Quality improvement Exam 1
The Medicare program s quality management requirements for healthcare facilities are found in what regulations? Accreditation standards State licensing documents Hospital standardization program Conditions of Participation
Conditions of Participation
Which of the following is one aspect of the definition of healthcare quality? Helps safeguard providers against malpractice Consistent with current professional knowledge Contributes to the rising cost of services Information linked between healthcare facilities
Consistent with current professional knowledge
"When measurement data show that a department s performance is meeting expectations, what action should the manager take?" Stop measuring performance Continue to monitor performance Judge performance against similar departments Plot performance data on a control chart
Continue to monitor performance
Which of the following healthcare dimensions was NOT mentioned by the Committee on Quality of Health Care in America as an area that needed improvement? Timeliness Equity Convenience Safety
Convenience
"When desired results are achieved with minimal expenditure of resources, the healthcare services are most accurately described as what?" Beneficial Reasonable Cost-effective Customer-friendly
Cost-effective
What type of data display uses symbols or colors to draw people s attention to performance concerns? Bar graph Pie chart Line graph Dashboard
Dashboard
During which phase of quality management are raw data examined to draw conclusions about performance? Data analytics Performance measurement Goal setting Data mining
Data analytics
What document does The Joint Commission require hospitals create to describe each data element captured electronically? Measure specifications Data dictionary Data attributes Measure plan
Data dictionary
A hospital improvement team has brainstormed several potential solutions to the problem of high nursing staff turnover. What tool could the team use to select the solutions most likely to be successful? Flowchart Pareto analysis Decision matrix Questionnaire
Decision matrix
Six Sigma projects commonly involve which of these steps? Plan-Do-Check-Act Define-Measure-Analyze-Improve-Control Focus-Analyze-Develop-Execute Plan-Do-Study-Act
Define-Measure-Analyze-Improve-Control
"A health maintenance organization conducted a study on outpatient treatment of patients with asthma. The need for a new asthma management protocol was identified, and it was developed. Now the protocol is being piloted by physicians at two primary care clinics. This project is in which phase of the Plan-Do-Study-Act improvement cycle?" Do Plan Act Study
Do
What is the data source for an e-measure? Electronic database Excel spreadsheet Patient surveys Paper records
Electronic database
A healthcare service is considered underused when the added benefits are less than the added costs of that service. True or false
False
Healthcare organizations do not use performance comparisons with other organizations to set performance targets. True or False
False
Measures of clinical decision making often originate from medical license requirements. True and False
False
Participants in a structured brainstorming session write their ideas on papers that are collected and posted for everyone to see. True or False
False
Qualitative tools provide numeric information for an improvement project team. True or False
False
The healthcare quality Triple Aim framework was developed by the National Academy of Medicine. True or False
False
Visual controls are used in a Lean project to make process waste more visible to help identify where it can be minimized. True or False
False
What qualitative tool would be used by an improvement team to undercover the root cause of a performance problem? Five Whys Flow chart Stakeholder analysis Pareto chart
Five Whys
Staff in an ambulatory surgery center want to streamline the patient admission process. What performance improvement tool would they use to get a better understanding of how patients are currently admitted? Affinity diagram Flowchart Stakeholder analysis Histogram
Flowchart
"An improvement team in a home health agency wants to streamline the process of discharging patients. The team identifies all the factors that will hinder the success of their improvement plans, as well as those factors that will increase the likelihood of success. The team is using what improvement tool?" Force field analysis Nominal group technique Pareto analysis Lean thinking
Force field analysis
"For a healthcare process to achieve Six Sigma, what level of quality is expected?" No variation Free of defects Minimal waste Meets expectations
Free of defects
What federal act created incentives for hospitals and providers to adopt electronic health records? National Quality Strategy Health Information Technology for Economic and Clinical Health Patient Protection and Affordable Care Act Medicare Access and CHIP Reauthorization
Health Information Technology for Economic and Clinical Health
What type of healthcare organization uses measures found in the Healthcare Effectiveness Data and Information Set (HEDIS)? Urgent care clinic Health insurance plan Home health agency Rehabilitation facility
Health insurance plan
What is a publicly available source of comparative healthcare performance data? National Quality Forum Healthcare Cost and Utilization Project American Customer Satisfaction Index Hospital Association Quality Measures
Healthcare Cost and Utilization Project
Which graph is used to display the frequency distribution of measurement data? Scatter diagram Pie chart Histogram Line graph
Histogram
What is the first step in constructing a performance measurement? Establish performance goals Identify topic of interest Identify data sources Establish measurement team
Identify topic of interest
Which step follows the assessment phase in the quality management cycle? Improvement Evaluation Measurement Planning
Improvement
What are the three primary quality management activities? Quality planning, control, and improvement Goal setting, prioritization, and measurement Overuse, underuse, and misuse Measurement, assessment, and improvement
Measurement, assessment, and improvement
What are the three primary quality management activities? "Quality planning, control, and improvement" "Goal setting, prioritization, and measurement" "Overuse, underuse, and misuse" "Measurement, assessment, and improvement"
Measurement, assessment, and improvement"
Which of the following statements regarding control charts is TRUE? Control charts are used to reduce assignable variation. Time-series data are plotted on a control chart. The Pareto principle is highlighted by the use of control charts. A control chart is a good tool for displaying cause and effect.
Time-series data are plotted on a control chart.
What does an organization use benchmarking for? To compare current performance to previous performance To determine the level of current performance To determine if current performance meets performance goals To compare current performance to an exemplary organization
To compare current performance to an exemplary organization
What is the denominator for the performance measure percentage of home health patients admitted to the hospital ? Total number of hospitalized patients Total number of home health patients Total number of home health patients admitted to the hospital Total number of home health patients not admitted to the hospital
Total number of home health patients
"A flowchart is a visual representation of the movement of people, materials, paperwork, or information during a process." True or false
True
"During the Do phase of a Plan-Do-Check-Act improvement project, process changes are implemented on a small scale and success is measured." True or False
True
"In a high-reliability organization, there are fewer accidents than would be expected." True or false
True
A cause and effect diagram is a structured brainstorming technique. True or False
True
A line graph can be used to distinguish between common cause and special cause variations in performance. True or False
True
A performance measure is considered evidence based if it is derived from nationally recognized practice guidelines. True or False
True
Doctors often practice defensive medicine for the purpose of avoiding malpractice liability. True or False
True
Healthcare quality can not be achieved without reliability. True or False
True
One reason healthcare organizations seek accreditation is to stimulate internal quality improvement efforts. True or False
True
Performance targets are set at 100% for aspects of healthcare that affect patient satisfaction. True or False
True
Process improvement teams use analytic tools to evaluate where changes are needed to improve performance. True or False
True
Tampering can occur when a manager reacts to performance measurement results without knowing how much natural performance variance occurs in the process. True or False
True
The percentage of patients receiving home health services who develop a pressure ulcer is a measure of potentially avoidable events. True or False
True
The response rate to a survey is usually expressed as a percentage. True or False
True
What factors unique to healthcare delivery inhibit adoption of some industrial quality improvement techniques? Need for adequately trained and competent staff Variable conditions and behaviors of patients Regulatory requirements and accreditation standards Customer expectations for quality and reliability
Variable conditions and behaviors of patients
Who is considered the father of statistical quality control? W. Edwards Deming Walter Shewhart Joseph Juran Kaoru Ishikawa
Walter Shewhart
Who was the originator of the Plan-Do-Check-Act model of performance improvement? W. Edwards Deming Toyota Walter Shewhart Motorola
Walter Shewhart
What is the first question asked during a FOCUS-PDCA project? Who are the key stakeholders? How will we know that a change is an improvement? What process do we want to improve? What changes can we make that will result in improvement?
What process do we want to improve?
A team in the hospital registration department is conducting a Lean project to reduce wasteful steps in the process of preregistering elective admissions. What qualitative improvement tool could the team use to better understand the movement of preadmission paperwork throughout the department? Staff survey Workflow diagram Cause and effect diagram Multi-voting
Workflow diagram
What improvement model involves small process changes and careful measurement of the effect of the changes? Lean Six Sigma Plan-Do-Check-Act Rapid cycle improvement
Rapid cycle improvement
"What statistic is used to report a measurement that is comparing two things (e.g., the actual number of hospital deaths as compared to the expected deaths)?" Average Percentage Ratio Absolute number
Ratio
"During the Act phase of a PDSA project, if changes made to improve performance are found to be unsuccessful, what is the next step?" Start a different process improvement project. Add new members to the improvement project team. Repeat the project starting at the Plan phase. Continue to monitor process performance.
Repeat the project starting at the Plan phase.
What can cause data gathered through the use of patient satisfaction surveys to be unreliable? Surveys are sent to a representative sample Response rate is low Questions are graded on a continuum Survey is conducted online
Response rate is low
The clinic medical director wants to know if there is a correlation between the number of minutes patients must wait to see a physician and the time of day. Which graph would you use to display the data to help determine if a relationship exists between the two variables? Scatter diagram Pie chart Histogram Control chart
Scatter diagram
What is an example of a quantitative improvement tool? Scatter diagram Cause and effect diagram Decision matrix Nominal group technique
Scatter diagram
Achieving near-perfect quality is the primary goal of which performance improvement model? FOCUS-PDCA Six Sigma Rapid cycle improvement Lean
Six Sigma
"When a data point on a control chart falls above the upper control limit, the process being measured is exhibiting what type of characteristic?" Common cause variation Random variation Exceptional variation Special cause variation
Special cause variation
"To improve productivity in the hospital operating room, the manager wants to start scheduling elective surgeries on Saturday. What tool can the manager use to identify strategies for gaining support from individuals who may resist this change?" Pareto analysis Stakeholder analysis Five Whys Nominal group technique
Stakeholder analysis
Staff members in the physical therapy department gather information about the reasons why patient treatments do not start at the scheduled time. They want to group the reasons for late treatment starts into related categories to identify commonalities. What performance improvement tool could be used to sort the reasons into similar categories? Prioritization matrix Force field analysis Flowchart Affinity diagram
Affinity diagram
Which of the following is one of the three broad aims of the National Quality Strategy? Affordable care Fewer health disparities Improved satisfaction Efficient care
Affordable care
What group sponsors the National Guidelines Clearinghouse? Centers for Medicare & Medicaid Services The Joint Commission National Quality Forum Agency for Healthcare Research and Quality
Agency for Healthcare Research and Quality
What organization sponsored the first program to improve quality in US hospitals? American College of Surgeons The Joint Commission Medical Group Management Association Centers for Medicare & Medicaid Services
American College of Surgeons
Which of the following formats can be used to display measurement data from different time periods? Pie chart Scatter diagram Tabular report Pareto chart
Tabular report
Which of the following statements best represents the philosophy employed by the Pareto principle? The majority of quality defects are caused by a small percentage of identifiable problems. "Generally, 80% of quality problems are candidates for improvement actions." Problems that have a measurable effect on patient outcomes should be corrected. "To achieve ideal performance, all quality problems should be investigated."
The majority of quality defects are caused by a small percentage of identifiable problems.
Which of the following factors is NOT considered when selecting a format for displaying measurement data? The need for improvements The information s intended use The measurement time frame The audience
The need for improvements
What is one of the core values found in the Baldrige healthcare criteria for performance excellence? Quality control Employee empowerment Do no harm Management by fact
Management by fact
What is a step common to all performance improvement models? Identify customer expectations Measure success Evaluate special cause variation Prevent rework
Measure success
What framework is used by an organization to categorize system-level performance measures? Balanced scorecard Check sheet Triple Aim ORYX project
Balanced scorecard
What quality program is managed by the National Institute of Standards and Technology in the US Commerce Department? Baldrige National Quality Program The healthcare quality Triple Aim Conditions of Participation National Quality Strategy
Baldrige National Quality Program
What type of data display is commonly used to report performance measurement data over time? Bar graph Scatter diagram Histogram Pareto chart
Bar Graph
What is a measure of the performance potential of a process? Benchmark Value index Capability Efficiency
Capability
An improvement team in the emergency department brainstorms all factors that have an effect on how long patients wait before being seen by a physician. What performance improvement tool would be useful for categorizing the factors identified through this brainstorming activity? Cause and effect diagram Five Whys Workflow diagram Pareto chart
Cause and effect diagram
What is another name for a fishbone diagram? Workflow diagram Affinity diagram Cause and effect diagram Force field diagram
Cause and effect diagram
Which of the following is a data-gathering tool used to collect performance measurement data? Dashboard Sampling Check sheet Scorecard
Check sheet
What organization published Crossing the Quality Chasm: A New Health System for the 21st Century? Institute for Healthcare Improvement American Hospital Association Institute of Medicine Centers for Medicare & Medicaid Services
Institute of Medicine
What group acts on the behalf of consumers to keep healthcare costs down? Hospital trade association National Academy of Medicine Insurance industry Securities and Exchange Commission
Insurance industry
What is a short-term Lean project? DMAIC PDCA Rapid cycle Kaizen event
Kaizen event
What Lean technique makes it easier for staff to quickly recognize when an inventory item needs to be restocked? Value stream map Mistake-proofing Kanban Standards
Kanban
Eliminating wasteful inefficiencies in a process is the primary goal of which performance improvement model? FADE Rapid cycle improvement Plan-Do-Study-Act Lean
Lean
What improvement model originated in the Toyota automobile production system? Lean Six Sigma Focus-PCDA Baldrige
Lean
Statistical process control techniques can be applied to which type of graph? Scatter diagram Histogram Pareto chart Line graph
Line Graph
Which external group does NOT establish performance measurement requirements for healthcare organizations? Centers for Medicare & Medicaid Services National Committee for Quality Assurance National Quality Forum The Joint Commission
National Quality Forum
The hospital respiratory therapy department is conducting a Six Sigma project for the purpose of reducing the incidence of missed treatments. The department s medical director asks staff members to identify process changes that will result in fewer missed treatments. What qualitative improvement tool could the director use during this brainstorming session to narrow down potential solutions to those most likely to be successful? Nominal group technique Workflow diagram Planning matrix Cause and effect diagram
Nominal group technique
Which of the following is a structure measure used to evaluate hospital performance? Rate of patient falls in various units Percentage of patients educated about their medications Number of disaster drills conducted annually Percentage of patients with private insurance
Number of disaster drills conducted annually
What is a process measure of staff performance in a nursing home? Percentage of residents developing a pressure ulcer Percentage of residents regularly participating in social activities Number of records lacking documentation of resident s allergies Number of requests for equipment maintenance
Number of records lacking documentation of resident s allergies
Which of the following best describes a reliable healthcare service? One that meets customer expectations One that consistently performs as intended One that adds value for the customer One that is provided in a timely manner
One that consistently performs as intended
"The hospital has collected patient satisfaction data for more than one year. It is now time for strategic planning, and you ve been asked to summarize the satisfaction data so senior leaders can establish two or three strategic objectives related to improving patient satisfaction. They want to focus on the vital few issues that cause the most problems. What type of graph would you use to provide senior leaders with the information they need?" Pie chart Control chart Pareto chart Radar chart
Pareto chart
Which of the following is a patient experience measure for a hospital? Percentage of patients completing preadmission forms Percentage of patients reporting pain was well controlled Percentage of patients developing a urinary tract infection
Percentage of patients reporting pain was well controlled
What activity-level measure is related to the system-level measure percentage of hospital patients who are very satisfied with the overall quality of care? Percentage of hospital physicians who are board certified Rate of staff compliance with hand hygiene procedures Rate of insurance claims submitted within 10 days of patient discharge Percentage of patients reporting that nurses treated them with respect
Percentage of patients reporting that nurses treated them with respect
Which of the following is a process measure of performance in a hospital intensive care unit? Percentage of patients on ventilators who develop pneumonia Rate of patient readmissions to the intensive care unit Percentage of staff using hand cleaner when entering patient room Number of complaints received from family members
Percentage of staff using hand cleaner when entering patient room
What is revealed by evaluating the difference between a department s actual and expected performance? Performance goal Performance gap Performance trend Performance target
Performance gap
The hospital team charged with reducing the incidence of patient falls has selected four different patient care process changes that need to be implemented. What tool would the team use to document the tasks necessary for making these process changes? Planning matrix Storyboard Workflow diagram Deployment flow chart
Planning matrix
What situation puts data accuracy at risk when more than two people are independently gathering data for the same performance measure? Poor interrater reliability Only a sample of the population is measured Patient records are the data source Data are collected on different days
Poor interrater reliability
"Until the 1970s, healthcare quality activities were primarily based on which management system?" Deming approach to continuous improvement Quality assurance methodology Synthesis and alignment principle Pre-Industrial Revolution craft model
Pre-Industrial Revolution craft model
What is a visual representation of the flow of process steps? Process diagram Process analysis Flow stream Statistical process control
Process diagram
What activity is done to achieve compliance with minimum quality standards in a healthcare organization? Quality planning Performance assessment Performance measurement Quality assurance
Quality assurance
