Quality improvement Exam 1

The Medicare program s quality management requirements for healthcare facilities are found in what regulations? Accreditation standards State licensing documents Hospital standardization program Conditions of Participation

Conditions of Participation

Which of the following is one aspect of the definition of healthcare quality? Helps safeguard providers against malpractice Consistent with current professional knowledge Contributes to the rising cost of services Information linked between healthcare facilities

Consistent with current professional knowledge

"When measurement data show that a department s performance is meeting expectations, what action should the manager take?" Stop measuring performance Continue to monitor performance Judge performance against similar departments Plot performance data on a control chart

Continue to monitor performance

Which of the following healthcare dimensions was NOT mentioned by the Committee on Quality of Health Care in America as an area that needed improvement? Timeliness Equity Convenience Safety

Convenience

"When desired results are achieved with minimal expenditure of resources, the healthcare services are most accurately described as what?" Beneficial Reasonable Cost-effective Customer-friendly

Cost-effective

What type of data display uses symbols or colors to draw people s attention to performance concerns? Bar graph Pie chart Line graph Dashboard

Dashboard

During which phase of quality management are raw data examined to draw conclusions about performance? Data analytics Performance measurement Goal setting Data mining

Data analytics

What document does The Joint Commission require hospitals create to describe each data element captured electronically? Measure specifications Data dictionary Data attributes Measure plan

Data dictionary

A hospital improvement team has brainstormed several potential solutions to the problem of high nursing staff turnover. What tool could the team use to select the solutions most likely to be successful? Flowchart Pareto analysis Decision matrix Questionnaire

Decision matrix

Six Sigma projects commonly involve which of these steps? Plan-Do-Check-Act Define-Measure-Analyze-Improve-Control Focus-Analyze-Develop-Execute Plan-Do-Study-Act

Define-Measure-Analyze-Improve-Control

"A health maintenance organization conducted a study on outpatient treatment of patients with asthma. The need for a new asthma management protocol was identified, and it was developed. Now the protocol is being piloted by physicians at two primary care clinics. This project is in which phase of the Plan-Do-Study-Act improvement cycle?" Do Plan Act Study

Do

What is the data source for an e-measure? Electronic database Excel spreadsheet Patient surveys Paper records

Electronic database

A healthcare service is considered underused when the added benefits are less than the added costs of that service. True or false

False

Healthcare organizations do not use performance comparisons with other organizations to set performance targets. True or False

False

Measures of clinical decision making often originate from medical license requirements. True and False

False

Participants in a structured brainstorming session write their ideas on papers that are collected and posted for everyone to see. True or False

False

Qualitative tools provide numeric information for an improvement project team. True or False

False

The healthcare quality Triple Aim framework was developed by the National Academy of Medicine. True or False

False

Visual controls are used in a Lean project to make process waste more visible to help identify where it can be minimized. True or False

False

What qualitative tool would be used by an improvement team to undercover the root cause of a performance problem? Five Whys Flow chart Stakeholder analysis Pareto chart

Five Whys

Staff in an ambulatory surgery center want to streamline the patient admission process. What performance improvement tool would they use to get a better understanding of how patients are currently admitted? Affinity diagram Flowchart Stakeholder analysis Histogram

Flowchart

"An improvement team in a home health agency wants to streamline the process of discharging patients. The team identifies all the factors that will hinder the success of their improvement plans, as well as those factors that will increase the likelihood of success. The team is using what improvement tool?" Force field analysis Nominal group technique Pareto analysis Lean thinking

Force field analysis

"For a healthcare process to achieve Six Sigma, what level of quality is expected?" No variation Free of defects Minimal waste Meets expectations

Free of defects

What federal act created incentives for hospitals and providers to adopt electronic health records? National Quality Strategy Health Information Technology for Economic and Clinical Health Patient Protection and Affordable Care Act Medicare Access and CHIP Reauthorization

Health Information Technology for Economic and Clinical Health

What type of healthcare organization uses measures found in the Healthcare Effectiveness Data and Information Set (HEDIS)? Urgent care clinic Health insurance plan Home health agency Rehabilitation facility

Health insurance plan

What is a publicly available source of comparative healthcare performance data? National Quality Forum Healthcare Cost and Utilization Project American Customer Satisfaction Index Hospital Association Quality Measures

Healthcare Cost and Utilization Project

Which graph is used to display the frequency distribution of measurement data? Scatter diagram Pie chart Histogram Line graph

Histogram

What is the first step in constructing a performance measurement? Establish performance goals Identify topic of interest Identify data sources Establish measurement team

Identify topic of interest

Which step follows the assessment phase in the quality management cycle? Improvement Evaluation Measurement Planning

Improvement

What are the three primary quality management activities? Quality planning, control, and improvement Goal setting, prioritization, and measurement Overuse, underuse, and misuse Measurement, assessment, and improvement

Measurement, assessment, and improvement

What are the three primary quality management activities? "Quality planning, control, and improvement" "Goal setting, prioritization, and measurement" "Overuse, underuse, and misuse" "Measurement, assessment, and improvement"

Measurement, assessment, and improvement"

Which of the following statements regarding control charts is TRUE? Control charts are used to reduce assignable variation. Time-series data are plotted on a control chart. The Pareto principle is highlighted by the use of control charts. A control chart is a good tool for displaying cause and effect.

Time-series data are plotted on a control chart.

What does an organization use benchmarking for? To compare current performance to previous performance To determine the level of current performance To determine if current performance meets performance goals To compare current performance to an exemplary organization

To compare current performance to an exemplary organization

What is the denominator for the performance measure percentage of home health patients admitted to the hospital ? Total number of hospitalized patients Total number of home health patients Total number of home health patients admitted to the hospital Total number of home health patients not admitted to the hospital

Total number of home health patients

"A flowchart is a visual representation of the movement of people, materials, paperwork, or information during a process." True or false

True

"During the Do phase of a Plan-Do-Check-Act improvement project, process changes are implemented on a small scale and success is measured." True or False

True

"In a high-reliability organization, there are fewer accidents than would be expected." True or false

True

A cause and effect diagram is a structured brainstorming technique. True or False

True

A line graph can be used to distinguish between common cause and special cause variations in performance. True or False

True

A performance measure is considered evidence based if it is derived from nationally recognized practice guidelines. True or False

True

Doctors often practice defensive medicine for the purpose of avoiding malpractice liability. True or False

True

Healthcare quality can not be achieved without reliability. True or False

True

One reason healthcare organizations seek accreditation is to stimulate internal quality improvement efforts. True or False

True

Performance targets are set at 100% for aspects of healthcare that affect patient satisfaction. True or False

True

Process improvement teams use analytic tools to evaluate where changes are needed to improve performance. True or False

True

Tampering can occur when a manager reacts to performance measurement results without knowing how much natural performance variance occurs in the process. True or False

True

The percentage of patients receiving home health services who develop a pressure ulcer is a measure of potentially avoidable events. True or False

True

The response rate to a survey is usually expressed as a percentage. True or False

True

What factors unique to healthcare delivery inhibit adoption of some industrial quality improvement techniques? Need for adequately trained and competent staff Variable conditions and behaviors of patients Regulatory requirements and accreditation standards Customer expectations for quality and reliability

Variable conditions and behaviors of patients

Who is considered the father of statistical quality control? W. Edwards Deming Walter Shewhart Joseph Juran Kaoru Ishikawa

Walter Shewhart

Who was the originator of the Plan-Do-Check-Act model of performance improvement? W. Edwards Deming Toyota Walter Shewhart Motorola

Walter Shewhart

What is the first question asked during a FOCUS-PDCA project? Who are the key stakeholders? How will we know that a change is an improvement? What process do we want to improve? What changes can we make that will result in improvement?

What process do we want to improve?

A team in the hospital registration department is conducting a Lean project to reduce wasteful steps in the process of preregistering elective admissions. What qualitative improvement tool could the team use to better understand the movement of preadmission paperwork throughout the department? Staff survey Workflow diagram Cause and effect diagram Multi-voting

Workflow diagram

What improvement model involves small process changes and careful measurement of the effect of the changes? Lean Six Sigma Plan-Do-Check-Act Rapid cycle improvement

Rapid cycle improvement

"What statistic is used to report a measurement that is comparing two things (e.g., the actual number of hospital deaths as compared to the expected deaths)?" Average Percentage Ratio Absolute number

Ratio

"During the Act phase of a PDSA project, if changes made to improve performance are found to be unsuccessful, what is the next step?" Start a different process improvement project. Add new members to the improvement project team. Repeat the project starting at the Plan phase. Continue to monitor process performance.

Repeat the project starting at the Plan phase.

What can cause data gathered through the use of patient satisfaction surveys to be unreliable? Surveys are sent to a representative sample Response rate is low Questions are graded on a continuum Survey is conducted online

Response rate is low

The clinic medical director wants to know if there is a correlation between the number of minutes patients must wait to see a physician and the time of day. Which graph would you use to display the data to help determine if a relationship exists between the two variables? Scatter diagram Pie chart Histogram Control chart

Scatter diagram

What is an example of a quantitative improvement tool? Scatter diagram Cause and effect diagram Decision matrix Nominal group technique

Scatter diagram

Achieving near-perfect quality is the primary goal of which performance improvement model? FOCUS-PDCA Six Sigma Rapid cycle improvement Lean

Six Sigma

"When a data point on a control chart falls above the upper control limit, the process being measured is exhibiting what type of characteristic?" Common cause variation Random variation Exceptional variation Special cause variation

Special cause variation

"To improve productivity in the hospital operating room, the manager wants to start scheduling elective surgeries on Saturday. What tool can the manager use to identify strategies for gaining support from individuals who may resist this change?" Pareto analysis Stakeholder analysis Five Whys Nominal group technique

Stakeholder analysis

Staff members in the physical therapy department gather information about the reasons why patient treatments do not start at the scheduled time. They want to group the reasons for late treatment starts into related categories to identify commonalities. What performance improvement tool could be used to sort the reasons into similar categories? Prioritization matrix Force field analysis Flowchart Affinity diagram

Affinity diagram

Which of the following is one of the three broad aims of the National Quality Strategy? Affordable care Fewer health disparities Improved satisfaction Efficient care

Affordable care

What group sponsors the National Guidelines Clearinghouse? Centers for Medicare & Medicaid Services The Joint Commission National Quality Forum Agency for Healthcare Research and Quality

Agency for Healthcare Research and Quality

What organization sponsored the first program to improve quality in US hospitals? American College of Surgeons The Joint Commission Medical Group Management Association Centers for Medicare & Medicaid Services

American College of Surgeons

Which of the following formats can be used to display measurement data from different time periods? Pie chart Scatter diagram Tabular report Pareto chart

Tabular report

Which of the following statements best represents the philosophy employed by the Pareto principle? The majority of quality defects are caused by a small percentage of identifiable problems. "Generally, 80% of quality problems are candidates for improvement actions." Problems that have a measurable effect on patient outcomes should be corrected. "To achieve ideal performance, all quality problems should be investigated."

The majority of quality defects are caused by a small percentage of identifiable problems.

Which of the following factors is NOT considered when selecting a format for displaying measurement data? The need for improvements The information s intended use The measurement time frame The audience

The need for improvements

What is one of the core values found in the Baldrige healthcare criteria for performance excellence? Quality control Employee empowerment Do no harm Management by fact

Management by fact

What is a step common to all performance improvement models? Identify customer expectations Measure success Evaluate special cause variation Prevent rework

Measure success

What framework is used by an organization to categorize system-level performance measures? Balanced scorecard Check sheet Triple Aim ORYX project

Balanced scorecard

What quality program is managed by the National Institute of Standards and Technology in the US Commerce Department? Baldrige National Quality Program The healthcare quality Triple Aim Conditions of Participation National Quality Strategy

Baldrige National Quality Program

What type of data display is commonly used to report performance measurement data over time? Bar graph Scatter diagram Histogram Pareto chart

Bar Graph

What is a measure of the performance potential of a process? Benchmark Value index Capability Efficiency

Capability

An improvement team in the emergency department brainstorms all factors that have an effect on how long patients wait before being seen by a physician. What performance improvement tool would be useful for categorizing the factors identified through this brainstorming activity? Cause and effect diagram Five Whys Workflow diagram Pareto chart

Cause and effect diagram

What is another name for a fishbone diagram? Workflow diagram Affinity diagram Cause and effect diagram Force field diagram

Cause and effect diagram

Which of the following is a data-gathering tool used to collect performance measurement data? Dashboard Sampling Check sheet Scorecard

Check sheet

What organization published Crossing the Quality Chasm: A New Health System for the 21st Century? Institute for Healthcare Improvement American Hospital Association Institute of Medicine Centers for Medicare & Medicaid Services

Institute of Medicine

What group acts on the behalf of consumers to keep healthcare costs down? Hospital trade association National Academy of Medicine Insurance industry Securities and Exchange Commission

Insurance industry

What is a short-term Lean project? DMAIC PDCA Rapid cycle Kaizen event

Kaizen event

What Lean technique makes it easier for staff to quickly recognize when an inventory item needs to be restocked? Value stream map Mistake-proofing Kanban Standards

Kanban

Eliminating wasteful inefficiencies in a process is the primary goal of which performance improvement model? FADE Rapid cycle improvement Plan-Do-Study-Act Lean

Lean

What improvement model originated in the Toyota automobile production system? Lean Six Sigma Focus-PCDA Baldrige

Lean

Statistical process control techniques can be applied to which type of graph? Scatter diagram Histogram Pareto chart Line graph

Line Graph

Which external group does NOT establish performance measurement requirements for healthcare organizations? Centers for Medicare & Medicaid Services National Committee for Quality Assurance National Quality Forum The Joint Commission

National Quality Forum

The hospital respiratory therapy department is conducting a Six Sigma project for the purpose of reducing the incidence of missed treatments. The department s medical director asks staff members to identify process changes that will result in fewer missed treatments. What qualitative improvement tool could the director use during this brainstorming session to narrow down potential solutions to those most likely to be successful? Nominal group technique Workflow diagram Planning matrix Cause and effect diagram

Nominal group technique

Which of the following is a structure measure used to evaluate hospital performance? Rate of patient falls in various units Percentage of patients educated about their medications Number of disaster drills conducted annually Percentage of patients with private insurance

Number of disaster drills conducted annually

What is a process measure of staff performance in a nursing home? Percentage of residents developing a pressure ulcer Percentage of residents regularly participating in social activities Number of records lacking documentation of resident s allergies Number of requests for equipment maintenance

Number of records lacking documentation of resident s allergies

Which of the following best describes a reliable healthcare service? One that meets customer expectations One that consistently performs as intended One that adds value for the customer One that is provided in a timely manner

One that consistently performs as intended

"The hospital has collected patient satisfaction data for more than one year. It is now time for strategic planning, and you ve been asked to summarize the satisfaction data so senior leaders can establish two or three strategic objectives related to improving patient satisfaction. They want to focus on the vital few issues that cause the most problems. What type of graph would you use to provide senior leaders with the information they need?" Pie chart Control chart Pareto chart Radar chart

Pareto chart

Which of the following is a patient experience measure for a hospital? Percentage of patients completing preadmission forms Percentage of patients reporting pain was well controlled Percentage of patients developing a urinary tract infection

Percentage of patients reporting pain was well controlled

What activity-level measure is related to the system-level measure percentage of hospital patients who are very satisfied with the overall quality of care? Percentage of hospital physicians who are board certified Rate of staff compliance with hand hygiene procedures Rate of insurance claims submitted within 10 days of patient discharge Percentage of patients reporting that nurses treated them with respect

Percentage of patients reporting that nurses treated them with respect

Which of the following is a process measure of performance in a hospital intensive care unit? Percentage of patients on ventilators who develop pneumonia Rate of patient readmissions to the intensive care unit Percentage of staff using hand cleaner when entering patient room Number of complaints received from family members

Percentage of staff using hand cleaner when entering patient room

What is revealed by evaluating the difference between a department s actual and expected performance? Performance goal Performance gap Performance trend Performance target

Performance gap

The hospital team charged with reducing the incidence of patient falls has selected four different patient care process changes that need to be implemented. What tool would the team use to document the tasks necessary for making these process changes? Planning matrix Storyboard Workflow diagram Deployment flow chart

Planning matrix

What situation puts data accuracy at risk when more than two people are independently gathering data for the same performance measure? Poor interrater reliability Only a sample of the population is measured Patient records are the data source Data are collected on different days

Poor interrater reliability

"Until the 1970s, healthcare quality activities were primarily based on which management system?" Deming approach to continuous improvement Quality assurance methodology Synthesis and alignment principle Pre-Industrial Revolution craft model

Pre-Industrial Revolution craft model

What is a visual representation of the flow of process steps? Process diagram Process analysis Flow stream Statistical process control

Process diagram

What activity is done to achieve compliance with minimum quality standards in a healthcare organization? Quality planning Performance assessment Performance measurement Quality assurance

Quality assurance