(Test Bank) CPHQ Practice exam-with 100% verified answers-2022-2023

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Test Bank for CPHQ Practice exam-with 100% verified answers-2022-2023, The downloadable file consists of 158 pages, and the total size of the file is 2.3 MB. Purchase now only for highly discounted price.

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WGU C 215-QBank For CPHQ Practice exam-with 100% verified answers-2022-2023 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 4) sharing the data with the staff to provide feedback Correct Ans - 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