1) Who We Are (Office of Quality & Safety)
Q: What is Quality Management?
A: We track numbers like infection rates and no-shows to see if care is getting better or worse.
Q: What is a CAUTI (catheter-associated urinary tract infection)?
A: This infection can happen when a urinary (Foley) catheter stays in too long.
Q: What is a KPI (key performance indicator)?
A: This three-letter term means “a number we track,” like no-show rate.
Q: What is CMS (Centers for Medicare & Medicaid Services)?
A: The federal agency that pays Medicare/Medicaid and sets hospital Conditions of Participation.
Q: What is the gap (problem statement)?
A: First step when performance drops below target: look at the data and find this.
Q: What is Performance Improvement?
A: We help frontline teams test small changes and see what works before spreading it.
Q: What are pressure injuries (HAPI)?
A: Bed-bound patients can develop these skin injuries if we don’t offload pressure.
Q: What is PDSA
A: Plan, Do, Study, Act—drives small tests of change.
The approach most commonly used for rapid cycle improvement in health care is the plan-do-study-act method in which 4 repetitive steps are carried out over the course of small cycles.
I. PLAN State objectives Make predictions Develop plan to carry out test cycle
II. DO Carry out the test, document problems and unexpected observations Begin analysis of the data
III. STUDY Summarize what was learned
IV. ACT Determine what changes are to be made
Q: Who is The Joint Commission?
A: The independent accreditor that surveys hospitals for safety and quality standards.
Q: Who are frontline staff/stakeholders?
A: We involve them because they know the workflow best.
Q: What is Regulatory Affairs?
A: We make sure the hospital follows CMS and Joint Commission rules and is ready for surveys.
Q: What is a safety culture (or just culture)?
Environment where personnel are safe to report errors. Assess risks in order to identify ways of overcoming them. Blaming or punishing is not an option in a Just Culture.
Q: What is HCAHPS?
A: This survey asks patients about their hospital experience and is publicly reported.
Q: What is the CMS Overall Hospital Quality Star Rating?
A: These CMS stars (1–5) summarize multiple domains like mortality and safety.
Q: What is improvement (a positive effect)?
A: A simple “before vs after” measure tells us if a change produced this.
Q: What is performance monitoring?
A: When a unit meets its targets, it stays here rather than needing advisement.
Q: What are green, yellow, and red?
A: Daily huddles report these three colors to show staffing status.
Q: What is SIR (standardized infection ratio)?
A: This risk-adjusted infection statistic compares observed vs. expected events.
Q: What is QAPI (Quality Assessment & Performance Improvement)?
A: This required hospital program (per CMS) combines measurement and improvement.
Q: What is sustain and spread (standardize)?
A: After a change works and is stable, we do this to keep gains over time.