CPHQ Study Guide Part 2

What is immediate jeopardy?

IJ is a mechanism to escalate crisis survey issues immediately within both state and federal agencies and with the healthcare provider.

What is non probability snowball sampling?

Involves subjects suggesting for inclusion in the study so the sampling process gains momentum

Which of the following groups is LEAST likely to report errors? primary care physicians, support staff, independent contractors, nurses

independent contractors

Confronted by excessive WIP Levels, many laboratories take the unhelpful step of: decreasing # of test runs, hiring more employees, acquiring a longer labatory, installing new technology

installing new technology

In the perfect lean enterprise, delivery to the customer is: instantaneous, rapid, customizable, optional

instantaneous

For health information technology to be MOST effective in reducing harm, the technology needs to be: numeric and easy to use, integrated with clinical workflow, able to correct claims date, flexible and accessible

integrated with clinical workflow

What are the types of benchmarking projects?

internal, external. zero-incidence

by-laws within a healthcare facility

list of organizational laws that define activities and procedures within a facility; internal expectations

organizational transparency in a healthcare facility

means active leadership to ensure the public image matches the private image as closely as possible

What is URAC?

Utilization Review Accreditation Commission. Also known as the American Accreditation Healthcare Commission

Most famous industrial quality guru?

W. Edwards Deming, coined the 85/15 theory.

According to Institute of Medicine, which of the following is NOT one of the domains of quality care? government regulation, customization, safety, interventions consistent with the latest medical findings

government regulation

Which of the following types of charts is best for determining cause & effect? run, control, fishbone, pareto

fishbone

Which of the following charts would most likely be used first in a root cause analysis? Pareto, control, flow, gantt

flow

A hospital needs to decide whether or not to incorporate a new feature into its current services, and as a result has commissioned qualitative research that will provide detailed feedback. Specifically, the hospital would like to collect opinions from patients and other hospital customers with a wide range of experience and backgrounds. Which of the following types of assessment is MOST likely to be of use to the hospital? case study, team analysis, survey, focus group

focus group

A presentation on the basic structures and processes of clinical governance would be MOST useful: small team employees, for the organization as a whole, for the directorate, for individual employees

for the organization as a whole

Failure modes can be prioritized by calculating the criticality index. Which of the following three categories are normally used to calculate a criticality index? frequency/severity/ease of detection, probability/likelihood/criticality, response/evidence/outcome, effectiveness/risk/priority

frequency/severity/ease of detection

What are the 3 basic closely interrelated activities that quality management employ?

quality planning, control, improvement

A hospital-wide out of professional standards is important because it: reduces the waste & resources, eliminates bottlenecks, encourages duplication, minimizes the need for communication

reduces the waste of time and resources

When considering the use of an external subject matter expert (SME), which of the following characteristics is MOST critical? references of the SME, cost of the SME's services, geographic location of the SME, leadership's personal preference

references of the SME

The process of risk management for the healthcare quality management professional includes all of the following EXCEPT? identification of risk, reporting of incidents, analysis of effects, prevention of risk

reporting of incidents

To cut down on costs, a clinic has been hiring outside consultants to perform many of its tasks, but there are concerns that the performance of many of these consultants does not meet the state's standards for the clinic's operation. What is the healthcare quality management professional's role in this? develop educational programs to assist the consultants and ensure that the standards are met, supply the consultants with the information about state standards and ensure full compliance, review the activities of the consultants and report the results to the clinic administration, create simulated activities to test the consultants and see if they are meeting the standards

review the activities of the consultants and report the results to the clinic administration

A disagreement has arisen between the hospital administration and the members of one of its departments. The disagreement is in connection with the authority of the different parties involved and whether or not the administration can require the department to perform a certain task. What is the healthcare quality management professional's role in this? advise the department to respect the authority of the hospital and to follow its expectations for department professional, review the rules establishing authority and inform the parties about how these rules apply to the department and the administration, consider the statement from both sides and participate in finding a solution that meets the expectations of both parties, create a review board to act as a mediator between the hospital administration and the department to find an agreeable solution

review the rules establishing authority and inform the parties about how these rules apply to the department and the administration

Which of the following is the first step in preparing for an initial accreditation or certification survey of an organization? assesses staff knowledge and plan staff training, hire a consultant and conduct a mock survey, appoint a survey coordinator and prepare a survey agenda, review the standards and determine readiness

review the standards and determine readiness

A hospital has recently conducted extensive updates on its website and wants to make sure that the new site is ready to be made available to the public. What is the healthcare quality management professional's role in this? compile a list of required information for the website and report this to the hospital, review the website to ensure that the reported information is accurate and complete, evaluate the changes that have been made in the website and recommend improvements, compare the website to other hospital sites to ensure that the new compares favorably

review the website to ensure that the reported information is accurate and complete

The process chain in a laboratory is particularly subject to: variability, delay, disorganization, conflict

variability

Which of the following is source of MOST medication errors? orders that require lab results, high risk orders, automatic orders, verbal orders

verbal orders

What is probability stratified random sampling?

A subpopulation is a stratum, and strata are two or more homogeneous subpopulations. Once divided into strata, each member of a stratum has an equal probability of being selected.

What is nonprobability convenience sampling?

Allows the use of any available group of subjects.

What is probability systematic sampling?

Drawing every nth element from a population. (Picking every third name from a list.)

What is EBP?

Evidence-based practice. Promotes patient-safety through the provision of effective and efficient healthcare resulting in less variation in care and fewer unnecessary or nontherapeutic interventions

What is NCQA? and it what 3 ways does it evaluate healthcare?

National Committee for Quality Assurance -non-profit -Accredits, certifies and recognizes healthcare organizations, services and providers

What is Work-In-Progress (WIP)?

Product that is within the boundaries of the process at any given time

which of the following performance improvement models would be the BEST recommendation for a clinic that wants to discover the source of problems in patient care, eliminate these problems, and achieve consistently high quality results in patient care? PDCA, Six Sigma, FOCUS, LEAN

Six Sigma

What is data?

The abstract representation of things, facts, concepts, and instructions that are stored in a defined format and structure on a passive medium (e.g., paper, computer, microfilm).

Which of the following conditions should a quality assessment program NOT examine? condition that is thought to be treatable, condition for which treatment is susceptible to significant healthcare providers; condition that has cost-effective treatments, a rare condition that has small effect on mortality or morbidity

a rare condition that has small effect on mortality or morbidity

What is Risk adjustment?

a technique used to take into account the fact that different patients with the same diagnosis may have additional conditions that change their response to treatment

What is risk adjustment?

a technique used to take into account the fact that different patients with the same diagnosis may have additional conditions that change their response to treatment

Deemed status refers to: surveyors who work for both an accrediting body and a healthcare organization, physicians who have been reported to the National Practitioner Database, accreditation equivalency with a Census for Medicare & Medicaid Services (CMS) survey, a healthcare organization that passes a Centers for Medicare & Medicaid services (CMS) survey

accreditation equivalency with a Census for Medicare & Medicaid Services (CMS) survey

A hospital has found that the performance of one of its departments is consistently below the expected standards. The hospital administration wants to locate the source of the problems and see improvement in the department within six months. What is the healthcare quality management professional's role in this? recommend that the hospital replace the current administration of the individual department, research the problems and develop a program that applies current standards to the department, advise that a performance improvement team be assembled to review and address the failings, review the expected standards and submit these to the department for immediate application

advise that a performance improvement team be assembled to review and address the failings

A delay in discharging patients is likely to cause recurrent bottlenecks in: admissions from ER, filling of prescriptions, admissions from surgical wards, all of the above

all of the above

A strategy used in brainstorming is that ideas are: prioritized as they occur, all recorded, discussed when they are mentioned, progressively eliminated

all recorded

A healthcare quality management professional ahs all of the following responsibilities toward improving patient safety EXCEPT: appointing a supervisor for a patient safety program, helping to develop a patient safety program, incorporating new technology into a patient safety program, setting and reviewing goals for patient safety program

appointing a supervisor for a patient safety program

A simple but effective way for managers to obtain the support of team members is to: threaten punishment, ask fir it, mandate it, ignore team members

ask for it

One of the largest departments within a hospital has been running over budget for some time. The increasing expenditure has become problematic, and therefore the department has been asked to maintain a budget. What is the healthcare quality management professional's role in this? follow the hospital administration's guidelines in setting a budget for the department, provide the department with software tools to enable it to set a manageable budget, appoint a financial advisor to support the department in developing a compliant budget, assist the department in developing a manageable budget and reviewing it for compliance

assist the department in developing a manageable budget and reviewing it for compliance

When is the best time for chairing during a meeting? one hour beforehand, at the beginning, in the middle, at the end

at the beginning

Which of the following is source of LEAST medication errors? orders that require lab results, high risk orders, automatic orders, verbal orders

automatic orders

A summary of antibiotic usage for the fourth quarter showed that an internal medicine department did not meet pre-established criteria in 82% of the patients reviewed. following review, the pharmacy and therapeutics committee should recommend that the results be shared first with the: utilization committee, Quality Council, governing body, chief of the department

chief of the department

The administration of a hospital has discovered that a lack of communication among different hospital departments has led overspending and unnecessary errors in patient care. The administration has asked the healthcare quality management professional to assemble a team that can improve department communication and address the problems. What type of team would be most useful for this task? quality circle, work group, cross functional, self-directed

cross functional

A doctor fails to administer an indicated test and patients condition determines to the point that he must be admitted to an inpatient facility. This is an example of: preventive error, treatment error, diagnostic error, communication error

diagnostic error

Whenever possible, medication orders should be by: weight, volume, dose, strength

dose

Which of the following should a Quality Council provide to best ensure success of performance improvement teams? empowerment and training, indicators and a data analyst, standards and procedures, facilitator and recorder

empowerment and training

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 would provide the most useful information? number of complaints, physician attendance, medical record review, frequency of meetings

medical record review

For a continuous quality improvement team to be successful, who must be included on the team? department supervisor, person performing the process, quality management representative, administrator

person performing the process

In a successful lean healthcare facility, the largest costs related to quality will be increased by: preventive efforts, internal failures, assessment programs, external failures

preventive efforts

All of the following represent federally mandated patient rights in the US EXCEPT: rights to obtain a copy of medical records, right to informed consent for medical treatment, right to maintain the privacy of medical records, right to receive healthcare services

right to receive healthcare services

Random screening of newborns by the neonatology department has confirmed a high incidence of glucose insufficiency (G6PD) in the local population. Management believes that the cost of testing all newborns would be too high. which of the following should the healthcare quality professional suggest? review literature to determine best practices, continue to conduct random testing, conduct an analysis to confirm management's beliefs, test only newborns with a family history of G6PD

test only newborns with a family history of G6PD