Healthcare Quality Improvement: Reducing Medication Errors and Enhancing Patient Safety, Exams of Nursing

Download Healthcare Quality Improvement: Reducing Medication Errors and Enhancing Patient Safety and more Exams Nursing in PDF only on Docsity! CPHQ Study Guide Questions and Answers The process chain in a laboratory is particularly subject to: variability, delay, disorganization, conflict - ✔variability Confronted by excessive WIP Levels, many laboratories take the unhelpful step of: decreasing # of test runs, hiring more employees, acquiring a longer, installing new technology - ✔installing new technology According to Institute of Medicine, which of the following is NOT one of the domains of quality care? government regulation, customization, safety, interventions consistent with the latest medical findings - ✔government regulation In a successful lean healthcare facility, the largest costs related to quality will be increased by: preventive efforts, internal failures, assessment programs, external failures - ✔preventive efforts Whenever possible, medication orders should be by: weight, volume, dose, strength - ✔dose A delay in discharging patients is likely to cause recurrent bottlenecks in: admissions from ER, filling of prescriptions, admissions from surgical wards, all of the above - ✔all of the above A doctor fails to administer an indicated test and patients condition determines to the point that he must be admitted to an inpatient facility. This is an example of: preventive error, treatment error, diagnostic error, communication error - ✔diagnostic error When is the best time for chairing during a meeting? one hour beforehand, at the beginning, in the middle, at the end - ✔at the beginning In the perfect lean enterprise, delivery to the customer is: instantaneous, rapid, customizable, optional - ✔instantaneous A healthcare quality management professional ahs all of the following responsibilities toward improving patient safety EXCEPT: appointing a supervisor for a patient safety program, helping to develop a patient safety program, incorporating new technology into a patient safety program, setting and reviewing goals for patient safety program - ✔appointing a supervisor for a patient safety program Which of the following types of charts is best for determining cause & effect? run, control, fishbone, pareto - ✔fishbone 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 assessment is MOST likely to be of use to the hospital? case study, team analysis, survey, focus group - ✔focus group The process of risk management for the healthcare quality management professional includes all of the following EXCEPT? identification of risk, reporting of incidents, analysis of effects, prevention of risk - ✔reporting of incidents 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? a. recommend that the hospital replace the current administration of the individual department, b. research the problems and develop a program that applies current standards to the department, c. advise that a performance improvement team be assembled to review and address the failings, d. review the expected standards and submit these to the department for immediate application - ✔c.advise that a performance improvement team be assembled to review and address the failings The administration of a hospital has discovered that a lack of communication among different hospital departments has led 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? quality circle, work group, cross functional, self-directed - ✔cross functional All of the following represent federally mandated patient rights in the US EXCEPT: rights to obtain a copy of medical records, right to informed consent for medical treatment, right to maintain the privacy of medical records, right to receive healthcare services - ✔right to receive healthcare services b. indicators and a data analyst, c. standards and procedures, d. facilitator and recorder - ✔a. empowerment and training Failure modes can be prioritized by calculating the criticality index. Which of the following three categories are normally used to calculate a criticality index? a. frequency/severity/ease of detection, b. probability/likelihood/criticality, c. response/evidence/outcome, d. effectiveness/risk/priority - ✔a. frequency/severity/ease of detection Which of the following charts would most likely be used first in a root cause analysis? a. Pareto, b. control, c. flow, d. gantt - ✔c. flow 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 - ✔d. chief of the department 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 - ✔a. references of the SME 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 would provide the most useful information? a. number of complaints, b. physician attendance, c. medical record review, d. frequency of meetings - ✔c. medical record review For a continuous quality improvement team to be successful, who must be included on the team? a. department supervisor b. person performing the process, c. quality management representative, d. administrator - ✔b. person performing the process Deemed status refers to: a. surveyors who work for both an accrediting body and a healthcare organization, b. physicians who have been reported to the National Practitioner Database, c. accreditation equivalency with a Census for Medicare & Medicaid Services (CMS) survey, d. a healthcare organization that passes a Centers for Medicare & Medicaid services (CMS) survey - ✔accreditation equivalency with a Census for Medicare & Medicaid Services (CMS) survey 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 - ✔d. test only newborns with a family history of G6PD Frequency distribution can best be displayed through use of: a. interrelationship diagram, b. force field analysis, c. flow chart, d. histogram - ✔d. histogram 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? 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 - ✔c. evaluate compliance with the pathway Which of the following is an example of information that should be included in an incident report, but should not be recorded in a patient's medical record? a. the date/time/dose/name of a medication administered to a patient in error b. the patient found on the floor next to the bed with the patients right leg appearing to be rotated c. the patient's right knee replaced after consenting to replacement of the left knee d. details concerning a medication preparation error discovered and corrected prior to administration - ✔d. details concerning a medication preparation error discovered and corrected prior to administration Comparing healthcare organizations by using medical error rates: a. provides the best method for benchmarking patient safety b. must include a minimum of 10 different facilities c. may present bias due to differences in reporting practices d. cannot be performed by facilities with less than 100 beds - ✔provides the best method for benchmarking patient safety 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 overtime. The best way to display the data is to use a: a. gantt chart, b. pareto chart, c. flow chart, d. control chart - ✔d. control chart What is the best explanation for the relatively slow introduction of lean practices into medical laboratories? a. the variability and complexity of the samples in a laboratory is much bigger than a manufacturing environment b. scientists are less receptive to the core principles of lean c. medical laboratories function differently than factories d. medical research is mostly funded by the government - ✔scientists are less receptive to the core principles of lean Which of the following conditions should a quality assessment program NOT examine? a. condition that is thought to be treatable, b. condition for which the treatment is susceptible to significant influence by health care providers, c. condition that has cost effective treatments, d. rare condition that has a small effect on mortality or morbidity - ✔a rare condition that has a small effect on mortality or morbidity A doctor fails to administer an indicated test, and the patients condition deteriorates to the point that he must be admitted to an inpatient facility. This is an example of: preventive error, treatment error, diagnostic error, communication error - ✔diagnostic error In managed care, the most widely used performance measure are: Agency for Healthcare and Quality (AHRQ), Healthcare Effectiveness Data for Information Set (HEDIS), National Quality Forum (NQF), Uniform Hospital Discharge Data Set (UHDDS) - ✔Healthcare Effectiveness Data for Information Set (HEDIS) b. vision c. structure d. culture - ✔d. culture An operating room circulating nurse reported that the instrument count indicated a missing clamp. X-ray findings were negative, and the patient showed no adverse effects. This occurrence is an example of which of the following? a. malpractice b. potentially compensable event c. clinical incompetency d. claims management - ✔b. potentially compensable event Balances scorecards are useful because they: a. concentrate on the performance of individual units b. focus on the most significant strategic initiative c. evaluate the pros and cons of the governing body's priorities d. put strategy and vision at the center of an organization's efforts - ✔d. put strategy and vision at the center of an organization's efforts When a team evaluating the use of restraints starts to discuss a liability claim related to a patient, the facilitator should: a. consult the risk manager, b. redirect the team, c. review team ground rules, d. request the medical record - ✔review team ground rules 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 - ✔a. observed behavioral changes Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization's quality improvement program? a. integrated data collection, b. quantifiable objectives, c. support from the medical staff, d. well-defined organizational structure - ✔b. quantifiable objectives In providing length-of-stay data for benchmarking, it is important that date be: a. raw numbers, b. severity adjusted, c. equal numbers, d. reported monthly - ✔b. severity adjusted 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? a. gap analysis, b. gantt chart, c. kanban method, d. ishikawa diagram - ✔a. gap analysis which of the following is the best example of use of human factors engineering? a. implementing a Kaizen process to reduce inventory b.eliminating waste through reduction in motion c. using PDCA to improve compliance with hand hygiene d. designing products to prevent tubing misconnections - ✔eliminating waster through reduction in motion A valid data collection tool should incorporate: a reliable graphic presentation, the definition of data elements, allowance for variance of interpretation, a minimum of 20 data elements - ✔the definition of data elements Leaders enhance employee commitment to organizational values by fostering which of the following types of communication? clear/written/top-down, timely/open/two-way, formal/electronic/need to know, face-to-face/oral/scheduled - ✔timely/open/two-way A healthcare quality professional wants to develop a continuous survey readiness model, the initial step should be: selecting the standards to be taught, establishing leadership accountability, appointing a steering group, planning education for the entire team - ✔planning education for the entire team When errors are discovered, staff and supervisors best demonstrate a culture of safety by: planning which details of the error to disclose to senior leadership, studying the process to understand the error, performing a root cause analysis to determine which individuals were involved, developing a plan for just-in-time training - ✔studying the process to understand the error After a significant unexpected event, an intense analysis is performed to : collect risk management data, prepare the facility for a lawsuit, understand the cause, identify who made the error - ✔understand the cause Which of the following is the best example of an outcome measure? laboratory turnaround, average length of stay, medication dispensing error, mortality rate - ✔mortality rate Underuse is evidence by the fact that many scientifically sound practices are not used as often they should be. For example, biannual mammography screening in woman ages 40-69 has been proven beneficial and yet is performed less than 75 percent of the time. This is the categorization of: Defects, la of Professionalism in Medical Field, Healthcare practice - ✔Defects What is a term applied when the proper clinical car process is not executed appropriately, such as giving the wrong drug to a patient or incorrectly administering the correct drug? underuse, overuse, misuse, illegal use - ✔misuse Crossing the Quality Chasm provided a blueprint for the future that classified and unified the components of quality through six aims for improvement, chain of effects, and simple rules for redesign of healthcare. The six aims for improvement, viewed also six dimensions of quality. which of the following is NOT out of those dimensions? safe, care centered, efficient, effective - ✔care centered Quality and technical performance refers to how current scientific medical knowledge and technology are applied in a given situation. It is usually assessed in terms of? a.timeliness and accuracy of the diagnosis, b.appropriateness of therapy and other medical interventions are performed, c.the quality of interpersonal relationships, d.both A & B - ✔both A &B timeliness and accuracy of the diagnosis, appropriateness of therapy and other medical interventions are performed Today's patients perception of the quality of our healthcare system is not favorable. In healthcare, quality is household word that evokes great emotion, including? a. frustration and despair, exhibited by patients who experience healthcare services firsthand or family members who observe the care of their loved ones b. anxiety over the ever-increasing costs and complexities of care, c. patient centered measures, The relationship between patient satisfaction and hours per patient day on a medical unit was found to be (r = 0.60, p < 0.05). What is the correlation between these two values? A. 0.05 B. 0.36 C. 0.55 D. 0.60 - ✔EXPLANATIONS: D. The correlation coefficient (r) is an index that ranges from -1.0 to 1.0 and reflects the extent of a linear relationship between two data sets. The correlation coefficient is 0.60. Hospital A has recently merged with Hospital B. After 6 months, it is noted that Hospital A has successfully transitioned their staff to new organizational values, while Hospital B still struggles. Hospital A's success can best be attributed to: A. requiring adoption of new values by all staff. B. support of both hospitals' mission statements. C. acceptance of the new mission and vision statements. D. integrating technology and databases. - ✔EXPLANATIONS: C. Acceptance of the new mission and vision statements demonstrates integration of the two facilities. For a quality improvement team to deal effectively with conflict, it is important to appoint which of the following to its membership? A. risk manager B. human resources representative C. facilitator D. senior leader - ✔EXPLANATIONS: C. A facilitator is an unbiased party that may help groups deal with conflict. Which of the following best describes an organizational vision statement? A. It is used as a marketing strategy. B. It defines the structure of the institution. C. It describes the organization's strategic plan. D. It reflects the organization's aspirations. - ✔EXPLANATIONS: D. Vision is the image or description of what the organization desires to become. Quality improvement team progress is best evaluated by which of the following? A. team leader B. senior leadership C. PDCA process D. nominal group technique - ✔EXPLANATIONS: C. The Plan, Do, Check, Act process is a comprehensive methodology used to conduct performance improvement activities, including the analysis of progress. To reduce the incidence of ventilator-associated pneumonia (VAP) in a critical care unit, who should be included on a quality improvement team? A. intensivist, ICU nurse, and respiratory therapist B. primary care physician, infection control nurse, and surgeon C. ICU manager, respiratory therapist, and pharmacist D. pharmacist, intensivist, and infection control nurse - ✔EXPLANATIONS: A. In this scenario, the healthcare quality professional would involve staff that would most commonly be related to the care of a patient with VAP. The involvement of the intensivist, ICU nurse, and respiratory therapist would be considered common, and would comprise the ideal and appropriate team to care for a patient with VAP. A team has identified a process for improvement, selected examples of best practice performers, visited those sites, gathered all necessary data, and compiled the results. The most effective next step for the team is to A. identify the next process to benchmark. B. implement change at the team's site. C. compare results to historical data. D. make the results public for others to use for benchmarking. - ✔EXPLANATIONS: B. Implementation is the next step in the performance improvement cycle. A continuous quality improvement organization promotes vigorous education and training/retraining in order to A. restructure internal jobs. B. reduce the need for competency testing. C. promote harmony within the organization. D. acquire new knowledge and new skills. - ✔EXPLANATIONS: D. As the stem of the question identifies a component of continuous quality improvement as one that promotes education and training, this will yield new knowledge and skills. Which of the following is essential to an effective quality council? A. involvement of leadership B. consultation of the legal advisor C. participation of the strategic planning committee D. direction from the organization's quality department - ✔EXPLANATIONS: A. Leadership involvement promotes an effective quality council through resource and support allocation to achieve objectives. A Quality Council has chartered a Failure Mode and Effects Analysis (FMEA) team to examine the best method of preventing medication errors after the installation of a new medication dispensing system. The team's first major task should be to A. identify ways to detect the likelihood of the equipment breaking down. B. brainstorm on potential failure modes of the equipment. C. multi-vote on the severity of the potential equipment breakdowns. D. develop a flow chart of how the equipment will be installed. - ✔EXPLANATIONS: B. In an FMEA, brainstorming potential failures is the first major step. Based on identified issues, a healthcare quality professional examines 100% of one physician's admissions and only 20% of all other physicians' admissions. This is best described as a A.focused review. B.prospective review. C.retrospective review. D.concurrent review. - ✔EXPLANATIONS: A. A focused review is performed for a predetermined reason and is concentrated on a select sample of cases or data elements. Case or data element selection is usually based on internally identified problem areas or on external demands. Since the quality professional examined 100% of one physician's admission based on identified issues, a focused review is the best description of this case. Which of the following are essential functions of an infection control program? A. risk management and surveillance B. prevention and education C. surveillance and prevention D. patient safety and risk management - ✔EXPLANATIONS: C. Two principal functions of infection control are surveillance and prevention. A surgery department's monthly case review revealed 10 records meeting criteria and six additional records that did not meet the criteria. In calculating the incidence rate, the denominator is A. 4. B. 6. C. 10. D. 16. - ✔EXPLANATIONS: D. The denominator is the total of all of the medical records, which equals 16. Patient satisfaction scores for a community hospital demonstrate multiple areas for improvement including a need to improve attractiveness of the facility, responsiveness to patient needs, and physician and nursing communication. Based on these results, which of the following should the healthcare quality professional also expect to find? A. administration prioritizing and leading units to achieve organizational goals B. unit managers who openly discuss patient satisfaction scores C. units operating independently with little communication between units A hospital is working to reduce readmissions. Which of the following is the best approach to accomplish this goal? A. giving an education sheet on patient medication to the patient and family B. having the patient provide return demonstration of the knowledge provided C. showing a video to a patient and their family D. requesting the home health nurse provide patient instruction - ✔EXPLANATIONS: B. Return demonstration is an evidence-based approach for learning. The evaluation of the quality and appropriateness of patient care in the radiology department is the responsibility of the A. medical director of radiology. B. chief medical officer. C. medical director of the quality department. D. administrator of clinical services. - ✔EXPLANATIONS: A. The medical director of a department has the ultimate responsibility for everything within that department (care, quality, technology, etc.). Benchmarking is based on identifying which of the following? A. best practices B. competition C. deficiencies D. statistical control - ✔EXPLANATIONS: A. Benchmarking is the comparison of results against a reference point, which is a best practice. Which of the following sampling techniques involves selecting the medical record of every fifth patient undergoing cardiovascular bypass? A. convenience B. systematic C. stratified D. simple random - ✔EXPLANATIONS: B. Systematic sampling is the selection of every nth element from a population. An effective facilitator should be skilled in process evaluation and the tools of performance evaluation, and must A. not have a vested interest in the content. B. be in a salaried position. C. not speak unless directed by the team leader. D. be a front-line employee. - ✔EXPLANATIONS: A. The role of the facilitator is to be the process expert and remain objective. Which of the following patient safety goals is applicable to everyone in a healthcare facility? A. hand-off communication B. medication safety C. hand hygiene D. prevention of falls - ✔EXPLANATIONS: C. Good hand hygiene is appropriate for everyone, whether in direct contact with patients or not. A Quality Council is preparing a Patient Safety Plan. A key factor that needs to be considered for the long-term success of the program is to: A. determine which patient safety goals need to be monitored. B. involve the entire organization in the program. C. review incident reports to identify what disciplinary action should occur. D. research how technology can be used to prevent errors. - ✔EXPLANATIONS: B. The program must be organization-wide to be successful. It must include all members of the healthcare team. Which of the following steps occurs first in facilitating change in an organization? A.Identify problems to be addressed in the organization. B.Get feedback from management. C.Identify key people in the organization who should be involved. D.Develop a performance improvement plan. - ✔EXPLANATIONS: A. Performance improvement methodology includes identifying issues and/or problems before taking action. Which of the following tools should be used to record patient and practitioner-specific data? A. flowchart B. graphs C. histogram D. spreadsheet - ✔EXPLANATIONS: D. A spreadsheet allows for individualized data to be represented. 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 A. believe the costs are justified by the benefits. B. be a visible participant in the process. C. receive quarterly reports. D. limit training to managers and supervisors - ✔EXPLANATIONS: B. Administration and organization leaders, such as the chief quality officer, must be part of the effort to affect cultural change. Meaningful quality process measures must be A.relevant and valid. B.feasible and explainable. C.relevant and explainable. D.valid and feasible. - ✔EXPLANATIONS: A. Data must be reproducible to be valid. For data to be reproduced, it should be relevant. Relevance of data is important because the data must relate to the quality process being measured. Clinical decision support systems can best support medication safety by alerting prescribers to A. patient compliance and allergies. B. the need for dose adjustments and patient weight changes. C. drug interactions and patient weight changes. D. allergies and drug interactions. - ✔EXPLANATIONS: D. A clinical decision support system involves a computerized medication management system that allows medication alerts to be programmed (including allergies and drug interactions). The following data are being analyzed based on 6 months of incident reports for falls in a facility with 10 ICU beds and 40 Med/Surg beds: Which of the following is the next step for the healthcare quality professional to pursue? A.Continue to track and trend incident reports. B.Educate Med/Surg units on fall prevention. C.Form a team to change the ICU fall protocol. D.further analysis of fall data. - ✔EXPLANATIONS: D. The data need to be analyzed further to determine the significance and/or incidence. Which of the following is the first step in the strategic planning process? A. setting goals and objectives B. defining organizational structure C. determining productivity indicators D. establishing and controlling a budget - ✔EXPLANATIONS: A. The strategic planning process is based on what the organization wants to achieve (i.e., goals and objectives). The quality professional might consider other possibilities as first steps, but those were not presented in the options. A patient is transferred to a neighboring hospital for a magnetic resonance imaging (MRI) exam. Due to a misinterpretation of orders, the procedure is performed on the wrong part of the body. Which of the following should the healthcare quality professional do? A. Report this as a sentinel event to the transferring hospital. B. Do nothing since it happened at another facility. C. Conduct an analysis to reduce future occurrences. D. Recommend disciplinary action for the offenders. - ✔EXPLANATIONS: Healthcare quality professionals can best communicate organizational values and commitment through A. establishing a multidisciplinary task force. B. disseminating monthly newsletters. C. creating a mission statement. D. leading by example. - ✔EXPLANATIONS: D. Demonstrating and practicing expected values are the best ways to communicate organizational values. A critically ill patient is admitted and requires a specialized procedure; however, the surgeon does not have privileges at the facility. Which of the following documents will be most helpful in identifying the course of action the hospital should take? A. patient safety manual B. risk management plan C. medical staff bylaws D. surgical policies and procedures - ✔EXPLANATIONS: C. Medical staff privilege rules are defined in the medical staff bylaws. Measuring the time it takes a nurse to perform a procedure addresses which of the following aspects of care? A. monitoring B. process C. outcome D. structure - ✔EXPLANATIONS: B. Process is the systematic approach to the delivery of medical care. Which of the following accrediting bodies have deemed status with the Centers for Medicare and Medicaid Services (CMS)? A. ISO Certification and The Joint Commission (TJC) B. Det Norske Veritas (DNV) and the Healthcare Facility Accreditation Program (HFAP) C. The American Osteopathic Association (AOA) and the National Quality Forum (NQF) D. The American Medical Association (AMA) and Commission Accreditation of Rehabilitation Facilities (CARF) - ✔B. Det Norske Veritas (DNV) and the Healthcare Facility Accreditation Program (HFAP)**** The concept of organizational responsibility is most important to the field of healthcare quality because it holds the organization responsible for: A. maintaining confidentiality of all documents. B. requiring physicians to carry adequate malpractice insurance. C. maintaining a process to identify deficiencies in the provision of care. D. ensuring that peer review physicians have no conflict of interest in cases being reviewed. - ✔C. maintaining a process to identify deficiencies in the provision of care. The Joint Commission (TJC) Standards and Elements of Performance are used A. to define expectations for safety and quality care. B. in place of Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. C. to determine compliance with the Department of Health and Human Services (HHS). D. to calculate pay-for-performance incentives or penalties. - ✔A. to define expectations for safety and quality care.********* The primary reason healthcare organizations use benchmarking is to A. comply with accreditation standards. B. improve performance. C. decrease risk to the organization. D. provide risk adjustment. - ✔B. improve performance.********** When a healthcare organization is contracting with an outside provider for services, the subcontractor must: A. provide a representative to the Quality Council. B. meet all regulatory requirements. C. have an active risk management program. D. have a competitively priced service. - ✔B. meet all regulatory requirements.******************** A former patient emails an organization's chief executive officer complimenting the friendliness of the nurses while complaining that her pain was not well-managed. To comply with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, what actions are needed? A. Interview staff involved, track performance over time, and report to the Quality Council. B. Investigate the complaint, write the patient, and report to the governing board C. Call the patient, put compliments in the nurses' personnel records, and report to the Quality Council. D. Review the medical record, put compliments and complaints in the appropriate staff personnel records, and report to the governing board. - ✔B. Investigate the complaint, write the patient, and report to the governing board.******* The most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staff is by A. developing professional relationships. B. inviting medical staff to an inservice on quality tools. C. evaluating physician participation on quality teams. D. providing outcome data at medical staff meetings - ✔D. providing outcome data at medical staff meetings.******** To be useful in preventing future error, a root cause analysis (RCA) should be performed A. at least 45 days after the event. B. using practitioners who were not involved in the event. C. utilizing a multidisciplinary team. D. documenting opinion as well as facts. - ✔C. utilizing a multidisciplinary team.******** The best tool to display stability of nosocomial infection rates over time is a A. run chart. B. histogram. C. Pareto chart. D. control chart. - ✔D. control chart.**************** A quality improvement manager received the results from the most recent customer survey. Sixty percent of the residents in a nursing home have rated the temperature of foods served as poor. Which of the following actions should be taken first? A. Call the dietitian and ask for an explanation. B. Review previous results and assess trends. C. Set up a continuous monitor for review. D. Ignore the results and assess next quarter. - ✔B. Review previous results and assess trends.************* An organization's data demonstrate an increase in the number of patient falls. A healthcare quality professional should recommend A. revising the fall-risk assessment tool. B. convening a focus group of medical staff to discuss fall risks. C. increasing staffing on weekends and nights. D. sharing the data with the staff to provide feedback. - ✔D.sharing the data with the staff to provide feedback.************* The prevalence rate of a disease depends on the A. incidence rate and duration of the disease. B. number of new cases and the population at risk. C. total number of cases and the population at risk. D. incidence and change in the balance of etiological factors. - ✔C. total number of cases and the population at risk.**************** When introducing continuous quality improvement (CQI) into an organization, a chief executive officer must first: A. reach consensus with the staff. B. educate supervisors in CQI principles. C. obtain funding from the governing body. D. assess the organization's readiness for change. - ✔D. assess the organization's readiness for change.*********** An ambulatory/outpatient care facility identifies an opportunity to improve the turnaround time for reports of x-rays performed at a local hospital. Which of the following groups should be involved in the team to improve the process? C. practitioner profile and diagnostic codes D. severity level and occurrence types - ✔D. severity level and occurrence types *********** Which of the following is the most appropriate question to ask when reviewing an organization's performance improvement (PI) plan? A. "Are there sufficient organizational resources to support the PI plan?" B. "Does the PI plan include statistical methods for monitoring change?" C."Is the PI plan consistent with the organization's mission and strategic priorities?" D. "Has the organization been successful in communicating the intent and message of the PI plan to employees?" - ✔C.√ "Is the PI plan consistent with the organization's mission and strategic priorities?"****************** An organization has established a culture of patient safety when A. fear of retaliation is eliminated. B. reports of potential errors have decreased. C. patient safety goals are implemented. D. employee education is completed. - ✔A. fear of retaliation is eliminated. **************** In continuous quality improvement programs, surveys are essential to determine which of the following? A. customer needs B. performance standards C. effective management D. population demographics - ✔A. customer needs **************** A process indicator is defined as one that measures A. an activity carried out to provide care or service. B. significant events that require further investigation. C. unexpected or negative variations. D. the appropriateness of procedure or treatment. - ✔A. an activity carried out to provide care or service.********* When developing department-specific performance measures and indicators, the quality manager as a consultant should A. conduct a literature search and select quality indicators. B. ensure that the numerator and denominator are clearly defined. C. prioritize the quality indicators for selection by the department leader. D. review the mission statement and seek physician input - ✔B. ensure that the numerator and denominator are clearly defined. ************ Situation-Background-Assessment-Recommendation (SBAR) is a A. tool to improve communication among caregivers. B. Six Sigma methodology. C. method that measures process variation. D. software package used in quality improvement. - ✔A. tool to improve communication among caregivers.************* The responsibility for providing organizational direction for a facility's continuous quality improvement program frequently rests with the quality A. teams. B. leader. C. council. D. facilitator. - ✔C. council.************ Which of the following is NOT a function of the facilitator on a quality improvement team? A. Keep minutes and records of the team's efforts. B. Keep the group focused on a central issue. C. Tactfully prevent anyone from dominating the discussion. D. Manage time. - ✔A. Keep minutes and records of the team's efforts.***************** The best approach for training staff about quality and patient safety is to A. require staff to complete mandatory online training at convenient times. B. develop posters and brochures that explain key quality concepts and place them strategically throughout the workplace. C. conduct multidisciplinary interactive sessions consistent with adult-learning principles. D. have the CEO meet with each department to explain the department's role in quality and safety. - ✔C. conduct multidisciplinary interactive sessions consistent with adult- learning principles. ************** An emergency department trends wait times from patient arrival to physician assessment. Data are reported using a run chart. Which of the following demonstrates a true statistical increase in treatment delays? A. 6 consecutive ascending data points B. 7 consecutive descending data points C. a zigzag pattern of 10 data points D. data points close to the mean line - ✔A. 6 consecutive ascending data points The term "performance" as used in healthcare quality improvement activities refers to: A. Interactive series of process steps B. Statement of expectation C. Effective execution of functions & processes D. Demonstration during accreditation survey - ✔C A key physician/licensed independent practitioner QM function is: A. Determination of what constitutes a deviation from an accepted standard of care B. Researching criteria options for peer review C. Determination of data collection methodology D. Tabulation of peer review data - ✔A Of the following conclusions concerning a licensed independent practitioners care drawn from org QM/QI activities would most likely be used during: A. Case management B. Re-privileging C. Productivity management D. Initial privileging - ✔B The most effective way to ensure patient safety as a dimension of performance is to: A. Sponsor a hotline B. Focus on processes/minimize blame C. Encourage patients & families to identify risks D. Have leaders who commit to & foster a safe culture - ✔D The responsibility to reduce risks of endemic & epidemic healthcare associated infection is vested in: A. An interdisciplinary team B. A qualified infection control practitioner C. The organization D. A qualified infection control attending physician - ✔C A trend has developed over the past year indicating that an internal medicine physician has significant difficulty treating patients with out of control diabetes. After 10 months of peer case review & meetings what additional actions may be appropriate? A. A letter B. Required consultation for all of the physicians diabetic patients C. Medical education D. Summary suspension of privileges - ✔B In any QM approach how can you best evaluate the effectiveness of action taken? A. Formulate a new special study B. Interview staff C. Do nothing D. Use the same performance measures to remonitor the process - ✔D The Baldrige Healthcare Criteria for Performance Excellence establish standards for: A. An award B. Corporate compliance C. A certification D. An accreditation - ✔A Based on most QI standards, those responsible to prioritize data collection to monitor org wide performance are: A. The Quality Counsel B. Evaluating dental care C. Performing peer review D. Analyzing sentinel events - ✔D Concerns arise after a new solo practice urologist receives membership in medical staff of an established practice. In order to avoid conflict of interest issues the best way to handle these concerns would be to : A. Have each urologist sign a confidentiality agreement B. Have a urologist from outside the group conduct the review C. Have each urologist review the cases & issues independently D. Have the urologist/head of group handle the review - ✔B Hospital infection control policies generally require: A. 100% concurrent surveillance for healthcare associated tracking B. Periodic monitoring (cultures) of staff/equipment C. The infection control committee be a medical staff committee D. Coordination of activities in patient care, ancillary & support services - ✔D The appraisal of individual practitioner performance in healthcare beyond minimum standards & criteria is known as: A. Continuous QI B. Peer review C. Intensive analysis D. Perceptive quality - ✔B What of the following is the greatest benefit of concurrent clinical review? A. Timely intervention to reduce the risk of adverse outcomes B. Ability to focus review on prioritized performance measures C. Ability to review outcomes of care & processes D. Timely assessment at onset of care for continuity - ✔A In conjunction with hospital credentialing, clinical privileges are granted: A. To all licensed independent practitioners B. Only to members of the medical/professional staff C. To all employees performing clinical procedures D. Only to active members of medical/professional staff - ✔C The most important patient safety issue to a utilization reviewer is : A. Timeliness of treatment B. Correct assignment of diagnosis or procedure code C. Medical necessity for treatment D. Appropriateness of healthcare setting - ✔C Patients are a key customers in PI. Of the following what is the most accurate way to measure patient perception of care after completion of treatment? A. Log & analyze concerns B. Collect data C. Utilize patient satisfaction surveys each quarter D. Utilize patient health outcome questionnaires for specific illnesses - ✔D In the Xerox 10 step benchmarking model the team seems to emphasize what QI component the most? A. Identifying customer needs B. Partnering/collaboration C. Innovation D. Prioritization - ✔B What can the QI professional do to best facilitate buy in on the part of a department? A. Restate the mandate B. Offer to do the work C. Provide background data concerning the selection of initiative D. Provide cost data - ✔C Once a department has gathered & aggregated their data the department QI task team should: A. Provide the data to the QI professional & the QI team B. Provide summary findings C. Provide information only to the medical staff D. Provide data & ongoing monitoring activity data - ✔A Clinical performance measures in disease management programs are based on: A. Standards of practice B. Practice guidelines C. Clinical privilege criteria D. Clinical pathways - ✔B Criteria based performance appraisal is used to: A. Assess current competence against standards of practice B. Document process is improvement C. Determine staffing needs D. Determine effectiveness of QI team improvements - ✔A A medical director who primarily manages from a distance, takes no time for review of studies or data & has little apparent interest in the QI process can be said to be: A. Autocratic B. Bureaucratic C. Participative D. Laisse faire - ✔D In a facility with a medical director who primarily manages from a distance, takes no time for review of studies or data & has little apparent interest rate n the QI process, QI efforts may fail due to: A. Lack of education B. Lack of resources C. Lack of leadership commitment D. Too many locations - ✔C The primary goal of quality/PI is to improve: A. Patient outcomes B. Patient care process C. Patient safety D. Patient satisfaction - ✔A Who has the ultimate responsibility for quality & patient safety? A. QI committee B. CEO C. Board of Directors D. Org leaders - ✔C Which is NOT correct regarding successful leaders? A. Define & inspire a shared vision B. Understand that transformation depends on successful leadership C. Enable others to lead D. Make quality everyone's responsibility E. Understand that significant change takes 18-24 months to implement & 8 years to anchor it in practice & culture - ✔E What is a fixed payment per patient paid in advance to medical service provider by a managed care group, amount doesn't change whether patient seeks medical care or not, risk is on providers side as patients may require more care than fixed amounts covers: A. Capitation B. Pay for performance system C. Performance appraisal D. Sliding payment system - ✔A What was implemented by Medicare & private payers to compensate/reimburse healthcare providers, includes pre-established quality & efficiency measures, includes financial incentives for attaining clinical care objectives? A. Capitation B. Pay for performance system C. Performance appraisal D. Sliding payment system - ✔B E. Emergency - ✔D What applies to TJC & HFAP accredited hospitals; approval of all new privileges, including new practitioners & new privileges for existing practitioners; peer review process is a part of it? A. Privileging B. Focused Professional Practice Evaluation- FPPE C. Ongoing professional practice evaluation D. Credentialing - ✔B What has criteria for conducting performance monitoring; has a method for establishing monitoring plan specific to requested privilege & determining duration of performance monitoring; circumstances under which monitoring by external source required; limited time & focused; implemented for all initially requested privileges ; criteria developed by medical staff for evaluating performance of practitioners when issues affecting provision of safe, high quality patient care is identified; focused period implemented for all initially requested privileges: A. Privileging B. Focused professional practice evaluation C. Ongoing professional practice evaluation D. Credentialing - ✔B What is a clearly defined process that facilitates ongoing evaluation of practitioners professional practice; data collected determined by individual specialty & approved by medical staff; used to determine whether to continue, limit, or revoke existing privileges; used like a report card to help practitioner improve patient care; compare one practitioner to peers to identify opportunities for improvements: A. Privileging B. Focused professional practice evaluation C. Ongoing professional practice evaluation D. Medical peer review - ✔C What is when medical staff are involved in measuring , assessing, & improving performance of licensed practitioners? A. Privileging B. Focused professional practice evaluation C. Ongoing professional practice evaluation D. Medical peer review - ✔D What are the following criteria used for - outcomes & processes should be measured; performance in relation to design of processes & expected or intended outcomes should be assessed; individuals with clinical privileges whose performance is questioned as a result of quality improvement activities should be evaluated; a peer of the medical practitioner should review the practitioners actions: A. Privileging B. Focused professional practice evaluation C. Ongoing professional practice evaluation D. Medical peer review - ✔D Which of the following isn't true regarding documentation of peer reviews? A. Minutes are normally part of the credentialing file B. Access/circumstances defined by policies & procedures C. Determine when external peer review is required D. Governed by state laws E. Peer review files are marked confidential - ✔A Which of the following isn't important for practitioner profiles? A. Based on performance B. Provided to each practitioner on a regular basis at the time of appointment & at regular intervals C. Quality determines the metrics D. Organizations may use software with risk adjusted algorithms - ✔C Improves safety of care using accreditation & certification as risk reduction activities; accredits hospitals , healthcare networks, home healthcare, nursing homes, long term care facilities, behavioral health, assisted living, ambulatory care, clinical laboratories, & disease specific care: A. NCQA B. Det Norske Veritas C. International organization for standardization D. The joint commission- TJC - ✔D Offers 6 accreditation, 5 certification, & 5 physician recognition programs; applies to organizations & individuals such as HMOs, PPOs, physician networks, medical groups, & individual physicians; organizations pass a rigorous, comprehensive review & annually report on their performance to use the seal: A. NCQA B. Det Norske Veritas C. International organization for standardization D. The joint commission - ✔A Accreditation program CMS approved (called NIAHO) to accredit hospitals & critical access hospitals & acquire ISO 9001 certification by the 4th year; annual deemed status surveys & quality improvement: A. NCQA B. Det Norske Veritas C. International organization for standardization D. The joint commission - ✔B Developer of voluntary international standards; state of the art specifications for products, services, & good practice; in healthcare, focus of standards is on quality management program: A. NCQA B. Det Norske Veritas C. International organization for standardization D. The joint commission - ✔C CMS authorized accreditation organization to survey hospitals on compliance with Medicare Conditions of Participation & Coverage; applicable to organizations such as hospitals & their clinical laboratories, ambulatory care/surgical facilities, mental health & substance abuse facilities, physical rehab facilities & clinical laboratories: A. Healthcare Facilities Accreditation Program- HFAP B. Commission on Accreditation of Rehabilitation Facilities- CARF C. Baldrige Program D. The joint commission - ✔A Accreditation process that assists service providers in improving service quality, demonstrating value, meeting internationally recognized organizational & program standards; includes an internal exam , onsite survey, quality improvement plan, & evidence of conformance to standards: A. HFAP B. CARF C. Baldrige Program D. The joint commission - ✔B Provides organizational assessment tools & criteria; educates leaders about practices of best in class organizations; recognizes national role models with presidential award for performance excellence; has 7 criteria categories; an organization may choose to use this for self assessment : A. HFAP B. CARF C. Baldrige Program D. The joint commission - ✔C Recognizes healthcare organizations for quality patient care, nursing excellence, & innovations in professional nursing practice; 5 model components- transformational leadership, structural empowerment, exemplary professional practice, new knowledge, innovation & Improvements,empirical quality results: A. Baldrige program B. Magnet Recognition Program C. NCQA D. The joint commission - ✔B Willingness to change culture & commit to personal change; understand business case for compliance; include continuous readiness within strategic priorities: A. Quality Managers B. Quality leaders - ✔B