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Quality Improvement & Program Management Flashcards

7 cards from real ASC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.

Read the first 7 Quality Improvement & Program Management flashcards as text
  1. A stroke coordinator presents quarterly data showing DTN times have improved from a median of 68 minutes to 48 minutes over 12 months. Which statistical display BEST demonstrates this sustained improvement over time?

    Answer: Run chart or control chart tracking monthly median DTN times

    Run charts and control charts display trends over time, making sustained improvement or regression immediately visible.

  2. The hospital stroke committee is reviewing its stroke education program for primary prevention. Which population has the HIGHEST priority for targeted community education?

    Answer: Adults with hypertension, diabetes, or prior TIA in underserved communities

    Adults with modifiable risk factors in underserved communities represent the highest-priority population for primary prevention education due to elevated risk and reduced healthcare access.

  3. Which element is REQUIRED in a root cause analysis (RCA) conducted after a delayed tPA administration?

    Answer: Identification of contributing system and process factors

    RCA must identify contributing system and process factors — not individual blame — to produce actionable improvements.

  4. A stroke coordinator is preparing a business case to hospital administration for expanded stroke unit staffing. Which data type is MOST persuasive to include?

    Answer: Cost-effectiveness data showing stroke unit care reduces length of stay and readmissions

    Cost-effectiveness data directly linking stroke unit investment to reduced LOS and readmissions addresses the financial concerns of hospital administrators.

  5. Under TJC stroke certification, how frequently must a stroke center's performance data be reviewed by its stroke committee?

    Answer: At least quarterly

    TJC requires certified stroke programs to conduct data review and performance improvement activities at least quarterly.

  6. A stroke program coordinator identifies that a specific attending physician has a tPA administration rate significantly below the program average. The MOST appropriate initial action is to:

    Answer: Provide individual confidential feedback comparing performance to program benchmarks

    Confidential individualized feedback with benchmark comparisons is the standard initial QI approach for physician outlier performance.

  7. Which framework is MOST aligned with the Joint Commission's approach to continuous stroke program quality improvement?

    Answer: TRACER methodology with ongoing tracers between certification cycles

    TJC uses tracer methodology — following a patient's care pathway — as its primary ongoing QI and survey tool for certified stroke programs.