CPHQ Practice Questions

a capital expenditure such as for new equipment is generally expected to have a useful life of more than 1) 1 year 2) 3 years 3) 5 years 4) 10 years

1) 1 year

to comply with OSHA regulations, a healthcare worker exposed to HIV through a needlestick must be monitored after exposure for at least: 1) 12 months 2) 8 months 3) 6 months 4) 3 months

1) 12 months

in a typical hospital, approximately what percentage of errors is reported? 1) >5 2) between 25-50 3) 75 4) between 80-90

1) >5

the federal agency that is the leader in quality care research is: 1) AHRQ 2) CMS 3) NIH 4) NQF

1) AHRQ

which of the following accreditation organizations provides voluntary accreditation to health and human services organizations, BH, medical rehab, opioid treatment programs and youth services? 1) CARF 2) DNV GL 3) TJC 4) AAAHC

1) CARF

the best tool to display stability of nosocomial infection rates over time is a: 1) Control chart 2) Histogram 3) Run Chart 4) Pareto Chart

1) Control chart. they key word is stability in the question

when utilizing the prototype classification system to allocate nursing care, patients are often grouped according to: 1) DRGs 2) treatments needed 3) cost of care 4) time needed to care for the patient

1) DRGs the assumption is that patients with the same diagnosis will require the approximately the same amount of care and have about the same length of stay

the primary reason healthcare organizations use benchmarking is to: 1) improve performance 2) decrease risk to the organization 3) Comply with accreditation 4) Provide Risk adjustment

1) Improve performance - it helps to identify best practices

which of the following documented orders could lead to error? 1) MS 10 mg IV stat 2) Insulin Glulisine 70 units TID 15 minutes before each meal 3) Levothyroxine 112 mcg daily 4) cogentin 0.5 mg BID

1) MS 10 mg IV stat what is MS? it could be several things

which of the following developed the list of serious reportable events? 1) NQF 2) IHI 3) AHRQ 4) WHO

1) NQF

According to the Lean Six Sigma framework, which two quality tools are typically utilized in the analyze phase? 1) run charts and pareto charts 2) process capability assessments and critical to quality trees 3) project charter and process mapping 4) brainstorming and benchmarking

1) Run charts and pareto charts

what is the best description of SIPOC? 1) Supplier, inputs, processes, outputs, customer 2) supporter, inputs processes, outcomes, consumer 3) supplier, improvement, product, outputs consumer 4) supporters, inputs, products, outcomes, consumer

1) Supplier, inputs, processes, outputs, customer

a quality improvement team wants to construct a simple chart that will depict how institutional spending and time are applied to a set of basic tasks. this chart will take the form of: 1) T shaped matrix 2) L shaped matrix 3) X shaped matrix 4) y shaped matrix

1) T shaped matrix this matrix compares two sets of data to a common third set i.e. time and spending vs basic tasks

small, rural hospital wishes to evaluate customer satisfaction using a survey. The organization has four patient care units, an emergency department, and an ambulatory unit. Which of the following survey methods provides the most reliable information? 1) a random sample of annual discharges/visits per unit 2) a random sample of all annual discharges/visits 3) all discharges/visits in January and July 4) all discharges/visits of customers with a last name beginning with the letters A-E

1) a random sample of annual discharges/visits per unit - this will allow you to drilldown

if assessing some patients heart rates before they eat lunch and other patients heart rates after they eat lunch, the type of error in measurement that may occur is: 1) administrative variation 2) situational variation 3) response-set bias 4) item sampling

1) administrative variation

when establishing a clinical governance training program for the directorate, it is useful to: 1) align the subject matter with the specific tasks of the audience 2) eschew case studies 3) emphasize the basic concepts of clinical governance 4) customize instructions for each person

1) align the subject matter with the specific tasks of the audience

The IHI Simple Data Collection Plan begins data collection by first doing which of the following? 1) asking why these data are being collected 2) deciding on the tools to use 3) deciding on team members 4) setting goals

1) asking why these data are being collected

if carrying out a chart audit for risk management, patient records should generally be selected: 1) at random 2) by order of admission 3) only from discharged patients 4) from all patients during a specified time period

1) at random

one way to create useful alignment in an organization is to: 1) base the assessment of each dept on the same set of performance standards 2) have each employee report to a single manager 3) eliminate adverse drug events 4) organize interdepartmental meetings

1) base the assessment of each dept on the same set of performance standards

a healthcare facility has eleven wheelchairs, the likelihood that a wheelchair will be available when needed can be calculated with an: 1) binomial distribution 2) multinomial distribution 3) factorial 4) effects analysis

1) binomial distribution a binomial distribution is appropriate for illustrating probabilities when there are two possible events/outcomes (i.e. available wheelchair or not)

according to havelocks six phases of planned change, the first phase involves: 1) building a relationship with the system 2) diagnosing problems 3) obtaining necessary resources 4) selecting a solution

1) building a relationship with the system

the four basic elements of malpractice include 1) duty to use due care, 2) breach of duty, 3) damages, and 4): 1) causation 2) intent 3) liability 4) conspiracy

1) causation

According to Blooms taxonomy, the three types of learning that must be considered when developing trainings are: 1) cognitive, affective and psychomotor 2) assimilative, divergent and convergent 3) linguistic, visuospatial, and body/kinesthetic 3) emotional, environmental, and sociological

1) cognitive, affective and psychomotor

which of the following represents the first step that the healthcare quality management professional should take before assembling a performance improvement team? 1) collect organizational data for analysis 2) identify patient safety goals to apply 3) communicate with an accreditation body 4) survey customers for needed improvements

1) collect organizational data for analysis

a healthcare facility is facing criticism for inadequate patient treatment and upon looking into the matter further, a review board discovers that most of the problems are related to the equipment that is being used. in particular, the equipment is poorly maintained and thus is inconsistent in how it functions: on some days the readings are accurate, while on other days the readings prove to be highly inaccurate. which of the following best describes this type of statistical variation? 1) common variation 2) supply variation 3) special cause variation 4) mechanical variation

1) common variation a common variation occurs commonly due to a lack of clear protocol or procedure, in this case, its the proper maintenance of the equipment

a hospital's automated pharmacy program will not fill a prescription unless the patients allergy information has been entered. this is an example of: 1) constraint 2) natural mapping 3) affordance 4) standardization

1) constraint

if utilizing the DMAIC model of six sigma, what should be included in the define phase? 1) cost and benefits 2) balanced scorecard 3) root causes of current defects 4) baseline data

1) costs and benefits

to evaluate activities of a performance improvement team, the CPHQ should do all of the following except: 1) creating a training program for the performance improvement team 2) offering feedback to the members of a performance improvement team 3) analyzing the productivity reports from the performance improvement team 4) adding information from the performance improvement teams into employee appraisals

1) creating a training program for the performance improvement team

what is the purpose of a dashboard in performance improvement? 1) dashboards are tools that enable the management team to visually analyze the KPIs of each individual on the team 2) dashboard depict the precipitating factors or root causes for an event or outcome 3) dashboards contain measurable data that indicates whether the goals and objectives are attainable 4) dashboards are a written account that compares and measures the performance of individuals against the projected goals of the organization

1) dashboards are tools that enable the management team to visually analyze the KPIs of each individual on the team

a patient care team is in disagreement over new admission procedures. what decision making model should management use? 1) decision criteria 2) consensus 3) invocation 4) tenure influence

1) decision criteria decision criteria is a model that explores all options equally and gives unorthodox or unpopular opinions a fair chance

a small city has two hospitals. the HCAHPS reports show Hospital A is performing far below Hospital B in customer service. the administrators of Hospital A decide to set an organizational goal of ranking higher than Hospital B in one year. what is the most logical first step in the goal setting process? 1) develop an overall picture of the partial goals to be achieved 2) identify a specific and singular goal to be initially pursued 3) require immediate training of all employees 4) bring in customer service experts to evaluate and improve processes

1) develop an overall picture of the partial goals to be achieved 2 is wrong because it disregards the overall goal for the sake of a smaller goal 3 and 4 are wrong because they are reactive steps, not proactive steps.

regarding employee evaluations, the healthcare quality management professional is expected to do all of the following except 1) developing a ranking system that identifies which employees should be promoted and which should remain at their current grade 2) incorporate the findings from performance improvement activities into job appointment opportunities 3) identify improved employee activities and apply these activities to the facilities employee evaluation system 4) recognize employees who have contributed to performance improvement through a privilege delineation system.

1) developing a ranking system that identifies which employees should be promoted and which should remain at their current grade

according to the complex adaptive theory of change, an adaptive system is most likely to value: 1) effectiveness 2) efficiency 3) rule oriented approaches 4) linear relationships

1) effectiveness

when a hospital administration decides on a strategy, this information should be shared with: 1) employees, patients, and the community 2) employees only 3) employees and patients only 4) no one

1) employees, patients, and the community

in the lean enterprise model, what is the first step toward improving quality? 1) establishing performance metrics 2) reviewing product design 3) understanding the expectations of the customer 4) identifying potential defects

1) establishing performance metrics the other answers represent essential steps in lean enterprise but they are based on the established performance metrics

if one of the hospitals strategic goals is to enhance the organizations clinical capabilities, which of the following improvement projects would have priority? 1) expanding the emergency dept to become a trauma center 2) investing in updated technology, including digital tools for patients 3) providing educational programs for community members 4) entering partnerships with health systems and provider organizations

1) expanding the emergency dept to become a trauma center trauma centers include specialized staff including surgeons and other physicians

the primary purpose of a walkthrough is to: 1) experience a visit from the perspective of a patient 2) observe processes involved in patient care 3) determine areas of weakness in a system 4) evaluate nurse/patient interactions

1) experience a visit from the perspective of a patient

the first stage of strategic planning involves: 1) external and internal environment assessment 2) review of mission goals and objectives 3) identifying a list of possible strategies 4) conducting a cost effectiveness analysis

1) external and internal environment assessment

in a traditional meeting, the timekeeper and the minute taker roles are: 1) filled by different people every time 2) filled by the same person 3) filled by the same two people in each meeting 4) filled by employees who are not required to participate in the meeting

1) filled by different people every time rotating these positions enables every member of the group to participate

if a patient survey shows widespread patient dissatisfaction with services, what approach may be most helpful to bring about a more in depth discussion to identify problems? 1) focus group 2) staff survey 3) staff interviews 4) patient interviews

1) focus group

what do pareto charts allow the leadership team to do? 1) focus on the value of the services provided 2) focus on the just in time process timeline 3) view statistics on their dashboard 4) all of the above

1) focus on the value of the services provided

which component of decision making typically receives much less time than it deserves? 1) framing 2) gathering information 3) drawing conclusions 4) voting

1) framing framing is the process of organizing the question to be decided. it entails listing the possible sources of information and prioritizing the decision making process.

which nursing care delivery system is most economical but fragments care? 1) functional care 2) primary care 3) team nursing 4) total care

1) functional care

which of the following types of team structures is best for combining employees from the same dept but with different skill sets to complete a task. 1) functional team 2) work group 3) quality circle 4) task force team

1) functional team

According to the Institute of Medicine, which of the following is not one of the domains of quality care? 1) government regulation 2) customization 3) safety 4) interventions consistent with the latest medical findings

1) government regulation

organizations that adopt which of the following methods of risk management achieve a high level of excellence because they focus on anticipating the best response to the worst case scenario? 1) high reliability 2) six sigma 3) systems thinking 4) human factor engineering

1) high reliability

if a reimbursement method is going to change, and a date (6 months in the future) and a grace period (an additional 3 months) have been set for implementation, the best time to begin to implement the change is: 1) immediately 2) in 4 months (before implementation) 3) in 6 months 4) before the end of the grace period

1) immediately

which of the following diagrams is appropriate for categorizing the needs of the customers? 1) kano model 2) histogram 3) flow chart 4) matrix diagram

1) kano model the kano model is appropriate for categorizing the needs of the customer. the product qualities are broken up into 5 categories

which of the following abbreviations is generally acceptable for written documentation? 1) mL 2) ug 3) > and < 4) cc

1) mL

the baldridge 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? 1) managers can get tunnel vision and overlook non-measured errors and issues 2) data far above the national standard can result in inflated self opinion 3) data far below the national standard can result in depression 4) hospitals with high data scores are held to impossibly high standards

1) managers can get tunnel vision and overlook non-measured errors and issues.

what is the primary purpose of the HEDIS tool? 1) measure performance 2) reduce costs 3) set performance goals 4) assess best practices

1) measure performance

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. 1) misalignment of departmental and organizational strategic goals 2) age and generational differences of dept employees 3) gender based bias of treatment times for incoming patients 4) standard deviation of staffing levels against previous patient influx levels.

1) misalignment of departmental and organizational strategic goals

as a performance improvement team facilitator, what are your most important functions? 1) motivating and communicating effectively 2) allocating resources and mining data 3) instructing and redirecting employees 4) dictating duties and reprimanding offenders

1) motivating and communicating effectively the other answers may perform the other duties but they are not the most important, or even necessary

a hospital uses infusion pumps to deliver intravenous medications. however these pumps occasionally malfunction, so a nurse is assigned to periodically monitor their operation. is this a good strategy? 1) no, because it depends on the vigilance of one employee 2) no because it will distract the nurse from her other duties 3) yes because it makes one person directly responsible 4) yes because it gives the nurse a clear directive

1) no, because it depends on the vigilance of one employee

which of the following would be most appropriate for discussing individual patient management issues with a care provider? 1) one on one discussion 2) focus group 3) care provider survey 4 ) all of the above

1) one on one discussion

a hospital is undergoing a change in an administration and many employees feel that they no longer understand their expectations or the larger goals of the organization. the role of the CPHQ in this situation includes all of the following EXCEPT: 1) organizing committee meetings to review the changing policies of the facility 2) assisting in developing a clear list of strategic goals for the organization and its employees 3) developing a list of employee and administrative objectives to be met over time 4) participating in creating a mission statement for the new administration of the hospital

1) organizing committee meetings to review the changing policies of the facility

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 issues, what two elements must be addressed? 1) patient perceptions and clinical quality 2) patient perceptions and physician education 3) physician education and time constraints 4) quality standards and time constraints

1) patient perceptions and clinical quality patient perceptions include the mode of communication and the depth of information. clinical quality would include the doctors understanding of communication techniques, health literacy etc.

if a patient gives permission for a staff person to accompany her throughout a visit and take notes of the experience, this is an example of: 1) patient shadowing 2) walk through 3) process review 4) gap analysis

1) patient shadowing

as an administrator, you are planning to implement a process change that will improve patient safety throughout your organization. who will likely play the biggest role in getting employees motivated to change? 1) process champion 2) administrators 3) new hires 4) team faciliators

1) process champions

What is the primary purpose of rapid cycle testing? 1) reduce the time needed for implementation 2) eliminate the need for ongoing evaluation 3) justify a process improvement process 4) reduce the costs of implementation

1) reduce the time needed for implementation

one consequence of the implementation of lean six sigma practices in a hospital will be: 1) reduction in inventory 2) the creation of systems for verifying orders 3) reduction in staff 4) reduction in manufacturing costs

1) reduction in inventory

which of the following best expresses the way a healthcare quality management professional can utilize technology for a healthcare facilities patient safety program? 1) research available software and assist in selecting the best software option for the facility 2) work with the IT dept to ensure that patient safety goals are met throughout the facility 3) send out email reminders about patient safety to each dept 4) provide patient safety information on the facilities website for the public to review

1) research available software and assist in selecting the best software option for the facility

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? 1) research into the causes of the employees challenges 2) a clear statement of the problems to be addressed 3) specific action steps to be taken as part of the plan 4) a desired outcome or goal behavior and timeline

1) research into the causes of the employees challenges the performance improvement plan process should include a clear problem statement, specific action steps and a goal behavior

a dept within a clinic has ended a long term relationship with a supplier due to an increasingly poor quality of the supplies that were purchased. But the dept is also running low on inventory and needs to find a new supplier to meet its needs. what is the primary role of the CPHQ in this situation? 1) research, identify and recommend the best supplier for the depts needs 2) draw up the documentation that formally ends the relationship between the dept and the supplier 3) create a list of potential suppliers for the dept administration to review 4) evaluate all suppliers whom the dept is considering and review contract expectations

1) research, identify and recommend the best supplier for the depts needs

What is the appropriate chart for the following situation? The amount of calories and weight 1) scatter diagram 2) control chart 3) histogram 4) pareto chart

1) scatter diagram

a hospital administrator wants to determine how changes in resource allocation would affect total profit. by manipulating a variable, for instance the number of nurses assigned to a floor of the hospital, the administrator can calculate the difference in profit. the administrator is performing a: 1) sensitivity analysis 2) risk analysis 3) force field analysis 4) decision analysis

1) sensitivity analysis this is a technique for assessing the influences of different inputs on a measurable output.

if an at risk patient is left unattended and has an adverse response to the medication, this is known as: 1) sentinel event 2) initiator 3) latent outcome 4) slip

1) sentinel event

you are part of a cost analysis team evaluating a proposed inpatient nutrition program. what is the first step your team should take in the cost analysis process? 1) study framing 2) report formatting 3) audience defining 4) patient polling

1) study framing 2/3 are parts of cost analysis but not the first step, they are later 4 is not part of the process at all

during the periods with the highest incoming workload, a laboratory that has not implemented lean practices is likely to have: 1) substandard lead time performance 2) diminished productivity 3) false positives 4) selective engagement errors

1) substandard lead time performance lead time is the full interval required to complete a process or fill an order

after numerous staff meetings, a hospital administrator notices that one of his subordinates is an excellent content leader. which of the following would the subordinate most likely to do? 1) suggest amendments to the meeting agenda 2) establish a tone of collegiality 3) enforce rules of conduct during the meeting 4) introduce new tools for examining data

1) suggest amendments to the meeting agenda

under the TJC policies, which of the following is a reviewable sentinel event for hospitals? 1) suicide within 72 hours of discharge 2) death of a preterm infant 3) theft of personal belongings 4) assault resulting in contusions

1) suicide within 72 hours of discharge

if planning to carry out a needs assessment to determine gaps in knowledge or performance, the first step is to identify the: 1) target learners 2) costs 3) administrative support 4) resources

1) target learners

if an organization is implementing major changes in policies and processes and experiences a sharp increase in staff turnover, this likely indicates: 1) that the staff members are not adequately prepared for change 2) that the workload for staff members will increase 3) a common cause variation in staff numbers has occurred 4) that the changes will negatively impact patient care

1) that the staff members are not adequately prepared for change

if as part of a research project, an analysis of the null hypothesis results in a p value of 0.001, this suggests that: 1) the null hypothesis is wrong 2) the null hypothesis is right 3) the null hypothesis may or not be correct 4) the null hypothesis cannot be evaluated

1) the null hypothesis is wrong

the minimum practical lead time for an analytical laboratory is: 1) the release constraint test time for the microbiology lab 2) greater than the release constraint test time for the microbiology lab 3) less than the release constraint test time for the microbiology lab 4) unrelated to the release constraint test time for the microbiology lab

1) the release constraint test time for the microbiology lab

the main difference between the taguchi model of service provision and the traditional model is that: 1) the taguchi model identifies waste any time a process varies from the target 2) the traditional model is less forgiving of error 3) the taguchi model is only applicable to manufacturing processes 4) the traditional model requires and organization with at least fifty employees

1) the taguchi model identifies waste any time a process varies from the target

in a scatter diagram, if the data begin to form a straight line pattern, this is evidence that: 1) there is a correlation between the two variables 2) there is no correlation between the two variables 3) no conclusion can be reached regarding correlation 4) data were incorrectly plotted

1) there IS a correlation between the two variables

why is it crucial for the leadership team to prepare the entire organization for the on site survey? 1) to actively observe any gaps in processes, procedures and policies prior to the survey 2) to provide uniformity of practice across other departments within the organization 3) to assure that the leadership team is prudent and acting in the best interest of the organization 4) to encourage competition across other departments

1) to actively observe any gaps in processes, procedures and policies prior to the survey

which of the following best describes the purpose and value of a scattergram chart? 1) to compare two different variables of data 2) to consider change in data over time 3) to indicate the probability of change in data 4) to specify the proportion of each variable

1) to compare two different variables of data 2 = line graph 3= bar graph 4 = pie chart

why should processes be evaluated frequently? 1) to eliminate waste and reduce risk 2) because it is mandated by TJC 3) to reinforce employee trainings 4) to determine if they still work

1) to eliminate waste and reduce risk

what is the primary purpose and ultimate goal of performance improvement training? 1) to improve performance in a specific area 2) to improve performance throughout an organization 3) to introduce new ideas to employees 4) to create uniformity across an organization

1) to improve performance in a specific area 2 is incorrect because performance improvement should be targeted at a specific area to be improved. 3/4 are desirable goals but not the ultimate goal

what is the purpose of the five whys in a root cause analysis? 1) to sift through current policies and reveal causal factors within the control of the team 2) to make sure patients understand what happened 3) to prepare an incident report 4) to communicate the cause to the leadership of the organization

1) to sift through current policies and reveal causal factors within the control of the team

which of the following is not one of the typical questions in a force field analysis? 1) what do you hope to accomplish in the meeting? 2) what was bad about the meeting? 3) what was good about the meeting? 4) how can we improve meetings in the future?

1) what do you hope to accomplish in the meeting? a force field analysis is a retrospective tool. it is used to review what has happened in the past rather than to plan for the future

in general, how many steps should a FMEA take in each direction? 1) 1 2) 2 3) 5 4) 10

2) 2

to ensure that food service areas of the hospital are in compliance with saftey regulations, records of cleaning should be documented every: 1) 8 hours 2) 24 hours 3) week 4) month

2) 24 hours

what is the best method for noting quantitative or qualitative data? 1) scorecards 2) check sheets 3) fishbone diagrams 4) KPI

2) Check Sheets

which of the following accreditation organizations for hospitals, critical access hospitals and ancillary services (HHS, hospice) provides a number of certificates, including managing infection risk and primary stroke center? 1) CARF 2) DNV GL 3) TJC 4) AAAHC

2) DNV GL

which of the following is true of competitive benchmarking? 1) it is not advised by TJC 2) It can be done by reviewing the public summary on a competitors website 3) it helps improve internal quality processes 4) it is not necessary for accreditation

2) It can be done by reviewing the public summary on a competitors website

which of the following is true about FMEA? 1) It is a program evaluation method that is primarily process based 2) It is a program evaluation method that is primarily outcome based 3) It is a program evaluation method that is primarily observation based 4) It is a program evaluation method that is mandated by OSHA

2) It is a program evaluation method that is primarily outcome based

what is a major drawback of using raw numbers to present the results of quality monitoring is that they: 1) Only measure compliance to the established area 2) Lack proper reference points for interpretation 3) Cannot be graphed 4) May be used for focused review

2) Lack proper reference points for interpretation

a hospital experiences very infrequent problems with infusion equipment. the best statistical distribution model for examining these errors would be the: 1) binomial distribution 2) Poisson distribution 3) normal distribution 4) multinomial distribution

2) Poisson distribution Poisson distribution is best for determining the minimum and maximum number of occurrences of an unlikely event over a specific interval.

all of the following reflect important qualities of effective teams EXCEPT: 1) A solid sense of goals and responsibilities for the team 2) a clear leader to guide the activities of the team members 3) good internal relationships among the members of the team 4) a willingness to discuss the effectiveness of decisions and activities

2) a clear leader to guide the activities of the team members a leader is not necessarily part of every team (i.e. self directed teams)

the definitive proof of the success of a regulation program is: 1) fewer complaints from customers 2) a decreased need for inspections 3) a boost in employee morale 4) an increase in throughput

2) a decreased need for inspections the other answers are indicative effective regulation but not necessarily indicative of regulatory success

when making major changes in policies and procedures, the most effectives approach is to: 1) criticize past approaches 2) acknowledge the value in past approaches 3) ignore the past and focus on the future 4) stress the advantage of the new plans

2) acknowledge the value in past approaches

the first and most important step in a disclosure conversation is: 1) assessing the patients mood 2) admitting error and apologizing 3) discussing the RCA 4) compensating the patient

2) admitting error and apologizing

which of the following is the best definition of vision in regards to creating an organizational vision statement? 1) the ability to see the future 2) an ideal future state 3) a realistic action plan for future performance 4) an outline of future organizational purpose

2) an ideal future state

in what part of a survey should questions about demographics be asked? 1) at the beginning 2) at the end 3) at random 4) new the beginning but not first

2) at the end

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?" 1) process measurement 2) balanced scorecard 3) dashboard 4) six sigma

2) balanced scorecard dashboard scoring is not as quick or comprehensive as a balanced scorecard. dashboard provide a snapshot. the key works were "quick yet comprehensive"

if the information from patient EHRs has been shared with unauthorized individuals, the best approach to identify how the breach occurred is to: 1) interview staff members 2) carry out audit trails 3) ask for anonymous reports 4) provide rewards for information

2) carry out audit trails

what is the best method of noting quantitative and qualitative data? 1) scorecards 2) check sheets 3) fishbone diagrams 4) KPI

2) check sheets

the following is an example of what kind of test? 15 of 30 men (50%) fail to keep appointments 10 of 40 women (25%) fail to keep appointments Rate 50%/25%= 2 (men are 2x as likely to not show up as women) 1) t-test 2) chi square test

2) chi square test

in order to enter demographic data from surveys into a computer software program for analysis, the data should generally first undergo: 1) cleaning 2) coding 3) simplification 4) evaluation

2) coding i.e. converting categorical data (male/female) into numerical data male = 1 and female = 2

the healthcare quality management professional should work to integrate performance improvements into all areas of a healthcare facilities governance EXCEPT: 1) bylaws 2) committee meetings 3) admin policies 4) facility policies

2) committee meetings committee meetings are part of the performance improvement process itself

after a performance improvement team has completed its activities, what is the primary role of the CPHQ? 1) disband the group and discontinue current activities of the performance improvement team but maintain a core group 2) compose and present a report to the administration about the results of the performance improvement team 3) disseminate the results of the performance improvement team to all employees within the health facility 4) report the performance improvement results to the public to ensure organizational transparency

2) compose and present a report to the administration about the results of the performance improvement team

if a team leader states "I am worried about nurse X's anger and hostility and wonder how I can help to reduce tension." the communication pattern the team member is using is: 1) placation 2) congruence 3) irrelevance' 4) blame

2) congruence

what challenge often occurs with the use of aggregated data? 1) the numbers become too large and complicated 2) context is lost and solutions are not identified 3) impersonality and vagueness are not engaging 4) special interpreters are needed for understanding

2) context is lost and solutions are not identified

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? 1) sort the surveys into separate folders 2) create a taxonomy for coding complaints 3) address complaints one at a time 4) match complaints with performance issues

2) create a taxonomy for coding complaints

a set of key measures that is used to judge progress is known as an: 1) performance factor 2) dashboard 3) independent variable 4) benchmark

2) dashboard

if an organizational goal is to decrease the rate of postoperative infections, which method of communication of results is likely the most effective in encouraging ongoing efforts? 1) written report to administration 2) dashboard updates 3) oral report at staff meetings 4) posted paper notices on bulletin boards

2) dashboard updates

you are deeply involved in preparing for 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? 1) describe your departmental approach to patient care 2) describe your departmental approach to customer service 3) describe your departmental approach to financial management 4) all of the above

2) describe your departmental approach to customer service. the other options are dependent on the dept and/or subject, therefore limited.

a top level administrative is asked by a lower level manager to lead a meeting of new employees. what should the administrator do first? 1) review the notes from the previous meetings 2) discuss the meeting participants with the manager 3) organize preliminary notes 4) compose an introductory statement

2) discuss the meeting participants with the manager

what is the most necessary step in evaluating the success of process improvement? 1) teamwork 2) executing the pilot study 3) informing administration of the plan 4) an action plan

2) executing the pilot study

An organizational structure in which decision making is decentralized and staff have authority to make decisions is: 1) matrix 2) flat 3) functional 4) service line

2) flat organizations with a flat structure tend to be less hierarchal or rule governed and this can lead to more creative solutions. however decision making can be inconsistent.

aa presentation on the basic structures and processes of clinical governance would be most useful: 1) for a small team of employees 2) for the organization as a whole 3) for the directorate 4) for individual employees

2) for the organization as a whole

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? 1) find the standard deviation for the national heart attack mortality rates 2) gather mortality data for a random sample of heart attack patients at your hospital 3) do a direct comparison of heart attack mortality variance rates at your hospital 4) collect qualitative data on heart attack mortality

2) gather mortality data for a random sample of heart attack patients at your hospital a one sample t-test requires a random sample of applicable data

which of the following is an example of operational variance to a clinical pathway? 1) patient refuses to participate in physical therapy 2) insurance company won't authorize treatment 3) broken equipment delays treatment 4) patient develops a post operative infection

2) insurance company won't authorize treatment

Under HIPAA regulations, individuals requesting information from their EHR may be required to: 1) use a web portal to request access to the records 2) make the request in writing 3) wait 60 days for the records to be provided 4) receive the records only in electronic format

2) make the request in writing some individuals may not have access to the internet and records must be provided within 30 days

if present on admission indicators for diagnoses have been frequently overlooked for patients because of inadequate data collection and evaluation, the most likely impact for the organization is: 1) negligible impact 2) misclassification as complications 3) inadequate patient care 4) decreased patient satisfaction

2) misclassification as complications

if a mental health patient has eloped from a locked unit when the exit was advertently left open, the initial response should be: 1) contact the patients family 2) notify security and search the facility 3) notify the police 4) broadcast the description on public intercom

2) notify security and search the facility

which of the following is a structure designed to help facilitate team or group pursuit of specific goals and objectives? 1) management 2) organization 3) intelligent design 4) delegation

2) organization 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, not the structure itself

patients on the post surgical ward have been complaining about a lack of privacy when nurses are performing wound care. what process is most appropriate to initiate resolution for this issue? 1) quality control 2) patient advocacy 3) quality assurance 4) peer review

2) patient advocacy

which nursing care delivery model is likely to be most costly for a hospital? 1) team nursing 2) primary care 3) functional 4) patient focused

2) primary care in this model, the nurse is responsible for everything (care plan, patient care, assign tasks etc) and thus the nurse is able to manage very few patients, increasing the cost of care

how frequently are scorecards used internally for performance improvement? 1) quarterly 2) quarterly and annually 3) annually 4) monthly and quarterly

2) quarterly and annually

one difference between evidence based practice and research utilization is that: 1) research utilization takes into account the preferences of the patient 2) research utilization relies on only one study 3) evidence based practice is based on tradition 4) evidence based practice incorporates the ideas of opinion leaders.

2) research utilization relies on only one study

what is the primary role of the healthcare quality management professional in assessing and improving the quality culture within an organization? 1) create a survey program that allows staff members to comment on organizational errors that need to be corrected 2) review the various activities of the organization and develop a performance improvement program to apply changes 3) facilitate a focus group of patients to determine how well the organization is providing service and meeting patient needs 4) review the organizations website to ensure that all necessary information is conveyed to the public

2) review the various activities of the organization and develop a performance improvement program to apply changes

when conducting education or training programs for adults, its important to remember that according to the theory of andragogy (Knowles), adult learners tend to be: 1) enlightened 2) self-directed 3) aggressive 4) defensive

2) self-directed

what type of error in measurement may occur if the participant reacts to the interviewers lack of friendliness? 1) response set bias 2) situational contamination 3) transitory personal factor 4) administrative variation

2) situational contamination

when prescriptions are being prepared, the labeling process begins at the same time as the medication is being packaged. however, the labeling does not take as long as the packaging. this difference in time does not add to the overall duration of the prescription filling process. this is an example of: 1) just in time manufacturing 2) slack time 3) mistake proofing 4) inherent process variation

2) slack time slack time is the interval between the first and last times in which a process can be completed without delaying the overall project.

which of the following is NOT a primary goal of lean enterprises? 1) improve quality 2) stabilize total costs 3) eliminate wastes 4) reduce lead time

2) stabilize total costs

a BH specialist notices a particularly high number of restraint deaths at a facility. an analysis of the root causes of these events is most likely to indicate problems with: 1) equipment 2) staff orientation and training 3) staffing levels 4) alarm systems

2) staff orientation and training

if utilizing the lean six sigma approach to performance improvement, the primary focus should be on: 1) execution of the project by project 2) strategic goals 3) cost effectiveness 4) identification of errors

2) strategic goals

every quality management initiative must be tied to what? 1) the key business processes 2) the mission and values 3) how competitors are doing 4) patient care

2) the mission and values

the most common source of the goal statement for a tree diagram is: 1) an affinity diagram 2) the root cause identified by an interrelationship diagram 3) an assignment 4) a histogram

2) the root cause identified by an interrelationship diagram

the main disadvantage to the team nursing model of patient care becomes evident when: 1) patient census increases 2) the team leader is weak 3) the team comprises a skill mix 4) one unit supports multiple teams

2) the team leader is weak

which of the following contracts would be most important when remodeling an old wing of a hospital? 1) formal contract 2) time and materials contract 3) cost reimbursement contract 4) fixed price contract

2) time and materials contract

what is the goal of the improve phase of the DMAIC model? 1) to enable the management team to visually analyze the KPIs of each individual on the team 2) to assimilate all the ideas into a strategic plan that prioritizes opportunities for improvement 3) during the improve phase of the DMAIC model, the CPHQ professional will need to implement strategies to determine the sustainability and benefits of the newly designed process 4) during this phase, the manager enables team members to do it themselves

2) to assimilate all the ideas into a strategic plan that prioritizes opportunities for improvement

what is the goal of the improve phase within the DMAIC model? 1) to enable the management team to visually analyze the KPIs of each individual on the healthcare team 2) to assimilate all the ideas into a strategic plan that prioritizes opportunities for improvement and amends all processes associated with changes, including any process flows and job aids 3) during the improve phase of the DMAIC model, the CPHQ professional will need to implement strategies to determine the sustainability and benefits of the newly defined processes 4) during this phase, the manager enables the team members to do it themselves

2) to assimilate all the ideas into a strategic plan that prioritizes opportunities for improvement and amends all processes associated with changes, including any process flows and job aid

which of the following is NOT a goal of quality circles? 1) to improve customer relations 2) to develop new services 3) to improve job satisfaction 4) to maximize employee potential

2) to develop new services a quality circle is a small group of employees who perform similar tasks who meet to discuss their jobs and come up with solutions to shared problems.

which of the following best describes the purpose of storming? 1) to develop countermeasures to solve any problems before they actually occur 2) to explain the stages of the process and confirm that each team member is aware of their expected contribution 3) to adopt and integrate practices in the proposed setting 4) to visually analyze the KPIs of each individual on the team

2) to explain the stages of the process and confirm that each team member is aware of their expected contribution

when developing a process improvement team, the first consideration should be: 1) what the ultimate costs of the project will be 2) what dept/units are part of the process 3) who the patients clients or customers are 4) how much support the team will receive.

2) what dept/units are part of the process

Philip Crosby's quality improvement process introduced the idea of: 1) quality control 2) zero defects 3) quality planning 4) healthcare deliverables

2) zero defects

the need for more extensive medical record keeping increased during what time period? 1) 1950s 2) 1960s 3) 1970s 4) 1980s

3) 1970s

According to the pandemic planning guidelines, if a pandemic occurs, the percentage of the population that becomes infected is likely to range from: 1) 5-10% 2) 10-20% 3) 20-30% 4) 30-40%

3) 20-30%

Based on HHS guidelines for pandemic planning, if 500,000 people in the local population fall ill, what number is likely to seek outpatient medical care? 1) 50,000 2) 100,000 3) 250,000 4) 400,000

3) 250,000

when creating a control chart, the control limits are set at: 1) 1 sigma above and below the central line 2) 2 sigma above and below the central line 3) 3 sigma above and below the central line 4) 4 sigma above and below the central line

3) 3 sigma above and below the central line

if the same value occurs 5 times in a data collection set of 100, the relative frequency is: 1) 5 2) 100 3) 5% 4) 20%

3) 5% relative frequency is the percentage of times that a value occurs. i.e. 5/100 = 5%

when analyzing variability, the semi interquartile range uses: 1) 100% of data 2) 75% of data 3) 50% of data 4) 25% of data

3) 50% of data

which of the following demonstrates a true statistical increase in a run chart? 1) Data points close to the mean line 2) 7 descending data points 3) 6 Consecutive ascending data points 4) A zigzag pattern of data points

3) 6 Consecutive ascending data points

Your clinic has had three recent instances of chart mix-ups. 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? 1) medication barcode scanners 2) tablet computers or smart phones 3) EHR 4) individual record RFID tags

3) EHRs the doctors had the wrong chart IN HAND. meaning they do not have EHRs yet

which of the following is not one of the four elements of a health service microsystem? 1) a clear and identifiable population of patients 2) an environment in which self assessment information can be obtained 3) a broad collection of healthcare providers, support personnel and private contractors 4) well thought out work processes

3) a broad collection of healthcare providers, support personnel and private contractors

a root cause analysis revealed a patient in an acute psychiatric unit committed suicide by hanging himself with his shoelaces. to prevent this from occurring again, the most appropriate action is to institute: 1) a 24 hour video monitoring system 2) patient checks every 15 minutes 3) a policy only allowing non-laced shoes 4) a buddy system for the patients

3) a policy only allowing non-laced shoes

All of the following are important elements of organizational transparency for a healthcare facility except 1) annual reports about facility costs and activities 2) a public statement about facility values 3) a public explanation of all activities within the facility 4) a clear information about facility partnerships

3) a public explanation of all activities within the facility

which of the following outlines the systematic procedures based on a patients treatment response, such as for asthma care? 1) protocol 2) clinical pathway 3) algorithm 4) guideline

3) algorithm

if the load and the mix of a testing laboratory are leveled, the result will be: 1) an increase in capacity 2) a reduction in cost 3) an increase in capacity and/or a reduction in cost 4) an increase in capacity or a reduction in cost

3) an increase in capacity and/or a reduction in cost leveling, also known as smoothing reduces the volatility of the workload and makes it possible for the lab to process more samples, reduce the costs of operation, or both.

a healthcare facility is making changes to its data collection system. what is the primary role of the healthcare quality management professional in this situation? 1) inform the healthcare facility about regulatory requirements for data collection 2) create a program that ensures the confidentiality of all data collected into the new system 3) assist in developing a methodology for different types of data collection 4) research data collection systems for the facility and ensure the new system meets the budget

3) assist in developing a methodology for different types of data collection

following the implementation of large organizational change within a healthcare facility, what is the healthcare quality management professionals role? 1) facilitate educational programs to begin the process of implementing the change in the facility 2) survey patients to determine whether or not the change has improved the overall quality of care for them 3) consider whether the change has been effective and whether ongoing improvement needs to continue 4) assemble the performance improvement team to continue integrating the change within the organization

3) consider whether the change has been effective and whether ongoing improvement needs to continue

a healthcare facility would like to apply for an external quality award. the role of the CPHQ in this includes all of the following EXCEPT: 1) reviewing the available awards to understand each of them better 2) assisting in evaluating the different awards for relevance to the facility 3) contributing to improving the facilities public image on its website 4) ensuring that the facilities standards meet the requirements for the awards

3) contributing to improving the facilities public image on its website

if administrators are given a list of the variables that predict mortality for patients with a given condition, they should be able to: 1) reduce the number of deaths 2) eliminate wasteful therapies 3) create a formula for the risk of death for each patient 4) reduce bottlenecks in the emergency room

3) create a formula for the risk of death for each patient such a formula could be used to allocate resources and organize intervention strategies

what is the first step that must be carried out for an organization utilizing the Baldridge excellence framework to promote excellence? 1) complete a cost assessment 2) carry out a needs assessment 3) create an organizational profile 4) assess staff commitment

3) create an organizational profile

which of the following steps takes place during the initiation phase of the process improvement cycle? 1) estimate timeline for activities 2) begin training program 3) create mission and vision statements 4) develop criteria for standards

3) create mission and vision statements

if a nurse administers the wrong drug to a patient but the patient suffers no ill effects, what elements of malpractice are missing? 1) duty to use care and breach of duty 2) duty to use care and damages 3) damages and causation 4) breach of duty and causation

3) damages and causation

what is the primary role of the healthcare quality management professional regarding the integration of quality concepts within an organization? 1) creating training programs that inform staff members about the organizations quality concepts and expectations for them 2) reviewing benchmarking data from other facilities to ensure that all standards are being met within the organization 3) defining the quality concepts for the organization and developing ways to incorporate these concepts into day to day activities 4) incorporating quality concepts into the employee appraisal system, to reward employees who effectively apply the concepts

3) defining the quality concepts for the organization and developing ways to incorporate these concepts into day to day activities

if the purpose of a project is to develop a new emergency preparedness plan, the document that is provided at the end of the project would be categorized as: 1) plan 2) report 3) deliverable 4) product

3) deliverable

A doctor fails to administer an indicated test and patients condition determines to the point that he must be admitted to an inpatient facility. This is an example of: 1) preventive error 2) treatment error 3) diagnostic error 4) communication error

3) diagnostic error

if a physician has written a DNR order for a patient with heart failure but the patients living will indicates a desire for life prolonging interventions, a nurse who is concerned should first: 1) report the issue to the ethics committee 2) report the issue through the chain of command 3) discuss the issue with the patient's physician 4) discuss the issue with the patient or patients family

3) discuss the issue with the patient's physician

most quality problems in healthcare are the result of: 1) lack of compassion 2) lack of resources 3) disorganization 4) ignorance

3) disorganization

when possible, medication orders should be by: 1) weight 2) volume 3) dose 4) strength

3) dose

an innovation adopter who doesn't propose innovations but is willing to readily adopt them when proposed by others would be categorized as: 1) late majority 2) early adopter 3) early majority 4) laggard

3) early majority

a CPHQ is expected to contribute to the process of educating a facilities employees about patient safety goals. all of the following would fall within the expected process of education EXCEPT: 1) monthly reminder emails to the employees within each dept 2) safety reminder documents posted in each document 3) education programs for patients to understand facility goals 4) occasional training events for employees to provide safety reminders.

3) education programs for patients to understand facility goals

the most essential step in supply management is: 1) control of inventory 2) establishing relationships with suppliers 3) effective purchasing 4) administrative oversight

3) effective purchasing

a hospital would like to improve its patient safety outlook over the course of the next year. the role of the healthcare quality management professional in this situation includes all of the following except: 1) assisting in developing a patient safety program 2) contributing to writing a plan for a patient safety program 3) enforcing the rules for a patient safety program 4) connecting the goals of the patient safety program with the larger goals of the organization

3) enforcing the rules for a patient safety program

the primary cause of quality defects is: 1) unmotivated workers 2) negligence 3) errors in process 4) inadequate oversight

3) errors in process

which types of plans for change in condition should be included in patients discharge care plans? 1) expected changes 2) unexpected changes 3) expected and unexpected changes 4) emergent changes

3) expected and unexpected changes

if a measure appears reasonably valid to those utilizing the measure, the measure has: 1) construct validity 2) content validity 3) face validity 4) discriminant validity

3) face validity construct validity - scale measures what it is intended to measure content validity - the scale measures the range of meanings/items that make up the concept

a hospital medication system is vast and various elements of it fall within the purview of several departments. one important step towards reducing errors in this system is to: 1) make each dept responsible for the system as a whole 2) have each dept use the same self assessment tools 3) give a single person responsibility for overseeing the entire system 4) simplify it

3) give a single person responsibility for overseeing the entire system

the healthcare quality management professional typically participates in all of the following processes EXCEPT: 1) medical record review 2) peer review 3) governance review 4) service specific review

3) governance review

when conducting an audit of a large dept, an administrator will likely apply the central limit theorem. what does this mean? 1) he will average all of the data from the dept 2) he will focus his efforts on the dept leadership 3) he will assume that a sample is representative of the dept as a whole 4) he will compare the depts performance to ISO 9001 standards

3) he will assume that a sample is representative of the dept as a whole the central limit theorem asserts that when a sufficiently large sample is taken, its characteristics can be expected to represent the entire population

the first step in the quality improvement process is to: 1) establish outcomes 2) assemble a team 3) identify needs 4) collect data

3) identify needs

which of the following is likely to be most disruptive to healthcare quality? 1) increased regulations 2) social changes 3) increasing costs 4) ethnic diversity

3) increasing costs

which of the following groups is least likely to report errors? 1) PCPs 2) support staff 3) independent contractors 4) Nurses

3) independent contractors

which of the following is a reactive system? 1) questionnaires 2) market research 3) information obtained from customer complaints 4) interviews with customers

3) information obtained from customer complaints

the type of outcomes data that includes measures of mortality, longevity and cost effectiveness is: 1) clinical 2) perception 3) integrative 4) physiological

3) integrative

a quality council is preparing a patient safety program. A key factor that needs to be considered for the long term success of the patient safety program is to: 1) determine which patient safety goals need to be monitored 2) review incident reports to identify what disciplinary action should occur 3) involve the entire organization in the program 4) research how technology can be used to prevent errors.

3) involve the entire organization in the program

volatility in nursing workload is less likely to be reported than other sources of waste because: 1) nurses are unlikely to complain 2) in can only be perceived through the use of advanced metrics 3) it is less observable 4) it takes place infrequently

3) it is less observable

if an evidence based intervention has been implemented but outcomes measures show that the results are not on par with those experienced by other organizations, most likely the reason is: 1) different populations 2) inadequate measures 3) lack of treatment fidelity 4) common cause variation

3) lack of treatment fidelity

a hospital manager finds that he is unable to effectively supervise all of the employees who report directly to him. a reorganization of the hospital hierarchy should: 1) eliminate some of the subordinate employees 2) reallocate material resources 3) minimize the managers span of control 4) call for the hiring of another manager

3) minimize the managers span of control

it has been determined that a hospitals blood transfusions are 99.7 percent error free. which function can be used to determine the number of blood transfusions that are likely to be performed before an error is made? 1) binomial distribution 2) Poisson distribution 3) negative binomial distribution 4) multinomial distribution

3) negative binomial distribution negative binomial distributions are effective for indicating how many successful events are likely to occur before a failure

when conducting a SWOT analysis as part of strategic planning, the opening of a housing development nearby with 5000 units and increased population would be entered as: 1) strength 2) weakness 3) opportunity 4) threat

3) opportunity

which of the following is the primary role of the healthcare quality management professional in terms of committee meetings? 1) lead the committee meeting as an objective participant 2) review the topics to be discussed in the committee meeting 3) organize and maintain the information from the committee meeting 4) disseminate information from the committee meeting to different depts

3) organize and maintain the information from the committee meeting

Using donabedians model, which of the following areas most needs to be addressed in a clinic with elevated levels of post treatment infection? 1) structure measures 2) process measures 3) outcome measures 4) none of the above

3) outcome measures

what four type of quality measures are pay for performance programs usually based on? 1) costs, outcomes, timeliness and best practices 2) performance, costs, outcomes and patient experiences 3) performance outcomes patient experience and structure/technology 4) patient experience, outcomes, costs and timeliness

3) performance, outcomes, patient experience, and structure/technology notice how its the only one that doesn't reference costs

what is the advantage of identifying process champions for process and performance improvement projects? 1) process champions provide a visual representation of the current processes in an effort to find areas of redundancy 2) it will always be more advantageous to consider the important of adding to, rather than detracting from the value delivered to customers 3) process champions can identify potential pitfalls during the brainstorming phase of process improvement 4) process champions ensure that the VOC is heard and to confirm that there is a precisely defined focus on the correct process

3) process champions can identify potential pitfalls during the brainstorming phase of process improvement

when designing educational activities, the first step is to determine: 1) costs 2) time needed 3) purpose 4) expected outcomes

3) purpose

According to the definition of a just culture, which of the following errors/behaviors requires remedial action and/or punitive action? 1) human error 2) at risk behavior 3) reckless behavior

3) reckless behavior this is a conscious disregard for proper procedures

a brief analysis of interventions for stroke is likely to be relatively unhelpful because: 1) most stroke victims die 2) stroke victims tend to be very old 3) research has yet to discover an effective standard treatment 4) strokes are likely to be accompanied by other conditions

3) research has yet to discover an effective standard treatment

the concept of patient safety applies most appropriately to: 1) environmental safety measures 2) patient complaint management 3) risk prevention 4) serious patient injuries

3) risk prevention

which of the following is not mandatory in a generic dispensing program? 1) active ingredient must be the same 2) chemical composition must be the same 3) salt form must be the same 4) dosage form must be the same

3) salt form must be the same

which of the following is a nursing sensitive quality indicator? 1) patient readmission rate 2) patient acuity classification 3) skill mix of nursing staff 4) cost of care

3) skill mix of nursing staff this refers to the percentage of each type of nursing personnel (APRN, RN, LPN etc)

The pathology dept of Hospital A is up for a service specific review. what documents should be considered as part of this review? 1) general P&P for the hospital 2) employee work history and performance statistics 3) specific P&P for pathology 4) all of the above

3) specific P&P for pathology

which of the following types of statistical analysis might be used to compare the results of people trying out a certain type of new medication against those in a placebo group? 1) RCT 2) probability analysis 3) t-test 4) parametric analysis

3) t-test the question asks about statistical analysis, NOT study design (RCT)

one of the consequences of successful application of the theory of constraints is: 1) major system changes 2) fewer employees 3) the creation of new constraints 4) capital improvements

3) the creation of new constraints

what is one disadvantage of visioning strategy for setting goals? 1) it isolates team members 2) it tends to bring internal conflicts to the surface 3) the group must have at least six members for it to be feasible 4) it tends to reinforce group norms

3) the group must have at least six members for it to be feasible

a RCA of inpatient suicides would be most likely to discover problems with: 1) staffing levels 2) staff orientation 3) the physical environment 4) the availability of information

3) the physical environment

because of a doctors poor handwriting, a prescription must be reworked before it leaves the pharmacy. which of the following is true? 1) the doctor should be reprimanded 2) the pharmacy should incorporate bar coding 3) the prescription should not count towards the pharmacies yield 4) the error should be reported to the FDA

3) the prescription should not count towards the pharmacies yield

why is it important to review scorecards and dashboards during the performance improvement project? 1) the professional accountability and adherence to ongoing performance and process improvement measures afford the chosen organization the opportunity to remain competitive in the healthcare marketplace 2) managers must always remain diligent and keenly aware that the responses of the process innovators, early adopters and the early majority will most likely determine the success of the newly developed process 3) the results from the aggregated quality and performance data equip the management team to develop SMART metrics for gauging the staffs effectiveness and efficiency 4) when employees feel that their contribution is linked to the mission, values and goals of the host organization, they are more likely to accept responsibility for their results

3) the results from the aggregated quality and performance data equip the management team to develop SMART metrics for gauging the staffs effectiveness and efficiency

the primary disadvantage of mailed surveys is: 1) they are prohibitively expensive 2) return times vary widely 3) the return rate is low 4) participants cannot ask questions

3) the return rate is low

a hospital manager operates on the assumption that his employees will thrive when they are given responsibility and the opportunity to perform well. the managers beliefs are aligned with: 1) the theory of constraints] 2) theory x 3) theory y 4) theory z

3) theory y theory y is the management philosophy that believes employees will thrive when they are given responsibility. theory X is a more skeptical management orientation, theory x believes that people are lazy by nature. most managers blend these two theories in their management practice

Healthcare organizations are often classified as "systems". What is the primary reason for this designation? 1) they span several states with a network of providers 2) they are dynamically complex and have multiple levels of management 3) they are a collection of parts that function as an interdependent whole 4) they employ a broad cross section of the population in various positions

3) they are a collection of parts that function as an interdependent whole.

when a hospital official notes that most errors are occurring at the sharp end, he means that: 1) they involve surgical tools or knives 2) they occur in clusters 3) they occur during the interactions between caregivers and patients 4) they are more likely to occur during busy periods

3) they occur during the interactions between caregivers and patients sharp end = all of the operations that involve direct contact with the patient blunt end = all of the behind the scenes actions that take place outside of the awareness of the patient

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? 1) through the use of a pareto chart 2) by using benchmark data 3) through comparative analysis 4) by evaluating standard deviation

3) through comparative analysis

During strategic planning, what is the main task of the leadership team? 1) To lead teams 2) to act as clinical advisors 3) to develop strategy 4) to maintain records

3) to develop strategy

What is the leaderships team first action when preparing for a survey by an accreditation agency? 1) to assemble all of the policy and procedure books 2) to inform all of the staff of the impending survey by email 3) to engage in discussions regarding how each department has succeeded 4) to begin writing an action plan

3) to engage in discussions regarding how each department has succeeded

which of the following does not contribute to evidence based practice in healthcare? 1) clinical expertise 2) evidence collected by expert panels 3) tradition 4) patient preferences

3) tradition

According to AHRQs quality indicators, which of the following is included in the patient safety indicators? 1) acute stroke mortality rate 2) hypertension admission rate 3) transfusion reaction count 4) neonatal mortality

3) transfusion reaction count most safety indicators relate to complications, especially associated with surgery or other invasive procedures

as part of an initiative for administrators to be more involved in day to day business, you have been spending a great deal of time in the wards of Hospital B. You notice there seems to be unreasonably long wait times between patient requests and nurse responses. what statistical process could you use to determine if this is a new or worsening problem? 1) random variation 2) qualitative data collection 3) trend analysis 4) special cause variation

3) trend analysis the other answers are wrong because while they offer statistical analysis, they do not demonstrate long term trends or changes in service levels

to be useful in preventing future error, a RCA should be performed: 1) documenting opinion as well as facts 2) at least 45 days after the event 3) utilizing a multidisciplinary team 4) compare the practitioner to their peers, using practitioners who were not involved in the event

3) utilizing a multidisciplinary team

during a meeting, the facilitator notices that one of the participants is getting agitated. after the meeting, what would be the best question for the facilitator to ask the participant? 1) why are you so angry? 2) what didn't you like about the meeting? 3) were you feeling irritated during the meeting? 4) don't you hate it when your coworkers act that way?

3) were you feeling irritated during the meeting? this question doesn't make any assumptions about the participants feelings

a facilitator needs to consider all EXCEPT which of the following: 1) the time available for the meeting 2) the structure of the meeting 3) which goals to set 4) the number of team members

3) which goals to set goals are set by the team during the meeting, not solely by the facilitator

when evaluating the effectiveness of staff safety initiatives that were introduced 12 months earlier, the most reliable measures include: 1) staff surveys and awareness of initiatives 2) onsite observations of staff members 3) workers compensation claims and sick time records 4) rates of staff turnover before and after implementation

3) workers compensation claims and sick time records

when establishing hospital standard measures, what is an appropriate benchmark for admitting patients for observation who actually meet criteria for inpatient admission? 1) <3% 2) <2% 3) <1% 4) 0%

4) 0%

how many individuals usually form a quality circle? 1) 1 to 2 2) 3 to 4 3) 5 to 10 4) 10 to 15

4) 10 to 15

medical orders for BH restraints for those ages 9-17 are time limited to: 1) 8 hours 2) 6 hours 3) 4 hours 4) 2 hours

4) 2 hours <9 = 1 hour >17 = 4 hours

a complete history and physical examination should be completed on an inpatient with no recent history of care within 1) 6 hours 2) 12 hours 3) 18 hours 4) 24 hours

4) 24 hours

a patient who has had nonbehavioral restraints applied must be examined by an independent licensed professional within: 1) 2 hours 2) 6 hoursa 3) 12 hours 4) 24 hours

4) 24 hours

considering measures of distribution, what percentage of values should be expected to fall outside the 3 deviations from the mean? 1) 10% 2) 5% 3) 2% 4) <1%

4) <1% 1 deviation = 68% 2 deviation = 95% 3 deviation = 99%

which regulatory body is responsible for the HCAHPS currently in use in more than 98% of acute care hospitals? 1) TJC 2) CMS 3) AHRQ 4) B & C

4) B & C it was jointly created by CMS and AHRQ

Extra safety and security measures are important for which specialized hospital area? 1) ICU 2) ED 3) Surgery 4) Nursery

4) Nursery

the organization that developed the Do Not Use list to reduce the risk of errors in documentation is : 1) ISO 2) CMS 3) NCQA 4) TJC

4) TJC

who developed the national patient safety goals? 1) the leapfrog group 2) HCAHPS 3) CDC 4) TJC

4) The Joint Commission

which of the following is a characteristic of a high performing group? 1) more advocacy than inquiry 2) more internal than external focus 3) more skepticism than optimism 4) a blend of internal focus and external review

4) a blend of internal focus and external review

which of the following best represents the goal of a healthcare facility in maintaining organizational transparency for the public? 1) complete public availability of all records that are not protected by privacy laws 2) full presentation of facility goals, objectives and standards on the public website 3) public accountability for all facility leadership when mistakes occur within the facility 4) active leadership to ensure the public image matches the private ones as closely as possible

4) active leadership to ensure the public image matches the private ones as closely as possible

which of the following is necessary for a team meeting to be considered successful? 1) actions have follow up 2) there are clear activities 3) process owners are present 4) all of the above

4) all of the above

which of the following is true regarding informed consent forms? 1) they must be completed at admission 2) they must be signed dated and witnessed 3) they must be maintained under lock and key 4) all of the above

4) all of the above

a failure mode and effects analysis is performed: 1) if the severity of the incident led to a patient death 2) when there is a chance of an incident occurring 3) to immediately investigate an incident that occurred 4) as a preventative measure before an incident occurs.

4) as a preventative measure before an incident occurs.

material safety data sheets (MDSSs) must be available: 1) on file in administration 2) in each dept 3) upon request 4) at locations of hazardous materials

4) at locations of hazardous materials

the "four bads" associated with drug related morbidity are: 1) bad drugs, bad doctors, bad pharmacists, and bad patients 2) bad drugs, bad patients, bad luck, and bad doctors 3) bad drugs, bad pharmacists, bad nurses and bad luck 4) bad drugs, bad patients, bad prescribing and bad luck

4) bad drugs, bad patients, bad prescribing and bad luck

what data display tool is most appropriate for display of discrete categories of data 1) histogram 2) pareto chart 3) line chart 4) bar graph

4) bar graph histogram looks at numerical data while a bar graph looks at discrete categorical

if the CPHQ has determined that the hospital can better improve trauma care with the data provided by a trauma registry, the next step is to develop the: 1) protocol for case finding 2) protocol for the submission of data 3) reporting schedule 4) case definition

4) case definition the case definition usually includes the trauma diagnostic codes that will be included in the registry

according to the general systems theory, which of the following would be classified as an output? 1) praise 2) facts 3) lived experience 4) changed behavior

4) changed behavior

if a hospital has instituted a just culture to encourage staff to report incidents and unsafe practices, a nurse who misread a medication order and administered an incorrect dosage to a patient should be: 1) placed on probation 2) provided a coach and further training 3) fired for incompetence 4) consoled and supported

4) consoled and supported

the most common and effective style of checklist for hospital employees is: 1) standardized and rarely updated 2) requires detailed responses 3) only required for new employees 4) designed to prompt a yes to almost every question

4) designed to prompt a yes to almost every question

when assessing quality performance, the degree to which an intervention accomplishes desired outcomes refers to its: 1) efficiency 2) appropriateness 3) effectiveness 4) efficacy

4) efficacy

research suggests that the largest proportion of adverse events attributable to negligence occur in the: 1) post trauma unit 2) surgery unit 3) maternity ward 4) emergency room

4) emergency room

when Hospital A's neonatal infection rates rise unexpectedly, the quality council establishes a new set of performance measures. they base their measure on internal standards, customer survey data and employee survey data. what important element are the quality council member disregarding? 1) epidemiological standards 2) customer satisfaction data 3) employment records 4) external standards

4) external standards (i.e. national goals and requirements)

a hospital uses the same labels for all of its prescriptions, but these labels do not fit on the smallest container. so employees must cut and paste the labels in a special way in order to fill the prescription. this is an example of: 1) overproduction 2) queuing 3) work in progress 4) extra processing

4) extra processing

What is the appropriate chart for the following situation? where problem areas in a particular process are located 1) scatter diagram 2) control chart 3) histogram 4) flow chart

4) flow chart

in the optimal decision making process, the most time will be devoted to: 1) framing the question 2) learning from feedback 3) drawing conclusions 4) gathering information

4) gathering information

if an outbreak of C diff has occurred resulting in multiple cases of severe diarrhea in hospitalized patients and staff members on one unit, the initial infection control efforts should be aimed at: 1) isolating patients with the infection 2) closing the unit for disinfection 3) penalizing staff members 4) hand washing procedures

4) hand washing procedures

a meeting facilitator notices that the team has a tendency towards groupthink. what is one structural way to correct this problem? 1) meet late in the day 2) meet more often 3) break down the groups into smaller subgroups 4) have comments submitted in writing

4) have comments submitted in writing

what do control charts tell the team? 1) the control limits of the process 2) what processes are out of control 3) if they met their goals 4) how a process changes over time

4) how a process changes over time

if intending to measure customer satisfaction with a service, the process improvement team must first: 1) establish quality measures 2) collect data 3) outline products and services in detail 4) identify internal and external customers

4) identify internal and external customers

what is the first step in change management? 1) acknowledge losses 2) provide information 3) request input and feedback 4) identify losses

4) identify losses

regarding employee performance within a healthcare facility, the CPHQ's primary role includes all of the following EXCEPT: 1) assembling comparative data to measure employee performance 2) applying employee performance improvement to the facilities evaluation system 3) creating a program that recognizes employee performance improvement activities 4) identifying positive employee activity and indicating employees appropriate for promotion.

4) identifying positive employee activity and indicating employees appropriate for promotion.

Confronted by excessive WIP Levels, many laboratories take the unhelpful step of: 1) decreasing # of test runs, 2) hiring more employees, 3) acquiring a larger laboratory 4) installing new technology

4) installing new technology

following an audit by an regulatory body, what is the CPHQ's role in assisting a healthcare facility? 1) present the healthcare facility with the list of recommendations from the regulatory body 2) review the audits from the regulatory body and research improvements to be done 3) determine the source of the problems to ensure future compliance with regulations 4) integrate the recommendations of the regulatory body into the facility goals and activities.

4) integrate the recommendations of the regulatory body into the facility goals and activities.

how does the world health organization surgical safety checklist lead to tight coupling in the operating room? 1) it establishes universality to patients 2) it compartmentalizes the procedures 3) it establishes a clear operating room hierarchy 4) it closely aligns the various individuals involved in the process

4) it closely aligns the various individuals involved in the process the checklist must be read out loud to the surgical team to ensure that all important elements of the surgical procedure have been reviewed and agreed upon by the entire team. This includes patient allergies, surgical site confirmation and patient risks.

one advantage of the kaizen approach to DMAIC implementation is that 1) it replicates the project team approach 2) all of the team members are involved in all phases of the process 3) in can be performed while employees complete their normal tasks 4) it is accomplished in about a week

4) it is accomplished in about a week in the kaizen approach, all employees devote themselves entirely to learning the new system

because the hospital is busy, an anesthesiologist, is given less time than usual to examine the infusion device that will be delivering medication to a patient during surgery. the machine malfunctions and the doctors on hand must work to save the patients life. this is an example of: 1) active error 2) equipment error 3) system error 4) latent error

4) latent error a latent error is one made during setup or programming that creates negative consequences in the future

the primary predictor of hospital costs is: 1) patient acuity 2) patient diagnosis 3) service utilization 4) length of stay

4) length of stay

A program for assessing the validity of rolled throughput yield calculation is called: 1) composite clinical indication 2) performance measurement selection 3) continuous quality management 4) measurement systems analysis

4) measurement systems analysis

the best approach to assessing an organizations safety culture is: 1) staff surveys 2) focus groups 3) observations 4) multiple measures

4) multiple measures

which of the following is NOT one of the operational measurements emphasized by the theory of constraints? 1) throughput 2) operating expense 3) inventory 4) net profit

4) net profit FYI - throughput is the rate at which money is generated and can be calculated as selling price minus the price of raw materials

With the CMS's quality assurance and performance improvement (QAPI) requirements for nursing homes, the focus of quality assurance is on: 1) processes 2) systems 3) compliance 4) outliers/individuals

4) outliers/individuals the quality assurance is focused on outliers and individuals while performance improvement is focused on processes and systems.

in lean enterprise, which is the worst type of waste? 1) extra processing 2) queuing 3) transport 4) overproduction

4) overproduction this is the worst because is contributes to all of the other types of waste

What is the appropriate chart for the following situation? where to begin looking at over one hour delays in recover room leading to back log 1) scatter diagram 2) control chart 3) histogram 4) pareto chart

4) pareto chart

Mrs. Jones waits more than an hour past her scheduled appointment time. she leaves in a huff, calling the doctors office a joke and saying she has better things to do. Mrs. Jones perception of quality in this instance is based on: 1) medical care 2) statistical anomalies 3) provider norms 4) patient care

4) patient care her evaluation was based entirely on her patient care experience. this includes waiting times, communication, accessibility and patient treatment

The HCAHPS initiatives goal is to provide a standardized survey instrument and data collection methodology for measuring which of the following? 1) the quality of care in hospitals 2) patient satisfaction 3) employee satisfaction 4) patient perceptions of care

4) patient perceptions of care

which of the following is most important? 1) patient satisfaction 2) clinical satisfaction 3) employee satisfaction 4) patient, clinical and employee satisfaction are equally important

4) patient, clinical and employee satisfaction are equally important

when using the PICOT to research best practices, the P represents: 1) perception 2) phenomenon 3) parameter 4) patient/population

4) patient/population P-Patient/population I - Intervention/Indicator C - comparison/control O - Outcome T - Time

one common model for administrative meetings is for small groups to discuss specific problems and then join together in a: 1) process intervention 2) confab 3) colloquium 4) plenary

4) plenary a plenary sessions usually includes a general summary of what has been discussed in the small group meetings with an opportunity for participants to ask questions and offer comments

to assist with meeting the professional goals of a facility, the healthcare quality management professional should contribute to a written plan for all of the following EXCEPT: 1) Care management 2) disease managemennt 3) case management 4) practitioner management

4) practitioner management this is the odd one out, the other 3 deal with patients

it is easy to conduct a survey of medication related errors because: 1) there are very few of them relative to other types of error 2) deaths caused by such errors are rarely discovered 3) such errors have small but noticeable effects on health care costs 4) prescription drug use is common and well documented

4) prescription drug use is common and well documented

which of the following is not one of the basic components of an optimization model? 1) constraints 2) objective information 3) variable inputs 4) price information

4) price information

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? 1) process behavior 2) process measurement 3) process capability 4) process requirements

4) process requirements process requirements are the element of process performance that represents the VOC, outlining the change or action needed.

the highest level of measurement is: 1) interval 2) nominal 3) ordinal 4) ratio

4) ratio

the type of power that a staff nurse obtains by closely affiliating with the unit supervisor is: 1) connective 2) coercive 3) legitimate 4) referent

4) referent

a clinic is reviewing the option of adding a new program to its available treatments but needs to be sure the program is worth the cost. what is the first step that the CPHQ should take in this? 1) create a cost analysis plan that enables the clinic to add the program within the budget 2) revise the clinics budget to ensure that the treatment program can be added 3) contact other facilities to generate feedback and see if the program should be added 4) research the program and submit information indicating the feasibility of adding it.

4) research the program and submit information indicating the feasibility of adding it.

According to the change theory, the first stage, motivation to change (unfreezing), may be characterized by: 1) overriding of defensive actions 2) changes in perceptions of self and relationships 3) identification of needed changes 4) survival anxiety and learning anxiety

4) survival anxiety and learning anxiety

one important driver of customer dissatisfaction in health care over the past decade has been: 1) the introduction of online services 2) the lack of communication between physicians and patients 3) the rise in income inequality 4) the improvement of customer care in other service industries

4) the improvement of customer care in other service industries

why would a hospital include an APACHE III score on an analysis of the infection rate? 1) to indicate trends related to age 2) to link infection with SES 3) to find areas of resource waste 4) to establish the general likelihood of infection for patients with various conditions

4) to establish the general likelihood of infection for patients with various conditions

the primary goal of the continuum of care is to provide healthcare: 1) throughout a patients life 2) that is cost effective 3) without adverse effects 4) to the point of optimal health

4) to the point of optimal health

which of the following characteristics suggests that a team is likely to be ineffective? 1) leadership shifts periodically 2) conflicts are discussed openly 3) constructive criticism is freely given 4) two members dominate team meetings

4) two members dominate team meetings

which of the following best describes what occurs during the norming phase of Tuckmans model for team development? 1) when the project comes to a close and the team moves on, appreciating and reflecting on the growth as a team 2) selecting the team members based on the areas of expertise necessary to achieve optimal results 3) diffusing or quieting the naturally occurring conflicts between different team members communication style 4) when team members are encouraged to assume responsibility of their assigned roles

4) when team members are encouraged to assume responsibility of their assigned roles

which of the following best describes what occurs during the "norming" phase of Tuckmans model for team development? 1) when the project comes to a close and the team moves on, appreciating and reflecting their growth as a team 2) selecting team members based on the areas of expertise necessary to achieve optimal results 3) diffusing of quieting the naturally occurring conflicts between different team members 4) when team members are encouraged to assume responsibilities for their assigned roles

4) when team members are encourages to assume responsibilities for their assigned roles

________________ is the degree to difference between survey results when the scales are applied in different settings. Survey scores should reflect differences institutions, where care is presumably different. A - Discriminant validity B - Criterion validity C - Content validity D - Construct validity

A - Discriminant validity

Reliability is a matter of whether a particular technique applied repeatedly to the same object yields the same results each time. The reliability of a survey is initially addressed within ________________. A - Questionnaire development phase B - Questionnaire analysis phase C - Evaluation phase D - Implementation phase

A - Questionnaire development phase

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

A. Defects

There is a story of an intensive care unit (ICU) at Dominican Hospital in Santa Cruz Country, California. Dominican, a 379-bed community hospital, is part of the41-hospital Catholic Healthcare West system. "We used to replace ventilator circuit for incubated patients daily because we thought this helped to prevent pneumonia," explained Lee Vanderpool, vice president. "But the evidence shows that the more you interfere with that device, the more often you risk introducing infection. It turns out it is often better to leave it alone until it begins to become cloudy, or 'gunky,' as the no clinicians say."The hospital staff learned an important lesson from this experience that: A. Evidence is more powerful than intuition B. Intuition is more powerful than evidence C. Efforts improve mortality rate D. Introduction of a new protocol, or any new idea, involves education

A. Evidence is more powerful than intuition

Todays patients perception of the quality of our healthcare system is not favorable.In healthcare, quality is household word that evokes great emotion, including (Choose two): A. Frustration and despair, exhibited by patients who experience healthcare services firsthand or family members who observe the care of their loved ones B. Anxiety over the ever-increasing costs and complexities of care C. Patient centered measures D. Timely care that may be experienced in terms of performance of services

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

Weighting of scores is frequently recommended if members of a (patients) population have unequal probabilities of being selected for the sample. If necessary, weights are assigned to the different observations to provide a representation picture of the total population. Weighting should be considered when: A - An equal distribution of patients exists by discharge service, nursing unit, or clinic B - An unequal distribution of patients exists by discharge service, nursing unit, or clinic C - An unequal distribution of patients exists by laboratories D - An equal distribution of patients exists by ICUs

B - An unequal distribution of patients exists by discharge service, nursing unit, or clinic

Face validity is based on the logical relationship among variables (or questions) and refers to the extent to which a scale measures the structure, or theoretical framework, it is designed to measure (e.g., satisfaction) A - True B - False C - True in a situation where external factors are not affecting D - True in a situation where internal factors are not affecting

B - False

Crossing the Quality Chasm provided a blueprint for the future that classified and unified the components of quality through six aims for improvement, chain of effects, and simple rules for redesign of healthcare. The six aims for improvement, viewed also six dimensions of quality. Which of the following is NOT out of those dimensions? A. Safe B. Care centered C. Efficient D. Effective

B. Care centered

The test-retest reliability coefficient is a method to measure instrument reliability. This method measures the degree of correspondence between: A - Answers to the different questions asked of the same respondents at different points in time B - Answers to the same questions asked of the same respondents at same point in time C - Answers to the same questions asked of the same respondents at different points in time D - Answers to the different questions asked of the same respondents at same point in time

C - Answers to the same questions asked of the same respondents at different points in time

The quality of amenities of care refers to the characteristics of the setting in which the encounter between patient and clinician takes place, such as: A. Comfort B. Comfort, care and access C. Comfort, convenience and privacy D. Responsive to patient preferences

C. Comfort, convenience and privacy

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

C. Effective care

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

C. Excess staff

__________ is a term applied when the proper clinical car process is not executed appropriately, such as giving the wrong drug to a patient or incorrectly administering the correct drug. A. Underuse B. Overuse C. Misuse D. Illegal use

C. Misuse

Quality and technical performance refers to how well current scientific medical knowledge and technology are applied in a given situation.It is usually assessed in terms of: A. Timeliness and accuracy of the diagnosis B. Appropriateness of therapy and other medical interventions are performed C. The quality of interpersonal relationships D. Both A and B

D. Both A and B

Amenities may cover areas as mentioned below EXCEPT: A. Ample and convenient parking B. Good directional signs C. Comfortable waiting rooms D. Vast and facilitated food providing area

D. Vast and facilitated food providing area

which of the following is an essential component in a performance improvement report? 1) Data analysis and display 2) Governing body approval 3) Team composition and attendance 4) Individual performance review

Data analysis and display to assess progress towards goals

Root cause analysis is used to do which of the following? 1) analyze healthcare systems 2) prevent incidents from happening again 3) respond to OSHA complaints 4) investigate patients

Prevent incidents from happening again

What is the best description of statistical process control? 1) the continual and collaborative discipline of measuring and comparing the results of key work processes 2) the process by which numerous small general factors result in a specific effect on a process 3) the specific rare factors that can influence a process 4) a strategy for instituting ongoing process improvement

a strategy for instituting ongoing process improvement

what is output? 1) tangible results 2) goods and services 3) under team control 4) all of the above

all of the above

What is the appropriate chart for the following situation? statistically significant patient fall rate identified 1) scatter diagram 2) pareto chart 3) control chart 4) histogram

control chart

what do control charts tell the team? 1) the control limit of the process 2) what processes are out of control 3) if they met their goals 4) how a process changes over time

how a process changes over time

what is the industry standard methodology for measuring and controlling quality during the manufacturing process in real time with predetermined control limits called? 1) lean manufacturing 2) statistical process control 3) variability index 4) quality control

statistical process control

Every quality management initiative must be tied to what? 1) the key business processes 2) the mission and values 3) How the competitors are doing 4) Patient care

the mission and values

why is it important to review scorecards and dashboards during performance improvement initiatives?

the results from the quality and performance data equip the management team to develop SMART goals for gauging the staffs effectiveness and efficiency

when does implementation occur? 1) when the board signs off on the request 2) when everyone on the team agrees on the process 3) when practices are adopted and integrated 4) when the team finishes its work

when practices are adopted and integrated

Which of the following should be included in an annual performance improvement report to a governing body? 1) meeting minutes 2) team achievements 3) physician peer reviews 4) incident/occurrences reports

2) team achievements

When is the best time for chairing during a meeting? 1) At the beginning 2) One hour beforehand 3) In the middle 4) At the end

1) At the beginning

In order to perform a task for which one is held accountable, there must be an equal balance between responsibility and 1) Authority 2) Education 3) Delegation 4) Specialization

1) Authority

A physician complains to a healthcare quality professional that the nursing staff did not strictly follow orders for a patient. The physician requests that the quality professional speak with the nurse manager. To facilitate improved communication, the quality professional should 1) arrange a meeting with the physician and nurse manager 2) speak with the nurse manager on behalf of the physician 3) evaluate the patient outcome to determine organizational risk 4) review the patient record to determine legibility of the physicians orders

1) arrange a meeting with the physician and nurse manager

how many patients had surgery this month is an example of _________ data 1) categorical 2) continuous 3) ongoing

1) categorical

a quality council has chartered a performance improvement team to reduce medication errors. the team has been meeting for several months and progress has been slow. which of the following is the most important factor for the quality council to assess with the team leader? 1) composition of the team 2) number of medication errors since the team was chartered 3) team members ability to interpret graphs 4) length of team meetings

1) composition of the team

A performance improvement team reviewing timeliness of outpatient clinic appointments identified the following issues: multiple patient moves, redundant paperwork, and long waiting times to be triaged. In lean terminology, these issues are 1) waste 2) variation 3) poor performance 4) poka-yoke

1) waste

A hospital has recently conducted extensive updates on its website and wants to make sure that the new site is ready to be made available to the public. What is the healthcare quality management professional's role in this? 1) Evaluate the changes that have been made in the website and recommend improvements 2) Compare the website to other hospital sites to ensure that the new site compares favorably 3) Review the website to ensure that the reported information is accurate and complete 4) Compile a list of required information for the website and report this to the hospital

3) Review the website to ensure that the reported information is accurate and complete He might evaluate the changes and recommend improvements, but this falls under the larger role of making sure the information is accurate and complete. Similarly, the other answer choices - comparing the new site to other hospital sites and compiling a list of required information - would fall under this larger category of ensuring accuracy and completeness in the information.

organizational leaders can best demonstrate commitment to a new quality improvement initiative by: 1) reviewing the quality improvement plan 2) offering solutions to identified problems 3) allocating resources for the process 4) maintaining performance appraisals for staff

3) allocating resources for the process

A critical difference between quality assurance (QA) and quality improvement is a shift in focus from 1) retrospective review to concurrent review 2) nonclinical aspects to customer satisfaction 3) identifying poor performers to improving group performance 4)QA coordinators to teams

3) identifying poor performers to improving group performance

T/F: Data for physician profiles should be meaningful to physicians

True

T/F: Examples of data for physician profiles include data representing major service lines, patient safety issues and outpatient information.

True

T/F: The best information for physician profiles use national targets and benchmarks.

True

the most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staff is by: 1) Developing professional relationships 2) Evaluating physician participation on quality teams 3) Providing outcome data at medical staff meetings 4) Inviting medical staff to an in-service on quality tools

C - Providing outcome data because it communicates feedback to medical staff

T/F: data for physician profiles is useful if kept in a number of different information systems.

False - Data should be easily accessed and used

a healthcare organizations strategic plan objectives include a customer satisfaction rating of 85%. The following data are available for three units:- customer satisfaction Rate: Unit A = 88%, Unit B = 80%, Unit C = 62%.Which of the following should a healthcare quality professional recommend. 1) change the target to 90% satisfaction 2) provide incentives for the staff of Units B & C 3) Review the performance improvement plan 4) share Unit A's practices with other units

Share Unit A's practices with the other units

A healthcare quality management professional has all of the following responsibilities toward improving patient safety EXCEPT: 1) Appointing a supervisor for a patient safety program 2) Incorporating new technology into a patient safety program 3) Helping to develop a patient safety program 4) Setting and reviewing goals for a patient safety program

1) Appointing a supervisor for a patient safety program In terms of improving patient safety, the healthcare quality management professional's responsibilities include the following: - helping to develop a patient safety program - incorporating new technology into a patient safety program - setting and reviewing goals for a patient safety program. The healthcare quality management professional's responsibilities do not necessarily include the responsibility of appointing a supervisor for a patient safety program. That particular task will likely fall to others within hospital administration.

A review of supplies determined that a clinic is running low on several items essential for operation. With recent budget cuts, the clinic has to review costs carefully to find the best price for each item. What is the healthcare quality management professional's role in this? 1) Assist in developing a list of suppliers, by cost, for each item 2) Oversee the purchase of each item to ensure cost management 3) Determine which items need to be purchased from which supplier 4) Delegate the purchasing of each item to the appropriate department

1) Assist in developing a list of suppliers, by cost, for each item The responsibilities do not include overseeing the actual purchase (as this is the responsibility of the purchasing department) Determining the specific items (as this falls to individual departments), or delegating the purchasing of each item to the appropriate department (as most large purchases would be grouped under the responsibility of the purchasing department).

The primary benefit of adopting a countrywide or global uniform set of discharge data is to 1) Facilitate collection of comparable health information 2) Facilitate computerization of data 3)Validate data being collected from other sources. 4) Assist medical records personnel in collecting internal data.

1) Facilitate collection of comparable health information

Failure modes can be prioritized by calculating the criticality index. Which of the following three categories are normally used to calculate a criticality index? 1) probability, likelihood and criticality 2) frequency, severity and ease of detection 3) effectiveness, risk and priority 4) response, evidence and outcome

2) frequency, severity and ease of detection

A culture of patient safety in an organization will have been successfully created when 1) personal accountability is removed from the organization 2) near miss reporting of safety issues decline 3) staff members serve as safety advocates 4) a root cause analysis is performed regularly

3) staff members serve as safety advocates

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? 1) physician attendance 2) number of complaints 3) frequency of meetings 4) medical record review

4) medical record review

A pharmacy has been dispensing a higher than acceptable rate of antibiotics to patients with documented allergies to the antibiotics. Which forcing function should the performance improvement coordinator recommend to decrease the rate of inappropriately dispensed antibiotics? 1) require the pharmacist to call the physician to confirm the appropriateness of each antibiotic ordered 2) provide mandatory education for pharmacy staff on medication profile documentation requirements 3) revise policy to require nursing documentation of allergies before medication administration 4) modify pharmacy software to require review of allergic profile before dispensing antibiotics

4) modify pharmacy software to require review of allergic profile before dispensing antibiotics

The evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to the performance of the 1) medical staff 2) governing body 3) ancillary department 4) organizations systems

4) organizations systems

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 1) 10% of all discharge records for the past quarter 2) all active records on one day of the past month 3) 30% of all records based on preliminary compliance review 4) the number of records needed for using a statistical method

4) the number of records needed for using a statistical method

A quality professional needs to assign a staff member to assist a medical director in the development of a quality program for a newly established service. Which of the following staff members is MOST appropriate for this project? 1) A competent staff member who has good interpersonal skills 2) A newly hired staff member who has demonstrated competence and has time to complete the task 3) A knowledgeable staff member who works best on defined tasks 4) A motivated staff member who is actively seeking promotion

1) A competent staff member who has good interpersonal skills

Which of the following conditions should a quality assessment program NOT examine? 1) A rare condition that has a small effect on mortality or morbidity 2) A condition that is thought to be treatable 3) A condition for which the treatment is susceptible to significant influence by health care providers 4) A condition that has cost-effective treatments

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

A delay in discharging patients is likely to cause recurrent bottlenecks in... 1) All of the above 2) Admissions from the emergency room 3) The filling of prescriptions 4) Admissions from surgical wards

1) All of the above

A doctor fails to administer an indicated test, and the patient's condition deteriorates to the point that he must be admitted to an inpatient facility. This is an example of... 1) Communication error 2) Preventive error 3) Treatment error 4) Diagnostic error

1) Communication error

an ongoing quality council has just had 6 out of 18 members rotate off and replaced by 6 new members. There is pressure on the council to quickly establish strategic direction for the coming year. You are worried that some of the newer members may feel intimidated and reluctant to share. what stage in team development are they in? 1) forming 2) storming 3) norming 4) performing

1) Forming

A patient was in the operating room when a piece of a surgical instrument broke off and was left in the patient's body. The patient was readmitted for removal of the foreign object. Which of the following would most likely apply in this situation? 1) Res ipsa loquitur 2) Contributory negligence 3) Contractual liability 4) Tort liability

1) Res ipsa loquitur

All of the following represent federally-mandated patient rights in the United States EXCEPT: 1) Right to receive healthcare services 2) Right to informed consent for medical treatment 3) Rights to obtain a copy of medical records 4) Right to maintain the privacy of medical records

1) Right to receive healthcare services There is no federally mandated right to healthcare services for people in the United States. There are other statutes - such as the law that forbids emergency rooms from turning away people without insurance - but the federal government does not guarantee to people that they have the right to receive healthcare services. The other rights listed (right to informed consent, right to privacy, right to a copy of medical records) are all protected at the federal level.

What is the best explanation for the relatively slow introduction of lean practices into medical laboratories? 1) The variability and complexity of the samples in a laboratory is much higher than in a manufacturing environment 2) Medical research is mostly funded by the government 3) Scientists are less receptive to the core principles of lean 4) Medical laboratories function differently than factories

1) The variability and complexity of the samples in a laboratory is much higher than in a manufacturing environment

One aspect of a quality process that integrates with risk management is the review and evaluation of 1) adverse drug events 2) encounter data 3) case mix analysis reports 4) accreditation survey reports

1) adverse drug events

The administration of a hospital has discovered that a lack of communication among different hospital departments has led to overspending and unnecessary errors in patient care. The administration has asked the healthcare quality management professional to assemble a team that can improve department communication and address the problems. What type of team would be most useful for this task? 1) cross functional 2) work group 3) quality circle 4) self-directed

1) cross functional The key here is the need for a team that can find ways to improve communication among the different departments. This type of team would need to be cross functional, because it would be composed of people from the different departments who would then be delegated to communicate with one another and pass on the communication to others in their respective departments. The other types of teams - work group, quality circle, and self-directed - all have their place in professional improvement, but a cross-functional team would be best in this situation.

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? 1) evaluate compliance with the pathway 2) correlate the pathway with staffing levels 3) re-educate the staff on the purpose of the pathway 4) continue to monitor and collect data

1) evaluate compliance with the pathway

The quality improvement director is responsible for coordination of accreditation survey activities. Responsibilities will most likely include 1) facilitating self assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda of the survey 2) educating staff to all standards, writing the survey report and completing the survey application 3) developing a protocol for a mock survey, conducting unannounced surveys and challenging the survey report 4) preparing for unannounced surveys, disseminating the survey report and developing new standards

1) facilitating self assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda of the survey

A healthcare quality professional is attempting to refine the differences between an organization's objectives and the stakeholder needs. Which of the following tools is most appropriate? 1) gap analysis 2) ishikawa diagram 3) gantt chart 4) kanban method

1) gap analysis

Frequency distribution can best be displayed through use of 1) histogram 2) a flow chart 3) a force field analysis 4) an interrelationship diagram

1) histogram

which of the following steps occur first in facilitating change in an organization? 1) identify problems to be addressed in the organization 2) solicit feedback from management 3) select key people in the organization to serve on the team 4) develop a performance improvement plan

1) identify problems to be addressed in the organization

which of the following is essential to effective quality councils? 1) involvement of leadership 2) consultation of the legal advisor 3) participation in the strategic planning committee 4) direction from the organizations quality department

1) involvement of leadership

The best way to evaluate the effectiveness of performance improvement training is through 1) observed behavioral changes 2) self-assessments 3) participants feedback 4) post-test results

1) observed behavioral changes

a performance improvement training program has been conducted. The healthcare quality professionals has determined that improvement has NOT occurred. the most likely cause for the lack of improvement would be that: 1) organizational systems are inhibiting change 2) employee practice what they are trained to do 3) staff members thought the program was too long 4) the facilitator did not prepare agenda materials

1) organizational systems are inhibiting change

Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization's quality improvement program? 1) quantifiable objects 2) support from the medical staff 3) well defined organizational structure 4) integrated data collection

1) quantifiable objects

The process of risk management for the healthcare quality management professional includes all of the following EXCEPT: 1) reporting of incidents 2) identification of risk 3) prevention of risk 4) analysis of effects

1) reporting of incidents The healthcare quality management professional is responsible for the following, in terms of risk management: - - identifying the risk - analyzing the effects of the risk - preventing the risk. These responsibilities do not necessarily include the responsibility of reporting an incident of risk; that may or may not apply, depending on the source of the risk. (It should be noted, however, that the healthcare quality management professional is responsible for reviewing the incident report about the risk; of course, this is not the same as actually reporting an incident of risk.)

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? 1) staff fear of negative consequences of reporting 2) lack of knowledge about how to use the system 3) time required to complete an incident report 4) incomplete understanding about required reporting

1) staff fear of negative consequences of reporting

when a team is in the norming phase, what actions should be taken

1. assign a devils advocate 2. assign small groups to work on a portion of the project

A hospital needs to decide whether or not to incorporate a new feature into its current services, and as a result has commissioned qualitative research that will provide detailed feedback. Specifically, the hospital would like to collect opinions from patients and other hospital customers with a wide range of experience and backgrounds. Which of the following types of assessments is most likely to be of use to the hospital? 1) Case Study 2) Focus Group 3) Team analysis 4) survey

2) The focus group will be most useful in providing the hospital with a broad range of opinions, as well as detailed feedback. The survey would limit answers to those available among the answer choice options, so this would not necessarily guarantee detailed feedback. The team analysis would largely remove patient and customer opinion from the decision. The case study would isolate findings to a single scenario and would fail to offer broad findings and detailed feedback.

Which of the following types of budgets itemizes the major equipment to be purchased in the next year? 1) Capital 2) Variable 3) Operating 4) Fixed

2) Variable

A chief quality officer has the responsibility for education and implementation of a quality improvement process. To affect cultural change, the chief quality officer must. 1) believe the costs are justified by the benefits. 2) be a visible participant in the process. 3) receive quarterly reports. 4) limit training to managers and supervisors

2) be a visible participant in the process

You want to know what the average daily census was for each month in the first six months of the year. This is an example of _______ data 1) categorical 2) continuous 3) ongoing

2) continuous

An outpatient clinic is attempting to measure the quality of a newly developed diabetes disease management program. To accomplish this, laboratory results will be measured over time. The best way to display the data is to use a 1) gantt chart 2) control chart 3) pareto chart 4) flow chart

2) control chart

Which of the following should a Quality Council provide to best ensure success of performance improvement teams? 1) facilitator and recorder 2) empowerment and training 3) indicators with a data analyst 4) standards and procedures

2) empowerment and training

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 1) the length of time the team has been together 2) how well the team met the intended outcome 3) the effectiveness of the team leader and facilitator 4) the amount of data the team has collected

2) how well the team met the intended outcome

the best way to facilitate change in a healthcare organization is to: 1) communicate through group meetings 2) involve individuals directly affected by the change 3) arrange presentations by senior leaders 4) communicate through group email

2) involve individuals directly affected by the change

An interdisciplinary team is looking at a better process for checking in patients. At the last meeting, everyone suggested ideas but there was criticism of almost every solution. one person tended to dominate the conversation. What stage in team development are they in? 1) forming 2) storming 3) norming 4) performing

2) storming

A valid data collection tool should incorporate: 1) a reliable graphic presentation, 2) the definition of data elements, 3) allowance for variance of interpretation, 4) a minimum of 20 data elements

2) the definition of data elements

A clinic is looking into adding a new computer software program to update an outdated program. The new computer system will keep better track of patient records and will enable the clinic to streamline the care that patients receive. What is the healthcare quality management professional's role in this? 1) Research the history of the software to see how it has impacted other clinics 2) Create a simulation for the software to allow the clinic to see how it operates day to day 3) Assist the clinic in evaluating the pros and cons of the software 4) Advise the clinic to implement the software because of its value in improving patient care

3) Assist the clinic in evaluating the pros and cons of the software Advising the clinic to adopt the software would come after the necessary evaluation process Researching the software and creating a simulation would be part of the evaluation process, but each item is limited in itself. The larger goal for the healthcare quality management professional is one of evaluation to assist the facility in making the best decision.

One of the largest departments within a hospital has been running over budget for some time. The increasing expenditure has become problematic, and therefore the department has been asked to maintain a budget. What is the healthcare quality management professional's role in this? 1) Provide the department with the software tools to enable it to set a manageable budget 2) Follow the hospital administration's guidelines in setting a budget for the department 3) Assist the department in developing a manageable budget and reviewing it for compliance 4) Appoint a financial advisor to support the department in developing a compliant budget

3) Assist the department in developing a manageable budget and reviewing it for compliance He or she is not necessarily responsible for setting the budget; that would require the assistance of the financial department. Providing software tools to help with developing a budget would be part of the process, but the process is not limited to this. Additionally, the healthcare quality management professional might appoint a financial advisor, but this again is part of the process but not the only part.

A hospital has implemented a quality program to improve the overall quality of patient care. It is discovered, however, that the program is running over budget, so the hospital administrative board conducts a review of the program to see if it should continue. What is the healthcare quality management professional's role in this? 1) Create a committee to review the quality program and develop a list of reasons to keep it 2) Assist the administrative board in making a final decision about the quality program 3) Evaluate the financial benefits of the program and demonstrate these to the board 4) Prove to the administrative board that the quality program should continue in the hospital

3) Evaluate the financial benefits of the program and demonstrate these to the board The healthcare quality management professional is not obligated to prove to the board that the quality program should continue. He also is unlikely to assist the board in making a final decision or creating a committee to review the program. the role is limited to one of evaluating the financial benefits and demonstrating them as objectively as possible.

Which of the following types of charts is best for determining cause and effect? 1) Pareto 2) Run 3) Fishbone 4) Control

3) Fishbone A fishbone chart is most useful for helping to determine cause and effect. A control chart is useful for seeing the changes in a process; this would include effects but not necessarily causes. A run chart is most useful for viewing data over a time sequence. A Pareto chart uses two types of charting techniques to determine statistical information, but it is not necessarily useful for determining cause and effect.

By and large the pediatric group is a tight knit group that works well together. they like to work on every problem as a large team, but this is slowing down planning for the upcoming TJC visit. you also notice that there is some reluctance to disagree once a solution is proposed. everyone tends to jump on board and move forward. what stage in team development are they in? 1) forming 2) storming 3) norming 4) performing

3) Norming

which of the following is the best way to determine if a quality improvement initiative was successful? 1) present findings to the quality council 2) conduct a retrospective review 3) compare outcomes with pre-established goals 4) survey patients and customers.

3) compare outcomes with pre-established goals

The primary objective of the operational linkage between risk management and quality/performance improvement is to 1) meet regulatory requirements 2) develop a plan of action 3) develop comprehensive plan to prevent future occurrences 4) alert the hospital attorney of a potentially compensable event

3) develop comprehensive plan to prevent future occurrences

Hospital administration is considering designating 20 beds for long-term, chronically ill patients. Which of the following information best supports this? 1) premature discharges over the last 6 months 2) readmissions within 30 days over the last year 3) discharge placement problems over the last year 4) admissions, discharges, and transfers over the last 30 days

3) discharge placement problems over the last year

team building goals for a first meeting should include all of the following EXCEPT: 1) learning to work as a team 2) setting meeting ground rules 3) evaluating the project 4) getting to know one another

3) evaluating the project

One difference between continuous quality improvement and traditional quality assurance is that quality improvement always 1) requires the application of statistical process control 2) excludes monitoring and evaluation of care provided 3) focuses on systems or processes 4) addresses potential problems

3) focuses on systems or processes

The primary reason to analyze customer satisfaction surveys is to 1) provide data for the quality improvement program 2) meet pay for performance requirements 3) identify how perceptions relate to the services provided 4) assist with evaluating employee performance

3) identify how perceptions relate to the services provided

A healthcare quality professional has been asked to examine a new method of reviewing adverse events in an organization. It has been decided that a system of triggers will be established to alert the Quality Council of a potential problem. The best example of a trigger that should be set with a threshold of zero is a 1) medical record not completed by a physician 2) staff member not using proper handwashing technique 3) near miss from failure to perform a "time out" 4) patient complaint regarding wait times

3) near miss from failure to perform a "time out"

Balanced scorecards are useful because they 1) focus on the most significant strategic initiative 2) evaluate the pros and cons of the governing body's priorities 3) put strategy and vision at the center of the organizations effort 4) concentrate on the performance of individual units

3) put strategy and vision at the center of the organizations effort

Which of the following is the most effective way to integrate performance improvement concepts throughout an organization? 1) quarterly newsletters 2) monthly lectures 3) quality teams 4) continuous monitoring

3) quality teams

A health plan is required to have a mechanism for members to submit complaints. Which of the following actions must be included in the complaint analysis to ensure the plan makes full use of this type of information? 1) total each complaint category at least on an annual basis 2) calculate the average number of complaints per office site 3) review complaints to find system problems that can be improved 4) determine the date/time the complaint occurred and the person responsible

3) review complaints to find system problems that can be improved

A hospital has found that the performance of one of its departments is consistently below the expected standards. The hospital administration wants to locate the source of the problems and see improvement in the department within six months. What is the healthcare quality management professional's role in this? 1) Review the expected standards and submit these to the department for immediate application 2) Research the problems and develop a program that applies current standards to the department 3) Recommend that the hospital replace the current administration of the individual department 4) Advise that a performance improvement team be assembled to review and address the failings

4) Advise that a performance improvement team be assembled to review and address the failings The healthcare quality management professional might be involved in researching the problems, but the development of a program that applies the standards to the department would exceed his responsibilities. He would certainly not be expected to advise the hospital to replace the current administration of the department; this would be the role of a larger group (such as a performance improvement team) that takes the time to review the situation. Also, he would need to do far more than simply submit the expected standards to the department for application since they are already failing them

Two surveys were completed in a healthcare facility that showed conflicting results concerning inpatient satisfaction with food services. The two surveys were independently designed & distributed by different departments within the facility. The healthcare quality professional should first 1) Set up a quality improvement team to improve food services 2) Redistribute the surveys to obtain a larger sample size 3) Design, distribute, & analyze a new survey instrument 4) Meet with the departments to review the survey processes.

4) Meet with the departments to review the survey processes.

To cut down on costs, a clinic has been hiring outside consultants to perform many of its tasks, but there are concerns that the performance of many of these consultants does not meet the state's standards for the clinic's operation. What is the healthcare quality management professional's role in this? 1) Develop educational programs to assist the consultants and ensure that the standards are met 2) Create simulated activities to test the consultants and see if they are meeting the standards 3) Supply the consultants with the information about state standards and ensure full compliance 4) Review the activities of the consultants and report the results to the clinic administration

4) Review the activities of the consultants and report the results to the clinic administration The healthcare quality management professional is not responsible for overseeing consultants in general, but in the case of a failure in consultant activities, he or she is expected to review the activities of consultants and report on results. The other answer choices all contain details that might be part of the review process for the healthcare quality management professional, but they lack the larger role of reviewing and reporting.

A disagreement has arisen between the hospital administration and the members of one of its departments. The disagreement is in connection with the authority of the different parties involved and whether or not the administration can require the department to perform a certain task. What is the healthcare quality management professional's role in this? 1) Create a review board to act as a mediator between the hospital administration and the department to find an agreeable solution 2) Consider the statements from both sides and participate in finding a solution that meets the expectations of both parties 3) Advise the department to respect the authority of the hospital administration and to follow its expectations for department performance 4) Review the rules establishing authority and inform the parties about how these rules apply to the department and the administration

4) Review the rules establishing authority and inform the parties about how these rules apply to the department and the administration He should not take sides in any way, making "Advise the department to respect..." incorrect. Additionally, he is not responsible for mediating or even finding a solution (unless asked specifically to do so). The role in this case is largely one of providing the information and allowing the parties to consider it.

Which of the following performance improvement models would be the best recommendation for a clinic that wants to discover the source of problems in patient care, eliminate these problems, and achieve consistently high quality results in patient care? 1) FOCUS 2) LEAN 3) PDCA 4) Six Sigma

4) Six Sigma Six Sigma is recommended as a performance improvement model that enables an organization to reduce problems and, more importantly, achieve consistency in results. The other performance improvement models - FOCUS, PDCA, and LEAN - offer variations of problem identification and reduction, but only Six Sigma specifically focuses on generating consistently good results.

Problem-solving, cross-functional understanding, expanded areas of expertise, and increased span of knowledge are examples of 1) strategic alliance 2) customer expectations 3) resource requirements 4) a benefit of teams

4) a benefit of teams

A strategy used in brainstorming is that ideas are 1) prioritized as they occur 2) discussed when they are mentioned 3) progressively eliminated 4) all recorded

4) all recorded

In evaluating "long waiting times," a healthcare quality professional best demonstrates components related to staffing, methods, measures, materials, and equipment utilizing: 1) run chart. 2) histogram. 3) pie chart. 4) an Ishikawa diagram.

4) an ishikawa (cause and effect) diagram helps to analyze potential causes

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 1) quality council 2) governing body 3) utilization committee 4) chief of the department

4) chief of the department

Quality improvement teams go through stages of development. These team development stages include all of the following EXCEPT 1) norming 2) forming 3) performing 4) conforming

4) conforming

Which of the following sampling techniques selects participants based on their availability in a certain place during a specific time frame? 1) quota 2) random 3) volunteer 4) convenience

4) convenience

Which program best describes the following: Recognizes national role model with presidential award

Baldridge Program

Which program best describes the following: Primary focus is on rehab facilities

CARF

the relationship between patient satisfaction and hours per patient per day on a medical unit was found to be (r = 0.60, p <0.05). what is the correlation between these two values? 1) 0.05 2) 0.36 3) 0.55 4) 0.60

D - 0.60. "r" is used to signify the correlation coefficient

Which program best describes the following: Accreditation program CMS approved to accredit hospitals and critical access hospitals and require ISO 9001 certification by the 4th year

DNV GL

T/F: Physician profiles are the same for all physicians

False

the following is an example of what kind of analysis: Driving Force: Families provide comfort and reassurance to patients during ICU stays. Restraining Force: Nursing staff find the open visiting policy disruptive to nursing routines and getting their work done

Force Field Analysis

Which program best describes the following: Survey hospitals on compliance with Medicare Conditions of Participation and Coverage

HFAP

Which program best describes the following: Primarily covers nursing excellence and innovation

MAGNET

Which program best describes the following: Dedicated to improving healthcare quality and driving improvement throughout the healthcare system

NCQA

a healthcare quality professional is developing a policy regarding access to physician quality files. In addition to the date and time of the person requesting the information, which of the following should be included in the policy? 1) purpose of the request 2) approval from the department chair 3) approval from legal counsel 4) permission from the applicable physician

Purpose of the request

physician profiles should be reviewed at the time of reappointment to: 1) review the number of complaints 2) compare the practitioner to their peers 3) assess the practitioner competency 4) facilitate reappointment approval

assess the practitioners competency

the best approach for training staff about quality and safety is to: 1) require staff to complete mandatory online training at convenient times 2) develop posters and brochures that explain key quality concepts and place them strategically throughout the workplace 3) conduct multidisciplinary interactive sessions consistent with adult learning principles 4) have the CEO meet with each department to explain the departments role in quality and safety

conduct multidisciplinary interactive sessions

What is the appropriate chart for the following situation? urinary tract infections over one year 1) scatter diagram 2) histogram 3) control chart 4) pareto chart

control chart

For a quality improvement team to deal effectively with conflict, it is important to appoint which of the following to its membership? 1) risk manager 2) human resources representative 3) facilitator 4) senior leader

facilitator - they are an unbiased party that may help groups deal with conflict

when a healthcare organization is contracting with an outside provider for services, the subcontractor must: 1) provide a representative to the quality council 2) have an active risk management plan 3) have a competitively priced service 4) meet all regulatory requirements

meet all regulatory requirements

an organizations data demonstrates an increase in the number of patient falls. a healthcare quality professional should recommend: 1) revising the fall risk assessment tool 2) convening a focus group of medical staff to discuss fall risks 3) increasing staff on the weekends and nights 4) sharing the data with the staff to provide feedback

sharing the data with the staff to provide feedback