Quality Improvement & Audits Flashcards
6 cards from real DHA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Quality Improvement & Audits flashcards as text
In healthcare quality improvement, what is the purpose of a 'run chart' in tracking quality metrics over time?
Answer: To display data over time and identify trends, shifts, or unusual patterns in a process
A run chart displays a quality metric plotted over time (y-axis = metric, x-axis = time). It helps identify trends (gradual rise or fall), shifts (sustained change in level), and special cause variation. Run charts are a simple but powerful quality improvement tool preceding more complex statistical process control (SPC) charts.
A hospital quality team is investigating a high rate of catheter-associated urinary tract infections (CAUTI) on a medical ward. Which quality improvement methodology uses the structured approach of 'Define, Measure, Analyze, Improve, Control'?
Answer: Six Sigma DMAIC
The Six Sigma DMAIC methodology is specifically structured as Define (problem statement), Measure (baseline data), Analyze (root causes), Improve (interventions), Control (sustain gains). It is data-driven and uses statistical methods to reduce variation and defects — appropriate for complex quality problems like CAUTI.
In the context of hospital accreditation, what does the abbreviation 'KPI' stand for and how is it used?
Answer: Key Performance Indicator — a measurable value demonstrating how effectively an organization is achieving key objectives
KPIs (Key Performance Indicators) are specific, measurable metrics that track progress toward organizational goals. In healthcare, KPIs include clinical quality indicators (infection rates, mortality), patient satisfaction scores, operational metrics (bed occupancy, ALOS), and safety indicators (medication errors, falls). DHA and JCI require facilities to define, track, and report KPIs.
What is the difference between a 'prospective' and 'retrospective' clinical audit?
Answer: Prospective audit collects data on current/future practice in real time; retrospective audit reviews past records to assess past practice
Prospective audit: data collected in real time as care is delivered, allowing immediate feedback and correction — more resource-intensive but catches errors in progress. Retrospective audit: reviews past medical records to assess how care was delivered — easier to conduct but cannot change what already happened.
A hospital wishes to reduce its surgical site infection (SSI) rate. They implement a bundle intervention (pre-op antibiotic timing, glucose control, normothermia, chlorhexidine wash). After 6 months, SSI rates fall significantly. To confirm this is a real improvement and not random variation, which statistical tool is most appropriate?
Answer: Statistical process control (SPC) chart with control limits
Statistical process control (SPC) charts — specifically Shewhart control charts — distinguish between common cause variation (normal random variation within a stable process) and special cause variation (real change in process performance). If post-intervention data points fall outside control limits or show non-random patterns, the improvement is statistically significant.
In the PDSA (Plan-Do-Study-Act) quality improvement cycle, what should happen in the 'Act' phase?
Answer: Decide to adopt, adapt, or abandon the change based on study results, then plan the next cycle
In the Act phase of PDSA: based on the Study phase results, the team decides whether to: adopt the change (if successful), adapt it (modify and run another PDSA cycle), or abandon it (if unsuccessful). The Act phase feeds into the next Plan phase — making PDSA a continuous improvement cycle.