Quality Improvement & Audits Flashcards

A hospital's clinical audit reveals that antibiotic prophylaxis is administered on time in only 58% of surgical cases, against a standard of 90%. After a root cause analysis, the team implements a checklist and re-audits six months later, finding compliance at 87%. According to the audit cycle, what is the MOST appropriate next action?

Answer: Implement a further targeted intervention and plan a third audit cycle to reach or exceed the 90% standard

The audit cycle requires closure only when the standard is fully met. An improvement from 58% to 87% is significant but still falls short of the 90% benchmark. The correct response is to identify the residual gap, implement an additional targeted intervention, and re-audit — continuing the cycle until the standard is achieved or the team decides to revise the standard with justification.

In a Failure Mode and Effects Analysis (FMEA) conducted for a medication dispensing process, a failure mode is assigned a Severity score of 8, an Occurrence score of 3, and a Detectability score of 2. What is the Risk Priority Number (RPN), and how should this failure mode be prioritized relative to another with RPN 60 but a Severity score of 10?

Answer: RPN is 48; it should be deprioritized, but the failure mode with Severity 10 warrants immediate action regardless of its lower RPN

RPN = Severity × Occurrence × Detectability = 8 × 3 × 2 = 48. While an RPN of 60 is numerically higher, best FMEA practice mandates that any failure mode with a Severity score of 9 or 10 (catastrophic/critical harm) must be actioned immediately regardless of its overall RPN, because the consequence of that failure is unacceptable. RPN alone should never be the sole prioritization criterion when severity is extreme.

A quality manager is comparing two process improvement methodologies for reducing patient wait times in the ED. Lean targets waste elimination while Six Sigma targets variation reduction. Which scenario BEST justifies choosing Six Sigma over Lean as the primary methodology?

Answer: Average wait time is acceptable at 35 minutes, but wait times range unpredictably from 10 to 90 minutes causing patient dissatisfaction

Six Sigma is specifically designed to reduce process variation (defects per million opportunities), making it ideal when the average performance is acceptable but unpredictable variation is the core problem. The scenario with acceptable mean wait time but extreme variance (10–90 minutes) is a classic Six Sigma target. The other scenarios describe waste types (motion, excess inventory, inappropriate processing) that are quintessential Lean targets.

During a sentinel event review at a DHA-licensed facility, the root cause analysis team identifies 'inadequate staffing' as a contributing factor. Under the DHA Patient Safety framework, which action is MOST aligned with a systems-based (rather than person-based) corrective response?

Answer: Revising the staffing ratio policy and implementing a real-time acuity-based staffing tool with escalation triggers

A systems-based approach addresses the organizational conditions that allowed the error to occur rather than attributing blame to individual practitioners. Revising staffing ratio policy and implementing an acuity-based tool with escalation triggers directly modifies the system that failed. Individual warnings, competency tests, and performance reviews are person-focused responses that do not address the structural root cause and are inconsistent with modern patient safety science and 'just culture' principles.

A hospital implements a Statistical Process Control (SPC) chart to monitor central line-associated bloodstream infection (CLABSI) rates. After three months, the chart shows eight consecutive data points all below the mean but none outside the control limits. How should the quality team interpret this pattern?

Answer: This represents a special-cause signal (a run rule violation) indicating a sustained shift in the process that requires investigation

In SPC, a run of eight or more consecutive points on the same side of the mean (even within control limits) is a recognized special-cause signal — often called the 'run rule' or 'Western Electric Rule 2.' It indicates a non-random, sustained process shift that is statistically unlikely to occur by chance. The team should investigate the cause: it could reflect a genuine improvement (e.g., new bundle compliance) that should be standardized, or an early deterioration before it breaches control limits.

A DHA-accredited facility is preparing for a Joint Commission International (JCI) survey. The quality team discovers that its ongoing professional practice evaluation (OPPE) data for physicians shows that 40% of practitioners have not had a peer review in over 18 months. Which of the following represents the HIGHEST-risk compliance gap this finding creates?

Answer: It undermines the credentialing and privileging process, potentially allowing practitioners with performance concerns to continue practicing without detection

OPPE is a cornerstone of the medical staff credentialing and privileging cycle. Its purpose is to detect performance concerns between formal re-credentialing cycles. A 40% gap in peer review compliance means nearly half of practitioners have not been evaluated for performance risks within the expected timeframe. This directly undermines the privileging process — the mechanism that ensures only competent, safe practitioners hold clinical privileges — and represents the most critical patient safety and accreditation compliance risk among the options listed.