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Question # 1
In managed care, the most widely used performance measures are
A. Agency for Healthcare Research and Quality (AHRQ).
B. Healthcare Effectiveness Data and Information Set (HEDIS).
C. National Quality Forum (NQF).
D. Uniform Hospital Discharge Data Set (UHDDS).
Question # 2
Which of the following charts would most likely be used first in a root cause analysis?
A. Pareto
B. control
C. flow
D. Gantt
Question # 3
The perception of how an organization operates, including how employees relate to internal and external customers, is the organizational
A. mission.
B. vision.
C. structure.
D. culture.
Question # 4
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
A. the amount of data the team has collected.
B. the effectiveness of the team leader and facilitator.
C. how well the team met the intended outcome.
D. the length of time the team has been together.
Question # 5
When considering the use of an external subject matter expert (SME), which of the following characteristics is most critical?
A. references of the SME
B. cost of the SME's services
C. geographic location of the SME
D. leadership's personal preference
Question # 6
A consulting firm has been selected by a facility's quality professional to assess the quality improvement program. Before starting the assessment, the quality professional should
A. define expectations and outcomes.
B. develop potential action plans.
C. help the consulting firm to identify problem areas.
D. schedule the activities of the consulting firm.
Question # 7
Performing a root cause analysis of a sentinel/unexpected event provides all of the following EXCEPT
A. recommendation for actions to prevent or decrease recurrence.
B. measurement strategies for each factor affecting the outcome.
C. continuous monitoring to identify opportunities for improvement.
D. identification of why the variance occurred.
Question # 8
The best way to evaluate the effectiveness of performance improvement training is through
A. observed behavioral changes.
B. participants' feedback.
C. post-test results.
D. self-assessments.
Question # 9
When examining the relationship between staff and patient outcomes, which of the following would be most appropriate to assess?
A. occurrence reports and sentinel events
B. staff turnover and budget
C. overtime data and absenteeism rates
D. patient safety data and overtime data
Question # 10
A new quality director has reviewed the information related to the Quality Council minutes and notes the following: - The council meets quarterly. Meetings last approximately two hours. - The council roster includes all clinical department managers and the quality director. Attendance ranges from 45-60%. -The primary role of the council is to receive department quality reports, which are then forwarded to the organization's governing body. Based on the information above, which of the following actions is most appropriate
A. Redefine the council's role to coordinate and prioritize quality activities.
B. Require departments to forward reports for review prior to the meetings.
C. Eliminate the council and directly report quality data to the governing body.
D. Switch to a monthly meeting with a new agenda format
Question # 11
A patient safety program can best be enhanced by which of the following technologies?
A. online evidence-based medicine guidelines
B. computers on wheels at the patients' bedsides
C. digital medication reference materials
D. barcode system for medication administration
Question # 12
Which of the following actions would have the greatest impact in reducing harm?
A. increasing data collection frequency
B. forming a performance improvement team
C. improving interdisciplinary communication
D. revising the patient safety evaluation tool
Question # 13
Which of the following is the major responsibility of senior management regarding continuous quality improvement?
A. Communicate the organizational mission and values.
B. Develop organization-wide training sessions.
C. Participate in Quality Council activities.
D. Conduct periodic reviews of the program.
Question # 14
In the quality improvement process, performing a cost-benefit analysis would be most useful in
A. designing solutions and controls.
B. checking performance.
C. analyzing process problems.
D. implementing solutions and controls.
Question # 15
Which of the following is always true regarding a sentinel event?
A. The findings must be reported to a regulatory body.
B. The occurrence requires an immediate investigative response.
C. The cause is established as a deviation from standards.
D. The incident is a result of a medical error.
Question # 16
A. Suspend privileges for physician C.
B. Initiate peer review with physician C.
C. Initiate peer review with physician A.
D. Suspend privileges for physician A.
Question # 17
Which of the following is the most effective way to integrate performance improvement concepts throughout an organization?
A. quality teams
B. monthly lectures
C. continuous monitoring
D. quarterly newsletters
Question # 18
A clinical pathway on the management of hip fractures has been developed by a multidisciplinary 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?
A. Correlate the pathway with staffing levels.
B. Re-educate the staff on the purpose of the pathway.
C. Evaluate compliance with the pathway.
D. Continue to monitor and collect additional data.
Question # 19
Results of physician practice pattern studies are most likely to promote behavior changes when disseminated to the
A. practitioners.
B. governing body.
C. quality committee.
D. administration.
Question # 20
Random screening of newborns by the neonatology department has confirmed a high incidence of glucose insufficiency (G6PD) in the local population. Management believes that the cost of testing all newborns would be too high. Which of the following should the healthcare quality professional suggest?
A. Review literature to determine best practices.
B. Continue to conduct random testing.
C. Conduct an analysis to confirm management's beliefs.
D. Test only newborns with a family history of G6PD.
Question # 21
Which of the following topics are discussed at a morbidity and mortality conference?
A. planned readmissions and newborn mortality rates
B. healthcare-acquired infections and perioperative mortality
C. inpatient mortality and admissions
D. Cesarean section rates and number of physicians
Question # 22
A healthcare quality professional is conducting a study to determine how many patients contractedinfluenza after receiving flu shots. This study is evaluating
A. prevalence.
B. efficacy.
C. process.
D. appropriateness.
Question # 23
Which of the following should be included in an annual performance improvement report to a governing body?
A. team achievements
B. meeting minutes
C. incident/occurrence reports
D. physician peer reviews
Question # 24
A. caring and most satisfied with cost.
B. cost and most satisfied with caring.
C. communication and most satisfied with comfort.
D. cost and most satisfied with communication.
Question # 25
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
A. utilization committee.
B. Quality Council.
C. governing body.
D. chief of the department
Question # 26
Frequency distribution can best be displayed through use of
A. an interrelationship diagram.
B. a force field analysis.
C. a flow chart.
D. a histogram.
Question # 27
In lean thinking, a process step is defined as "value added" if the
A. customer recognizes the value.
B. process owner recognizes the value.
C. process owner changes the value of the product.
D. customer corrects a mistake to add value.
Question # 28
A physician who has a high inpatient mortality rate compared to others in a facility should first be
A. suspended in the interest of patient safety.
B. counseled by the department chairperson.
C. evaluated by the credentialing committee.
D. subjected to a more in-depth review of cases.
