Quality leadership, in contrast to management by results, starts with which of the following?

In continuous quality improvement programs, surveys are essential to determine which of the following?

An organization can best measure its effectiveness in meeting customer expectations by :

The evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to the performance of the

One difference between continuous quality improvement and traditional quality assurance is that quality improvement always

According to continuous quality improvement principles, which of the following concepts is most important?

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?

The success of a performance improvement program will be most influenced by the :

A patient is being taught how to self-administer insulin. Which of the following is the BEST method to assess this patient’s understanding of the teaching?

Which of the following is the best approach when implementing a National Patient Safety Goal related to identifying potential errors in a patient’s care, treatment, and services?

The most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staff is by

A healthcare quality professional is teaching staff members to respond to patient complaints. Which of the following is the most effective behavior when dealing with angry patients?

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

The best way to evaluate the effectiveness of performance improvement training is through :

A process indicator is defined as one that measures

Which of the following is the best example of an outcome measure?

A healthcare organization’s strategic plan objectives include a customer satisfaction rating of 85%. The following data are available for three units:

Customer Satisfaction Rate:   Unite A/89%     Unite B/80%     Unite C/62% 

Which of the following should a healthcare quality professional recommend?

A quality improvement manager received the results from the most recent customer survey. Sixty percent of the residents in a nursing home have rated the
temperature of foods served as poor. Which of the following actions should be taken first?

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

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?

42- The following information about patient falls is obtained from a facility with
units that have a similar average daily census:
Unit A: 6%
Unit B: 4%
Unit C: 9%
Unit D: 8%
Which of the following additional information is most important to evaluate the
cause of the falls?

A facility has identified a trend of increased falls for patients aged 60 to 85 years. An effective fall prevention program should include

The following data is being analyzed based on 6 months of incident reports for falls in a facility with 10 ICU beds and 40 Med/Surg beds:

Which of the following is the next step for the healthcare quality professional to pursue?

A hospital-wide medical record audit on documentation has been completed.
The following table shows the compliance rate of documentation:

Compliance Rate (%) Documentation:        1st Qtr           2nd Qtr
Surgical “time-outs” performed                     90                      95
Communication of critical results                 91                        95
Pain score used                                                  50                       60
Initial patient assessment performed            52                      45

Which of the following is the next step?

Organizational leaders can best demonstrate commitment to a new quality improvement initiative by:

A chief quality officer has the responsibility for education and implementation of a continuous quality improvement (CQI) process. To affect cultural change, administration must

Empowerment gives employees the opportunity to :

The concept of organizational liability is most important to the field of healthcare quality because it holds the organization responsible for

For health information technology to be most effective in reducing harm, the technology needs to be

Which of the following steps occurs first in facilitating change in an organization?

When introducing continuous quality improvement (CQI) into an organization, a chief executive officer must first

Results of physician practice pattern studies are most likely to promote behavior changes when disseminated to the

A facility is becoming part of a healthcare network. Which of the following employee education programs is most important?

A curriculum developed by healthcare organizations for staff education in organizational change should include all of the following EXCEPT

The primary purpose of an organization’s quality improvement (QI) strategic plan is to

An organization’s vision statement addresses

Which of the following is the FIRST step in the strategic planning process?

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?

Which of the following best demonstrates use of the Plan-Do-Check-Act performance improvement model?

Which of the following is the best way to determine if a quality improvement initiative is successful?

A performance improvement (PI) training program for supervisors should include:

When developing department-specific performance measures and indicators, the quality manager as a consultant should

Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization’s quality improvement program?

The prevalence rate of a disease depends on the

Benchmarking is based on identifying which of the following?

A performance improvement team has been created to examine infection rates following surgery. Which of the following is the best reference for the team to use?

In profiling length-of-stay data for benchmarking, it is important that data be

A utilization management department of a hospital has collected data on length of stay and readmission rates. Compared to benchmarks, the length of stay rates are higher and readmission rates are lower. Which of the following is the next step?

A balanced scorecard for an organization is best described as

Standards of care based on the knowledge and research of recognized experts are known as

A critically ill patient is admitted and requires a specialized procedure; however, the surgeon does not have privileges at the facility. Which of the following documents will be MOST helpful in identifying the course of action the hospital should take?

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?

Healthcare leaders are confronted with the challenge of increasing quality while reducing costs. Which of the following approaches best advances improvement efforts?

Situation-Background-Assessment-Recommendation (SBAR) is a

Generic screening is an example of risk

One aspect of a quality process that integrates with risk management is the review and evaluation of

A trend analysis of incidents occurring in a healthcare facility should focus on which of the following areas?

Which of the following is the primary goal of risk management?

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?

Physician profiles are reviewed at time of reappointment to

A healthcare quality professional is developing a policy regarding access to physician quality files. In addition to the date and name of the person requesting the information, which of the following should be included in the policy?

The clinical competency of a physician is determined by

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?

Which of the following is an essential component in a performance improvement report?

Which of the following should be included in an annual performance improvement report to a governing body?

Leadership can best integrate performance improvement within an organization through

Problem-solving, cross-functional understanding, expanded areas of expertise, and increased span of knowledge are examples of

A team approach in quality improvement activities is preferred when

A team approach to problem solving is most useful when

In order for a quality improvement team to deal effectively with conflict, it is important to appoint which of the following to its membership?

Which of the following is NOT a function of the facilitator on a quality improvement team?

Upon completion of a performance improvement project, who is the best person to compile and write a report?

Team building goals for a first meeting should include all of the following EXCEPT:

The best reason to evaluate team meetings is to

Which of the following actions should a facilitator make the highest priority during the customer focus group process?

The responsibility for providing organizational direction for a facility’s continuous quality improvement program frequently rests with the quality

To reduce the incidence of ventilator-associated pneumonia (VAP) in a critical care unit, who should be included on a quality improvement team?

A valid data collection tool should incorporate

The first step in conducting an epidemiological study is to

What sampling technique involves selecting the medical record of every fifth patient undergoing cardiovascular bypass?

Which of the following sampling techniques selects participants based on their availability in a certain place during a specific time frame?

Which of the following tools should be used to record patient and practitioner specific data?

Which of the following are measures of central tendency?

A t-test may be used to

The relationship between patient satisfaction and hours per patient day on a medical unit was found to be (r= 0.60, p < 0.05). What is the correlation between these two values?

Frequency distribution can best be displayed through use of

A healthcare quality professional has been asked to provide a report on the rate of Cesarean sections performed at a hospital over the past five years. Which of the following is the best way to present the data?

When a case manager wants to demonstrate length of stay data that depicts both common cause and special cause variation, which of the following should be used?

To avoid misinterpreting variances, which of the following statistical tools should be used?

Prior to plotting a line graph, a healthcare quality professional should FIRST

A healthcare quality professional is provided the following data: Which of the following steps should be taken to prioritize areas of concern?

In developing a performance improvement action plan, which of the following tools should be used FIRST?

In evaluating “long waiting times,” a healthcare quality professional best demonstrates components related to staffing, methods, measures, materials, and equipment utilizing a

Which of the following charts will most likely be used first in a root cause analysis?

A large facility has fostered a culture of patient safety through staff education, support of process improvements at department levels, and implementation of a  nonpunitive approach to error reporting. Compliance with patient safety goals ranges from 75-100%. In assessing the culture of patient safety, a healthcare quality professional should

A facility decided to implement Standard Precautions 1 year ago, but compliance has been poor. In addition to assessing the causes for poor compliance, the most effective way for the organization to improve compliance is to

A culture of patient safety in an organization will have been successfully created when

Patient safety is promoted in an organization through

Which of the following is an example of a “never event” or sentinel event?

The concept of “patient safety” applies most appropriately to

Which of the following are the primary reasons for developing drug formularies?

Clinical decision support systems can support medication safety by alerting prescribers to

When examining the relationship between staff and patient outcomes, which of the following is the most appropriate to assess?

Human factors engineering is defined as the study of humans and their interaction with

Which of the following adverse events is NOT considered a sentinel event?

Which of the following is an example of information that should be included in an incident report, but should NOT be recorded in a patient’s medical record?

A failure mode and effects analysis (FMEA) provides which of the following types of review?

A Failure Mode and Effects Analysis (FMEA) is performed

A Quality Council has chartered a Failure Mode and Effects Analysis (FMEA) team to examine the best method of preventing medication errors after the installation of a new medication dispensing system. The team’s first major task should be to

A patient in an acute psychiatric unit committed suicide by hanging himself with his shoelaces. To prevent this from occurring again, the most appropriate action is to institute

When conducting a sentinel event review, a root cause analysis

After a significant unexpected event, an intense analysis is performed to

When errors are discovered, staff and supervisors best demonstrate a culture of safety by

Minimizing the chances for an adverse event to reoccur includes determining the primary contributing factor by using

Which of the following accrediting bodies have deemed status with the Centers for Medicare and Medicaid Services (CMS)?

In managed care, the most widely used performance measures are

Deemed status refers to

The quality improvement director is responsible for coordination of accreditation survey activities.

Responsibilities will most likely include

A private insurer has contracts with two area hospitals. Hospital A is a 250- bed community facility and Hospital B is a 900-bed tertiary care center. It was noted that costs were less at the tertiary care center. From a financial standpoint, the best option for the private insurer is to

Which of the following topics are discussed at a morbidity and mortality conference?

A federally certified electronic health record (EHR) with the capacity for eprescribing, electronic exchange of health information, and submission of healthcare quality measures meets

The phrase “reaching consensus” is often used in performance improvement. The term consensus refers to

When considering the use of an external subject matter expert (SME), which of the following is most critical?

A group of pediatric patients diagnosed with cystic fibrosis is being studied. Their attitudes toward the disease have been measured each year for the past 4 years. The methodology used is an example of a

The primary purpose of integrating financial and quality management information is to

In the quality improvement process, performing a cost-benefit analysis is most useful in

The following table shows the percentage of hospital-acquired pressure ulcers: Which of the following should the healthcare quality professional do next?