Shared Flashcard Set

Details

NSG 472 Final
Quiz 1 IHI modules, articles
200
Nursing
Undergraduate 4
12/15/2015

Additional Nursing Flashcards

 


 

Cards

Term

Three essential elements for systems improvement

What is special about the 3rd one?

(QI 102)

Definition

1.will to improve

2. ideas to improve

3. execution-aka the model for improvement or what QI 102 focuses on

Term

The model for improvement begins with three fundamental questions?

What are these three key words and what do they mean?

(QI 102)

Definition

1. Aim-what are we trying to accomplish?

2. measures-how will we know a change is an improvement?

3.Changes- what change can we make that will result in an improvement?

Term

What is a PDSA cycle?

What are the four phases of a PDSA cycle?

(QI 102)

Definition

The PDSA cycle gives us a way to quickly test changes on a small scale, observe what happens, tweak the changes as necessary, and then test again (perhaps with a larger or broader test group, if our confidence in the idea has grown). Instead of spending weeks or months planning out a comprehensive change, then putting it into practice only to find that it’s fundamentally flawed, the PDSA cycle enables rapid testing and learning.

The four phases are Plan, Do, Study, Act

Term

6 steps an improvement team may go through when applying the model for improvement in a clinical setting

Tell me a little more about each step

(QI 102)

Definition

1. set an aim with an aim statement

2. form a team-crucial when changing a complex system, team should include reps of all processes affected by improvement measure

3.establish measures-how you can tell change occured

4. identify changes-how is this going to happen and where ideas are going to come from

5. test changes-run a PDSA cycle

6. implement change-make the change standard in a defined setting

Term

When it comes to selecing a framework for improvement studies have shown that...

(QI 102)

Definition
it is more important for an organization to have a standard road map to conduct improvement projects rather than have any specific framework
Term

Six sigma

(QI 102)

Definition

another example of a framework that can be used for improvement

Six Sigma focuses on reducing variation, or the defect rate, measured by Sigma level, or “Defects per Million Opportunities.” The Six Sigma improvement framework consists of five basic steps, known as "DMAIC": 
  • Define the problem in detail. 
  • Measure defects (in terms of “defects per million,” or Sigma level). 
  • Analyze under what conditions defects occur by using process measures, flow charts, and defect analysis. 
  • Improve by defining and testing changes aimed at reducing defects. 
  • Control your results by determining what steps you will take to maintain performance.
 
Term

Lean

(QI 102)

Definition

Another framework that can be used for improvement

Lean focuses on improving value from the customer’s point of view, by reducing waste of time and resources. The basic steps for Lean include: 
  • Specify the value desired by the customer. 
  • Identify the value stream for each product providing that value and challenge all of the wasted steps currently necessary to provide it.
  • Make the product flow continuously through the remaining value-added steps. 
  • Introduce pull between all steps where continuous flow is not possible. 
  • Manage toward perfection so that the number of steps and the amount of time and information needed to serve the customer continually fall. 
 
Term

(QI 102) 

The Model for Improvement begins with three questions designed to clarify the following concepts:

a) Plan, do, act
b) Mission, goal, strategy
c) Aims, measures, changes
d) Will, ideas, and execution
Definition
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?).
Term

(QI 102) An orthopedic clinic in a busy metropolitan area would like to improve its patient scheduling process. More specifically, the clinic wants to improve its efficiency and the satisfaction of its patients.

2) Applying the Model for Improvement to the clinic’s improvement goal, which of the following is the most reasonable aim statement?

 a) Implement two PDSA cycles within six months of beginning the project.
b) Increase the number of patients reporting they are “very satisfied” with the clinic’s scheduling by 50 percent within six months.
c) Modify the scheduling process to allow both front desk staff AND nurses to directly schedule appointments.
 d) Create an efficient process for scheduling return appointments at the time of checkout.

Definition
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.
Term

(QI 102) An orthopedic clinic in a busy metropolitan area would like to improve its patient scheduling process. More specifically, the clinic wants to improve its efficiency and the satisfaction of its patients.

After assembling a team and working through the three questions of the Model for Improvement, the orthopedic clinic decides to implement an automated reminder phone call 24 hours prior to each clinical appointment. The clinic’s improvement team hopes that this small change will improve scheduling.

 

3) What is the team's next step?

a) Take a well-deserved break.
b) Develop their project-level measures.
c) Test their change plan using the PDSA cycle.
d) Report their results to clinic leadership and prepare a poster for a national meeting.
e) Clarify their aim statement.

Definition
Correct Answer:c) Test their change plan using the PDSA cycle.
Once you have worked through the first three questions of the Model for Improvementthe questions about aims, measures, and changesit’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 breakbecause the hard work of improvement is just beginning!
Term

After assembling a team and working through the three questions of the Model for Improvement, the orthopedic clinic decides to implement an automated reminder phone call 24 hours prior to each clinical appointment. The clinic’s improvement team hopes that this small change will improve scheduling.

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?

 a) Change their measures.
 b) Measure to see if the change led to improvement.
 c) Report their results to the clinic leadership and prepare a poster for a national meeting.
d) Implement the new scheduling process based upon their initial impressions of how everything is working

Definition
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).
Term
(QI 102)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:

a) PDSA cycles are easier to run with a large team of people.
b) The results of PDSA cycles are more generalizable than other methods.
  c)PDSA cycles are simpler to use than other methods.
 d) PDSA cycles provide a mechanism to adjust improvement ideas as the project progresses.
 e) Both C and D

Definition
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.
Term
(QI 102) Aim statement
Definition

What are we trying to accomplish?

A good aim addresses an issue that is important to those involved; it is specific, measurable, and addresses these points:

  • How good?
  • By when?
  • For whom (or what system)?

 

Term
(QI 102) Developing Aim statements in health care can be best developed from the 6 dimensions of the health care system from the IOM crossing the chasm report.  These 6 are
Definition

1.Health care should be safe-Do no harm

2.Health care should be timely

3. health care should be effective

4. the health care system should be efficient

5. health care should be equitable

6. health care should be patient centered

remember the acronym STEEP

Term

(QI 102) Is this aim strong or weak?

  We aim to reduce harm and improve patient safety for all of our internal and external customers.

 

Definition

Answer: Weak


The aim is too broad. It doesn’t say how good or by when.
Term

(QI 102) Is this aim strong or weak?

  By June of 2015, we will reduce the incidence of pressure ulcers in the critical care unit by 50 percent.

 

Definition

Answer: Strong

This aim is specific. It tells us how good, by when, and for whom.
Term

(QI 102) Is this aim strong or weak?

  We will reduce all types of hospital-acquired infections.
Definition

Answer: Weak


This is not an aim; it’s more like a mission statement. It needs to be turned into a how good, by when aim.
Term

(QI 102) Is this aim strong or weak?

Our most recent data reveal that, on average, we reconcile the medications of only 35 percent of our discharged inpatients. We intend to increase this average system-wide to 50 percent by April 1, 2015, and to 75 percent by August, 31, 2015.

Definition
Answer: Strong

This aim is clear and specifies how good and by when, along with a staged goal (50 percent by one date and 75 percent by the next). It is reasonable and could be suitable for a team’s work and management’s expectations.
Term
(QI 102) Effective team members includes three types of expertise
Definition
authority within the system (authority in all areas affected, understands remote consquences of the change), technical expertise(knows what to measure), and day-to-day leadership (daily driver, ensures testing/data collection done daily, understands various efforts of making change in the system). There may be one or more individuals on the team with each kind of expertise, or one individual may have expertise in more than one area, but all three areas should be represented in order to drive improvement successfully.
Term
(QI 102) Example Team
Definition

 

Aim: Improve patient satisfaction by reducing the time in the clinic waiting room to an average of 10 minutes within the next four months

Team Leader: MD, medical director for primary care clinic
Technical Expert:  DO, physician at downtown primary care clinic
Day-to-Day Leader:  RN, manager of downtown primary care clinic

Additional Team Members: patient educator, two patients, medical assistant, clerk/scheduler, quality expert

Term

( QI 102)

Having a clear aim statement is important in quality improvement work because:

a) Aim statements provide a clear and specific goal for the organization to reach.
b) All grant agencies require clear aim statements when they are considering funding requests.
 c) Aim statements remove all obstacles from quality improvement projects.
d) The leaders of all organizations expect to see these types of goals.
Definition
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.
Term
(QI 102) 2) An aim statement should include the following:

a) Specific time frame, team membership, numeric goals
b) Numeric goals, specific time frame, patient population or system affected

 c) Patient population or system affected, estimated cost of improvement, numeric goals
d) All of the above

Definition
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.
Term

(QI 102) Brenda, an emergency room nurse, notes that there seems to be a significant delay between the ordering and the administration of pain medications in her department. She decides to conduct a small improvement project to reduce this delay and obtains the support of the charge nurse (head nurse).

3) Which of the following is the most effective aim statement for this project?

a) Within one month, 95 percent of physicians will tell nurses when a pain medication is ordered on emergency room patients.
b) Within three months, the emergency department will administer all pain medications within 45 minutes of order time.
 c) Within two months, improve the timeliness of pain medication delivery by allowing nurses to stock the most commonly used medications in the emergency unit
d) Within three months, the emergency department will improve the timeliness of pain medication delivery to 100 percent of patients.

Definition
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.
Term

(QI102) Brenda, an emergency room nurse, notes that there seems to be a significant delay between the ordering and the administration of pain medications in her department. She decides to conduct a small improvement project to reduce this delay and obtains the support of the charge nurse (head nurse).

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:

a) Review the aim statement to make sure the team includes representatives of all processes affected by the team’s aim.
 b) Create a team of volunteers.
c) Create a team of managers and administrators.
d) Make sure only nurses are on the team, as they are the most likely to help her achieve her aim.

Definition
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.
Term

(QI 102) Brenda, an emergency room nurse, notes that there seems to be a significant delay between the ordering and the administration of pain medications in her department. She decides to conduct a small improvement project to reduce this delay and obtains the support of the charge nurse (head nurse)

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:

a) Reconsider who should be on the improvement team.
 b) Move the meeting to a later date, so that she can come better prepared.
c) Explain to the group that the aim is set, as both she and the charge nurse have already agreed on the wording.
 d) Remind the team of the Institute of Medicine’s dimensions of health care quality.
 
 
Definition
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.)
Term
(QI 102) Data will help you to do these 4 things
Definition
  • Understand current performance. (People doing improvement usually call this developing a baseline.)
  • Come up with ideas to improve the process. 
  • Test changes to see if they lead to improvement.
  • Ensure improvements are being maintained.
Term
(QI 102)measuring for improvement is quite different from measuring for research.
Definition

In QI, keeping track of a few simple measures lets the team see how it’s progressing toward improvement. Through a rapid series of small, sequential tests (PDSA cycles), the team works out the kinks in their ideas and grows their confidence that they have a successful change; they “adapt, adopt, or discard.” They don’t pick just one hypothesis and stick with it until the bitter end.
Term
(QI 102) Differences for measuring in quality reasearch vs differences in measuring quality improvement
Definition

quality research-look for proof of effectiveness, gather enough data to authoritatively study for effect and control confounding variables, method is one large test with a fixed hypothesis and a control of bias as much as possible, results have a pre and post eval

 

quality improvement-sustained improvement, gather just enough data to inform improvement and only collect data on 1-2 confounders (balancing measures), method has rapid sequential test with a hypothesis that changes as learning takes place and no effort to control bias, assessment is made regularly with run charts

 

Term
  Which of the clinics is measuring for improvement?



At Clinic A, the plan is to meet as a team and start with 10 patients. The team will note how many clinicians washed their hands before and after each patient encounter to learn what might be the barriers to hand washing. The team will continue to track 10 patients per week as various interventions are tested and then will determine if hand hygiene compliance gets better over time.

At Clinic B, the plan is to meet as a team and choose a test to implement. The team will randomly assign patients to two groups, making sure both have similar attributes. The team will then develop a database, and over the next six months, measure how many clinicians in each group washed their hands before and after each patient encounter. After that, the team will implement the chosen intervention with one of the groups and reassess hand hygiene compliance as compared to the control group.

Definition
Clinic A is measuring for improvement. That team is using many sequential, observable tests, gathering just enough data to learn and start another cycle, and using small, rapid tests of change to accelerate improvement.
Term

family of measures that consists of these three types of measures:

what is the definition of each?

Definition
  • Outcome measures are the measures you ultimately want to move. They tell you how the system is performing, i.e., what is the ultimate result?
  • Process measures tell you if the parts or steps in the system are performing as planned to affect the outcome measure.
  • Balancing measures, which are often not directly related to the aim, assess whether the changes designed to improve one part of the system are introducing problems elsewhere.
Term

(QI 102)
Aim: Reduce the incidence of ventilator-associated pneumonia (VAP) by reducing the number of ventilator days in the intensive care unit (ICU) by 20 percent within five months.


indicate whether each of the following measures are outcome measures, process measures, or balancing measures

 

Average number of days on mechanical ventilation

Definition
This is a process measure. Reducing the number of ventilator days leads to the ultimate goal of reducing the cases of ventilator-associated pneumonia.
Term

(QI 102)
Aim: Reduce the incidence of ventilator-associated pneumonia (VAP) by reducing the number of ventilator days in the intensive care unit (ICU) by 20 percent within five months.


ndicate whether each of the following measures are outcome measures, process measures, or balancing measures

  Percent of patients with ventilator-associated pneumonia
Definition
The is an outcome measure. This is the ultimate measure we are trying to move.
Term

(QI 102)
Aim: Reduce the incidence of ventilator-associated pneumonia (VAP) by reducing the number of ventilator days in the intensive care unit (ICU) by 20 percent within five months.


ndicate whether each of the following measures are outcome measures, process measures, or balancing measures

  Readmission of ventilated patients to the ICU who then require mechanical ventilation
Definition
This is a balancing measure. We need to be sure that changes we’re making to reduce VAP aren’t causing an increase in readmission of ventilated patients.
Term

(QI 102)

AimReduce the waiting time in the emergency department (ED) to 30 minutes by next August.

Determine if each statement below is outcome, process, or balancing measure


Patient cycle times (e.g., time to registration, time from arrival to triage, time from triage to bed placement) and the percent of the time nurses arrive for their shifts early


Average number of minutes in the ED per patient


Percent of staff reporting they’re satisfied at work and total ED staffing costs

Definition
These are process measures. They will help us understand if we’re successfully doing the things we think will lead to the ultimate improvement of decreasing wait times.
 
This is the outcome measure. It is the ultimate measure we’re trying to move.
 
These are balancing measures. If more staff are dissatisfied or costs go up, we'll suspect our changes are introducing new problems.
Term
(QI 102) These are the basic ingredients of a run chart
Definition
  • X axis, for plotting time
  • Y axis, for plotting the variable you’re measuring
  • Goal line, indicating the desired cycle time
  • Annotations, showing when the team made specific process changes or noteworthy events occurred
You should add other information as needed. For example, a median line, if appropriate. Annotate unusual events, changes tested, or other pertinent information.
Term

(QI 102)

As a nurse manager of a medicine unit in an academic hospital, you’re aware that your unit has a high rate of patient readmissions. In fact, 36 percent of the patients discharged from your unit are readmitted to the hospital within 30 days. After reviewing the literature, you become aware that this rate is quite high compared to national standards. Working with other members of your unit, you develop a plan to call patients on the phone within 48 hours of discharge, with the aim of cutting readmission rates to 18 percent.

1) What would you identify as the outcome measure for the project?

a) Average length of stay
b) The cost of labor associated with the calls
c) Rate of job satisfaction of those on the unit making the calls
d) Percent of patients that are readmitted to the hospital

Definition
Correct Answer:d) Percent of patients that are readmitted to the hospital
Answer Dhospital readmissionsis 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.
Term

(QI 102) As a nurse manager of a medicine unit in an academic hospital, you’re aware that your unit has a high rate of patient readmissions. In fact, 36 percent of the patients discharged from your unit are readmitted to the hospital within 30 days. After reviewing the literature, you become aware that this rate is quite high compared to national standards. Working with other members of your unit, you develop a plan to call patients on the phone within 48 hours of discharge, with the aim of cutting readmission rates to 18 percent.

2) Which of the following is an example of a process measure that you may collect as part of this improvement effort?

a) The rate of patients being readmitted within 30 days
 b) The reasons for readmission to the hospital
c) The percent of patients receiving a call within 48 hours of discharge
d) The cost of the labor associated with the calls

Definition
Correct Answer:c) The percent of patients receiving a call within 48 hours of discharge
Gathering data about process changes is importantotherwise 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.
Term

(QI 102) As a nurse manager of a medicine unit in an academic hospital, you’re aware that your unit has a high rate of patient readmissions. In fact, 36 percent of the patients discharged from your unit are readmitted to the hospital within 30 days. After reviewing the literature, you become aware that this rate is quite high compared to national standards. Working with other members of your unit, you develop a plan to call patients on the phone within 48 hours of discharge, with the aim of cutting readmission rates to 18 percent.

3) Why might you consider collecting balancing measures?

a) To show that you met your aim
b) To make sure you are able to publish your study
 c) To demonstrate to your hospital board that you were justified in using resources for this project
 d) To make sure you did not unintentionally damage other aspects of the unit’s work

Definition
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.
Term
4) What else should you add to the graph to best explain the work your unit has done?

a) The cost of the improvement effort
 b) Annotations to show when specific changes were tested
c) Explanation of what a PDSA cycle is
 d) P-values showing statistical significance

Definition
B) annotations to show when specific changes were tested
Term
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?

a) How will we know that a change is an improvement?
 b) What are we trying to accomplish?
 c) What changes can we make that will result in improvement?

Definition
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.
Term
(QI 102) 5 useful ways to develop changes
Definition

1. critical thinking about the current system-ex create a flow chart to ID what isnt working

2. benchmarking-looking at best practice and way others do things for comparrison

3. using technology-not always reliable but can be helpful if need to upgrade

4. creative thinking-ex exposing self to new situations; temporarily setting unrealistic goals

5. using change concepts-expert ideas on how to start changes

Term

(QI 102) Change concept

and 9 categories of change concepts

Definition

“is a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement.”

1. Eliminate waste
2. Improve workflow
3. Optimize inventory
4. Enhance the producer-customer relationship
5. Change the work environment
6. Manage time
7. Manage variation
8. Design systems to prevent errors
9. Focus on the design of products and services

Term

(QI 102) 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?

a) Review the process for scheduling these appointments with colleagues to identify opportunities for improvement.
b) Quit and start working in a new clinic that functions more effectively.
c) Research possible upgrades to the appointment scheduling software.
 d) Tell a member of the office staff that it would be great if follow-ups were scheduled more quickly.
Definition
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.
Term
(QI 102) 2) What’s the main benefit of using change concepts to come up with improvement ideas?

 a) Using change concepts makes PDSA cycles unnecessary.
 b) Using change concepts makes it much more likely that the implementation will go smoothly.
c) Using change concepts will lead you to focus on quantifiable technological improvements.
 d) Using change concepts can help you develop specific improvement ideas that might not have occurred to you initially.

Definition
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!
Term
(QI 102) 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?

 a) Manage Time
 b) Optimize Inventory
 c) Focus on Error Proofing
d) Improve Work Flow

Definition
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.
Term
(QI 102) 4) Which of the following changes falls under the heading of “eliminating waste”?

a) Physicians type all consult responses directly into a computer rather than writing them in a patient’s chart, thus saving paper.
b) Dispensers full of hand sanitizer are placed throughout a floor, thus improving compliance with hand hygiene protocols.
c) A clinic starts tracking the number of foot exams that diabetic patients receive each year, thus ensuring they receive evidence-based care
 d) A hospital invites patients to participate in the redesign of one of its centers, thus making them feel like valued members of a care team

Definition
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.
Term
(QI 102) 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?
 a) Comparing the time she leaves to that of the person who seems to go home earliest each day.
b) Cancelling two meetings every day.
 c) Scheduling a reminder into her work calendar that pops up daily at 6:15 PM with the message, “Leave!”
d) Taking work home each night on a laptop computer.
 

 

Definition
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.
Term
(QI 102) What if the same changes have been tested and proven somewhere else? You should still test them, and here's why:
Definition
  • To increase your belief that the change will result in improvement in your setting
  • To learn how to adapt the change to the particular conditions in your setting
  • To evaluate the costs and side effects of changes
  • To minimize resistance when implementing the change in the organization
Term
(QI 102) Planning in PDSA
Definition

plan test including plan for collecting data

state the objective of the test

state questions you want to answer and predictions

develop a plan to test change

Term
(QI 102) Do in PDSA cycle
Definition

carry out test on small scale

docment probs and unexpected observations

begin to analyze data

 

Term
(QI 102) Study in PDSA cycle
Definition

try out test on small scale

complete your analysis of the data

compare data to predictions

summarize and reflect on what you learned

Term
(QI 102) Act in PDSA cycle
Definition

refine change based on what you need from test

determine modifications you should make

prepare a plan for the next PDSA cycle

Term

 

 

When testing changes, you should be sure to gain consensus and buy-in from all the people who would eventually be affected by the change.

true or false?

Definition
The answer is false. Try to choose changes that do not require a long process of approval or buy-in. Rather, use the results of the test itself, if successful, to gain consensus and buy-in. Consensus often occurs during the "study" step, not during the "plan" step.
Term
You and your team should reflect on the results of every change. True or false?
Definition
The answer is true. After testing a change, a team should address several issues, including comparing the prediction to what actually happened, identifying unintended consequences, and understanding the best and worst aspect of the change. This is the "study" step of the PDSA cycle.
Term
You should never end a test of change before the planned time. True or false?
Definition
The answer is false. Stop the test if it is not leading to improvement or if things are not safe. However, much can be learned from a failed test of change, so be sure to study it thoroughly.
Term
Linking PDSA cycles
Definition

One should lead into the other

  • Think ahead. You already know you’ll want to do multiple tests. So make your life easier by planning for it. Think a couple of cycles ahead, testing over a wide range of conditions and collecting useful data from each test to guide the next one.
  • Start small. Keep it simple at the beginning. Scale down the size of the test (for instance, start with just one provider testing a change with one patient). Test with volunteers, and don’t try to get consensus from everyone in the organization before starting. 
  • Get started. Don’t wait around! Ask, “What change can we test by next Tuesday?”

  • Running a series of tests, by the way, also helps overcome the resistance people often feel to change and ensure buy-in from all the people involved. Think about how you felt when you were 16 years old and your parents said you had to be home by 11:00 PM every night for the rest of the year. You probably screamed and yelled and periodically violated your curfew just to make a point. 

    Now imagine your parents had instead said, “Let’s try this new curfew for one week. At the end of the week, we’ll talk about how it went and what changes we can make.” You still might not have liked it — but you’d have been much more likely to try it, knowing your input would count for something at the end.
Term
(QI 102) Implementation and spread
Definition

During an implementation PDSA, your goal is to “hardwire” the change into the system, and make it a permanent part of how the process is done.

You or other people may also want to spread the change (i.e., bring it to other environments). Bringing the change to a new place or a different population requires an improvement team at that location to run PDSA test cycles to evaluate and possibly adapt the change. Additional testing is the only way to ensure that the changes that worked so well in one setting won't fall flat somewhere else.

Term

You are working on shortening the time it takes patients with chest pain to get to the cardiac catheterization lab in your hospital. Your aim is to have 90 percent of patients brought to the lab within 45 minutes of arrival to the hospital. You decide to try a care protocol that another hospital in the area implemented with great success.

1) The care protocol was successful at the other hospital. Why would it be important to test this proven change at your hospital?
a) because the last success may have been a fluke.
b) So that you can publish your results.

 c) Because this change may not be as effective in your hospital.
d) In order to demonstrate the ability of this protocol to improve care in other hospitals for those that created it.

Definition
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.
Term


You are working on shortening the time it takes patients with chest pain to get to the cardiac catheterization lab in your hospital. Your aim is to have 90 percent of patients brought to the lab within 45 minutes of arrival to the hospital. You decide to try a care protocol that another hospital in the area i

implemented with great success.

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?

 a) Develop the final plan for the protocol implementation.
 b) Document unexpected observations.
 c) Analyze information collected.
d) Strategize how to move this to another hospital in the system.

Definition
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.
Term

You are working on shortening the time it takes patients with chest pain to get to the cardiac catheterization lab in your hospital. Your aim is to have 90 percent of patients brought to the lab within 45 minutes of arrival to the hospital. You decide to try a care protocol that another hospital in the area implemented with great success.

After implementing the new protocol, you observe that patients are getting to the lab more quickly than before, but not as quickly as you had predicted. You examine the data and realize that there are really multiple issues delaying patients’ arrival to the catheterization lab. Specifically, the emergency department needs to notify the lab staff in advance, but this communication rarely happens. Further, the schedule that the emergency department uses to contact the lab staff is riddled with errors.

3) Based on the recommendations in this lesson, what should you do next?

a) Focus on fixing the schedule.
b) Discipline the emergency department staff who have failed to contact the catheterization lab in the past.
c) Focus on improving the communication between the emergency staff and the catheterization staff.
d) Work on improving both the schedule and communication at the same time.

Definition
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.
Term
4) Starting with small tests of change:

a) Allows you to start testing on live patients right away
b) Improves the likelihood of buy-in from opinion leaders
c) Means you don't need to do any planning before each test
d) Should be done only with the consent of opinion leaders

Definition
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.
Term
5) Which of the following statements is true?

a) All changes lead to improvement; therefore, all improvement requires change.
b) While not all changes lead to improvement, all improvement requires change.
 c) The changes that are known to lead to improvement should be implemented before testing.

Definition
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.
Term
(QI 103) Goal for measurement
Definition

The goal is to spend as little time collecting data as possible.

 
Term
(QI 103) 5 questions to consider when coming up with measurements?
Definition

 


1. What do you want to learn about and improve?
2. What measures will be most helpful for this purpose?
3. What is the operational definition for each measure?
4. Whats your goal?
5. What’s your baseline?
Term

(QI 103) In addition to defining the measures you want to collect, you should plan for how you’ll collect them.

Heres some questions to ask

Definition
  • Who is responsible for collecting the data?
  • How often will the data be collected, e.g., hourly, daily, or weekly?
  • What is to be included or excluded, e.g., include only inpatients or include inpatients and outpatients?
  • How will these data be collected, e.g., manually on a data collection form or by an automated system? (Tip: You should integrate measurement into the daily routine as much as possible.)
Measurement for improvement should be used to speed things up, not slow them down. “Seek usefulness, not perfection” is a favorite mantra at IHI.
Term
(QI 103) 3 samples for QI and their defintions
Definition

Simple random sampling. This is like spinning around blindfolded and pointing at people in a crowded room that contains absolutely everyone in your target population. It’s a selection of data from a sample of the population by use of a random process, such as random numbers obtained from a computer or a random number table

Proportional stratified random sampling. This involves dividing the population into separate categories, then taking a random sample for each category. For instance, you might stratify the population into medical patients, surgical patients, obstetric patients, and pediatric patients — and then select a random sample from each of the strata (or categories). Note that to make the sample proportional, you have to select different sample sizes for each stratum depending on the size of that stratum.
Judgment sampling. This type of sampling is not random; instead, it relies on the judgment of people with knowledge of the system you’re trying to improve. People with subject matter expertise intentionally select useful samples for learning about the impact of changes on process performance

Term
 
2. Your improvement team is trying to improve outcomes for patients with diabetes who are younger than age 18. You need a baseline measure for the percent of patients in the population you're studying who have hemoglobin A1c (blood sugar) levels greater than 8. You request this information from your information systems department, located in the central office. Then you wait. And wait. And wait. Frustrated, you decide to take matters into your own hands.
a) Review all the charts for a four-month period, of which there are 210.
b) Select a sample of 10 charts from each of the four months to review.
c) Review a sample of the first 40 charts in chronological order.
d) Skip baseline data collection because it’s not important for this project.
Definition

The best answer is B. Knowing that there are 210 charts in total, you can save time by selecting a smaller sample, such as 40 charts, to give you “just enough data” to proceed.

 
In conducting the review, you discover that 15 of the 40 patients in the sample (37.5 percent) had a hemoglobin A1c greater than 8. When the information systems folks get back to the team several weeks later with the summary data from running all the charts for the same four-month period, the percentage they give you is almost identical.
Term

You volunteer at a student-run clinic associated with your academic health center. As a member of the student board, you are constantly looking for ways to improve the clinic. One common complaint is that it takes too long to check patients in once they arrive, and you decide to tackle this problem.

Which of the following might be an outcome measure for this effort?

 a) Average number of minutes between patient arrival at the clinic and completion of check-in
b) Number of patients seen by the clinic
 c) Average number of students helping to check a patient in
d) None of the above
Definition
Correct Answer:a) Average number of minutes between patient arrival at the clinic and completion of check-in
Outcome measures tell you how the system is performing. In this case, the aim of the project is to decrease the time it takes to check in patients, so an appropriate outcome measure for this project could be “average number of minutes between patient arrival at the clinic and completion of check-in.” The average number of patients seen by the clinic and the average number of students helping to check in patients might be useful to track as balancing and process measures, respectively.
Term

You volunteer at a student-run clinic associated with your academic health center. As a member of the student board, you are constantly looking for ways to improve the clinic. One common complaint is that it takes too long to check patients in once they arrive, and you decide to tackle this problem.

2) Which of the following is the best way to collect baseline data for this improvement project?

 a) Look at a few patients every day for a week.
b) Look at 10 percent of patients for a year.
c) Look at 100 percent of patients for a month.
d) There is no reason to collect baseline data.

Definition
Correct Answer:a) Look at a few patients every day for a week.
The best answer is to use a small sample and gather the data quickly. When measuring for improvement, it’s often unnecessary (and may defeat the goal of rapid, iterative testing) to collect all available information over an extended period of time. Baseline data is important for knowing whether changes you are making are, in fact, leading to improvement.
Term
3) Which of the following is an example of an effective measurement technique for improvement?

a) Always strive for perfection.
b) Use quantitative and qualitative data.
 c) Always set aside designated time for data collection.
d) All of the above

Definition
Correct Answer:b) Use quantitative and qualitative data.
The best answer is to use qualitative and quantitative data. Qualitative data, which is not so much about numbers as it is about the depth of the information collected, can be a rich source of knowledge in improvement projects. Interviews or focus groups are common sources of qualitative data. Measurement is not the goal; improvement is the goal. In order to move forward to the next step, a team needs just enough data to know whether changes are leading to improvement. (“Seek usefulness, not perfection” is a mantra at IHI.) To save time, integrate data collection into the daily routine as much as possible.
Term
4) Why should you consider collecting a family of measures when undertaking an improvement?

a) It makes the project more publishable.
b) A single measure may not be enough to determine the impact of a change on the system.
c) All improvement projects are so complex that they require multiple measures.
d) All of the above

Definition
Correct Answer:b) A single measure may not be enough to determine the impact of a change on the system.
Health care systems are extremely complex. A small change in a complex system can lead to many unexpected results, so using only one measure may not capture the effect of the change upon the system. Using more measures will not necessarily increase the likelihood of publication. Finally, it is health care that is complex, not necessarily the improvement project itself. The most successful projects are often the simplest ones.
Term
5) You’re working on an improvement project at a community mental health center. Your project aim: “Within two months, 100 percent of our patients will wait less than 30 minutes to be seen by a physician.” You decide to gather data on patient wait times over a week-long period in order to establish a baseline. What might be an important consideration as you plan your data collection strategy?
a) Whether you’ll provide food for the patients who wait more than 30 minutes.
b) What exactly you mean by “wait less than 30 minutes to be seen” — does this include the time the patient spends checking in, for instance?
c) How to establish consensus among the clinic’s caregivers about the value of the project before gathering data.
d) How to inform the supervisors of individual physicians quickly when those physicians’ patients wait more than 30 minutes.
 

 

Definition
Correct Answer:b) What exactly you mean by “wait less than 30 minutes to be seen” — does this include the time the patient spends checking in, for instance?
It is crucial to clearly define your measure before you begin gathering data, so that you and your team members measure the same thing each time — and so that others understand what you are measuring. It’s not necessary to establish consensus at the outset about the value of the project; by doing small tests of change, you are likely to gain buy-in as you go. Finally, you are gathering data for improvement, not accountability, so for this project, it doesn’t make sense to notify supervisors about the performance of individual caregivers.
Term
(QI 103) 5 steps of a run chart
Definition
1. Plot time along the X axis. Choose the appropriate time increment based on your improvement project — minutes, hours, days, weeks, months, etc. Note that individual patients could also be the unit plotted on the X axis. In this case, the patients would be placed in time order (e.g., chronologically as they presented at the reception desk — Patient 1, Patient 2, etc.).

2. Plot the variable you’re measuring along the Y axis. In this case, the CLABSI rate is the outcome measure, so it will be the Y-axis variable. Note that a run chart becomes more powerful as you add more data points because there will be more opportunities to identify patterns. If you’re looking for signs of improvement, usually you need at least 10 data points.2

3. Label both the X and Y axes, and give the graph a useful title. For your project in the NICU at SAMSO, your run chart for your outcome measure might be called “Number of CLABSIs per Catheter Days.”

4. Calculate and place a median of the data on the run chart. The median is the number in the middle of the data set when the data are ordered from the highest to the lowest. Including a median for your baseline data comes in very handy when you’re looking for sign of improvement, as you’ll see in the next lesson.

5. Add other information as needed. Add a goal or target line, if appropriate. Annotate unusual events, changes tested, or other pertinent information
Term

(QI 103) Counting runs on a run chart

 

Definition
a run consists of one or more consecutive data points on the same side of the median. It doesn’t include data points that fall on the median.
it's the chunks of data points on the same side, not the actual points themselves
Term
 

During a clinical rotation on the medical-surgical floor of a hospital, you notice several patients have developed urinary tract infections (UTIs) associated with their Foley catheters (tubes inserted into the bladder to drain urine). Your staff physician agrees that this is a problem and offers to help with an improvement project. Together, you work through several PDSA cycles to improve the rate of UTIs on your floor.

2) When designing your run chart, it is important to include:

 a) The rate of UTIs at the hospital where you worked previously
b) The ages of the patients who developed catheter-associated UTIs
c) The organisms identified in the urine of patients with UTIs
 d) None of the above

Definition
Term
5) Which of the following is a reason for using a dynamic display for data?

a) To show variation
b) To make the case for improvement over time
c) To look for patterns
d) All of the above

Definition
Term
four non random patterns on run charts
Definition
[image]
Term
(QI 103) Shewhart said that every process has inherent variation. If you want a stable, predictable system, you need to identify and remove the...
Definition
special causes (i.e., those that are not common causes) of variation.
Term
common cause variation
Definition
Term
(QI 103) special cause variation
Definition
Term
control limits, (QI 103)
Definition

allow you to determine if the process is stable (containing only common cause variation) or not stable (containing special cause variation).

 
Term
four non random data defintions (QI 103)
Definition
  • A shift in the process is indicated by six or more consecutive points above or below the median.
  • A trend is indicated by five or more consecutive points all increasing or decreasing.
  • Too many or too few runs indicate a nonrandom pattern. (This one is a bit complicated, and we’ll explain it in detail in another course.)
  • An astronomical data point is a pretty good signal of a nonrandom pattern.
Term
1) What is one advantage that Shewhart charts have over run charts?

a) Shewhart charts display data in a more visually appealing way than run charts.
b) Shewhart charts allow you to plot several changes within one chart, whereas run charts allow you to plot only one change.
c) Shewhart charts include control limits, which run charts do not.
d) There is no advantage to using Shewhart charts over run charts — it all comes down to personal preference.

Definition
answer c
Term
2) Which of the following is the best example of special cause variation?

a) A person’s body temperature changes slightly throughout the day.

 b) A patient with pneumonia has very high white blood cell counts.
 c) The hemoglobin levels of a healthy young woman vary somewhat from one day to the next.
d) All of the above

Definition
answer B
Term
3) What is a reason to count the number of runs in a chart?

a) Because it’s the only way to know if your change is an improvement.
b) Because if you have a lot of runs, you likely have an improvement.
c) Because too many or too few runs indicate nonrandom variation.

 d) All of the above.

Definition
Correct Answer:c) Because too many or too few runs indicate nonrandom variation.

The best answer is because too many or too few runs indicate nonrandom variation. What you are looking for in a run chart is evidence of nonrandom variation — in other words, evidence that the process or outcome is changing in some way. Counting runs is especially helpful to identify nonrandom patterns that are not visually obvious. (Sometimes patterns are easy to see, so counting runs is not the only way to identify improvement.

Term
4) A trend is defined by at least how many data points, which are all decreasing or increasing?

 a) 2
b) 5
c) 10
d) 20

Definition
answer B
Term
[image]
Definition
Answer: Shift
Term
(QI 104) Four phases of an improvement project
Definition

innovation-coming up with new ideas for change

pilot-testing change on small scale

implementation-making the change the new standard process in a defined setting

spread-implementing the change in several settings

Term
innovation phase (QI 104)
Definition

This is the stage in which teams brainstorm good ideas for changes to test. You and your fellow improvers will set an aim (i.e., determine “What are we trying to accomplish?”) and develop some early logistical plans.

Start by identifying the patient or target population you want to help and which delivery sites and providers will be involved. Then, you can think about how to improve the current system

once team developed ideas, can write formal aim statement and data collection plan

Term
driver diagram (QI 104)
Definition
example of a visual tool that can help jump start innovation phase in implementation project
Term
pilot phase implementation cycle (QI 104)
Definition

gradually build knowledge with PDSA cycles while minimizing risk

Beginning with a 1:1:1 test (e.g., one encounter between one provider and one patient) allows you to see how your new process works — and adjust it if necessary — with minimal risk. Once you have evidence that a change is working (i.e., it brings you closer to your aim, based on the measures you’ve identified), you can expand the size or conditions of subsequent tests.

Term
implemention phase of implementation cycle (QI 104)
Definition

In implementing the change, you will continue to run PDSAs: making predictions, collecting data, and documenting things that go wrong so that you learn from them and use them to plan the next test

compared to PDSAs in the pilot phase, these tests will require significantly more people, time, and resources

requires more support, more people, longer time, and a lower tolerance for failure

Term
hardwiring (QI 104)
Definition

the steps we take to prevent us from slipping back to the comfortable position after we identify a better way of doing something. Some tactics for hardwiring include:

  • Documenting the flow of the new process — the new way of doing things
  • Providing training on the new process
  • Teaching people new skills that might be required of them
  • Making changes to job descriptions, policies, procedures, and forms
  • Addressing supply and equipment issues
  • Assigning day-to-day ownership for the improvement and maintenance of the new process
  • Having senior leaders remove any barriers that might allow slippage back to the old process
Term
spread phase of implementation cycle (QI 104)
Definition
package content for easy spread at new sites, monitor adoption and performance at new sites
Term

What are the four phases of an improvement project?


 a) Plan-Do-Study-Act
b) Innovation-Pilot-Study-Act
c) Plan-Implement-Pilot-Spread
 d) Innovation-Pilot-Implementation-Spread

Definition
answer d
Term

Sandy Liu, a cardiac care unit nurse, notices that a few of her patients are suffering from inadequate pain control. Currently, a patient who needs pain medication must call the front desk, which then calls the nurse, who then goes to the patient’s room to find out what he or she needs. Sandy finds out that a hospital in the next county has a simpler process: Patients can send a text message directly to the nurse to request pain medication. Sandy goes to her manager and suggests that they form a team to work on improving pain control and test this change in the cardiac care unit.

2) How should Sandy and her improvement team try out the new process for improving pain control?

a) Test the new process with one patient and closely review the results.
b) Bring together a group of stakeholders to develop an implementation plan.
c) Test the new process throughout the hospital to build a pool of data.
 d) None of the above: There is no need to test this process because another hospital has already proved it to be effective.

Definition
a) Test the new process with one patient and closely review the results.
Term


Sandy Liu, a cardiac care unit nurse, notices that a few of her patients are suffering from inadequate pain control. Currently, a patient who needs pain medication must call the front desk, which then calls the nurse, who then goes to the patient’s room to find out what he or she needs. Sandy finds out that a hospital in the next county has a simpler process: Patients can send a text message directly to the nurse to request pain medication. Sandy goes to her manager and suggests that they form a team to work on improving pain control and test this change in the cardiac care unit.

3) After a successful pilot, which of the following should Sandy’s improvement team undertake as a next step?

a) Work on seeing that the change is widely adopted by the unit, such as by making it a formal policy and training new staff on it.
b) Continue to run PDSA cycles.
 c) Spread the change to other hospitals in the network.
 d) A and B

Definition
answer d-a and b
Term


Heather, the medical director of the medicine ward, wants to lower the 30-day readmission rate of the patients on her unit (i.e., the percentage of patients readmitted to the hospital within 30 days of discharge). She meets with the nurse manager and other stakeholders, and, together, they develop a process to improve the way the ward discharges patients and transfers care back to each patient’s primary care provider. The team tests the change on the ward and runs multiple PDSA cycles to improve the process. The data look promising.

4) What improvement project phase have Heather and her team just completed?

 a) Spread
 b) Pilot
 c) Implementation
 d) Planning

Definition
answer b-pilot
Term

Heather, the medical director of the medicine ward, wants to lower the 30-day readmission rate of the patients on her unit (i.e., the percentage of patients readmitted to the hospital within 30 days of discharge). She meets with the nurse manager and other stakeholders, and, together, they develop a process to improve the way the ward discharges patients and transfers care back to each patient’s primary care provider. The team tests the change on the ward and runs multiple PDSA cycles to improve the process. The data look promising.

5) Heather and her team continue to test the new idea. Assuming things continue to go well, what might they eventually do?

a) Share the innovation with other units and/or hospitals.
 b) Utilize the IHI Framework for Spread.
 c) Develop a communication and dissemination plan.
d) All of the above.

Definition
answer D-all of the above
Term
(QI 104) Roger's 5 attributes of change that make ideas easier to spread and their definitions
Definition

1.relative advantage-degree to which innovation is better than idea that supercedes it

2.simplicity-idea is simple to understand and use

3. compatability-consisent with exisiting values, experiences, beliefs, and needs of potential adopters

4. trialbility-degree to which innovation can be tested on a small scale

5. observability-degree to which user can see results of an innovation

Term
(QI 104) new idea score card
Definition

help assess the relative ease or difficulty they’re likely to experience in spreading an innovation.

rank 1-5 in each of roger's categories

The group members then compare and discuss their answers, focusing on the low-scoring areas and areas of disagreement. Once they have identified potential barriers, they work together on developing specific strategies to overcome them — for example, developing clear instructions to make the change concept easier to understand, developing communications to explain why the change is an improvement, or brainstorming low-risk ways to test the change.

Term
7 components of the the framework for spread (QI 104)
Definition

1. leadership

2. setup for spread

3.better ideas

4.social system

5.communication

6. knowledge management

7.measurement and feedback

Term
leadership and the framework for spread (QI 104)
Definition

Setting the agenda and assigning responsibility for spread

  • Designate an executive sponsor for spread.
  • Assign a day-to-day manager for spread.
  • Ensure that the topic to be spread is a key strategic initiative of the organization.
  • Align the goals and incentives of the organization with the topic to be spread.
Term
setup up for spread and the framwork for spread (QI 104)
Definition

Identifying the target population and the initial strategy to reach all sites in the target population with the new ideas

  • Select the target population for spread.
  • Identify the adopter audiences.
  • Identify successful internal and external sites.
  • Develop a plan to attract adopters.
Term
better ideas and the framework for spread (QI 104)
Definition

Describing the new ideas and evidence to “make the case” to others

  • Describe the better ideas.
  • Develop the case for better ideas.
Term
social system and the framework for spread (QI 104)
Definition

Understanding the relationships among the people who will be adopting the new ideas

  • Develop and use key messengers.
  • Build communities to spread improvements.
  • Identify people and mechanisms to provide technical support.
  • Remove obstacles to spreading improvements
Term
communication and the framework for spread (QI 104)
Definition

Sharing awareness and technical information about the new ideas

  • Select appropriate communication methods to provide technical information.
  • Use appropriate communication methods and messages to build awareness about the improvements.
Term
knowledge managment and the framework for spread
Definition

Observing and using the best methods for spread as they emerge from the practice of the organization

  • Capture and transfer spread knowledge.
Term
measurement and feedback and the framework for spread
Definition

Collecting and using data about process and outcomes to monitor the spread progress

  • Track and monitor progress.
  • Develop an outcome measure and a measure for the rate of spread.

 

Term
1) According to sociologist Everett Rogers’ attributes of spreadable ideas, ideas that spread naturally are:

a) Trialable
b) Complex
c) Intriguing
 d) Groundbreaking

Definition
a) triable
Term


An innovation in the United States that is spreading is the concept of a “medical home.” Medical homes are meant to be a comprehensive, integrated approach to primary care. The people developing medical homes believe that providing care this way will improve access, patient satisfaction, and patient-centeredness — and improve clinical outcomes. Implementing a medical home involves redesigning the clinic system on a large scale and changing many behaviors of the staff and providers. As of yet, there is limited and conflicting data about whether medical homes lead to improved clinical outcomes.

2) Which of the following is an accurate statement about the spread of this innovation?

a) This innovation has a high degree of simplicity, so it is likely to spread quickly.
b) Because the relative advantage of this new care model is highly apparent, it is likely to spread quickly.

 c) The complexity of the change involved will likely slow the spread of this innovation.
d) There are obvious and low-cost ways to make this innovation more “trialable,” which might help it spread more quickly.

Definition
Correct Answer:d) The complexity of the change involved will likely slow the spread of this innovation.
Implementing an entirely new clinic system is quite complex, making this a difficult innovation to spread. Improved outcomes may take time to appear and may not be easily observable, which could also slow spread. Finally, because this innovation involves a large-scale system change in most cases, it is difficult to test this easily and in a safe setting. This analysis does not imply that the medical home is not an improvement — only that it may be more difficult to spread than less complicated innovations.
Term


An innovation in the United States that is spreading is the concept of a “medical home.” Medical homes are meant to be a comprehensive, integrated approach to primary care. The people developing medical homes believe that providing care this way will improve access, patient satisfaction, and patient-centeredness — and improve clinical outcomes. Implementing a medical home involves redesigning the clinic system on a large scale and changing many behaviors of the staff and providers. As of yet, there is limited and conflicting data about whether medical homes lead to improved clinical outcomes.

3) ABC Medical Center’s leadership team has implemented the medical home model in one pilot site. Now the team wants to spread the innovation to other sites, and it is using IHI’s Framework for Spread. Which of the following should the spread team do?

a) Ask staff to give daily feedback, to assess progress along the way.
b) Avoid asking staff for feedback at any point, to convey that the new system is mandatory.
c) Ask staff for feedback on the idea prior to implementation only, to encourage and then enforce staff buy-in.
 d) Ask staff to try the new system for a year before giving feedback, so they have time to adjust to the new system before critiquing it.

Definition
Correct Answer:a) Ask staff to give daily feedback, to assess progress along the way.
The best answer is to solicit daily feedback. One key factor in IHI’s Framework for Spread is knowledge management, which includes gathering information about the spread process as it unfolds. Waiting a year to gather feedback is too long.
Term

) When attempting to spread a change that you feel is valuable but is not spreading naturally, if possible, it’s a good idea to:

a) Move on to something else that does spread naturally.
b) Use IHI’s Framework for Spread.
 c) Use the New Idea Scorecard.
 d) B and C
Definition
Correct Answer:d) B and C
Changes that do not spread naturally might benefit from IHI’s Framework for Spread and from brainstorming with the New Idea Scorecard. You could switch to a different innovation that’s easier to spread, but it would be wiser to use the tools available to you before abandoning a potentially valuable innovation.
Term
5) The “setup” component of IHI’s Framework for Spread is best defined as:

a) Tracking and monitoring spread progress
b) Identifying the target population and the initial strategy to reach all sites in the target population with the new idea
 c) Understanding the relationships within the system
d) Assessing innovations and identifying those that are of value

Definition
Correct Answer:b) Identifying the target population and the initial strategy to reach all sites in the target population with the new idea
The best answer is “identifying the target population and the initial strategy to reach all sites in the target population with the new idea.” Understanding the relationships within the system falls under the “social” component of IHI’s Framework for Spread, and tracking and monitoring progress falls under “measurement and feedback.” The identification and piloting of worthwhile innovations should occur before leaders attempt to spread those innovations throughout a system.
Term
1) What is the purpose of IHI's Framework for Spread?

a) To spread health education to underserved communities
 b) To spread improvements across health systems
c) To eliminate the spread of disease

 d) To ensure accurate spread of information

Definition
Correct Answer:b) To spread improvements across health systems

IHI's Framework for Spread is a useful way to think about the most important components to consider when developing and executing a strategy to spread improvements across health systems

Term
2) Which of the following is NOT one of the key components of the IHI Framework for Spread?

a) Piloting innovation
 b) Better ideas
 c) Setup
d) Social system

Definition
Correct Answer:a) Piloting innovation
The pilot phase of an improvement project occurs before the spread effort, as a prerequisite. The improvement team will initiate a spread plan only if the pilot is successful.
Term
3) Regarding the Seton network goal for spread, which of the following is true?

a) They surpassed it.
b) They met it exactly.
 c) They failed to meet it.
d) The goal was unclear, so it was unclear whether they met it.

Definition
Correct Answer:a) They surpassed it.
The Seton Family of Hospitals set a spread goal to introduce 15 medical-surgical units to TCAB by June 2007. At project completion, they had exceeded the initial goal: 17 units were using the TCAB process within 18 months.
Term
4) Which of the following communications strategies did the TCAB spread team use at Seton?

a) Regular meetings
 b) One-to-one calls
c) A website
 d) All of the above

Definition
Correct Answer:d) All of the above
The best answer is “all of the above.” Because communication is at the heart of spread, the spread initiative needs an organized communication campaign. It’s helpful to use many types of communication.
Term
5) Seton’s Chief Nursing Officer was a key supporter of the TCAB spread effort. Which component of IHI’s Framework for Spread does this fact best represent?

a) Communication
 b) Leadership
c) Setup
 d) Measurement

Definition
Correct Answer:b) Leadership

The best answer is “leadership.” Executive leaders in an organization play an important role in spread initiatives by supporting and facilitating the efforts. The ultimate success and sustainability of TCAB depended on leadership commitment at all levels: from the senior executives who set strategic priorities and ensured that good changes spread, to midlevel clinical leaders who empowered staff and orchestrated change, to local leaders and staff who redesigned care processes to achieve unprecedented patient outcomes.
Term
(QI 105) Herbert Kaufman identified a number of barriers that can affect the implementation of significant change in health care, including the following:
Definition

The expected autonomy or independence of health care workers
Stability that comes with routine
Programmed behavior or behaviors that result from processes within a system, including division of labor, recruitment, reward structures, and promotions:

A limited focus or tunnel vision, resulting from only being able to see the impact of change from one individual perspective
A real or perceived limit on resources

An accumulation of policies, procedures, regulations

Term
  (QI 105) “Nice idea, but there’s no chance I’ll have the time to fill out another form. We're understaffed, and I'm just too busy.”

 what barrier to change does this suggest?

Definition
perceived lack of resources
Term

“I’ve been doing this job for thirty years. I don’t need a form to tell me whether a patient is at risk for falling

What percieved barrier to implementation is this (QI 105)

Definition

Autonomy of health care workers

It sounds like this person has gained a lot of experience over the years, and she’s worried the form will reduce her autonomy as a professional.

Term

Don’t we already do a pretty good job of helping patients avoid falls? What’s wrong with how we do it now? (QI 105)

What barrier to implementation does this suggest?

Definition

stability that comes with routine

It sounds like this person is comfortable with the current routine and doesn’t see why it should change.

Term

(QI 105) “Great, another form. Don't they realize we're already drowning in paperwork?”

What barrier to implementation is this?

Definition

accumulation of policies or procedures

It sounds like this person feels overburdened by the forms he's already required to fill out.  The perceived accumulation of policies and procedures at this organization makes it hard for him to accept yet another form.

Term
(QI 105) Everett Rogers said there were five categories of adopters:
Definition

innovation spreads in an S curve

  • Innovators
  • Early adopters
  • Early majority
  • Late majority
  • Laggards
Term
innovator (QI 105)
Definition

“venturesome.” They’re often willing to take risks and experience setbacks when ideas or improvements are unsuccessful.

first to try something out

Term
early adopters (QI 105)
Definition

2nd to try something out

Early adopters aren’t as venturesome as innovators for a given change or idea; however, they are among the first ones willing to try the idea. Unlike innovators, who take risks, early adopters are often respected by their peers as being “smart” about the ideas that they adopt relative to a given innovation. Consequently, early adopters can take away some of the uncertainty that may be associated with a change. They also might be seen as opinion leaders in their social systems.

Early adopters are more data driven than innovators. They look at the facts and the details and make a logical decision about the value of the idea and whether it’s worth adopting. They will evaluate the ideas brought forth by “the innovators” and look for confirmation that these ideas make sense.

Term
early majority (QI 105)
Definition

The next category of adopter is known as the early majority. This group’s adoption of an innovation indicates the stage at which the masses begin to accept it.

may be an important link in the diffusion of any innovation.

They’re not considered opinion leaders with respect to the innovation at hand, but they will embrace the innovation earlier than the average person.

Term
late majority (QI 105)
Definition

fourth category of adopters

can be seen as skeptical about a given innovation. They may be driven to adopt the change out of economic need, peer pressure, or policy, rather than personal interest.

may hold on to old way of doing things because it's been "good enough"

This group may not adopt the given change until the process they use disappears or truly offers no advantage.

Term
laggards (QI 105)
Definition

Last group to adopt change

They’ll adopt the change only because they have no other alternative.

The old way of doing things may literally need to be eliminated in order for laggards to adopt a new way.

Term

1. Apple is about to introduce a state-of-the-art phone/computer/printer/food processor combo. Nothing like it is on the market, and the media hype about the product is huge. The night before the product goes on sale, your neighbor camps out in front of the Apple store so she can be the first one to buy the new technology. 

What type of adopter is your neighbor for this new technology?


a) Innovator
 b) Early adopter
c) Early majority
 d) Late majority
 e) Laggard

Definition
B. Because she needs to be the first to use the technology, your neighbor is showing characteristics of an early adopter. If she were an innovator, she would have been a beta tester for the project and helped work out all the kinks.
Term
2. Unit X in a hospital is preparing to implement its electronic medical record. Bob, Susan, and Gretchen are all nurses on the unit. Bob has been a part of the implementation team and is excited about the new system. He read about it in a patient safety newsletter and encouraged the organization to consider implementing the system. He is well respected by others on the unit as someone who is knowledgeable about new technology and makes good decisions. 


Susan is resistant to implementing the new electronic medical record. She says it's complicated and confusing, and she much prefers the paper medical records. She’s heard about the advantages of the electronic medical record, but she claims she is more efficient when jotting things down on sticky notes and then copying this information into the paper medical record later.

Gretchen is undecided. She respects Bob and has agreed to participate in testing the new system. She knows it is the wave of the future and is pretty confident it will make her patient care more efficient. But she’s cautious — she still wants to do more research.

 

What type of adopters are Bob, Susan, and Gretchen for the implementation of the EMR

Definition

Bob is an early adopter because he is eager to try the new system, he is well respected among his peers, and he’s known for making smart decisions. He has done the research on the system, and he is pretty confident it will work.


Susan is a laggard because, even when told of the advantages of the new system, she clings to the old. She’s likely not to adopt the change until she has no other option.


  Gretchen has agreed to participate in the project, but she will not be one of the first. She is relying on Bob's good opinion and some research she has done.

Term
Lewin proposed that organizational change occurs in the following three stages: (QI 105)
Definition


1. Unfreezing; -loosening attachement to current practice and explain why change is necessary

2. Change or transition-where change actually occurs, may be a difficult time

3. Freezing (or re-freezing)-ensures people won't return to the old way of doing things,

Term

When adapting to new change, most people fall into which of the following two categories?

 a) Innovators and early majority
b) Early adopters and innovators
c) Early majority and early adopters d) Early majority and late majority
Definition
Correct Answer:d) Early majority and late majority
For any given change, the bulk of the population will fall into the early majority and late majority.
Term
2) Which of the following is a summary of Kurt Lewin’s model of change?

a) Introduction, testing, implementation
 b) Research, communication, measurement
 c) Unfreezing, changing, re-freezing
 d) Collaboration, integration, standardization

Definition
Correct Answer:c) Unfreezing, changing, re-freezing
Kurt Lewin wrote that successful change efforts involve preparing people for the change (“unfreezing”), helping them transition (“changing”), and ensuring that the new process becomes the norm (“re-freezing”).
Term
3) For people to accept change, you MUST address which of the following in change efforts?

a) Technology
 b) Funding
 c) Human behavior
 d) A, B
 e) B, C

Definition
Correct Answer:c) Human behavior

Although technology and funding may be necessary for some people to accept change, human behavior is present in any change effort and must be addressed for the change to be effective.

Term

Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient’s earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult.

4) In this scenario:

 a) Rose is right; Dave is just being difficult.
b) Dave is probably too busy and that is why he is throwing up roadblocks.
 c) Dave's behavior is normal; everyone has some challenges when adapting to new things.

Definition
Correct Answer:c) Dave's behavior is normal; everyone has some challenges when adapting to new things.
In this scenario Dave's behavior is perfectly normal. Everyone struggles with change to some extent.
Term


Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient’s earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult.

5) Using Everett Rogers’ theory of adoption of innovation, which category of adopter best describes Rose?

 a) Innovator
b) Early adopter
c) Early majority
 d) Late majority
e) Laggard

 f) Not enough information to tell

Definition
Correct Answer:a) Innovator
Rose is considered an innovator because she was involved and committed to the new process before it had even come to the hospital.
Term

Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient’s earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult.

6) Using Rogers’ theory of adoption of innovation, which category of adopter best describes Joan?

 a) Innovator
 b) Early adopter
 c) Early majority
 d) Late majority
e) Laggard
 f) Not enough information to tell

Definition
Correct Answer:b) Early adopter
Joan is an early adopter because she wants her unit to be the first to pilot test the program.
Term


Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient’s earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult.

7) Using Rogers’ theory of adoption of innovation, which category of adopter best describes Dave?

 a) Innovator
 b) Early adopter
 c) Early majority
 d) Late majority
 e) Laggard
f) Not enough information to tell

Definition
Correct Answer:e) Laggard

Dave is a laggard with respect to this particular change because he clings to the old way of doing things, and he likely will not change unless he has no other option.

Term


Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient’s earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult.

8) To help Dave adopt the new change, Rose should consider which of the following actions?

a) Call Dave's boss
 b) Provide Dave with literature, including statistics, on the benefits of patient-centered care
 c) Provide Dave with patient testimonials from the pilot test of the new process, showing how much patients value the bedside change-of-shift report
 d) A, B
e) B, C

Definition
Correct Answer:e) B, C
By providing Dave with literature and patient testimonials, Rose can help address some of his barriers to change.
Term
(QI 105) improving any complex system requires knowledge of the following four areas:

Definition
1. Systems thinking: What is the whole system that you’re trying to manage? How do the different parts of that system interact with and rely on one another?

2. Variation: What is the variation in results trying to tell us about the system?

3. Theory of knowledge: What are the predictions about the system’s performance? What are the theories that form the basis for these predictions?

4. Psychology: How do people in a system react to change, and what are the important interactions among people in the system? What motivates people to act as they do?
Term
Using Assessment Tools to Understand Team Dynamics
Definition

There are many assessment instruments that can help the members of a team better understand their individual strengths and preferences. For instance:

  • StrengthsFinder 2.0
  • Myers-Briggs Type Indicator
  • Strength Deployment Inventory
  • DiSC Profile
  • Riso-Hudson Enneagram Type Indicator (RHETI)

all offer a lens into understanding our diversity.

Term
(QI 102) extroverts v introverts
Definition

When introverts and extraverts are working together, it is not a bad idea to let the extraverts brainstorm out loud, but it’s important to build in a break to enable the introverts to process information so they can generate good questions and come back ready to make good decisions.


This difference has two aspects: how people maintain their energy and how they prefer to brainstorm and interpret information.

Term
(QI 105) sensing v intution
Definition
Intuitive individuals take in information and note patterns in the details that they discover.
Sensing individuals, on the other hand, are more oriented toward the concrete information they take in through their five senses.
want to have team members offer more information about ideas than necessary up front
Term
(QI 105) perspective thinkers v feelers
Definition

If you prefer to make decisions from a feeling perspective, you will make the decision with your heart and consider its impact on everyone involved

Thinkers make judgement on matter-of-fact data

Term
(QI 105) Judging v percieving
Definition

the way that we organize our world

People with a preference for judging tend to be very organized and methodical in their approach to their work and project management

Perceivers, on the other hand, are a little bit more flexible. They’ll still complete a task on time, but they may be completing it at the last minute or pulling an “all nighter.

Term
QI 105 Demming's Intrinsic motivators
Definition
joy or idealism
Term
(QI 105) Demmings extrinsic motivators
Definition

promotions or gold stars

He asserted that extrinsic motivators diminish joy in work, compromise people’s ability to cooperate for the common good, and reduce the inherent potential in virtually every sector of economic life.

If these become the core reason someone does something, once extrinsic motivators disappear, people may not want to do something anymore

Term
(QI 105) intrinsic v extrinsic motivation in healthcare
Definition
emphasizing intrinsic motivators — such as improved patient outcomes, increased satisfaction, and decreased mortality — is critical to gaining support for an improvement initiative for the "right" reasons. Providing extrinsic motivators — such as bonuses, gift cards, and gold stars — may improve compliance in one area, such as with a form or tool, but in the long term may impact or shift the focus away from improving care and saving lives.
Term
1) Personality and work style profile assessments help us understand:

 a) Diverse preferences of people
 b) Why people don’t like change
 c) What jobs to place people in
 d) Who is more prepared than another

Definition
Correct Answer:a) Diverse preferences of people

Personality and work style profile assessments help us understand how different people prefer to perceive the world and make decisions.

Term
2) Which of the following is an example of a personality or work style profile assessment?

 a) Myers-Briggs Type Indicator
 b) Strength Deployment Inventory
 c) DiSC Profile
 d) Riso-Hudson Enneagram Type Indicator (RHETI)
e) All of the above

Definition
Correct Answer:e) All of the above
The Myers-Briggs Type Indicator, the Strength Deployment Inventory, the DiSC Profile, and the Riso-Hudson Enneagram Type Indicator (RHETI) are all examples of personality or work style profile assessments.
Term
3) In designing a performance improvement team, it is helpful to

 a) Choose people who are unlikely to disagree with one another
 b) Have a mix of different types of people on the team
c) Have everyone on the team exhibit similar personality preferences
d) Identify the personalities present and work to everyone's strengths
e) A, C
 f) B, D

Definition
Correct Answer:f) B, D
A healthy mix of personality types can ensure that a team captures many perspectives on an issue. This can be valuable — particularly if team leaders appreciate these differences and design the work to accommodate diverse preferences.
Term
4) Alfie Kohn's theory is that extrinsic motivators are

 a) Helpful in ensuring consistent performance
 b) Helpful in ensuring all team members participate in a project
 c) Unhelpful because they can reduce people’s innate desire to do a task
 d) A, B

Definition
Correct Answer:c) Unhelpful because they can reduce people’s innate desire to do a task
Kohn felt that extrinsic motivators could have unintended negative consequences. He said that external rewards have a tendency to displace people’s innate desire to complete a task.
Term
5) W. Edwards Deming would say that, when you’re seeking to implement and spread improvements, it is most helpful to incorporate

a) Intrinsic motivators
 b) Extrinsic motivators
 c) Both intrinsic and extrinsic motivators
d) No motivators

Definition
Correct Answer:a) Intrinsic motivators
According to Deming, intrinsic motivators are critical to ensure the success of any improvement project.
Term

Your organization is implementing a fall risk assessment form to help identify patients at risk for falls. The team in charge of the initiative has designed the screening form to identify five critical pieces of information: patient medications, patient age, reasons for admission, patient mental state, and previous falls. To ensure that every nurse captures all five data points for every patient, the organization is offering a prize — a trip to Las Vegas — for the nurse who completes the most forms correctly in a three-month period.

6) The vacation to Las Vegas is an

a) Intrinsic motivator
b) Extrinsic motivator
c) Opportunity for further continuing education

Definition
Correct Answer:b) Extrinsic motivator
The trip to Las Vegas is an external reward – an extrinsic motivator.
Term

Your organization is implementing a fall risk assessment form to help identify patients at risk for falls. The team in charge of the initiative has designed the screening form to identify five critical pieces of information: patient medications, patient age, reasons for admission, patient mental state, and previous falls. To ensure that every nurse captures all five data points for every patient, the organization is offering a prize — a trip to Las Vegas — for the nurse who completes the most forms correctly in a three-month period.

7) The work of W. Edwards Deming and Alfie Kohn suggests that after the three-month period is over and the Las Vegas trip has been awarded, the following will likely happen:

a) Nurses will use the screening form more.
b) Nurses will use the screening form less.
c) There will be no change to the nurses’ use of the screening form.

Definition
Correct Answer:b) Nurses will use the screening form less.
The Las Vegas trip does not address the fundamental reason why the nurses should use the screening form. When this extrinsic motivator is taken away, they are therefore likely to return to their old habits.
Term


Your organization is implementing a fall risk assessment form to help identify patients at risk for falls. The team in charge of the initiative has designed the screening form to identify five critical pieces of information: patient medications, patient age, reasons for admission, patient mental state, and previous falls. To ensure that every nurse captures all five data points for every patient, the organization is offering a prize — a trip to Las Vegas — for the nurse who completes the most forms correctly in a three-month period.

8) According to the work of Deming and Kohn, a better motivator for using the checklist might be:
a) A trip to Hawaii
b) A bonus
c) Tying patient falls into performance reviews and compensation
d) Showing that using the form can reduce the likelihood of patient falls
 

 

Definition
Correct Answer:d) Showing that using the form can reduce the likelihood of patient falls
Showing that the form really works would tap into the nurses’ intrinsic motivation to give patients the best possible care. According to Deming and Kohn, this type of motivation is more likely to improve performance in the long term.
Term
(QI 105) process changes
Definition
changes in the way a task is performed — whether it’s the way you admit a patient, administer a medication, or just brush your teeth in the morning.
Term
(QI 105) culture change
Definition
more fundamental type of change, typically involving a shift in the perspective and values of a group. Culture change often involves a transformation to a new way of thinking that leads to new norms of behavior.
Term

Your organization is working to reduce the number of unplanned emergency department visits among patients with diabetes. To accomplish this goal, your team is trying to improve communication with these patients. Using the Model for Improvement, the team makes a plan to design a patient education form that staff will go over with patients with diabetes during their regular appointments. After finalizing the look of the form, your improvement team works with staff on one unit to carry out the first test.

What type of change does this represent?

a) culture change
 b) process change
 c) both culture and process change
 d) none of the above

Definition
B.  In the example, the form represents the process change your organization is testing to achieve better communication with patients with diabetes.
Term

Your organization is working to reduce the number of unplanned emergency department visits among patients with diabetes. To accomplish this goal, your team is trying to improve communication with these patients. Using the Model for Improvement, the team makes a plan to design a patient education form that staff will go over with patients with diabetes during their regular appointments. After finalizing the look of the form, your improvement team works with staff on one unit to carry out the first test.

In this example, how will you know when the culture has changed?


 a) When the form has been tested on all patients with diabetes
b) When fewer patients with diabetes make unplanned emergency department visits
 c) When staff members believe communication is a way of preventing unplanned emergency department visits
 d) When the form has been implemented across your organization

Definition
C.  Your organization will undergo a culture change when the staff members believe that communication — in this case, using the form — will lead to better outcomes for patients.
Term
(QI 105) Positive deviance
Definition
based on the idea that “solutions to community problems already exist in the community.”4 The idea is to identify who is performing the best and then identify the attributes of successful performance – rather than focusing on what not to do.
Term
(QI 105) Can culture change result in process improvement?
Definition

Culture  change won't always lead to a direct process improvement

ex-giving away awards for improved performance

Process change and culture change must work together to achieve improved performance. While one does not always accompany the other, both are critical to achieve success.

Term
1) In improvement work, a process change

a) Is a change to the way a task is performed
b) Results in a change in the attitude of a team
 c) Is a change in the outcome of a given procedure
 d) Is a transformational change in which an organizational shift occurs

Definition
Correct Answer:a) Is a change to the way a task is performed
A process change is a change to the way a task is performed.
Term
2) In improvement work, a culture change is

 a) A change to the way a task is performed
b) A change that results in a change in outcome
 c) A change that results in a change in behavior
 d) A transformational change in which an organizational shift occurs

Definition
Correct Answer:d) A transformational change in which an organizational shift occurs
A culture change is typically involves a shift in the perspective and values of a group. Culture change often involves a transformation to a new way of thinking that leads to new norms of behavior.
Term
3) Within a performance improvement project

a) Process change always results in culture change
b) Culture change always results in process change
c) Process change can result in culture change but doesn't always
d) Culture change does not result in process change
 e) A, B
 f) C, D

Definition
Correct Answer:f) C, D
Process change and culture change do not always go hand in hand. Process change can yield culture change, but it doesn’t always. Culture change in and of itself cannot yield a change in process.
Term
4) The theory of positive deviance focuses on

a) Identifying the attributes of negative performance
 b) Identifying the attributes of successful performance
c) Identifying opportunities for improvement
 d) Expressing appreciation for hard work

Definition
Correct Answer:b) Identifying the attributes of successful performance
The theory of positive deviance — used by Dr. Jon Lloyd in improving hand hygiene in Pittsburgh, Pennsylvania — focuses on identifying attributes of successful performance. This positive approach to improving performance can yield culture change.
Term

Your improvement team is working on a planned nap program in which you offer the opportunity for staff members working a shift of more than 12 hours to take a planned nap. You have identified a designated room for the nap, and you have communicated with the staff about the importance of rest in ensuring patient safety. Unfortunately, data reveal that workers are not taking advantage of the program. Your team is frustrated, because this program worked at another hospital in a neighboring town.

5) In the example, which of the following is the process change?

 a) The planned nap
 b) The data that show whether staff members are taking a planned nap
c) The belief that a planned nap can support patient safety

Definition
Correct Answer:a) The planned nap
The process change is the planned nap. It is the method by which the organization hopes to decrease worker fatigue.
Term

Your improvement team is working on a planned nap program in which you offer the opportunity for staff members working a shift of more than 12 hours to take a planned nap. You have identified a designated room for the nap, and you have communicated with the staff about the importance of rest in ensuring patient safety. Unfortunately, data reveal that workers are not taking advantage of the program. Your team is frustrated, because this program worked at another hospital in a neighboring town.

6) Which of the following represents the culture change?

 a) The planned nap
 b) The designated room for the nap
 c) The staff education about the nap
 d) The belief that a planned nap can support patient safety

Definition
Correct Answer:d) The belief that a planned nap can support patient safety
The culture change is the fundamental belief that a planned nap can support patient safety and that napping is okay during a shift.
Term

Your improvement team is working on a planned nap program in which you offer the opportunity for staff members working a shift of more than 12 hours to take a planned nap. You have identified a designated room for the nap, and you have communicated with the staff about the importance of rest in ensuring patient safety. Unfortunately, data reveal that workers are not taking advantage of the program. Your team is frustrated, because this program worked at another hospital in a neighboring town.

7) What’s the likeliest reason the program failed?

 a) The nap wasn't long enough.
 b) The room for the nap was too noisy.
 c) The culture of the organization did not support napping during a shift.
 d) Workers weren’t as tired as managers thought they were.

Definition
Correct Answer:c) The culture of the organization did not support napping during a shift.

The program probably failed because the culture of the organization did not support napping on the job as a way to decrease worker fatigue and boost patient safety

Term

Your improvement team is working on a planned nap program in which you offer the opportunity for staff members working a shift of more than 12 hours to take a planned nap. You have identified a designated room for the nap, and you have communicated with the staff about the importance of rest in ensuring patient safety. Unfortunately, data reveal that workers are not taking advantage of the program. Your team is frustrated, because this program worked at another hospital in a neighboring town.

8) How could the organization use culture change to support the process change?

 a) Ask staff to offer opinions on how to reduce worker fatigue.
b) Develop an aim statement reinforcing the reasons for the planned nap.
c) Require the planned nap and have a zero tolerance policy for missing it.
 d) A, B
 e) B, C

Definition
Correct Answer:d) A, B

By asking staff opinions about the issue of worker fatigue, the organization can highlight the importance of the issue and gain buy-in from staff. In addition, the process of identifying and committing to an aim can also help bring about a culture change

Term
Now imagine your organization has implemented a team training program to enhance communication between nurses and physicians. Six months after the training program occurred, your organization experiences a wrong-site surgery. Organization leaders are baffled at how such an error could occur. They discover there was little communication between the surgeon and the circulating nurse, both of whom had attended the team training.

 

9) What is the likeliest reason the team training did not prevent the wrong-site surgery?

a) There was no process change that supported the cultural change.
b) The surgeon was being difficult and should be punished.
 c) The nurse was being difficult and should be punished.
 d) The teamwork training was not sufficient in length or scope.

Definition
Correct Answer:a) There was no process change that supported the cultural change.

Although the teamwork training is a valid approach to improving communication, without a specific process change, improvement may stall.

Term

Now imagine your organization has implemented a team training program to enhance communication between nurses and physicians. Six months after the training program occurred, your organization experiences a wrong-site surgery. Organization leaders are baffled at how such an error could occur. They discover there was little communication between the surgeon and the circulating nurse, both of whom had attended the team training.

10) To reduce the likelihood of another wrong-site surgery, the organization may want to

a) Provide another, more comprehensive teamwork training course
b) Introduce a presurgical briefing in which all members of the surgical team discuss their concerns
 c) Gather data on wrong-site surgeries within the organization and share the results with staff
 d) A, B
 e) A, B, C

Definition
Correct Answer:e) A, B, C
The teamwork training course and the sharing of data are valid approaches to culture change. They need to be used in conjunction with a process change, such as implementing a presurgical briefing.
Term

Now imagine your organization has implemented a team training program to enhance communication between nurses and physicians. Six months after the training program occurred, your organization experiences a wrong-site surgery. Organization leaders are baffled at how such an error could occur. They discover there was little communication between the surgeon and the circulating nurse, both of whom had attended the team training.

11) If your organization chose to introduce a presurgical briefing, that would represent

 a) A process change
b) A culture change
 c) Neither a process nor culture change
d) Both a process and culture change

Definition
Correct Answer:a) A process change

The presurgical briefing would be considered a process change, because it is a change to the way that staff members actually do their work prior to performing surgery.

Term

(QI 106)

1) Which of the following can you select as an objective for your PDSA cycle on the PDSA template?

a) Test a change.
 b) Implement a change.
 c) Spread a change.
d) Any of the above.

Definition
Correct Answer:d) Any of the above.
The best response is “any of the above.” You’ll be asked to select among these three objectives when you begin to fill out the PDSA template.
Term

Your organization wants to reduce the number of patient falls occurring in particular units. A multidisciplinary group develops a fall reduction questionnaire, the purpose of which is to identify patients at risk for falls. The team believes that a provider should be able to use the questionnaire within the assessment process without adding time to the overall assessment; further, the team believes that patients will understand the questions and feel comfortable answering them. As they embark on a PDSA cycle to test the questionnaire, the team is looking to you for help.

3) What question(s) is the team trying to answer in the test?

 a) Is the questionnaire adequate in assessing fall risk?
 b) Can a provider incorporate the questionnaire into the patient assessment process without increasing the time involved in the process?
c) Will patients understand and be comfortable answering the questions?
d) Both B and C

Definition
Correct Answer:d) Both B and C
The team is trying to determine whether a provider can use the questionnaire during the assessment process and whether patients are able to answer the questions within the questionnaire.
Term

Your organization wants to reduce the number of patient falls occurring in particular units. A multidisciplinary group develops a fall reduction questionnaire, the purpose of which is to identify patients at risk for falls. The team believes that a provider should be able to use the questionnaire within the assessment process without adding time to the overall assessment; further, the team believes that patients will understand the questions and feel comfortable answering them. As they embark on a PDSA cycle to test the questionnaire, the team is looking to you for help.
4) What does the team predict?

a) Providers can use the questionnaire but it will add time to the interview.
 b) Patients will understand the questions about fall risk and answer them.
c) Patients could have trouble understanding the questions about fall risk and may have trouble answering them.
 d) Both A and C

Definition
Correct Answer:b) Patients will understand the questions about fall risk and answer them.

Per the narrative, the team believes that the questionnaire will not add time to the assessment process; further, the team believes patients will understand the questions and be able to answer them

Term

Your organization wants to reduce the number of patient falls occurring in particular units. A multidisciplinary group develops a fall reduction questionnaire, the purpose of which is to identify patients at risk for falls. The team believes that a provider should be able to use the questionnaire within the assessment process without adding time to the overall assessment; further, the team believes that patients will understand the questions and feel comfortable answering them. As they embark on a PDSA cycle to test the questionnaire, the team is looking to you for help.

5) What are some reasons you tell the team that they should use a PDSA template?

a) It acts as a stimulus for learning.
 b) It will help keep them aligned around a common purpose.
c) It will help them communicate about changes to their audience.
d) All of the above

Definition
Correct Answer:d) All of the above

The best answer is all of the above. A PDSA template can act as a stimulus for learning, help keep performance improvement teams aligned around a common purpose, and communicate about changes to the audience affected by those changes

Term
scale and scaling up (QI 106)
Definition

” refers to the timespan or number of events included in a test cycle — such as a specific number of patient encounters


When you scale up your test of change, you’re thinking about more (more patients, more time, more events).

Term
scope and expanding scope (QI 106)
Definition

refers to the variety of conditions under which your tests occur — such as different combinations of patient, staff, and environmental conditions.

When you expand the scope of your test, you’re thinking about difference (different patients, different times, different staff).

Term

deciding the size of your first test: (QI

106)

Definition

How small your first test cycle should be and the size of each subsequent test cycle should be based upon your degree of belief that the change will lead to improvement, and the consequences if the change does not lead to improvement.

How likely is this change to lead to improvement?


What are the consequences if the change does not lead to improvement?

1:1:1 a good rule of thumb for the first test (1 provider, 1 patient, 1 encounter)

Term
5x rule (QI 106)
Definition
when scaling up the number of encounters or events, multiply the number of encounters or events used in the last cycle by five.
Term
broadening scope of test with variety in three ways (QI 106)
Definition

change charac of patients

change charac of staff

change time PDSA is performed

Term
A preliminary test with staff in other PDSA cycles accomplishes all of the following
Definition
  • Allows you to catch issues before involving patients
  • Confirms the “face validity” of the test (i.e., that staff generally feel your change is likely to result in improvement)
  • Provides a method for training staff members in the use of the new procedure before they’re asked to use it in their regular work
Term
Observers in the Do phase should take note of: (QI 106)
Definition
  • What happens as the tester tries to accomplish the task(s)?
  • What seems hard or awkward?
  • What steps get skipped or altered?

The best observers are physically present, mentally attentive, and non-judgmental. This means they’re ready to note any information or events observed during the test, whether or not they align with the original plan.

Term
3 reasons a PDSA cycle may have failed: (QI 106)
Definition
1. The test was not conducted as planned. The change may still be a good one, but there would need to be a better support system in place to properly execute it.

2. There was a problem with the data collection. Without sufficient data, you can’t be sure whether the change led to improvement or not.

3. The test was conducted as planned and data collection went smoothly; however, the data doesn’t show improvement. In this case, the change does not appear to be an improvement; it’s probably time to go back to the drawing board.
Term
1) Imagine you’re a member of a newly formed improvement team that has taken up the challenge to reduce health care–associated infections at your hospital. You have an idea for a change to the room cleaning process that you want to test, but you’re slightly nervous because improper cleaning and disinfection can carry a high risk for patients with compromised immune systems. You haven’t run any PDSA cycles yet. Which of the following would be the best next step?

 a) Have one housekeeper use the process with one room cleaning.
 b) Have all housekeepers use the process for a week.
c) Have one housekeeper use the process on five room cleanings.
d) Confirm the “face validity” of the new cleaning process by demonstrating it with a couple of housekeeping staff members and a supervisor.

Definition
Correct Answer:d) Confirm the “face validity” of the new cleaning process by demonstrating it with a couple of housekeeping staff members and a supervisor.
Based on your concern about patient safety, you’d likely first want to confirm the “face validity” of the new cleaning process by demonstrating it with a couple of housekeeping staff members and a supervisor. When testing changes that involve patients, it can be helpful to conduct an initial test using staff only. A simulation or practice session before going live is often a good way to uncover issues with high risk.
Term
2) When planning a sequence of PDSA cycles for a change that involves patients, which of the following is a true statement?

a) Patient characteristics in each PDSA cycle should be as uniform as possible to allow valid comparisons.
b) The number of patients in each cycle should stay fixed, to allow valid comparisons.
c) We would expect the number of patients involved to grow rapidly from early cycles to later cycles.
 d) None of the above

Definition
Correct Answer:c) We would expect the number of patients involved to grow rapidly from early cycles to later cycles.
As improvement work progresses and the number of cycles increases, we would expect the scope and scale of the tests to increase, meaning both a rapidly growing number of patients involved in the tests as well as increasing diversity in the test population.
Term
3) When increasing the number of patients or events from one PDSA cycle to the next, it is usually helpful to multiply by what number?

a) 2
 b) 5
c) 10
 d) 20

Definition
Correct Answer:b) 5
The 5X Rule recommends an increase by a factor of five whenever you finish one successful test and move on to the next.
Term

A hospital is trying to implement a new patient assessment form. They want to first test the usability and efficacy of the form.

4) When determining sample size for the first test, it is most important to:

 a) Look at similar research to see what sample size other organizations use.
 b) Weigh the potential consequences of a test that does not lead to improvement against the belief in success.
c) Use a random sampling technique, so results can be extrapolated.
 d) Ask all staff members what sample size they think should be used.

Definition
Correct Answer:b) Weigh the potential consequences of a test that does not lead to improvement against the belief in success.
With improvement work, you should weigh the potential consequences of a test that does not lead to improvement against the belief in success. How small your first PDSA cycle should be rests on your degree of belief and the stakes involved.
Term

A hospital is trying to implement a new patient assessment form. They want to first test the usability and efficacy of the form.

5) Let’s say the hospital has an English-speaking nurse (Nurse Moss) assess one English-speaking patient with the new form. It is a successful test and the improvement team wants to increase the scale of the next test. What would they do?

a) Have a Spanish-speaking nurse give the assessment to one of her Spanish-speaking patients.
 b) Have a different English-speaking nurse give the assessment to one of her English-speaking patients.
c) Increase the number of patients Nurse Moss assesses by a factor of 5.
d) Increase the number of patients Nurse Moss assesses by a factor of 10.

Definition
Correct Answer:c) Increase the number of patients Nurse Moss assesses by a factor of 5.
The best answer is to increase the number of patients Nurse Moss assesses by a factor of 5. Scale is the number of interactions within the test — in this case, the number of patients receiving the assessment, and the 5X Rules recommends an increase by a factor of five in each subsequent test. Changing the conditions of the test — such as the language involved or the staff involved — would be a change in scope, rather than scale.
Term
1) In a run chart, units of time (or a numerical sequence in cases where data doesn’t correspond to units of time) are typically placed on what axis?

a) X axis
 b) Y axis
c) Either axis
 d) Neither axis; run charts do not depict time

Definition
Correct Answer:a) X axis
The X axis is usually the time — minutes, hours, days, weeks, months, etc. — or a numerical sequence in cases where data doesn’t correspond to units of time. The measured value is usually represented on the Y axis of a run chart.
Term
2) Within the following data set, what is the median? [5, 2, 18, 2, 6, 7, 9]
 a) 18

 b) 7
 c) 6
 d) 2

Definition
Correct Answer:c) 6

You calculate the median by finding the midpoint of a set of numbers. In this case, the median is 6 because there are three values before 6 and three values after 6 (2, 2, 5, 6, 7, 9, 18), making it the midpoint

Term
3) When formatting the run chart, it’s generally best for labels to appear as:

 a) Between 1 and 5
 b) Between 2 and 10
c) Between 5 and 10
d) Between 5 and 20

Definition
Correct Answer:c) Between 5 and 10
For readability, it is helpful when labels appear in multiples of 1, 2, and 5.
Term
4) What aspect of the run chart helps you compare data before and after a PDSA cycle?

a) The average of the key measure values
b) The baseline median
c) The median for the entire set of key measure values
d) A and C

Definition
Correct Answer:b) The baseline median
A baseline helps you understand your performance before you started your tests of change, to give you a basis for comparison. The baseline should be the median of only measurements prior to any specific tests of change.
Term
5) When you are graphing a proportion or a percent, what should you look at to help you understand the bigger picture?

a) The numerator of the measured value
b) The denominator of the measured value
 c) The median of the numerator
d) The median of the denominator

Definition
Correct Answer:b) The denominator of the measured value
By tracking the denominator of the measured value, you can confirm that your improvement effort is really showing signs of success, and there are not other factors at work.
Term
Here are the four rules that you can use to identify non-random patterns and the significance of these rules:
Definition
  • Rule 1: A shift in the process is indicated by six or more consecutive data points either all above or all below the median. 
  • Rule 2: A trend is indicated by five or more consecutive data points, all increasing or all decreasing. 
  • Rule 3: Too many or too few runs indicate a non-random pattern. (A run consists of one or more consecutive data points on the same side of the median, excluding data points that fall on the median.) 
  • Rule 4: An astronomical data point signals a non-random pattern. (This is not just the highest or lowest data point, but one that is so dramatically outside the others that anyone looking at the chart would think it was unusual.)
  • When it comes to gaining information about whether the changes you’re testing are leading to improvements in processes, generally you’ll focus on Rules 1 and 2. If you find that either or both of these rules apply, you can look into whether the non-random patterns you’ve identified are associated with your interventions (or if other changes may be driving what you see).

    Rules 3 and 4 are more useful for coming up with ideas for tests of change. For instance, if you observed a significant improvement for just one month (i.e., an astronomical data point), it probably wasn’t tied to a deliberate process change, but perhaps you could identify an unintended variation that you could intentionally replicate.
Term
what two types of non-random patterns are most important to look for in our analysis? (QI 106)
Definition
generally you want be looking for shifts and trends, or Rules 1 and 2. As a reminder, a shift in the process is indicated by six or more consecutive data points, either all above or all below the median; a trend is indicated by five or more consecutive data points, all increasing or all decreasing.
Term
1) Which of the following is a rule for determining non-random patterns?

 a) A run of six points or more
b) An astronomical point
 c) A trend of three points or fewer
 d) A and B

Definition
Correct Answer:d) A and B
The best answer is A and B. A run of six points or more and an astronomical point both indicate non-random patterns. A trend of three points or fewer does not. In order to indicate a non-random pattern, a trend must consist of five data points or more.
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