ABQAURP EXAM STUDY GUIDE WITH
QUESTIONS AND ANSWERS RATED A.
What is Six Sigma?
✔✔Quality approach that uses data-driven information to "eliminate
defects", focusing not only on improvement no process flow but in
reducing process variation to achieve six standard deviations between the
mean and the nearest specification limit.
What is LEAN Six Sigma?
✔✔Consists of five basic phases:
Define, Measure, Analyze, Improve, and Control (aka follow-up). DMAIC
What should you think when you here terms "should, could, or would"?
✔✔So what? These terms are usually indications that the process may be
getting off track. These words often divert attention from the actual issues
because they address expected performance rather than the reality of the
situation.
What was the first mainstream article arguing for a systems approach to
safety?
✔✔"Error in Medicine" by Lucien Leape in JAMA, December 1994
Who said "Physicians and Nurses must accept the notion that error is an
inevitable accompaniment of the human condition, even among
conscientious professionals with high standards. ERRORS MUST BE
ACCEPTED AS EVIDENCE OF SYSTEM FLAWS NOT CHARACTER FLAWS.
Until and UNLESS that happens, it is unlikely that any substantial progress
will be made in reducing medical errors.
✔✔Lucien Leap
,What are the "two stories" in the aftermath of a medical accident?
✔✔The first is about the immediate details-who, what, when, where, why-
and often focus on the human error committed. Media coverage of
"celebrated accidents" tends to focus on telling the first story in simple and
sensational detail.
The second story develops when investigation of the accident digs deeper
into root causes, which may reveal contributory conditions and decisions
far removed from the actual time and place of the event. Second stories
promote understanding of the underlying systems and unintended
consequences that increase the hazards of already complex medical
domains.
Developing second stories requires what?
✔✔That individuals and community involved accept that an accident has
occurred, might have been prevented, deserves deep analysis, and should
result in change to protect patients in the future. In short, second stories
only happen in organizations that are willing to learn from mistakes.
Which report is thought to have launched the current patient safety
movement?
✔✔The IOM's Committee on Quality of Care in America report called 'To
Err is Human: Building a Safer Health System' issued in 1999 published by
the National Academies Press in 2000
Focus of voluntary reporting systems
✔✔Focus on a much broader set of errors, mainly those that do no or
minimal harm, and help detect system weaknesses that can be fixed
before the occurrence of serious harm.
, How is it proposed to foster participation on voluntary reporting systems?
✔✔Congress should enact laws to protect the confidentiality of certain
information collected to alleviate the fears that such information may be
subpoenaed and used in lawsuits.
What was learned from the aviation industry?
✔✔Reinforcing current approaches to training and pressuring pilots to be
more careful would not improve safety. Much of aviation's safety
improvement came from applying principles of social and cognitive
psychology and human factors engineering to its own challenging work
environment.
Human factors engineering contributes to safety through:
✔✔understanding the interrelations between humans, the tools they use,
and the environment in which they live and work
Difference between complicated and complex systems:
✔✔Complicated systems may include multiple individuals, supplies, and
steps, but function predictably, such as is seen on an assembly line or can
be mapped in a flow chart. In complex systems, where interrelationships
among individuals, technology, and other aspects of the environment
affect each other and are continually changing, safety improvement never
ends. A change in one part of the system may create unintended hazards
somewhere else.
Important point brought home by the Swiss Cheese Model:
✔✔Multiple failures are all necessary and only jointly sufficient to let the
hazard reach the place it should not be.
QUESTIONS AND ANSWERS RATED A.
What is Six Sigma?
✔✔Quality approach that uses data-driven information to "eliminate
defects", focusing not only on improvement no process flow but in
reducing process variation to achieve six standard deviations between the
mean and the nearest specification limit.
What is LEAN Six Sigma?
✔✔Consists of five basic phases:
Define, Measure, Analyze, Improve, and Control (aka follow-up). DMAIC
What should you think when you here terms "should, could, or would"?
✔✔So what? These terms are usually indications that the process may be
getting off track. These words often divert attention from the actual issues
because they address expected performance rather than the reality of the
situation.
What was the first mainstream article arguing for a systems approach to
safety?
✔✔"Error in Medicine" by Lucien Leape in JAMA, December 1994
Who said "Physicians and Nurses must accept the notion that error is an
inevitable accompaniment of the human condition, even among
conscientious professionals with high standards. ERRORS MUST BE
ACCEPTED AS EVIDENCE OF SYSTEM FLAWS NOT CHARACTER FLAWS.
Until and UNLESS that happens, it is unlikely that any substantial progress
will be made in reducing medical errors.
✔✔Lucien Leap
,What are the "two stories" in the aftermath of a medical accident?
✔✔The first is about the immediate details-who, what, when, where, why-
and often focus on the human error committed. Media coverage of
"celebrated accidents" tends to focus on telling the first story in simple and
sensational detail.
The second story develops when investigation of the accident digs deeper
into root causes, which may reveal contributory conditions and decisions
far removed from the actual time and place of the event. Second stories
promote understanding of the underlying systems and unintended
consequences that increase the hazards of already complex medical
domains.
Developing second stories requires what?
✔✔That individuals and community involved accept that an accident has
occurred, might have been prevented, deserves deep analysis, and should
result in change to protect patients in the future. In short, second stories
only happen in organizations that are willing to learn from mistakes.
Which report is thought to have launched the current patient safety
movement?
✔✔The IOM's Committee on Quality of Care in America report called 'To
Err is Human: Building a Safer Health System' issued in 1999 published by
the National Academies Press in 2000
Focus of voluntary reporting systems
✔✔Focus on a much broader set of errors, mainly those that do no or
minimal harm, and help detect system weaknesses that can be fixed
before the occurrence of serious harm.
, How is it proposed to foster participation on voluntary reporting systems?
✔✔Congress should enact laws to protect the confidentiality of certain
information collected to alleviate the fears that such information may be
subpoenaed and used in lawsuits.
What was learned from the aviation industry?
✔✔Reinforcing current approaches to training and pressuring pilots to be
more careful would not improve safety. Much of aviation's safety
improvement came from applying principles of social and cognitive
psychology and human factors engineering to its own challenging work
environment.
Human factors engineering contributes to safety through:
✔✔understanding the interrelations between humans, the tools they use,
and the environment in which they live and work
Difference between complicated and complex systems:
✔✔Complicated systems may include multiple individuals, supplies, and
steps, but function predictably, such as is seen on an assembly line or can
be mapped in a flow chart. In complex systems, where interrelationships
among individuals, technology, and other aspects of the environment
affect each other and are continually changing, safety improvement never
ends. A change in one part of the system may create unintended hazards
somewhere else.
Important point brought home by the Swiss Cheese Model:
✔✔Multiple failures are all necessary and only jointly sufficient to let the
hazard reach the place it should not be.
