WGU C215 Q Bank For CPHQ Practice Questions And Answers

WGU C215 Q Bank For CPHQ Practice Questions And Answers A healthcare quality management professional has all of the following responsibilities toward improving patient safety EXCEPT: 1) Appointing a supervisor for a patient safety program 2) Incorporating new technology into a patient safety program 3) Helping to develop a patient safety program 4) Setting and reviewing goals for a patient safety program Correct Ans - 1) Appointing a supervisor for a patient safety program In terms of improving patient safety, the healthcare quality management professional's responsibilities include the following: - helping to develop a patient safety program - incorporating new technology into a patient safety program - setting and reviewing goals for a patient safety program. The healthcare quality management professional's responsibilities do not necessarily include the responsibility of appointing a supervisor for a patient safety program. That particular task will likely fall to others within hospital administration. Which of the following types of charts is best for determining cause and effect? 1) Pareto 2) Run 3) Fishbone 4) Control Correct Ans - 3) Fishbone A fishbone chart is most useful for helping to determine cause and effect. A control chart is useful for seeing the changes in a process; this would include effects but not necessarily causes. A run chart is most useful for viewing data over a time sequence. A Pareto chart uses two types of charting techniques to determine statistical information, but it is not necessarily useful for determining cause and effect. A hospital needs to decide whether or not to incorporate a new feature into its current services, and as a result has commissioned qualitative research that will provide detailed feedback. Specifically, the hospital would like to collect opinions from patients and other hospital customers with a wide range of experience and backgrounds. Which of the following types of assessments is most likely to be of use to the hospital? 1) Case Study 2) Focus Group 3) Team analysis 4) survey Correct Ans - 2) The focus group will be most useful in providing the hospital with a broad range of opinions, as well as detailed feedback. The survey would limit answers to those available among the answer choice options, so this would not necessarily guarantee detailed feedback. The team analysis would largely remove patient and customer opinion from the decision. The case study would isolate findings to a single scenario and would fail to offer broad findings and detailed feedback. The process of risk management for the healthcare quality management professional includes all of the following EXCEPT: 1) reporting of incidents 2) identification of risk 3) prevention of risk 4) analysis of effects Correct Ans - 1) reporting of incidents The healthcare quality management professional is responsible for the following, in terms of risk management: - - identifying the risk - analyzing the effects of the risk - preventing the risk. These responsibilities do not necessarily include the responsibility of reporting an incident of risk; that may or may not apply, depending on the source of the risk. (It should be noted, however, that the healthcare quality management professional is responsible for reviewing the incident report about the risk; of course, this is not the same as actually reporting an incident of risk.) A review of supplies determined that a clinic is running low on several items essential for operation. With recent budget cuts, the clinic has to review costs carefully to find the best price for each item. What is the healthcare quality management professional's role in this? 1) Assist in developing a list of suppliers, by cost, for each item 2) Oversee the purchase of each item to ensure cost management 3) Determine which items need to be purchased from which supplier 4) Delegate the purchasing of each item to the appropriate department Correct Ans - 1) Assist in developing a list of suppliers, by cost, for each item The responsibilities do not include overseeing the actual purchase (as this is the responsibility of the purchasing department) Determining the specific items (as this falls to individual departments), or delegating the purchasing of each item to the appropriate department (as most large purchases would be grouped under the responsibility of the purchasing department). A hospital has implemented a quality program to improve the overall quality of patient care. It is discovered, however, that the program is running over budget, so the hospital administrative board conducts a review of the program to see if it should continue. What is the healthcare quality management professional's role in this? 1) Create a committee to review the quality program and develop a list of reasons to keep it 2) Assist the administrative board in making a final decision about the quality program 3) Evaluate the financial benefits of the program and demonstrate these to the board 4) Prove to the administrative board that the quality program should continue in the hospital Correct Ans - 3) Evaluate the financial benefits of the program and demonstrate these to the board The healthcare quality management professional is not obligated to prove to the board that the quality program should continue. He also is unlikely to assist the board in making a final decision or creating a committee to review the program. the role is limited to one of evaluating the financial benefits and demonstrating them as objectively as possible. A hospital has found that the performance of one of its departments is consistently below the expected standards. The hospital administration wants to locate the source of the problems and see improvement in the department within six months. What is the healthcare quality management professional's role in this? 1) Review the expected standards and submit these to the department for immediate application 2) Research the problems and develop a program that applies current standards to the department 3) Recommend that the hospital replace the current administration of the individual department 4) Advise that a performance improvement team be assembled to review and address the failings Correct Ans - 4) Advise that a performance improvement team be assembled to review and address the failings The healthcare quality management professional might be involved in researching the problems, but the development of a program that applies the standards to the department would exceed his responsibilities. He would certainly not be expected to advise the hospital to replace the current administration of the department; this would be the role of a larger group (such as a performance improvement team) that takes the time to review the situation. Also, he would need to do far more than simply submit the expected standards to the department for application since they are already failing them The administration of a hospital has discovered that a lack of communication among different hospital departments has led to overspending and unnecessary errors in patient care. The administration has asked the healthcare quality management professional to assemble a team that can improve department communication and address the problems. What type of team would be most useful for this task? 1) cross functional 2) work group 3) quality circle 4) self-directed Correct Ans - 1) cross functional The key here is the need for a team that can find ways to improve communication among the different departments. This type of team would need to be cross functional, because it would be composed of people from the different departments who would then be delegated to communicate with one another and pass on the communication to others in their respective departments. The other types of teams - work group, quality circle, and self-directed - all have their place in professional improvement, but a cross-functional team would be best in this situation. A clinic is looking into adding a new computer software program to update an outdated program. The new computer system will keep better track of patient records and will enable the clinic to streamline the care that patients receive. What is the healthcare quality management professional's role in this? 1) Research the history of the software to see how it has impacted other clinics 2) Create a simulation for the software to allow the clinic to see how it operates day to day 3) Assist the clinic in evaluating the pros and cons of the software 4) Advise the clinic to implement the software because of its value in improving patient care Correct Ans - 3) Assist the clinic in evaluating the pros and cons of the software Advising the clinic to adopt the software would come after the necessary evaluation process Researching the software and creating a simulation would be part of the evaluation process, but each item is limited in itself. The larger goal for the healthcare quality management professional is one of evaluation to assist the facility in making the best decision. All of the following represent federally-mandated patient rights in the United States EXCEPT: 1) Right to receive healthcare services 2) Right to informed consent for medical treatment 3) Rights to obtain a copy of medical records 4) Right to maintain the privacy of medical records Correct Ans - 1) Right to receive healthcare services There is no federally mandated right to healthcare services for people in the United States. There are other statutes - such as the law that forbids emergency rooms from turning away people without insurance - but the federal government does not guarantee to people that they have the right to receive healthcare services. The other rights listed (right to informed consent, right to privacy, right to a copy of medical records) are all protected at the federal level. One of the largest departments within a hospital has been running over budget for some time. The increasing expenditure has become problematic, and therefore the department has been asked to maintain a budget. What is the healthcare quality management professional's role in this? 1) Provide the department with the software tools to enable it to set a manageable budget 2) Follow the hospital administration's guidelines in setting a budget for the department 3) Assist the department in developing a manageable budget and reviewing it for compliance 4) Appoint a financial advisor to support the department in developing a compliant budget Correct Ans - 3) Assist the department in developing a manageable budget and reviewing it for compliance He or she is not necessarily responsible for setting the budget; that would require the assistance of the financial department. Providing software tools to help with developing a budget would be part of the process, but the process is not limited to this. Additionally, the healthcare quality management professional might appoint a financial advisor, but this again is part of the process but not the only part. A hospital has recently conducted extensive updates on its website and wants to make sure that the new site is ready to be made available to the public. What is the healthcare quality management professional's role in this? 1) Evaluate the changes that have been made in the website and recommend improvements 2) Compare the website to other hospital sites to ensure that the new site compares favorably 3) Review the website to ensure that the reported information is accurate and complete 4) Compile a list of required information for the website and report this to the hospital Correct Ans - 3) Review the website to ensure that the reported information is accurate and complete He might evaluate the changes and recommend improvements, but this falls under the larger role of making sure the information is accurate and complete. Similarly, the other answer choices - comparing the new site to other hospital sites and compiling a list of required information - would fall under this larger category of ensuring accuracy and completeness in the information. A disagreement has arisen between the hospital administration and the members of one of its departments. The disagreement is in connection with the authority of the different parties involved and whether or not the administration can require the department to perform a certain task. What is the healthcare quality management professional's role in this? 1) Create a review board to act as a mediator between the hospital administration and the department to find an agreeable solution 2) Consider the statements from both sides and participate in finding a solution that meets the expectations of both parties 3) Advise the department to respect the authority of the hospital administration and to follow its expectations for department performance 4) Review the rules establishing authority and inform the parties about how these rules apply to the department and the administration Correct Ans - 4) Review the rules establishing authority and inform the parties about how these rules apply to the department and the administration He should not take sides in any way, making "Advise the department to respect..." incorrect. Additionally, he is not responsible for mediating or even finding a solution (unless asked specifically to do so). The role in this case is largely one of providing the information and allowing the parties to consider it. To cut down on costs, a clinic has been hiring outside consultants to perform many of its tasks, but there are concerns that the performance of many of these consultants does not meet the state's standards for the clinic's operation. What is the healthcare quality management professional's role in this? 1) Develop educational programs to assist the consultants and ensure that the standards are met 2) Create simulated activities to test the consultants and see if they are meeting the standards 3) Supply the consultants with the information about state standards and ensure full compliance 4) Review the activities of the consultants and report the results to the clinic administration Correct Ans - 4) Review the activities of the consultants and report the results to the clinic administration The healthcare quality management professional is not responsible for overseeing consultants in general, but in the case of a failure in consultant activities, he or she is expected to review the activities of consultants and report on results. The other answer choices all contain details that might be part of the review process for the healthcare quality management professional, but they lack the larger role of reviewing and reporting. Which of the following performance improvement models would be the best recommendation for a clinic that wants to discover the source of problems in patient care, eliminate these problems, and achieve consistently high quality results in patient care? 1) FOCUS 2) LEAN 3) PDCA 4) Six Sigma Correct Ans - 4) Six Sigma Six Sigma is recommended as a performance improvement model that enables an organization to reduce problems and, more importantly, achieve consistency in results. The other performance improvement models - FOCUS, PDCA, and LEAN - offer variations of problem identification and reduction, but only Six Sigma specifically focuses on generating consistently good results. What is the best explanation for the relatively slow introduction of lean practices into medical laboratories? 1) The variability and complexity of the samples in a laboratory is much higher than in a manufacturing environment 2) Medical research is mostly funded by the government 3) Scientists are less receptive to the core principles of lean 4) Medical laboratories function differently than factories Correct Ans - 1) The variability and complexity of the samples in a laboratory is much higher than in a manufacturing environment A delay in discharging patients is likely to cause recurrent bottlenecks in... 1) All of the above 2) Admissions from the emergency room 3) The filling of prescriptions 4) Admissions from surgical wards Correct Ans - 1) All of the above Which of the following conditions should a quality assessment program NOT examine? 1) A rare condition that has a small effect on mortality or morbidity 2) A condition that is thought to be treatable 3) A condition for which the treatment is susceptible to significant influence by health care providers 4) A condition that has cost-effective treatments Correct Ans - 1) A rare condition that has a small effect on mortality or morbidity A doctor fails to administer an indicated test, and the patient's condition deteriorates to the point that he must be admitted to an inpatient facility. This is an example of... 1) Communication error 2) Preventive error 3) Treatment error 4) Diagnostic error Correct Ans - 1) Communication error When is the best time for chairing during a meeting? 1) At the beginning 2) One hour beforehand 3) In the middle 4) At the end Correct Ans - 1) At the beginning The primary benefit of adopting a countrywide or global uniform set of discharge data is to 1) Facilitate collection of comparable health information 2) Facilitate computerization of data 3) Validate data being collected from other sources. 4) Assist medical records personnel in collecting internal data. Correct Ans - 1) Facilitate collection of comparable health information In order to perform a task for which one is held accountable, there must be an equal balance between responsibility and 1) Authority 2) Education 3) Delegation 4) Specialization Correct Ans - 1) Authority A patient was in the operating room when a piece of a surgical instrument broke of f and was left in the patient's body. The patient was readmitted for removal of the foreign object. Which of the following would most likely apply in this situation? 1) Res ipsa loquitur 2) Contributory negligence 3) Contractual liability 4) Tort liability Correct Ans - 1) Res ipsa loquitur Which of the following types of budgets itemizes the major equipment to be purchased in the next year? 1) Capital 2) Variable 3) Operating 4) Fixed Correct Ans - 2) Variable A quality professional needs to assign a staf f member to assist a medical director in the development of a quality program for a newly established service. Which of the following staf f members is MOST appropriate for this project? 1) A competent staf f member who has good interpersonal skills 2) A newly hired staf f member who has demonstrated competence and has time to complete the task 3) A knowledgeable staf f member who works best on defined tasks 4) A motivated staf f member who is actively seeking promotion Correct Ans - 1) A competent staf f member who has good interpersonal skills The evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to the performance of the 1) medical staff 2) governing body 3) ancillary department 4) organizations systems Correct Ans - 4) organizations systems The best way to evaluate the effectiveness of performance improvement training is through 1) observed behavioral changes 2) self-assessments 3) participants feedback 4) post-test results Correct Ans - 1) observed behavioral changes The primary objective of the operational linkage between risk management and quality/performance improvement is to 1) meet regulatory requirements 2) develop a plan of action 3) develop comprehensive plan to prevent future occurrences 4) alert the hospital attorney of a potentially compensable event Correct Ans - 3) develop comprehensive plan to prevent future occurrences The primary reason to analyze customer satisfaction surveys is to 1) provide data for the quality improvement program 2) meet pay for performance requirements 3) identify how perceptions relate to the services provided 4) assist with evaluating employee performance Correct Ans - 3) identify how perceptions relate to the services provided Which of the following should a Quality Council provide to best ensure success of performance improvement teams? 1) facilitator and recorder 2) empowerment and training 3) indicators with a data analyst 4) standards and procedures Correct Ans - 2) empowerment and training Which of the following is the most effective way to integrate performance improvement concepts throughout an organization? 1) quarterly newsletters 2) monthly lectures 3) quality teams 4) continuous monitoring Correct Ans - 3) quality teams A critical difference between quality assurance (QA) and quality improvement is a shift in focus from 1) retrospective review to concurrent review 2) nonclinical aspects to customer satisfaction 3) identifying poor performers to improving group performance 4) QA coordinators to teams Correct Ans - 3) identifying poor performers to improving group performance 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? 1) evaluate compliance with the pathway 2) correlate the pathway with staffing levels 3) re-educate the staf f on the purpose of the pathway 4) continue to monitor and collect data Correct Ans - 1) evaluate compliance with the pathway One difference between continuous quality improvement and traditional quality assurance is that quality improvement always 1) requires the application of statistical process control 2) excludes monitoring and evaluation of care provided 3) focuses on systems or processes 4) addresses potential problems Correct Ans - 3) focuses on systems or processes Which of the following sampling techniques selects participants based on their availability in a certain place during a specific time frame? 1) quota 2) random 3) volunteer 4) convenience Correct Ans - 4) convenience The quality improvement director is responsible for coordination of accreditation survey activities. Responsibilities will most likely include 1) facilitating self assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda of the survey 2) educating staf f to all standards, writing the survey report and completing the survey application 3) developing a protocol for a mock survey, conducting unannounced surveys and challenging the survey report 4) preparing for unannounced surveys, disseminating the survey report and developing new standards Correct Ans - 1) facilitating self assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda of the survey Frequency distribution can best be displayed through use of 1) histogram 2) a flow chart 3) a force field analysis 4) an interrelationship diagram Correct Ans - 1) histogram 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 1) gantt chart 2) control chart 3) pareto chart 4) flow chart Correct Ans - 2) control chart A valid data collection tool should incorporate: 1) a reliable graphic presentation, 2) the definition of data elements, 3) allowance for variance of interpretation, 4) a minimum of 20 data elements Correct Ans - 2) the definition of data elements Balanced scorecards are useful because they 1) focus on the most significant strategic initiative 2) evaluate the pros and cons of the governing body's priorities 3) put strategy and vision at the center of the organizations effort 4) concentrate on the performance of individual units Correct Ans - 3) put strategy and vision at the center of the organizations effort Hospital administration is considering designating 20 beds for long-term, chronically ill patients. Which of the following information best supports this? 1) premature discharges over the last 6 months 2) readmissions within 30 days over the last year 3) discharge placement problems over the last year 4) admissions, discharges, and transfers over the last 30 days Correct Ans - 3) discharge placement problems over the last year Problem-solving, cross-functional understanding, expanded areas of expertise, and increased span of knowledge are examples of 1) strategic alliance 2) customer expectations 3) resource requirements 4) a benefit of teams Correct Ans - 4) a benefit of teams 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? 1) total each complaint category at least on an annual basis 2) calculate the average number of complaints per office site 3) review complaints to find system problems that can be improved 4) determine the date/time the complaint occurred and the person responsible Correct Ans - 3) review complaints to find system problems that can be improved 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 1) 10% of all discharge records for the past quarter 2) all active records on one day of the past month 3) 30% of all records based on preliminary compliance review 4) the number of records needed for using a statistical method Correct Ans - 4) the number of records needed for using a statistical method Quality improvement teams go through stages of development. These team development stages include all of the following EXCEPT 1) norming 2) forming 3) performing 4) conforming Correct Ans - 4) conforming 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? 1) physician attendance 2) number of complaints 3) frequency of meetings 4) medical record review Correct Ans - 4) medical record review A strategy used in brainstorming is that ideas are 1) prioritized as they occur 2) discussed when they are mentioned 3) progressively eliminated 4) all recorded Correct Ans - 4) all recorded 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 1) the length of time the team has been together 2) how well the team met the intended outcome 3) the effectiveness of the team leader and facilitator 4) the amount of data the team has collected Correct Ans - 2) how well the team met the intended outcome Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization's quality improvement program? 1) quantifiable objects 2) support from the medical staff 3) well defined organizational structure 4) integrated data collection Correct Ans - 1) quantifiable objects 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? 1) gap analysis 2) ishikawa diagram 3) gantt chart 4) kanban method Correct Ans - 1) gap analysis A performance improvement team reviewing timeliness of outpatient clinic appointments identified the following issues: multiple patient moves, redundant paperwork, and long waiting times to be triaged. In lean terminology, these issues are 1) waste 2) variation 3) poor performance 4) poka-yoke Correct Ans - 1) waste Which of the following should be included in an annual performance improvement report to a governing body? 1) meeting minutes 2) team achievements 3) physician peer reviews 4) incident/occurrences reports Correct Ans - 2) team achievements A physician complains to a healthcare quality professional that the nursing staf f 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 1) arrange a meeting with the physician and nurse manager 2) speak with the nurse manager on behalf of the physician 3) evaluate the patient outcome to determine organizational risk 4) review the patient record to determine legibility of the physicians orders Correct Ans - 1) arrange a meeting with the physician and nurse manager 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 1) quality council 2) governing body 3) utilization committee 4) chief of the department Correct Ans - 4) chief of the department A pharmacy has been dispensing a higher than acceptable rate of antibiotics to patients with documented allergies to the antibiotics. Which forcing function should the performance improvement coordinator recommend to decrease the rate of inappropriately dispensed antibiotics? 1) require the pharmacist to call the physician to confirm the appropriateness of each antibiotic ordered 2) provide mandatory education for pharmacy staf f on medication profile documentation requirements 3) revise policy to require nursing documentation of allergies before medication administration 4) modify pharmacy software to require review of allergic profile before dispensing antibiotics Correct Ans - 4) modify pharmacy software to require review of allergic profile before dispensing antibiotics A culture of patient safety in an organization will have been successfully created when 1) personal accountability is removed from the organization 2) near miss reporting of safety issues decline 3) staf f members serve as safety advocates 4) a root cause analysis is performed regularly Correct Ans - 3) staff members serve as safety advocates One aspect of a quality process that integrates with risk management is the review and evaluation of 1) adverse drug events 2) encounter data 3) case mix analysis reports 4) accreditation survey reports Correct Ans - 1) adverse drug events Failure modes can be prioritized by calculating the criticality index. Which of the following three categories are normally used to calculate a criticality index? 1) probability, likelihood and criticality 2) frequency, severity and ease of detection 3) effectiveness, risk and priority 4) response, evidence and outcome Correct Ans - 2) frequency, severity and ease of detection Staf f has been trained and oriented on a new electronic incident reporting system. In the past, staf f could report anonymously. The new system requires staf f 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? 1) staf f fear of negative consequences of reporting 2) lack of knowledge about how to use the system 3) time required to complete an incident report 4) incomplete understanding about required reporting Correct Ans - 1) staf f fear of negative consequences of reporting 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 1) medical record not completed by a physician 2) staf f member not using proper handwashing technique 3) near miss from failure to perform a "time out" 4) patient complaint regarding wait times Correct Ans - 3) near miss from failure to perform a "time out" T/F: Examples of data for physician profiles include data representing major service lines, patient safety issues and outpatient information. Correct Ans - True T/F: data for physician profiles is useful if kept in a number of different information systems. Correct Ans - False - Data should be easily accessed and used T/F: Physician profiles are the same for all physicians Correct Ans - False T/F: The best information for physician profiles use national targets and benchmarks. Correct Ans - True T/F: Data for physician profiles should be meaningful to physicians Correct Ans - True Which program best describes the following: Recognizes national role model with presidential award Correct Ans - Baldridge Program Which program best describes the following: Dedicated to improving healthcare quality and driving improvement throughout the healthcare system Correct Ans - NCQA Which program best describes the following: Accreditation program CMS approved to accredit hospitals and critical access hospitals and require ISO 9001 certification by the 4th year Correct Ans - DNV GL Which program best describes the following: Primary focus is on rehab facilities Correct Ans - CARF Which program best describes the following: Survey hospitals on compliance with Medicare Conditions of Participation and Coverage Correct Ans - HFAP Which program best describes the following: Primarily covers nursing excellence and innovation Correct Ans - MAGNET A chief quality officer has the responsibility for education and implementation of a quality improvement process. To affect cultural change, the chief quality officer must. 1) believe the costs are justified by the benefits. 2) be a visible participant in the process. 3) receive quarterly reports. 4) limit training to managers and supervisors Correct Ans - 2) be a visible participant in the process when a healthcare organization is contracting with an outside provider for services, the subcontractor must: 1) provide a representative to the quality council 2) have an active risk management plan 3) have a competitively priced service 4) meet all regulatory requirements Correct Ans - meet all regulatory requirements a healthcare quality professional is developing a policy regarding access to physician quality files. In addition to the date and time of the person requesting the information, which of the following should be included in the policy? 1) purpose of the request 2) approval from the department chair 3) approval from legal counsel 4) permission from the applicable physician Correct Ans - Purpose of the request physician profiles should be reviewed at the time of reappointment to: 1) review the number of complaints 2) compare the practitioner to their peers 3) assess the practitioner competency 4) facilitate reappointment approval Correct Ans - assess the practitioners competency which of the following is the first step in the strategic planning process? 1) determining the productivity indicators 2) settings goals and objectives 3) defining organizational structure 4) establishing and controlling a budget Correct Ans - organizational leaders can best demonstrate commitment to a new quality improvement initiative by: 1) reviewing the quality improvement plan 2) offering solutions to identified problems 3) allocating resources for the process 4) maintaining performance appraisals for staf f Correct Ans - 3) allocating resources for the process the best approach for training staf f about quality and safety is to: 1) require staf f to complete mandatory online training at convenient times 2) develop posters and brochures that explain key quality concepts and place them strategically throughout the workplace 3) conduct multidisciplinary interactive sessions consistent with adult learning principles 4) have the CEO meet with each department to explain the departments role in quality and safety Correct Ans - conduct multidisciplinary interactive sessions a performance improvement training program has been conducted. The healthcare quality professionals has determined that improvement has NOT occurred. the most likely cause for the lack of improvement would be that: 1) organizational systems are inhibiting change 2) employee practice what they are trained to do 3) staf f members thought the program was too long 4) the facilitator did not prepare agenda materials Correct Ans - 1) organizational systems are inhibiting change a healthcare organizations strategic plan objectives include a customer satisfaction rating of 85%. The following data are available for three units:- customer satisfaction Rate: Unit A = 88%, Unit B = 80%, Unit C = 62%.Which of the following should a healthcare quality professional recommend. 1) change the target to 90% satisfaction 2) provide incentives for the staf f of Units B & C 3) Review the performance improvement plan 4) share Unit A's practices with other units Correct Ans - Share Unit A's practices with the other units when a team is in the norming phase, what actions should be taken Correct Ans - 1. assign a devils advocate 2. assign small groups to work on a portion of the project In evaluating "long waiting times," a healthcare quality professional best demonstrates components related to staffing, methods, measures, materials, and equipment utilizing: 1) run chart. 2) histogram. 3) pie chart. 4) an Ishikawa diagram. Correct Ans - 4) an ishikawa (cause and effect) diagram helps to analyze potential causes the relationship between patient satisfaction and hours per patient per day on a medical unit was found to be (r = 0.60, p <0.05). what is the correlation between these two values? 1) 0.05 2) 0.36 3) 0.55 4) 0.60 Correct Ans - D - 0.60. "r" is used to signify the correlation coefficient the most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staf f is by: 1) Developing professional relationships 2) Evaluating physician participation on quality teams 3) Providing outcome data at medical staf f meetings 4) Inviting medical staf f to an in-service on quality tools Correct Ans - C - Providing outcome data because it communicates feedback to medical staff An interdisciplinary team is looking at a better process for checking in patients. At the last meeting, everyone suggested ideas but there was criticism of almost every solution. one person tended to dominate the conversation. What stage in team development are they in? 1) forming 2) storming 3) norming 4) performing Correct Ans - 2) storming an ongoing quality council has just had 6 out of 18 members rotate of f and replaced by 6 new members. There is pressure on the council to quickly establish strategic direction for the coming year. You are worried that some of the newer members may feel intimidated and reluctant to share. what stage in team development are they in? 1) forming 2) storming 3) norming 4) performing Correct Ans - 1) Forming By and large the pediatric group is a tight knit group that works well together. they like to work on every problem as a large team, but this is slowing down planning for the upcoming TJC visit. you also notice that there is some reluctance to disagree once a solution is proposed. everyone tends to jump on board and move forward. what stage in team development are they in? 1) forming 2) storming 3) norming 4) performing Correct Ans - 3) Norming the following is an example of what kind of analysis: Driving Force: Families provide comfort and reassurance to patients during ICU stays. Restraining Force: Nursing staf f find the open visiting policy disruptive to nursing routines and getting their work done Correct Ans - Force Field Analysis For a quality improvement team to deal effectively with conflict, it is important to appoint which of the following to its membership? 1) risk manager 2) human resources representative 3) facilitator 4) senior leader Correct Ans - facilitator - they are an unbiased party that may help groups deal with conflict which of the following is essential to effective quality councils? 1) involvement of leadership 2) consultation of the legal advisor 3) participation in the strategic planning committee 4) direction from the organizations quality department Correct Ans - 1) involvement of leadership 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? 1) composition of the team 2) number of medication errors since the team was chartered 3) team members ability to interpret graphs 4) length of team meetings Correct Ans - 1) composition of the team Two surveys were completed in a healthcare facility that showed conflicting results concerning inpatient satisfaction with food services. The two surveys were independently designed & distributed by different departments within the facility. The healthcare quality professional should first 1) Set up a quality improvement team to improve food services 2) Redistribute the surveys to obtain a larger sample size 3) Design, distribute, & analyze a new survey instrument 4) Meet with the departments to review the survey processes. Correct Ans - 4) Meet with the departments to review the survey processes. which of the following steps occur first in facilitating change in an organization? 1) identify problems to be addressed in the organization 2) solicit feedback from management 3) select key people in the organization to serve on the team 4) develop a performance improvement plan Correct Ans - 1) identify problems to be addressed in the organization which of the following is the best way to determine if a quality improvement initiative was successful? 1) present findings to the quality council 2) conduct a retrospective review 3) compare outcomes with pre-established goals 4) survey patients and customers. Correct Ans - 3) compare outcomes with pre-established goals team building goals for a first meeting should include all of the following EXCEPT: 1) learning to work as a team 2) setting meeting ground rules 3) evaluating the project 4) getting to know one another Correct Ans - 3) evaluating the project an organizations data demonstrates an increase in the number of patient falls. a healthcare quality professional should recommend: 1) revising the fall risk assessment tool 2) convening a focus group of medical staf f to discuss fall risks 3) increasing staf f on the weekends and nights sharing the data with the staf f to provide feedback the best way to facilitate change in a healthcare organization is to: 1) communicate through group meetings 2) involve individuals directly affected by the change 3) arrange presentations by senior leaders 4) communicate through group email Correct Ans - 2) involve individuals directly affected by the change how many patients had surgery this month is an example of data 1) categorical 2) continuous 3) ongoing Correct Ans - 1) categorical You want to know what the average daily census was for each month in the first six months of the year. This is an example of data 1) categorical 2) continuous 3) ongoing Correct Ans - 2) continuous What is the appropriate chart for the following situation? urinary tract infections over one year 1) scatter diagram 2) histogram 3) control chart 4) pareto chart Correct Ans - control chart What is the appropriate chart for the following situation? medication admin errors for ordering, dispensing or administering medications 1) scatter diagram 2) pareto chart 3) control chart 4) histogram Correct Ans - What is the appropriate chart for the following situation? The amount of calories and weight 1) scatter diagram 2) control chart 3) histogram 4) pareto chart Correct Ans - 1) scatter diagram What is the appropriate chart for the following situation? where to begin looking at over one hour delays in recover room leading to back log 1) scatter diagram 2) control chart 3) histogram 4) pareto chart Correct Ans - 4) pareto chart What is the appropriate chart for the following situation? statistically significant patient fall rate identified 1) scatter diagram 2) pareto chart 3) control chart 4) histogram Correct Ans - control chart What is the appropriate chart for the following situation? where problem areas in a particular process are located 1) scatter diagram 2) control chart 3) histogram 4) flow chart Correct Ans - 4) flow chart the following is an example of what kind of test? 15 of 30 men (50%) fail to keep appointments 10 of 40 women (25%) fail to keep appointments Rate 50%/25%= 2 (men are 2x as likely to not show up as women) 1) t-test 2) chi square test Correct Ans - 2) chi square test which of the following demonstrates a true statistical increase in a run chart? 1) Data points close to the mean line 2) 7 descending data points 3) 6 Consecutive ascending data points 4) A zigzag pattern of data points Correct Ans - 3) 6 Consecutive ascending data points which of the following is an essential component in a performance improvement report? 1) Data analysis and display 2) Governing body approval 3) Team composition and attendance 4) Individual performance review Correct Ans - Data analysis and display to assess progress towards goals the primary reason healthcare organizations use benchmarking is to: 1) improve performance 2) decrease risk to the organization 3) Comply with accreditation 4) Provide Risk adjustment Correct Ans - 1) Improve performance - it helps to identify best practices 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? 1) a random sample of annual discharges/visits per unit 2) a random sample of all annual discharges/visits 3) all discharges/visits in January and July 4) all discharges/visits of customers with a last name beginning with the letters A-E Correct Ans - 1) a random sample of annual discharges/visits per unit - this will allow you to drilldown what is a major drawback of using raw numbers to present the results of quality monitoring is that they: 1) Only measure compliance to the established area 2) Lack proper reference points for interpretation 3) Cannot be graphed 4) May be used for focused review Correct Ans - 2) Lack proper reference points for interpretation the best tool to display stability of nosocomial infection rates over time is a: 1) Control chart 2) Histogram 3) Run Chart 4) Pareto Chart Correct Ans - 1) Control chart. they key word is stability in the question 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: 1) a 24 hour video monitoring system 2) patient checks every 15 minutes 3) a policy only allowing non-laced shoes 4) a buddy system for the patients Correct Ans - 3) a policy only allowing non-laced shoes the concept of patient safety applies most appropriately to: 1) environmental safety measures 2) patient complaint management 3) risk prevention 4) serious patient injuries Correct Ans - 3) risk prevention a quality council is preparing a patient safety program. A key factor that needs to be considered for the long term success of the patient safety program is to: 1) determine which patient safety goals need to be monitored 2) review incident reports to identify what disciplinary action should occur 3) involve the entire organization in the program 4) research how technology can be used to prevent errors. Correct Ans - 3) involve the entire organization in the program to be useful in preventing future error, a RCA should be performed: 1) documenting opinion as well as facts 2) at least 45 days after the event 3) utilizing a multidisciplinary team 4) compare the practitioner to their peers, using practitioners who were not involved in the event Correct Ans - 3) utilizing a multidisciplinary team a failure mode and effects analysis is performed: 1) if the severity of the incident led to a patient death 2) when there is a chance of an incident occurring 3) to immediately investigate an incident that occurred 4) as a preventative measure before an incident occurs. Correct Ans - 4) as a preventative measure before an incident occurs. During strategic planning, what is the main task of the leadership team? 1) To lead teams 2) to act as clinical advisors 3) to develop strategy 4) to maintain records Correct Ans - 3) to develop strategy What is the leaderships team first action when preparing for a survey by an accreditation agency? 1) to assemble all of the policy and procedure books 2) to inform all of the staf f of the impending survey by email 3) to engage in discussions regarding how each department has succeeded 4) to begin writing an action plan Correct Ans - 3) to engage in discussions regarding how each department has succeeded why is it crucial for the leadership team to prepare the entire organization for the on site survey? 1) to actively observe any gaps in processes, procedures and policies prior to the survey 2) to provide uniformity of practice across other departments within the organization 3) to assure that the leadership team is prudent and acting in the best interest of the organization 4) to encourage competition across other departments Correct Ans - 1) to actively observe any gaps in processes, procedures and policies prior to the survey Root cause analysis is used to do which of the following? 1) analyze healthcare systems 2) prevent incidents from happening again 3) respond to OSHA complaints 4) investigate patients Correct Ans - Prevent incidents from happening again Every quality management initiative must be tied to what? 1) the key business processes 2) the mission and values 3) How the competitors are doing 4) Patient care Correct Ans - the mission and values The HCAHPS initiatives goal is to provide a standardized survey instrument and data collection methodology for measuring which of the following? 1) the quality of care in hospitals 2) patient satisfaction 3) employee satisfaction 4) patient perceptions of care Correct Ans - 4) patient perceptions of care The IHI Simple Data Collection Plan begins data collection by first doing which of the following? 1) asking why these data are being collected 2) deciding on the tools to use 3) deciding on team members collected what do control charts tell the team? 1) the control limit of the process 2) what processes are out of control 3) if they met their goals 4) how a process changes over time Correct Ans - how a process changes over time According to the Lean Six Sigma framework, which two quality tools are typically utilized in the analyze phase? 1) run charts and pareto charts 2) process capability assessments and critical to quality trees 3) project charter and process mapping 4) brainstorming and benchmarking Correct Ans - 1) Run charts and pareto charts What is the best description of statistical process control? 1) the continual and collaborative discipline of measuring and comparing the results of key work processes 2) the process by which numerous small general factors result in a specific effect on a process 3) the specific rare factors that can influence a process 4) a strategy for instituting ongoing process improvement Correct Ans - a strategy for instituting ongoing process improvement what is the best method for noting quantitative or qualitative data? 1) scorecards 2) check sheets 3) fishbone diagrams 4) KPI Correct Ans - 2) Check Sheets what is the industry standard methodology for measuring and controlling quality during the manufacturing process in real time with predetermined control limits called? 1) lean manufacturing 2) statistical process control 3) variability index 4) quality control Correct Ans - statistical process control which of the following is true regarding informed consent forms? 1) they must be completed at admission 2) they must be signed dated and witnessed 3) they must be maintained under lock and key 4) all of the above Correct Ans - 4) all of the above which of the following best describes what occurs during the "norming" phase of Tuckmans model for team development? 1) when the project comes to a close and the team moves on, appreciating and reflecting their growth as a team 2) selecting team members based on the areas of expertise necessary to achieve optimal results 3) diffusing of quieting the naturally occurring conflicts between different team members 4) when team members are encouraged to assume responsibilities for their assigned roles Correct Ans - 4) when team members are encourages to assume responsibilities for their assigned roles what is the purpose of a dashboard in performance improvement? 1) dashboards are tools that enable the management team to visually analyze the KPIs of each individual on the team 2) dashboard depict the precipitating factors or root causes for an event or outcome 3) dashboards contain measurable data that indicates whether the goals and objectives are attainable 4) dashboards are a written account that compares and measures the performance of individuals against the projected goals of the organization Correct Ans - 1) dashboards are tools that enable the management team to visually analyze the KPIs of each individual on the team what is the goal of the improve phase of the DMAIC model? 1) to enable the management team to visually analyze the KPIs of each individual on the team 2) to assimilate all the ideas into a strategic plan that prioritizes opportunities for improvement 3) during the improve phase of the DMAIC model, the CPHQ professional will need to implement strategies to determine the sustainability and benefits of the newly designed process 4) during this phase, the manager enables team members to do it themselves Correct Ans - 2) to assimilate all the ideas into a strategic plan that prioritizes opportunities for improvement why is it important to review scorecards and dashboards during performance improvement initiatives? Correct Ans - the results from the quality and performance data equip the management team to develop SMART goals for gauging the staffs effectiveness and efficiency a facilitator needs to consider all EXCEPT which of the following: 1) the time available for the meeting 2) the structure of the meeting 3) which goals to set 4) the number of team members Correct Ans - 3) which goals to set goals are set by the team during the meeting, not solely by the facilitator which of the following is necessary for a team meeting to be considered successful? 1) actions have follow up 2) there are clear activities 3) process owners are present 4) all of the above Correct Ans - 4) all of the above what is output? 1) tangible results 2) goods and services 3) under team control 4) all of the above Correct Ans - all of the above when does implementation occur? 1) when the board signs of f on the request 2) when everyone on the team agrees on the process 3) when practices are adopted and integrated 4) when the team finishes its work Correct Ans - when practices are adopted and integrated which of the following best describes the purpose of storming? 1) to develop countermeasures to solve any problems before they actually occur 2) to explain the stages of the process and confirm that each team member is aware of their expected contribution 3) to adopt and integrate practices in the proposed setting 4) to visually analyze the KPIs of each individual on the team Correct Ans - 2) to explain the stages of the process and confirm that each team member is aware of their expected contribution what is the most necessary step in evaluating the success of process improvement? 1) teamwork 2) executing the pilot study 3) informing administration of the plan 4) an action plan Correct Ans - 2) executing the pilot study which of the following is true about FMEA? 1) It is a program evaluation method that is primarily process based 2) It is a program evaluation method that is primarily outcome based 3) It is a program evaluation method that is primarily observation based 4) It is a program evaluation method that is mandated by OSHA Correct Ans - 2) It is a program evaluation method that is primarily outcome based Extra safety and security measures are important for which specialized hospital area? 1) ICU 2) ED 3) Surgery 4) Nursery Correct Ans - 4) Nursery which of the following is the best definition of vision in regards to creating an organizational vision statement? 1) the ability to see the future 2) an ideal future state 3) a realistic action plan for future performance 4) an outline of future organizational purpose Correct Ans - 2) an ideal future state a patient care team is in disagreement over new admission procedures. what decision making model should management use? 1) decision criteria 2) consensus 3) invocation 4) tenure influence Correct Ans - 1) decision criteria decision criteria is a model that explores all options equally and gives unorthodox or unpopular opinions a fair chance which of the following is a structure designed to help facilitate team or group pursuit of specific goals and objectives? 1) management 2) organization 3) intelligent design 4) delegation Correct Ans - 2) organization while management and delegation are both important, they are not central to the unification of a team or group for goal pursuit. they are aspects of the structure, not the structure itself Mrs. Jones waits more than an hour past her scheduled appointment time. she leaves in a huff, calling the doctors office a joke and saying she has better things to do. Mrs. Jones perception of quality in this instance is based on: 1) medical care 2) statistical anomalies 3) provider norms 4) patient care Correct Ans - 4) patient care her evaluation was based entirely on her patient care experience. this includes waiting times, communication, accessibility and patient treatment Healthcare organizations are often classified as "systems". What is the primary reason for this designation? 1) they span several states with a network of providers 2) they are dynamically complex and have multiple levels of management 3) they are a collection of parts that function as an interdependent whole 4) they employ a broad cross section of the population in various positions Correct Ans - 3) they are a collection of parts that function as an interdependent whole. how does the world health organization surgical safety checklist lead to tight coupling in the operating room? 1) it establishes universality to patients 2) it compartmentalizes the procedures 3) it establishes a clear operating room hierarchy 4) it closely aligns the various individuals involved in the process Correct Ans - 4) it closely aligns the various individuals involved in the process the checklist must be read out loud to the surgical team to ensure that all important elements of the surgical procedure have been reviewed and agreed upon by the entire team. This includes patient allergies, surgical site confirmation and patient risks. the baldridge performance excellence program health care criteria remark on the importance of measurement and analysis of data. what can be the downside of a heavy performance data focus? 1) managers can get tunnel vision and overlook non-measured errors and issues 2) data far above the national standard can result in inflated self opinion 3) data far below the national standard can result in depression 4) hospitals with high data scores are held to impossibly high standards Correct Ans - 1) managers can get tunnel vision and overlook non- measured errors and issues. a small city has two hospitals. the HCAHPS reports show Hospital A is performing far below Hospital B in customer service. the administrators of Hospital A decide to set an organizational goal of ranking higher than Hospital B in one year. what is the most logical first step in the goal setting process? 1) develop an overall picture of the partial goals to be achieved 2) identify a specific and singular goal to be initially pursued 3) require immediate training of all employees 4) bring in customer service experts to evaluate and improve processes Correct Ans - 1) develop an overall picture of the partial goals to be achieved 2 is wrong because it disregards the overall goal for the sake of a smaller goal 3 and 4 are wrong because they are reactive steps, not proactive steps. which of the following can be defined as "a set of measures and data that give managers and administrators a quick yet comprehensive overview of performance?" 1) process measurement 2) balanced scorecard 3) dashboard 4) six sigma Correct Ans - 2) balanced scorecard dashboard scoring is not as quick or comprehensive as a balanced scorecard. dashboard provide a snapshot. the key works were "quick yet comprehensive" when Hospital A's neonatal infection rates rise unexpectedly, the quality council establishes a new set of performance measures. they base their measure on internal standards, customer survey data and employee survey data. what important element are the quality council member disregarding? 1) epidemiological standards 2) customer satisfaction data 3) employment records 4) external standards Correct Ans - 4) external standards (i.e. national goals and requirements) what challenge often occurs with the use of aggregated data? 1) the numbers become too large and complicated 2) context is lost and solutions are not identified 3) impersonality and vagueness are not engaging 4) special interpreters are needed for understanding Correct Ans - 2) context is lost and solutions are not identified as a manager, you are working with a new employee who has challenges with appropriate customer service processes. together you are establishing a performance improvement plan. which of the following should NOT be a part of the plan? 1) research into the causes of the employees challenges 2) a clear statement of the problems to be addressed 3) specific action steps to be taken as part of the plan 4) a desired outcome or goal behavior and timeline Correct Ans - 1) research into the causes of the employees challenges the performance improvement plan process should include a clear problem statement, specific action steps and a goal behavior Recent HCAHPS data for Hospital A indicate that doctors are not providing adequate explanations to patients. In improving the patient safety culture with regards to this issues, what two elements must be addressed? 1) patient perceptions and clinical quality 2) patient perceptions and physician education 3) physician education and time constraints 4) quality standards and time constraints Correct Ans - 1) patient perceptions and clinical quality patient perceptions include the mode of communication and the depth of information. clinical quality would include the doctors understanding of communication techniques, health literacy etc. an issue with response time to patient requests has been identified in the post surgical ward of Hospital A. the administrators desire to improve performance in this area. what element of process performance will most help determine the best course of action? 1) process behavior 2) process measurement 3) process capability 4) process requirements Correct Ans - 4) process requirements process requirements are the element of process performance that represents the VOC, outlining the change or action needed. who developed the national patient safety goals? 1) the leapfrog group 2) HCAHPS 3) CDC 4) TJC Correct Ans - 4) The Joint Commission as part of an initiative for administrators to be more involved in day to day business, you have been spending a great deal of time i