Quality Improvement in Rad Onc Part 1

what is the definition of quality improvement in healthcare

an approach to the continuous study and improvement of the processes of providing health care services to meet needs of pts and others

who made the 14 principles of management

Dr. W.E Deming

what did dr w.e deming do in 1950 for japan

he transformed industry by improving design, product quality, testing, and sales

what did Deming propose was the major factor influencing customer purchase

quality rather than price

what is the first deming principles

delineation of the mission and goals

what is the 2nd deming principles

always strive for improvement

what is the 3rd deming principles

improve the process

what is the 4th deming principles

plan for the future by analyzing long term costs

what is the 5th deming principles

allow the employee to contribute to improvement

what is the 6th deming principles

encourage and support employees through education

what is the 7th deming principles

ensure qualified leaders`

what is the 8th deming principles

eliminate fear by encouraging employees to offer suggestions

what is the 9th deming principles

eliminate staffing barriers

what is the 10th deming principles

require management to keep employees informed

what is the 11th deming principles

emphasize quality first rather than quantity

what is the 12th deming principles

promote and encourage teamwork

what is the 13th deming principles

encourage and support employees educational and self improvement

what is the 14th deming principles

support and train all employees in transformation process

what are two big challenges facing health care

cost containment and quality concerns

what is the definition of quality

absence of flaws, a measure of excellence

what does CQI mean

continuous quality improvement

what has CQI demonstrated

decrease in cost, increase in customer satisfaction, improved quality throughout the organization

what does the joint commission focus on

facility performance

what is the focus of the joint commission

doing the right thing and doing the right thing well

what are terms that has replaced quality assurance

quality improvement or CQI

why has words like quality improvement/CQI replaced quality assurance

because the focus now is on ongoing improvement

what are some join commission national patient safety goals

2 ways to identify pts, label medicines that are not labeled, mark place on pts body where surgery is to be done

what are some quality efforts that have a more emphasis on today

administrative, clinical, physical, technical

what does NRC stand for

nuclear regulatory commission

what is the NRC

ensures adequate protection of the public health and safety; radioisotopes

what does EPA stand for

environmental protection agency

what is the EPA

regulates disposal, storage, and handling of nuclear waste material

what does DOT stand for

department of transportation

what is the DOT

monitors the transportation of hazardous material such as radioactive agents

how many states have entered into agreement with NRC to follow their guidelines

37

what kind of state is alabama

agreement state

what is an agreement state

we use our own state employees but we use the NRC guidelines

what does the PCR stand for

american college of radiology

what is the ACR

huge organization with focus on high quality patient care

what does AAPM stand for

american association of physicists in medicine

who are the AAPM

medical physics organizations which has produced task groups

what outlines a comprehensive quality assurance program for xrt treatment planning for the AAPM

TG53

how is quality improvement defined

a broad based program to ensure excellence through data collection and evaluation

what are examples of QI

patient satisfaction, side effects of tx, staff qualifications and education

what does QI refer to the assessment and activities related to

human factors

how is quality control defined

refers to activities related to technical factors and equipment

what are examples of quality control

laser alignment, beam flatness, ODI accuracy

what are the two concepts fit best for all aspects of xrt process

CQI and TQM

what does TQM stand for

total quality management

what are 4 goals of CQI/TQM is to continually exceed standards

• focuses on the organization as a whole

• focuses on not only collecting data, but analyzing and responding to data

• driven by customer satisfaction

• focuses on systems and processes rather than on individuals

who is responsible for establishing/approving a quality improvement program and appointing team

medical director

what are task of the QI commitee

develops and monitors the program, collects and evaluates the data, determines areas for improvements, etc

what is another name for the 80/20 rule

pareto rule

what does the 80/20 rule state

that 80% of the problems are the result of 20% of the causes (80% of the problems can be eliminated by resolving 20% of the causes)

what is a flowchart

pictorial representation of a process

what does a rectangle represent in flowcharts

an activity

what does a circle represent in flowcharts

signifies a beginning or end of a process

what does a diamond represent in flowcharts

signifies a decision

what is a venn diagram

circles that join to show a relationship between things

what is a histogram

bar graphs that shows frequency of events

what is a pareto chart

variation of a histogram in which the x-axis depicts the problems and the y-axis depicts the frequency

what is a fishbone diagram

demonstrate cause and effect of different conditions

what is another name of the fishbone diagram

cause and effect diagram

what is the head of a fishbone diagram

error

what is the bone of the fishbone diagram

factors that could lead to the error

what is a scatter plot

points are plotted to determine the presence or absence of a correlation bt 2 conditions

what does major components of the QI plan focus on

quality control

what is a main criticism that the joint commission has with QI plans upon review

the information collected but little is doe with the information

what does the TJC and external customers now require them to submit

QI data that has been analyzed

what is required of all healthcare organization that receive government reimbursements

compliance programs

what is the purpose of a compliance plan

educate employees about documentation, billing, and ethical standards in order to prevent unattended fraud

what does the compliance program also prepare the organization for a potential audit by

office of inspector general

what does OIG stand for

office of inspector general

what were 3 causes of overpayment of medicare in 1998

improper biling, upcoding, discrepancies of documentation

what areas has OIF specifically targeted because of their big-ticket charges or very high volumes

radiology, cardiology, radiation oncology, laboratory

what does CPT stand for

current procedural terminology

what developed the CPT codes

AMA

what are CPTs based on

procedure/service performed

what are the group of levels of CPT codes

simple, intermediate, complex

what does ICD stand for

international classification of disease

what is an ICD code

a diagnosis code

look at 7 elements of a compliance plan

what are 5 things the OID audits are looking for

duplicate billing, false cost report, upcoding, ICD code errors, patient dumping

why are therapists involved in the processing charges

because they are at the point of delivery

what is a super bill

an itemized report of everything that was billed to an insurance company along with the dates of services

what is the charge master

list of codes and charges for every procedure done by the department

what should be done before charges are submitted to insurance company

verify accuracy of them before

what is the cycle of cqi has

plan, do, study, act