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