CPHQ Practice Exam Questions

A clinical pathway on the management of hip fractures has been developed by a multi-disciplinary team and implemented in a large teaching hospital. After monitoring for 6 months, the length of stay continues to exceed the guidelines. Which of the following should be the next step? 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 change in the outcome.

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.

Healthcare leaders are confronted with the challenge of increasing quality while reducing costs. Which of the following approaches best advances improvement efforts? A. Support activities that improve outcomes and reduce variation. B. Incorporate customer satisfaction results into quality initiatives. C. Increase charges and decrease costs. D. Develop new services to increase revenues

A. Support activities that improve outcomes and reduce variation. Best action since this will effect multiple domains within quality, including safety, effectiveness, and efficiencies.

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 required 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., and D. The CEO, Governing Body, and Quality Committee do not have the same clinical experience, expertise, and education to determine competency.

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

A. a histogram. A. A histogram displays data in a 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

A 69-year-old female admitted for 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.' Correct, as the "time-out" is a team briefing conducted by the surgeon before the procedure starts and includes verification of the surgical site.

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 reports. D. accreditation survey reports.

A. adverse drug events. Risk management has a role related to incident reporting.

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.

A group of pediatric patients diagnosed with cystic fibrosis is being studied. Their attitudes toward the disease have been measured each year for the past 4 years. The methodology used is an example of a A group of pediatric patients diagnosed with cystic fibrosis is being studied. Their attitudes toward the disease have been measured each year for the past 4 years. The methodology used is an example of a A. cohort study. B. regression analysis. C. case-mix study. D. cross-sectional analysis

A. cohort study. A. Cohort study analyzes a group with a specific characteristic, such as cystic fibrosis. B. Regression analysis looks at the relationship among variables. This study is looking at a single variable: attitudes toward disease. C. Case-mix study is more definitive and would require more analysis of each case within the study. This study is looking at a qualitative measure and does not require a quantitative analysis. D. A cross-sectional analysis measures data at a specific point in time.

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

A. control chart Control charts exhibit points between control limits, therefore displaying the variation.

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. From the graph above, cost has the largest percent of customers reporting they are disappointed. Caring has the largest percent of customer reporting they are delighted.

In lean thinking, a process step is defined as "value added" if the A. customer recognizes the value. B. customer corrects a mistake to add value. C. process owner recognizes the value. D. process owner changes the value of the product.

A. customer recognizes the value. Customer value is the key concept of lean thinking and improvement efforts.

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. part of the process

A policy for "time-outs" in an operating room was initiated in the first quarter. The second quarter data demonstrated only 40% compliance with all elements of the process. The first step the Quality Council should take is to A. examine if the policy is clear and user-friendly. B. ask the nurses to identify non-compliant surgeons. C. continue to audit to confirm that a problem exists. D. create a letter for the CEO to send to all surgeons

A. examine if the policy is clear and user-friendly. Since process has changed, it is important to make sure it is clear and all understand.

The quality improvement director is responsible for coordination of accreditation survey activities. Responsibilities will most likely include A. facilitating self-assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda for the survey. B. educating staff to all standards, writing the survey report, and completing the survey application. C. developing a protocol for a mock survey, conducting unannounced surveys, and challenging the survey report. D. preparing for unannounced surveys, disseminating the survey report, and developing new standards

A. facilitating self-assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda for the survey. A. These are essential functions for overseeing accreditation process. B. Writing survey reports is not in scope of the work, but the role of a surveyor. The other items could be part of their responsibility. C. Conducting unannounced surveys is not in scope of the work; that is a surveyor function. The other items could be part of their responsibilities. D. Developing standards is not a function of their work, but of the accreditation organization. The other items could be part of their responsibilities

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 Both healthcare-acquired infections and perioperative mortality are concerns to be addressed at a morbidity and mortality conference.

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. Correct; 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.

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. A. This ties financial impact to quality management. B. This is not related to physician profiles. C. This is more financially-related, not quality-related. D. Information is determined through resource management and evidence-based practice

Which of the following action plans is the first step in correcting inappropriate blood usage in an emergency department? A. 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. in-service on ordering blood usage for the physicians Educating the physicians on the critical use of blood products will assist to better utilize blood supply.

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

A. integrated with clinical workflow. Best answer, since staff at the line has to know how to use the tool with their daily work

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

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.

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 it 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 of the program 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 need for revision.

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 A. Individuals closest to the process must be included as they have the most in-depth knowledge of the process being evaluated. B. Although the supervisor may have some knowledge, they are not the experts on how the process is actually performed. C. Administrators lend support to the team, but do not have the expertise and typically are not part of the team evaluating a process unless their support is needed to remove barriers. D. A quality management representative often serves as a team facilitator. However, they do not have the direct process expertise, and other staff may perform this role if trained.

Results of 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. A. Practitioners have vested interest in this information since the data is about them.

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. Correct, as the FMEA tool is used to proactively design or redesign a process

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

A. process improvement. A. Eight points below the control limit indicate a positive shift in the problem (special cause variation). B. See explanation for A. C. Based on statistical process control rules, this is a shift, not a trend. D. An outlier would either be above or below the control limits.

Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization's quality improvement program? A. quantifiable objectives B. support from the medical staff C. well-defined organizational structure D. integrated data collection

A. quantifiable objectives To evaluate effectiveness, an organization must have quantifiable objectives in order to measure progress toward meeting goals. B. Support from the medical staff is helpful in the success of a quality improvement problem, but it does not evaluate effectiveness. C. A well-defined organization is helpful in the success of a quality improvement program, but it does not evaluate effectiveness. D. Integrated data collection would make it easier to evaluate effectiveness, but is not critical.

When a team evaluating the use of restraints starts to discuss a liability claim related to a patient, the facilitator should A. redirect the team. B. consult the risk manager. C. request the medical record. D. review team ground rules.

A. redirect the team. A. Redirection is needed to move team back on topic and towards performance improvement effort. B. This would be done following meeting. C. This is not an applicable action. D. This should be done at the start of the meeting.

Minimizing the chances for an adverse event to reoccur includes determining the primary contributing factor by using A. root cause analysis. B. force field analysis. C. clinical pathways. D. failure mode and effects analysis (FMEA).

A. root cause analysis A. Correct, as exploration of system and process issues should be primary in identifying root causes of error. B. Incorrect, as force field analysis identifies forces that influence success or failure of improvement of a process and not the identification of the root cause of an incident. C. Incorrect, as clinical pathways are guidelines developed to assist in clinical management decisions. D. Incorrect, as FMEA is a tool to design or redesign a process.

Staff has been trained and oriented on a new electronic incident reporting system. In the past, staff could report anonymously. The new system requires staff to sign in with an individualized username and password. Three months after implementation, there is a sharp reduction in the number of reported incidents. Which of the following reasons for 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 organization's culture.

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.

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. UHDDS are hospital-based measures. B. HEDIS provides data for managed care performance measures. C. AHRQ is the agency that does not establish managed care performance measures. D. NQF measures are not the most widely used performance measures for managed care.

A new quality director has reviewed the information related to the 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 council's role to coordinate and prioritize quality activities. C. Switch to a monthly meeting with a new agenda format. D. Eliminate the council and directly report quality data to the governing body.

B. Redefine the council's role to coordinate and prioritize quality activities. This is the best answer available.

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 physician's privileges. D. Assign a proctor to the physician.

B. Refer the case for peer review. It is a single episode which is appropriate for peer review.

Which 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 built on.

Which of the following is always true regarding a sentinel event? A. The cause is established as a deviation from 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. B. Correct, as a sentinel event should be as high a priority as a reactive response to a sentinel event.

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 Consultant provides external assistance with filling in knowledge gaps.

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 individual

B. constancy of purpose This is the best answer

Which of the following should a Quality Council provide to best ensure success of performance improvement teams? A. facilitator and recorder B. empowerment and training C. indicators and a data analyst D. standards and procedures

B. empowerment and training A. These are important roles to have, but not the best answer. B. This is the best answer. These are two key elements for ensuring success for the teams. C. May be a function or work of the team with the data analyst; there are no guarantees that these items will directly contribute to the success of the teams. D. The presence of these items are important, but not factors that will guarantee success.

Which of the following actions should a facilitator make the highest priority during the 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 facilitator must establish rapport in order facilitate the group towards outcomes.

A t-test may be used to A. display the size of a sampling variation. B. evaluate the effects of two different treatments. C. evaluate differences among three or more treatments. D. display a listing of the number of occurrences of a variable.

B. evaluate the effects of two different treatments. A t-test is used to examine if the mean of two treatments are statistically different from one another

Which of the following team members is responsible for keeping meetings focused? A. time keeper B. facilitator C. recorder D. leader

B. facilitator A. A time keeper monitors time and does not focus on team performance. B. The facilitator facilitates and is responsible for team focus. C. A recorder records minutes. D. A leader guides the team towards outcomes

The leader of a pain management performance improvement team has asked the Quality Council to disband the team. The most important factor for the Quality Council to assess is A. the length of time the team has been together. B. how well the team met the intended outcome. C. the effectiveness of the team leader and facilitator. D. the amount of data the team has collected.

B. how well the team met the intended outcome. A. The length of time the team has been together does not indicate that the team has met its goals and intended outcomes. B. The decision to disband should be based upon how well the team has met the intended outcomes. C. The effectiveness of the team leader and facilitator may impact team performance, but is not a reason to disband the team. D. The amount of data the team collected is not an indicator of whether the goals or intended outcomes have been met

Which of the following actions has the greatest impact in reducing harm? A. revising the patient safety evaluation tool B. improving interdisciplinary communication C. forming a performance improvement team D. increasing data collection frequency

B. improving interdisciplinary communication A. A safety tool may not be utilized constantly and accurately. B. Improved communication has been proven to be a key factor in reducing harm. C. Performance improvement items are not always focused on reducing harm. Other focus areas may be efficiency, financial, etc. D. Data collection does not reduce harm independently.

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 organizational expectations and address culture changes before addressing quality teams, consumer expectations, or 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 data and overtime data C. overtime data and absenteeism rates D. occurrence reports and sentinel events

B. patient safety data and overtime data Using patient safety data and correlation to overtime data are appropriate indicators to identify a relationship between the two.

A healthcare entity initiating re-structuring must consider the impact on 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 Best answer, these actions promote transparency and trust through communication and leadership.

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

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

When errors are discovered, staff and supervisors best demonstrate a culture of safety by A. developing a plan for just-in-time training. B. studying the process to understand the error. C. planning which details of the error to disclose to senior leadership. D. performing a root cause analysis to determine which individuals were involved.

B. studying the process to understand the error. Foundational statement

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 those concerned. They may support without unanimously agreeing. B. Consensus is general support from those concerned. C. Consensus implies partial satisfaction from those involved, but is not total satisfaction. D. Although consensus includes support from those concerned, it does not require agreement by a majority.

Leaders enhance employee commitment to organizational values by fostering which 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 for leadership to have visibility and to promote engagement with staff

Which of the following is most appropriate in preparation for an external survey of a healthcare facility? A. Assign key staff to answer all questions. B. Ask department heads to prepare a presentation for the survey team. C. Educate staff about the types of questions they may be asked. D. Set up teams to make a good showing for the survey.

C. Educate staff about the types of questions they may be asked. A. Survey process may involve all staff, so to assign certain staff might not be the best strategy. B. May be an element for survey preparation, but not the best answer. C. Best answer; survey process will involve all staff. D. May be an element for survey preparation, but not the best answer.

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 reoccurring, 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. Correct; this step addresses the result of the root cause.

A root cause analysis team examined a serious medication error and recommended changes. Which of the following should be done next? A. Random checks for compliance should be made by patient safety staff. B. The Quality Council should review medication errors quarterly. C. The process owner should implement and assess effectiveness. D. Monthly reports should be sent to the regulatory body.

C. The process owner should implement and assess effectiveness. A. Incorrect; random checks would not be the next step. B. Incorrect; this is not the function of implementing changes, but a continued monitoring function. C. Correct; the recommended changes need to be assigned ownership. D. Incorrect; this may be a regulatory requirement, but not the next step of implementing change

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? (Image missing) 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.

Facility A is investigating its medication administration time for a specific diagnosis. Evidence-based guidelines indicate that administration of a particular drug within 30 minutes significantly improves patient outcomes. The national average is 32 minutes. The average for Facility B is 28 minutes. If the average for Facility A is 35 minutes, Facility A should A. determine whether its rate is within one standard deviation of the national average. B. decrease its rate to meet the national average. C. contact Facility B to determine its practices. D. identify the average time of its competitors.

C. contact Facility B to determine its practices. A. Facility A is aware their average is low. There is no reason for additional calculations. B. Decreasing rates is the result. C. Sharing best practices is encouraged for process improvement. D. Progress is not gained from focusing on competitors' rates.

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. Significant factor that must be considered when implementing any program.

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

C. define the future direction for quality. This is a function of having a QI strategic 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. A. Cost-benefit analysis is not used for checking performance alone. B. Cost-benefit analysis is more financial in nature. C. Cost-benefit analysis allows for financial controls to be considered towards outcome achievement. D. Implementation would follow the cost-benefit analysis.

Which of the following is an example of information that should be included in an incident report, but should NOT be recorded in a patient's medical record? A. the patient found on the floor next to the bed with the patient's right leg appearing to be rotated B. the date, time, dose, and name of a medication administered to a patient in error C. details concerning a medication preparation error discovered and corrected prior to administration D. the patient's right knee replaced after consenting to replacement of the left knee

C. details concerning a medication preparation error discovered and corrected prior to administration C. Correct, as this information is a part of identifying the root cause of the incident and not appropriate for the clinical medical record.

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

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

C. flow A. A Gantt chart is a project management chart. B. A Pareto chart is a prioritization tool. C. A flow chart is the best chart to use first for a root cause analysis. D. A control chart is a tool to evaluate process.

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 a tool to facilitate quality improvement, but is not a required component of quality improvement.

When choosing an outside consultant to lead employee focus groups, which of the following priority areas of expertise should a healthcare quality professional look for? A. team development and management B. organization assessment and change management C. group dynamics and facilitation D. organization design and re-engineering

C. group dynamics and facilitation A. This is the responsibility of the team leader, not an outside consultant. B. A consultant is not tasked with changing culture, but with gathering information. C. The primary role of a consultant who is leading focus groups is to facilitate interaction in the group dynamic. D. Focus groups are not about design and re-engineering, but information gathering.

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. A. Reduction in risk may help to meet regulatory requirements, but is not the primary purpose of risk management. B. Provision of report to liability carriers is a component risk management, but is not the purpose of risk management. C. 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. D. Risk management does focus attempts to reduce financial loss due to risk issues, but does not eliminate financial loss to the organization which may result from many other factors.

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

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 is the stage during which team members get to know each other. B. During storming, team members deal with conflict. C. The team moves towards cohesion and collaboration during the norming stage. D. Purpose of the performing stage is meeting the expectations and outcomes.

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

C. post-delivery septicemia Post-delivery septicemia is a complication and morbidity issue.

Balanced scorecards are useful because they A. focus on the most significant strategic initiative. B. evaluate the pros and cons of the governing body's priorities. C. put strategy and vision at the center of an organization's effort. D. concentrate on the performance of individual units

C. put strategy and vision at the center of an organization's efforts A. There may be some sort of visual display to highlight most significant strategic initiative, but the intent of the scorecard is to highlight multiple objectives of the organization. B. Not in scope of a balanced scorecard. C. The balanced scorecard is a management framework that translates an organization's strategic objectives into a set of performance measures that are measured, monitored, and changed, if necessary, to ensure that organization's strategic goals are met. D. The intent is to have a visual display of the entire organization's progress, not individual units.

Which of the following is the most effective way to integrate performance improvement concepts throughout an organization? A. quarterly newsletters B. monthly lectures C. quality teams D. continuous monitoring

C. quality teams A., B. Quarterly newsletters and monthly lectures are a mechanism to communicate information, but may not be read/heard by all and do not guarantee integration. C. Quality teams include participation by front-line staff, which allows direct integration of performance improvement into practice. D. Monitoring does not include a communication component and does not address integration.

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 culture of patient safety in an organization will have been 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 to be able to report out.

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 interpretation.

C. the definition of data elements. All data elements need to be defined to ensure data collection accuracy, reliability, and validity.

Satisfaction surveys, focus groups, and complaint tracking are tools used to A. benchmark satisfaction. B. develop clinical pathways/guidelines. C. understand customers' expectations. D. measure professional practice patterns.

C. understand customers' expectations. A. Benchmarks establish best practices and targets. B. Clinical pathways are the steps in care used by caregivers. C. Surveys, focus groups, and complaints with or from customers can provide information directly from the customers regarding a variety of topics including customer expectations. D. Measurements of professional practice patterns provide information about internal performance, not customer expectations.

Which of the following graphs provides the best information for re-appointment/re-evaluation of an individual physician? (Use the scroll bar to the right to scroll down as needed.) A. B. C. D.

D A. This chart doesn't compare the physician. B. This chart doesn't compare the physician. C. This chart doesn't show data over time. D. This chart includes the best information to compare using time.

The following table shows the percentage of hospital-acquired pressure ulcers: Which of the following should the healthcare quality professional do next? A. Implement a new pressure ulcer protocol. B. Re-educate staff. C. Continue to track and trend the data. D. Conduct a focused analysis of pressure ulcer cases.

D. Conduct a focused analysis of pressure ulcer cases. Advanced-stage, hospital-acquired pressure ulcers are considered never-events. Because this is a significant patient safety issue, it is important to not delay analysis so that trends and opportunities for improvement can be determined.

A hospital-wide medical record audit on documentation has been completed. The following table shows the compliance rate of documentation: Compliance Rate (%) Documentation: 1st Qtr 2nd Qtr Surgical "time-outs" performed 90 95 Communication of critical results 91 95 Pain score used 50 60 Initial patient assessment performed 52 45 Which of the following is the next step? A. Benchmark the compliance rates against another facility. 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. Although benchmarking is helpful for comparison to external organizations, it is not critical to initiating internal improvement when opportunities are identified. B. Although pain score compliance is low, there has been improvement from Q1 to Q2, so a focused review of patient assessments should be permitted first (See D). C. None of the data provided is related to physician signature. D. A focused review of the patient assessment process should be prioritized because of 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 been 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. A. This is not necessary to pass a CMS survey to obtain deemed status. B. Deemed status has no relation with a surveyor's employment status. C. Deemed status is not related to physicians. D. 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. A. Prioritization takes place later in the process. Idea generation should not be disrupted by prioritizing ideas during the brainstorming process. B. Discussion takes place later in the process. Idea generation should not be disrupted by discussion during the brainstorming process. C. Idea elimination takes place later in the process. Idea generation should not be disrupted by eliminating ideas during the brainstorming process. D. 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 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. Quality Council. B. governing body. C. utilization committee. 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 medication error occurred and resulted in a severe adverse outcome. In addition to informing the patient and/or family, a healthcare quality professional 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. A. Incorrect; a regression analysis identifies how a change in an independent variable affects the dependent variable. B. Incorrect; this intervention would not identify the root cause of an adverse outcome. C. Incorrect; this would be a disciplinary action and would not identify the root cause of an adverse outcome D. Correct; exploration of system and process issues should be the primary function of a root cause analysis.

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

D. conforming. his is not one of the stages outlined by Tuckman's A. 3rd stage B. 1st stage C. 4th stage D. This is not one of the stages outlined by Tuckman's

During quality management data analysis activities, Pareto charts are most appropriately used for A. displaying parts of a whole. B. displaying trends over time. C. determining cause and effect relationships. D. determining priorities among contributing factors.

D. determining priorities among contributing factors. Pareto charts most appropriately assist to determine priority using represented values.

A physician who has a high inpatient mortality rate compared to others in a facility should first be A. counseled by the department chairperson. B. reviewed by the credentialing committee. C. suspended in the interest of patient safety. D. evaluated via a more in-depth review of cases.

D. evaluated via a more in-depth review of cases Required to make a determination based on quantity of cases and quality

In the process of strategic planning, an organization makes decisions about the future. A basic component of the planning process is to A. develop contractual relationships to enhance market share. B. contract with a consulting firm to assist with the planning process. C. determine organizational profitability during the most recent fiscal year. D. examine both internal and external environments.

D. examine both internal and external environments. Includes an examination of internal strength and weaknesses, and external opportunities and threats.

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 A. The quality improvement director has a key role in facilitation and operations of the QIPS program, but is generally not the ultimate responsible individual. B. Same as A; provides input and facilitates interactions between medical staff and operations. C. Same as A; provides input and facilitates interactions throughout the organization. D. This is the expectation of TJC and Centers for Medicare and Medicaid Services (CMS).

Generic screening is an example of risk A. evaluation. B. reduction. C. prevention. D. identification.

D. identification. A. Evaluation follows all the processes. B. Reduction follows prevention. C. Prevention follows identification. D. Identification is the first step in disease management/risk management.

The utilization management committee is reviewing length-of-stay 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 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 length of stay 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 robust than the mean as there can be more than one mode. D. The mean is the statistical average in a data set. It is often used to describe average length of stay for comparison and is used with the standard deviation to understand the variability around the mean.

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

An operating room circulating nurse reported that the instrument count indicated a missing clamp. X-ray findings were negative, and the patient showed no adverse effects. This occurrence is an example of which of the following? A. claims management B. malpractice C. clinical incompetency D. potentially compensable event

D. potentially compensable event Although the clamp was not found, this has potential to become a compensable event. A potentially compensable event is an event for which there is risk of future claim or settlement.

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 criteria that are based 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 Data element definitions and instructions are essential in ensuring data validity and reliability.

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

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 services D. references of the SME

D. references of the SME The positive clinical reputation provides credibility support to the project.

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 the patient population across organizations.

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

D. the benefits of teams All are key benefits of a performance improvement team

A healthcare quality professional wants to measure the success of a corrective action plan with a 95% confidence level. The average daily census at the quality professional's organization is 1,000 patients. The best sampling technique for this study is to review A. 10% of all discharge records for the past quarter. B. all active records on one day of the past month. C. 30% of records based on preliminary compliance review. D. the number of records needed using a statistical method

D. the number of records needed using a statistical method D. Correct; the confidence level and interval would be determined through calculation