CPHQ practice

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 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.

A. Evaluate compliance with the pathway. (Evaluation of compliance with the proven (pathway) should be conducted first to see if that may be influencing the lack of outcome change.) B. May be a helpful following step C. Compliance should be assessed first to see if further training is needed and perhaps narrow focus. D. Lack of outcome in 6 months, additional monitoring without action will not increase performance.

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

A. Healthcare acquired infections and perioperative mortality B. Planned readmissions are expected occurrences and not appropriate. C. Rates alone without complications are not appropriate D. admissions not appropriate

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.

A. a committee of peers. (Competence is demonstrated in knowledge and understanding of skills needed 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,D. Do not have the same clinical experience, expertise, and education to determine competency.

To avoid misinterpreting variances, which of the following statistical tools should be used? A. a control chart B. fishbone diagram C. force field analysis D. Pareto chart

A. a control chart (control charts exhibit points between control limits, therefore displaying the variation) B. Fishbone = cause and effect of a problem C. Force field = looks at a project and analyzes all the reasons impacting a change D. Pareto = help determine priority

Refer to the following control chart: In assessing timeliness for the administration of antibiotics for pneumonia, this control chart demonstrates: A. a process improvement B. no process improvement C. evidence of a trend D. evidence of an outlier

A. a process improvement (8 points below the control limit indicate a positive shift in the problem - "special cause variation") C. based on statistical process control rules, this is a shift, not a trend. D. An outlier would be above or below the control limits

A 69-year-old female admitted for a 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

A. a surgical team "time out" (team briefing conducted by the surgeon before the procedure starts and includes the verification of the surgical site. B. this document may be wrong as well. C. the equipment would function even if incorrect surgical site. D. this is a function of investigating a sentinel event.

One aspect of a quality process that integrates with risk management is the review and evaluation of: A. adverse drug events B. encounter data C. case-mix analysis D. accreditation survey reports

A. adverse drug events (Risk management has a role related to incident reporting) B,C,D. Not a primary component of risk management

Which of the following action plans is the first step in correcting inappropriate blood usage in an emergency department? A. an in-service on ordering blood usage for the physicians B. elimination of wasted blood C. improvements in documentation D. development of a new procurement procedure.

A. an in-service on ordering blood usage for the physicians (educating the providers on the critical use of blood products will assist to better utilize blood supply) B. not a factor in blood use C. important, but does not apply to blood usage D. procurement relates to donation, not usage.

An organization can best measure its effectiveness in meeting customer expectations by: A. analyzing satisfaction data B. benchmarking occupancy rates C. creating a run chart of complaints D. tracking length of stay

A. analyzing satisfaction data (satisfaction data evaluates customer satisfaction) B,C,D. Do not reveal information or measure customer expectations.

A physician complains to a HQP 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 the organizational risk. D. review the patient record to determine the legibility of the physician's orders.

A. arrange a meeting with the physician and nurse manager. (best answer to facilitate communication between the parties) B. Not your role C. Doesn't address the MD concerns or promote teamwork/collaboration D. Not relevant

The best reason to evaluate team meetings is to: A. assess performance. B. rate leader performance. C. keep participants interested. D. assess accuracy of the minutes.

A. assess performance. (assessing team performance is critical to determining whether the team is on track to meet established goals.) B,C,D. May impact team effectiveness, but are not the best reasons to evaluate team meetings.

A healthcare provider recently conducted a customer satisfaction survey that focused on the five key quality characteristics in the graph below: By analyzing the information, the provider can identify that customers were most dissatisfied with: A. cost and most satisfied with caring B. communication and most satisfied with comfort C. cost and most satisfied with communication D. caring and most satisfied with cost

A. cost and most satisfied with caring (cost has the largest percentage of customers reporting that they are disappointed. Caring has the largest percent of customers reporting that they are delighted.)

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 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.

A. decreasing repeat tests when a patient is seen in more than one facility. Decreasing the rate for repeating tests is the best way for a network to decrease costs and increase patient satisfaction. B,C. Not the biggest way to decrease costs D. may also be used inappropriately and create more issues.

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.

A. designing products to prevent tubing misconnections. (human factor engineering takes into account the interactions between humans and product.) B. LEAN tool that promotes efficiencies C. LEAN concept not directly related to humans factor engineering D. This is process improvement.

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.

A. evaluate data. B. not unless executive decision barriers need removal C. special cause would be required D. not addressed by this team

Which of the following is used to summarize a characteristic of a population? A. frequency distribution B. regression analysis C. case control study D. control chart

A. frequency distribution A frequency distribution can be used to summarize data into categories; for instance, we could summarize insurance type to 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 design and not the data analysis D. A control chart is used to monitor progress over time and process variation

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 cart D. Kanban method

A. gap analysis (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

Frequency distribution can best be displayed through use of: A. histogram. B. a flow chart. C. a force field analysis. D. an interrelationship diagram.

A. histogram. A histogram displays data in 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.

Medication reconciliation is a process intended to: A. identify and resolve discrepancies B. investigate formulary discrepancies C. increase use of electronic medication administration D. improve efficiency of medication administration

A. identify and resolve discrepancies (The definition of medication reconciliation is a process of identifying the most accurate list of all medications by comparing the medical record to an external list of medications.) B. incorrect. formularies define the universal list of medications available to hospital patients or payor benefits. C. function of medication ADMINISTRATION D. referring medication administration processes and not an individual's medication list

The primary purpose of integrating financial and quality management information is to: A. identify problems in resource management B. develop physician profiles C. identify potential cash flow problems D. determine medical necessity of treatment

A. identify problems in resource management (This ties financial impact to quality management) B. not related C. more financially related D. information is determined through resource management and evidence-based practice

For health information technology to be most effective in reducing harm, the technology needs to be: A. integrated with clinical workflow. B. able to connect to claims data. C. flexible and accessible. D. numeric and easy to use.

A. integrated with clinical workflow. (Best answer, since staff has to know how to use the tool with their daily work.) B. necessary but does not reduce harm. C. Nice component, but not something that will reduce harm. D. Does not 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.

A. may present bias due to differences in reporting practices. Bias will be present if there are no standards for reporting. B. You do not need 10 organizations to compare rates. C. facilities should still be compared in a category with its number of beds D. Using medical error rates is not necessarily the best method.

Leadership can best integrate performance improvement within an organization through: A. multidisciplinary teams B. newsletters C. focus groups D. seminars

A. multidisciplinary teams (multidisciplinary teams best integrate performance improvement by promoting an interdisciplinary approach to the process and including multiple subject matter experts.) B. Do not promote collaboration and engagement C,D. Do not integrate performance improvemen

The best way to evaluate the effectiveness of performance improvement training is through: A. observed behavioral changes B. self-assessments C. participants' feedback D. post-test results

A. observed behavioral changes (all of these are methods to evaluate effectiveness of performance improvement training. However, observed behavioral change is the best method as is demonstrates transfer of knowledge into practice.)

An annual evaluation of a laboratory's quality program identified no opportunities for improvement. Which of the following elements should be reviewed? A. performance indicators B. format of data display C. committee meeting attendance D. frequency of data collection

A. performance indicators (performance indicators need to be reviewed for potential revision) D. frequency is one of the concepts related to data collection, but not related to elements.

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

A. person performing the process Individuals performing the process must be included as they have the most in-depth knowledge of the process being evaluated. B. Supervisor may have some knowledge but are not the experts in how the process is performed. C. Lend support but don't have the expertise. Not typically part of the team unless a barrier needs to be removed. D. Often serves as facilitator but may be performed by another role if they do not have the direct process expertise.

Results of the 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

A. practitioners - Practitioners have a vested interest in this information since the data is about them B. Not the best answer, because is bypasses the party most vested in the information C. See B D. See B

A failure mode and effects analysis (FMEA) provides which of the following types of review? A. proactive. B. retrospective. C. concurrent D. retroactive.

A. proactive.

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, 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 unacceptable.

A. review all dissatisfied responses for similarities. 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,D. The target rate was not met.

Which of the following are the first steps when preparing for an initial accreditation or certification survey of an organization? A. review the standards and determine readiness. B. appoint a survey coordinator and prepare a survey agenda. C. Hire a consultant and conduct a mock survey. D. Assess staff knowledge and plan staff training.

A. review the standards and determine readiness. (These actions are part of the gap analysis, which establishes a good baseline to determine where to focus and how to prioritize efforts.) B,C,D. Good steps, but not the first.

Empowerment gives the opportunity to: A. solve problems. B. make more money. C. gain respect of peers. D. achieve upward mobility.

A. solve problems. 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,C,D: May be a result, but not the best answer

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. 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.

A. staff fear of negative consequences of reporting. this IS a reflection of the organization's culture. B,C,D. This is an operational/educational issue and not necessarily reflective of the organization's culture.

Human factors engineering is defined as the study of humans and their interaction with: A. the tools they use and their environment. B. medical technology and the organizational systems. C. adverse events and latent errors. D. patients and the organization.

A. the tools they use and their environment. B. Elements, but A is more comprehensive. C These are outcomes of human factor failures.

After a significant unexpected event, an intense analysis is performed to: A. understand the cause B. collect risk management data C. prepare the facility for a lawsuit D. identify who made the error

A. understand the cause (the root cause analysis is performed after an event with the goal to identify causes and contributing factors.) B,C,D. Not the intended purpose of intense analysis.

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).

B. Healthcare Effectiveness Data and Information Set (HEDIS). A. these are hospital based measures C. does not establish managed care performance measures D. not the most widely used.

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

B. Provide the service chief with further analyses of surgeon-specific data A. Not required C. Not beneficial D. This could be done if further analysis is required.

A new quality director has reviewed the information related to Quality Council minutes, and notes the following: -The council meets quarterly. Meetings last approximately 2 hours. -The council roster includes all clinical department managers and the quality director. Attendance ranges from 45-60% -The primary role of the council is to receive department quality reports, which are then forwarded to the organization's governing body. Based on the information above, which of the following actions is most appropriate? A. Require departments to forward reports for review prior to the meetings. B. Redefine the councils role to coordinate and prioritize quality activities. C. Switch to a monthly meeting with a new format. D. Eliminate the council and directly report data to the governing body.

B. Redefine the councils role to coordinate and prioritize quality activities. A. This action may be helpful in facilitating the meeting, but is not the best answer available. C. Based on the information available, this may or may not be a factor D. This action is not appropriate.

Which one 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.

B. Systems, not poor job performance, are responsible for most problems. Foundation of what quality improvement programs should be based on. A. This is the opposite of the Pareto principle and does not apply. C. It would not be appropriate to do the improvement work and have it last only temporarily. D. Th program does not cause empowerment. It is leadership behavior and actions that will change the culture.

Which of the following is always true for a sentinel event? A. The cause is established as a deviation from the 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.

B. The occurrence requires an immediate investigative response. (a sentinel event should be as high a priority as a reactive response to a sentinel event) D. regulatory body may not require reporting.

Leaders enhance employee commitment to organizational values by fostering which one 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'

B. Timely, open, two-way Best answer to have visibility and to promote engagement with staff. A. scheduled could be inflexible C. Top-down may not be the most effective in some organizations. D. 'Need-to-know' and formal may not be encouraging transparency and promoting communication.

A patient safety program can best be enhanced by which of the following technologies? A. computers at patient bedside B. barcode system for medication administration. C. digital medication reference materials. D. online evidence-based medicine guidelines.

B. barcode system for medication administration. Best answer - forces double-checking of patients against medication orders. A. increase nurse efficiency but not necessarily impactful on patient safety. C,D. Having info readily available, not the best answer for promoting patient safety.

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.

B. bridging knowledge gaps. Consultants provide external assistance with filling in knowledge gaps. A,C,D. This is an internal benefit

According to continuous quality improvement principles, which of the following concepts is most important? A. financial impact B. constancy of purpose C. resistance to change D. performance of individuals

B. constancy of purpose A a factor, but not most important C. Must be addressed, but not best answer D. a factor, but not the most important concept

An outpatient clinic is attempting to measure the quality of a newly developed diabetes disease management program. To accomplish this, laboratory tests will be measured over time. The best way to display this data is to use a: A Gantt chart B. control chart C. Pareto chart D. flow chart

B. control chart (used to display data over time with upper and lower control limits to help monitor process variability.) A. Gantt chart is used in project management to show a project timeline and deliverable. C. Pareto chart is used to help determine priorities by showing data in descending order with a line chart overlaid, depicting the cumulative percent. D. Flow chart is a diagram of a process in sequential order.

Which of the following actions should a facilitator make the highest priority during a customer focus group process? A. selecting a homogeneous group B. establishing rapport with the group C. providing written ground rules to the group D. generalizing the findings to the population

B. establishing rapport with the group (Must establish rapport in order to facilitate the group toward the outcome.) A. Facilitator is not responsible for selecting the group. C. Done by the leader. D. Done by leader or reporter.

A hospital has recently moved to a paperless system. It is noticed 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.

B. evaluating the computerized data entry process. Further analysis is needed to determine the root cause of the missing data. A. Until further analysis is completed, it is not known whether additional education is needed. C. Providing a paper trail does not address the electronic loss of data. D. Until further analysis is completed, it is not known whether additional data entry is needed. In addition adding an additional person does not address the problem with the current workflow.

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, criticality B. frequency, severity, and ease of detection C. effectiveness, risk, and priority D. response, evidence, and outcome

B. frequency, severity, and ease of detection

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 cause and effects.

B. identifies gaps in patient care processes. (a RCA is a structured facilitated team process that identifies gaps in processes.) C. consensus not needed for a sentinel event review. D. Does not identify cause and effect

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.

B. organizational change. During times of significant change, it is critical to facilitate training on organizational change to set overarching expectations and address culture changes before addressing quality teams, consumer expectations, and conflict resolution.

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 and overtime data. C. overtime data and absenteeism rates. D. occurrence reports and sentinel events.

B. patient safety and overtime data. Using patient safety data and correlation to overtime data are appropriate indicators to identify a relationship between the two. A. The budget has little effect on the correlation between staff and patient outcomes. C. Only reviewing overtime and absenteeism rates will not provide data on patient outcomes. D. Occurrence reports/sentinel events do not promote any correlation between staff and patient outcomes.

A healthcare entity initiating re-structuring must consider the impact of the staff to ensure the greatest opportunity for success by: A. defining the concepts of re-structuring to the staff and the community B. planning carefully, communicating openly, and leading effectively C. developing policies to assist in the change process so that fear will be minimized D. selecting a consultant, conducting a needs assessment, and analyzing results

B. planning carefully, communicating openly, and leading effectively (These actions promote transparency and trust through communication and leadership) A. not the best answer C. policies will not help at this point D. The organization would have already completed the needs assessment and analyzed the result prior to the restructuring

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 provider's privileges. D. assign a proctor to the provider.

B. refer the case for peer review. It is a single episode which is appropriate for peer review. A. Not necessary. A focused review on the specific case is more appropriate initially. C,D. Not appropriate until further assessment or physician performance has been completed.

A quality improvement manager must decide how to present data that demonstrates the relationship between two process characteristics. Which of the following display techniques is the most appropriate? A. bar chart B. scatter diagram C. pareto chart D. line graph

B. scatter diagram (Scatter diagram is used to share the relationship between two variables) A. A bar chart is used to present grouped data using rectangular bars. C. A Pareto chart is used to determine priority by showing grouped data in descending order and overlaying a line graph with cumulative totals. D. A run chart or line graph is used to depict data over time for a single variable.

Which of the following adverse events is NOT considered a sentinel event? A. death due to medication error. B. suicide threat by patient in a confined 24-hour care setting. C. surgery on the wrong patient or body part. D. hemolytic transfusion reaction.

B. suicide threat by patient in a confined 24-hour care setting. This is a clinical behavior expression and not an unanticipated event.

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.

B. support by all members. A. Consensus is the general support from all those involved. They may support without unanimously agreeing. C. Consensus implies partial satisfaction from those involved, but is not total satisfaction. D. Includes support from all those concerned, but does not require agreement by a majority.

Which of the following should be included in the annual performance improvement report to a governing body? A. meeting minutes B. team achievements C. physician peer reviews D. incident/occurrence reports

B. team achievements This is an overview of accomplishments to established strategic goals. Critical component to an annual report. A. Too detailed to include D. Overview may be helpful, but individual event detail would not be included.

Upon completion of a performance project, who is the best person to compile and write a report? A. quality manager B. team leader C. facilitator D. recorder

B. team leader Team leaders are responsible for the completion of the projects, based on the charter of the project. They may delegate certain aspects of the report to others on the team, but ultimately are responsible for the project. A. The quality manager serves in an advisory capacity. 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.

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.

C. Review complaints to find system problems that can be improved. (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.) A. doesn't show trends B. Helpful for benchmarking but not trends C. causation of individual complaint is an important identifier of satisfaction but doesn't speak to process that may be improved.

A serious event has occurred related to the timely notification of critical test results. The root cause was traced to nursing difficulty with following the organizational policy. To prevent a similar event from happening, which of the following should be done next? A. Refer the involved nurse to nursing peer review. B. Educate nursing staff on the importance of timely notification of critical test results. C. Review the policy with nursing representatives to identify ambiguities. D. Continue to collect data as one event is insufficient to take action.

C. Review the policy with nursing representatives to identify ambiguities. A. disciplinary process B,D. does not address the root cause.

Training is being determined based on treatment record review results. The following weighted results are available: Based on these results, which of the following areas should take priority for training? A. assessment B. external communication C. care plan D. progress notes

C. care plan (when ranked by weight and non-compliance [weight*(100-%compliance)], care plan results in the highest weighted rank)

Which of the following charts will be most likely used first in a root cause analysis? A. Gantt B. Pareto C. flow D. control

C. flow A. project management chart B. prioritization tool C. used to evaluate process

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.

C. culture of the organization. Culture is a significant factor that must be considered when implementing any program. A. May be a factor, but not best answer. B. See A. D. This may be a factor, but culture will be the strongest influencer for and program success.

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

C. define expectations and outcomes All answers could be done, however, expectations and outcomes should be established FIRST

The purpose of an organization's quality improvement strategic plan is to: A. determine accountability for outcomes. B. assess improvement opportunities. C. define the future direction for quality. D. explain the performance of teams.

C. define the future direction for quality. A. This item is done as a result of a plan, but is not the purpose of the plan. B. Assessment and reassessment should be done before developing the plan. D. Performance improvement teams are a part of executing the plan.

In the quality improvement process, performing a cost-benefit analysis is most useful in: A. checking performance B. analyzing process problems C. designing solutions and controls D. implementing solutions and controls

C. designing solutions and controls (allows for financial controls to be considered towards outcome achievement) B. cost benefit is more financial in nature. D. implementation would follow cost-benefit

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.

C. develop a comprehensive plan to prevent future occurrences. (Expectation is to align quality and risk to address quality and safety activities.) A,D. no regulatory requirement for this B. not beneficial for individual cases.

A healthcare quality professional is conducting a study to determine how many patients contracted influenza despite having received flu shots. This study is evaluating: A. appropriateness. B. process. C. efficacy. D. prevalence.

C. efficacy. Efficacy measures the effectiveness or ability of the intervention(flu vaccine) to achieve the desired results. A. determining the number of patients that contracted flu does not address appropriateness. B. Process is the steps involved in an intervention or workflow. D. Prevalence measures the percentage 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

C. flow chart (provides a picture of the separate steps of the labeling process in sequential order) A. used when group consensus is needed. B. Used when there are a list of solutions that must be reduced to one of a few choices. D. Histogram is used to determine whether the output of a process is distributed approximately normally.

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.

C. focuses on systems or processes. Quality improvement is focused on systems, processes, and groups to improve. Quality assurance is focused on monitoring problem areas or individuals. Statistical process control may be employed as a tool, but is not required.

The following data has been provided to a healthcare quality professional: Which of the following is the best choice for beginning clinical-pathways in an organization? A. diabetes B. total knee replacement C. heart failure D. gastroenteritis

C. heart failure Physician champions are key in the development of clinical pathways. Heart failure should be prioritized not only because they have a champion but have data supporting the need for outcome improvements with LOS variance and a readmission rate of 10%. A. Although a physician champion is present, the volume for this condition is small with no loss variance and low readmission rate. B. Project lacks a physician champion.

The primary purpose of risk management trend analysis is to: A meet regulatory requirements B. provide required reports to liability carriers. C. identify opportunities for improvements. D. eliminate financial loss for organizations.

C. identify opportunities for improvements. (risk management focuses on identification, assessment, and reduction of risk. The goal is to protect the organization from losses, the key component of which is proactive improvement to avoid and reduce risk.) A,B. not the primary purpose of risk management D. risk does not *eliminate * loss

A critical difference between quality assurance (QA) and quality improvement is a shift in focus from: A. 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.

C. 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.

A federally certified electronic health record (EHR) with the capacity for e-prescribing, electronic exchange of health information, and submission of healthcare quality measures meets: A. bar-code technology specifications B. computer-based monitoring specifications. C. meaningful use requirements. D. health privacy requirements.

C. meaningful use requirements. (meaningful use has several elements including those that are listed in the stem)

Which is the following is the best example of an outcome measure? A. availability of computers B. pathway compliance C. mortality rate D. laboratory turnaround

C. mortality rate (an outcome measure is used to determine how the system or improvement project impacts the patient.) A. structure measure B,D. process measures

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. A medical record not completed by the physician. B. staff member not using proper handwashing technique. C. near miss from failing to perform a time out. D. patient complaint regarding wait times.

C. near miss from failing to perform a time out. This event should trigger further action by the Quality Council. A,B,D. This is not an adverse event.

Team cohesion is established during which of the following stages of team growth? A. forming B. storming C. norming D. performing

C. norming A. forming - members get to know each other B. storming - team members deal with conflict D. performing - meeting the expectations and outcomes

Which of the outcomes will result in a morbidity review? A. normal deliveries B. neonatal deaths C. post-delivery septicemia D. Cesarean sections

C. post-delivery septicemia This is a complication and a morbidity issue. A. Not an example of morbidity B. mortality related D. See A

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.

C. rapid-cycle process. This is a key fundamental "need to know" concept. A,D. This item may need to have a PI, but is not part of a PI. B. Supervisors need to know, but not a concept for PI.

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 mediation review of patients who have fallen.

C. share unit-specific data on falls. A characteristic of an effective team includes communication. A,B. This function does not communicate data to the applicable team. D. Not a first step.

A culture of patient safety in an organization will be 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.

C. staff members serve as safety advocates. Front line staff are key to identifying safety issues and are able to report out. A. personal accountability is a component of culture of safety. B. An organization would see an increase in reporting. D. volume or frequency of root cause analyses are not relevant. What is important is how the RCA are done and improvements are made as a result.

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 interruption.

C. the definition of data elements. (All data elements need to be defined to ensure data collection accuracy, reliability, and validity.) A. number is not relative B. graphics are not relative to a data collection tool D. variation reduces data validity and reliability.

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.

D. Initiate peer review with physician C. Physician C has the highest infection rate. Low number of patients with high incidence of events. Peer review would be the first step in the process.

A hospital-wide medical record audit on documentation has been completed. The following table shows the compliance rate of documentation: Compliance Rate (%) 1Q 2Q Surgical timeouts 90 95 Communication of 91 95 critical results Pain score used 50 60 Assessment performed 52 45 Which of the following is the next step? A. Benchmark the compliance rates against other facilities. B. Conduct training regarding pain score. C. Give data feedback on physician signature to the units. D. Conduct a focused review on the patient assessment process.

D. Conduct a focused review on the patient assessment process. (A focused review of the patient assessment process should be prioritized because of the low performance and decreased performance from Q1 to Q2.

Deemed status refers to: A. a healthcare organization that passes a Centers for Medicare and Medicaid Services (CMS) survey. B. surveyors who work for both an accrediting body and a healthcare organization. C. physicians who have reported to the National Practitioner Database. D. accreditation equivalency with a Centers for Medicare and Medicaid Services (CMS) survey

D. accreditation equivalency with a Centers for Medicare and Medicaid Services (CMS) survey (CMS allows deemed status with meeting all conditions of participation requirements through Joint Commission Accreditation.)

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.

D. all recorded. (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.) A,B,C. All these steps take place later in the process, idea generation should not be disrupted.

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. utilization committee. B. Quality Council. C. governing body. D. chief of the department

D. chief of the department In a medical staff hierarchy, the chief or chair of the department has responsibilities for addressing departmental performance. A. Doing this will bypass the owners of the process B. See A C. Utilization committee is not typically the first group that would address the pharmaceutical issue.

A medication error occurred and resulted in a sever adverse outcome. In addition to informing the patient/and or family, a HQP should: A. perform a regression analysis B. implement new technology C. reassign the employees involved D. conduct a root cause analysis

D. conduct a root cause analysis (exploration of system and process issues should be the primary function of a RCA.) A. regression analysis identifies how a change in an independent variable affects the dependent variable. B,C. Would not identify the root cause.

Quality improvement team development stages include all of the following EXCEPT: A. norming. B. forming. C. performing. D. conforming.

D. conforming. (Tuckman's stages of Group Development.) A. 3rd stage B. 1st stage C. 4th stage

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

D. convenience (selection based on convenience would help ensure selection based on time and place.) A. quota is not related to a specific timeframe; only to a a required number of participants B. Random selection would not necessarily allow for selection within a certain time frame. C. Volunteer would not ensure selection based on specific time or place.

The perception of how an organization operates, including how employees relate to internal and external customer, is the organizational: A. structure. B. mission. C. vision. D. culture.

D. culture. Best answer. Culture includes behavioral norms and how staff interact with all parties. A. Structure describes organizational charts and departmental structure, not how the organization functions. B. Mission is the organization's purpose. C. Vision is the organization's future state.

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? A. quality improvement director B. medical director C. CEO D. governing body

D. governing body (This is the expectation of TJC and the Centers for Medicare and Medicaid Services (CMS) A,B,C. Key role, but not the ultimate responsible individual

The utilization management committee is reviewing the LOS data for a particular procedure. In comparing data by physician, which of the following statistics will be most useful? A. correlation B. range C. mode D. mean

D. mean (the mean is the statistical average in a data set. It is often used to describe average LOS for comparison and is used with the standard deviation to understand the variety around the mean.) A. correlation is used to describe the degree of relationship between two variables B. The range for a data set is the difference between the largest and smallest value. The range shows the spread of the data, but alone is not as helpful in comparing the LOS for physicians. C. The mode is a measure of central tendency. It is the data element that occurs most often in the data set. This is less than robust than the mean as there can be more than one mode.

Timeliness and compliance of documentation were discussed at a multidisciplinary team meeting. To evaluate the effectiveness of a 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.

D. medical record review D is the only mechanism to determine the compliance and timeliness of documentation.

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.

D. organization's systems. (The quality improvement concept focuses is on systems and processes where individuals work, not individual performance.) A,B,C. Groups of individuals, not systems.

Informed consent for hip surgery was obtained and documented for an elderly patient. In the recovery room, a nurse discovered that the wrong hip had been replaced. A HQP should: A. conduct a failure mode and effects analysis (FMEA). B. initiate the disciplinary action process. C. review the practitioner's licensure and qualifications. D. perform a root cause analysis

D. perform a root cause analysis Exploration of a system and process issues should be primary in identifying root causes of error. A. FMEA is a tool to design or redesign a process

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 a criteria 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.

D. providing a practice-based definition and specific instructions for each element. (Essential for ensuring data validity and reliability) A. Evidence-based does not make a data collection tool valid or reliable. B. Adding inaccurate data makes the data invalid. C. Could create bias in the data.

When using cost-benefit analysis in decision making, it is important to remember: A. consideration of the benefit is more important than the 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.

D. qualitative and quantitative data should be used. In addition to quantitative data such as cost, qualitative information such as patient experience should be considered when performing a cost-benefit analysis. A. Benefit and cost should be equally considered. B. Return on investment decisions vary by organization. C. Importance of implementation costs vs ROI vary by organization.

When considering the use of an external subject matter expert (SME), which of the following is most critical? A. leadership's personal preference B. geographic location of the SME C. cost of the SME's service D. references of the SME

D. references of the SME (The positive clinical reputation provides credibility to support the project) A. must be an overall, not personal preference. B,C. Important but not most critical

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.

D. severity adjusted. (Benchmarking data should be severity adjusted to allow for meaningful comparisons while reducing bias and incorrect comparisons due to differences in patient population across organizations.) 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 needed if the data is adjusted. C. Data could be provided in any time increment. It is more important to be severity adjusted for fair comparison.

Problem solving, cross-functional understanding, expanded areas of expertise, and increased span of knowledge are examples of: A. strategic alliances. B. customer expectations. C. resources requirements. D. the benefits of teams.

D. the benefits of teams. A. Strategic alliances are not related to problem solving. C. resource requirements are addressed as part of the team's overall performance efforts.