In deciding whether to apply for an external quality award, the first step is to determine if the award criteria

Which of the following is the BEST way for a healthcare quality professional to involve nursing staff in the restructuring of a patient care unit?

Each of the following activities are part of an organization’s patient safety program, except

The main purpose of conducting a focus group is to

Analysis of post-operative surgical site infection rates over the past 12 months demonstrates an increase in infections. Which of the following BEST provides a display of aggregated data compared to data from a local facility?

A patient was admitted to a hospital with chest pain on Monday evening. A myocardial infarction was ruled out and the patient was discharged on Wednesday. The utilization management coordinator reviewed the chart on Thursday to determine medical necessity for admission. This type of review is

In the Institute of Medicine’s report “Crossing the Quality Chasm: A New Health System for 21^st the Century”, several aims for improvement were articulated which included the following EXCEPT:

Root cause analysis following a sentinel event will probably require a

A cardiologist refuses to accept that his inpatient acute myocardial infarction rate for the past 12 months is high. To convince the cardiologist, which of the following steps should the healthcare quality professional take?

In a facility which allows verbal/telep=hone orders, a nurse is asked to take a telephone order for the sedative medication Zoplicone to help a patient with insomnia. The nurse should:

A suspicious death after surgery occurred in a prestigious hospital. Initial reports suggested that post-operative nurses might have misread physician orders for intravenous fluids. Senior management had concerns about litigation and adverse publicity. In making rapid decisions, the Chief Executive Officer of the hospital should adopt a leadership style that is

A 35 year old man presented to the Emergency Room with diabetic ketoacidosis, a life-threatening complication of diabetes mellitus. The patient’s diabetes had been undiagnosed previously. Discharge planning should begin

Which of the following interventions has the least likelihood of improving patient safety in a hospital?

In implementing a care bundle for the management of acute myocardial infarction, the recording of the extent to which smoking cessation counseling is provided is a measure of

The Board and Chief Executive Officer have renewed their commitment to improving quality in Hospital X. Your primary role as the Director of Quality & Patient Safety should be

The performance improvement model adopted by any healthcare organization should include all of the following, EXCEPT

Which of the following should have the least impact on the selection of improvement opportunities in a healthcare organization?

A healthcare quality professional is asked to investigate an unusually high rate of healthcare-associated infections in the last month. In trying to determine the cause of this sudden increase in the healthcare-associated infection rate, she categorized The possible root causes. Which of the following was NOT a category of possible root causes?

A healthcare quality professional is conducting a study to examine the relationship between cigarette smoking and unanticipated admission to the Intensive Care Unit (ICU). All patients were categorized as being current smokers or non-smokers (the latter category included ex-smokers). The patients were also categorized as having been admitted to the ICU unexpectedly or not. Assuming the expected value in any category is greater than 20, the most appropriate statistical test is the

The second sponge count at the end of a hernia repair operation on an obese patient was incorrect. This was confirmed by repeat sponge counts, and the surgeon eventually located and retrieved the missing sponge. The patient’s recovery was uneventful. The healthcare professional should

The senior leaders of a hospital have decided to adopt Lean methodology, to which there is a large degree of resistance among the staff. Each of the following is an effective strategy for change management except

Among the following factors, competency assessment of staff is least influenced by data related to

The senior leaders of a managed care organization have consulted a healthcare quality professional on the purchase of a clinical data management software system to support performance improvement.

Which of the following is the most important issue in identifying the system requirements?

In your capacity as the Director of Quality and Patient Safety at a 1600-bed tertiary referral center, you are consulted to assist in the development of a balanced scorecard. In selecting measures for the scorecard, the “perspectives” commonly used include all of the following except

The chart below shows the overall inpatient mortality at a hospital: Based on the data, the healthcare quality professional should

The chart below shows the rate of Cesarean Sections in a hospital. The healthcare quality profesional should

In participative management,

For a patient with insulin-dependent diabetes mellitus, which of the following programs is the most appropriate to administer?

Impressed by what he saw at a healthcare conference, the Chief Executive Officer decided to adopt Lean Six Sigma as the hospital’s new approach to process improvement. If the desired results are not achieved, which of the following is the most likely reason for this?

The Body Mass Index (a measure of body fat) was measured in a group of women attending a primary care clinic. The graph below summarizes the results. Which of the following measures best summarizes the data?

To reach team consensus, team leaders should do all of the following except

A hospital purchases additional malpractice insurance and general tort liability insurance prior to introducing a pediatric heart surgery program. This is an example of

The following table shows the risk-adjusted Acute Myocardial Infarction (AMI) inpatient mortality for 10 different hospitals in 2009:What is the benchmark risk-adjusted AMI inpatient mortality?

In closing a project, a team is evaluating its work. This evaluation may include all of the following except

In conducting a multi vote, all of the following steps are taken except

Productive teams must have all of the following except

In improvement work, a constraint is

Which of the following is least likely to be included in an effective project charter?

In strategic planning, critical success factors

Medication errors related to medication reconciliation are most likely to occur when

The person responsible for evaluating and improving care and services in a radiation oncology department is the

Common causes of process variation refer to causes of variation that

Which of the following attributes is best associated with being a role model as a healthcare quality professional?

Which of the following tools is most useful in identifying ways to shorten nurses’ walking time from one activity to another in a hospital ward?

Which of the following is the most effective way to prevent accidental intravenous administration of epidural bupivacaine (a local anaesthetic) due to epidural catheters being inadvertently attached to intravenous lines?

Which of the following is most effective in communicating instructions to patients before their discharge from hospital?

Effective quality management in healthcare requires leaders who are

Which of the following are examples of continuous variables?

According to the Law of Diffusion of Innovations, the highest rate of rise in innovation diffusion occurs among the

Which of the following strategies is MOST effective in achieving widespread adoption of a new electronic medical record system?

Which of the following statements about the balanced scorecard is FALSE?

Transparent communication with patients and families after a serious clinical adverse event

#Risk_Management

Which of the following is the first step in implementing lean management effectively in a hospital?

#Lean_Management

All of the following methods of presenting data obscure the time-order of the data EXCEPT

In the operating room, who is the most appropriate individual to initiate the “time- out” process?

From a quality perspective, which of the following is the BEST way to control costs in healthcare?

Which of the following is the FIRST step in creating a cause-and-effect diagram?

Functional fire doors are an example of a key hospital

In a project to increase hand hygiene compliance, an improvement team attempted to identify the root causes for noncompliance. Which of the following tools is the LEAST helpful?

In applying principles of lean management to reduce the cycle time of the drug dispensing process at an inpatient pharmacy, inspection is considered a

The main purpose of conducting a focus group is to

An acute care facility is planning to implement an Electronic Health Record (EHR) system but staff is resisting this change. Which aspect of the new system should the leaders address/emphasize first in order to build support for EHR among the staff?

Which of the following charts is most appropriate for displaying the results of a survey of staff perception of the overall level of customer service (e.g. Excellent/Very Good/Average/Below Average/Poor) provided in a hospital?

 #Chart

Where should the surgical “time out” for a total knee replacement occur?

#IPSG

The senior leaders of a hospital are prioritizing performance improvement initiatives for the coming year. Which of the following tools will be most useful for this purpose

Which of the following statements is TRUE about any brainstorming session?

In a project to improve the safety of surgical care in an acute care facility, which of the following is a responsibility of the healthcare quality professional?

IHI Global Trigger Tool record reviewers found an unreported case of a radiologist inadvertently causing a small pneumothorax (collapsed lung) by incorrectly positioning a percutaneous small-bowel feeding tube. To whom should the reviewers report this finding?

In healthcare quality improvement, common causes, in comparison to special causes, are

The criticality index in failure mode and effect analysis is

#FMEA

Which of the following information should an organization consider first when developing the Quality Management and Patient Safety plan?

In a risk register, risks are ranked by the

A 700-bed acute care facility receives 40% of its admissions from the emergency department(ED). Quality problems, especially wait time, were expressed by patients, family members, and physicians.

Which tool should the ED team use first in the investigational phase of the improvement process?

The dimension of care on which complete discharge summaries by the time of follow-up have the greatest impact is

One member of an improvement team has been exhibiting disruptive behavior since work on the project began 6 weeks ago. What should the team leader do in the first instance?

In comparing the percentage of falls with injuries in calendar year 2012 between facilities that use restraints and those that do not, which chart should be used?

What is the main purpose of the team charter?

Which of the following display formats is best used to evaluate the number of ear infections, urinary tract infections, and conjunctivitis experienced by individuals served in a group home?

The monthly rate of resident falls in the past 12 months was plotted on a control chart. All data points are within the control limits but the last data point falls exactly on the upper control limit. The improvement team should conclude that

A team plans to improve the reliability of the time-out. procedure in the Operating Room. What should it do first?

In improving safety and reliability in the operating room, the organization has designated a clinical leadership group to own and drive the work. What should the next step be?

The office layout at an acute care facility was restricting the work flow and was not customer friendly. The management decided that a redesign of both the layout and the process in which patients are registered and receive care was required. What is the greatest barrier to success?

What is the most frequent cause of failure in any improvement effort?

A team is developing a checksheet to record the reasons patients are readmitted within 48 hours of discharge. What is the best way of ensuring the checksheet is effective?

Which of the following is LEAST likely to be a patient perspective of quality?

In an acute care facility, the delivery times of x-ray results were higher on Saturday and Sunday, compared with the other days of the week. What should the management do next to improve weekend performance?

#RCA

The upper and lower control limits of a process control chart are three standard deviations from the mean. A data point that falls outside these limits

The medication administration process at an acute care facility was deemed to be unacceptable due to frequent errors associated with patient harm. A subsequent trial of a handheld device, conducted at the same facility, showed that use of the device in two patient care units significantly reduced the rate of medication administration errors. How should the facility conduct a cost-benefit analysis to the change from the old process to the new process?

Diverting traffic away from wet floors until dry in a hospital is an example of

You are the Director of Quality Management at an acute care facility that will soon open. The Chief Executive Officer has asked you to select the organization’s key performance indicators. What information will you request first?

A multidisciplinary team is tasked to implement a picture archiving and communication system (PACS) in a large acute care facility. Staff in the outpatient department are resisting the necessary changes. Who should the team leader approach about this issue in the first instance?

#Teams

In a hospital accredited by The Joint Commission, ultimate responsibility for all medical credentialing decisions lies with the

Which of the following factors is LEAST likely to contribute to the success of a team?

Which of the following tools is most useful for linking an organization’s strategy to action and desired outcomes?

When implementing a Continuous Quality Improvement (CQI) program in an acute care facility, surveys are used to better understand

A performance improvement team aims to reduce the rate of post-surgical infection rates in a small rural acute care facility. Which of the following should the team use as a reference?

The outcomes of cardiopulmonary resuscitation (CPR) at an acute care facility in the past 12 months have been poorer than similar organizations in the area. How can the facility assess multidisciplinary team performance during CPR?

Responsibility for providing organizational direction for a facility’s Continuous Quality Improvement program rests with the

An organization has achieved a culture of patient safety when

Quality improvement teams are responsible for all of the following EXCEPT

Which of the following should be omitted from a performance improvement project report?

Proctoring is

A healthcare system has decided to centralize its credentialing departments. What is the main purpose for doing so?

In which of the following situations is Focused Professional Practice Evaluation (FPPE) NOT applicable?

Which of the following is NOT a reason for using external peer review?

A Gantt chart shows

A team that uses the scientific approach ideally does all of the following EXCEPT

What is the most frequently used accrediting body for managed care organizations?

For which of the following situations is closed-loop communication most beneficial?

In improving safety and reliability in the operating room, the organization has designated a clinical leadership group to own and drive the work. What should the next step be?

An acute care facility is tracking the monthly rate of ventilator-associated pneumonia in the adult ICU. What is the most sensitive tool for identifying special cause variation?

Which of the following factors is LEAST likely to contribute to poorly executed transitional care?

In discussing ways to improve patient flow in the Operating Room (OR)—a potentially controversial issue due to a possible change in the OR schedule—which of the following techniques should a team employ?

Which of the following is a characteristic of error-reducing industries?

Which of the following actions is the most appropriate for the Team Leader to take during the Norming stage of team development?

Which of the following is LEAST useful as an early sign of system failure in an organization?

In the patient’s care path, the wait time between initial suspicion of a problem and seeing a doctor is

Percentage of children two years of age who had one or more capillary or venous lead blood tests for lead poisoning by their second birthday is a

At one of its meetings, the team has digressed from its original discussion. Who is responsible for bringing the conversation back to the meeting agenda?

Which of the following activities is NOT usually part of project closure?

Process improvement is new to a team leader and her team. How should the team move forward with their improvement project?

Which of the following best demonstrates the commitment of senior leaders to patient safety in an acute care facility?

Who has the responsibility of determining improvement priorities in a healthcare organization?

In a 250-bed acute care facility, the length of each admission is measured in days. Which of the following is most appropriate for displaying the data for the past 12 months?

Which of the following is NOT an appropriate criterion for an inservice training program on pain management?

An example of integrating the results of a utilization management assessment in the performance improvement process is

A healthcare quality professional is reviewing data with a wide range of values between the highest and lowest points. The BEST way to rank order is using a

When gathering data on adverse events in an acute care facility over time, why is it necessary to measure the number of patients admitted and their length of stay?

The first step in collecting meaningful data is

A 300-bed multidisciplinary acute care hospital has consulted a healthcare quality consultant to assist in the investigation of a series of sentinel events that have occurred in the past 6 months. The consultant should expect to find all of the following except:

Which of the following charts is used to institute quality improvement and monitor cost reduction on an ongoing basis?