Chapter XIV. Quality & Performance Improvement

as per governmental and facility policies

The current hospital policy time frame for authenticating verbal orders adheres to the CMS COP that requires the ordering physician, or another healthcare practitioner responsible for the care of the patient, to write orders according to hospital policy and authenticate

CRITICAL QUALITY TREE

100. The Six Sigma methodology differs from other qua lit improvement models by defining by improving opportunities using: a. Scientific management b. critical quality tree C. .non-value activities/processes D. brainstorming

HIGHRISK

38. In quality review activities, departments are directed to focus on clinical processes that are

BRAINSTORMING

42. You sit on the QI team for the Nursing department to generate ideas to address verbal orders documentation problems about the "Read Back Verbal Order: policy. What QI tool would be useful in sharing input and various recommendations for solving this problem.

FISHBONE DIAGRAM

54. The use of metrics to conduct root cause analysis that will facilitate changes throughout the organization can best be presented using a?

BREAST CANCER SCREENINGS

57. HEDIS gathers data in which of the following areas?

CONTROL CHART

79.The Board of directors see a rise in the in the cesarean section rate and want to know if it is a significant increase. What is the best QI tool for this purpose.

DUE PROCESS

104. When a decision is made to restrict or deny clinical privileges during the re credentialing process to a medical staff member, a _________ must be offered. A. privilege suspension C. due process B. revocation of license D. crisis intervention

OUTCOME INDICATOR

105. A patient satisfaction survey conducted after discharge is a method of quality measurement through. A. prospective indicator C. process indicator B. structure indicator D. outcome indicator

INTRA-CYCLE MONITORING

106. The Joint Commissions emphasis on improving quality of patient care for a participating facility is exemplary through the required self-assessment process tool known as:

PLANNING

108. Traditional management functions, such as ______-_______, must be applied to performance improvement initiatives. A. education B. planning C. accreditation D. reimbursement

CREDENTIALING A process of evaluating an individuals knowledge and experience against a standard to determine whether the individual is qualified to perform certain tasks

109. THE PROCESS OF REVIEWING AND VALIDATING QUALIFICATIONS, GRANTING PROFESSIONAL OR MEDICAL STAFF MEMBERSHIP AND AWARDING DELINEATED PRIVILEGE IS CALLED THE _________ A. licensure C. professional review B. appointment D. credentialing

SEVERITY OF ILLNESS/INTENSITY OF SERVICE CRITERIA

11. MOST ACUTE CARE FACILITIES USE THIS TYPE OF SCREENING CRITERIA FOR UTILIZATION REVIEW PURPOSES TO DETERMINE THE NEED FOR INPATIENT SERVICES AND JUSTIFICATION FOR CONTINUED STAY.

KEY PERFORMANCE INDICATORS

111. An area identified for needed improvement through bench-marking and continuous quality improvement is know as a ____________ A. key attribute C. knowledge base B. measure hierarchy D. key performance indicators

SHARED LEADERSHIP

113. To properly implement performance improvement organization should ensure that all employees participate in an integrated, continuous PI program. This is know as: A. shared leadership B. organizational PI C. quality management liaison group D. shared vision

DELINEATION OF PRIVILEGES

14. An opthalmologist has requested permission to perform specialized laser procedures within the hospital. His request is evaluated by the Credentials Committee through a process to determine the specific procedures and services this physician can perform. This is known as

Clinical chairpersons of medical staff committees or ancillary department directors.

17. The responsibility for performing quality monitoring and evaluation activities in a departmentalized hospital is delegated to the.

The indicators must include the most important aspects of performance.

18. What criterion is critical in selecting performance indicators for a health information management department?

NGT determines the importance of responses through a rating system.

20. What feature distinguishes the Nominal Group Technique (NGT) from brainstorming?

RISK MANAGEMENT

22. The medical malpractice crisis of the 1970s prompted the development of

HIPAA Security Rule

23 The following legislation requires that patient identifiable health information remains confidential and protected against unauthorized disclosure, alteration or destruction.

Available at the right place and the right time.

24. The hospital Quality Department adopted the Lean Management quality model using JIT, which ensures required process items and resources are.

CONTINUED STAY REVIEW

25. The Utilization Review Coordinator reviews inpatient records at regular intervals to justify necessity and appropriateness of care to warrant further hospitalization. Which of the following utilization review activities is being performed?

REQUIREMENTS FOR IMPROVEMENTS

26.The Joint Commission recently surveyed an acute care hospital. The hospital just received the survey report and the accreditation decision. Which of the following categories should the hospital leaders address first. A. Requirements for improvement B. Grid Elements C. Written Progress Reports D. Triennial Exception Rules

ALL RELEVANT DATA

3. The Blood Usage Review Committee has a quality monitor established to review all blood transfusion reaction cases. The HIM director will be working with the committee to identify and abstract patient outcome information for committee evaluation. What data should be collected?

B. cases with elements missing in the preoperative anesthesia consultation

30. Surgical case review includes all the following EXCEPT: A, determination of surgical justification based on clinical indication(s) in cases where no tissue has been removed. B. cases with elements missing in the preoperative anesthesia consultation c. cases where there is a significant discrepancy between preoperative, postoperative and pathological diagnoses. D. cases with serious surgical complications or surgical mortalities

Healthcare Quality Improvement Act

31. What federal legislation passed in 1986 gave immunity from legal action to practitioners regarding some peer review process activities?

FLOWCHART

35. What visual tool would be best to identify all logical STEPS & SEQUENCING OF EACH PROCEDURE when comparing the current coding process with a proposed concurrent coding process.

Fishbone (cause and effect diagram)

39. A QUALITY IMPROVEMENT TEAM IS ASSEMBLED TO IDENTIFY THE OUTCOME VARIABLE AND THE MAJOR OR ROOT CAUSES OF A BACKLOG IN LOOSE REPORT FILING. WHAT VISUAL QI TOOL IS HELPFUL TO REPORT THE FINDINGS?

AFFINITY DIAGRAMS- Reduces larger amounts of information into a smaller number of categories (from large to small)

41. Providing feedback through BRAINSTORMING thats you compiled on FLIP-CHARTS and ORGANIZED IN CATEGORIES. Is known as

DEMINGS

45. What quality engagement theorist focused on the use of the PDCA cycle in continuous clinical quality management improvement efforts?

NOMINAL GROUP PROCESS SIMILAR TO BRAINSTORMING BUT USES SILENT GENERATION OF IDEAS AND A SEQUENTIAL REPORTING APPROACH TO ENSURE PARTICIPATION BY ALL GROUP MEMBERS.

46. Your committee has collect information, and you bring your committee together to prioritize their suggestions. This method of working with information is known as. A> force field analysis B. Delphi process C. nominal group process D. Correlation analysis

DOUGLAS MCGREGOR

48. Which quality management theorist believed in the contrasting views of Theory X (presumed that workers disliked work)and Theory Y(assumed that under the right conditions, people would seek responsibility and be creative)

MEDICARE CLAIMS

5. The Recovery Audit Contractor (RAC) program was developed to identify and reduct improper payments for:

LICENSURE

52.What process is mandatory for health care facilities.

PHYSICAL SAFEGUARD

55.. A HIPAA security component concerned with having a building alarm system instaledl would be A. administrative safeguard B. technical safeguard C. physical safeguard D. organizational standard

deficiencies in documentation can effect reimbursement

61. A disadvantage of retrospective data collection:

PROSPECTIVE REVIEW

65. The manager of the utilization review wants to monitor and evaluate the prevention of inappropriate admissions. When would the manager need to collect data? A> Prospective review C. retrospective review B. concurrent review D. Long term care review

QUALITY IMPROVEMENT INFORMATION

66. The manager of the quality department is listing various sources of data. Which of the following data sources would be an example of an external source. A. emergency room logs B. incident reports C. pt. registrations /admission, discharge info. D. quality improvement information

CHART COMPLETION ISSUES CAN BE REMEDIED PROMPTLY.

67.. Primary advantage of concurrent quality data collection is:

2 YEARS

7. Clinical privileges are granted to the physician for an interval specified inthe medical staff bylaws, but not longer than.

RETROSPECTIVE

74. The nursing department would like to assess its documentation of education on colostomy care for patients with new colostomies. When should this be done. A. prospective B. concurrent C. retrospective D. long term care

CONTROL CHART

80.WHAT IS THE BEST TOOL FOR DIFFERENTIATING BETWEEN COMMON CAUSE VARIATION AND SPECIAL CAUSE VARIATION.

DIABETES

83. All of the following are among the Joint Commissions initial core measure sets for hospitals EXCEPT: A. Acute myocardial infarction. C. Pneumonia B. diabetes D. Surgical infection prevention

NCQA (National Committee for Quality Assurance)

87. An accreditation agency counterpart to the Joint Commission for managed care organizations is the :

QUALITY MEASURE REPORTING

88. The PQRS is a reporting system established by the federal government for physician practices who participate in Medicare for:

HEALTH CARE INTEGRITY & protection data bank

89. Which data bank is a result of HIPAA legislation A. Fraud and abuse data bank B. Health care integrity & protection data bank C. National Practitioner data bank D. Privacy Information breach data bank

BOARD OF DIRECTORS OR GOVERNING BODY

9.the person or group who is overall responsible and accountable for maintaining the quality and safety of patient care is the

INSTITUTIONAL REVIEW BOARD: approves research

97. Dr, Jeremy is conducting a clinical trial research study. As Director, you are responsible for clinical abstract of data and advise him to first seek approval of research involving human subject thru the: A. medical staff B. governing board C. institutional review board D. Office of National Coordinator

C. both system & patient tracers

98. The Joint Commission onsite survey process incorporates tracer methodology, which emphasizes surveyor review by means of: A. patient tracers C. both system & patient traers B. system tracers D. policy & procedure manual reviews