NAHQ

Which of the following is always true regarding a sentinel event?

The occurrence requires an immediate investigative response.

generally serves in an advisory capacity.

The quality manager

To avoid misinterpreting variances, which of the following statistical tools should be used?

control chart

exhibit points between control limits, therefore displaying the variation.

control charts

The perception of how an organization operates, including how employees relate to internal and external customers, is the organizational

culture

takes into account the interactions between humans and product.

Human factor engineering

A quality improvement manager must decide how to present data that demonstrates the relationship between two process characteristics. Which of the following data display techniques is most appropriate

Scatter diagram

The clinical competency of a physician is determined by

a committee of peers.

When choosing an outside consultant to lead employee focus groups, which of the following priority areas of expertise should a healthcare quality professional look for?

group dynamics and facilitation

Which of the following topics are discussed at a morbidity and mortality conference?

healthcare-acquired infections and perioperative mortality

Generic screening is an example of risk

identification

When conducting a sentinel event review, a root cause analysis

identifies gaps in patient care processes

Medication reconciliation is a process intended to

identify and resolve discrepancies

The primary purpose of integrating financial and quality management information is to

identify problems in resource management.

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

identifying poor performers to improving group performance.

Which of the following action plans is the first step in correcting inappropriate blood usage in an emergency department

in-service on ordering blood usage for the physicians

A t-test may be used to

evaluate the effects of two different treatments.

In the process of strategic planning, an organization makes decisions about the future. A basic component of the planning process is to

examine both internal and external environments.

The quality improvement director is responsible for coordination of accreditation survey activities. Responsibilities will most likely include

facilitating self-assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda for the survey.

Which of the following is used to summarize a characteristic in a population?

frequency distribution

can be used to summarize data into categories; for example, we could summarize insurance type into Medicare, Medicaid and private insurance.

frequency distribution

Failure modes can be prioritized by calculating the criticality index. Which of the following three categories are normally used to calculate a criticality index?

frequency, severity, and ease of detection

Balanced scorecards are useful because they

put strategy and vision at the center of an organization's effort.

When using cost-benefit analysis in decision-making, it is important to remember that

qualitative and quantitative data should be used

is focused on monitoring problem areas

quality assurance

Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization's quality improvement program?

quantifiable objectives

A performance improvement (PI) training program for supervisors should include

rapid-cycle process.

When a team evaluating the use of restraints starts to discuss a liability claim related to a patient, the facilitator should

redirect the team

facilitates and is responsible for team focus.

the facilitator

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

the number of records needed using a statistical method

monitors time and does not focus on team performance.

time keeper

Leaders enhance employee commitment to organizational values by fostering which of the following types of communication

timely, open, two-way

shows how different issues are related to one another

An interrelationship diagram

analyzes a group with a specific characteristic, such as cystic fibrosis.

Cohort study

Which of the following is the best tool to begin an investigation into the causes of laboratory labeling errors?

Flow chart

identify cause and effect of a problem.

fishbone diagram

is used in project management to show a project timeline and deliverable.

A Gantt chart

guides the team towards outcomes.

A Leader

is used to help determine priorities by showing data in descending order with a line chart overlaid, depicting the cumulative percent.

A Pareto chart

is used to display data over time with upper and lower control limits to help monitor process variability.

A control chart

is used to monitor data over time and process variation.

A control chart

measures data at a specific point in time.

A cross-sectional analysis

is a diagram of a process

A flow chart

is a diagram of a process in sequential order

A flow chart

is a method for listing, discussing and evaluating various forces for and against a proposed change.

A force field analysis

Frequency distribution can best be displayed through use of

A histogram

displays data in a bar chart by frequency distribution.

A histogram

records minutes.

A recorder

is used to depict the relationship between two variables

A scatter diagram

A strategy used in brainstorming is that ideas are

All recorded

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

B. improving interdisciplinary communication

Which of the following is the primary benefit of using external quality consultants?

Bridging knowledge gaps

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

C. flow

is more definitive and would require more analysis of each case within the study. This study is looking at a qualitative measure and does not require a quantitative analysis.

Case-mix study

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

Control chart

Which of the following sampling techniques selects participants based on their availability in a certain place during a specific time frame?

Convenience

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

D. conforming

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?

Evaluate compliance with the pathway.

Performance improvement teams should always be required to

Evaluate data

Which of the following team members is responsible for keeping meetings focused?

Facilitator

involved with moving the process along and have no formal authority over the project.

Facilitators

helps look at the project and analyzes all the reasons impacting a change.

Force field analysis

display and help determine priority.

Pareto charts

Data collected about surgical cases shows significant delays. Further analysis shows the following chart: Which of the following should a healthcare quality professional do first?

Provide the service chief with further analyses of surgeon-specific data.

is focused on systems, processes, and groups to improve.

Quality improvement

only document the outcomes or activities of the team

Recorders

A new quality director has reviewed the information related to the Quality Council minutes, and notes the following: - The council meets quarterly. Meetings last approximately 2 hours. - The council roster includes all clinical department managers and the quality director. Attendance ranges from 45-60%. - The primary role of the council is to receive department quality reports, which are then forwarded to the organization's governing body. Based on the information above, which of the following actions is most appropriate?

Redefine the council's role to coordinate and prioritize quality activities.

is used to measure the relationship between variables.

Regression analysis

looks at the relationship among variables. This study is looking at a single variable: attitudes toward disease.

Regression analysis

Which of the following principles applies to continuous quality improvement in an organization?

Systems, not poor job performance, are responsible for most problems

Upon completion of a performance improvement project, who is the best person to compile and write a report?

Team leader

are responsible for completion of the projects, based on the charter of the project. They may delegate aspects of the report to others on the team, but ultimately are responsible for the project.

Team leaders

Deemed status refers to

accreditation equivalency with a Centers for Medicare and Medicaid Services (CMS) survey.

One aspect of a quality process that integrates with risk management is the review and evaluation of

adverse drug events

is an idea generation tool intended to allow for all ideas to be considered without judgment, censoring, or prioritization. It is critical to the process that no ideas or participation is discouraged. All ideas should be recorded

brainstorming

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

chief of the department

A medication error occurred and resulted in a severe adverse outcome. In addition to informing the patient and/or family, a healthcare quality professional should

conduct a root cause analysis

According to continuous quality improvement principles, which of the following concepts is most important

constancy of purpose

Facility A is investigating its medication administration time for a specific diagnosis. Evidence-based guidelines indicate that administration of a particular drug within 30 minutes significantly improves patient outcomes. The national average is 32 minutes. The average for Facility B is 28 minutes. If the average for Facility A is 35 minutes, Facility A should

contact Facility B to determine its practices.

The success of a performance improvement program will be most influenced by the

culture of the organization

In lean thinking, a process step is defined as "value added" if the

customer recognizes the value.

The primary purpose of an organization's quality improvement (QI) strategic plan is to

define the future direction for quality

Which of the following is the best example of use of human factors engineering

designing products to prevent tubing misconnections

In the quality improvement process, performing a cost-benefit analysis is most useful in

designing solutions and controls.

During quality management data analysis activities, Pareto charts are most appropriately used for

determining priorities among contributing factors

The primary objective of the operational linkage between risk management and quality/performance improvement is to

develop a comprehensive plan to prevent future occurrences.

Which of the following should a Quality Council provide to best ensure success of performance improvement teams?

empowerment and training

Leadership can best integrate performance improvement within an organization through

multidisciplinary teams.

Team cohesion is established during which of the following stages of team growth?

norming

The best way to evaluate the effectiveness of performance improvement training is through

observed behavioral changes

When examining the relationship between staff and patient outcomes, which of the following is the most appropriate to assess?

patient safety data and overtime data

A healthcare entity initiating re-structuring must consider the impact on staff to ensure the greatest opportunity for success by

planning carefully, communicating openly, and leading effectively.

Which of the following obstetrical outcomes will result in a morbidity review

post-delivery septicemia

An operating room circulating nurse reported that the instrument count indicated a missing clamp. X-ray findings were negative, and the patient showed no adverse effects. This occurrence is an example of which of the following?

potentially compensable event

A failure mode and effects analysis (FMEA) provides which of the following types of review?

proactive

In profiling length-of-stay data for benchmarking, it is important that data be

severity adjusted

A Quality Council has examined data on patient falls and determined that a comprehensive falls prevention program is needed. The first step in increasing staff awareness of this initiative is to

share unit-specific data on falls.

The phrase "reaching consensus" is often used in performance improvement. The term consensus refers to

support by all members.

Which of the following should be included in an annual performance improvement report to a governing body?

team achievements