Quality Improvement & Program Management Flashcards
7 cards from real ASC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Quality Improvement & Program Management flashcards as text
In developing a stroke performance improvement plan, a coordinator identifies that 70% of tPA delays occur during CT imaging. The BEST next step is to:
Answer: Form a multidisciplinary team to redesign the CT workflow specifically
A multidisciplinary team redesigning the specific workflow bottleneck (CT process) is the evidence-based QI approach before investing in equipment or staffing.
The stroke coordinator is preparing the annual program report. Which data element is REQUIRED to demonstrate compliance with Joint Commission TSC standards?
Answer: Volume of endovascular thrombectomy procedures performed
Thrombectomy Stroke Center (TSC) and CSC standards require documentation of endovascular procedure volumes to demonstrate capability and experience.
Which approach BEST describes 'failure mode and effects analysis' (FMEA) in stroke program management?
Answer: Proactively identifying potential points of failure in a process before they cause harm
FMEA is a prospective tool that identifies potential failure modes in a process before harm occurs, allowing preventive action.
A stroke coordinator notices a downward trend in dysphagia screening compliance over 6 months. Which action should be prioritized to sustain the improvement?
Answer: Integrate dysphagia screening into the electronic order set as a mandatory field
Embedding screening into mandatory electronic order sets creates a system-level hardwire that sustains compliance independent of individual recall.
When analyzing stroke outcomes by race and ethnicity, a coordinator finds Black patients have significantly longer DTN times. This finding indicates the need for:
Answer: A targeted equity analysis and protocol redesign to eliminate disparate delays
Health equity requires targeted analysis and process redesign to identify and eliminate systemic disparities in care delivery.
Which tool is MOST appropriate for mapping the current state of a stroke patient's journey from ED door to tPA administration to identify inefficiencies?
Answer: Value stream mapping
Value stream mapping visually depicts each step and time interval in a process, making inefficiencies and delays immediately visible.
A hospital is applying for Primary Stroke Center certification for the first time. Which preparatory step is MOST important before submitting the application?
Answer: Conducting an internal gap analysis against TJC PSC standards
An internal gap analysis against TJC standards identifies deficiencies that must be addressed before the formal certification survey.