CPHQ 2
Which of the following steps should be taken before QA activities begin?
The scope of involvement should be identified
Which is the following does NOT contribute to evidence-based practice inhealthcare?
Tradition
A healthcare provider recently conducted a customer satisfaction survey that focused on the five key quality characteristics in the graph below. Be analyzing the information, the provider can identify that customers were most dissatisfied with
cost and most satisfied with caring
Because of a doctor's poor handwriting, a prescription must be reworked before it leaves the pharmacy. Which of the following is true
the prescription should not count towards the pharmacy's yield
The protocol for ordering a medication should be
the same every time
The leader of a pain management performance improvement team has asked the quality council to disband the team. The most important factor for the quality council to assess is
How well the team met the intended outcome
An adverse drug reaction can be best described as
harm that occurs as a result of the administration of a drug
When conducting a sentinel event review, a root cause analysis
identifies gaps in patient care processes
Medication reconciliation is a process intended to
identify and resolve discrepancies
The primary purpose of risk management trend analysis is to
identify opportunities for improvements
Which of the following action plans is the first step in correcting inappropriate blood usage in an emergency department?
improvements in documentation
Which of the following should be included in an annual performance improvement report to a governing body?
incident/occurence reports
Confronted by excessive WIP levels, many laboratories take the unhelpful step of
installing new technology
In the perfect lean enterprise, delivery to the customer is
instantaneous
One advantage of the kaizen approach to DMAIC implementation is that
it is accomplished in about a week
Because the hospital is busy, an anesthesiologist is given less time than usual to examine the infusion device that will be delivering medication to a patient during surgery. The machine malfunctions and the doctors on hand must work feverishly to save the patients life. This is example of
latent error
In a typical hospital, approximately what percentage of error is reported?
less than 5%
The practice of waiting for a certain number of samples before commencing a test run results in
longer lead times
A failure mode and effects analysis (FEMA) provides which of the following types of review?
Proactive
In the lean enterprise model, what is the first step toward improving quality
establishing performance metrics
In a traditional meeting, the timekeeper and the minute taker roles are
filled by different people every time
Which of the following charts would most likely be used first in a root cause analysis?
flow
A good meeting facilitator will
focus on the process rather than the content
A presentation on the basic structures and processes of clinical governance would be most useful
for the organization as a whole
Failure modes can be prioritized by calculating the critically index. Which of the following three categories are normally used to calculate a criticality index?
frequency, severity and ease of detection
A performance improvement training program for supervisors should include
rapid-cycle process
A hospital-wide set of professional standards is important because it
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 SME
A hospital manager notices that a significant proportion of medication errors in the facility involve the same two drugs. What is the most likely cause of this?
the drugs come in similar packaging
What is one disadvantage of the visioning strategy for setting goals
the group must have at least six members for it to be feasible
Human factors engineering is defined as the study of humans and their interaction with
the tools they use and the enviroment
What is the best explanation for the relatively slow introduction of lean practices into medical laboratories?
the variability and complexity of the samples in a laboratory are much higher than in a manufacturing enviroment
A hospital manager operates on the assumption that his employees will thrive when they are given responsibility and the opportunity to perform well. THe manager's beliefs are aligned with
theory y
Satisfaction Surverys, focus groups, and complaint tracking are tools used to
understand customers' expectations
The process chain in a laboratory is particularly subject to
variability
Which of the following is the source of the most medication errors?
verbal orders
A meeting of department managers is discussing the catering service and menu for a hospital-wide special occasion. This decision should be made by
voting
Which of the following groups is least likely to report errors?
Independent contrators
During a meeting, the facilitator notices that one of the participants is getting agitated. After the meeting, what would be the best question for the facilitator to ask the participant?
"Were you feeling irritated during the meeting?"
Which of the following is NOT one of the typical questions in a force-field analysis
"What do you hope to accomplish in the meeting?"
Frequency distribution can best be displayed through us of
A histogram
Which of the following conditions should a quality assessment program NOT examine?
A rare condition that has a small effect on mortality or morbidity
Which of the following is NOT one of the types of quality problems identified by the Institute of Medicine's National Roundtable on Health Care Quality
Abuse
Deemed status refers to
Accreditation equivalency with a Centers for Medicare & Medicaid (CMS) survey
Quality improvement teams go through stages of development. These team development stages include all of the following EXCEPT
Conforming
An outpatient clinic is attempting to measure the quality of a newly developed diabetes disease management program. To accomplish this, laboratory results will be measured overtime. The best way to display the data is to use a
Control chart
According to the Institute of medicine, which of the following is NOT one of the domains of quality care?
Customization
Which of the following is an example of information that should be included in an incident report, but should not be recorded in a patients medical record?
Details concerning a medication preparation error discovered and corrected prior to administration
Which of the following is most appropriate in preparation for an external survey of a healthcare facility?
Educate staff about the types of questions they may be asked
A clinical pathway on the management of a hip fractures has been developed by a multidisciplinary team and implemented in a large teaching hospital. After monitoring for 6 months, the length of stay continues to exceed the guidelines. Which of the following should be the next step?
Evaluate the compliance with the pathway
The quality improvement director is responsible for coordination of accreditation survey activities. Responsibilities will most likely include
Facilitating self-assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda for the survey
In managed care, the most widely used performance measures are
Healthcare Effectiveness Data and Information Set (HEDIS)
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
Medical record review
For continuous quality improvement team to be successful, who must be included on the team?
Person performing the process
Data collected about surgical cases show significant delays. Further analysis shows the following chart: Which of the following should a healthcare quality professional do?
Provide the service chief with further analyses of surgeon-specific data
Comparing healthcare organizations by using medical error rates
Provides the best method for benchmarking patient safety
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?
Review the policy with nursing representatives to identify ambiguities
Which of the following is the first step in preparing for an initial accreditation or certification
Review the standards and determine readiness
Which of the following is vastly different from the others
SIPOC (suppliers, inputs, process, outputs, customers)
Staff has been trained and oriented on a new electronic incident reporting system. In the past, staff could report anonymously. The new system requires staff to sign in with an individualized username and password. Three months after implementation, there is a sharp reduction in the number of reported incidents. Which of the following reasons for the underreporting of incidents is of greatest concern
Staff fear of negative consequences of reporting
Random screening of newborns by neonatology department has so firmed a high incident 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?
Test only newborns with a family history of G6PD
A 69-year old female admitted for hip replacement is taken to surgery. The patient is identified, surgical site is marked incorrectly, and the equipment/x-rays are present. A near miss was most likely identified as a result of
a surgical team "time-out"
Before conducting a safety audit in an emergency department, an administrator must first obtain
a written set of safety standards
A delay in discharging patients is likely to cause recurrent bottlenecks in
admissions from ER, the filling of scripts, and admissions from surgical wards
When establishing a clinical-governance training program for the directorate, it is useful to
align the subject matter with the specific tasks of the audience
A strategy used in brainstorming is that ideas are
all recorded
A physician complains to the healthcare quality professional that the nursing staff did not strictly follow orders for a patient. The physician requests that the healthcare quality professional speak with the nurse manager. To facilitate improved communication, the healthcare quality professional should
arrange a meeting with the physician and nurse manager
A simple but effective way for managers to obtain the support of team members is to
ask for it
When is the best time for chairing during a meeting
at the beginning
When is the best time to discuss the results of a meeting exit survey
at the beginning of the next meeting
A patient safety program can best be enhanced by which of the following technologies?
barcode system for medication
A whole systems approach to clinical governance is important because
changes must be applied at all levels of the organization
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
chief of the department
A medication error occurred resulting on a severe adverse outcome. In addition to informing the patient and/or family, a healthcare quality professional should
conduct a root cause analysis
Facility A is investigating its medication administration time for a specific diagnosis. Evidence-based guidelines indicate that administration of a particular drug within 30 minutes significantly improves patient outcomes. The national average is 32 minutes. The average for Facility B is 28 minutes. If the average for Facility A is 35 minutes, Facility A should
contact facility B to determine its practices
To avoid misinterpreting variances, which of the following statistical tools should be used?
control chart
In lean thinking, a process step is defined as "value added" if the
customer recognizes the value
In behavioral health, the most important sentinel event for root cause analysis is
death
The definitive proof of the success of a regulation program is
decrease need for inspections
Time available divided by time available and time required is the Six Sigma ratio for
dependability
In the quality improvement process, performing a cost-benefit analysis would be most useful in
designing solutions and controls
A doctor fails to administer an indicated test, and the patient's condition deteriorates to the point that he must be admitted to an inpatient facility. This is an example of
diagnostic error
Whenever possible, medication orders should be by
dose
Research suggests that the largest proportion of adverse events attributable to negligence occur in the
emergency room
Which are the following are attributes of a culture of safety?
empowered staff and transparency
Which of the following should a Quality Council provide to best ensure success of performance improvement teams
empowerment and training
A monitoring system us 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?
establishing criteria that are based on the most recent changes in medical science and technology
Hospitals that implement computerized provider order entry (COPE) almost always see a decline in
medication errors
A hospital manager finds that he is unable to effectively supervise all of the employees who report directly to him. A reorganization of the hospital hierarchy should
minimize the manager's span of control
Team cohesion is established during which of the following stages of team growth?
norming
Which of the following obstetrical outcomes would result in a morbidity review?
post-delivery septicemia
It is easy to conduct a survey of medications-related errors because
prescription-drug use is common and well documented
In a successful lean healthcare facility, the largest costs related to quality will be incurred by
preventive errors
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?
scatter diagram
When prescriptions are being prepared, the labeling process begins at the same time as the medication is being packaged. However, the labeling does not take as long as the packaging. This difference in the time does not add to the overall duration of the prescription-filling process. This an example of
slack time
A culture of patient safety in an organization will have been successfully created when
staff members serve as advocates
A behavioral health specialist notices a particularly high number of restraint deaths at a facility. An analysis of root causes of these events is most likely to indicate problems with
staff orientation and training
A physician who has a high inpatient mortality rate compared to others in a facility should first be
subjected to a more in-depth review of cases
The phrase "reaching consensus" is often used in performance improvement. The term consensus refers to
supported by all members
The target for performance improvement should be
systems
