CPHQ quiz 2

What is the best explanation for the relatively slow introduction of lean practices into medical laboratories?

Scientists are less receptive to the core principles of lean

Frequency distribution can best be displayed through use of

a histogram.

A healthcare quality professional has been asked to assess a facility's patient safety culture. Which of the following should be targeted in a validated survey?

a random sample of leaders and staff

The leader of a pain management performance improvement team has asked the Quality Council to disband the team. The most important factor for the Quality Council to assess is

how well the team met the intended outcome

Generic screening is an example of risk

identification.

For health information technology to be most effective in reducing harm, the technology needs to be

integrated with clinical workflow.

Timeliness and compliance of documentation were discussed at a multidisciplinary team meeting. To evaluate the effectiveness of the team's action plan, which of the following would provide the most useful information?

medical record review

When is the best time for chairing during a meeting?

At the beginning

Quality and technical performance refers to how well current scientific medical knowledge and technology are applied in a given situation. It is usually assessed in terms of:

Timeliness and accuracy of the diagnosis Appropriateness of therapy and other medical interventions are performed

-Which of the following is an example of information that should be included in an incident report, but should not be recorded in a patient's medical record?

details concerning a medication preparation error discovered and corrected prior to administration

Which of the following should a Quality Council provide to best ensure success of performance improvement teams?

empowerment and training

-Which of the following actions should the facilitator make the highest priority during the customer focus group process?

establishing rapport with the group

Which of the following is the best example of an outcome measure?

mortality rate

Leadership can best integrate performance improvement within an organization through

multidisciplinary teams.

A healthcare quality professional wants to develop a continuous survey readiness model. The initial step should be

planning education for the entire team.

Results of physician practice pattern studies are most likely to promote behavior changes when disseminated to the

practitioners.

When considering the use of an external subject matter expert (SME), which of the following characteristics is most critical?

references of the SME

Which of the following conditions should a quality assessment program NOT examine?

A rare condition that has a small effect on mortality or morbidity

refers to the "degree to which individuals and groups are able to obtain needed services."

Access

A delay in discharging patients is likely to cause recurrent bottlenecks in...

Admissions from the emergency room The filling of prescriptions Admissions from surgical wards

-Crossing the Quality Chasm provided a blueprint for the future that classified and unified the components of quality through six aims for improvement, chain of effects, and simple rules for redesign of healthcare. The six aims for improvement, viewed also six dimensions of quality. Which of the following is NOT out of those dimensions?

Care centered

The quality of amenities of care refers to the characteristics of the setting in which the encounter between patient and clinician takes place, such as:

Comfort, convenience and privacy

Underuse is evidence by the fact that many scientifically sound practices are not used as often they should be, For example, biannual mammography screening in woman ages 40 to 69 has been proven beneficial and yet is performed less than 75 percent of the time." This is the categorization of:

Defects

doctor fails to administer an indicated test, and the patient's condition deteriorates to the point that he must be admitted to an inpatient facility. This is an example of.

Diagnostic error

-Amenities may cover areas as mentioned below EXCEPT:

Vast and facilitated food providing area

The quality improvement director is responsible for coordination of accreditation survey activities. Responsibilities will most likely include

facilitating self-assessments of compliance with standards, communicating new requirements to

Which of the following team members is responsible for keeping meetings focused?

facilitator

Which of the following charts would most likely be used first in a root cause analysis?

flow

Which of the following is the best tool to begin an investigation into the causes of laboratory labeling errors?

flow chart

Failure modes can be prioritized by calculating the criticality index. Which of the following three categories are normally used to calculate a criticality index?

frequency, severity, and ease of detection

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

Based on the principles from the Institute for Healthcare Improvement (IHI), who has the ultimate responsibility for the effectiveness of quality improvement and patient safety within an organization?

governing body

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. In this situation, a healthcare quality professional should

review all dissatisfied responses for similarities.

Leaders enhance employee commitment to organizational values by fostering which of the following types of communication?

timely, open, two-way

After a significant unexpected event, an intense analysis is performed to

understand the cause.

An organization can best measure its effectiveness in meeting customer expectations by

using satisfaction data.

can be measured by how well evidence-based practices are followed, such as the percentage of time diabetic patients receive all recommended care at each doctor visit, the percentage of hospital-acquired infections, or the percentage of patients who develop pressure ulcers (bed sores) while in the nursing home.

Effective care

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?

Evaluate compliance with the pathway.

A number of attributes can characterize the quality of healthcare services. As, there are different groups involved in healthcare, such as physicians, patients and health insurers, tend to attach different levels of importance to particular attributes and as a result define quality care differently. Which of the following is/are NOT out of those attributes?

Excess staff

Today's patients' perception of the quality of our healthcare system is not favorable. In healthcare, quality is household word that evokes great emotion, including:

Frustration and despair, exhibited by patients who experience healthcare services firsthand or family members who observe the care of their loved ones Anxiety over the ever-increasing costs and complexities of care

is a term applied when the proper clinical car process is not executed appropriately, such as giving the wrong drug to a patient or incorrectly administering the correct drug.

Misuse

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.

Which of the following is the first step in preparing for an initial accreditation or certification survey of an organization?

Review the standards and determine readiness.

Healthcare leaders are confronted with the challenge of increasing quality while reducing costs. Which of the following approaches will best advance improvement efforts?

Support activities that improve outcomes and reduce variation.

Random screening of newborns by the neonatology department has confirmed a high incidence of glucose insufficiency (G6PD) in the local population. Management believes that the cost of testing all newborns would be too high. Which of the following should the healthcare quality professional suggest?

Test only newborns with a family history of G6PD.

Which of the following is always true regarding a sentinel event?

The occurrence requires an immediate investigative response.

-Deemed status refers to

accreditation equivalency with a Centers for Medicare & Medicaid Services (CMS) survey

A strategy used in brainstorming is that ideas are

all recorded.

-A summary of antibiotic usage for the fourth quarter showed that an internal medicine department did not meet pre-established criteria in 82% of the patients reviewed. Following review, the pharmacy and therapeutics committee should recommend that the results be shared first with the

chief of the department

A medication error occurred resulting in a severe adverse outcome. In addition to informing the patient and/or family, a healthcare quality professional should

conduct a root cause analysis.

Quality improvement teams go through stages of development. These team development stages include all of the following EXCEPT

conforming.

A facility is becoming part of a healthcare network. Which of the following employee education programs is most important?

consumer expectations

-Performing a root cause analysis of a sentinel/unexpected event provides all of the

continuous monitoring to identify opportunities for improvement.

To avoid misinterpreting variances, which of the following statistical tools should be used?

control chart

An outpatient clinic is attempting to measure the quality of a newly developed diabetes disease management program. To accomplish this, laboratory results will be measured overtime. The best way to display the data is to use a

control chart.

A healthcare network has implemented an electronic medical record system allowing data to betransmitted, on demand, from one facility to another. Which of the following will best promote bothcost effectiveness and patient satisfaction?

decreasing repeat tests when a patient is seen in more than one facility

The primary purpose of an organization's quality improvement strategic plan is to

define the future direction for quality.

Which of the following is the best example of use of human factors engineering?

eliminating waste through reduction in motion

-A healthcare quality professional has been asked to examine a new method of reviewing adverse event sin an organization. It has been decided that a system of triggers will be established to alert the QualityCouncil of a potential problem. The best example of a trigger that should be set with a threshold of zeros a

near miss from failure to perform a "time-out."

The evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to the performance of the

organization's systems.

-For a continuous quality improvement team to be successful, who must be included on the team?

person performing the process

A failure mode and effects analysis (FMEA) provides which of the following types of review?

proactive

Comparing healthcare organizations by using medical error rates

provides the best method for benchmarking patient safety.

-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 under reporting of incidents is of greatest concern?

staff fear of negative consequences of reporting

When errors are discovered, staff and supervisors best demonstrate a culture of safety by

studying the process to understand the error.

A physician who has a high inpatient mortality rate compared to others in a facility should first be

subjected to a more in-depth review of cases.

Which of the following adverse events is NOT considered a sentinel event?

suicide threat by a patient in a confined 24-hour care setting

-Which of the following should be included in an annual performance improvement report to a governing body?

team achievements

Problem-solving, cross-functional understanding, expanded areas of expertise, gains in status and power, and increased span of knowledge are examples of

the benefits of teams.

A valid data collection tool should incorporate

the definition of data elements.