CPHQ Study Guide

The evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to the performance of the: a. Medical Staff b. Governing Body c. Ancillary Departments d. Organization's Systems

D. Organization's Systems

A clinical pathway on the management of hip fractures has been developed by a multi-disciplinary team and implemented in a large teaching hospital. After monitoring for 6 months, the length of stay continues to exceed the guidelines. Which of the following should be the next step? a. evaluate compliance with the pathway b. correlate the pathway with staffing levels c. re-educate the staff on the purpose of the pathway d. continue to monitor and collect additional data

a. evaluate compliance with the pathway

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

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

A 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? a. gap analysis b. Ishikawa diagram c. Gantt chart d. Kanban method

a. gap analysis

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 a. Gantt chart b. control chart c. Pareto chart d. flow chart

b. control chart

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

b. empowerment and training

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

b. frequency, severity, and ease of detection

The primary objective of the operational linkage between risk management and quality/performance improvement is to: a. Meet regulatory requirements b. Develop a plan of action for individual cases c. Develop a comprehensive plan to prevent future occurrences d. alert the hospital attorney of a potentially compensable event

c. Develop a comprehensive plan to prevent future occurrences

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

c. discharge placement problems over the last year

A strategy used in brainstorming is that ideas are a. prioritized as they occur. b. discussed when they are mentioned c. progressively eliminated d. all recorded

d. all recorded

A summary of antibiotic usage for the fourth quarter showed that an internal medicine department did not meet pre-established criteria in 82% of the patients reviewed. Following review, the Pharmacy and Therapeutics Committee should recommend that the results be shared first with the a. quality council b. governing body c. utilization committee d. chief of the department

d. chief of the department

Quality improvement teams go through stages of development. These team development stages include all of the following EXCEPT a. norming b. forming c. performing d. conforming

d. conforming

Which of the following sampling techniques selects participants based on their availability in a certain place during a specific time frame? a. quota b. random c. volunteer d. convenience

d. convenience

Timeliness and compliance of documentation were discussed at a multidisciplinary team meeting. To evaluate the effectiveness of the team's action plan, which of the following will provide the most useful information? a. physician attendance b. number of complaints c. frequency of meetings d. medical record review

d. medical record review

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? a. require the pharmacist to call the physician to confirm the appropriateness of each antibiotic ordered. b. provide mandatory education for pharmacy staff on medication profile documentation requirements. c. revise policy to require nursing documentation of allergies before medication administration. d. modify pharmacy software to require review of allergic profile before dispensing antibiotics.

d. modify pharmacy software to require review of allergic profile before dispensing antibiotics

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? a. Total each complaint category at least on an annual basis. b. Calculate the average number of complaints per office site. c. Review complaints to find system problems that can be improved. d. Determine the date/time the complaint occurred and the person responsible.

d. review complaints to find system problems that can be improved

Problem-solving, cross-functional understanding, expanded areas of expertise, and increased span of knowledge are examples of a. strategic alliances. b. customer expectations. c. resource requirements. d. the benefits of teams.

d. the benefits of teams

One aspect of a quality process that integrates with risk management is the review and evaluation of a. adverse drug events b. encounter data c. case-mix analysis d. accreditation survey reports

a. adverse drug events

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 a. arrange a meeting with the physician and nurse manager b. speak with the nurse manager on behalf of the physician c. evaluate the patient outcome to determine organizational risk d. review the patient record to determine legibility of the physician's orders

a. arrange a meeting with the physician and nurse manager

Frequency distribution can best be displayed through use of a. histogram b. a flow chart c. a force field analysis d. an interrelationship diagram

a. histogram

The best way to evaluate the effectiveness of performance improvement training is through: a. Observed behavioral changes b. Self-assessments c. Participant's Feedback d. Post-test results

a. observed behavioral changes

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

a. quantifiable objectives

Staff has been trained and oriented on a new electronic incident reporting system. In the past, staff could report anonymously. The new system requires staff to sign in with an individualized username and password. Three months after implementation, there is a sharp reduction in the number of reported incidents. Which of the following reasons for underreporting of incidents is of greatest concern? a. staff fear of negative consequences of reporting b. lack of knowledge about how to use the system c. time required to complete an incident report d. incomplete understanding about required reporting

a. staff fear of negative consequences of reporting

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 a. waste b. variation c. poor performance d. Poka-Yoke

a. waste

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

b. how well the team met the intended outcome

Which of the following should be included in an annual performance improvement report to a governing body? a. Meeting minutes b. team achievements c. Physician peer reviews d. incident/occurrence reports

b. team achievements

`One difference between continuous quality improvement and traditional quality assurance is that quality improvement always a. requires the application of statistical process control b. excludes monitoring and evaluation of care provided c. focuses on systems or processes d. addresses potential problems

c. focuses on systems or processes

The primary reason to analyze customer satisfaction surveys is to: a. provide data for the quality improvement program b. meet pay-for-performance requirements c. identify how perceptions relate to the services provided d. assist with evaluating employee performance

c. identify how perceptions relate to the services provided

A critical difference between quality assurance (QA) and quality improvement is a shift in focus from: a. retrospective review to concurrent screening b. nonclinical aspects to customer satisfaction c. identifying poor performers to improving group performance d. QA coordinators to teams

c. identifying poor performers to improving group performance

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 a. medical record not completed by a physician. b. staff member not using proper handwashing technique. c. near miss from failure to perform a "time- out." d. patient complaint regarding wait times.

c. near miss from failure to perform a "time-out"

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

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

Which of the following is the most effective way to integrate performance improvement concepts throughout an organization? a. quarterly newsletters b. monthly lectures c. quality teams d. continuous monitoring

c. quality teams

A culture of patient safety in an organization will have been successfully created when a. personal accountability is removed from the organization. b. near miss reporting of safety issues declines. c. staff members serve as safety advocates. d. a root cause analysis is performed regularly.

c. staff members serve as safety advocates

A valid data collection tool should incorporate a. a minimum of 20 data elements b. a reliable graphic presentation c. the definition of data elements d. allowance for variance of interpretation.

c. the definition of data elements

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

d. the number of records needed using a statistical method