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

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.

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

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.

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.

 a) 2
b) 5
c) 10
d) 20

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

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

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.

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

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

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

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.

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.

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.

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

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.

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

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.

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.

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

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.

1. leadership

2. setup for spread

3.better ideas

4.social system

5.communication

6. knowledge management

7.measurement and feedback

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.

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.

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

• Describe the better ideas.
• Develop the case for better ideas.

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

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.

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

• Capture and transfer spread knowledge.

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.

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

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.

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.

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.

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.

) 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) 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

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

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

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

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.

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

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

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

 what barrier to change does this suggest?

“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)

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.

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?

stability that comes with routine

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

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

What barrier to implementation is this?

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.

innovation spreads in an S curve

• Innovators
• Early adopters
• Early majority
• Late majority
• Laggards

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

first to try something out

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.

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.

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.

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.

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

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

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.

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

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

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

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

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

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.

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.

 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.

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.

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

 f) Not enough information to tell

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.

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

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.

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

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.

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.

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

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.

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.

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

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.

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

 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

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

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

 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

 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

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

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.

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

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.

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.

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.

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

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

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.

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

 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

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

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

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.

 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

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.

 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

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.

 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.

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

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.

 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

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

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.

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

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.

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

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.

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

(QI 106)

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

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.

 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

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

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

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.

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

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

” 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).

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).

deciding the size of your first test: (QI

106)

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)

change charac of patients

change charac of staff

change time PDSA is performed

• 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

• 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.

 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.

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

a) 2
 b) 5
c) 10
 d) 20

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

 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.

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

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.

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

 b) 7
 c) 6
 d) 2

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

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

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

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

• 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.

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