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The evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to the performance of the
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 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?
The concept of organizational liability is most important to the field of healthcare quality because it holds the organization responsible for
An organization’s vision statement addresses
The prevalence rate of a disease depends on the
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?
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:
Quality improvement teams are beneficial because they
For a continuous quality improvement team to be successful, who must be included on the team?
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?
A strategy used in brainstorming is that ideas are
Which of the following National Patient Safety Goals is applicable to everyone in a healthcare facility?
To be useful in preventing future error, a Root Cause Analysis (RCA) should be performed
Which of the following are the first steps when preparing for an initial accreditation or certification survey of an organization?
When using cost-benefit analysis in decision-making, it is important to remember that
Which of the following principles applies to continuous quality improvement in an organization?
Leaders enhance employee commitment to organizational values by fostering which of the following types of communication?
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
Which of the following is the most appropriate question to ask when reviewing an organization’s performance improvement (PI) plan?
Which of the following best describes an organizational vision statement?
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 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?
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?
A team approach to problem solving is most useful when
To reduce the incidence of ventilator-associated pneumonia (VAP) in a critical care unit, who should be included on a quality improvement team?
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?
Which of the following charts will most likely be used first in a root cause analysis?
Clinical decision support systems can support medication safety by alerting prescribers 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
The quality improvement director is responsible for coordination of accreditation survey activities.
Responsibilities will most likely include
In the quality improvement process, performing a cost-benefit analysis is most useful in
One difference between continuous quality improvement and traditional quality assurance is that quality improvement always
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
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?
For health information technology to be most effective in reducing harm, the technology needs to be
Which of the following is the FIRST step in the strategic planning process?
Benchmarking is based on identifying which of the following?
Healthcare leaders are confronted with the challenge of increasing quality while reducing costs. Which of the following approaches best advances improvement efforts?
A physician who has a high inpatient mortality rate compared to others in a facility should first be
An effective facilitator should be skilled in process evaluation and the tools of performance evaluation, and must
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?
Which of the following is used to summarize a characteristic in a population?
An organization has established a culture of patient safety when
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
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
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?
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
A critical difference between quality assurance (QA) and quality improvement is a shift in focus from :
A continuous quality improvement organization promotes vigorous education and training/retraining in order 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?
Which of the following is the FIRST step in facilitating change in an organization?
Which of the following is essential to an effective quality council?
The primary reason healthcare organizations use benchmarking is to
The most effective tool to improve communication between caregivers is known as
The clinical competency of a physician is determined by
In order for a quality improvement team to deal effectively with conflict, it is important to appoint which of the following to its membership?
A valid data collection tool should incorporate
The best tool to display stability of nosocomial infection rates over time is a
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
When examining the relationship between staff and patient outcomes, which of the following is the most appropriate to assess?
When conducting a sentinel event review, a root cause analysis
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
The following table shows the percentage of hospital-acquired pressure ulcers: Which of the following should the healthcare quality professional do next?
According to continuous quality improvement principles, which of the following concepts is most important?
The best way to evaluate the effectiveness of performance improvement training is through :
A facility has identified a trend of increased falls for patients aged 60 to 85 years. An effective fall prevention program should include
Which of the following steps occurs first in facilitating change in an organization?
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?
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?
Situation-Background-Assessment-Recommendation (SBAR) is a
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 team members is responsible for keeping meetings focused?
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 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?
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
Which of the following is always true regarding a sentinel event?
Which of the following is the best tool to begin an investigation into the causes of laboratory labeling errors?
When a healthcare organization is contracting with an outside provider for services, the subcontractor must
Training is being determined based on treatment record review results. The following weighted results are available:
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 :
Replacing retrospective review with concurrent review is an example of
An organization’s data demonstrate an increase in the number of patient falls. A healthcare quality professional should recommend
The best way to facilitate change within a healthcare organization is to
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 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
Evaluating medication administration to reduce medical errors is an example of
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 NOT a function of the facilitator on a quality improvement team?
The first step in conducting an epidemiological study is to
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?
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
Human factors engineering is defined as the study of humans and their interaction with
After a significant unexpected event, an intense analysis is performed to
Which of the following topics are discussed at a morbidity and mortality conference?
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?
A process indicator is defined as one that measures
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?
When introducing continuous quality improvement (CQI) into an organization, a chief executive officer must first
Which of the following best demonstrates use of the Plan-Do-Check-Act performance improvement model?
In profiling length-of-stay data for benchmarking, it is important that data be
The primary objective of the operational linkage between risk management and quality/performance improvement is to
Which of the following graphs provides the best information for reappointment/re-evaluation of an individual physician
When a team evaluating the use of restraints starts to discuss a liability claim related to a patient, the facilitator should
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?
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?
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?
Which of the following is the best example of use of human factors engineering?
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 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
The perception of how an organization operates, including how employees relate to internal and external customers, is the organizational
Measuring the time it takes a nurse to perform a procedure addresses which of the following aspects of care?
Data collected about surgical cases shows significant delays. Further analysis shows the following chart:
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 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:
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
One aspect of a quality process that integrates with risk management is the review and evaluation of
Which of the following is an essential component in a performance improvement report?
Upon completion of a performance improvement project, who is the best person to compile and write a report?
What sampling technique involves selecting the medical record of every fifth patient undergoing cardiovascular bypass?
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
A culture of patient safety in an organization will have been successfully created when
Which of the following adverse events is NOT considered a sentinel event?
When errors are discovered, staff and supervisors best demonstrate a culture of safety by
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 success of a performance improvement program will be most influenced by the :
Which of the following is the best example of an outcome measure?
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?
Results of physician practice pattern studies are most likely to promote behavior changes when disseminated to the
Which of the following is the best way to determine if a quality improvement initiative is successful?
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?
The healthcare risk manager is usually responsible for claims administration.
Which of the following is included in this process?
The major drawback of using raw numbers to present the results of quality monitoring is that they
Team cohesion is established during which of the following stages of team growth?
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
To avoid misinterpreting variances, which of the following statistical tools should be used?
Comparing healthcare organizations by using medical error rates
A patient safety program can best be enhanced by which of the following technologies?
A root cause analysis team examined a serious medication error and recommended changes. Which of the following should be done next?
Medication reconciliation is a process intended to
A healthcare quality professional is conducting a study to determine how many patients contracted influenza despite receiving flu shots. This study is evaluating
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
Which of the following obstetrical outcomes will result in a morbidity review?
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?
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:
Quality improvement team outcomes are best evaluated by which of the following?
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?
A trend analysis of incidents occurring in a healthcare facility should focus on which of the following areas?
Which of the following should be included in an annual performance improvement report to a governing body?
Team building goals for a first meeting should include all of the following EXCEPT:
Which of the following sampling techniques selects participants based on their availability in a certain place during a specific time frame?
Refer to the following control chart:
In assessing the timeliness for the administration of antibiotics for pneumonia, this control chart demonstrates
Patient safety is promoted in an organization through
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?
Minimizing the chances for an adverse event to reoccur includes determining the primary contributing factor by using
The phrase “reaching consensus” is often used in performance improvement. The term consensus refers to
Quality leadership, in contrast to management by results, starts with which of the following?
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?
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/80% Unite B/80% Unite C/62%
Which of the following should a healthcare quality professional recommend?
Organizational leaders can best demonstrate commitment to a new quality improvement initiative by:
A facility is becoming part of a healthcare network. Which of the following employee education programs is most important?
A performance improvement (PI) training program for supervisors should include:
A balanced scorecard for an organization is best described as
Which of the following is the primary goal of risk management?
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
Quality improvement team development stages include all of the following EXCEPT:
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?
Prior to plotting a line graph, a healthcare quality professional should FIRST
The following patient safety data were obtained for a facility:
Which of the following most likely used only one patient identifier?
Which of the following actions has the greatest impact in reducing harm?
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?
Which of the following is the primary benefit of using external quality consultants?
Management using quality improvement principles should emphasize the importance of
A hospital is working to reduce readmissions. Which of the following is the best approach to accomplish this goal?
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
Healthcare quality professionals can best communicate organizational values and commitment through
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
In lean thinking, a process step is defined as “value added” if the:
Balanced scorecards are useful because they
Which of the following is the primary goal of risk management?
Leadership can best integrate performance improvement within an organization through
The best reason to evaluate team meetings is to
Which of the following tools should be used to record patient and practitioner specific data?
During quality management data analysis activities, Pareto charts are most appropriately used for
Which of the following is an example of a “never event” or sentinel event?
A failure mode and effects analysis (FMEA) provides which of the following types of review?
Which of the following accrediting bodies have deemed status with the Centers for Medicare and Medicaid Services (CMS)?
When considering the use of an external subject matter expert (SME), which of the following is most critical?
In continuous quality improvement programs, surveys are essential to determine which of the following?
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?
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 chief quality officer has the responsibility for education and implementation of a continuous quality improvement (CQI) process. To affect cultural change, administration must
A curriculum developed by healthcare organizations for staff education in organizational change should include all of the following EXCEPT
When developing department-specific performance measures and indicators, the quality manager as a consultant should
Standards of care based on the knowledge and research of recognized experts are known as
The primary purpose of risk management trend analysis is to
Which of the following is the most effective way to integrate performance improvement concepts throughout an organization?
Which of the following should a Quality Council provide to best ensure success of performance improvement teams?
Conclusions in a statistical study are generalized to the
A healthcare quality professional is provided the following data: Which of the following steps should be taken to prioritize areas of concern?
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?
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?
The Joint Commission (TJC) Standards and Elements of Performance are used
Which of the following action plans is the first step in correcting inappropriate blood usage in an emergency department?
Satisfaction surveys, focus groups, and complaint tracking are tools used to
The best approach for training staff about quality and patient safety is to
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 chief quality offer has the responsibility for education and implementation of
a quality improvement process. To affect cultural change, the chief quality officer
A healthcare entity initiating re-structuring must consider the impact on staff to ensure the greatest opportunity for success by:
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?
The use of clinical pathways and guidelines in hospitals should do which of the following?
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?
Problem-solving, cross-functional understanding, expanded areas of expertise, and increased span of knowledge are examples of
Which of the following actions should a facilitator make the highest priority during the customer focus group process?
Which of the following are measures of central tendency?
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?
The concept of “patient safety” applies most appropriately to
A Failure Mode and Effects Analysis (FMEA) is performed
In managed care, the most widely used performance measures are
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
An organization can best measure its effectiveness in meeting customer expectations by :
The most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staff is by
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
Empowerment gives employees the opportunity to :
The primary purpose of an organization’s quality improvement (QI) strategic plan is to
Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization’s quality improvement program?
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?
Which of the following are essential functions of an infection control program?
Performance improvement teams should always be required to:
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?
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?
After brainstorming, which of the following should a quality improvement team use to identify items that need immediate attention?
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
Failure modes can be prioritized by calculating the criticality index. Which of the following three categories are normally used to calculate a criticality index?
Which of the following is most appropriate in preparation for an external survey of a healthcare facility?
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?
Using the 80/20 rule, 80% of organizational problems are issues related 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?
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?
Evaluation of the quality and appropriateness of patient care in the radiology department is the responsibility of the
In the process of strategic planning, an organization makes decisions about the future. A basic component of the planning process is to
Meaningful quality process measures must be
Which of the following is most useful in performing a morbidity/mortality review?
Physician profiles are reviewed at time of reappointment to
A team approach in quality improvement activities is preferred when
The responsibility for providing organizational direction for a facility’s continuous quality improvement program frequently rests with the quality
A t-test may be used to
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 are the primary reasons for developing drug formularies?
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
Deemed status refers to
The primary purpose of integrating financial and quality management information is to