CPHQ
The clinical competency of physician is determined by: a. A committee of peers b. The CEO c. The hospital governing body d. A Quality Management Committee
a. A committee of peers
A 69yo female admitted for hip replacement is taken to surgery. The patient is identified, the surgical site is marked incorrectly, and equipment/x-ray are present. A near miss was mostly likely identified as a result of: a. A surgical team "time-out" b. Informed consent documentation c. An equipment check d. A root cause analysis
a. A surgical team "time-out"
One aspect of quality process that integrates with risk management is the review and evaluation of: a. Adverse drug events b. Encounter data c. Care-mix analysis reports d. Accreditation survey reports
a. Adverse drug events
An organization can best measure its effectiveness in meeting customer expectations by: a. Analyzing satisfaction data b. Benchmarking occupancy rates c. Creating a run of complaints d. Tracking length of stay
a. Analyzing satisfaction data
A physician complains to a healthcare quality professional that the nursing staff did not strictly follow orders for a patient. The physician requests that the quality professional speak with the nurse manager. To facilitate improved communication, the quality professional should: a. Arrange a meeting with the physician and nurse manager b. Speak with the nurse manager on behalf of the physician c. Evaluate the patient outcome to determine organizational risk d. Review the patient record to determine legibility of the physician's orders
a. Arrange a meeting with the physician and nurse manager
The best reason to evaluate team meetings is to: a. Assess progress b. Rate leader performance c. Keep participants interested d. Assess accuracy of the minutes
a. Assess progress
A group of pediatric patients diagnosed with cystic fibrosis is being studied. Their attitudes toward the disease have been measured each year for the past 4 years. The methodology used is an example of a a. Cohort study b. Regression analysis c. Case-mix study d. Cross-sectional analysis
a. Cohort study
In lean thinking, a process step is defined as "value added" if the: a. Customer recognizes the value b. Customer corrects a mistake to add value c. Process owner recognizes the value d. Process owner changes the value of the product
a. Customer recognizes the value
A healthcare network has implemented an EMR system allowing data to be transmitted, on demand, from one facility to another. Which of the following will best promote both cost effectiveness and pt satisfaction? a. Decreasing repeat tests for pts seen in more than one facility b. Eliminating the need for patients to hand-carry records c. Improving the accuracy of medication reconciliation d. Increasing the security of confidential patient information
a. Decreasing repeat tests for pts seen in more than one facility
Which of the following is the best example of use of human factors engineering? a. Designing products to prevent tubing misconnections b. Implanting a Kaizen process to reduce inventory c. Eliminating waste through reduction in motion d. Using PDCA to improve compliance with hand hygiene
a. Designing products to prevent tubing misconnections
A clinical pathway on the management of hip fractures has been developed by a multi-disciplinary team and implemented in a large teaching hospital. After monitoring for 6 months, the LOS continues to exceed guidelines. From the following, select the next step: a. Evaluate compliance with the pathway b. Correlate the pathway with staffing levels c. Re-educate the staff on the purpose of the pathway d. Continue to monitor, and collect additional data
a. Evaluate compliance with the pathway
Performance improvement teams should always be required to: a. Evaluate data b. Include senior leadership c. Perform root cause analysis d. Write mission and vision statements
a. Evaluate data
Which of the following is used to summarize a characteristic in a population? a. Frequency distribution b. Regression analysis c. Case control study d. Control chart
a. Frequency distribution
A healthcare quality professional is attempting to refine the differences between an organization's objections and the stakeholders needs. Which of the following tools is most appropriate? a. Gap analysis b. Ishikawa diagram c. Gantt chart d. Kanban method
a. Gap analysis
Which of the following topics are discussed at a morbidity and mortality conference? a. Healthcare-acquired infections and perioperative mortality b. Planned readmission and newborn mortality rates c. Cesarean section rates and number of physicians d. Inpatient mortality and admissions
a. Healthcare-acquired infections and perioperative mortality
Frequency distribution can best be displayed through use of: a. Histogram b. Flow chart c. Force field analysis d. Interrelationship diagram
a. Histogram
Medication reconciliation is a process intended to: a. Identify and resolve discrepancies b. Investigate formulary discrepancies c. Increase use of electronic medication administration d. Improve efficiency of medication administration
a. Identify and resolve discrepancies
The primary purpose of integrating financial and quality management information is to: a. Identify problems in resource management b. Develop physician profiles c. Identify potential case flow problems d. Determine medical necessity of treatment
a. Identify problems in resource management
Which of the following action plans is the first step in correcting inappropriate blood usage in an emergency department? a. In-service on ordering blood usage for the physicians b. Elimination of wasted blood c. Improvement in documentation d. Development of a new procurement procedure
a. In-service on ordering blood usage for the physicians
For health information technology to be most effective in reducing harm, the technology needs to be: a. Integrated with clinical workflow b. Able to correct claims data c. Flexible and accessible d. Numeric and easy to use
a. Integrated with clinical workflow
Comparing healthcare organizations by using medical error rates: a. May present bias due to differences in reporting practices b. Must include a minimum of 10 different facilities c. Cannot be performed by facilitates with less than 100 beds d. Provides the best method for benchmarking patient safety
a. May present bias due to differences in reporting practices
Leadership can best integrate PI within an organization through: a. Multidisciplinary teams b. Newsletters c. Focus groups d. Seminars
a. Multidisciplinary teams
The best way to evaluate the effectiveness of PI training is through: a. Observed behavioral changes b. Self-assessments c. Participants feedback d. Post-test results
a. Observed behavioral changes
For a continuous quality improvement team to be successful, who must be included on the team? a. Person performing the process b. Department supervisor c. Administrator d. Quality management representative
a. Person performing the process
Results of physician practice pattern studies are most likely to promote behavior changes when disseminated to the: a. Practitioners b. Administration c. Governing body d. Quality committee
a. Practitioners
A failure mode and effects analysis (FMEA) provides which of the following types of review? a. Proactive b. Retrospective c. Concurrent d. Retroactive
a. Proactive
Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization's quality improvement program? a. Quantifiable objectives b. Support from the medical staff c. Well-defined organizational structure d. Integrated data collection
a. Quantifiable objectives
When a team evaluating the use of restraints starts to discuss a liability claim related to a patient, the facilitator should: a. Redirect the team b. Consult the risk manager c. Request the medical record d. Review team ground rules
a. Redirect the team
A hospice agency conducted a satisfaction survey of all 200 patients currently receiving pain management services. When asked if they were satisfied with their pain management, 170 patients said yes, and 30 said no. A target satisfaction rate of 90% has been set. In this situation, a healthcare quality professional should: a. Review all dissatisfied responses for similarities b. Collect more data to ensure statistical significance c. Discontinue monitoring because an 85% satisfaction rate is excellent d. Continue monitoring because a 15% dissatisfaction rate is acceptable
a. Review all dissatisfied responses for similarities
Which of the following are the first steps when preparing for an initial accreditation or certification survey of an organization? a. Review the standards and determine readiness b. Appoint a survey coordinator and prepare a survey agenda c. Hire a consultant and conduct a mock survey d. Assess staff knowledge and plan staff training
a. Review the standards and determine readiness
Minimizing the chances for an adverse event to reoccur includes determining the primary contributing factor by using: a. Root cause analysis b. Force field analysis c. Clinical pathways d. Failure mode and effects analysis (FMEA)
a. Root cause analysis
Empowerment gives employees the opportunity to: a. Solve problems b. Make more money c. Gain respect of peers d. Achieve upward mobility
a. Solve problems
Staff has been trained and orientated on a new incident reporting system. In the past, staff could report anonymously. The new system requires staff to sign in with an individual username and password. Three months after implementation, there is a sharp reduction in the number of reported incidents. Which of the following reasons for underreporting of incidents is of greatest concerns? a. Staff fear of negative consequences of reporting b. Lack of knowledge about how to use the system c. Time required to complete an incident report d. Incomplete understanding about required reporting
a. Staff fear of negative consequences of reporting
Human factors engineering is defined as the study of humans and their interaction with: a. The tools they use and the environment b. Medical technology and the organizational systems c. Adverse events and latent errors d. Patients and the organization
a. The tools they use and the environment
After a significant unexpected event, an intense analysis is performed to: a. Understand the cause b. Collect risk management data c. Prepare the facility for a lawsuit d. Identify who made the error
a. Understand the cause
A patient safety program can best be enhanced by which of the following technologies? a. Computers on wheels at the patients' bedside b. Barcode system for medication administration c. Digital medication reference materials d. Online evidence-based medicine guidelines
b. Barcode system for medication administration
Which of the following is the primary benefit of using external quality consultants? a. Promoting effective communication b. Bridging knowledge gaps c. Maintaining performance standards for the organization d. Clarifying the mission and vision of the organization
b. Bridging knowledge gaps
An outpatient clinic is attempting to measure the quality of a newly developed diabetes disease management program. To accomplish this, lab results will be measured over time. The best way to display the data is using a: a. Gantt chart b. Control chart c. Pareto chart d. Flow chart
b. Control chart
Which of the following should a Quality Council provide to best ensure success of PI teams? a. Facilitator and recorder b. Empowerment and training c. Indicators and a data analyst d. Standards and procedures
b. Empowerment and training
A t-test may be used to: a. Display the size of a sampling variation b. Evaluate the effects of two different treatments c. Evaluate differences among three or more treatments d. Display a listing of the number of occurrences of a variable
b. Evaluate the effects of two different treatments
A hospital has recently moved to a paperless system. It is noted that some data is missing from the obstetrics delivery record. A healthcare quality professional should recommend: a. Assessing the need for additional education b. Evaluating the computerized data entry process c. Providing a paper trail d. Designating one data entry person per shift
b. Evaluating the computerized data entry process
Failure modes can be prioritized by calculation the criticality index. Which of the following three categories are normally used to calculate a criticality index? a. Probability, likelihood, and criticality b. Frequency, severity, and ease of detection c. Effectiveness, risk, and priority d. Response, evidence, and outcome
b. Frequency, severity, and ease of detection
In managed care, the most widely used performance measures are: a. Uniformed Hospital Discharge Data (UHDDS) b. Healthcare Effectiveness Data and Information Set (HEDIS) c. Agency for Healthcare Research and Quality (AHRQ) d. National Quality Forum (NQF)
b. Healthcare Effectiveness Data and Information Set (HEDIS)
The leader of a pain management PI team has asked the Quality Council to disband the team. The most important factor for the Quality Council to assess is: a. The length of time the team has been together b. How well the team met the intended outcome c. The effectiveness of the team leader and facilitator d. The amount of data the team has collected
b. How well the team met the intended outcome
When conducting a sentinel event review, a root cause analysis: a. Provides judgement of staff behaviors b. Identified gaps in patient care processes c. Requires team consensus d. Proactively identifies causes and effects
b. Identified gaps in patient care processes
Which of the following actions has the greatest impact in reducing harm? a. A revising the patient safety evaluation tool b. Improving interdisciplinary communication c. Forming a performance improvement team d. Increasing data collection frequency
b. Improving interdisciplinary communication
A facility is becoming part of a healthcare network. Which of the following employee education programs is most important? a. Quality teams b. Organizational change c. Consumer expectations d. Conflict resolution
b. Organizational change
When examining the relationship between staff and patient outcomes, which of the following is the most appropriate to assess? a. Staff turnover and budget b. Patient safety data and overtime data c. Overtime data and absenteeism rate d. Occurrence reports and sentinel events
b. Patient safety data and overtime data
A healthcare entity initiating re-structuring must consider the impact on staff to ensure the greatest opportunity for success by: a. Defining the concepts of re-structuring to the staff & community b. Planning carefully, communicating openly, & leading effectively c. Developing policies to assist in the change process so that fear will be minimized d. Selecting a consultant, conducting a needs assessment, & analyzing results
b. Planning carefully, communicating openly, & leading effectively
Data collection about surgical cases shows significant delays, with further analysis showing most delays are due to one specific surgeon. Which of the following should a healthcare quality professional do first? a. Perform a focused professional practice evaluation (FPPE) on every surgeon b. Provide the service chief with further analyses of surgeon-specific data c. Ask the nurse manager to write a memo encouraging promptness d. Form a multidisciplinary team to develop recommendation for improvement
b. Provide the service chief with further analyses of surgeon-specific data
A staff member reports that a colon perforation occurred during a colonoscopy. Which of the following is a healthcare quality professional's next step? a. Review 100% of colonoscopy procedures b. Refer the case for peer review c. Modify the physician's privileges d. Assign a proctor to the physician
b. Refer the case for peer review
A quality improvement manager must decide how to present data that demonstrates the relationship between two process characteristics. Which of the following data display techniques is most appropriate? a. Bar chart b. Scatter diagram c. Pareto chart d. Line graph
b. Scatter diagram
Which of the following adverse events is NOT considered a sentinel event? a. Death due to a medical error b. Suicide threat by a patient in a confined 24-hour care setting c. Surgery on the wrong patient or body part d. Hemolytic transfusion reaction
b. Suicide threat by a patient in a confined 24-hour care setting
The phrase "reaching consensus" is often used in PI. The term consensus refers to: a. Unanimous agreement b. Support by all members c. Everyone being totally satisfied d. A majority vote of those present
b. Support by all members
Which of the following principles applies to continuous quality improvement in an organization? a. 20% of trouble comes from 80% of the problems b. Systems, not poor job performance, are responsible for most problems c. Causes of nonconformance must be identified and corrected temporarily d. Empowerment automatically occurs upon implementation of the program
b. Systems, not poor job performance, are responsible for most problems
Which of the following should be included in annual performance improvement report to a governing body? a. Meeting minutes b. Team achievements c. Physician peer reviews d. Incident/occurrence reports
b. Team achievements
Upon completion of a PI project, who is the best person to compile and write a report? a. Quality manager b. Team leader c. Facilitator d. Recorder
b. Team leader
Satisfaction surveys, focus groups, and complaint tracking are tools used to: a. Benchmark satisfaction b. Develop clinical pathways/guidelines c. Understand customers' expectations d. Measure professional practice pattern
c. Understand customers' expectations
Which of the following is always true regarding a sentinel event? a. The cause is established as a deviation from standards b. The occurrence requires an immediate investigation response c. The incident is a result of a medical error d. The findings must be reported to a regulatory body
b. The occurrence requires an immediate investigation response
Leaders enhance employee commitment to organizational values by fostering which of the following types of communication? a. Face-to-face, oral, scheduled b. Timely, open, two-way c. Clear, written, top-down d. Formal, electronic, "need to know"
b. Timely, open, two-way
Facility A is investigating its medication administration time for a specific diagnosis. Evidence-based guidelines indicate that administration of a particular drug within 30 mins significantly improves patient outcomes. The national average is 32 mins. The average for Facility B is 28 mins. If the average for Facility A is 35 mins, Facility A should: a. Determine whether its rate is within one standard deviation of the national average b. Decrease its rate to meet the national average c. Contact Facility B to determine its practices d. Identify the average time of its competitors
c. Contact Facility B to determine its practices
The success of a performance improvement program will be most influenced by the: a. Reliability of data management software b. Educational preparation of quality leaders c. Culture of the organization d. People skills of the facility leaders
c. Culture of the organization
A consulting firm has been selected by a healthcare Board of Directors to assess the quality improvement program. Before starting the assessment, the quality professional should first: a. Set up a project plan b. Develop potential action plans c. Define expectations and outcomes d. Design a dashboard
c. Define expectations and outcomes
In the quality improvement process, performing a cost-benefit analysis is most useful in: a. Checking performance b. Analyzing process problems c. Designing solutions and controls d. Implementing solutions and controls
c. Designing solutions and controls
A root cause analysis team examined a serious medication error and recommended changes. Which of the following should be done next? a. Random checks for compliance should be made by patient safety staff b. The Quality Council should review medication errors quarterly c. The process owner should implement and assess effectiveness d. Monthly reports should be sent to the regulatory body
c. The process owner should implement and assess effectiveness
Which of the following is an example of information that should be included in an incident report, but should NOT be recorded in a patient's medical record? a. The patient found on the floor next to the bed with the patient's right leg appearing to be rotated b. The date, time, dose, and name of a medication administered to a patient in error c. Details concerning a medication preparation error discovered and corrected prior to administration d. The patient's right knee replaced after consenting to replacement on the left knee
c. Details concerning a medication preparation error discovered and corrected prior to administration
The primary objective of the operational linkage between risk management and quality/performance improvement is to: a. Meet regulatory requirements b. Develop a place of action for individual cases c. Develop a comprehensive plan to prevent future occurrences d. Alert the hospital attorney of a potentially compensable event
c. Develop a comprehensive plan to prevent future occurrences
A healthcare quality professional is conducting a study to determine how many patients contracted influenza despite receiving flu shots. This study is evaluating: a. Appropriateness b. Process c. Efficacy d. Prevalence
c. Efficacy
Which of the following is the best tool to begin an investigation into the causes of lab labeling errors? a. Affinity diagram b. Prioritization matrix c. Flow chart d. Histogram
c. Flow chart
When choosing an outside consultant to lead employee focus groups, which of the following priority areas of expertise should a healthcare quality professional look for? a. Team development and management b. Organization assessment and change management c. Group dynamics and facilitation d. Organization design and re-engineering
c. Group dynamics and facilitation
The primary purpose of risk management trend analysis is to: a. Meet regulatory requirements b. Provide required reports to liability carriers c. Identify opportunities for improvement d. Eliminate financial loss for organization
c. Identify opportunities for improvement
A critical difference between quality assurance and quality improvement is a shift in focus from: a. Retrospective review to concurrent screening b. Nonclinical aspects to customer satisfaction c. Identifying poor performers to improving group performance d. Quality assurance to teams
c. Identifying poor performers to improving group performance
A federally certified electronic health record (EHR) with the capacity for e-prescribing, electronic exchange of health information, and submission of healthcare quality measures meets: a. Bar-code technology specifications b. Computer-based monitoring specifications c. Meaningful requirements d. Health privacy requirements
c. Meaningful requirements
A healthcare quality professional has been asked to examine a new method of reviewing adverse events in an organization. It has been decided that a system of triggers will be established to alert the Quality Council of a potential problem. The best example of a trigger that should be set with a threshold of zero is a: a. Medial record not completed by a physician b. Staff member not using proper handwashing technique c. Near miss from failure to perform a "time-out" d. Patient complaint regarding wait times
c. Near miss from failure to perform a "time-out"
Which of the following is the best choice for beginning clinical-pathways implementation in an organization? a. Physician champion, low volume, no loss variance and low readmission rate b. Lack of physician champion c. Physician champion, LOS variance and high readmission rate d. Lack of physician champion with variance
c. Physician champion, LOS variance and high readmission rate
Which of the following obstetrical outcomes will result in a morbidity review? a. Normal deliveries b. Neonatal deaths c. Post-delivery septicemia d. Cesarean sections
c. Post-delivery septicemia
Balanced scorecards are useful because they: a. Focus on the most significant strategic initiative b. Evaluate the pros and cons of the governing body's priorities c. Put strategy and vision at the center of an organization's effort d. Concentrate on the performance of individual units
c. Put strategy and vision at the center of an organization's effort
A PI training program for supervisors should include: a. Results of a failure mode and effects analysis (FMEA) b. Budget-variance reporting c. Rapid-cycle process d. Review of patient falls
c. Rapid-cycle process
A healthcare plan is required to have a mechanism for members to submit complaints. Which of the following actions must be included in the complaint analysis to ensure the plan makes full use of this type of info? a. Total each complaint category at least on an annual basis b. Calculate the average number of complaints per office site c. Review complaints to find system problems that can be improved d. Determine the date/time the complaint occurred and the person responsible
c. Review complaints to find system problems that can be improved
A serious event has occurred related to the timely notification of critical test results. The root cause was traced to nursing difficulty with following the organizational policy. To prevent a similar event from reoccurring, which of the following should be done next? a. Refer the involved nurse to nursing peer review b. Educate nursing staff on the importance of timely notification of critical test results c. Review the policy with nursing representatives to identify ambiguities d. Continue to collect data as one event is insufficient to take action
c. Review the policy with nursing representatives to identify ambiguities
A Quality Council has examined data on patient falls and determined that a comprehensive falls prevention program is needed. The first step in increasing staff awareness of this initiative is to: a. Require staff to sign that they have read and understood the falls policy b. Use an educator to teach falls prevention c. Share unit-specific data on falls d. Conduct a medication review of patients who have fallen
c. Share unit-specific data on falls
A culture of patient safety in an organization will have been successfully created when: a. Personal accountability is removed from the organization b. Near miss reporting of safety issues declines c. Staff members serve as safety advocates d. Root cause analysis is performed regularly
c. Staff members serve as safety advocates
A valid data collection tool should incorporate: a. A minimum of 20 data elements b. A reliable graphic presentation c. The definition of data elements d. Allowance for variance of interpretation
c. The definition of data elements
Problem-solving, cross-functional understanding, expanded areas of expertise, and increased span of knowledge area examples of: a. Strategic alliances b. Customer expectations c. Resource requirements d. The benefits of teams
d. The benefits of teams
A strategy used in brainstorming is that ideas are: a. Prioritized as they occur b. Discussed when they are mentioned c. Progressively eliminated d. All recorded
d. All recorded
A summary of antibiotic usage for the 4th quarter showed that an internal medicine dept did not meeting pre-established criteria in 82% of the pts reviewed. Following review, the Pharmacy and Therapeutics Committee should recommend that the results be shared first with the: a. Quality Council b. Governing body c. Utilization committee d. Chief of the department
d. Chief of the department
A medication error occurred and resulted in a severe adverse outcome. In addition to informing the patients and/or family, a healthcare quality professional should: a. Perform a regression analysis b. Implement new technology c. Reassign the employees involved d. Conduct a root cause analysis
d. Conduct a root cause analysis
Which of the following sampling techniques selects participants based on their availability in a certain place during a specific time frame? a. Quota b. Random c. Volunteer d. Convenience
d. Convenience
The perception of how an organization operates, including how employees relate to internal and external customers is the organizational: a. Structure b. Mission c. Vision d. Culture
d. Culture
During quality management data analysis activities, Pareto charts are most appropriately used for: a. Displaying parts of a whole b. Displaying trends over time c. Determining cause and effect relationships d. Determining priorities among contributing factors
d. Determining priorities among contributing factors
In the process of strategic planning, an organization makes decisions about the future. A basic component of the planning process is to: a. Develop contractual relationships to enhance market share b. Contract with a consulting firm to assist with the planning process c. Determine organizational profitability during the most recent fiscal year d. Examine both internal and external environments
d. Examine both internal and external environments
Based on the principles from the Institute for Healthcare Improvement (IHI), who has the ultimate responsibility for the effectiveness of quality improvement and pt safety within an organization? a. Quality improvement director b. Medical director c. CEO d. Governing body
d. Governing body
Generic screening is an example of risk: a. Evaluation b. Reduction c. Prevention d. Identification
d. Identification
Timeliness and compliance of documentation were discussed at a multidisciplinary team meeting. To evaluate the effectiveness of the team's action plan, which of the following will provide the most useful information? a. Physician attendance b. Number of complaints c. Frequency of meetings d. Medical record review
d. Medical record review
The evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to the performance of the: a. Medical staff b. Governing body c. Ancillary departments d. Organization's systems
d. Organization's systems
Informed consent for hip surgery was obtained and documented for an elderly patient. In the recovery room, a nurse discovered the wrong hip had been replaced. A healthcare quality professional should: a. Conduct a failure mode and effects analysis (FMEA) b. Initiate the disciplinary action process c. Review the practitioner's qualifications and licensure d. Perform a root cause analysis
d. Perform a root cause analysis
A monitoring system is being designed in which data will be collected and compared to criteria. Which of the following will best enhance the validity and reliability of the data? a. Establishing criteria that are based on the most recent changes in medical science and technology b. Using a computerized system to substitute data for missing responses c. Assigning one staff member to identify, collect, enter, and interpret all data d. Providing a practice-based definition and specific instructions for each element
d. Providing a practice-based definition and specific instructions for each element
When using cost-benefit analysis in decision-making, it is important to remember that: a. Consideration of the benefit is more important than the cost b. Return on investment should be at least 10 to 1 c. Implementation costs are more important than return on investment d. Qualitative and quantitative data should be used
d. Qualitative and quantitative data should be used
When considering the use of an external subject matter expert (SME), which of the following is most critical? a. Leadership's personal preference b. Geographic location of the SME c. Cost of the SME's services d. References of the SME
d. References of the SME
In profiling LOS data for benchmarking, it is important that data be: a. Raw numbers b. Equal numbers c. Reported monthly d. Severity adjusted
d. Severity adjusted
