Quality and performance Improvement Exam | Verified Exam Questions
and Answers | Latest Updated Study Material 2026
Question:
Quality and performance Improvement Exam | Comprehensive
The Joint Commission has a standard stating that a hospital must plan and design information
management processes to meet information needs.
Answer:
both internal and external
Question:
Referring to Case Study #2, which of the following ratios would you recommend?
Case Study #2
You are helping the nursing department to write indicators to determine appropriate formulas for
ratios and to determine data collection time frames. One important aspect of care is the
documentation of education of patients. More specifically, the nursing department would like to
assess its documentation of education on colostomy care for patients with new colostomies.
Answer:
Number of records with documentation of colostomy-care
teaching
Question:
Total number of patients with new colostomy
The following legislation requires that patient-identifiable health information remains
confidential and protected against unauthorized disclosure, alteration, or destruction.
Answer:
HIPAA Security Rule
Question:
What quality indicator would identify improvement needs in hospital electronic transmission of
health care claims and remittances to allow interoperability with ICD-10 codes?
Answer:
an increase in 5010 rejections
,Question:
The responsibility for performing quality monitoring and evaluation activities in a
departmentalized hospital is delegated to the
Answer:
clinical
chairpersons of medical staff committees or ancillary department directors.
Question:
A plaintiff must establish which burden of proof to recover damages for medical negligence or
malpractice?
1. A breach of the duty to care by the defendant.
2. Damages or injury resulted from the defendant's negligence.
3. A duty of care relationship between the defendant and patient.
4. Causation existed for harm to the plaintiff from the defendant's conduct.
Answer:
1, 2, 3, and 4
Question:
Which quality management theorist focused on the use of the PDCA cycle in continuous clinical
quality management improvement efforts?
Answer:
Deming
Question:
The Institute of Medicine (IOM) published report titled To Err Is Human: Building a Safer
Health System, heightened concern by the U.S. government and accrediting agencies. This led
the Joint Commission to place emphasis on improving patient safety and sentinel event
occurrences through its safety program, known as
Answer:
National
Patient Safety Goals (NPSG).
Question:
The Joint Commission recently surveyed an acute care hospital. The hospital just received the
survey report and the accreditation decision. Which of the following categories should the
hospital leaders address first?
, Answer:
Requirements for Improvement
Question:
In quality review activities, departments are directed to focus on clinical processes that are
Answer:
high risk.
Question:
According to current theory in the quality management field, should concurrent data collection or
retrospective data collection be utilized?
Answer:
Concurrent and
retrospective data collection methods are both necessary in order to effect meaningful
interventions and contain costs.
Question:
You sit on the quality improvement team for the Nursing department that meets to generate ideas
to address verbal order documentation problems about the "Read Back Verbal Order" policy.
What QI tool would prove useful in sharing input and various recommendations for solving this
problem?
Answer:
brainstorming
Question:
When the policy and procedures manual no longer reflect current practices, it creates a situation
that becomes a risk management issue because
Answer:
policy and
procedures should represent the normal course of business
Question:
Which quality management theorist believed in the contrasting views of Theory X (presumed
that workers disliked work) and Theory Y (assumed that under the right conditions, people
would seek responsibility and be creative)?
and Answers | Latest Updated Study Material 2026
Question:
Quality and performance Improvement Exam | Comprehensive
The Joint Commission has a standard stating that a hospital must plan and design information
management processes to meet information needs.
Answer:
both internal and external
Question:
Referring to Case Study #2, which of the following ratios would you recommend?
Case Study #2
You are helping the nursing department to write indicators to determine appropriate formulas for
ratios and to determine data collection time frames. One important aspect of care is the
documentation of education of patients. More specifically, the nursing department would like to
assess its documentation of education on colostomy care for patients with new colostomies.
Answer:
Number of records with documentation of colostomy-care
teaching
Question:
Total number of patients with new colostomy
The following legislation requires that patient-identifiable health information remains
confidential and protected against unauthorized disclosure, alteration, or destruction.
Answer:
HIPAA Security Rule
Question:
What quality indicator would identify improvement needs in hospital electronic transmission of
health care claims and remittances to allow interoperability with ICD-10 codes?
Answer:
an increase in 5010 rejections
,Question:
The responsibility for performing quality monitoring and evaluation activities in a
departmentalized hospital is delegated to the
Answer:
clinical
chairpersons of medical staff committees or ancillary department directors.
Question:
A plaintiff must establish which burden of proof to recover damages for medical negligence or
malpractice?
1. A breach of the duty to care by the defendant.
2. Damages or injury resulted from the defendant's negligence.
3. A duty of care relationship between the defendant and patient.
4. Causation existed for harm to the plaintiff from the defendant's conduct.
Answer:
1, 2, 3, and 4
Question:
Which quality management theorist focused on the use of the PDCA cycle in continuous clinical
quality management improvement efforts?
Answer:
Deming
Question:
The Institute of Medicine (IOM) published report titled To Err Is Human: Building a Safer
Health System, heightened concern by the U.S. government and accrediting agencies. This led
the Joint Commission to place emphasis on improving patient safety and sentinel event
occurrences through its safety program, known as
Answer:
National
Patient Safety Goals (NPSG).
Question:
The Joint Commission recently surveyed an acute care hospital. The hospital just received the
survey report and the accreditation decision. Which of the following categories should the
hospital leaders address first?
, Answer:
Requirements for Improvement
Question:
In quality review activities, departments are directed to focus on clinical processes that are
Answer:
high risk.
Question:
According to current theory in the quality management field, should concurrent data collection or
retrospective data collection be utilized?
Answer:
Concurrent and
retrospective data collection methods are both necessary in order to effect meaningful
interventions and contain costs.
Question:
You sit on the quality improvement team for the Nursing department that meets to generate ideas
to address verbal order documentation problems about the "Read Back Verbal Order" policy.
What QI tool would prove useful in sharing input and various recommendations for solving this
problem?
Answer:
brainstorming
Question:
When the policy and procedures manual no longer reflect current practices, it creates a situation
that becomes a risk management issue because
Answer:
policy and
procedures should represent the normal course of business
Question:
Which quality management theorist believed in the contrasting views of Theory X (presumed
that workers disliked work) and Theory Y (assumed that under the right conditions, people
would seek responsibility and be creative)?
