Quality Improvement Metrics Flashcards
7 cards from real HAC 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 Metrics flashcards as text
A quality team calculates a standardized mortality ratio (SMR) of 0.82 for their hospital. How should this be interpreted?
Answer: 18% fewer deaths than expected
An SMR below 1.0 indicates better-than-expected performance; 0.82 means the hospital experienced 18% fewer deaths than risk-adjusted models predicted.
Which quality improvement methodology focuses on eliminating non-value-added steps (waste) in healthcare processes?
Answer: Lean
Lean methodology, derived from the Toyota Production System, targets the elimination of eight types of waste to streamline care delivery and improve efficiency.
A run chart shows 8 consecutive data points all above the median line. What does this signal?
Answer: A non-random signal of shift in the process
Eight or more consecutive points on the same side of the median is a run chart rule that indicates a non-random shift requiring investigation.
Which organization accredits U.S. hospitals and requires demonstration of continuous quality improvement as a condition of accreditation?
Answer: The Joint Commission
The Joint Commission (TJC) accredits healthcare organizations and mandates ongoing quality improvement activities through its accreditation standards.
In risk-adjusted quality measurement, what is the purpose of adjusting for case mix?
Answer: To ensure fair comparison of outcomes across providers with different patient populations
Risk adjustment accounts for differences in patient severity and comorbidities so that outcome comparisons between providers reflect care quality rather than patient population differences.
A hospital reports its ED door-to-balloon time for STEMI patients has a mean of 68 minutes with a standard deviation of 12 minutes. What percentage of patients are likely treated within the 90-minute benchmark (approximately)?
Answer: 84%
90 minutes is approximately 1.83 standard deviations above the mean (90-68)/12 ≈ 1.83, placing approximately 84% of patients below that threshold.
Which of the following is NOT one of the Institute for Healthcare Improvement's (IHI) Triple Aim components?
Answer: Eliminating all adverse events
The IHI Triple Aim comprises improving patient experience, improving population health, and reducing per capita costs — eliminating all adverse events is not one of the three aims.