CPHQ Prep
Based on the principles from the Institue for Healthcare Improvement (IHI), who has the ultimate responsibility for the effectiveness of quality improvement and patient safety within an organisation?
The governing body. This is the expectation of The Joint Commission and Centers for Medicare and Medicaid Services (CMS). Domain: Organisational Leadership
Upon completion of a performance improvement project, who is the best person to compile and write a report?
The team leader. Team leaders 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. Domain: Performance and Process Improvement
A sentinel event always requires...
An immediate investigative response. A sentinel event should be as high a priority as a reactive response to a sentinel event. Domain: Patient Safety
A patient safety program can best be enhanced by which technology?
A barcode system for medication administration. A technology that forces a double checking of patients against medication orders. Domain: Patient Safety
The clinical competency of a physician is determined by...
A committee of peers. Competence is demonstrated in knowledge and understanding of skills required to perform the job. Peer review is a component of initial and ongoing performance evaluation conducted by a professional or professionals with similar experience, education, and expertise based on criteria established by the medical staff or medical executive committee. Domain: Organisational Leadership
To avoid misinterpreting variances, which of the following statistical tools should be used?
A control chart. Control charts exhibit points between control limits, therefore displaying the variation. Domain: Health Data Analytics
Which of the following charts will most likely be used first in a root cause analysis?
A flow chart. A flow chart is the best chart to use first for a root cause analysis. Domain: Patient Safety
Frequency distribution can best be displayed through use of...
A histogram. A histogram displays data in a bar chart by frequency distribution. Domain: Health Data Analytics
A failure mode and effects analysis (FMEA) provides which type of review?
A proactive review. The FMEA tool is used to proactively design or redesign a process. Domain: Patient Safety
A quality improvement manager must decide how to present data that demonstrates the relationship between two process characteristics. Which data display technique is most appropriate?
A scatter diagram. A scatter diagram is used to depict the relationship between two variables. Domain: Health Data Analytics
One aspect of a quality process that integrates with risk management is the review and evaluation of...
Adverse drug events. Risk management has a role related to incident reporting. Domain: Patient Safety
The primary benefit of using external quality consultants is...
Bridging knowledge gaps. Consultants provide external assistance with filling in knowledge gaps. Domain: Organisational Leadership
A hospital-wide medical record audit on documentation has been completed. What is the next step?
Conduct a focused review prioritising the process that shows low performance and decreased performance. Domain: Health Data Analytics
An example of use of human factors engineering?
Designing products to prevent tubing misconnections. Human factor engineering takes into account the interactions between humans and product. Domain: Patient Safety
Which of the following should a Quality Council provide to best ensure success of performance improvement teams?
Empowerment and training. These are two key elements for ensuring success for the teams. Domain: Organisational Leadership
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. These are the essential functions for overseeing accreditation process. Domain: Organisational Leadership
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. The primary role of a consultant who is leading focus groups is to facilitate interaction in the group dynamic. Domain: Performance and Process Improvement
For health information technology to be most effective in reducing harm, the technology needs to be...
Integrated with clinical workflow. Staff have to know how to use the tool with their daily work. Domain: Patient Safety
Team cohesion is established during which of the stages of team growth?
Norming. The team moves towards cohesion and collaboration during the norming stage. Domain: Performance and Process Improvement
When examining the relationship between staff and patient outcomes, which is the most appropriate to assess?
Patient safety data and overtime data. Using patient safety data and correlation to overtime data are appropriate indicators to identify a relationship between the two. Domain: Health Data Analytics
Data collected about surgical cases shows significant delays. A high number of delays are due to staff surgeon not being available. Next...
Provide the service chief with further analyses of surgeon-specific data. The quality professional should first notify the service chief so peer-to-peer feedback can be provided to the surgeon. Domain: Organisational Leadership
How to identify priority for training
Rank by weight and non-compliance. 100 minus percent compliance multiplied by weight. Domain: Performance and Process Improvement
When a team gets off track from the quality process at hand. The facilitator should...
Redirect the team. Redirection is needed to move the team back on topic and towards performance improvement effort. Domain: Performance and Process Improvement
In profiling length-of-stay data for benchmarking, it is important that data be...
Severity adjusted. Benchmarking data should be severity adjusted to allow for meaningful comparisons while reducing bias and incorrect comparisons due to differences in the patient population across organisations. Domain: Health Data Analytics
What should be included in an annual performance improvement report to a governing body?
Team achievements. A report to the governing body is an overview of accomplishments in relation to established strategic goals. Team achievements are a critical component of the annual report.. Domain: Performance and Process Improvement
Which team member is responsible for keeping meetings focused?
The facilitator. The facilitator facilitates and is responsible for team focus. Domain: Performance and Process Improvement
Satisfaction surveys, focus groups, and complaint tracking are tools used to...
Understand customers' expectations. Surveys, focus groups, and complaints with or from customers can provide information directly from the customers regarding a variety of topics including customer expectations. Domain: Organisational Leadership
Deemed status refers to...
accreditation equivalency with a Centers for Medicare and Medicaid Services (CMS) survey. CMS allows deemed status with meeting all conditions of participation requirements through Joint Commission Accreditation. Domain: Organisational Leadership
Generic screening is an example of risk...
identification. Identification is the first step in disease management/risk management. Domain: Patient Safety
A critical difference between quality assurance (QA) and quality improvement (QI) is a shift in focus from...
identifying poor performers to improving group performance. Quality improvement is focused on systems, processes, and groups to improve. Quality assurance is focused on monitoring problem areas or individuals. Domain: Organisational Leadership
An example of an outcome measure
mortality rate. An outcome measure is used to determine how the system or improvement project impacts the patient. Domain: Health Data Analytics
