CPHQ 2023
Discharge placement problems over the last year
Hospital administration is considering designating 20 beds for long-term, chronically ill patients. Which of the following information best supports this?
Conduct a gap analysis
If a hospital is interested in applying for the Magnet Recognition Program through the ANCC, the first step is to:
Deployment chart
Improvement tool that assists with development and adherence to project schedule. Typically in grid format with shading showing milestones and specific roles.
Less than 10
In a typical hospital, approximately what percentage of errors are reported?
Death
In healthcare, the most important sentinel event for root cause analysis is:
Quality planning, quality improvement, and quality control
Juran's quality trilogy comprises of:
2 hours
Medical orders for behavioral restraints for ages 9-17 are time-limited to:
SBAR
Situation, Background, Assessment, Recommendation. Tool commonly used for handoff ensuring pertinent information is relayed
Flow chart
When carrying out failure mode and effects analysis (FMEA) to identify and correct process failure before utilization, what type of chart/diagram is used to identify each step in the process?
At the beginning of the next meeting
When is the best time to discuss the results of a meeting exit survey?
Run
When using a run chart with more than 21 data points, 7 or more consecutive data points all above or all below the median or mean would be classified as a:
Trend
When using a run chart with more than 21 data points, 7 or more consecutive data points in ascending or descending order would be classified as a:
Dose
Whenever possible, medication orders should be by:
Framing
Which component of decision making typically receives much less time than it deserves?
Primary care
Which nursing care delivery system is likely to be most costly for a hospital?
The Joint Commission
Which organization developed the National Patient Safety Goals (NPSGs)?
NQF
Which organization developed the list of Serious Reportable Events?
Yellow
With primary triage patients who are able to wait 45-60 minutes for car are color-coded what color?
Philip Crosby's quality improvement process introduced the idea of:
Zero defects
Hoshin planning
________ is a process that ensures strategy is effectively implemented into an organization from the top down.
Quality teams
_________ are the most effective way to integrate performance improvement concepts throughout an organization.
The CMS 3 Day Rule requires:
a 3 consecutive day inpatient hospitalization prior to admission to a skilled nursing facility
True
True or False: Gonorrhea requires a mandatory written report
True
True or False: One difference between continuous QI and traditional QA is that QI always focuses on systems or processes.
True
True or False: Scientists are less receptive to the core principles of lean?
Performance, outcomes, patient experience, and structure/technology
What 4 types of quality measures are pay for performance programs usually based on?
Kano model
What diagram is appropriate for categorizing the needs of customers?
They occur during the interactions between caregivers and patients
What does it mean if errors are occurring at the "sharp end"?
Increase nurse to patient ratio
What has been shown to consistently reduce hospital associated adverse events?
Collect organizational data for analysis
What is the first step that a healthcare quality management professional should take before assembling a performance improvement team?
Create an organization profile
What is the first step that must be carried out for an organization utilizing the Baldrige Excellence Framework?
Reduce time needed to implementation
What is the primary purpose of rapid cycle testing?
Balanced scorecard
What represents a way to connect the activities of an organization to its larger strategies?
Team achievements
What should be included in an annual performance improvement report to a governing body?
VOC (voice of the customer)
4 components: Customer needs, hierarchical structure, priorities, and customer perceptions of performance
Empowerment and training
A Quality Council should provide __________ to best ensure success of performance improvement teams
1 year
A capital expenditure is generally expected to have a useful life of more than:
24 hours
A complete history and physical examination should be completed on an inpatient with no recent history of care within:
Decision criteria
A patient care team is in disagreement over new admissions procedures. What decision-making model should management use?
All recorded
A strategy used in brainstorming is that ideas are all:
The definition of data elements
A valid data collection tool should incorporate:
20 - 30%
According to the HHS, if a pandemic occurs, the percentage of the population that will be infected is likely:
5 Steps of the ADDIE Model
Analyze, design, develop, implement, evaluate
TQM (total quality management) includes at minimum:
Assessment, planning, implementation, and evaluation of continuous improvement
Life safety and infection control
Before construction begins on a renovation project, what assessment(s) should be completed?
4 types of leaders
Charismatic, bureaucratic, autocratic and consultative
Assignable variation
Clinical practice guidelines reduce:
In a _______, patients must receive care from in network providers. Services are limited to preventative or medically necessary care.
EPO (exclusive provider organization)
Frequency, severity, and ease of detection
Failure modes can be prioritized by calculating the criticality index. What 3 categories are normally used to calculate the criticality index?
Histogram
Frequency distribution can best be displayed through use of a:
Delphi Technique
Method of consensus building that operates with the idea that over time and with guidance people will compromise and move toward similar opinions
Value Stream Mapping
Most often used in lean performance improvement activities. It's a tool that identifies areas of waste that can be removed. It identifies priorities from a customer perspective.
Disorganization
Most quality problems in healthcare are the result of:
The Joint Commission
Organization that developed the Do-Not-Use list to reduce the risk of errors in documentation:
7 leadership styles
Participatory, Democratic, empowering, transactional, transformational, situational, and laissez-faire
the Governing board
Physician privileges are granted by
Value =
Quality of service + outcome / cost
Define each letter of the acronym RACE for fire safety
Remove, Alarm, Confine, Extinguish/Evacuate
True
True or False: A critical difference between QA and QI is a shift in focus from identifying poor performers to improving group performance.
6 S's
Sort, Set in order, Shine, Safety, Standardize, and Sustain
SIPOC
Suppliers, Input, Process, Output, Customer. Helps identify critical components of a process.
Norming
Team members begin to reach consensus on the rules for operation during this stage
Duty to use due care, breach of duty, damages, and causation
The 4 basic elements of malpractice
50%
The Joint Commission requires that a hospital's delinquint health record rate not exceed:
Observed behavioral changes
The best way to evaluate the effectiveness of performance improvement training is through:
Organization's systems
The evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to the performance of the:
Emergency room
The largest proportion of adverse events attributable to negligence occur where?
Designed to prompt a response of "yes"
The most common and effective style of checklist for hospital employees is:
Effective purchasing
The most essential step in supply management is:
Fire prevention plan
The primary component of a life safety management program:
Length of stay
The primary predictor of hopsital costs is:
Provider experience
The shift from the triple aim to the quadruple aim includes the addition of:
National Practitoner Data Bank
To determine whether an applicant requesting clinical privileges has settled malpractice claims, the organization must query:
24 hours
To ensure that food service areas of the hospital are in compliance with safety regulations, records of cleaning should be documented every:
Reviewing the number of records needed using a statistical method
To measure the success of a CAP the best sampling technique would be:
RASCI Chart
Tool used to clearly establish roles on a project. Responsible, Accountable, Supportive, Consulted, Informed.
Spaghetti Diagram
Tool used to understand redundancies in a process
The ADDIE model is an outline for:
Training programs
