement, as it contains no specifics about how much the clinic must improve, nor by when. Answer C is more of a “change” statement than an aim statement.

3) What is the team’s next step?
Your Answer:c) Test their change plan using the PDSA cycle.
Correct Answer:c) Test their change plan using the PDSA cycle. Once you have worked through the first three questions of the Model for Improvement—the questions about aims, measures, and changes—it’s time to do a small test of change using the PDSA cycle. The clinic should have already developed their measures, and now is not the time for a break—because the hard work of improvement is just beginning!

4) The orthopedic clinic plans the change to improve scheduling, and then it carries out a small test of change with three patients on Tuesday morning.
What’s the next thing the clinic’s improvement team should do? Your Answer:b) Measure to see if the change led to improvement. Correct Answer:b) Measure to see if the change led to improvement. The team has planned a test of change and now they’ve done the test. The team must now study how the test went (the “S” part of the PDSA cycle). They can look at a mix of process measures (such as how often appointments started on time) and outcome measures (such as how satisfied the patients were with the new process).

5) When trying to improve a process, one reason to use PDSA cycles rather than a more traditional version of the scientific method (such as a randomized, controlled trial) is that: Your Answer:e) Both C and D

Correct Answer:e) Both C and D
PDSA cycles allow for rapid and frequent review of data and then adjusting the test of change based upon those findings. For example, if a new guideline that’s meant to improve pneumonia care isn’t working, PDSA cycles allow you to change the guideline quickly and test its efficacy, rather than waiting until the end of a long study period. Post-Lesson Assessment

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1) Having a clear aim statement is important in quality improvement work because: Your Answer:a) Aim statements provide a clear and specific goal for the organization to reach. Correct Answer:a) Aim statements provide a clear and specific goal for the organization to reach. Whether you’re trying to reduce your commute time or cut down on the incidence of surgical-site infections, having a clear and specific statement makes your project more likely to succeed. Good aim statements include a specific, measurable goal, a deadline for achieving the goal, and information about which population will be affected: “how good, by when, for whom.” They do not, however, remove all obstacles from the process. And while many funding requests and leaders require strong aims, it’s not always a requirement.

2) An aim statement should include the following:
Your Answer:b) Numeric goals, specific time frame, patient population or system affected Correct Answer:b) Numeric goals, specific time frame, patient population or system affected Aim statements should specify measurable numeric goals, a time frame for attainment, and the group or system affected. Costs and team members, while important to the success of the quality improvement project, are not part of the aim statement itself.

3) Which of the following is the most effective aim statement for this project? Your Answer:b) Within three months, the emergency department will administer all pain medications within 45 minutes of order time. Correct Answer:b) Within three months, the emergency department will administer all pain medications within 45 minutes of order time. Effective aim statements contain a time frame, a definition of the population to be affected, and specific, measurable goals. Answer B meets all three of these criteria. While answers A and C may be useful process changes to reduce the delay between the ordering and administration of medications, they are not aims in and of themselves. Option D is not specific enough, as it does not contain information about how much the department should improve.

4) The charge nurse in the emergency room asks Brenda to assemble a team to improve the delivery of pain medication. As she considers who to place on the team, Brenda should: Your Answer:a) Review the aim statement to make sure the team includes representatives of all processes affected by the team’s aim. Correct Answer:a) Review the aim statement to make sure the team includes representatives of all processes affected by the team’s aim. Including the right people on the change team is crucial to a project’s success. The team should include representatives of all processes affected by the team’s aim, which is why Brenda should review the aim statement. Further, it should include people with enough authority in the system to remove barriers and implement changes; people with clinical or technical expertise; and people who can drive the project on a day-to-day basis. A team representing just one profession is rarely as effective as an interprofessional team.

5) During Brenda’s first group meeting, the members ask to review the aim statement to make sure they agree it addresses the current problem. With Brenda’s approval, they all decide to rewrite it. However, when they meet to consider what would be a better aim statement, the group loses direction. In order to help them, Brenda might want to: Your Answer:d) Remind the team of the Institute of Medicine’s dimensions of health care quality. Correct Answer:d) Remind the team of the Institute of Medicine’s dimensions of health care quality. Writing an effective aim, especially when it comes to being specific about the improvement desired, can be surprisingly difficult. The Institute of Medicine’s six dimensions of health care quality can often provide guidance and direction when a team is struggling to formulate an effective aim statement. (Reminder: A handy way to remember the six dimensions is the mnemonic “STEEEP”: safety, timeliness, effectiveness, equity, efficiency, and patient-centeredness.) Post-Lesson Assessment

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1) What would you identify as the outcome measure for the project? Your Answer:d) Percent of patients that are readmitted to the hospital Correct Answer:d) Percent of patients that are readmitted to the hospital Answer D—hospital readmissions—is the ultimate measure we’re trying to move with the project. In other words, that’s the main thing we’re trying to improve. Answer A is a process measure, which tells us if we are consistently doing the things that are leading to improvement. Answers B and C are both balancing measures, meaning that we’re keeping track of them to make sure the changes we’re making are not having a negative effect on other parts of the system.

2) Which of the following is an example of a process measure that you may collect as part of this improvement effort? Your Answer:c) The percent of patients receiving a call within 48 hours of discharge Correct Answer:c) The percent of patients receiving a call within 48 hours of discharge Gathering data about process changes is important—otherwise you won’t know if you are consistently doing the things that you predict will lead to improvement. Further, if your outcome measures show improvement over the course of your project, having good process measures allows you to make a reasonable conclusion about the efficacy of your new processes and their relation to the outcome. Answer A is an outcome measure for this project, and answer D is a balancing measure.

3) Why might you consider collecting balancing measures?
Your Answer:d) To make sure you did not unintentionally damage other aspects of the unit’s work Correct Answer:d) To make sure you did not unintentionally damage other aspects of the unit’s work Sometimes changes in one part of a complex health care system will lead to unintended additional changes in a different part, like ripples in a pond. Balancing measures can help ensure you’re aware of these significant negative consequences, so that you can address them.

4) What else should you add to the graph to best explain the work your unit has done? Your Answer:b) Annotations to show when specific changes were tested Correct Answer:b) Annotations to show when specific changes were tested When you go through multiple linked PDSA cycles in the course of a project, it’s important to note which changes were tested and when, so you can make sense of the results. While costs are important, they’re not generally shown on the main graph. P-values would also appear elsewhere, if at all.

5) Gathering and reviewing data during an improvement project—that is, measuring—helps you answer which of the three questions of the Model for Improvement? Your Answer:a) How will we know that a change is an improvement? Correct Answer:a) How will we know that a change is an improvement? Measures (both qualitative and quantitative) provide a way to gather information on the effects of the change you are testing. Without measures, you have no real way of knowing whether your change led to an improvement. Having good measures is critical if you wish to improve care and spread change throughout a system. Post-Lesson Assessment

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1) You’re a medical assistant at a community health clinic. Sometimes, patients with unresolved problems need to come in for follow-up appointments. However, you notice that it’s a real challenge to schedule these follow-ups within a week of the initial appointments. Which of the following techniques might be most useful as you search for a good idea for change? Your Answer:a) Review the process for scheduling these appointments with colleagues to identify opportunities for improvement. Correct Answer:a) Review the process for scheduling these appointments with colleagues to identify opportunities for improvement.

Coming up with a change that will address your problem is often one of the most difficult aspects of the change process. Brainstorming with colleagues may help, as can critical thinking and creative thinking about the problem at hand. In this case, simply moving to another clinic (answer B) might reduce your frustration but will not help the clinic. Improving the scheduling software (answer C) may be useful, but it’s unclear at this point that technology is at the heart of the delays. Finally, the office staff very likely already know that patient follow-ups should be scheduled sooner, but some aspect of the process is making this difficult for them (answer D). Simply reminding them is unlikely to get results.

2) What’s the main benefit of using change concepts to come up with improvement ideas? Your Answer:d) Using change concepts can help you develop specific improvement ideas that might not have occurred to you initially. Correct Answer:d) Using change concepts can help you develop specific improvement ideas that might not have occurred to you initially. Change concepts can help you develop new, specific ideas for change that could lead to improvement. They don’t necessarily improve the likelihood that implementation of these changes will go smoothly, however. Finally, testing the changes using PDSA cycles is still necessary!

3) You notice that it’s very easy to confuse medications at the community health center where you’re working. They are lined up on the shelf and the labels are very similar. You decide that it’s worth a try to highlight parts of drug names on certain labels to reduce confusion. Which change concept are you using? Your Answer:c) Focus on Error Proofing

Correct Answer:c) Focus on Error Proofing
By making it easier to identify the medications, you are making it harder for the people in your organization to make mistakes. Choices A, B, and D are all valuable types of change concepts, but they do not apply in this example.

4) Which of the following changes falls under the heading of “eliminating waste”? Your Answer:a) Physicians type all consult responses directly into a computer rather than writing them in a patient’s chart, thus saving paper. Correct Answer:a) Physicians type all consult responses directly into a computer rather than writing them in a patient’s chart, thus saving paper. Waste is an activity or resource that does not add value. When a physician writes an order and someone else enters that order into the computer (answer A), two steps are required. Changing the process so it only requires one step reduces waste as well as potential for error. None of the other answers explicitly focuses on reducing waste.

5) As you recall, the IHI staff member’s change idea involves leaving work by 6:30 PM each workday. Which of the following is an example of using technology to help her do so? Your Answer:c) Scheduling a reminder into her work calendar that pops up daily at 6:15 PM with the message, “Leave!” Correct Answer:c) Scheduling a reminder into her work calendar that pops up daily at 6:15 PM with the message, “Leave!” The programmed reminder is an example of using technology to make it harder for people to “drift” into less-than-optimal behavior. Answer A is an example of benchmarking. Answer B is an example of the change concept “eliminate waste” (assuming those meetings were not necessary in the first place). Answer D simply shifts the work to home, rather than creating a more efficient work pattern. Post-Lesson Assessment

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1) The care protocol was successful at the other hospital. Why would it be important to test this proven change at your hospital? Your Answer:c) Because this change may not be as effective in your hospital. Correct Answer:c) Because this change may not be as effective in your hospital. Changes that work in one complex system may not be as effective, or effective at all, in another. The only way you will know for sure is to test the changes. Other reasons to test “proven” changes are to evaluate costs, minimize resistance and gain buy-in, and increase your own confidence that the change will lead to improvement in your setting.

2) After several tests, you decide to try implementing a modified version of the protocol at your institution. Which of the following might you do within the “S” portion of your next PDSA cycle? Your Answer:c) Analyze information collected.

Correct Answer:c) Analyze information collected.
“S” stands for Study. In this step you review the information collected during the “Do” step. Planning for implementation is part of the “Plan” step, and documentation of outcomes is part of the the “Do” step. Considering how to spread the change to another hospital is outside the scope of this PDSA cycle.

3) Based on the recommendations in this lesson, what should you do next? Your Answer:d) Work on improving both the schedule and communication at the same time. Correct Answer:d) Work on improving both the schedule and communication at the same time. You should start testing changes to both processes and run the tests concurrently. That way you can see how all the required changes work together. Remember, your goal is to bring knowledge into action—not to discover the single change that works best.

4) Starting with small tests of change:
Your Answer:b) Improves the likelihood of buy-in from opinion leaders Correct Answer:b) Improves the likelihood of buy-in from opinion leaders Linking tests of change—with one test concluding and the next beginning at the same time, but this time on a larger scale or with a different scope—allows you to build support for your project. Each successive test is a way to demonstrate to key stakeholders that their input has value and that the project may actually lead to improvement. However, it’s not necessary to seek consensus among stakeholders before testing changes.

5) Which of the following statements is true?
Your Answer:b) While not all changes lead to improvement, all improvement requires change. Correct Answer:b) While not all changes lead to improvement, all improvement requires change. All improvement requires change—but unfortunately, not all changes lead to improvement. It is precisely for this reason that after you test a change, you should study the results to determine whether you’re closer to accomplishing your goal.