INT 6200 Module 4 Knowledge Check |
Questions and Answers | 2026 Updated |
100% Correct.
1. A hospital's quality committee observes that after implementing a new sepsis
protocol, mortality rates initially dropped but then plateaued and began to rise
slightly. Which improvement methodology is most appropriate to diagnose why the
intervention's effect is decaying over time?
A. Six Sigma DMAIC to reduce defect rates in the sepsis bundle
B. PDSA cycles to iteratively test and adapt the protocol under real-world conditions
C. Lean value-stream mapping to eliminate waste in the sepsis care pathway
D. Root cause analysis to identify the single cause of the mortality increase
Answer: B. PDSA cycles to iteratively test and adapt the protocol under real-world
conditions
Rationale: PDSA cycles are designed for iterative learning and adaptation, making them
ideal when an intervention's effectiveness wanes due to contextual changes. Six Sigma and
Lean focus on defect/waste reduction, not adaptive learning, and RCA seeks a single root
cause, which is insufficient for dynamic decay.
2. A covered entity experiences a breach of unsecured protected health information
affecting 750 individuals. Under the HIPAA Breach Notification Rule, which action is
required?
A. Notify only the affected individuals within 30 days
B. Notify the Secretary of HHS immediately and the media within 60 days
C. Notify affected individuals, the Secretary of HHS, and prominent media outlets
without unreasonable delay and no later than 60 days
D. Notify only the Secretary of HHS within 60 days
Answer: C. Notify affected individuals, the Secretary of HHS, and prominent media
outlets without unreasonable delay and no later than 60 days
Rationale: Breaches affecting 500 or more individuals require notification to affected
individuals, HHS, and media without unreasonable delay and within 60 days. Option A
omits HHS and media; B incorrectly requires immediate HHS notification; D omits
individual and media notification.
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,3. In a value-based purchasing model, a hospital's performance on the Hospital
Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey
directly affects reimbursement. Which domain of HCAHPS is most strongly linked to
clinical outcomes and patient safety?
A. Communication with nurses
B. Responsiveness of hospital staff
C. Care transition
D. Quietness of the hospital environment
Answer: A. Communication with nurses
Rationale: Communication with nurses is consistently associated with better clinical
outcomes, patient adherence, and safety. Responsiveness, care transition, and quietness are
important but less directly linked to clinical quality and safety.
4. A healthcare organization is conducting a failure mode and effects analysis (FMEA)
for a new medication administration process. The team assigns a severity score of 8,
occurrence score of 4, and detection score of 3. What is the risk priority number
(RPN), and what does it indicate?
A. RPN = 15; low risk, no action needed
B. RPN = 96; moderate risk, monitor
C. RPN = 96; high risk, prioritize corrective action
D. RPN = 15; high risk, immediate action required
Answer: C. RPN = 96; high risk, prioritize corrective action
Rationale: RPN = severity × occurrence × detection = 8 × 4 × 3 = 96. Higher RPN values
indicate greater risk and priority for corrective action. Options A and D miscalculate, and
B wrongly characterizes 96 as moderate.
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, 5. Which of the following best describes the primary purpose of the Joint
Commission's National Patient Safety Goals (NPSGs)?
A. To provide a framework for billing and reimbursement
B. To promote specific improvements in patient safety by focusing on problematic areas
in healthcare
C. To establish minimum staffing ratios for nursing units
D. To standardize electronic health record interoperability
Answer: B. To promote specific improvements in patient safety by focusing on
problematic areas in healthcare
Rationale: NPSGs target high-risk patient safety issues and require accredited
organizations to implement specific solutions. They do not address billing, staffing ratios,
or EHR interoperability, which are governed by other bodies.
6. A hospital's risk manager is reviewing a case where a patient developed a pressure
ulcer after surgery. Which of the following best represents a leading indicator that
could have predicted this adverse event?
A. The number of pressure ulcers reported in the last quarter
B. The percentage of patients who received a skin assessment within 2 hours of
admission
C. The total number of surgical procedures performed
D. The average length of stay for surgical patients
Answer: B. The percentage of patients who received a skin assessment within 2 hours
of admission
Rationale: Leading indicators are proactive measures that predict future outcomes, such as
timely skin assessments. The number of ulcers, procedure volume, and length of stay are
lagging or unrelated indicators.
Page 4 of 52
Questions and Answers | 2026 Updated |
100% Correct.
1. A hospital's quality committee observes that after implementing a new sepsis
protocol, mortality rates initially dropped but then plateaued and began to rise
slightly. Which improvement methodology is most appropriate to diagnose why the
intervention's effect is decaying over time?
A. Six Sigma DMAIC to reduce defect rates in the sepsis bundle
B. PDSA cycles to iteratively test and adapt the protocol under real-world conditions
C. Lean value-stream mapping to eliminate waste in the sepsis care pathway
D. Root cause analysis to identify the single cause of the mortality increase
Answer: B. PDSA cycles to iteratively test and adapt the protocol under real-world
conditions
Rationale: PDSA cycles are designed for iterative learning and adaptation, making them
ideal when an intervention's effectiveness wanes due to contextual changes. Six Sigma and
Lean focus on defect/waste reduction, not adaptive learning, and RCA seeks a single root
cause, which is insufficient for dynamic decay.
2. A covered entity experiences a breach of unsecured protected health information
affecting 750 individuals. Under the HIPAA Breach Notification Rule, which action is
required?
A. Notify only the affected individuals within 30 days
B. Notify the Secretary of HHS immediately and the media within 60 days
C. Notify affected individuals, the Secretary of HHS, and prominent media outlets
without unreasonable delay and no later than 60 days
D. Notify only the Secretary of HHS within 60 days
Answer: C. Notify affected individuals, the Secretary of HHS, and prominent media
outlets without unreasonable delay and no later than 60 days
Rationale: Breaches affecting 500 or more individuals require notification to affected
individuals, HHS, and media without unreasonable delay and within 60 days. Option A
omits HHS and media; B incorrectly requires immediate HHS notification; D omits
individual and media notification.
Page 1 of 52
,Page 2 of 52
,3. In a value-based purchasing model, a hospital's performance on the Hospital
Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey
directly affects reimbursement. Which domain of HCAHPS is most strongly linked to
clinical outcomes and patient safety?
A. Communication with nurses
B. Responsiveness of hospital staff
C. Care transition
D. Quietness of the hospital environment
Answer: A. Communication with nurses
Rationale: Communication with nurses is consistently associated with better clinical
outcomes, patient adherence, and safety. Responsiveness, care transition, and quietness are
important but less directly linked to clinical quality and safety.
4. A healthcare organization is conducting a failure mode and effects analysis (FMEA)
for a new medication administration process. The team assigns a severity score of 8,
occurrence score of 4, and detection score of 3. What is the risk priority number
(RPN), and what does it indicate?
A. RPN = 15; low risk, no action needed
B. RPN = 96; moderate risk, monitor
C. RPN = 96; high risk, prioritize corrective action
D. RPN = 15; high risk, immediate action required
Answer: C. RPN = 96; high risk, prioritize corrective action
Rationale: RPN = severity × occurrence × detection = 8 × 4 × 3 = 96. Higher RPN values
indicate greater risk and priority for corrective action. Options A and D miscalculate, and
B wrongly characterizes 96 as moderate.
Page 3 of 52
, 5. Which of the following best describes the primary purpose of the Joint
Commission's National Patient Safety Goals (NPSGs)?
A. To provide a framework for billing and reimbursement
B. To promote specific improvements in patient safety by focusing on problematic areas
in healthcare
C. To establish minimum staffing ratios for nursing units
D. To standardize electronic health record interoperability
Answer: B. To promote specific improvements in patient safety by focusing on
problematic areas in healthcare
Rationale: NPSGs target high-risk patient safety issues and require accredited
organizations to implement specific solutions. They do not address billing, staffing ratios,
or EHR interoperability, which are governed by other bodies.
6. A hospital's risk manager is reviewing a case where a patient developed a pressure
ulcer after surgery. Which of the following best represents a leading indicator that
could have predicted this adverse event?
A. The number of pressure ulcers reported in the last quarter
B. The percentage of patients who received a skin assessment within 2 hours of
admission
C. The total number of surgical procedures performed
D. The average length of stay for surgical patients
Answer: B. The percentage of patients who received a skin assessment within 2 hours
of admission
Rationale: Leading indicators are proactive measures that predict future outcomes, such as
timely skin assessments. The number of ulcers, procedure volume, and length of stay are
lagging or unrelated indicators.
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