Regulatory Agencies (TJC, CMS)
What does TJC stand for?
What does AHRQ stand for?
Agency for Healthcare Research and Quality
What does QI stand for?
Quality Improvement
How can nurses contribute to quality improvement?
By reporting errors, following safety protocols, and participating in QI initiatives.
What is benchmarking?
Comparing a hospital’s performance to national standards or top-performing institutions.
Centers for Medicare & Medicaid Services (CMS)
Which organization promotes the Plan-Do-Study-Act (PDSA)?
Instiute for Healthcare Improvement (IHI)
What is the first step of the PDSA cycle?
Plan (identify a problem and propose a solution).
What is the most common cause of medication errors?
Human errors such as misreading labels, distraction, or poor communication.
What’s an example of a "nursing-sensitive indicator"?
Patient falls, pressure ulcers, or nurse staffing levels.
What happens if a hospital fails TJC accreditation?
They risk losing accreditation, federal funding, and insurance reimbursements.
How does IHI help hospitals improve patient safety?
Provides research, training, and QI strategies such as PDSA and patient safety campaigns
How do we measure improvement in a QI project?
Using performance data, benchmarking, and patient outcome metrics.
How do nurses help prevent patient falls?
By conducting fall risk assessments, using bed alarms, and assisting high-risk patients.
What hospital metric is used to track patient satisfaction?
CAHPS (Consumer Assessment of Healthcare Providers and Systems) patient survey.
Name one consequence of not meeting OSHA workplace safety standards
Fines, penalities, and potential shutdown of unsafe work areas.
What is the role of NQF in hospital benchmarking?
National Quality Forum (NQF) establishes performance measures to help hospitals compare quality outcomes.
Give an example of a small-scale test in the "Do" phase of PDSA.
Testing a new medication administration checklist on one hospital unit before full implementation.
Why is patient-centered care important for quality health care?
It improves patient satisfaction, safety, and adherence to treatment plans.
How do hospitals compare their quality measures to national standards?
Using standardized performance metrics from TJC, CMS, and NQF.
Explain how CMS penalizes hospitals for high readmission rates
CMS reduces Medicare reimbursements for hospitals with high readmission rates within 30 days of discharge
By applying evidence-based guidelines, safety toolkits, and quality improvement recommendations.
What’s the difference between reactive and proactive quality improvement?
Reactive QI responds to existing problems, while proactive QI aims to prevent future issues before they occur.
How can a nurse advocate for a hospital-wide quality improvement change?
By collecting data on patient safety issues, presenting findings to leadership, and suggesting QI strategies.
Name one way hospitals use benchmarking to lower infection rates.
Comparing their infection control policies to best-performing hospitals and adopting proven strategies.