IHP 604
Healthcare Quality & Improvement
Proctored Midterm Exam Review
(With Solutions)
2026
1
,1. Case: A medical‑surgical unit has rising rates of inpatient falls. The
nurse manager wants to identify the most common contributing
factors. Which QI tool is best to prioritize causes for targeted
interventions?
- A. Fishbone (Ishikawa) diagram
- B. Pareto chart
- C. Control chart
- D. Run chart
Answer: B. Pareto chart
Rationale: Pareto charts rank causes by frequency or impact so
teams can focus on the “vital few” contributors to most falls.
2. Case: A team implements hourly rounding to reduce call bell use.
After 6 weeks they plot the metric and see a sustained downward
shift in median. Which conclusion is most appropriate?
- A. Random variation; no change
- B. Special cause variation indicating improvement
- C. Measurement error
- D. Need for larger sample size
Answer: B. Special cause variation indicating improvement
Rationale: A sustained shift in centerline on a run chart suggests a
real change attributable to the intervention.
3. Case: A hospital wants to reduce central line–associated
bloodstream infections (CLABSI). Which bundle element is
evidence‑based and should be included?
- A. Routine dressing changes every 24 hours regardless of condition
- B. Maximal sterile barrier precautions during insertion
- C. Use of central lines for routine blood draws only
- D. Prophylactic systemic antibiotics for all central line insertions
Answer: B. Maximal sterile barrier precautions during insertion
Rationale: Maximal sterile barriers are a core evidence‑based
component of CLABSI prevention bundles.
2
, 4. Case: A QI team uses Plan‑Do‑Study‑Act (PDSA) cycles. Which
activity belongs in the “Study” phase?
- A. Implementing the change across all units
- B. Collecting and analyzing data to assess impact
- C. Brainstorming potential interventions
- D. Writing the final policy
Answer: B. Collecting and analyzing data to assess impact
Rationale: The Study phase evaluates results from the Do phase to
determine effectiveness before wider adoption.
5. Case: A unit measures hand hygiene compliance by direct
observation. Observers are visible and staff compliance is 95%.
Which bias is most likely affecting results?
- A. Selection bias
- B. Hawthorne effect
- C. Recall bias
- D. Confounding
Answer: B. Hawthorne effect
Rationale: Staff alter behavior when they know they are observed,
inflating measured compliance.
6. Case: A nurse leader must choose a balancing measure when
reducing length of stay (LOS). Which is an appropriate balancing
measure?
- A. 30‑day readmission rate
- B. Average daily census
- C. Number of discharge summaries completed
- D. Percentage of patients with early mobility orders
Answer: A. 30‑day readmission rate
Rationale: Balancing measures detect unintended consequences;
shorter LOS may increase readmissions.
7. Case: A QI project reports a p‑value of 0.04 for reduced medication
errors after an intervention. Which interpretation is correct?
3
Healthcare Quality & Improvement
Proctored Midterm Exam Review
(With Solutions)
2026
1
,1. Case: A medical‑surgical unit has rising rates of inpatient falls. The
nurse manager wants to identify the most common contributing
factors. Which QI tool is best to prioritize causes for targeted
interventions?
- A. Fishbone (Ishikawa) diagram
- B. Pareto chart
- C. Control chart
- D. Run chart
Answer: B. Pareto chart
Rationale: Pareto charts rank causes by frequency or impact so
teams can focus on the “vital few” contributors to most falls.
2. Case: A team implements hourly rounding to reduce call bell use.
After 6 weeks they plot the metric and see a sustained downward
shift in median. Which conclusion is most appropriate?
- A. Random variation; no change
- B. Special cause variation indicating improvement
- C. Measurement error
- D. Need for larger sample size
Answer: B. Special cause variation indicating improvement
Rationale: A sustained shift in centerline on a run chart suggests a
real change attributable to the intervention.
3. Case: A hospital wants to reduce central line–associated
bloodstream infections (CLABSI). Which bundle element is
evidence‑based and should be included?
- A. Routine dressing changes every 24 hours regardless of condition
- B. Maximal sterile barrier precautions during insertion
- C. Use of central lines for routine blood draws only
- D. Prophylactic systemic antibiotics for all central line insertions
Answer: B. Maximal sterile barrier precautions during insertion
Rationale: Maximal sterile barriers are a core evidence‑based
component of CLABSI prevention bundles.
2
, 4. Case: A QI team uses Plan‑Do‑Study‑Act (PDSA) cycles. Which
activity belongs in the “Study” phase?
- A. Implementing the change across all units
- B. Collecting and analyzing data to assess impact
- C. Brainstorming potential interventions
- D. Writing the final policy
Answer: B. Collecting and analyzing data to assess impact
Rationale: The Study phase evaluates results from the Do phase to
determine effectiveness before wider adoption.
5. Case: A unit measures hand hygiene compliance by direct
observation. Observers are visible and staff compliance is 95%.
Which bias is most likely affecting results?
- A. Selection bias
- B. Hawthorne effect
- C. Recall bias
- D. Confounding
Answer: B. Hawthorne effect
Rationale: Staff alter behavior when they know they are observed,
inflating measured compliance.
6. Case: A nurse leader must choose a balancing measure when
reducing length of stay (LOS). Which is an appropriate balancing
measure?
- A. 30‑day readmission rate
- B. Average daily census
- C. Number of discharge summaries completed
- D. Percentage of patients with early mobility orders
Answer: A. 30‑day readmission rate
Rationale: Balancing measures detect unintended consequences;
shorter LOS may increase readmissions.
7. Case: A QI project reports a p‑value of 0.04 for reduced medication
errors after an intervention. Which interpretation is correct?
3
