NAHQ Test
Which of the following is always true regarding a sentinel event?
The occurrence requires an immediate investigative response
The perception of how an organization operates, including how employees relate to internal and external customers, is the organizational
culture
A review was conducted following a postoperative surgical infection rate increase. The following information was obtained about four physicians: Which of the following should be done next?
Initiate peer review with physician C
Which of the following topics are discussed at a morbidity and mortality conference?
healthcare-acquired infections and perioperative mortality
When conducting a sentinel event review, a root cause analysis
identifies gaps in patient care processes.
A critical difference between quality assurance (QA) and quality improvement is a shift in focus from
identifying poor performers to improving group performance
For health information technology to be most effective in reducing harm, the technology needs to be
integrated with clinical workflow.
Comparing healthcare organizations by using medical error rates
may present bias due to differences in reporting practices.
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?
medical record review
A facility is becoming part of a healthcare network. Which of the following employee education programs is most important?
organizational change
A hospital has recently moved to a paperless system. It is noted that some data is missing from the obstetrics delivery record. A healthcare quality professional should recommend
evaluating the computerized data entry process
Which of the following is used to summarize a characteristic in a population?
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
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?
gap analysis
When using cost-benefit analysis in decision-making, it is important to remember that
qualitative and quantitative data should be used.
A performance improvement (PI) training program for supervisors should include
rapid-cycle process.
A hospice agency conducted a satisfaction survey of all 200 patients currently receiving pain management services. When asked if they were satisfied with their pain management, 170 patients said yes, and 30 said no. A target satisfaction rate of 90% has been set. In this situation, a healthcare quality professional should
review all dissatisfied responses for similarities.
Human factors engineering is defined as the study of humans and their interaction with
the tools they use and the environment
Leaders enhance employee commitment to organizational values by fostering which of the following types of communication?
timely, open, two-way
Empowerment gives employees the opportunity to
Solve problems
The clinical competency of a physician is determined by
a committee of peers.
For a continuous quality improvement team to be successful, who must be included on the team?
person preforming the process
In profiling length-of-stay data for benchmarking, it is important that data be
severity adjusted
Frequency distribution can best be displayed through use of
A histogram
A strategy used in brainstorming is that ideas are
All recorded
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
Performance improvement teams should always be required to
Evaluate data
Which of the following is the best tool to begin an investigation into the causes of laboratory labeling errors?
Flow chart
In managed care, the most widely used performance measures are
Healthcare Effectiveness Data and Information Set (HEDIS).
The following data has been provided to a healthcare quality professional: Which of the following is the best choice for beginning clinical-pathways implementation in an organization?
Heart failure
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.
A staff member reports that a colon perforation occurred during a colonoscopy. Which of the following is a healthcare quality professional's next step?
Refer the case for peer review
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?
Review complaints to find system problems that can be improved
Which of the following principles applies to continuous quality improvement in an organization?
Systems, not poor job performance, are responsible for most problems.
Which of the following should be included in an annual performance improvement report to a governing body?
Team achievements
Upon completion of a performance improvement project, who is the best person to compile and write a report?
Team leader
A 69-year-old female admitted for hip replacement is taken to surgery. The patient is identified, the surgical site is marked incorrectly, and equipment/x-rays are present. A near miss was most likely identified as a result of
a surgical team 'time-out.'
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
arrange a meeting with the physician and nurse manager
The best reason to evaluate team meetings is to
assess progress
A patient safety program can best be enhanced by which of the following technologies?
barcode system for medication administration
Which of the following is the primary benefit of using external quality consultants?
bridging knowledge gaps
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
chief of the department.
The success of a performance improvement program will be most influenced by the
culture of the organization
A healthcare network has implemented an electronic medical record system allowing data to be transmitted, on demand, from one facility to another. Which of the following will best promote both cost effectiveness and patient satisfaction?
decreasing repeat tests when a patient is seen in more than one facility
A consulting firm has been selected by a healthcare Board of Directors to assess the quality improvement program. Before starting the assessment, the quality professional should first
define expectations and outcomes.
Which of the following is the best example of use of human factors engineering?
designing products to prevent tubing misconnections
The primary objective of the operational linkage between risk management and quality/performance improvement is to
develop a comprehensive plan to prevent future occurrences
A healthcare quality professional is conducting a study to determine how many patients contracted influenza despite receiving flu shots. This study is evaluating
efficacy
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
near miss from failure to perform a 'time-out.'
The evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to the performance of the
organization's systems
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
Informed consent for hip surgery was obtained and documented for an elderly patient. In the recovery room, a nurse discovered the wrong hip had been replaced. A healthcare quality professional should
perform a root cause analysis.
Which of the following obstetrical outcomes will result in a morbidity review?
post-delivery septicemia
Results of physician practice pattern studies are most likely to promote behavior changes when disseminated to the
practitioners
A failure mode and effects analysis (FMEA) provides which of the following types of review?
proactive
A monitoring system is being designed in which data will be collected and compared to criteria. Which of the following will best enhance the validity and reliability of the data?
providing a practice-based definition and specific instructions for each element
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
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.
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?
staff fear of negative consequences of reporting
A culture of patient safety in an organization will have been successfully created when
staff members serve as safety advocates.
Which of the following adverse events is NOT considered a sentinel event?
suicide threat by a patient in a confined 24-hour care setting
The phrase "reaching consensus" is often used in performance improvement. The term consensus refers to
support by all members.
Problem-solving, cross-functional understanding, expanded areas of expertise, and increased span of knowledge are examples of
the benefits of teams.
A valid data collection tool should incorporate
the definition of data elements
