Quality Improvement & Audits Flashcards

In healthcare quality management, what is a 'fishbone diagram' (Ishikawa diagram) used for?

Answer: Visualizing all potential causes of a problem, organized by categories such as People, Process, Equipment, Environment, Materials, and Management

The Fishbone (Ishikawa) diagram is a cause-and-effect analysis tool used to systematically identify all potential contributing factors to a problem. The 'head' of the fish is the problem; the 'bones' represent categories of causes (the '6 Ms' or '5 Ps' in healthcare). It is used in RCA and quality improvement.

A hospital's clinical governance committee reviews a report showing that 35% of blood culture samples are contaminated (normal <3%). Which quality improvement approach should be used to address this complex, multi-factorial problem?

Answer: Comprehensive quality improvement project using QI methodology (DMAIC or audit cycle): root cause analysis, multi-component intervention, and sustained monitoring

A contamination rate of 35% (>10× the accepted benchmark of <3%) represents a serious quality problem requiring systematic QI approach. This complex, multi-factorial issue (technique, equipment, training, protocols, workload) warrants DMAIC or audit cycle methodology with proper root cause analysis, multi-component intervention, and long-term monitoring.

Under DHA and JCI standards, what is the required frequency for reviewing and updating clinical policies and procedures?

Answer: Annually for high-risk policies and at least every 3 years for all others

JCI and DHA accreditation standards require high-risk/critical policies to be reviewed and updated annually, and all other policies at least every 3 years (or sooner if new evidence, regulatory changes, or incidents require earlier review). Outdated policies can contribute to patient harm by not reflecting current evidence-based practice.

A hospital quality manager is tasked with measuring patient satisfaction. Which validated, internationally recognized tool is most commonly used for measuring inpatient satisfaction?

Answer: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) or validated equivalent

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is the internationally recognized, validated standardized survey tool measuring patients' perceptions of hospital care. It covers communication with nurses/doctors, responsiveness, pain management, medication communication, discharge information, and overall rating. DHA and JCI require use of validated patient satisfaction tools.

In the context of infection control audits, what metric is used to measure hand hygiene compliance in healthcare settings?

Answer: Hand hygiene compliance rate (observed hand hygiene actions / opportunities × 100%)

Hand hygiene compliance rate is measured by direct observation: trained observers record occasions when hand hygiene is performed correctly vs. total hand hygiene opportunities observed (the 'five moments'). A compliance rate of ≥80% is the generally accepted minimum target, with ≥90% as the best practice target.

A healthcare quality team performs a process mapping exercise before redesigning the patient discharge process. The tool that visually shows all steps, decision points, and responsible parties in the discharge process is called:

Answer: Process flow chart (flowchart) or swim lane diagram

A process flowchart visually depicts every step in a process, including decision points (diamonds), actions (rectangles), and start/end points. A swim lane diagram extends this by showing which role/department is responsible for each step. These tools identify inefficiencies, redundancies, and handoff failures in complex processes like patient discharge.