Quality Test 2

barriers to patient safety
organized structure(understaffed, wrong procedures, overwhelming patients), culture unsupportive of patient safety, physicians intolerance of uncertainty, health care professions fears( liability)
Walk around
asks if anything needs to be changed, CEO gives opportunity to give feedback
Work around
work around the problem instead of fixing it
Forcing function
Constraining function- deliberate pause
Redundancy function- double check (med admin)
Normalizing of deviance- acceptance of work around
Diffusion of responsibility- no on is in charge, is this good or bad
Blameless reporting
focus on the whole story
emphasis on near misses
sharing knowledge
what is epidemiology
study of diseases- how, when or where
risk and protective factors
contagious diseases and non- transmissible dieseases
Confounding factors
factors that mask the real effects, make things worse, -age is a confounding factor
Relative risk
RR is the risk of an event relative to exposure. It is a ratio of the probability of the event occurring in the exposed group versus a non-exposed group. ( hazard ratio)
Odds ratio
is favored for case controlled studies and retrospective studies.
types of errors
Judgement error- did it but wrong decision
Execution error- right decisions but did it wrong
Error of omission- didn't' do it
Error of commission- shouldn't have done it but did it anyway
active error
near patient, last layer of defense
latent error
away from patients, poor design, easiest to fix
5 Lean principles
establish a high agreement of what and how, systematic waste elimination, systematic problem solving,
observe work activities connections and flows, create a learning oragnization
7 deadly wastes
over production, waiting, transport, over-processing, inventory, unnecessary motion, defects, underutilized employees
5 S's
sorting- organization
DMAIC 5 steps
define, measure, analyze, improve, control
limits are to narrow, looks wrong but is right
to wide, looks right but is wrong
H-is bad
Ho-not bad
A shoe manufacturing firm learned through a Lean Six Sigma project their boot soles
could be made of a different material requiring two less steps in the process. Removal
of these two steps yielded a monthly cost savings of $7,500. Therefore the reported
financial savings for this LSS project were _____________.
A Belt utilized a diamond symbol in a Process Map she created for the process that
was subject to her LSS project. By use of the diamond symbol she was showing a(n)
_______________ point in the process
. When in the process of trying to identify the Critical X's for a LSS project a Belt creates
a(n) _____________ because frequently it is 20% of the inputs that have an 80%
impact on the output.
Pareto Chart
When a Belt is developing a Macro Process Map to define a complex process he will
frequently include activities across various department to capture all the appropriate
activity. He will use _____________ to show which department is responsible for
which steps in the process.
swim lanes
This formula is used to calculate a Z score that, with the
appropriate table, can tell a Belt what
proprtion of data is between X and U
As we calibrate our Measurement System to assure accurate data we frequently
encounter Bias which is the __________________ of a measured value from the
________________ value.
deviation, true
In an "X" Sifting exercises a Belt will use a(n) _______________ to assist in isolating
families of variation that may exist within a subgroup, between subgroups or vary over
Multi- Vari Chart
. When analyzing sample data a Belt may experience a Bimodal Distribution with each
mode displaying Normal Distribution. This could be caused by
__________________________ .
a. Two different machines being read
b. Two operators on different shifts
c. Two suppliers parts being used
****d. All these are correct answers******
A battery manufacturer was considering changing suppliers for a particular part. The
purchasing manager required that the average cost of the part be less than or equal to
$32 in order to stay within budget. A sample of the 32 initial deliveries had a Mean of
the new product upgrade price of $28 with an estimated Standard Deviation of $3.
Based on the data provided, the Z value for the data assuming a Normal Distribution
When conducting Hypothesis Analysis a Belt
must use the formula shown to determine if a certain
value is between - 1 and + 1 which will lead to a
conclusion relative to the hypothesis. The value
calculated by this formula is the ________________________ .
d. Sample Correlation Coefficient
. When doing a graphical analysis of DOE results a Belt frequently uses the Main Effects
Plot. To determine the relative impact of a variety of inputs on the output of interest it
is easy to identify the most impactful input because the slope of the line on the Main
Effects Plot is __________________.
the steepest
A ____________________ is used to create a model of the affect on an output by the
variation in two or more of the inputs.
Multiple Regression
A Belt has used the 5S approach of Lean to set up a control method with frequently
used tools organized as shown in this graphic. The Belt has applied the
______________ principle of 5S.
In the Control Phase of a LSS project a Belt will identify key metrics that can be
monitored and analyzed to give an indication that a process may be moving towards
an out of spec condition. When he applies this approach he is using
Statiscial process control
As a Belt completes a LSS project she creates for the Process Owner a Control Plan.
The ________________ portion of the Control Plan details the actions to be taken
when the KPI's indicate they may be moving outside acceptable limits.
Response plan