Other CPHQ Practice Questions

Which of the following are the primary reasons for developing drug formularies? A. manage pharmacy costs, promote patient safety B. reduce medication errors, educate physicians C. encourage the appropriate use of medications, educate physicians D. decrease food and drug interactions, promote patient safety

A. A drug formulary is an approved list of medications, clinical indications, and doses that helps manage pharmacy costs and patient safety.

Situation-Background-Assessment-Recommendation (SBAR) is a A. tool to improve communication among caregivers. B. Six Sigma methodology. C. method that measures process variation. D. software package used in quality improvement.

A.√ tool to improve communication among caregivers.*************

56- Standards of care based on the knowledge and research of recognized experts are known as A. benchmark data. B. generic screens. C. pre-established criteria. D. evidence-based guidelines.

EXPLANATIONS: A. Benchmark data are included in establishing standards of care. B. Generic screens are used as triggers to identify potential problem areas. C. Pre-established criteria may not be based on research. D. Evidence-based guidelines are consensus driven and based on research or literature.

55- A re-engineering effort occurred at a facility. The activities, particularly those regarding staff layoffs, were carefully planned, communicated, and implemented according to the plan. One year later, the business is stable but staff morale is very low. A healthcare quality professional has been asked to consult in determining where the effort went wrong. Based on the concepts of change theory, the cause is most likely A. that the re-engineering decision was a mistake. B. a failure to address the needs of the staff who were retained. C. leadership was not properly trained in the change process. D. a few disgruntled staff are instigating dissension in the ranks.

EXPLANATIONS: A. There is not enough information to determine whether the re- engineering was a mistake. B. Addressing the needs of the retained staff is important for staff morale, "buy-in," or ownership of the change. C. Improperly trained leadership may be a component of the issues, but not necessarily the cause of low staff morale. D. Having disgruntled staff may be a component of the issues, but there is not enough information to determine whether this has occurred.

32- The concept of "patient safety" applies most appropriately to A. environmental safety measures. B. serious physical injuries. C. patient complaint management. D. risk prevention.

A. According to The Joint Commission and others, the physical environment is only one aspect of patient safety; therefore, this is an incomplete answer. B. According to The Joint Commission and others, patient safety encompasses not only prevention of serious physical injury, but also the identification of risks in the performance of tasks or the physical environment; therefore, this answer is incomplete. C. Complaint review and management may help to identify potential patient safety issues, but is not a reliable method to improve patient safety. D. The Joint Commission defines safety as the degree to which the risk of an intervention (e.g., use of drugs, procedures) in the care environment is reduced for a patient and other persons, including healthcare practitioners. Safety risks may arise from the performance of tasks, the structure of the physical environment, or situations beyond the organization's control, such as weather. Therefore, risk prevention is the correct answer because it best encompasses all areas of safety, while the other responses are limited to one area of patient safety.

Which of the following is the primary goal of risk management? A. Identify and manage risks to promote patient safety. B. Maintain an effective incident reporting system. C. Perform failure mode and effects analyses. D. Eliminate financial loss associated with legal actions.

A. Improving patient safety is the primary goal of risk management.

28- A facility has identified a trend of increased falls for patients aged 60 to 85 years. An effective fall prevention program should include A. a fall protocol, restraint criteria, and a family sitter program. B. restraint criteria, staff education, and a sedation protocol. C. a patient assessment process, a family sitter program, and a sedation protocol. D. a patient assessment process, a fall protocol, and staff education.

A. See explanation B. B. According to the CMS Conditions of Participation for hospitals and long-term care, patients or residents have the right to be free of restraints of any form (physical or drug) that are not medically necessary. Restraints should only be used when other less restrictive forms of management have failed and there is a need to ensure the safety or well-being of the patient/resident. Restraints should not be used as part of a routine falls prevention program. C. According to the CMS Conditions of Participation for hospitals and long-term care, patients or residents have the right to be free of restraints of any form (physical or drug) that are not medically necessary. Medications used to restrict the freedom of movement of a patient are considered a restraint when not used as medically necessary for their condition. Therefore, any sedation protocol used as part of the falls prevention program would be considered a restraint. D. The proper steps to reducing patient falls include assessing the risk for fall regularly during a patient stay, putting in place protocols to reduce falls based on the results of the assessment, then conducting staff education to ensure these steps are implemented.

53- A healthcare quality professional is developing a policy regarding access to physician quality files. In addition to the date and name of the person requesting the information, which of the following should be included in the policy? A. requestor's contact information B. purpose of the request C. the credentialing application D. the practitioner privilege form

A. The requestor's contact information is not an essential element to include as a requirement in this policy. B. The high degree of sensitivity related to the evaluation of practitioner experience and outcomes dictates the need to answer questions about who (to ascertain authority), when (to establish timing), why (to determine whether the access was valid and credible), and what (to establish the relevancy of the request to the stated reason for access). C. The credentialing application is not an essential element to include as a requirement in this policy. D. The practitioner privilege form is not an essential element to include as a requirement in this policy.

8-The Joint Commission (TJC) Standards and Elements of Performance are used A. to define expectations for safety and quality care. B. in place of Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. C. to determine compliance with the Department of Health and Human Services (HHS). D. to calculate pay-for-performance incentives or penalties.

A. to define expectations for safety and quality care.*********

Which of the following is NOT a function of the facilitator on a quality improvement team? A. Keep minutes and records of the team's efforts. B. Keep the group focused on a central issue. C. Tactfully prevent anyone from dominating the discussion. D. Manage time.

A.√ Keep minutes and records of the team's efforts.*****************

small, rural hospital wishes to evaluate customer satisfaction using a survey. The organization has four patient care units, an emergency department, and an ambulatory unit. Which of the following survey methods provides the most reliable information? A.a random sample of 20% of annual discharges/visits per unit B. a random sample of 5% of all annual discharges/visits C. all discharges/visits in January and July D. all discharges/visits of customers with a last name beginning with the letters A-E

A.√ a random sample of 20% of annual discharges/visits per unit*******

A process indicator is defined as one that measures A. an activity carried out to provide care or service. B. significant events that require further investigation. C. unexpected or negative variations. D. the appropriateness of procedure or treatment.

A.√ an activity carried out to provide care or service.*********

Which of the following is most useful in performing a morbidity/mortality review? A.autopsy results B. physician profiling C. do-not-resuscitate policy D. length of stay

A.√ autopsy results*******************

In continuous quality improvement programs, surveys are essential to determine which of the following? A.customer needs B. performance standards C. effective management D. population demographics

A.√ customer needs ****************

Patient safety is promoted in an organization through A.encouragement of error reporting, staff education, and reliable systems. B. reliable systems, open communication, and performance reviews. C. performance reviews, encouragement of error reporting, and willingness to pay overtime. D. willingness to pay overtime, open communication, and staff education.

A.√ encouragement of error reporting, staff education, and reliable systems.*******

40. Team building goals for a first meeting should include all of the following EXCEPT A.evaluating the project. B. learning to work as a team. C. getting to know one another. D. setting meeting ground rules.

A.√ evaluating the project.**********

An organization has established a culture of patient safety when A.fear of retaliation is eliminated. B. reports of potential errors have decreased. C. patient safety goals are implemented. D. employee education is completed.

A.√ fear of retaliation is eliminated. ****************

A performance improvement team has been created to examine infection rates following surgery. Which of the following is the best reference for the team to use? A.hospital infection rates following surgery among similar facilities B. individual infection rates for each surgeon C. postoperative antibiotic use among surgeons D. number of surgeries performed among similar facilities

A.√ hospital infection rates following surgery among similar facilities***********

3-Which of the following accrediting bodies have deemed status with the Centers for Medicare and Medicaid Services (CMS)? A. ISO Certification and The Joint Commission (TJC) B. Det Norske Veritas (DNV) and the Healthcare Facility Accreditation Program (HFAP) C. The American Osteopathic Association (AOA) and the National Quality Forum (NQF) D. The American Medical Association (AMA) and Commission Accreditation of Rehabilitation Facilities (CARF)

B. Det Norske Veritas (DNV) and the Healthcare Facility Accreditation Program (HFAP)****

23-A former patient emails an organization's chief executive officer complimenting the friendliness of the nurses while complaining that her pain was not well-managed. To comply with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, what actions are needed? A. Interview staff involved, track performance over time, and report to the Quality Council. B. Investigate the complaint, write the patient, and report to the governing board C. Call the patient, put compliments in the nurses' personnel records, and report to the Quality Council. D. Review the medical record, put compliments and complaints in the appropriate staff personnel records, and report to the governing board.

B. Investigate the complaint, write the patient, and report to the governing board.*******

23-A former patient emails an organization's chief executive officer complimenting the friendliness of the nurses while complaining that her pain was not well-managed. To comply with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, what actions are needed? A. Interview staff involved, track performance over time, and report to the Quality Council. B. Investigate the complaint, write the patient, and report to the governing board. C. Call the patient, put compliments in the nurses' personnel records, and report to the Quality Council. D. Review the medical record, put compliments and complaints in the appropriate staff personnel records, and report to the governing board.

B. Investigate the complaint, write the patient, and report to the governing board.*******

45-A team approach to problem solving is most useful when A. the organization's goals are unclear. B. diverse areas of expertise are required. C. communication challenges exist. D. required by a regulatory body.

B. diverse areas of expertise are required.*************

A facility decided to implement Standard Precautions 1 year ago, but compliance has been poor. In addition to assessing the causes for poor compliance, the most effective way for the organization to improve compliance is to A. stock personal protective equipment (PPE) in the clean utility room. B. have employees demonstrate the use of personal protective equipment (PPE) as a part of staff competency. C. show a videotape on Standard Precautions quarterly. D. review and revise handwashing policies and procedures.

B. have employees demonstrate the use of personal protective equipment (PPE) as a part of staff competency.

9-The primary reason healthcare organizations use benchmarking is to A. comply with accreditation standards. B. improve performance. C. decrease risk to the organization. D. provide risk adjustment.

B. improve performance.**********

20-When a healthcare organization is contracting with an outside provider for services, the subcontractor must A. provide a representative to the Quality Council. B. meet all regulatory requirements. C. have an active risk management program. D. have a competitively priced service.

B. meet all regulatory requirements.********************

11. A quality improvement manager received the results from the most recent customer survey. Sixty percent of the residents in a nursing home have rated the temperature of foods served as poor. Which of the following actions should be taken first? A. Call the dietitian and ask for an explanation. B.Review previous results and assess trends. C. Set up a continuous monitor for review. D. Ignore the results and assess next quarter.

B.√ Review previous results and assess trends.*************

The following information about patient falls is obtained from a facility with units that have a similar average daily census: Unit A: 6% Unit B: 4% Unit C: 9% Unit D: 8% Which of the following additional information is most important to evaluate the cause of the falls? A. number of falls B. compliance with fall protocol C. medication education D. time of day

B.√ compliance with fall protocol *************

56. When developing department-specific performance measures and indicators, the quality manager as a consultant should A. conduct a literature search and select quality indicators. B.ensure that the numerator and denominator are clearly defined. C. prioritize the quality indicators for selection by the department leader. D. review the mission statement and seek physician input.

B.√ ensure that the numerator and denominator are clearly defined. ************

Quality improvement teams are beneficial because they A. improve managerial control. B. promote competition and pride among members. C. maximize expertise and perspectives. D. authorize solutions to problems.

C. A diverse team, including members with different experience and backgrounds, provides a broader knowledge base and outcomes.

6-The concept of organizational responsibility is most important to the field of healthcare quality because it holds the organization responsible for A. maintaining confidentiality of all documents. B. requiring physicians to carry adequate malpractice insurance. C. maintaining a process to identify deficiencies in the provision of care. D. ensuring that peer review physicians have no conflict of interest in cases being reviewed.

C. maintaining a process to identify deficiencies in the provision of care.

44-To be useful in preventing future error, a root cause analysis (RCA) should be performed A. at least 45 days after the event. B. using practitioners who were not involved in the event. C. utilizing a multidisciplinary team. D. documenting opinion as well as facts.

C. utilizing a multidisciplinary team.********

Which of the following is the most appropriate question to ask when reviewing an organization's performance improvement (PI) plan? A. "Are there sufficient organizational resources to support the PI plan?" B. "Does the PI plan include statistical methods for monitoring change?" C."Is the PI plan consistent with the organization's mission and strategic priorities?" D. "Has the organization been successful in communicating the intent and message of the PI plan to employees?"

C.√ "Is the PI plan consistent with the organization's mission and strategic priorities?"******************

Which of the following best demonstrates use of the Plan-Do-Check-Act performance improvement model? A. Review current practice, form a multidisciplinary committee, schedule a meeting to develop a plan, and determine actions to be taken. B. Identify a problem, implement change, educate staff about the change, and rewrite policies and procedures to augment the change. C.Prioritize opportunities for improvement, pilot the improvement, compare pre- and post-implementation data, and rollout to the entire organization. D. Collect baseline data, form a committee to develop the plan, validate audit data, and formalize the change.

C.√ Prioritize opportunities for improvement, pilot the improvement, compare pre- and post-implementation data, and rollout to the entire organization.*************

Organizational leaders can best demonstrate commitment to a new quality improvement initiative by A. reviewing the quality improvement plan. B. offering solutions to identified problems. C.allocating resources for the process. D. maintaining performance appraisals for staff.

C.√ allocating resources for the process.*************

64. The best approach for training staff about quality and patient safety is to A. require staff to complete mandatory online training at convenient times. B. develop posters and brochures that explain key quality concepts and place them strategically throughout the workplace. C.conduct multidisciplinary interactive sessions consistent with adult-learning principles. D. have the CEO meet with each department to explain the department's role in quality and safety.

C.√ conduct multidisciplinary interactive sessions consistent with adult-learning principles. **************

The responsibility for providing organizational direction for a facility's continuous quality improvement program frequently rests with the quality A. teams. B. leader. C. council. D. facilitator.

C.√ council.************

16. The prevalence rate of a disease depends on the A. incidence rate and duration of the disease. B. number of new cases and the population at risk. C.total number of cases and the population at risk. D. incidence and change in the balance of etiological factors.

C.√ total number of cases and the population at risk.****************

The relationship between patient satisfaction and hours per patient day on a medical unit was found to be (r = 0.60, p < 0.05). What is the correlation between these two values? A. 0.05 B. 0.36 C. 0.55 D. 0.60

D. The correlation coefficient (r) is an index that ranges from -1.0 to 1.0 and reflects the extent of a linear relationship between two data sets. The correlation coefficient is 0.60.

11- Which of the following best describes an organizational vision statement? A. It is used as a marketing strategy. B. It defines the structure of the institution. C. It describes the organization's strategic plan. D. It reflects the organization's aspirations.

D. Vision is the image or description of what the organization desires to become.

37-The most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staff is by A. developing professional relationships. B. inviting medical staff to an inservice on quality tools. C. evaluating physician participation on quality teams. D. providing outcome data at medical staff meetings

D. providing outcome data at medical staff meetings.********

When introducing continuous quality improvement (CQI) into an organization, a chief executive officer must first A. reach consensus with the staff. B. educate supervisors in CQI principles. C. obtain funding from the governing body. D.assess the organization's readiness for change.

D.√ assess the organization's readiness for change.***********

An ambulatory/outpatient care facility identifies an opportunity to improve the turnaround time for reports of x-rays performed at a local hospital. Which of the following groups should be involved in the team to improve the process? A. administrative representatives from both facilities B. primary care physician, clinic nurse, and clinic administrator C. radiologist, primary care physician, and clinic medical records D.clerical, clinical, and administrative staff from both facilities

D.√ clerical, clinical, and administrative staff from both facilities**************

The best tool to display stability of nosocomial infection rates over time is a A. run chart. B. histogram. C. Pareto chart. D.control chart.

D.√ control chart.****************

A trend analysis of incidents occurring in a healthcare facility should focus on which of the following areas? A. timeliness of reporting and data accuracy B. case mix index and staffing patterns C. practitioner profile and diagnostic codes D.severity level and occurrence types

D.√ severity level and occurrence types ***********

An organization's data demonstrate an increase in the number of patient falls. A healthcare quality professional should recommend A. revising the fall-risk assessment tool. B. convening a focus group of medical staff to discuss fall risks. C. increasing staffing on weekends and nights. D.sharing the data with the staff to provide feedback.

D.√ sharing the data with the staff to provide feedback.*************

42- Which of the following tools should be used to record patient and practitioner-specific data? A. flowchart B. graphs C. histogram D. spreadsheet

EXPLANATIONS: A. A flowchart shows a process. B. There is not enough information provided to determine whether graphs could be used. C. There is not enough information provided to determine whether a histogram could be used. D. A spreadsheet allows for individualized data to be represented.

19- Based on identified issues, a healthcare quality professional examines 100% of one physician's admissions and only 20% of all other physicians' admissions. This is best described as a A. focused review. B. prospective review. C. retrospective review. D. concurrent review.

EXPLANATIONS: A. A focused review is performed for a predetermined reason and is concentrated on a select sample of cases or data elements. Case or data element selection is usually based on internally identified problem areas or on external demands. Since the quality professional examined 100% of one physician's admission based on identified issues, a focused review is the best description of this case. B. A prospective review is performed prior to care or practice. It is evident in the case above that the review was based on identified issues related to a physician's practice patterns. C. The case above can be described as a retrospective review; however, a focused review is a more accurate answer since the quality professional reviewed 100% of a physician's admissions compared to 20% or all other physician's admissions. D. A concurrent review is performed at the onset of and during care; there is no evidence in the case above that the review was performed at that time.

58- Replacing retrospective review with concurrent review is an example of A. a paradigm shift. B. a process improvement. C. an empowerment process. D. productivity enhancement.

EXPLANATIONS: A. A paradigm shift is a change in method or perspective. B. Switching from a retrospective to concurrent review represents a change that may or may not result in a process improvement. C. Empowerment typically gives the people involved the power to make decisions and is not related to the review process. D. Switching to a concurrent review may or may not result in an increase in productivity.

20- An emergency department tracks wait times from patient arrival to physician assessment. Data are reported using a run chart. Which of the following demonstrates a true statistical increase in treatment delays? A. 6 consecutive ascending data points B. 7 consecutive descending data points C. a zigzag pattern of 10 data points D. data points close to the mean line

EXPLANATIONS: A. A true statistical increase is indicated by 6 consecutive ascending data points. B. Descending data points do not indicate an increase in this particular case. C. A zigzag pattern of data points demonstrates variability in the data. D. Data points close to the mean demonstrate minimal variation in the data.

48- The following data are being analyzed based on 6 months of incident reports for falls in a facility with 10 ICU beds and 40 Med/Surg beds: Which of the following is the next step for the healthcare quality professional to pursue? A. Continue to track and trend incident reports. B. Educate Med/Surg units on fall prevention. C. Form a team to change the ICU fall protocol. D. Conduct further analysis of fall data.

EXPLANATIONS: A. Action needs to be taken to investigate fall patterns because not enough information is provided from the above data. B. Education should be targeted toward identified issues after further analyzing the data. C. Revision may be necessary, but the first step is to determine the cause of the falls. D. The data need to be analyzed further to determine the significance and/or incidence.

25- Patient satisfaction scores for a community hospital demonstrate multiple areas for improvement including a need to improve attractiveness of the facility, responsiveness to patient needs, and physician and nursing communication. Based on these results, which of the following should the healthcare quality professional also expect to find? A. administration prioritizing and leading units to achieve organizational goals B. unit managers who openly discuss patient satisfaction scores C. units operating independently with little communication between units D. employee satisfaction scores in the 80th percentile compared to other peer organizations

EXPLANATIONS: A. Based on the information provided, leadership may not have prioritized these issues to achieve organizational goals. B. There is not enough information provided to determine if managers are discussing patient satisfaction scores. C. Responsiveness to patient needs requires effective communication between multiple units as well as staff. D. Employee satisfaction does not necessarily correlate with these patient satisfaction scores.

36- Benchmarking is based on identifying which of the following? A. best practices B. competition C. deficiencies D. statistical control

EXPLANATIONS: A. Benchmarking is the comparison of results against a reference point, which is a best practice. B. See explanation A. C. See explanation A. D. See explanation A.

24- A root cause analysis revealed a patient in an acute psychiatric unit committed suicide by hanging himself with his shoelaces. To prevent this from occurring again, the most appropriate action is to institute A. patient checks every 15 minutes. B. a policy allowing only non-laced shoes. C. a 24-hour video monitoring system. D. a buddy system for the patients.

EXPLANATIONS: A. Checking patients every 15 minutes may not prevent suicide. B. This policy eliminates the object that was used to commit suicide and creates a safer environment. C. A monitoring system may not prevent suicide. D. A buddy system may not prevent suicide.

23- The concept of organizational liability is most important to the field of healthcare quality because it holds the organization responsible for A. maintaining confidentiality of all documents. B. requiring physicians to carry adequate malpractice insurance. C. maintaining a process to identify deficiencies in the provision of care. D. ensuring that peer review physicians have no conflict of interest in cases being reviewed.

EXPLANATIONS: A. Confidentiality of all documents is not the most important part of organizational liability. B. Carrying adequate malpractice insurance is usually required, but is not the most important aspect. C. Maintaining quality of care is the ultimate responsibility of the governing body of an organization. D. Conducting unbiased peer reviews is a process that helps identify deficiencies in care.

37- Which of the following sampling techniques involves selecting the medical record of every fifth patient undergoing cardiovascular bypass? A. convenience B. systematic C. stratified D. simple random

EXPLANATIONS: A. Convenience sampling allows the use of any arbitrarily selected medical record and while selecting every fifth record may be convenient, systematic sampling is the best answer. B. Systematic sampling is the selection of every nth element from a population. C. Stratified sampling allows for two or more populations, which is not appropriate in this situation. D. Simple random sampling allows every record an equal chance of being selected.

46- Meaningful quality process measures must be A. relevant and valid. B. feasible and explainable. C. relevant and explainable. D. valid and feasible.

EXPLANATIONS: A. Data must be reproducible to be valid. For data to be reproduced, it should be relevant. Relevance of data is important because the data must relate to the quality process being measured. B. See explanation A. C. While the data must be relevant; if it is not valid, it is not meaningful. D. While the data must be valid, feasibility is not one of the typical characteristics used to determine whether a quality process is meaningful.

18- A Quality Council has chartered a Failure Mode and Effects Analysis (FMEA) team to examine the best method of preventing medication errors after the installation of a new medication dispensing system. The team's first major task should be to A. identify ways to detect the likelihood of the equipment breaking down. B. brainstorm on potential failure modes of the equipment. C. multi-vote on the severity of the potential equipment breakdowns. D. develop a flow chart of how the equipment will be installed.

EXPLANATIONS: A. Detecting a specific failure mode, such as equipment failure, is a step in an FMEA, but it is not the first major step. B. In an FMEA, brainstorming potential failures is the first major step. C. Multi-voting on the severity of a failure mode, such a as equipment breakdown, is a step in the FMEA process; but it is not the first major step. D. Developing a flow chart of how equipment will be installed is not a step in an FMEA.

61- Healthcare quality professionals can best communicate organizational values and commitment through A. establishing a multidisciplinary task force. B. disseminating monthly newsletters. C. creating a mission statement. D. leading by example.

EXPLANATIONS: A. Establishing a task force does not communicate organizational values and is not ongoing. B. Newsletters may be one way of communicating, but are a passive form of communication. C. A mission statement is a passive form of communication. Leading by example is the best way to communicate values stated in the mission. D. Demonstrating and practicing expected values are the best ways to communicate organizational values.

52- The most effective tool to improve communication between caregivers is known as A. FMEA. B. PDCA. C. PDSA. D. SBAR.

EXPLANATIONS: A. Failure Mode and Effect Analysis (FMEA) is a prospective analysis tool. B. Plan, Do, Check, Act (PDCA) is a performance improvement methodology. C. Plan, Do, Study, Act (PDSA) is a performance improvement methodology. D. Situation, Background, Assessment, Recommendation (SBAR) creates a shared model for effective information transfer by providing a standardized structure for concise factual communication among clinicians.

44- A chief quality officer has the responsibility for education and implementation of a quality improvement process. To affect cultural change, the chief quality officer must A. believe the costs are justified by the benefits. B. be a visible participant in the process. C. receive quarterly reports. D. limit training to managers and supervisors

EXPLANATIONS: A. For administration support and resources to be provided, administration must believe the costs are justified in order to affect culture change. B. Administration and organization leaders, such as the chief quality officer, must be part of the effort to affect cultural change. C. Receiving quarterly reports does not affect culture change. D. Limiting training to certain staff members does not affect culture change.

39- Which of the following patient safety goals is applicable to everyone in a healthcare facility? A. hand-off communication B. medication safety C. hand hygiene D. prevention of falls

EXPLANATIONS: A. Hand-off communication is about communication among caregivers, not all healthcare workers. B. Medication safety primarily affects pharmacy and nursing units. C. Good hand hygiene is appropriate for everyone, whether in direct contact with patients or not. D. Prevention of falls primarily affects caregivers, housekeeping, and maintenance.

26- A team approach to problem solving is most useful when A. the organization's goals are unclear. B. diverse areas of expertise are required. C. communication challenges exist. D. there are ample resources within the organization.

EXPLANATIONS: A. It is leadership's responsibility, not the team's responsibility, to clearly define organizational goals. B. The make-up of a team that varies in perspective and experience provides a variety of skill sets that will help solve problems. C. Communication challenges may make working within a team more difficult. D. A team approach to problem solving should not be dependent on the amount of resources.

17- Which of the following is essential to an effective quality council? A. involvement of leadership B. consultation of the legal advisor C. participation of the strategic planning committee D. direction from the organization's quality department

EXPLANATIONS: A. Leadership involvement promotes an effective quality council through resource and support allocation to achieve objectives. B. A legal advisor is not commonly a member of a quality council. C. A strategic planning committee is not commonly a component of a quality council. D. The quality department may provide input, but not necessarily direction, to a quality council.

63- Measuring the time it takes a nurse to perform a procedure addresses which of the following aspects of care? A. monitoring B. process C. outcome D. structure

EXPLANATIONS: A. Monitoring is an observance of the process, outcome, or structure. B. Process is the systematic approach to the delivery of medical care. C. Outcome is the result of the medical care provided to patients. D. Structure involves the resources available for medical care delivery.

59- Which of the following is an example of a "never event" or sentinel event? A. missed dose of an antibiotic B. patient fall that results in a bruised tailbone C. fever of 101.2 °F after a blood transfusion D. patient suicide in the psychiatric ward

EXPLANATIONS: A. One missed dose of an antibiotic is not usually considered a sentinel event. B. A bruised tailbone is usually not a sentinel event. C. A fever alone is not a serious side effect of a blood transfusion. D. A suicide in a healthcare facility is serious, preventable, and of concern to all.

47- Clinical decision support systems can best support medication safety by alerting prescribers to A. patient compliance and allergies. B. the need for dose adjustments and patient weight changes. C. drug interactions and patient weight changes. D. allergies and drug interactions.

EXPLANATIONS: A. Patient compliance is not part of a support system. B. Dose adjustment and weight change alerts may be programmed, but are not the primary purpose of the system. C. Patient weight change alerts may be programmed, but are not the primary purpose of the system. D. A clinical decision support system involves a computerized medication management system that allows medication alerts to be programmed (including allergies and drug interactions).

40- A Quality Council is preparing a Patient Safety Plan. A key factor that needs to be considered for the long-term success of the patient safety program is to A. determine which patient safety goals need to be monitored. B. involve the entire organization in the program. C. review incident reports to identify what disciplinary action should occur. D. research how technology can be used to prevent errors.

EXPLANATIONS: A. Patient safety goals may be monitored as part of the program, but are not essential to the program's success. B. The program must be organization-wide to be successful. It must include all members of the healthcare team. C. Reviewing incident reports to identify what disciplinary action should occur would not be part of a patient safety program that aims for a non-threatening environment. D. Technology may be very useful to the program, but it is not essential to its success.

41- Which of the following steps occurs first in facilitating change in an organization? A. Identify problems to be addressed in the organization. B. Get feedback from management. C. Identify key people in the organization who should be involved. D. Develop a performance improvement plan.

EXPLANATIONS: A. Performance improvement methodology includes identifying issues and/or problems before taking action. B. Management feedback may be useful, but the problems should be identified first and feedback should be sought from all stakeholders. C. Identifying key people who should be involved is important, but those people cannot be selected until the problems have been identified. D. A performance improvement plan cannot be developed until the problems have been identified.

57- Physician profiles should be reviewed at time of reappointment to A. assess practitioner competency. B. compare the practitioner to their peers. C. review the number of complaints. D. facilitate reappointment approval.

EXPLANATIONS: A. Physician profiles demonstrate knowledge and skills through outcomes for individual practitioners. B. Comparisons are a component of physician profiles, but are not the main reason they are reviewed for reappointment. C. The number of complaints may be included in physician profiles, but this is not the main reason to review profiles. D. Physician profiles can help facilitate the reappointment process, but demonstrating physician competency is the reason for reviewing profiles.

54- Which of the following is the best way to determine if a quality improvement initiative is successful? A. Present findings to the Quality Council. B. Conduct an employee survey. C. Compare outcomes with pre-established goals. D. Survey patients and customers.

EXPLANATIONS: A. Presenting findings to a Quality Council does not help determine whether an initiative is successful. B. A survey of employees may not help determine if goals have been met. C. Outcomes are evidence of having accomplished pre-established goals. D. Surveying patients and customers may not determine whether an initiative is successful.

34- A hospital is working to reduce readmissions. Which of the following is the best approach to accomplish this goal? A. giving an education sheet on patient medication to the patient and family B. having the patient provide return demonstration of the knowledge provided C. showing a video to a patient and their family D. requesting the home health nurse provide patient instruction EXPLANATIONS:

EXPLANATIONS: A. Providing an education sheet without an opportunity for dialogue is not sufficient. B. Return demonstration is an evidence-based approach for learning. C. Showing a video does not ensure that learning has occurred. D. Delaying instruction until the patient reaches homecare is not appropriate.

60- A facility decided to implement Standard Precautions 1 year ago, but compliance has been poor. In addition to assessing the causes for poor compliance, the most effective way for the organization to improve compliance is to A. stock personal protective equipment (PPE) in the clean utility room. B. initiate return demonstration as a part of staff competency. C. show a videotape on Standard Precautions quarterly. D. review and revise handwashing policies and procedures.

EXPLANATIONS: A. Providing equipment does not necessarily improve compliance. B. Including return demonstration in competency testing ensures that staff understand proper technique. C. Showing a videotape does not necessarily improve compliance. D. Reviewing and revising handwashing policies and procedures does not necessarily improve compliance.

31- Evaluating medication administration to reduce medical errors is an example of A. quality management. B. utilization management. C. risk management. D. financial management.

EXPLANATIONS: A. Quality management involves the process of achieving organizational performance improvement goals. B. Utilization management relates to utilization of resources. C. Improving patient safety, including error reduction, is the primary goal of risk management. D. Financial management involves the process of achieving organizational financial goals.

12- The most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staff is by A. developing professional relationships. B. inviting medical staff to an inservice on quality tools. C. evaluating physician participation on quality teams. D. providing outcome data at medical staff meetings.

EXPLANATIONS: A. Relationships are needed, but they are not the most effective way to communicate quality improvement activities. B. Inviting medical staff to an inservice does not ensure attendance. C. Evaluating participation is not a communication tool. D. Outcome data communicates objective feedback to medical staff.

21- Which of the following are essential functions of an infection control program? A. risk management and surveillance B. prevention and education C. surveillance and prevention D. patient safety and risk management

EXPLANATIONS: A. Risk management is not an essential function of an infection control program. B. Education is a component of prevention, but is not an essential function of an infection control program by itself. C. Two principal functions of infection control are surveillance and prevention. D. Patient safety and risk management are not essential functions of an infection control program.

62- A critically ill patient is admitted and requires a specialized procedure; however, the surgeon does not have privileges at the facility. Which of the following documents will be most helpful in identifying the course of action the hospital should take? A. patient safety manual B. risk management plan C. medical staff bylaws D. surgical policies and procedures

EXPLANATIONS: A. See explanation C. B. See explanation C. C. Medical staff privilege rules are defined in the medical staff bylaws. D. See explanation C.

30- A number of specialty and primary care clinicians have participated in several meetings to develop clinical practice guidelines for the management of diabetes. The team leader has moved the team through the actual guideline development, and is now concentrating on the "evaluation of quality-of-care" phase. Which of the following sequences of steps should the team consider in developing the evaluation phase? A. identify medical review criteria, identify sampling methods to be used, define objectives of the performance review, pilot test B. develop data collection form, identify populations covered by the guideline, identify the data sources, conduct the review C. define objectives of the performance review, identify populations covered by the guideline, develop data collection form, pilot test D. consider costs of the review, identify clinicians and sites of care, define objectives of the performance review, develop data collection form

EXPLANATIONS: A. See explanation C. B. See explanation C. C. Objectives must be defined first. D. See explanation C.

22- A surgery department's monthly case review revealed 10 records meeting criteria and six additional records that did not meet the criteria. In calculating the incidence rate, the denominator is A. 4. B. 6. C. 10. D. 16.

EXPLANATIONS: A. See explanation D. B. See explanation D. C. See explanation D. D. The denominator is the total of all of the medical records, which equals 16.

45- A Quality Council has created a Patient Safety Council. The council is concerned that staff may see this as another program that has been added to their busy schedules that will eventually go away. The best way for the organization to establish patient safety as an ongoing part of the organization's culture is to A. display the number of incident reports monthly with lessons learned. B. identify the patient safety goals and how they will be monitored. C. make patient safety a part of the employees' job descriptions. D. include a presentation on patient safety in employee orientation.

EXPLANATIONS: A. Sharing risk data may help develop a patient safety program, but it will not change the culture of an organization. B. Identifying and monitoring goals is a necessary part of a patient safety program, but will not change the culture of an organization. C. Including patient safety in the job description provides a mechanism to hold employees accountable. D. Providing presentations on patient safety may be helpful, but is not the best way to change the culture of an organization

51- A patient is transferred to a neighboring hospital for a magnetic resonance imaging (MRI) exam. Due to a misinterpretation of orders, the procedure is performed on the wrong part of the body. Which of the following should the healthcare quality professional do? A. Report this as a sentinel event to the transferring hospital. B. Do nothing since it happened at another facility. C. Conduct an analysis to reduce future occurrences. D. Recommend disciplinary action for the offenders.

EXPLANATIONS: A. Simply reporting the event to the transferring hospital does not constitute an investigation. B. Performing a procedure on the wrong part of a patient's body is, by The Joint Commission definition, a sentinel event. Therefore, doing nothing is not the correct response, regardless of whether or not it occurred at another facility due to the fact the patient originated at the quality professional's facility. C. According to The Joint Commission definition, performing a procedure on the wrong patient or the wrong body part is a sentinel event. Any sentinel event that occurs, regardless if another facility is involved, must be investigated in an attempt to reduce further occurrences. D. Recommending disciplinary action would not be appropriate until the completion of the investigation determines its necessity.

29- A Quality Council has chartered a performance improvement team to reduce medication errors. The team has been meeting for several months and progress has been very slow. Which of the following is the most important factor for the Quality Council to assess with the team leader? A. composition of the team B. number of medication errors since team was chartered C. team members' ability to interpret graphs D. frequency of team meetings

EXPLANATIONS: A. The composition of the team is the most important factor and is often the main cause of team failure. Having the right team in place is essential. B. The number of medication errors is not relevant to the team's functionality. C. Interpreting graphs is a skill the team needs, but it is not as important as having the right team members. D. The frequency of meetings may need to be examined, but is not the most important factor

43- Two surveys were completed in a healthcare facility that showed conflicting results concerning patient satisfaction with food services. The two surveys were independently designed and distributed by different departments within the facility. The healthcare quality professional should first A. set up a quality improvement team to improve food service. B. distribute the surveys to obtain a larger sample size. C. design, distribute, and analyze a new survey instrument. D. meet with the departments to review the survey processes.

EXPLANATIONS: A. The data must be analyzed before action steps can be taken. B. A larger sample size may not be necessary. C. The current surveys should be investigated before creating a new survey. D. Reviewing the survey processes with the departments will help the understanding of the survey tools and the processes used

15- A team has identified a process for improvement, selected examples of best practice performers, visited those sites, gathered all necessary data, and compiled the results. The most effective next step for the team is to A. identify the next process to benchmark. B. implement change at the team's site. C. compare results to historical data. D. make the results public for others to use for benchmarking.

EXPLANATIONS: A. The first issue has not been resolved. It needs to be addressed before moving on to the next process. B. Implementation is the next step in the performance improvement cycle. C. All necessary data have already been compiled. D. The process has not been completed, so there is nothing to share at this point.

35- The evaluation of the quality and appropriateness of patient care in the radiology department is the responsibility of the A. medical director of radiology. B. chief medical officer. C. medical director of the quality department. D. administrator of clinical services.

EXPLANATIONS: A. The medical director of a department has the ultimate responsibility for everything within that department (care, quality, technology, etc.). B. The chief medical officer is responsible for facility-wide medical staff operations. C. The medical director of the quality department is responsible for activities within the quality department. D. The administrator of clinical services is responsible for facility-wide clinical activities.

27- A performance improvement training program has been conducted. The healthcare quality professional has determined that improvement has not occurred. The most likely cause for the lack of improvement would be that A. organizational systems are inhibiting changes. B. employees practice what they are trained to do. C. staff members thought the program was too long. D. the facilitator did not prepare agenda materials.

EXPLANATIONS: A. The most common failure of training programs is system challenges within the organization. There must be a culture that fosters safety as a priority for everyone within the organization. B. Employees practicing what they are trained for would lead to improvement and is one of the intended outcomes of a training program. C. While the employees' perception about the program may be that it was too long, it would not be the sole reason that improvement did not occur. This information could help to improve future training programs within the organization. D. The lack of agenda materials could have contributed to the lack of improvement, but would not be the sole cause.

33- The use of clinical pathways and guidelines in hospitals should A. minimize variation in patient care. B. reduce length of stay. C. improve patient satisfaction. D. identify errors in patient care.

EXPLANATIONS: A. The purpose of a clinical pathway and guideline is to standardize best practices. B. Reduced length of stay may occur as a result of minimizing variation in patient care. C. Improved patient satisfaction may occur as a result of minimizing variation in patient care. D. Identifying errors may occur as a result of minimizing variation in patient care.

16- A continuous quality improvement organization promotes vigorous education and training/retraining in order to A. restructure internal jobs. B. reduce the need for competency testing. C. promote harmony within the organization. D. acquire new knowledge and new skills.

EXPLANATIONS: A. The purpose of continuous quality improvement within an organization is to reduce risks and improve the quality of care and patient safety. Restructuring internal jobs would not be a result of a highly reliable organization with a continuous quality improvement program and processes. B. Continuous Quality Improvement (CQI) is a process of creating an environment in which management and workers strive to create constantly improving quality. A successful quality improvement program is one that inspires people to learn, but still requires competency testing. C. Promoting harmony is not a goal of continuous quality improvement. D. As the stem of the question identifies a component of continuous quality improvement as one that promotes education and training, this will yield new knowledge and skills.

38- An effective facilitator should be skilled in process evaluation and the tools of performance evaluation, and must A. not have a vested interest in the content. B. be in a salaried position. C. not speak unless directed by the team leader. D. be a front-line employee.

EXPLANATIONS: A. The role of the facilitator is to be the process expert and remain objective. B. See explanation A. C. See explanation A. D. See explanation A.

50- Which of the following is the first step in the strategic planning process? A. setting goals and objectives B. defining organizational structure C. determining productivity indicators D. establishing and controlling a budget

EXPLANATIONS: A. The strategic planning process is based on what the organization wants to achieve (i.e., goals and objectives). The quality professional might consider other possibilities as first steps, but those were not presented in the options. B. Organizational structure may not be a component of a strategic plan. C. Productivity indicators are measures of the progress made toward the goals and objectives. D. Budget determinations are made based on the goals and objectives.

13- Quality improvement team progress is best evaluated by which of the following? A. team leader B. senior leadership C. PDCA process D. nominal group technique

EXPLANATIONS: A. The team leader may be biased and is not the best source for team evaluations. B. Senior leadership is not usually involved in evaluating a team. C. The Plan, Do, Check, Act process is a comprehensive methodology used to conduct performance improvement activities, including the analysis of progress. D. The nominal group technique is a group decision-making process for generating a large number of ideas where each member works individually. This technique would not be helpful in evaluating team progress.

14- To reduce the incidence of ventilator-associated pneumonia (VAP) in a critical care unit, who should be included on a quality improvement team? A. intensivist, ICU nurse, and respiratory therapist B. primary care physician, infection control nurse, and surgeon C. ICU manager, respiratory therapist, and pharmacist D. pharmacist, intensivist, and infection control nurse

EXPLANATIONS: A. Intensive-care medicine or critical-care medicine is concerned with the provision of life support or organ support systems in patients who are critically ill and who usually require intensive monitoring. In this scenario, the healthcare quality professional would involve staff that would most commonly be related to the care of a patient with VAP. The involvement of the intensivist, ICU nurse, and respiratory therapist would be considered common, and would comprise the ideal and appropriate team to care for a patient with VAP. B. While the primary care physician may be involved, it is not common practice for the infection control nurse/preventionist to be involved in the daily care of a patient with VAP. C. While the ICU manager and pharmacist could be involved in the care of a patient with VAP, they would not be ideal members of a quality improvement team. D. While the pharmacist, intensivist, and infection control nurse/practitioner could be part of the VAP quality improvement team, this response is not ideal as it does not include the respiratory therapist or ICU nurse.

A performance improvement team aims to reduce the rate of post-surgical infection rates in a small rural acute care facility. Which of the following should the team use as a reference? The post-surgical infection rates among individual surgeons. Postoperative antibiotic use among the surgeons. National benchmark post-surgical infection rates based on the most recent research. Post-surgical infection rates in similar facilities.

Post-surgical infection rates in similar facilities.