NAHQ CPHQ PRACTICE TEST-WITH 100% VERIFIED ANSWERS

NAHQ CPHQ PRACTICE TEST-WITH 100% VERIFIED ANSWERS- True * Question - The governing body is responsible for setting policy, financial and strategic direction, quality of care, and setting goals and objectives A. True B. False False * Question - The governing body is responsible for implementing strategies and collecting measurements of quality indicators. A. True B. False d. 80% * Question - According to TJC (2012), how many serious medical errors involved miscommunication between caregivers when patients are transferred or handed-off? a. 67% b. 25% c. 32% d. 80% True * Question - Observation and documentation of interpersonal and communication skills is an example of an FPPE. A. True B. False True * Question - An example of criteria that might be tracked for OPPE is morbidity and mortality data A. True B. False True * Question - Examples of data for physician profiles include data representing major service lines, patient safety issues, and outpatient information A. True B. False b. Be a visible participant in the process * Question - A CQO has the responsibility for education and implementation of a quality improvement process. To affect cultural change, the CQO must: a. Receive quarterly reports b. Be a visible participant in the process c. Believe the costs are justified by the benefits d. Limit training to managers and supervisors a. Meet all regulatory requirements * Question - When a healthcare org is contracting with an outside provider for services, the subcontractor must: a. Meet all regulatory requirements b. Provide a representative to the Quality Council c. Have an active risk management program d. Have a competitively priced service a. Purpose of the request * Question - 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. Purpose of the request b. Permission from the applicable physician c. Approval from the department chair d. Approval from legal counsel b. Assess practitioner competency * Question - Physician profiles should be reviewed at the time of reappointment to: a. Review the number of complaints b. Assess practitioner competency c. Compare the practitioner to their peers d. Facilitate reappointment approval a. Setting goals and objectives * Question - Which of the following is the first step in the strategic planning process? a. Setting goals and objectives b. Defining organizational structure c. Establishing and controlling a budget d. Determining productivity indicators a. Set goals, measure performance, provide coaching and feedback, reward and recognize positive efforts * Question - If someone in your organization is resisting and not willing to make the change, what is the best strategy to take? a. Set goals, measure performance, provide coaching and feedback, reward and recognize positive efforts b. Communicate what, why, how, when and who of change process, present positive outlook, have clear focus and goal for change and expectations c. Provide education and training in new skills and use of various management techniques a. Provide education and training in new skills and use of various management techniques * Question - If someone in your organization is resisting and not able to perform change, what is the best strategy to take? a. Provide education and training in new skills and use of various management techniques b. Communicate what, why, how, when and who of change process, present positive outlook, have clear focus and goal for change and expectations c. Provide education and training in new skills and use of various management techniques b. Communicate what, why, how, when and who of change process, present positive outlook, have clear focus and goal for change and expectations * Question - If someone in your organization is resisting change and lack knowledge about what is required, what is the best strategy to take? a. Provide education and training in new skills and use of various management techniques b. Communicate what, why, how, when and who of change process, present positive outlook, have clear focus and goal for change and expectations c. Provide education and training in new skills and use of various management techniques c. Facilitator * Question - For a quality improvement team to deal effectively with conflict, it is important to appoint which of the following to its membership? a. Risk manager b. HR representative c. Facilitator d. Senior leader a. Involvement of leadership * Question - Which of the following is essential to effective Quality Councils? a. Involvement of leadership b. Consultation of legal advisor c. Participation of the strategic planning committee d. Direction from the organization's quality department a. Composition of the team * Question - 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 slow. Which of the following is the most important factor for the Quality Council to assess with the team leader? a. Composition of the team b. Number of medication errors since team was chartered c. Team members' ability to interpret graphs d. Length of team meetings d. Meet with the departments to review the survey processes * Question - 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. Set up a quality improvement team to improve food service b. Redistribute the surveys to obtain a larger sample size. c. Design, distribute, and analyze a new survey instrument d. Meet with the departments to review the survey processes a. Identify problems to be addressed in the organization * Question - Which of the following steps occurs first in the facilitating change in an organization? a. Identify problems to be addressed in the organization b. Solicit feedback from management c. Select key people in the organization to serve on the team d. Develop a performance improvement plan b. Facilitate discussion between the groups to enable them to assume ownership of their portions of the problem * Question - The separate services of pharmacy and nursing are having difficulty developing an action plan for med errors. Pharmacy services states that nursing services causes the majority of the problems related to errors, while nursing services states the opposite. What is the quality professional's role in resolving this problem? a. Provide them with directives on how to solve the problem b. Facilitate discussion between the groups to enable them to assume ownership of their portions of the problem c. Assign the task to an uninvolved manager d. Refer the problem to the facility-wide quality council a. Prioritize opportunities for improvement, pilot the improvement, compare pre- and post-implementation data, and rollout to the entire organization * Question - Which of the following best demonstrates the use of the PDCA performance improvement model? a. Prioritize opportunities for improvement, pilot the improvement, compare pre- and post-implementation data, and rollout to the entire organization b. Review current practice, form a multidisciplinary committee, schedule a meeting to develop a plan, and determine actions to be taken c. Identify a problem, implement change, educate staf f about the change, and rewrite policies and procedures to augment the change d. Collect baseline data, form a committee to develop the plan, validate audit data, and formalize the change d. Compare outcomes with pre-established goals * Question - Which of the following is the best way to determine if a quality improvement initiative is successful? a. Conduct a retrospective review b. Survey patients and customers c. Present findings to the Quality Council d. Compare outcomes with pre-established goals d. Evaluating the project * Question - Team building goals for a first meeting should include all of the following EXCEPT: a. Getting to know one another b. Learning to work as a team c. Setting meeting ground rules d. Evaluating the project d. Sharing the data with the staf f to provide feedback * Question - An organization's data demonstrate an increase in the number of patient falls. A healthcare quality professional should recommend: a. Revising the fall-risk assessment tool b. Convening a focus group of medical staf f to discuss fall risks c. Increasing staf f on weekends and nights d. Sharing the data with the staf f to provide feedback b. Involve individuals directly affected by the change * Question - The best way to facilitate change in healthcare organization is to: a. Communicate through group meetings b. Involve individuals directly affected by the change c. Arrange presentations by senior leaders d. Communicate through a group email a. Ishikawa diagram * Question - In evaluating long wait times, a quality professional can best demonstrate components related to staffing, methods, measures, materials, and equipment by using: a. Ishikawa diagram b. Pie chart c. Run chart d. Histogram a. 6 consecutive ascending data points * Question - Which of the following demonstrates a true statistical increase in a run chart? a. 6 consecutive ascending data points b. Data points close to the mean line c. 7 descending data points d. A zigzag pattern of data points d. 0.60 * Question - The relationship between patient satisfaction and hours per day on a medical unit was found to be (r=0.60, p<0.05). What is the correlation between these two values? a. 0.05 b. 0.36 c. 0.55 d. 0.60 d. Providing outcome data at medical staf f meetings * Question - The most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staf f is by: a. Inviting medical staf f to an in-service on quality tools b. Evaluating physician participation on quality teams c. Developing professional relationships d. Providing outcome data at medical staf f meetings b. Data analysis and display * Question - Which of the following is an essential component in a performance improvement report? a. Team composition and attendance b. Data analysis and display c. Individual performance review d. Governing body approval c. Improve performance * Question - The primary reason healthcare orgs use benchmarking is to: a. Provide risk adjustment b. Decrease risk to the org c. Improve performance d. Comply with accreditation a. A random sample of annual discharges/visits per unit * Question - A small rural hospital wishes to evaluate customer satisfaction using a survey. The organization has 4 patient care units, an ED, and an ambulatory unit. Which of the following survey methods provides the most reliable information? a. A random sample of annual discharges/visits per unit b. All discharges/visits in January and July c. A random sample of annual discharges/visits d. All discharges/visits of customers with a last name beginning with A-E b. Lack proper reference points for interpretation * Question - Rationale: A random sample of annual discharges/visits per unit provides a sample from all units which will yield the most valid information for a comparison of each unit The major drawback of using raw numbers to present the results of quality monitoring is that they: a. May be used for focused review b. Lack proper reference points for interpretation c. Cannot be graphed d. Only measure compliance to established criteria d. Control chart Rationale: Control charts display variation and stability of a process within defined upper and lower limits. * Question - The best tool to display stability of nosocomial infection rates over time is a: a. Pareto chart b. Histogram c. Run chart d. Control chart c. Define objectives of the performance review, develop data collection form, pilot test Rationale: Objectives must be defined first * Question - 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. Which of the following sequences of steps should the team consider in developing the quality of care product evaluation phase? a. Identify medical review criteria, identify sampling methods to be used, pilot test b. Identify populations covered by the guideline, identify the data sources, conduct the review c. Define objectives of the performance review, develop data collection form, pilot test d. Consider costs of the review, identify clinicians and sites of care, define objectives of the performance review b. Investigate the complaint write the patient and report to the governing board * Question - A former patient emails an organization's CEO 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, which of the following actions are needed? a. Interview staf f involved, track performance over time, and report to the Quality Council b. Investigate the complaint write the patient and report to the governing board c. Call the patient, put compliments in the nurses' personnel records, and report to the Quality Council d. Review the medical record, put compliments and complaints in the appropriate staf f personnel records, and report to the governing board b. Demonstrating understanding by return demonstration * Question - A hospital is working to reduce readmissions. Which of the following is the best approach to accomplish this goal? a. Giving an education sheet on patient medication to the patient and family b. Demonstrating understanding by return demonstration c. Showing a video to a patient and their family d. Requesting the home health nurse provide patient instruction a. An activity carried out to provide care or service * Question - A process indicator is defined as one that measures a. An activity carried out to provide care or service b. Significant events that require further investigation c. Unexpected or negative variations d. The appropriateness of procedure or treatment a. Lack proper reference points for interpretation * Question - The major drawback of using raw numbers to present the results of quality monitoring is that they a. Lack proper reference points for interpretation b. Only measure compliance to established criteria c. Cannot be graphed d. May be used for focused review b. Multi-voting * Question - After brainstorming, which of the following should a quality improvement team use to identify items that need immediate attention? a. Histogram b. Multi-voting c. Cost-benefit analysis d. Flow chart c. Compare outcomes with pre-established goals * Question - Which of the following is the best way to determine if a quality improvement initiative is successful? a. Present findings to the Quality Council b. Conduct a retrospective review c. Compare outcomes with pre-established goals d. Survey patients and customers a. A random sample of 20% of annual discharges/visits per unit * Question - A small, rural hospital wishes to evaluate customer satisfaction using a survey. The organization has 4 patient care units, an emergency department, and an ambulatory unit. Which of the following survey methods provides the most reliable information? a. A random sample of 20% of annual discharges/visits per unit b. A random sample of 5% of all annual discharges/visits c. All discharges/visits in January and July d. All discharges/visits of customers with a last name beginning with the letters A-E a. Systems * Question - Using the 80/20 rule, 80% of organizational problems are issues related to a. Systems b. Education c. Performance d. Staffing c. Allocating resources for the process * Question - Organizational leaders can best demonstrate commitment to a new quality improvement initiative by a. Reviewing the quality improvement plan b. Offering solutions to identified problems c. Allocating resources for the process d. Maintaining performance appraisals for staff b. Control chart * Question - 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. Pareto chart b. Control chart c. Cause-effect diagram d. Stratified histogram a. Customer needs * Question - In continuous quality improvement programs, surveys are essential to determine which of the following a. Customer needs b. Performance standards c. Effective management d. Population demographics a. The process has many owners * Question - A team approach in quality improvement activities is preferred when a. The process has many owners b. Financial resources are scarce c. The solution is evident d. Data management is required c. Documentation of nursing assessment * Question - A team has been tasked with developing a program to prevent patient falls. Which of the following data elements from an incident/occurrence report provides the most useful information for the team when evaluating the program's success? a. Patient demographics b. Record of the time of the fall c. Documentation of nursing assessment d. Staffing ratio at the time of the fall b. Review previous results and assess trends * Question - 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. Call the dietitian and ask for an explanation b. Review previous results and assess trends c. Set a continuous monitor for review d. Ignore the results and assess next quarter a. Organizational systems are inhibiting changes * Question - A performance improvement training program has been conducted. The heath care quality professional has determined that improvement has not occurred. The most likely cause for the lack of improvement would be that a. Organizational systems are inhibiting changes b. Employees practice what they are trained to do c. Staf f members thought the program was too long d. The facilitator did not prepare agenda materials c. Conduct multidisciplinary interactive sessions consistent with adult- learning principles * Question - The best approach for training staf f about quality and patient safety is to a. Require staf f to complete mandatory online training at convenient times b. Develop posters and brochures that explain key quality concepts and place them in strategically throughout the workplace c. Conduct multidisciplinary interactive sessions consistent with adult- learning principles d. Have the CEO meet with each department to explain the department's role in quality and safety d. Risk prevention * Question - The concept of "patient safety" applies most appropriately to a. Environmental safety measures b. Serious patient injuries c. Patient complaint management d. Risk prevention a. Composition of the team * Question - 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. Composition of the team b. Number of medication errors since the team was chartered c. Team members' ability to interpret graphs d. Length of team meetings b. Have employees demonstrate the use of PPE as part of staf f competency * Question - A facility decided to implement Standard Precautions one 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. Stock personal protective equipment (PPE) in the clean utility room b. Have employees demonstrate the use of PPE as part of staf f competency c. Show a video on standard precautions quarterly d. Review and revise handwashing policies and procedures b. Improve performance * Question - The primary reason healthcare organizations use benchmarking is to a. Comply with accreditation standards b. Improve performance c. Decrease risk to the organization d. Provide risk adjustment d. Severity level and occurrence types * Question - A trend analysis of incidents occurring in a healthcare facility should focus on which of the following areas? a. Timeliness of reporting and data accuracy b. Case mix index and staffing patterns c. Practitioner profile and diagnostic codes d. Severity level and occurrence types a. Tool to improve communication among caregivers * Question - Situation- Background-Assessment-Recommendation (SBAR) is a a. Tool to improve communication among caregivers b. Six sigma methodology c. Method that measures process variation d. Software package used in quality improvement b. Budgeting techniques * Question - A curriculum developed by healthcare organizations for staf f education in organizational change should include all of the following EXCEPT a. Conflict resolution b. Budgeting techniques c. The negotiating process d. Project and time management c. Risk management * Question - Evaluating medication administration to reduce medical errors is an example of a. Quality management b. Resource management c. Risk management d. Financial management c. Plan-do-check-act process * Question - Quality improvement initiative progress is best evaluated by which of the following? a. Team leader b. Senior leadership c. Plan-do-check-act process d. Nominal group technique d. Population * Question - Conclusions in a statistical study are generalized to the a. Subject b. Sample c. Mean d. Population b. Brainstorm on potential failure modes associated with equipment use * Question - A Quality Council has created 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. Identify ways to detect the likelihood of the equipment breaking down b. Brainstorm on potential failure modes associated with equipment use c. Multi-vote on the severity of potential equipment breakdowns d. Develop a flowchart of how the equipment will be installed c. Surveillance and prevention * Question - Which of the following are the two most ESSENTIAL functions of an infection control program a. Risk management and surveillance b. Prevention and education c. Surveillance and prevention d. Patient safety and risk management b. A policy allowing only non-laced shoes * Question - 34. A root cause analysis revealed 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 a. Patient checks every 15 minutes b. A policy allowing only non-laced shoes c. A 24 hour video monitoring system d. A buddy system for the patients d. Formulate the question to be answered * Question - 35. The first step in conducting an epidemiological study is to a. Collect the data b. Determine which statistical tests to use c. Develop the data collection tool d. Formulate the question to be answered c. Prioritize opportunities for improvement, pilot the improvement, compare pre- amd post-implementation data, and rollout to the entire organization * Question - Which of the following best demonstrates use of Plan-Do-Check- Act performance improvement model a. Review current practice, form a multidisciplinary committee, schedule a meeting to develop a plan, and determine actions to be taken. b. Identify a problem, implement change, educate staf f about the change, and rewrite policies and procedures to augment the change. c. Prioritize opportunities for improvement, pilot the improvement, compare pre- amd post-implementation data, and rollout to the entire organization d. Collect baseline data, form a committee to develop the plan, validate audit data, and formalize the change. a. Prepare a Pareto chart and develop an action plan * Question - A healthcare quality professional is provided the following data: Which of the following steps should be taken to prioritize areas of concern? a. Prepare a Pareto chart and develop an action plan b. Draw an affinity diagram and identify primary causes for delay c. Develop a control chart and create an action plan d. Create an ishikawa diagram and identify primary causes for delay a. Intensivist, ICU nurse, and respiratory therapist * Question - A large medical center wishes to reduce ventilator-associated pneumonia (VAP) in its ICUs. Who should be included as members of the quality improvement team? a. Intensivist, ICU nurse, and respiratory therapist b. Primary care physician, infection control nurse, and surgeon c. ICU manager, respiratory therapist, and pharmacist d. Pharmacist, intensivist, and infection control nurse b. Ensure that the numerator and denominator are clearly defined * Question - When developing department-specific performance measures and indicators, the quality manager as a consultant should a. Conduct a literature search and select quality indicators b. Ensure that the numerator and denominator are clearly defined c. Prioritize the quality indicators for selection by the department leader d. Review the mission statement and seek physician input b. Customer's expectations * Question - Management using quality improvement principles should emphasize the importance of a. Staf f orientation b. Customer's expectations c. Quarterly statistical reports d. Team selection c. Council * Question - The responsibility for providing organizational direction for a facility's continuous quality improvement program frequently rests with the quality a. Teams b. Leader c. Council d. Facilitator c. Medical staf f bylaws * Question - 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? a. Patient safety manual b. Risk management plan c. Medical staf f bylaws d. Surgical policies and procedures