Mock 1 CPHQ
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A healthcare quality professional is conducting a study to determine how many patients contracted influenza despite receiving flu shots. This study is evaluating
Management using quality improvement principles should emphasize the importance of
Satisfaction surveys, focus groups, and complaint tracking are tools used to
Using the 80/20 rule, 80% of organizational problems are issues related to :
Which of the following principles applies to continuous quality improvement in an organization?
A critical difference between quality assurance (QA) and quality improvement is a shift in focus from :
A performance improvement training program has been conducted. The healthcare quality professional has determined that improvement has not occurred. The most likely cause for the lack of improvement would be that :
The perception of how an organization operates, including how employees relate to internal and external customers, is the organizational
Hospital A has recently merged with Hospital B. After 6 months it is noted that Hospital A has successfully transitioned their staff to new organizational values, while Hospital B still struggles. Hospital A’s success can best be attributed to
A hospital is working to reduce readmissions. Which of the following is the best approach to accomplish this goal?
The best approach for training staff about quality and patient safety is to
Patient satisfaction scores for a community hospital demonstrate multiple areasfor improvement including a need to improve attractiveness of the facility, responsiveness to patient needs, and physician and nursing communication. Based on these results, which of the following would the healthcare quality professional
also expect to find?
Leaders enhance employee commitment to organizational values by fostering which of the following types of communication?
A continuous quality improvement organization promotes vigorous education and training/retraining in order to :
Replacing retrospective review with concurrent review is an example of
Measuring the time it takes a nurse to perform a procedure addresses which of the following aspects of care?
Which of the following obstetrical outcomes will result in a morbidity review?
Two surveys were completed in a healthcare facility that showed conflicting results concerning patient satisfaction with food services. The two surveys were independently designed and distributed by different departments within the facility. The healthcare quality professional should FIRST
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
A serious event has occurred related to the timely notification of critical test results. The root cause was traced to nursing difficulty with following the
organizational policy. To prevent a similar event from reoccurring, which of the following should be done next?
A policy for “time-outs” in an operating room was initiated in the first quarter. The second quarter data demonstrated only 40% compliance with all elements of the process. The first step the Quality Council should take is to
A team has been tasked with developing a program to prevent patient falls. Which of the following data elements from an incident/occurrence report would
provide the most useful information for the team in evaluating the program’s success?
An organization’s data demonstrate an increase in the number of patient falls. A healthcare quality professional should recommend
Data collected about surgical cases shows significant delays. Further analysis shows the following chart:
Based on the principles from the Institute for Healthcare Improvement (IHI),
who has the ultimate responsibility for the effectiveness of quality improvement
and patient safety within an organization?
Healthcare quality professionals can best communicate organizational values and commitment through
A chief quality offer has the responsibility for education and implementation of
a quality improvement process. To affect cultural change, the chief quality officer
Evaluation of the quality and appropriateness of patient care in the radiology department is the responsibility of the
Which of the following is the most appropriate question to ask when reviewing an organization’s performance improvement (PI) plan?
Which of the following is the FIRST step in facilitating change in an organization?
The best way to facilitate change within a healthcare organization is to
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 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:
A re-engineering effort occurred at a facility. The activities, particularly those regarding staff layoffs, were carefully planned, communicated, and implemented according to the plan. One year later, the business is stable but staff morale is very low. A healthcare quality professional has been asked to consult in determining where the effort went wrong. Based on the concepts of change theory, the cause is most likely
A healthcare entity initiating re-structuring must consider the impact on staff to ensure the greatest opportunity for success by:
In the process of strategic planning, an organization makes decisions about the future. A basic component of the planning process is to
Which of the following best describes an organizational vision statement?
Which of the following is essential to an effective quality council?
A quality council has chartered a performance improvement team to reduce medication errors. The team has been meeting for several months and progress has been very slow. Which of the following is the most important factor for the quality council to assess with the team leader?
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:
Quality improvement team outcomes are best evaluated by which of the following?
In lean thinking, a process step is defined as “value added” if the:
An annual evaluation of a laboratory’s quality program identified no opportunities for improvement. Which of the following elements of the program should be reviewed?
Meaningful quality process measures must be
The surgery department’s monthly case review revealed 10 records meeting criteria. Six records did not meet the criteria. In calculating the incidence rate, the denominator is
The primary reason healthcare organizations use benchmarking is to
A team has identified a process for improvement, selected examples of best practice performers, visited those sites, gathered all necessary data, and compiled the results. The most effective next step for the team is to
95- 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
Recent patient satisfaction surveys demonstrated that the responses to the following questions did not meet the 80% benchmark: Based on these results, which two performance improvement activities should the organization focus on FIRST?
Balanced scorecards are useful because they
The use of clinical pathways and guidelines in hospitals should do which of the following?
Which of the following is most useful in performing a morbidity/mortality review?
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?
The most effective tool to improve communication between caregivers is known as
Evaluating medication administration to reduce medical errors is an example of
The primary objective of the operational linkage between risk management and quality/performance improvement is to
The healthcare risk manager is usually responsible for claims administration.
Which of the following is included in this process?
Which of the following is the primary goal of risk management?
The primary purpose of risk management trend analysis is to
Which of the following are essential functions of an infection control program?
Based on identified issues, a healthcare quality professional examines 100% of one physician’s admissions and only 20% of all other physicians’ admissions. This is best described as a:
A physician who has a high inpatient mortality rate compared to others in a facility should first be
A staff member reports that a colon perforation occurred during a colonoscopy. Which of the following is a healthcare quality professional’s next step?
Which of the following graphs provides the best information for reappointment/re-evaluation of an individual physician
The major drawback of using raw numbers to present the results of quality monitoring is that they
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
Which of the following is the most effective way to integrate performance improvement concepts throughout an organization?
Performance improvement teams should always be required to:
Quality improvement teams are beneficial because they
An effective facilitator should be skilled in process evaluation and the tools of performance evaluation, and must
Which of the following team members is responsible for keeping meetings focused?
When a team evaluating the use of restraints starts to discuss a liability claim related to a patient, the facilitator should
Team cohesion is established during which of the following stages of team growth?
Quality improvement team development stages include all of the following EXCEPT:
Which of the following should a Quality Council provide to best ensure success of performance improvement teams?
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?
For a continuous quality improvement team to be successful, who must be included on the team?
An ambulatory/outpatient care facility identifies an opportunity to improve the turnaround time for reports of x-rays performed at a local hospital. Which of the following groups should be involved in the team to improve the process?
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?
A number of specialty and primary care clinicians have participated in several meetings to develop clinical practice guidelines for the management of diabetes. The team leader has moved the team through the actual guideline development, and is now concentrating on the “evaluation of quality-of- care” phase. Which of
the following sequences of steps should the team consider in developing the evaluation phase?
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 small, rural hospital wishes to evaluate customer satisfaction using a survey. The organization has four patient care units, an emergency department, and an ambulatory unit. Which of the following survey methods provides the most reliable information?
Conclusions in a statistical study are generalized to the
The utilization management committee is reviewing length-of-stay data for a particular procedure. In comparing data by physician, which of the following statistics will be most useful?
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?
Which of the following is used to summarize a characteristic in a population?
The best tool to display stability of nosocomial infection rates over time is a
An emergency department tracks wait times from patient arrival to physician assessment. Data is reported using a run chart. Which of the following demonstrates a true statistical increase in treatment delays?
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
Refer to the following control chart:
In assessing the timeliness for the administration of antibiotics for pneumonia, this control chart demonstrates
During quality management data analysis activities, Pareto charts are most appropriately used for
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?
After brainstorming, which of the following should a quality improvement team use to identify items that need immediate attention?
A strategy used in brainstorming is that ideas are
An organization has established a culture of patient safety when
A Quality Council has created a Patient Safety Council. The council is concerned that staff may see this as another program that has been added to their busy schedules that will eventually go away. The best way for the organization to establish patient safety as an ongoing part of the organization’s culture is to
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?
Comparing healthcare organizations by using medical error rates
The following patient safety data were obtained for a facility:
Which of the following most likely used only one patient identifier?
A patient is transferred to a neighboring hospital for a magnetic resonance imaging (MRI) exam. Due to a misinterpretation of orders, the procedure is performed on the wrong part of the body.
Which of the following should the healthcare quality professional do?
A Quality Council has decided that a Patient Safety Committee needs to be established to oversee the patient safety program. The Quality Council has asked this committee to prepare a Patient Safety Plan that would guide the program. A key factor that needs to be considered for the long-term success of the patient safety program is to
Which of the following National Patient Safety Goals is applicable to everyone in a healthcare facility?
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
Which of the following is always true regarding a sentinel event?
Which of the following is the best example of use of human factors engineering?
A patient safety program can best be enhanced by which of the following technologies?
Which of the following actions has the greatest impact in reducing harm?
Which of the following is an example of a leadership strategy to integrate the patient safety program into a healthcare organization’s overall performance improvement system?
Failure modes can be prioritized by calculating the criticality index. Which of the following three categories are normally used to calculate a criticality index?
To be useful in preventing future error, a Root Cause Analysis (RCA) should be performed
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
Which of the following is the best tool to begin an investigation into the causes of laboratory labeling errors?
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
A root cause analysis team examined a serious medication error and recommended changes. Which of the following should be done next?
A former patient emails an organization’s chief executive officer complimenting the friendliness of the nurses while complaining that her pain was not well managed. To comply with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, what actions are needed?
The Joint Commission (TJC) Standards and Elements of Performance are used
Which of the following is most appropriate in preparation for an external survey of a healthcare facility?
Which of the following are the first steps when preparing for an initial accreditation or certification survey of an organization?
In the following table, “Reviews” refers to utilization reviews, “FTE” refers to full time equivalent/employee, and “#” refers to the number. Consider the following productivity data: What is the approximate percentage of increase in productivity from January to May?
When a healthcare organization is contracting with an outside provider for services, the subcontractor must
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
Medication reconciliation is a process intended to
Which of the following is the primary benefit of using external quality consultants?
Which of the following action plans is the first step in correcting inappropriate blood usage in an emergency department?
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?
When using cost-benefit analysis in decision-making, it is important to remember that
A healthcare provider recently conducted a customer satisfaction survey that focused on the five key quality characteristics in the graph below:
By analyzing the information, the provider can identify that customers were most dissatisfied with
Training is being determined based on treatment record review results. The following weighted results are available: