CPHQ Practice exam

1. Which of the following is the best definition of "vision" in regard to creating an organizational vision statement? a. The ability to see the future b. An ideal future state c. A realistic action plan for future performance d. An outline of future organizational purpose.

1. B: In the creation of an organizational vision statement, vision is a description—realistic or not—of an ideal future state. This description of an ideal future state gives shape to the goals of an organization. A vision statement does not involve detailed descriptions about the specific actions necessary for bringing the vision to fruition.

10. Healthcare organizations are often classified as systems. What is the primary reason for this designation? a. They span several states with a network of providers. b. They are dynamically complex and have multiple levels of management. c. They are a collection of parts that function as an interdependent whole. d. They employ a broad cross-section of the population in various positions..

10. C: Healthcare organizations are often classified as systems because they are a collection of parts that function as an interdependent whole

101. The pathology department of Hospital A is up for a service-specific review. What documents should be considered as part of this review? a. General policies and procedures for the hospital b. Employee work history and performance statistics c. Specific policies and procedures for pathology d. All of the above.

101. C: A service-specific review of the pathology department would cover specific policies and procedures for pathology

102. What are some of the pitfalls faced when evaluating team performance? a. It is time-consuming and lacks objectivity. b. It is pointless and nonspecific. c. It is discriminatory and stressful. d. It is legally complex and doesnʼt improve productivity..

102. A: Some of the major pitfalls of team performance evaluations are the time they take and the lack of objectivity as team members evaluate one another.

103. What tool is most effective in evaluating team performance? a. Focus groups b. Data mining c. Department meetings d. Anonymous surveys.

103. D: Anonymous surveys are the most effective tool in evaluating team performance because they remove the fear of retribution for low rankings and a sense of obligation for high rankings.

104. When a hospital is facing low customer satisfaction ratings, what is the best initial goal in analyzing the data? a. Bring in experts to help analyze b. Identify the underlying problem c. Require mandatory training d. Re-survey dissatisfied customers

104. B: When a hospital is facing low customer satisfaction ratings, the best first step is identifying the underlying problem, after which performance improvement can be coordinated. A, C, and D are incorrect because, while bringing in experts, requiring training, and re-surveying customers may happen later in the process, they are not good first steps.

105. What is data inventory listing? a. Preparing a list of all reports currently produced b. Creating a spreadsheet that holds all available data c. Determining what information is available from which sources d. Taking inventory of all historical and organizational data.

105. C: Data inventory listing can be defined as determining what information is available from which sources, thereby making an inventory of available data sources.

106. Which of the following chart types would be most effective in showing reduction of influenza incidence over time as a result of a vaccination program? a. Pareto chart b. Run chart c. Fishbone diagram d. Flow chart.

106. B: A run chart is designed to show trending outcomes against passing time, which is perfect for the influenza incidence reduction presented in this question. A, C, and D are incorrect because even though Pareto charts, fishbone diagrams, and flow charts are accurate ways to visually display information, they do not fit the parameters of the given situation.

107. Patient-safety incident reports at Hospital A have increased over the past two years by almost 20 percent according to recent data. Patient complaints have not increased significantly over this period. What is the most likely explanation for this trend? a. Patients are not noticing the incidents b. Incidents have actually increased by 20 percent c. Care providers are self reporting incidents more d. None of the above

107. C: Increased provider self reporting is the most likely cause of the increased incident reporting in light of the absence of an increase in customer complaints.

108. When disseminating health information to minority populations, which of the following considerations is most vital in ensuring efficacy? a. Timeliness b. Cultural appropriateness c. Entertainment value d. Educational content

108. B: When disseminating health information to minority populations, cultural appropriateness is the most important consideration for efficacy because culturally inappropriate presentations of information will likely be ignored.

109. Performance improvement results should be disseminated to employees primarily for the purpose of... a. Positive reinforcement. b. Departmental bragging rights. c. Educational motivation. d. Punishment of low performers..

109. A: The main effect of performance improvement results among employees is an overall sense of positive reinforcement that encourages them to maintain the good work. B, C, and D are incorrect because, while they represent possible effects of performance improvement results, they are not the primary purpose of dissemination of results to employees

11. Mary has a family history of heart disease and type II diabetes. She also has pre-hypertension. Maryʼs doctor recently put her on a diet and exercise program. This is an example of system thinking called... a. Quality control. b. Preemptive medicine. c. Continuous improvement. d. History dependency..

11. B: System thinking that prescribes preventative actions to help prevent an impending problem is called preemptive medicine

110. What type of chart is most effective in demonstrating cause and effect? a. Flowchart b. Run chart c. Fishbone diagram d. Pareto chart

110. C: A fishbone diagram is the best type of visual representation to show cause and effect because it demonstrates how various effects branch from the same cause.

111. Which of the following is not likely to be included in a practitioner profile? a. Education and training b. Liability claims filed c. Staff/faculty privileges d. Practitioner age.

111. D: Practitioner age has no place in a practitioner profile, as it is irrelevant to competence levels, skills, and abilities. The other answer choices all represent information that belongs in a practitioner profile

112. The maternity ward of Hospital A has just added four FTE nursing staff members members. After 60 days, productivity numbers do not seem to be increasing as expected. What is the most likely cause of this phenomenon? a. The learning curve for new employees b. An increase in patient needs c. A data reporting error d. Resentment of new staff by older employees.

112. A: Productivity generally takes a brief dip after the addition of new employees due to the learning curve and their need for assistance from established staff members.

113. Clinic A has just completed six months of customer satisfaction surveys. Excellence in performance has been appropriately recognized. Now complaints must be analyzed and somehow quantified. What method would be most effective in the complaint analysis process? a. Sort surveys into separate folders b. Create a taxonomy for coding complaints c. Address complaints one at a time d. Match complaints with performance issues.

113. B: The most effective way to analyze large numbers of complaints is through the creation of a taxonomy for coding complaints because it helps classify and organize complaints in a logical way that lends itself well to analysis.

114. As department manager, it is your job to conduct an annual performance appraisal for each employee in your department. One of your employees is exhibiting significant issues in response times for patient requests. How can you best incorporate performance improvement into the employeeʼs performance appraisal? a. Incorporate punitive measures into the evaluation b. Use encouraging words to help the employee improve c. Set specific performance goals and a re-appraisal date d. Performance improvement is not part of performance appraisal.

114. C: The best way to incorporate performance improvement concepts into an employee appraisal is through specific performance goals and a set re-appraisal date. A and B are incorrect because they are not concrete performance improvement techniques.

115. Which of the following are important elements of a written patient safety plan? a. Scope b. Purpose c. Guidelines d. All of the above.

115. D: A written patient safety plan includes a scope, a purpose, and guidelines.

116. A seven-year-old girl receiving treatment for pneumonia at Hospital B has just been abducted by her noncustodial parent. Under standard patient safety guidelines, how would this event be classified? a. As an adverse incident b. As a sentinel event c. As a Baldrige occurrence d. As a risk management anomaly.

116. B: Abduction qualifies as a sentinel event under Joint Commission guidelines and standard practices.

117. What is the primary purpose of a patient safety program? a. To reduce medical errors and hazards b. To comply with local and national standards c. To reduce liability and tort claims d. To meet accreditation requirements.

117. A: The primary purpose of a patient safety program is to reduce medical errors and hazards.

118. Your clinic has had three recent instances of chart mixups. In each case, doctors made initial patient contact with the wrong chart in hand and incorrect information. What technology would be most helpful in this situation? a. Medication barcode scanners b. Tablet computers or smartphones c. Electronic health record software d. Individual record RFID tags

118. C: Electronic health record software is the best choice for preventing paper chart mix-ups and to ensure that doctors meet the patient with the most accurate and up-to-date information possible

119. To ensure proper identification of transfusion patients, your organization has recently adopted a two person bedside/chair-side verification process. What is his an example of? a. Requirements for accreditation b. National patient safety goals c. Joint Commission best practices d. Local and regional healthcare laws.

119. B: Two-person bedside/ chair-side verification of transfusion patients is a clear example of national patient safety goals being put into place.

12. How does the World Health Organization Surgical Safety Checklist lead to tight coupling in the operating room? a. It establishes universality for patients. b. It compartmentalizes the procedures. c. It establishes a clear operating room hierarchy. d. It closely aligns the various individuals involved in the process..

12. D: The World Health Organization Surgical Safety Checklist leads to tight coupling in the operating room by closely aligning the various individuals involved in the surgical process.

120. After experiencing a sentinel event, Hospital A is required to perform a root cause analysis. Which of the following is not a requirement of a root cause analysis? a. It must be conducted as soon as possible after the event. b. All personnel involved in the event must be present. c. Legal affidavits must be taken before questioning. d. Blame and liability should not be discussed or assigned..

120. C: During a root cause analysis, legal affidavits are not required before questioning. All of the other answer choices are elements that are required as part of a root cause analysis

121. What role does performance improvement data play in the appointment/privilege delineation process? a. Performance improvement and appointment/privilege delineation are unrelated. b. Performance improvement should be required for appointment/privilege eligibility. c. Performance improvement should take place after appointment/privilege delineation. d. Performance improvement oversight should be the job of a newly-advanced employee..

121. B: Performance improvement, as demonstrated over time with an organization, should be a required element for appointment/privilege delineation because it gives an idea of a providerʼs commitment to an organization and to quality.

122. A recent risk management assessment has demonstrated that several frequently-used pieces of medical equipment have not been serviced recently, posing a threat to proper patient care. What performance improvement process should be undertaken to correct this issue? a. Post/publish equipment maintenance guidelines b. Post/publish a set equipment maintenance schedule c. Designate a specific employee/group to oversee maintenance d. All of the above.

122. D: As part of performance improvement on the equipment maintenance, guidelines should be published or posted, a maintenance schedule should be published or posted, and a specific employee or group should be designated to handle maintenance.

123. How does performance improvement relate to risk management assessment? a. Performance improvement and risk management assessment are unrelated. b. Performance improvement is a part of risk management assessment. c. Risk management assessment is a part of performance improvement. d. Performance improvement corrects issues identified in risk management assessment..

123. D: Performance improvement is related to risk management because it is a tool to correct the issues that are uncovered during a risk management assessment.

124. Hospital A recently implemented shorter inpatient stays for most surgical procedures. A utilization management assessment has revealed, however, that more patients are returning to the emergency room for post-surgical treatment. What performance improvement measure would be most likely to reduce the incidence of post-surgical patient returns? a. Implement better predischarge evaluations b. Reverse the shorter-stay policies c. Provide more painkillers at discharge d. Carefully analyze the patient return data.

124. A: Implementing better pre-discharge evaluations is the most likely option for reducing post-surgical patient returns.

125. Which of the following is an external quality review that measures compliance against an industry standard for healthcare organizations? a. Peer review b. Accreditation c. Root cause analysis d. Credentialing.

125. B: Accreditation is an external quality review that measures compliance against industry standards.

13. Who created the hospital information management standard that states, "The hospital maintains the security and integrity of health information?" a. The Baldrige Committee b. The Joint Commission c. The National Institutes of Health d. The ORYX Initiative.

13. B: The Joint Commission set the standard that hospitals are responsible for health information security and integrity.

14. The rate of sick days among employees in the intensive care unit (ICU) falls well within the hospital standard, but the CNAs claim the RNs take too many sick days, and this prevents consistent care relationships between RNs and CNAs. What should management do to investigate this situation? a. Set up surveillance of the department b. Distribute patient surveys throughout the ICU c. Distribute employee surveys throughout the ICU d. Unbundle/disaggregate the data and reanalyze it.

14. D: The best way to understand exactly what is happening in the intensive care unit (ICU) is to unbundle or disaggregate the data and analyze it again, looking for specific challenges with RN sick days.

15. The new administrator of Hospital A implements a top down hand washing policy for all employees and visitors to the hospital. As a result, previously high infection rates drop below national standard levels for the first time. This new policy is an example of... a. Performance measures. b. Quality assurance. c. Risk management. d. Information management.

15. C: Risk management is defined as taking steps to avoid and control risks within an environment to accomplish a desired outcome, and the hand washing policy helps manage the risk of infection.

16. The Baldrige Performance Excellence Program Health Care Criteria remark on the importance of measurement and analysis of data. What can be the downside of a heavy performance data focus? a. Managers can get tunnel vision and overlook nonme assured errors and issues. b. Data far above the national standard can result in inflated self-opinion. c. Data far below the national standard can result in depression and despondency. d. Hospitals with high data scores are held to impossibly high standards..

16. A: The downside of a heavy data focus can be tunnel vision by managers, which can lead to oversight of non-measured errors.

17. A position has recently opened for a department head in human resources (HR). It is your job to select the best internal candidate to interview for the position. Which of the following candidates possesses the strongest leadership potential? a. An HR supervisor who has been with the organization for 10 years. b. An accounting supervisor who has a perfect quality record. c. An HR employee who mentors new hires and frequently attends voluntary training. d. A supervisor in the maintenance department who wants to try something new..

17. C: An employee with experience in the field who has emotional intelligence (demonstrated by mentoring new hires) and a quest for new knowledge shows excellent leadership potential.

18. In a large hospital setting, which of the following represents an internal customer? a. An admitted patient b. A physical therapy department assistant c. A medical equipment supplier d. A patientʼs family.

18. B: A physical therapy department assistant is an internal customer because he or she works within the organizational structure. The other choices all represent external customers.

19. Who should be considered when developing process requirements within a healthcare organization? a. Patients b. Internal customers c. Stakeholders d. All of the above.

19. D: Patients, internal customers, and stakeholders should all be considered when developing process requirements within a healthcare organization.

2. A patient care team is in disagreement over new admissions procedures. What decision-making model should management use? a. Decision criteria b. Consensus c. Invocation d. Tenure influence.

2. A: Decision criteria is a decision-making model that explores all options equally and gives unorthodox or unpopular options a fair chance, even when they are under dispute. Consensus is not the best choice because this approach often reduces decisions to options that everyone likes and discounts the unorthodox or unpopular options that could be appropriate and viable.

20. What happens right after a Joint Commission-accredited hospital experiences a sentinel event? a. An award is presented to administrators. b. A root cause analysis is performed. c. Immediate re-accreditation is granted. d. Performance improvement measures are implemented..

20. B: When a Joint Commission-accredited hospital experiences a sentinel event, a root cause analysis is performed

21. A small city has two hospitals. The Hospital Consumer Assessment of Healthcare Healthcare Providers and Systems (HCAHPS) reports show Hospital A is performing far below Hospital B in customer service. The administrators at Hospital A decide to set an organizational goal of ranking higher than Hospital B in customer service in one year. What is the most logical first step in the goal-setting process? a. Develop an overall picture of the partial goals to be achieved. b. Identify a specific and singular goal to be initially pursued. c. Require immediate training for all members of each department. d. Bring in customer service experts to evaluate and improve processes..

21. A: When undertaking a goal-setting process, the best first step is to develop an overall picture of the smaller partial goals to be achieved. B is wrong because it disregards the overall goal for the sake of a single smaller goal. C and D are incorrect because they are reactive steps, not proactive steps.

22. The process improvement team has recently established a goal that all patients be triaged within 20 minutes of arrival in the emergency room (ER). What might be a negative outcome of this goal? a. ER nurses will be overstressed. b. Mistakes are likely to be made. c. Triage will be less thorough. d. All of the above

22. D: If a strict time limit is established, all of these will occur - ER nurses will be overstressed, mistakes are likely to be made, and triage will be less thorough

23. Which of the following can be defined as, "A set of measures and data that give managers and administrators a quick yet comprehensive overview of performance?" a. Process measurement b. Balanced scorecard c. Dashboard d. Six Sigma.

23. B: A balanced scorecard is a set of data that give a quick and comprehensive overview of performance. Process measurement is lengthy and generally focused on a single process area, not quick and all encompassing. Dashboard scoring is not as quick or comprehensive as a balanced scorecard. Six Sigma deals with quality measurement, not performance data.

24. Within the last four days, three post-surgical patients have died of pneumonia complications at a large hospital. None of the patients presented as symptomatic for pneumonia at the time of surgery. What evaluation tool should be used to help identify and resolve this issue? a. Epidemiological theory b. Performance management measures c. Statistical analysis d. Improvement measures.

24. A: Epidemiological theory is used to identify the source and cause of an issue or anomaly, which is perfect for the surgical complications represented in this question

25. What is the primary purpose of the Consumer Assessment of Health Providers and Systems (CAHPS)? a. To relieve data collection efforts by administrators b. To offer patients an anonymous outlet for healthcare complaints c. To capture patient satisfaction data in a universal manner d. To provide a forum for more effective communication between patients and providers.

25. C: The primary purpose of the Consumer Assessment of Health Providers and Systems (CAHPS) is to capture patient satisfaction data in a universal way that can be compared among all hospitals. A, B, and D represent secondary or tertiary purposes of CAHPS; they do not represent its primary purpose.

26. When Hospital Aʼs neonatal infection rates rise unexpectedly, the quality council establishes a new set of performance measures. They base their measures on internal standards, customer survey data, and employee survey data. What important element are the quality council members disregarding? a. Epidemiological standards b. Customer satisfaction data c. Employment records d. External standards.

26. D: It is vital that quality council members take external standards (such as national goals and requirements) into account when addressing the rising infection rates.

27. What challenge often occurs with the use of aggregated data? a. The numbers become too large to comprehend. b. Context is lost and solutions are not identified. c. Impersonality and vagueness are not engaging. d. Special interpreters are needed for understanding..

27. B: When data are aggregated, one of the biggest challenges is the loss of context, which makes specific solutions hard to identify

28. As a quality professional, you are about to address administrators regarding a recent decrease in customer satisfaction with postpartum care. In preparation, you want to create a report to present at the meeting. Which of the following would be most important to consider as you prepare your report? a. Properly formatting the report to industry standards b. Identifying the data most relevant to the situation c. Expounding on historical data on postpartum care d. Reviewing postpartum satisfaction at other organizations.

28. B: When preparing the report on postpartum care to be presented to administrators, the most important goal is identifying which data are most relevant to the situation. A, C, and D are incorrect because while they may offer some items of interest, they do not best help you describe the situation at hand to the administration.

29. Which of the following is a good way to assess customer needs and expectations? a. Surveys b. Focus groups c. Informal discussions d. All of the above.

29. D: Surveys, focus groups, and informal discussions are all excellent ways to assess customer needs and expectations.

3. St. Josephʼs Hospital was recently ranked last in the region in the area of efficiency in transferring patients to inpatient beds. When working on process improvements, what type of data is likely to prove most helpful? a. Internal data b. Historical data c. Quality control data d. Comparative data.

3. D: Comparative data would prove most helpful in improving the processes at St. Josephʼs Hospital. By comparing their data and processes with those of higher ranked medical facilities, process improvement solutions could be derived. A and B are incorrect because internal data, whether historical or contemporary, will not help identify the reasons for the last place ranking and will not help improve processes. C is wrong because quality control data is another internal measure that will only compare the existing processes with established internal standards.

30. Which of the following is the most important way that transparency of healthcare data serves as a regulator for the industry? a. It encourages performance improvement to create more positive data. b. It tends to drive poorly performing organizations out of business. c. It creates a culture of shame and fear among employees. d. It does not serve any regulatory purpose.

30. A: When healthcare data is transparent and visible to a number of populations, it encourages performance improvement to create more positive data, thereby improving the image of the organization. B and C are incorrect because while they may be true for some organizations, they do not represent the most important regulatory function of healthcare transparency.

31. Which of the following is the logical first priority in process improvement? a. Training employees on improvements b. Measuring process improvement c. Identifying process issues d. Creating an improvement plan.

31. C: The first priority in process improvement should be identifying the existing process issues. A, B, and D are incorrect because while they are good steps in the process improvement journey, they are not the first priority in the process.

32. As a manager, you are working with a new employee who has challenges with appropriate customer service processes. Together you are establishing a performance improvement plan. Which of the following should not be a part of the plan? a. Research into the causes of the employeeʼs challenges b. A clear statement of the problems to be addressed c. Specific action steps to be taken as part of the plan d. A desired outcome or goal behavior and a timeline.

32. A: Researching the causes of an employeeʼs challenges has no place in the performance improvement plan process. A clear problem statement, specific action steps, and a goal behavior are all important elements in creating a performance improvement plan.

33. What role do clinical guidelines play in establishing process requirements for an organization? a. They conflict with one another. b. Clinical guidelines dictate process requirements. c. Process requirements dictate clinical guidelines. d. They are unrelated

33. B: Clinical guidelines dictate process requirements for an organization, as new processes must fall into line with the guidelines of an organization and industry practices. A and D are incorrect because they minimize the relationship between clinical guidelines and process requirements. C is wrong because process requirements are governed by clinical guidelines, not the other way around.

34. Recent HCAHPS data for Hospital A indicate that doctors are not providing adequate explanations to patients. In improving the patient safety culture with regards to this issue, what two elements must be addressed? a. Patient perceptions and clinical quality b. Patient perceptions and physician education c. Physician education and time constraints d. Quality standards and time constraints.

34. A: When improving the patient safety culture, both patient perceptions and clinical quality must be taken into account and balanced

35. Which of the following is a patient safety goal identified by the Joint Commission? a. Cut service times in emergency departments b. Apply Six Sigma principles to sentinel events c. Improve the effectiveness of caregiver communications d. Establish strong customer service numbers among patients.

35. C: Improving the effectiveness of caregiver communication is a patient safety goal that has been established by the Joint Commission. A, B, and D may be good goals, but they have not been established as specific patient safety goals by the Joint Commission.

36. How might an implicit organizational goal of service time reduction be an accidental adversary to patient safety goals? a. They could not be accidental adversaries. b. A rush to meet service times might impede adequate communication. c. Improved service times may negatively impact service levels. d. Customer satisfaction levels might be falsely elevated.

36. B: An implicit goal of service time reduction is a potential adversary to patient safety because providers who are hurrying may not communicate effectively with patients.

37. In a quest to improve patient satisfaction data, Clinic A is creating a patient survey. Which of the following areas should be the focus of the survey? a. Physical needs b. Emotional needs c. Social needs d. All of the above.

37. D: A good patient survey will address the physical, emotional, and social needs of the patient to give a provider a complete picture of how the patientʼs needs can best be met.

38. At a business lunch, a colleague from a hospital across town encourages you to try implementing Six Sigma to improve your organization. After discussing it at length with your colleague, you feel the biggest benefit of Six Sigma for your hospital would be, a. The goal of driving errors to zero. b. The long-standing tradition of use. c. The origins in manufacturing. d. The view that all work is a process.

38. A: The biggest benefit of Six Sigma is the goal of driving errors to zero, thereby dramatically improving the quality of care.

39. Two hospitals in your region have recently adopted computerized physician order entry (CPOE). You have assembled an evaluation team to determine if CPOE is right for your organization. Which of the following factors would likely have the strongest impact on your decision? a. It is important for your organization to be technologically competitive. b. Several patients and healthcare providers have endorsed the system. c. The system is shown to reduce prescribing errors by 50 percent or more. d. Major stakeholders are pressuring for adoption of the system..

39. C: The most influential reason for implementing CPOE is the fact that it has been shown to reduce prescribing errors by 50 percent or more, thereby improving quality of care. A, B, and D may all be influencing reasons for adopting CPOE, but they should not be the deciding factor, as they are much less important than reducing prescribing errors

4. Which of the following is a structure designed to help facilitate team or group pursuit of specific goals and objectives? a. Management b. Organization c. Intelligent design d. Delegation.

4. B: An organization is a structure that is designed to bring a group together for the pursuit of specific goals and objectives. While management and delegation are both important, they are not central to the unification of a team or group for goal pursuit. They are aspects of the structure, but not the structure itself.

40. The intensive care unit (ICU) is facing a problem with excessive sick days being taken by the CNA staff. After surveying ICU employees, you identify several potential causes for this issue. When you present this information to the management team, what type of visual representation would be most effective? a. A flowchart or deployment chart b. A pie chart or run chart c. A fishbone diagram or Pareto chart d. None of the above.

40. C: Either a fishbone diagram or Pareto chart is the best way to visually represent a specific problem and a list of contributory causes. A and B are not correct because flowcharts, deployment charts, pie charts, and run charts are designed to present a variety of data, not just to illustrate a specific problem and its causes.

41. What type of data analysis is most appropriate after an organization experiences a significant negative event? a. Prospective analysis b. Root cause analysis c. Failure mode and effects analysis d. Introspective analysis.

41. B: A root cause analysis is designed to investigate and pose possible remedies for a significant negative effect in a healthcare setting. A and C are not correct because they are both forward-looking evaluations instead of backward-looking investigations. D is wrong because it is not a relevant type of data analysis

42. An issue with response time to patient requests has been identified in the post-surgical ward of Hospital A. The administrators desire to improve performance in this area. What element of process performance will most help determine the best course of action? a. Process behavior b. Process measurement c. Process capability d. Process requirements.

42. D: Process requirements are the element of process performance that represents the voice of the customer, outlining the change or action that is needed. A, B, and C are incorrect because although they are all elements of process performance, they are not the elements that help define the needed change or best course of action.

43. In what way are benchmark data valuable to the performance improvement process? a. They provide a comparison standard for behavior. b. They can be used to punish underperformers. c. They can be used to reward high performers. d. They assist in achieving department-specific accreditation..

43. A: Benchmark data are valuable to the performance improvement process because they provide a comparison standard for behavior. B, C, and D are not the best choices because they do not demonstrate the way benchmark data can be used to help performance improvement.

44. Which of the following is absolutely essential for the leader of an effective performance improvement team? a. "Type A" personality b. Charisma and persuasion c. Modeling target behaviors d. Extended tenure with the organization.

44. C: The leader of a performance improvement team must model target behaviors above all else in order to set the example for team members.

45. Who developed the National Patient Safety Goals (NPSGs)? a. The Leapfrog Group b. HCAHPS c. Centers for Disease Control (CDC) d. The Joint Commission.

45. D: The Joint Commission created the National Patient Safety Goals (NPSGs) to improve patient safety nationwide.

46. Over the past year, Hospital A has become much busier, and there have been several significant medication administration errors. Management is determined to rectify this issue as quickly and efficiently as possible. Which of the following would be the best solution for patient safety? a. Retraining nursing staff on medication administration b. Implementing barcode medication administration technology c. Shortening nursing shifts to increase alertness d. Requiring two-person teams to administer medications.

46. B: Implementing barcode medication administration technology is the most effective and efficient way to reduce errors in medication administration, as it uses technology to double-check work performed by nursing staff before the medication is actually administered. A, C, and D are incorrect because, while they may help correct the issue, they would take longer and be less reliable than barcode medication administration technology.

47. Hospital B implemented a performance improvement and total quality overhaul just over a year ago. Upon analysis of financial data for this year, Hospital B discovers increased profits in spite of training costs for the program. What is the most likely reason for this profitability? a. There was an accounting error. b. All hospitals in the area saw profits. c. Increased quality drew new customers. d. Most of the staff took a pay cut..

47. C: New customers often result from performance improvement initiatives, boosting an organizationʼs bottom line

48. As a department manager, you notice increasing absences and decreasing performance levels among CNAs in your department. What could you do to help identify the cause of these issues? a. Distribute employee satisfaction surveys b. Organize employee feedback forums c. Aggregate and carefully evaluate relevant statistical data d. All of the above.

48. D: A good manager will use satisfaction surveys, feedback forums, and careful data analysis to help identify the cause of the CNA issues and help reestablish the status quo.

49. How does use of an electronic medical record (EMR) improve patient safety? a. Any use of technology reduces errors in healthcare. b. EMR brings an organization up to national standards. c. EMR provides all patient information in a centralized place. d. Using EMR does not improve patient safety..

49. C: Using an electronic medical record (EMR) keeps all patient information in a centralized location, making it easy to access and analyze.

5. Mrs. Jones waits more than an hour past her scheduled appointment time. She finally leaves in a huff, calling the doctorʼs office a joke and saying she has better things to do. Mrs. Jonesʼ perception of quality in this instance is based on... a. Medical care. b. Statistical anomalies. c. Provider norms. d. Patient care.

5. D: Mrs. Jonesʼ evaluation of the medical office was based entirely on her patient care experience, not the actual quality of the office or staff.

6. If managers fail to make organizational decisions consciously, what generally serves as the basis for outcomes? a. Circumstances b. Organizational policy c. Statistical norms d. Federal regulations.

6. A: When managers do not make conscious organizational decisions, those decisions are made by default according to circumstances. Decision making becomes reactive instead of pro-active, and more and more resources are devoted to managing current problems which could have been prevented, instead of planning for the future. This can lead to the beginning of a negative feedback loop which can be very destructive to an organization.

61. After three wrong-site surgeries in one year, Hospital A determined a need to change preoperative practices to help eliminate this issue. Their best response would be... a. Suggesting surgeons double check patient charts prior to surgery. b. Firing and replacing all involved surgical staff and support personnel. c. Creating written procedures mandating better preoperative communication. d. Highlighting surgical notes in patient charts for easier access..

61. C: Creating written policies mandating better pre-surgical communication would be the best response to the errors.

62. Although patient safety events are occurring with unacceptable frequency within your organization, staff members are reluctant to report these events because they fear retribution. What can be done to improve staff reporting? a. Nothing will improve staff reporting b. Implement a non-punitive reporting policy c. Increase punishments for reporting d. Implement punishment for not reporting.

62. B: Implementing a non punitive reporting policy is the best option to help encourage employees to report potential patient safety events. A is not the best choice because it represents capitulation to the problem instead of resolution. C and D are incorrect because increasing the punishments for voluntary reporters will discourage employees from reporting issues.

63. What effect will an extreme organizational focus on financial report results likely have on patient safety? a. It will have no effect on patient safety b. It will have a positive effect on patient safety c. It will have a negative effect on patient safety d. It will complicate patient safety policies.

63. C: A strong organizational focus on financial report results, the so-called "bottom line," will likely have a negative effect on patient safety as efforts are made to lower costs of service.

64. Who is responsible for patient safety in a healthcare organization? a. The patient safety officer b. Administrators and managers c. A and B d. All members of an organization.

64. D: All members of an organization, no matter their title or job duties, are responsible for patient safety.

65. What is the management term for a comprehensive expression of an organizationʼs identity and purpose? a. Vision statement b. Mission statement c. Cultural statement d. Organizational statement.

65. B: A mission statement is a comprehensive expression of an organizationʼs identity and purpose.

66. Using Donabedianʼs model, which of the following areas most needs to be addressed in a clinic with elevated levels of post-treatment infection? a. Structure measures b. Process measures c. Outcome measures d. None of the above

66. C: Outcome measures deal with the effects of treatment after the fact, so they are the most applicable portion of Donabedianʼs model to this particular situation. A and B are wrong because structure and process measures do not apply to this situation. D is incorrect because Donabedianʼs outcome measures do apply to this case.

67. A recent article from a prestigious health ranking organization has placed Hospital A at the very bottom of a list of regional hospitals. In order to move up in the rankings, what should Hospital A do first? a. Establish a steering committee to pinpoint problems and identify solutions b. Replace individuals at the administrative level with new hires c. Establish a quality council to enforce quality standards d. Launch an extensive public relations campaign to improve image.

67. A: To fix the low placement in rankings, Hospital A needs to establish a steering committee to pinpoint problem areas and identify potential solutions

68. National mortality rates for heart attack victims have recently come across your desk. If you want to conduct a one-sample t-test comparing mortality rates at your hospital with national rates, what should your first step be? a. Find the standard deviation for the national heart attack mortality rates b. Gather mortality rates for a random sample of heart attack patients at your hospital c. Do a direct comparison of heart attack mortality variance rates at your hospital d. Collect qualitative data on heart attack mortality.

68. B: A one-sample t-test requires a random sample of applicable data, so gathering the random sample would be the first step in conducting the t-test. A, C, and D are incorrect because they do not fit into the framework of a one-sample t-test.

69. You have established a patient satisfaction benchmark of 90 percent for each individual provider in your department. One provider consistently has scores between 87 and 89 percent over the course of a year. How would you describe his performance against the benchmark? a. Slightly substandard b. Dramatically substandard c. Standard d. Above standard.

69. A: When a benchmark of 90 percent patient satisfaction has been set, a provider who consistently scored between 87 and 89 percent would have performance that was considered slightly substandard.

7. During a surgical procedure, a small medical implement was left inside a patient. The follow-up surgery to remove the implement is an example of... a. Quality improvement. b. Quality control. c. Quality assurance. d. Total quality..

7. C: Quality assurance is a focus on outputs or quality after the point of production, including any corrective actions necessary to optimize post-production quality, as in the surgery performed to remove the implement left in the patient. A, B, and D are incorrect because they refer to quality processes that take place on different levels and are not corrective in the way that quality assurance is.

70. It has recently been brought to your attention that there is a disparity in admission rates between insured and uninsured patients with the same conditions. How could you best express this disparity statistically? a. Through use of a Pareto chart b. By using benchmark data c. Through comparative analysis d. By evaluating standard deviation.

70. C: The best way to statistically express a disparity between two categories of data is through comparative analysis. A, B, and D are incorrect because, while they statistically express data, they do not show disparities within a data set and they do not compare numbers as clearly as comparative analysis does.

71. After three years of rising influenza rates, Clinic A institutes an extensive vaccination campaign. What outcome data would be expected as a result of this campaign? a. More clinic visitors b. Higher healthcare costs c. Reduced clinic visits d. Decreased influenza incidence

71. D: The expected result of the vaccination campaign by Clinic A would be decreased influenza incidence.

72. Which of the following are important areas to consider when evaluating a public health surveillance system for data collection? a. Data quality b. System experience c. Validity of acquired data d. All of the above.

72. D: Data quality, system experience, and validity of acquired data are all important areas to consider when evaluating a public health surveillance system for data collection. A, B, and C are not correct because none of those options alone is the best answer, although they are all important elements of an effective system as a whole.

73. Hospital A has just implemented a new electronic health record system. As an administrator, it is your job to get everyone comfortable using this new system. What would be the best first step in this process? a. Presenting system benefits to stakeholders b. Requiring mandatory training for all employees c. Requiring mandatory usage by all employees d. Distributing a list of other organizations using the technology.

73. A: When implementing a new system and trying to get employees comfortable with it, one of the best first steps is presenting actual system benefits to stakeholders who can get others excited about the technology. B, C, and D are incorrect because although they are all possible tactics to get employees to use the new system, they are not effective as a first step.

74. When does the credentialing process generally take place? a. Prior to employment b. Prior to termination c. Every year of employment d. Every five years of employment.

74. A: Credentialing generally takes place prior to employment.

75. As a member of a quality improvement team, you are participating in a medication usage review. Who else must participate in this process? a. The patient b. A care provider c. A and B d. None of the above.

75. C: Both a patient and provider should be involved in a medication usage review to improve efficacy.

76. Patients on the postsurgical ward have been complaining about a lack of privacy when nurses are performing wound care. What process is most appropriate to initiate for resolution of this issue? a. Quality control b. Patient advocacy c. Quality assurance d. Peer review.

76. B: A lack of privacy during wound care should be resolved through the support of a patient advocate.

77. It is confirmed that a patient who sat for 30 minutes in the waiting room of your clinic was diagnosed with measles. What necessary infection-control step should be taken? a. Educate the patient on possible effects of the measles b. Document the case in your annual clinic statistics c. Train front-desk employees to recognize signs of measles d. Contact all patients who may have been in the waiting room that day.

77. D: The most important infection-control step in this situation would be to contact all patients who may have been in the waiting room that day.

78. You have been tasked with creating patient safety training for the nursing staff. What is your first step in preparing training materials? a. Determine learning objectives b. Write lessons for presentation c. Create supplemental materials d. Schedule training times/locations.

78. A: The first step in creating patient safety training (or any other kind of training training) should be determining the learning objectives. B, C, and D are incorrect because, although they are valid steps in creating training, they do not represent the first step of the process.

79. Which of the following are efficient ways to evaluate the effectiveness of performance improvement training? a. Exit surveys for participants b. Analysis of post-training performance c. Post-training focus groups with participants d. All of the above

79. D: Exit surveys for participants, analysis of post training performance, and post training focus groups are all effective ways to evaluate the effectiveness of performance improvement training.

8. Which of the following statements about quality in healthcare is true? a. Quality is a conglomerate of lessons, methods, and knowledge. b. Quality directly correlates to patient safety. c. Quality is multifaceted and multidimensional in nature. d. All of the above

8. D: All of the statements presented in A, B, and C are true statements about quality in healthcare.

80. When providing customer service training to employees from multiple departments, what is the most important concept to keep in mind? a. Diverse scheduling needs b. Lack of familiarity among trainees c. How differences may affect learning d. Some employees may not need training.

80. C: The most important thing to keep in mind when providing customer service training for employees from multiple departments is how differences may affect learning.

81. What is the primary purpose and ultimate goal of performance improvement training? a. To improve performance in a specific area b. To improve performance throughout an organization c. To introduce new ideas to employees d. To create uniformity across an organization.

81. A: The primary purpose and ultimate goal of performance improvement training is to improve performance in a specific area. B is incorrect because performance improvement should be targeted at a specific behavior to be improved. C and D wrong because, while they are both desirable goals, neither one represents the primary purpose and ultimate goal of performance improvement training

82. Who can initiate a peer review? a. A patient b. A physician c. An insurance carrier d. All of the above.

82. D: A peer review may be initiated by a patient, a physician, or an insurance carrier.

83. What is the relationship between peer review and root cause analysis? a. They are unrelated b. Peer review sparks root cause analysis c. They work together in failure analysis d. They were both designed by the Joint Commission.

83. C: Peer review and root cause analysis are both tools that are used hand-in-hand as part of failure analysis.

84. You are deeply involved in preparing an award application, and you need to survey internal subject matter experts to answer the questions needed for the application. What question would be appropriate for any survey, regardless of the department or subject? a. Describe your departmental approach to patient care b. Describe your departmental approach to customer service c. Describe your departmental approach to financial management d. All of the above

84. B: Every department can and should answer survey questions describing their approach to customer service.

85. Which regulatory body is responsible for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) currently in use in more than 98 percent of acute care hospitals? a. The Joint Commission b. The Centers for Medicare and Medicaid Services (CMS) c. The Agency for Healthcare Research and Quality (AHRQ) d. B and C

85. D: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) was designed jointly by the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ).

9. Which of the following is not considered a principle of total quality? a. Competent management b. Customer focus c. Continuous improvement d. Teamwork.

9. A: Competent management is not considered a principle of total quality. Customer focus, continuous improvement, and teamwork are the three principles of total quality.

92. Despite repeated training, the emergency room staff still exceeds suggested organizational wait times for incoming patients. What factor should be considered before future training to ensure change will occur? a. Misalignment of departmental and organizational strategic goals b. Age and generational differences of department employees c. Gender-based bias of treatment times for incoming patients d. Standard deviation of staffing levels against patient influx levels

92. A: Before pursuing further training for the emergency room staff, it is important to examine if there is a misalignment of departmental goals (quality care) and organizational strategic goals (reduced wait times).