CHPQ Study Set
A clinical pathway on the management of hip fractures has been developed by a multi-disciplinary team and implemented in a large teaching hospital. After monitoring for 6 months, the length of stay continues to exceed the guidelines. Which of the following should be the next step? a. evaluate compliance with the pathway b.correlate the pathway with staffing levels c. re-educate the staff on the purpose of the pathway d. continue to monitor and collect additional data
answer: a
A physician complains to a healthcare quality professional that the nursing staff did not strictly follow orders for a patient. The physician requests that the quality professional speak with the nurse manager. To facilitate improvement communication, the quality professional should: a. arrange a meeting with the physician and nurse manager b. speak with the nurse manager on behalf of the physician c. evaluate the patient outcome to determine organizational risk d. review the patient record to determine legibility of the physician's orders
answer: a
Frequency distribution can best be displayed through use of a. a histogram b. a flow chart c. a force field analysis d. an interrelationship diagram
answer: a
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 underreporting of incidents is of greatest concern? a. Staff fear of negative consequences of reporting b. Lack of knowledge about how to use the system c. Time required to complete an incident report d. incomplete understanding about required reporting
answer: a
The best way to evaluate the effectiveness of performance improvement training is through a. observed behavioral changes b. self-assessments c. participant's feedback d. post test results
answer: a
The quality improvement director is responsible for coordination of accreditation survey activities. Responsibilities will most likely include a. facilitating self-assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda for the survey b. educating staff to all standards, writing the survey report, and completing the survey application c. developing a protocol for a mock survey, conducting unannounced surveys, and challenging the survey report d. preparing for unannounced surveys, disseminating the survey report, and developing new standards
answer: a
A culture of patient safety in an organization will have been successfully created when a. personal accountability is removed from the organization b. near miss reporting of safety issues declines c. staff members serve as safety advocates d. a root cause analysis is performed regularly
answer: c
Which of the following is the most effective way to integrate performance improvement concepts throughout an organization? a. quarterly newsletters b. monthly lectures c. quality teams d. continuous monitoring
answer: c
A healthcare quality professional wants to measure the success of a corrective action plan with a 95% confidence level. The average daily census at the quality professional's organization is 1,000 patients. The best sampling technique for this study is to review a. 10% of all discharge records for the past quarter b. all active records on one day of the past month c. 30% of records based on preliminary compliance review d. the number of records needed using a statistical method
answer: d
What is safety?
avoiding injuries to patients from the care that is intended to help them
Leaders
cope with change by developing vision and aligning subsystems
What is patient-centeredness?
providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions
Balanced scorecards are useful because:
put strategy and vision at the center of the organization
4 aspects of Voice of the Customers (VOC)
-Customer needs -Hierarchical structure -priorities -Customer perceptions of performance
Successful Leaders
-Define and inspire a shared vision -Understand that transformation depends on successful leadership -Enable others to lead -Make quality everyone's responsibility -Understand that significant change takes 18-24 months to implement and 10 year to anchor it in practice and culture
A healthcare quality professional is attempting to refine the differences between an organization's objectives and the stakeholder's needs. Which of the following tools is most appropriate? 1. gap analysis 2. Ishikawa diagram 3. Gantt chart 4. Kanban method
answer: 1
Quality improvement teams go through these stages of development:
1. Forming 2. Storming 3. Norming 4. Performing 5. Adjourning
How to construct VOC research
1. Identify Customers of process output 2. Develop a list of questions to ask customers about the process and their needs 3. Refine the list to use with the process review and improvement
What are the 6 aims for healthcare improvement identified by the IOM?
1. Safety 2. Effectiveness 3. Patient-centeredness 4. Timeliness 5. Efficiency 6. Equity
benefits of systems thinking
1. aiding in solving complex problems by identifying and understanding "big picture" 2. Facilitating the identification of major components in early-stage product conception and design 3. addressing recurring problems 4. identifying important relationships and providing proper stakeholder perspectives 5. avoiding excessive attention to a single part 6. allowing a broad-scope of solution 7. fostering integration, including who to partner with to address capability or core competency challenges 8 providing a basis for architecture, design, development, and redesign
Results of physician practice pattern studies are most likely to promote behavior changes when disseminated to the: A. practitioners. B. administration. C. governing body. D. quality committee.
Answer 7 is A Feedback DOMAIN: Organizational Leadership EXPLANATION: A. Practitioners have vested interest in this information since the data is about them. B. Not the best answer, because it bypasses the party most vested in the information. C. See B. D. See B.
The perception of how an organization operates, including how employees relate to internal and external customers, is the organizational A. structure. B. mission. C. vision. D. culture.
Answer: D A. Structure subscribes to organization chart and departmental structure, not how the organization functions. B. Mission is organization's purpose. C. Vision is organization's future state. D. Best answer. Culture includes behavioral norms and how staff interacts with all parties.
IOM (Institute of Medicine)
Began 1863 under Congressional charter. Building on heritage of IOM's work in medicine while emphasizing increased focus on wider range of health matters.
Balanced Scorecard
Four Perspectives of Management 1. Financial 2. Customer 3. Internal Business Processes 4. Learning and Growth
CAS theory suggests that the relationship between elements and agents within any system is nonlinear and that these elements...
Groups of people create outcomes and effects that are far greater than prediction by summing up the resources and skills available within the group.
Survey of Customer Needs
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
The WHO (The Wold Health Organization)
Initiated on April 7, 1948. Goal build a better, healthier future for people all over the world. Main areas of work: Health systems, promoting health through the life-course, Non-communicable diseases, communicable diseases, preparedness, surveillance and response.
Voice of the Customer
Process conducted at the start of any new product, process or service design initiative to understand better the customer's wants and needs -serve as key input for new product definition, Quality Function Deployment, or the setting of detailed design specification
Balanced Scorecard
Provides an ongoing snapshot of how the organization is performing on strategic goals
What is timeliness?
Reducing waits and sometimes harmful delays for both those who receive care and those who give care.
What is system?
a regularly interacting or interdependent group of items forming a unified whole
Hoshin Planning
A Japanese term that means policy deployment -one approach for integration in a quality, safety, and performance improvement system
Elements of Culture
-core values and norms inspire commitment -symbols represents ideas -language, slogans, and brands convey cultural meaning -rituals reinforce core values and strengthen culture
A valid data collection tool should incorporate a. a minimum of 20 data elements b. a reliable graphic presentation c. the definition of data elements d. allowance for variance of interpretation
ANSWER C A. Number is not relative. B. Graphics are not relative to a data collection tool. C. All data elements need to be defined to ensure data collection accuracy, reliability, and validity. D. Variation reduces data validity and reliability.
severity adjustment
An adjustment process to control for confounding in case mix, etiology and severity among hospital patient populations: low values occur in groups that are not very ill; high values are seen in groups that are very ill.
A physician complains to a healthcare quality professional that the nursing staff did not strictly follow orders for a patient. The physician requests that the quality professional speak with the nurse manager. To facilitate improved communication, the quality professional should A. arrange a meeting with the physician and nurse manager. B. speak with the nurse manager on behalf of the physician. C. evaluate the patient outcome to determine organizational risk. D. review the patient record to determine legibility of the physician's orders.
Answer A A. Best answer to facilitate communication between parties. B. Not the quality professional's role to be the physician's representative. C. This does not address the physician's concerns, nor promote collaboration and teamwork. D. Not relevant for the healthcare professional to make the determination when communication is what is needed.
For health information technology to be most effective in reducing harm, the technology needs to be A. integrated with clinical workflow. B. able to correct claims data. C. flexible and accessible. D. numeric and easy to use.
Answer A A. Best answer, since staff at the line has to know how to use the tool with their daily work. B. This is necessary, but does not reduce harm. C. Nice component, but not something that will reduce harm. D. This does not help reduce harm.
Comparing healthcare organizations by using medical error rates A. may present bias due to differences in reporting practices. B. must include a minimum of 10 different facilities. C. cannot be performed by facilities with less than 100 beds. D. provides the best method for benchmarking patient safety.
Answer A A. Bias will be present if there are no standards for reporting. B. There does not need to be 10 organizations for comparing rates. C. Facilities could still be compared in a category within its number of beds. D. Using medical error rates is not necessarily the best method.
Which of the following topics are discussed at a morbidity and mortality conference? A. healthcare-acquired infections and perioperative mortality B. planned readmissions and newborn mortality rates C. Cesarean section rates and number of physicians D. inpatient mortality and admissions
Answer A A. Both healthcare-acquired infections and perioperative mortality are concerns to be addressed at a morbidity and mortality conference. B. Planned readmissions are expected occurrences and not appropriate to be discussed at a morbidity and mortality conference. C. Cesarean section rates alone without complications and number of physicians are not issues appropriate for discussion at a morbidity and mortality conference. D. Admissions are not appropriate for a discussion on morbidity and mortality.
The clinical competency of a physician is determined by A. a committee of peers. B. the CEO. C. the hospital governing body. D. a Quality Management Committee.
Answer A A. Competence is demonstrated in knowledge and understanding of skills required to perform the job. Peer review is a component of initial and ongoing performance evaluation conducted by a professional or professionals with similar experience, education, and expertise based on criteria established by the medical staff or medical executive committee. B., C., and D. The CEO, Governing Body, and Quality Committee do not have the same clinical experience, expertise, and education to determine competency.
A 69-year-old female admitted for hip replacement is taken to surgery. The patient is identified, the surgical site is marked incorrectly, and equipment/x-rays are present. A near miss was most likely identified as a result of A. a surgical team 'time-out.' B. informed consent documentation. C. an equipment check. D. a root cause analysis.
Answer A A. Correct, as the "time-out" is a team briefing conducted by the surgeon before the procedure starts and includes verification of the surgical site. B. Incorrect, as this document may be erroneous as well. C. Incorrect, as the equipment function would not identify an incorrect surgical site. D. Incorrect, as this is a function of investigating a sentinel event.
A failure mode and effects analysis (FMEA) provides which of the following types of review? A. proactive B. retrospective C. concurrent D. retroactive
Answer A A. Correct, as the FMEA tool is used to proactively design or redesign a process. B. Incorrect, as the FMEA is not a retrospective tool. C. Incorrect as the FMEA is not a concurrent tool. D. Incorrect, as the FMEA is not a retroactive tool.
A healthcare network has implemented an electronic medical record system allowing data to be transmitted, on demand, from one facility to another. Which of the following will best promote both cost effectiveness and patient satisfaction? A. decreasing repeat tests when a patient is seen in more than one facility B. eliminating the need for patients to hand-carry records C. improving the accuracy of medication reconciliation D. increasing the security of confidential patient information
Answer A A. Decreasing the rate for repeating tests is the best way for a network to decrease cost and increase patient satisfaction. B. While decreasing paper records and increasing patient satisfaction, it's not the biggest way to decrease cost. C. While data transmission of medications across the network might benefit patient satisfaction of the choices, it's not the most cost effective. D. While an EMR can increase security, it may also be used inappropriately and create more issues.
Empowerment gives employees the opportunity to A. solve problems. B. make more money. C. gain respect of peers. D. achieve upward mobility.
Answer A A. Empowerment is giving people autonomy and determination to enable people to overcome their sense of powerlessness and lack of influence, and to recognize and use their resources. B. May be a result, but not the best answer. C. May be a result, but not the best answer. D. May be a result, but not the best answer.
Which of the following is the best example of use of human factors engineering? A. designing products to prevent tubing misconnections B. implementing a Kaizen process to reduce inventory C. eliminating waste through reduction in motion D. using PDCA to improve compliance with hand hygiene
Answer A A. Human factor engineering takes into account the interactions between humans and product. B. This is a LEAN tool that promotes efficiencies. C. This is a LEAN concept not directly related to human factor engineering. D. This is an example of process improvement.
A hospice agency conducted a satisfaction survey of all 200 patients currently receiving pain management services. When asked if they were satisfied with their pain management, 170 patients said yes, and 30 said no. A target satisfaction rate of 90% has been set. In this situation, a healthcare quality professional should: A. review all dissatisfied responses for similarities. B. collect more data to ensure statistical significance. C. discontinue monitoring because an 85% satisfaction rate is excellent. D. continue monitoring because a 15% dissatisfaction rate is acceptable.
Answer A A. The goal was not reached. Further examination of potential trends to identify opportunities for improvement is a component of continuous quality improvement. B. A target rate (goal) was established regardless of statistical significance. C. The target rate was not met. 90% satisfaction was the established goal. D. The target rate was not met. 15% dissatisfaction is not considered acceptable per the established goal
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 underreporting of incidents is of greatest concern? A. staff fear of negative consequences of reporting B. lack of knowledge about how to use the system C. time required to complete an incident report D. incomplete understanding about required reporting
Answer A A. This is a reflection of organization's culture. B. This is an operational/educational issue and not necessarily reflective of organization's culture. C. See B. D. See B.
Human factors engineering is defined as the study of humans and their interaction with A. the tools they use and the environment. B. medical technology and the organizational systems. C. adverse events and latent errors. D. patients and the organization.
Answer A A. This is the most comprehensive definition of human factors engineering. B. These are elements of human factors, but A is more comprehensive. C. These items are outcomes of human factor failures. D. Patients and the organization are not part of human factors engineering.
A healthcare quality professional is attempting to refine the differences between an organization's objectives and the stakeholder needs. Which of the following tools is most appropriate? A. gap analysis B. Ishikawa diagram C. Gantt chart D. Kanban method
Answer A A. Whenever there is an evaluation between current state and future state/requirements, gap analysis is the tool of choice. B. cause and effect for contributing or root causes C. timeline project management tool D. lean tool for inventory management.
Performance improvement teams should always be required to A. evaluate data. B. include senior leadership. C. perform root cause analyses. D. write mission and vision statements.
Answer A A. part of the process B. not unless executive decisions barriers need removal C. special cause would be required D. not addressed by this term
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 over time. The best way to display the data is to use a: A. Gantt chart. B. control chart. C. Pareto chart. D. flow chart.
Answer B A. A Gantt chart is used in project management to show a project timeline and deliverable. B. A control chart is used to display data over time with upper and lower control limits to help monitor process variability. C. A Pareto chart is used to help determine priorities by showing data in descending order with a line chart overlaid, depicting the cumulative percent. D. A flow chart is a diagram of a process in sequential order.
A quality improvement manager must decide how to present data that demonstrates the relationship between two process characteristics. Which of the following data display techniques is most appropriate? A. bar chart B. scatter diagram C. Pareto chart D. line graph
Answer B A. A bar chart is used to present grouped data using rectangular bars. B. A scatter diagram is used to depict the relationship between two variables. C. A Pareto chart is used to help determine priority by showing grouped data in descending order and overlaying a line graph with the cumulative totals. D. A run chart or line graph is used to depict data over time for a single variable.
The phrase "reaching consensus" is often used in performance improvement. The term consensus refers to A. unanimous agreement. B. support by all members. C. everyone being totally satisfied. D. a majority vote of those present.
Answer B A. Consensus is the general support from those concerned. They may support without unanimously agreeing. B. Consensus is general support from those concerned. C. Consensus implies partial satisfaction from those involved, but is not total satisfaction. D. Although consensus includes support from those concerned, it does not require agreement by a majority.
When conducting a sentinel event review, a root cause analysis: A. provides judgment of staff behaviors. B. identifies gaps in patient care processes. C. requires team consensus. D. proactively identifies causes and effects.
Answer B A. Incorrect, as a root cause analysis does not provide judgments of staff behavior. B. Correct, as a root cause analysis is a structured facilitated team process that identifies gaps in processes. C. Incorrect, as team consensus is not needed for a sentinel event review. D. Incorrect, as a root cause analysis does not identify cause and effect.
Which of the following is always true regarding a sentinel event? A. The cause is established as a deviation from standards. B. The occurrence requires an immediate investigative response. C. The incident is a result of a medical error. D. The findings must be reported to a regulatory body.
Answer B A. Incorrect, as the deviation from standard may not always be the root cause. B. Correct, as a sentinel event should be as high a priority as a reactive response to a sentinel event. C. Incorrect, as a sentinel event may be something besides a medical error. D. Incorrect, as the regulatory body may not require reporting.
Which of the following adverse events is NOT considered a sentinel event? A. death due to a medication error B. suicide threat by a patient in a confined 24-hour care setting C. surgery on the wrong patient or body part D. hemolytic transfusion reaction
Answer B A. Incorrect; this is a sentinel event. B. Correct; this is a clinical behavior expression and not an unanticipated event. C. Incorrect; See A. D. Incorrect; See A.
A patient safety program can best be enhanced by which of the following technologies? A. computers on wheels at the patients' bedsides B. barcode system for medication administration C. digital medication reference materials D. online evidence-based medicine guidelines
Answer B A. Increase nurse efficiencies, but not necessarily impactful on patient safety. B. Best answer. A technology that forces a double checking of patients against medication orders. C. Having information readily available, not the best answer for promoting patient safety. D. Same as C.
Which of the following should be included in an annual performance improvement report to a governing body? A. meeting minutes B. team achievements C. physician peer reviews D. incident/occurrence reports
Answer B A. Meeting minutes provide documentation of discussions and actions, but are too detailed to include in a report to a governing body. B. A report to the governing body is an overview of accomplishments in relation to established strategic goals. Team achievements are a critical component of the annual report. C. Physician peer review is not included in an annual report to the governing body. D. An overview of incident/occurrence reports patterns and trends may be included. However, individual event detail would not be included in an annual report to the governing body.
A staff member reports that a colon perforation occurred during a colonoscopy. Which of the following is a healthcare quality professional's next step? A. Review 100% of colonoscopy procedures. B. Refer the case for peer review. C. Modify the physician's privileges. D. Assign a proctor to the physician.
Answer B A. Not necessary. A focused review on the specific case is more appropriate initially. B. It is a single episode which is appropriate for peer review. C. Not appropriate until further assessment or physician performance has been completed. D. Not appropriate until further assessment or physician performance has been completed.
Data collected about surgical cases shows significant delays. Further analysis shows the following chart: Which of the following should a healthcare quality professional do first? A. Perform a focused professional practice evaluation (FPPE) on every surgeon. B. Provide the service chief with further analyses of surgeon-specific data. C. Ask the nurse manager to write a memo encouraging promptness. D. Form a multidisciplinary team to develop recommendations for improvement.
Answer B A. Not required. B. The quality professional should first notify the service chief so peer-to-peer feedback can be provided to the surgeon. C. Not beneficial. D. This could be done if further analysis is required.
When examining the relationship between staff and patient outcomes, which of the following is the most appropriate to assess? A. staff turnover and budget B. patient safety data and overtime data C. overtime data and absenteeism rates D. occurrence reports and sentinel events
Answer B A. The budget has little effect on the correlation between staff and patient outcomes. B. Using patient safety data and correlation to overtime data are appropriate indicators to identify a relationship between the two. C. Only reviewing overtime data and absenteeism rates will not provide and information on patient outcomes. D. Occurrence reports and sentinel events review alone do not promote any correlation with staffing levels and patient outcomes.
Upon completion of a performance improvement project, who is the best person to compile and write a report? A. quality manager B. team leader C. facilitator D. recorder
Answer B A. The quality manager generally serves in an advisory capacity. B. Team leaders are responsible for completion of the projects, based on the charter of the project. They may delegate aspects of the report to others on the team, but ultimately are responsible for the project. C. Facilitators are involved with moving the process along and have no formal authority over the project. D. Recorders only document the outcomes or activities of the team.
Leaders enhance employee commitment to organizational values by fostering which of the following types of communication? A. face-to-face, oral, scheduled B. timely, open, two-way C. clear, written, top-down D. formal, electronic, 'need to know'
Answer B A. The scheduled component of the response can be considered inflexible. B.Best answer for leadership to have visibility and to promote engagement with staff. C. Top down might not be most effective in some organizations. B is still a better answer. D."Need to know" and formal may not be encouraging transparency and promoting communication.
Which of the following is the primary benefit of using external quality consultants? A. promoting effective communication B. bridging knowledge gaps C. maintaining performance standards for the organization D. clarifying the mission and vision of the organization
Answer B A. This is an internal benefit. B. Consultant provides external assistance with filling in knowledge gaps. C. This is an internal benefit. D. This is an internal benefit
Which of the following principles applies to continuous quality improvement in an organization? A. Twenty percent of trouble comes from 80% of the problems. B. Systems, not poor job performance, are responsible for most problems. C. Causes of nonconformance must be identified and corrected temporarily. D. Empowerment automatically occurs upon implementation of the program.
Answer B A. This is the opposite of the Pareto principle and does not apply. B. Foundation of what quality improvement programs should be built on. C. It would not be appropriate to do the improvement work to have it last only temporarily. D. The program does not cause empowerment. It is leadership behavior and actions that will change the culture.
In managed care, the most widely used performance measures are: A. Uniform Hospital Discharge Data Set (UHDDS). B. Healthcare Effectiveness Data and Information Set (HEDIS). C. Agency for Healthcare Research and Quality (AHRQ). D. National Quality Forum (NQF).
Answer B A. UHDDS are hospital-based measures. B. HEDIS provides data for managed care performance measures. C. AHRQ is the agency that does not establish managed care performance measures. D. NQF measures are not the most widely used performance measures for managed care.
A hospital has recently moved to a paperless system. It is noted that some data is missing from the obstetrics delivery record. A healthcare quality professional should recommend: A. assessing the need for additional education. B. evaluating the computerized data entry process. C. providing a paper trail. D. designating one data entry person per shift.
Answer B A. Until further analysis of the problem is completed, it is not known whether additional education is needed. B. Further analysis is necessary to determine the root causes of the missing data. C. Providing a paper trail does not address the electronic loss of data to solve the problem. D. Until further analysis of the problem is completed, it is not known whether additional data entry is the issue. In addition, designating one data entry person per shift does not address the problem within the current workflow.
A facility is becoming part of a healthcare network. Which of the following employee education programs is most important? A. quality teams B. organizational change C. consumer expectations D. conflict resolution
Answer B During times of significant change, it is critical to facilitate training on organizational change to set overarching organizational expectations and address culture changes before addressing quality teams, consumer expectations, or conflict resolution.
The following data has been provided to a healthcare quality professional: Which of the following is the best choice for beginning clinical-pathways implementation in an organization? A. diabetes B. total knee replacement C. heart failure D. gastroenteritis
Answer C A. Although a physician champion is present, the volume for this condition is small with no loss variance and low readmission rate. B. See explanation for C. The project lacks a physician champion. C. Physician champions are key in the development of clinical pathways. Heart failure should be prioritized because they not only have a champion but have data supporting the need for outcome improvements with LOS variance and a readmission rate of 10%. D. See explanation for C. The project lacks a physician champion.
A healthcare quality professional is conducting a study to determine how many patients contracted influenza despite receiving flu shots. This study is evaluating: A. appropriateness. B. process. C. efficacy. D. prevalence.
Answer C A. Determining the number of patients that contracted influenza does not address appropriateness. B. Process is the steps involved in an intervention or workflow. C. Efficacy measures the effectiveness or ability of the intervention (influenza vaccination) to achieve the desired results. D. Prevalence measures the percent of a population with a specific disease at a given point in time.
Which of the following is the best tool to begin an investigation into the causes of laboratory labeling errors? A. affinity diagram B. prioritization matrix C. flow chart D. histogram
Answer C A. Incorrect, an affinity diagram is used when group consensus is necessary. B. Incorrect, a prioritization matrix is used when there is a list of solutions that must be reduced to one of the few choices. C. Correct, a flow chart provides a picture of the separate steps of the labeling process in a sequential order. D. Incorrect, a histogram is used to determine whether the output of a process is distributed approximately normally.
A Quality Council has examined data on patient falls and determined that a comprehensive falls prevention program is needed. The first step in increasing staff awareness of this initiative is to A. require staff to sign that they have read and understood the falls policy. B. use an educator to teach falls prevention. C. share unit-specific data on falls. D. conduct a medication review of patients who have fallen.
Answer C A. Incorrect; this function does not communicate the data to the applicable team. B. Incorrect; see A. C. Correct; characteristic of an effective team includes communication. D. Incorrect; this would not be a first step.
The primary objective of the operational linkage between risk management and quality/performance improvement is to: A. meet regulatory requirements. B. develop a plan of action for individual cases. C. develop a comprehensive plan to prevent future occurrences. D. alert the hospital attorney of a potentially compensable event.
Answer C A. No regulatory requirement for this. B. Not beneficial for individual cases. C. Expectation is to align quality and risk to address quality and safety activities. D. No regulatory requirement for this.
Which of the following obstetrical outcomes will result in a morbidity review? A. normal deliveries B. neonatal deaths C. post-delivery septicemia D. Cesarean sections
Answer C A. Not an example of morbidity. B. Mortality related. C. Post-delivery septicemia is a complication and morbidity issue. D. Not an example of morbidity.
A culture of patient safety in an organization will have been successfully created when A. personal accountability is removed from the organization. B. near miss reporting of safety issues declines. C. staff members serve as safety advocates. D. a root cause analysis is performed regularly.
Answer C A. Personal accountability is a component of culture of safety. B. An organization would want to see an increase in reporting. C. Front line staff are key to identifying safety issues and to be able to report out. D. Volume or frequency of root cause analyses are not relevant. What is important is how the root cause analyses are done and improvements are made as a result.
A health plan is required to have a mechanism for members to submit complaints. Which of the following actions must be included in the complaint analysis to ensure the plan makes full use of this type of information? A. Total each complaint category at least on an annual basis. B. Calculate the average number of complaints per office site. C. Review complaints to find system problems that can be improved. D. Determine the date/time the complaint occurred and the person responsible.
Answer C A. Summation of complaints is a single element of complaint analysis, but does not assist in the identification of trends. B. Average rate of complaints is a single element of complaint analysis, and is helpful for benchmarking, but not identification of trends. C. Analysis of system trends is the key to identification of system-wide barriers to member satisfaction that may be improved by the organization and affect a larger percentage of health plan members. D. Causation of individual complaint issues of dissatisfaction is an important step of identification of individual member satisfaction, but not potential system processes that have the potential to positively affect collective member perception of health plan operations.
A performance improvement (PI) training program for supervisors should include A. results of a failure mode and effects analysis (FMEA). B. budget-variance reporting. C. rapid-cycle process. D. review of patient falls.
Answer C A. This item may need to have PI, but is not part of PI. B. Supervisors need to know, but not a concept for PI. C. This is a key fundamental "need to know" concept. D. See explanation A.
A consulting firm has been selected by a healthcare Board of Directors to assess the quality improvement program. Before starting the assessment, the quality professional should first A. set up a project plan. B. develop potential action plans. C. define expectations and outcomes. D. design a dashboard.
Answer C All answers could be done, however, expectations and outcomes should be established FIRST.
A critical difference between quality assurance (QA) and quality improvement is a shift in focus from: A. retrospective review to concurrent screening. B. nonclinical aspects to customer satisfaction. C. identifying poor performers to improving group performance. D. QA coordinators to teams.
Answer C EXPLANATION: Quality improvement is focused on systems, processes, and groups to improve. Quality assurance is focused on monitoring problem areas or individuals.
When using cost-benefit analysis in decision-making, it is important to remember that A. consideration of the benefit is more important than cost. B. return on investment should be at least 10 to 1. C. implementation costs are more important than return on investment. D. qualitative and quantitative data should be used.
Answer D A. Benefit and cost should be equally considered. B. Return on investment decisions vary by organization. C. Importance of implementation costs vs return on investment vary by organization. D. In addition to quantitative data such as cost, qualitative information such as patient experience should be considered when performing a cost-benefit analysis.
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 A. Quality Council. B. governing body. C. utilization committee. D. chief of the department.
Answer D A. Doing this will bypass the owners of this process. B. See A. C. Utilization committee is not typically the first group that would be addressing the pharmaceutical issue. D. In a medical staff hierarchy, the chief or chair of the department has responsibilities for addressing departmental performance.
A monitoring system is being designed in which data will be collected and compared to criteria. Which of the following will best enhance the validity and reliability of the data? A. establishing criteria that are based on the most recent changes in medical science and technology B. using a computerized system to substitute data for missing responses C. assigning one staff member to identify, collect, enter, and interpret all data D. providing a practice-based definition and specific instructions for each element
Answer D A. Evidence-based criteria does not make a data collection tool valid or reliable. B. Adding inaccurate data to a data collection tool makes the data invalid. C. This process could create bias in the data. D. Data element definitions and instructions are essential in ensuring data validity and reliability.
Informed consent for hip surgery was obtained and documented for an elderly patient. In the recovery room, a nurse discovered the wrong hip had been replaced. A healthcare quality professional should A. conduct a failure mode and effects analysis (FMEA). B. initiate the disciplinary action process. C. review the practitioner's qualifications and licensure. D. perform a root cause analysis.
Answer D A. Incorrect, as FMEA is a tool to design or redesign a process. B. Incorrect, as exploration of system and process issues should be primary in identifying root causes of error, not only disciplinary actions. C. Incorrect, as this is a function of the medical staff credentialing process and should have been completed. D. Correct, as exploration of a system and process issues should be primary in identifying root causes of error.
The evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to the performance of the A. medical staff. B. governing body. C. ancillary departments. D. organization's systems.
Answer D A. Medical staff is a group of individuals and not systems. B. Governing body is a collection of individuals and not systems. C. Ancillary departments are a collection of individuals. D. The quality improvement concept focus is on systems and processes where individuals work, not individual performance.
A strategy used in brainstorming is that ideas are: A. prioritized as they occur. B. discussed when they are mentioned. C. progressively eliminated. D. all recorded.
Answer D A. Prioritization takes place later in the process. Idea generation should not be disrupted by prioritizing ideas during the brainstorming process. B. Discussion takes place later in the process. Idea generation should not be disrupted by discussion during the brainstorming process. C. Idea elimination takes place later in the process. Idea generation should not be disrupted by eliminating ideas during the brainstorming process. D. Brainstorming is an idea generation tool intended to allow for all ideas to be considered without judgment, censoring, or prioritization. It is critical to the process that no ideas or participation is discouraged. All ideas should be recorded.
Which of the following sampling techniques selects participants based on their availability in a certain place during a specific time frame? A. quota B. random C. volunteer D. convenience
Answer D A. Quota is not related to a specific timeframe; only related to a required number of participants. B. Random selection of participants would not necessarily allow for selection within a specific time frame. C. Volunteer would not ensure selection based on a specific time or place. D. Selection based on convenience would help ensure selection based on time and place.
A review was conducted following a postoperative surgical infection rate increase. The following information was obtained about four physicians: Which of the following should be done next? A. Suspend privileges for physician A. B. Suspend privileges for physician C. C. Initiate peer review with physician A. D. Initiate peer review with physician C.
Answer D A. See explanation for D. B. See explanation for D. C. See explanation for D. D. Provider C has the highest infection rate. Low number of patients with high incidence of events; peer review would be first step in process.
Problem-solving, cross-functional understanding, expanded areas of expertise, and increased span of knowledge are examples of: A. strategic alliances. B. customer expectations. C. resource requirements. D. the benefits of teams.
Answer D A. Strategic alliances are not related to problem solving. B. Customer expectations have nothing to do with the above concepts. C. Resource requirements are addressed as part of the team's overall performance efforts. D. All of the above are key benefits of a performance improvement team
In profiling length-of-stay data for benchmarking, it is important that data be: A. raw numbers. B. equal numbers. C. reported monthly. D. severity adjusted.
Answer D A. When comparing data, it is most important for the data to be adjusted for accurate comparison. Raw unadjusted data without the sample/population size will limit accurate comparisons B. Equal numbers are not necessary if the data is adjusted. C. Data could be provided in any time increment. It is more important for it to be severity adjusted for fair comparison. D. Benchmarking data should be severity adjusted to allow for meaningful comparisons while reducing bias and incorrect comparisons due to differences in the patient population across organizations.
Timeliness and compliance of documentation were discussed at a multidisciplinary team meeting. To evaluate the effectiveness of the team's action plan, which of the following will provide the most useful information? A. physician attendance B. number of complaints C. frequency of meetings D. medical record review
Answer D D is the only mechanism to determine compliance and timeliness of documentation through credit.
For a continuous quality improvement team to be successful, who must be included on the team? A. person performing the process B. department supervisor C. administrator D. quality management representative
Answer: A A. Individuals closest to the process must be included as they have the most in-depth knowledge of the process being evaluated. B. Although the supervisor may have some knowledge, they are not the experts on how the process is actually performed. C. Administrators lend support to the team, but do not have the expertise and typically are not part of the team evaluating a process unless their support is needed to remove barriers. D. A quality management representative often serves as a team facilitator. However, they do not have the direct process expertise, and other staff may perform this role if trained.
A healthcare quality professional has been asked to examine a new method of reviewing adverse events in an organization. It has been decided that a system of triggers will be established to alert the Quality Council of a potential problem. The best example of a trigger that should be set with a threshold of zero is a: A. medical record not completed by a physician. B. staff member not using proper handwashing technique. C. near miss from failure to perform a 'time-out.' D. patient complaint regarding wait times.
Answer: C A. Incorrect; this not an adverse event. B. Incorrect; see explanation for A. C. Correct; this event should trigger further action by the Quality Council. D. Incorrect; see explanation for A.
What is overtime data?
Any hours worked by an employee that exceed their normally scheduled working hours. While a generalized overtime definition refers simply to those hours worked outside of the standard working schedule, overtime commonly refers concurrently to the employee's remunerations of such work.
Organizations direction
Built on mission and guided by vision
Managers
Cope with complexity through planning and budgeting
What is systems thinking needed?
More than ever, we are becoming overwhelmed by complexity
Mission
Organizations Purpose or reason for existence, why are we here?
Vision
Organizations statement of its goals for the future
What is equity?
Providing care that does not vary in quality with respect to personal characteristics, ethnicity, geographic location, or socioeconomic status.
What is effectiveness?
Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those who are not likely to benefit (avoiding overuse and underuse).
What is rapid cycle process?
Rapid-cycle improvement is a "quality improvement method that identifies, implements and measures changes made to improve a process or a system." Rapid-cycle improvement implies that changes are made and tested over periods of three or months or less, rather than the standard eight to twelve months.
culutre
Shared values and behavioral norms. Provides sense of identity, enhances cooperation, creates system of informal rules, creates distinctions between organizations, allowing competitive edge.
Which of the following is used to summarize a characteristic in a population? A. frequency distribution B. regression analysis C. case control study D. control chart
Answer A A. A frequency distribution can be used to summarize data into categories; for example, we could summarize insurance type into Medicare, Medicaid and private insurance. B. Regression analysis is used to measure the relationship between variables. C. A case control study is involved in research/study decision and not the data analysis. D. A control chart is used to monitor data over time and process variation.
Frequency distribution can best be displayed through use of: A. a histogram. B. a flow chart. C. a force field analysis. D. an interrelationship diagram.
Answer A A. A histogram displays data in a bar chart by frequency distribution. B. A flow chart is a diagram of a process. C. A force field analysis is a method for listing, discussing and evaluating various forces for and against a proposed change. D. An interrelationship diagram shows how different issues are related to one another.
The best reason to evaluate team meetings is to: A. assess progress. B. rate leader performance. C. keep participants interested. D. assess accuracy of the minutes.
Answer A A. Assessing team progress is critical to determining whether the team is on track to meet established goals. B., C., and D. Evaluating leader performance, participant interest, and accuracy of minutes may impact team effectiveness, but are not the best reasons to evaluate team meetings.
Hospital administration is considering designating 20 beds for long-term, chronically ill patients. which of the following best supports this?
Discharge placement problems over the last year
The success of a performance improvement program will be most influenced by the: A. reliability of data management software. B. educational preparation of quality leaders. C. culture of the organization. D. people skills of the facility leaders.
answer: C A. This may be a factor, but not the best answer.B. See A.C. Significant factor that must be considered when implementing any program.D. This may be factor, but culture will be the strongest influencer for any program success.
A performance improvement team reviewing timeliness of outpatient clinic appointments identified the following issues: multiple patient moves, redundant paperwork, and long waiting times to be triaged. In lean terminology, these issues are: a. waste b. variation c. poor performance d. Poka-Yoke
answer: a
One aspect of quality process that integrates with risk management is the review and evaluation of a. adverse drug event b. encounter data c. case-mix analysis reports d. accreditation survey reports
answer: a
Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization's quality improvement program? a. quantifiable objectives b. support from the medical staff c. well-defined organizational structure d. integrated data collection
answer: a
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 over time. The best way to display the data is to use a a. gantt chart b. control chart c. pareto chart d. flow chart
answer: b
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: a. the length of time the team has been together b. how well the team met the intended outcome c. the effectiveness of the team leader and facilitator d. the amount of data the team has collected
answer: b
Which of the following should a Quality Council provide to best ensure success of performance improvement teams? a. facilitator and recorder b. empowerment and training c. indicators and a data analyst d. standards and procedures
answer: b
Which of the following should be included in an annual performance improvement report to a governing body? a. meeting minutes b. team achievements c. physician peer reviews d. incident/occurrences reports
answer: b
Failure modes can be prioritized by calculating the criticality index. Which of the following three categories are normally used to calculate a criticality index? A. probability, likelihood, and criticality B. frequency, severity, and ease of detection C. effectiveness, risk, and priority D. response, evidence, and outcome
answer: b A. Incorrect, as these are not part of the criticality index. B. Correct, as these are the components of the criticality index. C. Incorrect. See A. D. Incorrect. See A.
A critical difference between quality assurance (QA) and quality improvement is a shift in focus from a. retrospective review to concurrent screening b. nonclinical aspects to customer satisfaction c. identifying poor performers to improving group performance d. QA coordinators to teams
answer: c
A health plan is required to have a mechanism for members to submit complaints. Which of the following actions must be included in the complaint analysis to ensure the plan makes full use of this type of information? a. total each complaint category at least on an annual basis. b. calculate the average number of complaints per office site c. review complaints to find system problems that can be improved d. determine the date/time the complaint occurred and the person responsible
answer: c
A healthcare quality professional has been asked to examine a new method of reviewing adverse events in an organization. It has been decided that a system of triggers will be established to alert the Quality Council of potential problem. The best example of a trigger that should be set with a threshold of zero is a: a. medical record not completed by a physician b. staff member not using proper hand-washing technique c. near miss from failure to perform a "time-out" d. patient complaint regarding wait times
answer: c
One difference between continuous quality improvement and traditional quality assurance is that quality improvement always a. requires the application of statistical process control b. excludes monitoring and evaluation of care provided c. focuses on systems or processes d. addresses potential problems
answer: c
The primary objective of the operational linkage between risk management and quality/performance improvement is to: a. meet regulatory requirements b. develop a plan of action for individual cases c. develop a comprehensive plan to prevent future occurrences d. alert the hospital attorney of potentially compensable event
answer: c
The primary reason to analyze customer satisfaction surveys is to: a. provide data for the quality improvement program b. meet pay-for-performance requirements c. identify how perceptions relate to the services provided d. assist with evaluating employee performance
answer: c
A pharmacy has been dispensing a higher than acceptable rate of antibiotics to patients with documented allergies to the antibiotics. Which forcing function should the performance improvement coordinator recommend to decrease the rate of inappropriately dispensed antibiotics? a. required the pharmacist to call the physician to confirm the appropriateness of each antibiotic ordered b. provide mandatory education for pharmacy staff on medication profile documentation requirements c. revise policy to require nursing documentation of allergies before medication administration d. modify pharmacy software to require review of allergic profile before dispensing antibiotics
answer: d
A strategy used in brainstorm is that ideas are: a. prioritized as they occur b. discussed when they are mentioned c. progressively eliminated d. all recorded
answer: d
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: a. quality council b. governing body c. utilization committee d. chief of the department
answer: d
Problem-solving, cross-functional understanding, expanded areas of expertise, and increased span of knowledge are examples of a. strategic alliances b. customer expectations c. resource requirements d. the benefits of teams
answer: d
The evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to performance of the: a. medical staff b. governing body c. ancillary departments d. organization's systems
answer: d
Timeliness and compliance of documentation were discussed at a multidisciplinary team meeting. To evaluate the effectiveness of the team's action plan, which of the following will provide the most useful information? a. physician attendance b. number of complaints c. frequency of meetings d. medical record review
answer: d
Which of the following sampling techniques selects participants based on their availability in a certain place during a specific time frame? a. quota b. random c. volunteer d. convenience
answer: d
What is efficiency?
avoiding waste, particularly waste of equipment, supplies, ideas and energy
complexity science
study of complete adaptive systems-is a field applied to healthcare to understand complex human organizations complex-implies the inclusion of a significant number of elements adaptive-refers to the capacity to change and the ability to learn from experience system-set of independent or connected items that are referred to CAS as independent agents
Hoshin Planning
used to ensure that the vision set forth by top management is being translated into planning objectives and actions that both management and employees will take to accomplish long-term organizational strategic goals.
Goals
-Broad, general statement specifying a purpose of desired outcome -May be more abstract than objective -One goal can have several objectives
Successful Leaders cont.
-Foster a sense of community -Create consistent systems of rewards -Incorporate quality into strategic planning, budget, and other internal systems
Organization Board's responsiblity
-Setting policy -Financial and strategic direction -Quality of care -Goals and Objectives
SMART goals
-Specific -Measurable -Attainable -Relevant -Time-bound
Objectives
-Specific statements that detail how goal(s) will be achieved through specific and measurable action(s) -Relatively narrow and concrete
Core Values
Define an organization's attitudes and help direct vision
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Developed by CMS as a standardized method to compare the performance of hospitals and link payment to performance
