d with your academic health center. As a member of the student board, you are constantly looking for ways to improve the clinic. One common complaint is that it takes too long to check patients in once they arrive, and you decide to tackle this problem. Which of the following might be a process measure for this effort? Your Answer:a) Average number of minutes between patient arrival at the clinic and completion of check-in Correct Answer:c) Number of students helping to check a patient in In this case, you're trying to decrease wait times by increasing the number of staff members on duty, so an appropriate process measure for this project would benumber of students helping to check a patient in. Keeping track of costs associated with a new process could be a balancing measure. The average number of minutes between patient arrival at the clinic and completion of check-in may be a useful outcome measure. 2) You work on a surgical unit that receives 87 new patients per week. In your spare time, you are trying to improve pain control across the unit. As you prepare to collect your baseline data before testing your change, you consider your plan to gather this information. Which of the following would be the best data collection plan for this project, and why? Your Answer:c) Collect data on a representative selection of patients for two weeks. Correct Answer:c) Collect data on a representative selection of patients for two weeks. Collecting data on a representative portion of your population Ñ that is, sampling Ñ allows you to collect baseline data and start making improvements faster, using fewer resources, than would be possible if you tried to look at every patient. Baseline data is important so that you can see if the changes you are testing are leading to improvement. Collecting data about a nonrepresentative sample of your population, such as by looking only at patients with the most severe pain, won't show the broad impact of your project on your unit. 3) You're trying to improve patient satisfaction scores in your hospital's emergency department. You decide to poll 40 patients a day for three weeks. Your charge nurse says that the quality of service really fluctuates depending on the time of day. So your daily sample consists of 10 patients polled at 8 AM, another 10 at noon, another 10 at 5 PM, and the final 10 at 9 PM. This is an example of what kind of sampling? Your Answer:d) None of the above Correct Answer:c) Judgment The best answer is judgment sampling. Judgment sampling chooses samples based on subject matter expertise. 4) Which of the following is an example of an effective measurement technique for improvement? Your Answer:b) Use quantitative and qualitative data. Correct Answer:d) All of the above The best answer is all of the above. Qualitative data, which is not so much about numbers as it is about the depth of the information collected, can be a rich source of knowledge in improvement projects. Interviews or focus groups are common sources of qualitative data. In order to move forward to the next step, a team needs just enough data to know whether changes are leading to improvement, so don't seek perfection. To save time, integrate data collection into the daily routine as much as possible. 5) You're working on an improvement project at a community mental health center. Your project aim: "Within two months, 100 percent of our patients will wait less than 30 minutes to be seen by a physician." You decide to gather data on patient wait times over a week-long period in order to establish a baseline. What might be an important consideration as you plan your data collection strategy? Your Answer:c) Who will collect the data and what method he or she will use for collecting it. Correct Answer:c) Who will collect the data and what method he or she will use for collecting it. It is crucial to clearly define not just what the data is that you want to collect, but how you will collect it. You are gathering data for improvement, not accountability, so for this project, it doesn't make sense to notify supervisors about the performance of individual caregivers. It's not necessary to establish consensus at the outset about the value of the project; by doing small tests of change, you are likely to gain buy-in as you go. 1) Which of the following methods would you recommend to display your improvement data? Your Answer:d) Draw a run chart. Correct Answer:d) Draw a run chart. Run charts are an effective way to view changes over time. They are much easier to interpret visually than a list of numbers or a static display of data such as a bar chart. Incorrect 2) When designing the run chart, it is important to include: Your Answer:d) A and B Correct Answer:c) Units of time on the X axis The run chart should display units of time Ñ whether it's days, weeks, or months Ñ on the X axis. The Y axis is where you plot the key variable you are measuring, which in this case is the rate of UTIs. Correct 3) How many runs are there on this run chart? Your Answer:c) 6 Correct Answer:c) 6 The answer is six. In order to count runs, you can draw a circle around each run Ñ that is, around each set of points clumped together above or below the median line Ñ and count the total number of circles. Note that a run can consist of just ONE data point, and points directly on the median don't count. If that seems confusing, just count the number of times the line crosses the median and add 1. Incorrect 4) What is the minimum number of data points you should usually have to look for signs of improvement on a run chart? Your Answer:a) 6 Correct Answer:b) 10 A run chart becomes more powerful as you add more data points because there will be more opportunities to identify patterns. If you're looking for signs of improvement, usually you need at least 10 data points. Correct 5) Which of the following is a problem with static data? Your Answer:a) It doesn't adequately portray variation. Correct Answer:a) It doesn't adequately portray variation. Summary statistics that are static in nature don't give you the appropriate picture of the variation that lives in your data. Although you can accurately display data such as the mean, median, or mode, it is not a good way to observe change over time. Incorrect 1) What are the four phases of an improvement project? Your Answer:c) Plan-Implement-Pilot-Spread Correct Answer:d) Innovation-Pilot-Implementation-Spread The four phases of an improvement project are "Innovation-Pilot-Implementation-Spread." Plan-Do-Study-Act (PDSA) cycles are tests of change that improvers conduct during different phases of their improvement projects. Correct 2) How should Sandy and her improvement team try out the new process for improving pain control? Your Answer:a) Test the new process with one patient and closely review the results. Correct Answer:a) Test the new process with one patient and closely review the results. The best answer is "test the new process with one patient on and closely review the results." Sandy and her team have an innovation and are ready to conduct a pilot. (Every organization is different, so just because the idea worked at another hospital does not mean it will work here.) Piloting involves starting small, such as with one patient, and carefully refining the change to make sure it works. Incorrect 3) After a successful pilot, which of the following should Sandy's improvement team undertake as a next step? Your Answer: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. Correct Answer:d) A and B The best answer is "A and B." After a successful pilot, they should move on to the implementation phase. This phase includes actions to "hardwire" the change, such as making it standard policy and training new staff on it. In implementing the change, the team will continue to run PDSAs: making predictions, carrying out the test, collecting data, and refining the change based on results. (Note that compared to PDSAs in the pilot phase, these tests will require significantly more people, time, and resources.) Incorrect 4) What improvement project phase have Heather and her team just completed? Your Answer:d) Planning Correct Answer:b) Pilot The team has just completed the improvement stage that consists of early, rapid-cycle tests of change: the pilot phase. Correct 5) Heather and her team continue to test the new idea. Assuming things continue to go well, what might they eventually do? Your Answer:d) All of the above. Correct Answer:d) All of the above. The best answer is "all of the above." After a successful pilot, the next steps are implementation and spread. IHI's Framework for Spread, which includes developing a communication and dissemination plan, is a helpful tool to use during the final phase of an improvement project. 1) The four steps for testing a change are: Your Answer:d) Innovation-Pilot-Implementation-Spread Correct Answer:a) Plan-Do-Study-Act The four steps for testing a change are "Plan-Do-Study-Act." PDSA cycles are tests of change that improvers conduct during different phases of their improvement projects. (Note: The four phases of an improvement project are "Innovation-Pilot-Implementation-Spread.") 2) What improvement project phase is Sandy looking to embark on? Your Answer:a) Innovation Correct Answer:b) Pilot Sandy has identified an innovation and is hoping to conduct a pilot. Piloting involves trying out the new process in one place and carefully refining the system to make sure it works. Depending on the success of the pilot, implementation and spread may come later. 3) Sandy and her improvement team begin to test the change using PDSA. Assuming their early testing is successful, how will their PDSA cycles change over time? Your Answer:c) The team will utilize more staff and resources. Correct Answer:c) The team will utilize more staff and resources. The best answer is "the team will utilize more staff and resources." For example, when they are eventually ready to implement the change, they will continue to run PDSAs (making predictions, collecting data, and documenting things that go wrong so that they learn from them). However, compared to PDSAs in the pilot phase these tests will require significantly more people, time, and resources. 4) Sandy and her improvement team test the new pain control idea in the cardiac unit over the course of six weeks. The results continue to show improvement. What phase will the project enter next? Your Answer:c) Implementation Correct Answer:c) Implementation Sandy and her team have completed their pilot, which means they should move on to implementation next. 5) Which of the following is a mechanism for "hardwiring" an innovation during the implementation phase? Your Answer:d) All of the above Correct Answer:b) Training all staff to use a new process "Hardwiring" helps sustain an idea after it has been tested and implemented. Training all staff is one way to do this. Other ways include assigning a day-to-day leader for the new process or having senior leadership remove barriers for staff. 1) According to sociologist Everett Rogers' attributes of spreadable ideas, ideas that spread naturally are: Your Answer:b) Complex Correct Answer:a) Trialable One characteristic of ideas that spread naturally is trialability Ñ that is, there is the opportunity for people to test the idea in a safe setting. The other four characteristics, according to Everett Rogers, are relative advantage, compatibility, simplicity, and observability. 2) Which of the following is an accurate statement about the spread of this innovation? Your Answer:d) The complexity of the change involved will likely slow the spread of this innovation. Correct Answer:d) The complexity of the change involved will likely slow the spread of this innovation. Implementing an entirely new clinic system is quite complex, making this a difficult innovation to spread. Improved outcomes may take time to appear and may not be easily observable, which could also slow spread. Finally, because this innovation involves a large-scale system change in most cases, it is difficult to test this easily and in a safe setting. This analysis does not imply that the medical home is not an improvement Ñ only that it may be more difficult to spread than less complicated innovations. 3) ABC Medical Center's leadership team has implemented the medical home model in one pilot site. Now the team wants to spread the innovation to other sites, and it is using IHI's Framework for Spread. Which of the following should the spread team do? Your Answer:c) Ask staff for feedback on the idea prior to implementation only, to encourage and then enforce staff buy-in. Correct Answer:a) Ask staff to give daily feedback, to assess progress along the way. The best answer is to solicit daily feedback. One key factor in IHI's Framework for Spread is knowledge management, which includes gathering information about the spread process as it unfolds. Waiting a year to gather feedback is too long. 4) When attempting to spread a change that you feel is valuable but is not spreading naturally, if possible, it's a good idea to: Your Answer:d) B and C Correct Answer:d) B and C Changes that do not spread naturally might benefit from IHI's Framework for Spread and from brainstorming with the New Idea Scorecard. You could switch to a different innovation that's easier to spread, but it would be wiser to use the tools available to you before abandoning a potentially valuable innovation. 5) The "setup" component of IHI's Framework for Spread is best defined as: Your Answer:b) Identifying the target population and the initial strategy to reach all sites in the target population with the new idea Correct Answer:b) Identifying the target population and the initial strategy to reach all sites in the target population with the new idea The best answer is "identifying the target population and the initial strategy to reach all sites in the target population with the new idea." Understanding the relationships within the system falls under the "social" component of IHI's Framework for Spread, and tracking and monitoring progress falls under "measurement and feedback." The identification and piloting of worthwhile innovations should occur before leaders attempt to sprea d those innovations throughout a system. Status Question 1) What is the purpose of IHI's Framework for Spread? Your Answer:c) To eliminate the spread of disease Correct Answer:b) To spread improvements across health systems 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. 2) Which of the following is NOT one of the key components of the IHI Spread? Your Answer:a) Piloting innovation Correct Answer:a) Piloting innovation The pilot phase of an improvement project occurs before the spread effort, as a prerequisite. The improvement team will initiate a spread plan only if the pilot is successful. 3) Regarding the Seton network goal for spread, which of the following is true? Your Answer:b) They met it exactly. Correct Answer:a) They surpassed it. The Seton Family of Hospitals set a spread goal to introduce 15 medical-surgical units to TCAB by June 2007. At project completion, they had exceeded the initial goal: 17 units were using the TCAB process within 18 months. 4) Which of the following communications strategies did the TCAB spread team use at Seton? Your Answer:d) All of the above Correct Answer:d) All of the above The best answer is "all of the above." Because communication is at the heart of spread, the spread initiative needs an organized communication campaign. It's helpful to use many types of communication. 5) Seton's Chief Nursing Officer was a key supporter of the TCAB spread effort. Which component of IHI's Framework for Spread does this fact best represent? Your Answer:b) Leadership Correct Answer:b) Leadership The best answer is "leadership." Executive leaders in an organization play an important role in spread initiatives by supporting and facilitating the efforts. The ultimate success and sustainability of TCAB depended on leadership commitment at all levels: from the senior executives who set strategic priorities and ensured that good changes spread, to midlevel clinical leaders who empowered staff and orchestrated change, to local leaders and staff who redesigned care processes to achieve unprecedented patient outcomes. 1) Which of the following is NOT one of the key components of IHI's Framework for Spread? Your Answer:d) Social system Correct Answer:c) Testing a change concept The testing phase of an improvement project occurs before the spread effort, as a prerequisite. Only if the pilot is successful will the improvement team initiate a spread plan. 2) What is the purpose of the IHI Framework for Spread? Your Answer:b) To spread improvements across health systems Correct Answer:b) To spread improvements across health systems IHI's Framework for Spread is a handy way to think about the most important components to consider when developing and executing a strategy to spread improvements across health systems. 3) Regarding the Seton network goal for spread, which of the following is true? Your Answer:a) They met it exactly. Correct Answer:d) None of the above The Seton Family of Hospitals set a spread goal to introduce 15 medical-surgical units to TCAB by June 2007; at project completion, they had exceeded the initial goal. With 18 months, 17 units were using the TCAB process. 4) The TCAB spread team use at Seton relied on regular meetings, one-to-one calls, and a website to support their spread effort. Which component of IHI's Framework for Spread does this best represent? Your Answer:a) Communication Correct Answer:a) Communication The best answer is "communication." Because communication is at the heart of spread, the spread initiative needs an organized communication campaign. It's helpful to use many types of communication. 5) Regarding Seton's plan for measurement in the TCAB spread initiative, which of the following is true? Your Answer:b) The spread team had a goal to reach a certain number of units by a certain time. Correct Answer:d) All of the above The best answer is "all of the above." The Seton Family of Hospitals set an overall spread aim to introduce 15 medical-surgical units to TCAB by June 2007. They tracked their progress in terms of both coverage and completion, and they also tracked clinical outcome measures related to quality and safety. 1) Which of the following is NOT one of the key components of IHI's Framework for Spread? Your Answer:d) Social system Correct Answer:c) Testing a change concept The testing phase of an improvement project occurs before the spread effort, as a prerequisite. Only if the pilot is successful will the improvement team initiate a spread plan. 2) What is the purpose of the IHI Framework for Spread? Your Answer:b) To spread improvements across health systems Correct Answer:b) To spread improvements across health systems IHI's Framework for Spread is a handy way to think about the most important components to consider when developing and executing a strategy to spread improvements across health systems. 3) Regarding the Seton network goal for spread, which of the following is true? Your Answer:a) They met it exactly. Correct Answer:d) None of the above The Seton Family of Hospitals set a spread goal to introduce 15 medical-surgical units to TCAB by June 2007; at project completion, they had exceeded the initial goal. With 18 months, 17 units were using the TCAB process. 4) The TCAB spread team use at Seton relied on regular meetings, one-to-one calls, and a website to support their spread effort. Which component of IHI's Framework for Spread does this best represent? Your Answer:a) Communication Correct Answer:a) Communication The best answer is "communication." Because communication is at the heart of spread, the spread initiative needs an organized communication campaign. It's helpful to use many types of communication. 5) Regarding Seton's plan for measurement in the TCAB spread initiative, which of the following is true? Your Answer:b) The spread team had a goal to reach a certain number of units by a certain time. Correct Answer:d) All of the above The best answer is "all of the above." The Seton Family of Hospitals set an overall spread aim to introduce 15 medical-surgical units to TCAB by June 2007. They tracked their progress in terms of both coverage and completion, and they also tracked clinical outcome measures related to quality and safety.