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      56. Who defines the rules in relation to any given issue?

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      57. Why is this needed?

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      58. Did you miss any major Quality in Health Care issues?

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      59. Are there any specific expectations or concerns about the Quality in Health Care team, Quality in Health Care itself?

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      60. Consider your own Quality in Health Care project, what types of organizational problems do you think might be causing or affecting your problem, based on the work done so far?

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      61. What Quality in Health Care events should you attend?

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      62. What needs to be done?

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      63. Are problem definition and motivation clearly presented?

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      64. Who are your key stakeholders who need to sign off?

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      65. Does Quality in Health Care create potential expectations in other areas that need to be recognized and considered?

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      66. Do you recognize Quality in Health Care achievements?

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      67. To what extent would your organization benefit from being recognized as a award recipient?

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      68. Who needs to know about Quality in Health Care?

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      69. What prevents you from making the changes you know will make you a more effective Quality in Health Care leader?

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      70. Is it clear when you think of the day ahead of you what activities and tasks you need to complete?

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      71. Does the problem have ethical dimensions?

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      72. What should be considered when identifying available resources, constraints, and deadlines?

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      73. Is the need for organizational change recognized?

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      74. What Quality in Health Care coordination do you need?

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      75. How are you going to measure success?

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      76. What are the stakeholder objectives to be achieved with Quality in Health Care?

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      77. Where is training needed?

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      78. How do you identify subcontractor relationships?

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      79. Are controls defined to recognize and contain problems?

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      80. Would you recognize a threat from the inside?

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      81. Where do you need to exercise leadership?

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      82. How do you assess your Quality in Health Care workforce capability and capacity needs, including skills, competencies, and staffing levels?

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      83. Are employees recognized or rewarded for performance that demonstrates the highest levels of integrity?

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      84. What information do users need?

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      85. What activities does the governance board need to consider?

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      86. What do you need to start doing?

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      87. What is the problem or issue?

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      88. What are the timeframes required to resolve each of the issues/problems?

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      89. What resources or support might you need?

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      90. What Quality in Health Care capabilities do you need?

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      91. What are the minority interests and what amount of minority interests can be recognized?

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      92. Is it needed?

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      93. Is the quality assurance team identified?

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      94. How are the Quality in Health Care’s objectives aligned to the group’s overall stakeholder strategy?

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      95. Do you need to avoid or amend any Quality in Health Care activities?

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      96. How many trainings, in total, are needed?

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      97. Do you have/need 24-hour access to key personnel?

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      Add up total points for this section: _____ = Total points for this section

      Divided by: ______ (number of statements answered) = ______ Average score for this section

      Transfer your score to the Quality in Health Care Index at the beginning of the Self-Assessment.

      CRITERION #2: DEFINE:

      INTENT: Formulate the stakeholder problem. Define the problem, needs and objectives.

      In my belief, the answer to this question is clearly defined:

      5 Strongly Agree

      4 Agree

      3 Neutral

      2 Disagree

      1 Strongly Disagree

      1. Are audit criteria, scope, frequency and methods defined?

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      2. Is the Quality in Health Care scope complete and appropriately sized?

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      3. Has a high-level ‘as is’ process map been completed, verified and validated?

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      4. Has a team charter been developed and communicated?

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      5. Has anyone else (internal or external to the group) attempted to solve this problem or a similar one before? If so, what knowledge can be leveraged from these previous efforts?

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      6. What is the definition of success?

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      7. Is the Quality in Health Care scope manageable?

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      8. How often are the team meetings?

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      9. Scope of sensitive information?

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