CPHQ
the evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to the performance of the
organization's systems
A summary of antibiotic usage for the fourth quarter showed that an internal medicine department did not meet pre-established criteria in 82% of the patients reviewed. Following review, the pharmacy and Therapeutics Committee should recommend that the results be shared first with the
Chief of the department (hierarchy)
A review was conducted following a postoperative surgical infection rate increase. The following information was obtained about four physicians: [see picture] Which of the following should be done next?
Initiate peer review with physician 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?
Review complaints to find system problems that can be improved (Analysis of systems trends is the key to identification of system-wide barriers to members satisfaction that may be improved by the organization and affect a larger percentage of health plan members)
The clinical competency of a physician is determined by
a committee of peers
The best reason to evaluate team meetings is to
assess progress
A patient safety program can best be enhanced by which of the following technologies?
barcode system for medication administration
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
evaluating the computerized data entry process.
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?
gap analysis (whenever there is an evaluation between current state and future state/requirements, gap analysis is the tool of choice)
Which of the following topics are discussed at a morbidity and morality conference?
healthcare-acquired infections and perioperative mortality
When conducting a sentinel event review, a root cause analysis
identifies gaps in patient care processes
A critical difference between quality assurance (QA) and quality improvement is a shift in focus from
identifying poor performers to improving group performance (quality improvement is focused on systems, processes, and groups to improve. quality assurance is focused on monitoring problem areas or individuals)
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?
medical records review
When examining the relationship between staff and patient outcomes, which of the following is the most appropriate to assess
patient safety data and overtime data (using patient safety data and correlation to overtime data are appropriate indicators to identify a relationship between the two)
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
perform a root cause analysis.
A failure mode and effects analysis (FMEA) provides which of the following types of review?
proactive
A performance improvement (PI) training program from supervisors should include
rapid-cycle process
A staff member reports that a colon perforation occurred during a colonoscopy. Which of the following is a healthcare quality professional's next step?
refer the case for peer review
A quality improvement manager must decide how to present data that demonstrates the relationship between two process characteristics. Which of the following data display techniques is most appropriate?
scatter diagram
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
share unit-specific data on falls (an effective team includes communication)
The phrase "reaching consensus" is often used in performance improvement. The term consensus refers to
support by all members
A valid data collection tool should incorporate
the definition of data elements
