مزاوله مختبرات

2021 ‫يناير‬ ‫الملف يخضع للتحديث المستمر‬
in project improvement , We pilot it in small scale and the results was

sustained for a year what is the next step should do ?
A- Another pilot study
B- public the result
C – repeat cycle
d – start new project
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A recent review of the risk management process within a medical facility
has revealed a number of serious failings. What is the healthcare quality
management professional’s role in preventing future risk management
errors from occurring?
a. Identify employees and staff members who contributed to the risk
management failures
b. Create a new risk management program that utilizes improvements in
technology and identifies failures earlier
c. Notify all employees about the risk management failures and disseminate
information to prevent future failures
d. Assist in revising the current risk management plan to take findings from
the review into account
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Healthcare quality professional is comparing healthcare associated
infection among hospital of varying sizes specialized services and
geographical region which of the following most useful
A- readmission rate
B- Healthcare associated pneumonia rates
C- risk adjustment rates
D- overall infection rates
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Medication errors with drug-drug interactions was 15.3 per 1000 admissions
dispensing , Benchmark was 5 , What is the best safety measure to do?
A. BCMA
B. CPOE
C. EMR
d. CDSS
Aly amin WTE file Excellence 2021

website : waytoexcellence.net/ whats app : 00201033838257
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Utilization management need to produce report of Cost, Effectiveness and
Appropriateness of care , what is the most suitable review approach :
A - prospective
B - retrospective
C - clinical data
D - administration claims
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the effectiveness of performance improvement training is best determined
by assessing
a. staff competencies
b. guideline compliance
c. organizational culture
d. patient satisfaction
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If organization’s leaders decided to integrate staff knowledge, skills,
behaviors for performance improvement into decisions regarding
recruitment, selection and promotion. All of the following will be
influenced EXPECT:
A- The culture of quality management will be fortified.
B- Those decisions will increase revenues in short term.
C- Staff feels leadership commitment toward performance improvement.
D- Organization’s employees will be motivated to share in quality activities.
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to facilitate change In your organization , you should focus on staff who
are:
A. Perceptive of change
B. Attitude business usual
C. Unmotivated appearance
d. motivated appearance
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in healthcare organization had high rate of Post operative urinary tract infection
, after change to new urinary catheter , the rate decreased , as a CPHQ you
should :
A- trend data over another quarter
B- send the data to procurement
C- get a new catheter
D- find statistical significance for decrease

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Team members are divided about the next course of action in an important
project. It appears that the conflict is severe enough to warrant
intervention. Who is responsible for managing the conflict?
A- Sponsor or Team Leader
B- Team Leader or Coach
C- Coach or Sponsor
D- Team Leader only
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The strategy for conflict resolution that emphasizes facts and finding an
appropriate alternative solution is called
1.smoothing
2. Negotiation
3.forcing
4. Discussion
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A failure mode and effects analysis (FMEA) provides which of the following
types of review?
a- Proactive
b- Retroactive
c- Concurrent
d- Retroactive
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A quality improvement manager must decide how to present data that
demonstrates the relationship between two process characteristics. Which
of the following data display techniques is most appropriate?
A. bar chart
B. scatter diagram
C. Pareto chart
D. line graph
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Which area you are recommending first for improvement action: they
change dispensing with transcription errors same numbers so same answer
a) Medication dispensing in ICU and observation
b) Medication administration in ICU and observation
c) Medication dispensing in north 2 and observation
d) Medication administration in ICU and south
Unit Time Medication Medication
dispensing Administration
errors errors
Observation 7am-7pm 30% 70%

7pm-7am 10% 40%
North2 7am-3pm 40% 20%
3pm-11pm 0% 10%
11pm-7am 10% 10%
South 7am-7pm 40% 30%
7pm-7am 20% 20%
ICU 7am-7pm 50% 40%
7pm-7am 30% 20%
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A healthcare organization's strategic plan objectives include a customer

satisfaction rating of 85%. The following data are available for three
units: Which of the following should a healthcare quality professional
recommend?
A. Change the target to 90% satisfaction.

B. Share Unit A's practices with other units.
C. Provide incentives for the staff of Units B and C.
D. Review the performance of the manager of Unit C.

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For a run chart for tracking the Central Line infection is called :
a- Mode
b- Standard division
c- Median
d- Mean
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Which is best to do during the accreditation survey:
A. To assign a team to answer the questions asked by surveyors
B. To have a departmental director who know 3 standards about their
concerned departments
C. To educate all staff members the FAQs by the surveyors
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CEO decides to have accreditation to the hospital after 18 months, what
should he do
A. Communicate accreditation process to all staff
B. Hire external quality expert to give lectures
C. Make monthly newspaper
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In profiling length-of-stay data for benchmarking, it is important that data be
A. raw numbers.
B. severity adjusted.
C. equal numbers.
D. reported monthly.
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Publicly report measures are developed through a life cycle in which of the
following sequences
A- first year data collection, public comment, evaluation
B- topic select, measure develop , public comment
C- measure developed, evaluation, topic selection
D- public comment, Measure developed, first year data collection
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Which of the following should be used to create clinical practice guideline :
A- national norms
B-Population based standard
C- established criteria
D-evidence based literature

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Primary consideration in selecting and evaluating criterion is that it be
a- team approve by the quality review committee
B- concerned with the cost of care
C- reflect the clinical practice
D-data that can be measured
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New pediatric psychiatry will open in one year. The utilization coordinator
is responsible for developing the utilization management progress. The
program success will depend on which factor
A- obtaining approve from the chief psychiatry of each stage
B-Provide education in service to all team member involved
C- develop program and present it to approve
D- involving the process owner in developing program
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Which of the following is true regarding medication errors:-
a- Associated with process failure
b- Prevented by review of evidence based practice
c- caused by gap between patients expectations and practice
d- avoid by uniform practice
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A surgeon did a surgery to a patient on the wrong organ ,the chief surgeon
admitted that the cause is not removing the splint doesn't give a chance
for marking the organ , there is disclosure happened with the patient with
an a apology ,the surgeon said that he knows his mistake and promise not
to repeat it again , you as a quality officer what you should do:
1.considering disclosure with a patient could lead to a litigation process...
2.consider that the chief surgeon has a hindsight bias to the surgeon and wants
to minimize the situation
3.no harm has happened and no need for further investigation
4.immediate investigation should be started and consider that the disclosure
of the surgeon reflect a strong safety culture
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Which of the following is the FIRST step in the strategic planning

process?
A. Defining organizational structure.
B. Setting goals and objectives.
C. Determining productivity indicators.
D. Establishing and controlling a budget
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Which of the following is the first step in facilitating change in an
organization?
a- Identify problems to be addressed in the organization
b- Get feedback from management on the problems to be addressed
c- Identify key people in the organization who should be involved
d- Develop a performance improvement plan
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There is a complain from patients or family regarding delay in care what
is the best action
A. Discuss with the nurses involved
B. Report to the manager
C. Trend the delay data
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facility has admission from different sources as below, what is the best
tool to demonstrate the proportion of admission for each source?
Source Admission
Home. 20,000
Physician referral. 10,000
Skilled nursing facility. 786
Others 50
a) Run
b) Histogram
c) Pareto
d) Control
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Quality professional want to improve communication with patient family

,but there are 3 problems faced him
“1” Patient family did not understand English
” 2” Difficulty in meeting treating physician
What he will do
A- Calculate RBN
B- Bring English translator
C- Convince patient family advisor
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The best tool to display stability of process rates over time is
A. run chart.
B. histogram.
C. Pareto chart.
D. control chart
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Outpatient Surgery Center a assembled a quality council from CEO, CFO
and Medical Director , who should else be added:
A- Nursing Director
B- Safety Environment Supervisor
C- Head of HR
D- Head of medical record
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Surgeon has 6.7 % SSI in a specific procedure, while his colleague has 3.3%
SSI for the same procedure. the data was reviewed by the Chair of
department; the Quality Professional Recommend ?
1- RCA
2- Focus review
3- Temporarily Suspension the surgeon
4. Stop the privilege of the first doctor.
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first task in a continuous quality improvement process analysis to
a. Define problems arising within the system
b. Monitor the system to ensure no new problems occur
c. Evaluate the effects of changes to the system
d-Separate external from internal problem.
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CPHQ believes that MARS infection rate is high what should CPHQ first do?
a. Repeat data collection process to justify a new rate
B. form a multidisciplinary team
b. Call infection control practitioner to obtain benchmark data
c. Inform risk manager to counsel staff to following infection (follow infection
control policies)?
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An organization set a goal 90% of waiting time to be below 15 mins, here is
a 10 cases time 5,5,9,10,12,12,12,14,22,25 with average 12.6 min what to
do?
1/set a trigger at 80%
2/review data with more than 15 mins
3/nothing, the target is met
4/ no thing
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Which tool used in major problems or issues that need to be addressed:
a- Affinity
b- Force field
c- Nominal group technique
d- Interrelationship diagram
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The major difference between traditional “quality assurance” activities
and the expanded quality improvement/performance improvement
activities is the QI/PI focus on:
A. People and competency
B. Analysis of data
C. Performance measures
D. Systems and processes
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One difference between Research Process and Quality Improvement
Process is that Quality Improvement Process:
A- Collect data for investigation.
B- Analyze data for making decisions.
C- Act on recommendations deduced from the conclusions.
D- Define the customers and problems.
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By forming a team After 1 month team attendance is declined ( team

dissolved ) , which stage of team development :
A- Storming
B- Norming
C- Performing
d-forming
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CPHQ wants to determine process measure to improve wound care
outcome, FIRST thing to do:
a- Three years prior best practice in wound care
b- Clinical trials in wound care
c- Search guidelines for wound care
d- Review clinical record for wound care sentinel events
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The role of a team facilitator is to focus on:
a) Analyzing problem during meetings
b) The process
c) Generating and selecting solutions
d) The content
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Availability of hand sanitizer is an example of:
a) Structure measure
b) Process measure
c) Outcome measure
d) clinical measure
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Internal customer in admission process ,or who is considered the internal
customer in an advanced nursing facility
a) nurse competing the initial assessment
b) family and patient
c) patient being admitted
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Which indicator can be considered most important for radiology

department
a) Timeout
b) Mammography turnaround reporting
c) Contrast induced complications
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Confidentiality of information is best accomplished by
a. limiting access.
b. obtaining proper consent to release.
c. having all staff sign a confidentiality agreement.
d. removing all patient and practitioner identifiers from documents.
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Which of the following is an example of patient-centered care?
a) Bedside rounds
b) Using two patient identifications
c) Pre-printed discharge instructions
d) Age based dosing
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Who is responsible about performance improvement plan:
a) Quality manager
b) Leaders
c) GB
d) CEO
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Which of the following is the major responsibility of senior management
regarding continuous quality improvement?
a) Communicate the organizational mission and values.
b) Develop organization-wide training sessions.
c) Participate in Quality Council activities.
d) Conduct periodic reviews of the program
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It's noticed that increase aggressive behavior among psychiatric patients ,

what is the appropriate action
A- Focus group with end user
B- Trend data over time
C- Review restrains policy
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Hospital plan applied telehealth program and need to spread it among its
facility, among who of the following need to be added in the team to help
in communicate it:
A-Adopter audiences
B-Local media
C-Legal legislation
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in control chart , the upper and lower control limit is :
1- used to identify the distribution of data.
2- calculated by using the collected data.
3- it is in threshold
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Characteristics about performance improvement:
a) Systematic
b) Timely
c) Autonomous
d) departmental
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Joe Smith wants to study patient satisfaction in his institution but wants to get the
largest group possible so he conducts his study in the local mall. His study might be
criticized not only for reaching individuals who are not patients, but also that it is
a) Capitated
b) Non randomized
c) Randomized
d) Varied
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Who is responsible for creating and monitoring the implementation of improvement

project work plan and time line
a) Sponsor
b) Team leader
c) Team facilitator
d) Quality council
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What is the tool used to display large amount of data language in the group that
have related topics
a- ishikawa
b- force field
C- affinity diagram
d- control chart
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to assist physician to improve their performance with pay for performance program,
first begin with:
A- obtain a copy of the physician measures.
B- Suggest educational program for the physician
C- Searching for benchmark data for physician practice
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An outbreak of measles in a school district resulted in 58 cases over a period of 5
months. Which of the following data displays best illustrate the monthly occurrence of
measles
a) Run chart
b) Pie chart
c) Gantt chart
d) Scatter diagram
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Which of the following is the best tool to begin on investigation into the causes of
laboratory labeling error?
a) Affinity diagram
b) Prioritization matrix
c) Flow chart
d) Histogram

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Empowerment give employees the opportunity to:
a) Solve problem
b) Make more money
c) Gain respect of peers
d) Achieve upward mobility
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Quality improvement team outcomes are best evaluated by which of the following?
a) Team leader
b) Senior leadership
c) PDCA process
d) Nominal group technique
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Based on identified issues, a healthcare quality professional examines 100% of one
physician’s admission 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
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What sampling technique involve selecting the medical record of every fifth patient
undergoing cardiovascular bypass?
a) Convenience
b) Systematic
c) Stratified
d) Simple random
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Which of the following sample techniques selects participants based on their
availability in a certain place during a specific time frame?
a) Quota
b) Random
c) Volunteer
d) Convenience

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An outbreak 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) Control chart
c) pareto chart
d) flow chart
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A failure mode and effects analysis (FMEA) provides which of the following types of
review?
a) Proactive
b) Retroactive
c) Concurrent
d) Retroactive
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Replacing retrospective review with concurrent review is an example of
A. a paradigm shift.
B. a process improvement.
C. an empowerment process.
D. productivity enhancement.
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To reduce the incidence of ventilator-associated pneumonia (VAP) in a critical care
unit, who should be included on a quality improvement team?
A. Intensives , 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
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Medication reconciliation is a process intended to
A. improve efficiency of medication administration.
B. investigate formulary discrepancies.
C. identify and resolve discrepancies.
D. increase use of electronic medication administration.

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The key element for safety medication management
A . Relying on barcode instead of two patient identifiers
B. use standard method for medication administration
C. restricting formulary generic drug
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The results from a Nominal Group Technique session can be presented as 5 points
A. bar chart
B. pie chart
C. run chart
D. scatter plot
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The key element for safety medication management
A . Relying on barcode instead of two patient identifiers
B. use standard method for medication administration
C. restricting formulary generic drug
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Leader of a project did a brain storming then he put the ideas into ( Thematic) group.
What is the tool he used for this?
1- Affinity Diagram
2- Ishikawa
3- flow chart
4- nominal group
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Leader of a project did a brain storming then he put the ideas into ( Thematic) group.
What is the tool he should use next?
1- Affinity Diagram
2- Ishikawa
3- flow chart
4- multi voting
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When a healthcare organization is contracting with an outside provider for services,

the subcontractor must:
A. provide a representative to the Quality Council.
B. Agreed upon performance expectations
C. have an active risk management program.
D. have a competitively priced service.
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Which is best solved by quality team:
A. System problem
B. Customer complains
C. Financial problem
D. Administrative problem
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The patient discharged without any counseling of his care, this problem, concerned
with:
A-medical coverage
B-case management
C-transition care
D-reconciliation
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Performance improvement program should be initiated when:
a. Staff turnover is very high in certain units
b. Staff overtime is increasing
c. Staff wants new working schedule with4 days off
d. Data analyzer in lab is giving wrong results
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One difference between continuous quality improvement and traditional quality
assurance is that quality improvement always
A. requires the application of statistical process control.
B. excludes monitoring and evaluation of care provided.
C. focuses on systems or processes.
D. addresses potential problems.
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For continuous quality improvement to be successful who must be included in staff
A. administrator
B. person performing process
C. quality management representative
D. department supervisor

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Who is responsible for providing continuous quality improvement direction
A. facilitator
B. quality council
C. leader
D. team
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Who is responsible for quality improvement within organization
A. quality manager
B. frontline staff
C. everyone within organization
D. chief executive office
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Who is ultimately responsible for the effective implementation of the quality program:
a. Governing Body
b. CEO
c. All staff
d. The CFO
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To establish evidence based practice guideline, it is best to
A. reply on subjective, expert opinion
B. review every possible intervention or treatment
C. include those who resist process
D. allow individual practitioner to make any exception to guideline
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The best way to facilitate change within a healthcare organization is to
a. Involve the individuals directly affected by change
b. Communicate through group meeting
c. Arrange presentations by senior leaders
d. Communicate through group e – mail
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An ambulatory / outpatient care facility identifies an opportunity to improve the
turnaround time for report of X- Rays performed at a local hospital. Which of the
following groups should be involved in the team to improve the process
a. Administrative representative from both facilities
b. Primary care physician, clinical nurse, and clinical administrators
c. Radiologist, primary care physician, and clinical medical records
d. Clerical, clinical, and administrative staff from both facilities
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The use of clinical pathways and guidelines in hospitals should do which of the
following?
a. Minimize variation in patient care
b. Reduce length of stay
c. Improve patient satisfaction
d. Identify errors in patient care
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Hospital leaders are confronted with challenge of increasing quality while reducing
cost. Which of following branch is the best advance for improving effort:
A. Support activity that improves outcomes and reduce variation
B. Develop a new service and increase revenues
C. Increase charge and decrease cost
D. In collaborate customer satisfaction result to quality initiative
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In statistical process control, it is important first to:
a. Eliminate assignable causes of variation
b. Eliminate random causes of variation
c. Prioritization causes of variation
d. Eliminate all causes of variation
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Once statistical control is established, the next step in continuous quality improvement is to:
a. Slowly increase the rate of control monitoring
b. Rapidly increase the rate of control monitoring
c. Eliminate the need for rework
d. Improve the process by reducing variation
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IHI Global Trigger Tool record , reviewers found an unreported case of a radiologist
inadvertently causing a small pneumothorax (collapsed lung) by incorrectly
positioning a percutaneous small-bowel feeding tube , To whom should the reviewers
report this finding?
A. Chief Medical Officer
B. Chief of Radiology
C. Risk Manager
D. Director of Quality
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A poster contain information will most effectively convey outcome information to

internal customers?
A. 2 Bar graphs showing the 2 unites with fewest number of falls over past year
B. Patient fall decreased over 4 years printed above a line graph showing percentage
of falls to patient days
C. Patient fall indicate downward trend. Go team!
D. Patient fall last year were 0.5% of patient days printed to photograph
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Healthcare quality professional wants to develop a continuous survey readiness model
the initial step should be
A. Establishing leadership accountability
B. Appointment a steering group
C. Planning education for all entire team
D. Selecting the standards to be taught
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A pilot test was completed, action determine to be effective, what is the next step in
rapid cycle methodology:
A- Spread change
B- Benchmark
C- Define scope
D- Set aims
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Results from the Laboratory always delay. Multidisciplinary team is formed and
discovered there is high turnaround. Which tool can be used to display overlap in work
flow process?
A. Tree diagram
B. Spaghetti
C. Force field analysis
D. Process mapping with swim lane
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Risk manager asked CPHQ to help to improve compliance with process by corrective
action plan, what he will do to help:
A- Identify non-compliance causes by RCA
B- Analyze the data to risk management committee.
C- Check if the action plan is compliance with national standards.
D- Provide education to staff about compliance standards.
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The hospital considering changing the process of admission from emergency
department. To support patient safety when this process deployed. What should the
healthcare quality professional during the redesign of the process?
a. Complete FMEA of the new process
b. Analysis incidents report of the last year PARETO CHART
c. Examining the stability and variation of the new process by using control chart
d. Conducting RCA to predict errors of the new process
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The hospital leader decided to use leverage technology in ambulatory surgery clinic in
order to improve patient safety. Which of the following can reflect it?
A-Decrease/ less oral communication, more on electronic
B-The staff unable to process to next unless double checks done by other staff using
their login.
C-Decrease incident reported within the system
D-increase workaround recorded using BcA
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When a Sentinel Event (SE) occurs, the Risk Manager initiates a Root Cause Analysis
(RCA). To appropriately evaluate the cause of an SE,
A. terminate all processes that led to the event until the RCA is completed.
B. start with the assumption that human error was the most likely cause of the SE.
C. leadership must participate in the RCA.
D. start the RCA immediately to appropriately deal with causality.
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in best describe the study of: The interrelationships between people, tools they use,
and the environment they work
A- Human factors/ ergonomics
B- Environment factors
C- process mapping
D- work engineering
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To integrate performance improvement with the organization planning there must be
alignment :
A-performance improvement teams and human resource
B-strategic and improvement objectives
C- measuring and monitoring performance results
D- quality control processes and system
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last step in FMEA methodology is
A. Analysis of effects
B. Measure results
C. Keep monitoring
D. Results reporting
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FMEA is basically considered a technique of
1- risk reduction
2- risk identification
3- risk analysis
4- risk assessment
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Which statement best describes the selection of the FMEA team members?
a. The FMEA team should be limited to no more than 4 people to minimize disruption
of processes.
b. The FMEA team should include “front-line” representatives of each part of the
processes under analysis.
c. The process will last 1 year and consist of bi-weekly meetings.
d. The FMEA team is more efficient when managers can attend and speak about
their employees’ processes.
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leader that always arrange meetings and encourage employee on day to day
operation, which type of leadership?
a. Participative
b. Transformational
c. Motivated.
D. transactional
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Leader assigned few meetings and facilitating the staff for more autonomy for daily
operation and scheduling :
A- Participative
b. Transactional
c. Transformational
d. Motivated
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Leader that always arrange meetings and facilitating it to reach for staff moral with
the scheduling and day operation , which type of leadership?
a. Participative
b. Transactional
c. Transformational
d. Motivative
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New quality manager was assigned to review current projects in a hospital. There is a
time constraints, and all projects have to be done on time. What should he do?
a. explicit all the project goals
b. meet with all supervisors and follow with them weekly
c. do a plan and distribute tasks and objectives of projects according to the specified
period and follow-up projects.
d. purchase a new software to help in follow up projects
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An important reason for monitoring near miss is to
A-prevent negative publicity
B-identify incompetent staff
C-provide lesson to the staff
D-support disciplinary action

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tools used to compared the current level with desired level
A-work flow
B- flow map
C-qualitative analysis
D-gap analysis
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If were in meeting showing low results, and someone said this not the problem. The
problem is the protocol was not followed. Other one said the data is not valid and how
to have good outcome in this way? As a CPHQ What should you do?
A-Met them after meeting
B-Ask them to show evidence ( data ) for what they said
C- voting for the rest the meeting members
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Organization with notable fewer than expected adverse events
A. low reliable
B. high reliable
C. effective risk management
D. effective quality management
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what is meant by " lean production“
a. assess intervention effectiveness
b. making each person more efficient
c. eliminating waste in all form.
D. reducing process variation

quality council decided to start new 3 initiatives ( hand hygiene , surgical checklist , guideline )
and ordered Who achieves target of ( level 1) with 100$, and reward the staff who achieves
target of (level 2) with 200$. According to the following table, who of the following staff will
NOT take any incentives?
Staff # Staff # 2 Staff # 3 Staff # 4 Level of achievement
1 Level 1 Level 2
Hand Hygiene 75% 60% 95% 80% 70% 90%
Surgical check list 70% 60% 90% 80% 65% 85%
Guidelines 80% 70% 95% 90% 75% 95%
a) Staff # 1
b) Staff # 2
c) Staff # 3
d) Staff # 4
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Recent patient satisfaction surveys demonstrated that responses to the following
statements did not meet the 80% benchmark : Which two performance improvement
activities should the organization focus on FIRST?
a) Add magazines and music to the holding area; monitor staff conversations for
appropriateness.
b) Provide educational sessions for staff to improve patient communication skills;
renovate waiting area.
c) Add magazines and music to holding area; renovate waiting area.
d) Provide educational sessions; review with staff about the appropriateness of
personal conversations in front of patients.

An employee health program includes a pre-employment health

assessment for all prospective employees which is asked to be completed
and the results should be known prior to assumption of duties. A
retrospective study of 200 records displayed in the following chart. Review
of this information indicate which of the following:
A- Approximately 95% failed to meet the standard objectives.

B- There is no problem since 35% of health assessments are completed.
C- A significant number of terminations resulted from lack of completion of
health.
D- The provider is in significance compliance with the program.
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Quality council wants to evaluate team improvement for last year. Which
one you choose to improve?
A- staff productivity
B- team satisfaction
C- team growth
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An emergency department’s quality improvement report for the first
quarter of the year showed the following:
In which of the following areas should the healthcare quality professional

initiate further process analysis? And which tool can be used for data
display?
A. Problems associated with treatment, flow chart.

B. Misinterpreted x-rays; control chart.
C. Problems associated with treatment; pareto chart.
D. Misinterpreted x-rays; run chart
***************************************************

Of the following possibilities, what is does the control chart below tell you
(CL = Center Line—either mean or median, depending on type of data; LCL
= 0)?
a. Three sentinel events occurred since mid-2006 with effective intervention.

b. Special cause variation occurred with effective intervention in mid-2007.
c. Falls are within control limits since mid-2006.
d. Falls are out of control since mid-2007.
***************************************************

The following data is 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. Review ICU fall protocol.
D. Conduct further analysis of fall data.
***************************************************

Training is being determined based on treatment record review results.

The following weighted results are available: Based on these results, which
of the following areas should take priority for training?
A. assessment
B. external communication
C. care plan
D. progress notes
***************************************************
Use the following data to answer the following:
The rate of overall surgical wound infections:

a.32%.
b.23%.
c.30%
d.40%
***************************************************

The following table present los in one hospital for 2 years. What you can
conclude and which tool you will use to display the data over the last two
years
A- LOS in second year increase and can be displayed by Pareto

B- LOS of stay in second year decrease and can be displayed by control chart
C- LOS in second year decreased and can be displayed by Pareto
***************************************************
Which topic should has the opportunity first?
A. Drinking
B. Smoking
C. Preterm Birth
D. Diabetic foot examination
***************************************************

According to the table, Which of the following has the higher priority:
A. ( D ) Because higher severity

B. ( A ) Because higher frequency
C. ( C ) Because higher criticality
D. ( B ) Because higher sum of all
***************************************************
Of the followings NOT example for sentinel event
A. PT attempt suicide
B. hemolytic Drug reaction
C. death of patient due to medication error
D. surgery on wrong part of the body
***************************************************
Of the followings NOT example for sentinel event
A. PT threating to suicide within 24 after admit
B. hemolytic TRANSFUSION reaction
C. death of patient due to medication error
D. surgery on wrong part of the body
In the business cycle, the negative cash flow present in which of the
following stages:
A- Harvest stage
B- Growth stage
C- Maintenance stage
D- Gains stage

***************************************************
Which of the following is the best approach when implementing a National
Patient Safety Goal related to identifying potential errors in a patient’s
care, treatment and services?
A. Providing the patient and family an opportunity to ask questions
B. Having the patient provide return demonstration of the knowledge
provided
C. Showing a video to a patient and their family
D. Giving both written and verbal instructions to a patient and family
***************************************************
A hospital is working to reduce re admissions. 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. demonstrating understanding by return demonstration
C. showing a video to a patient and their family
D. requesting the home health nurse provide patient instruction
***************************************************
A patient was taught how to self-administer insulin. Which of the following
is the best method to assess patient’s understanding of the teaching?
A. Return demonstration
B. Patient satisfaction survey
C. Family’s ability to verbalize instructions
D. Written pre and post-test
***************************************************

facility decided to implement Standard Precautions 1 year ago, but

compliance has been poor. In addition to assessing the causes for poor
compliance, the most effective way for the organization to improve
compliance is to
A. stock personal protective equipment (PPE) in the clean utility room.
B. initiate return demonstration as a part of staff competency.
C. show a videotape on Standard Precautions quarterly.
D. review and revise hand washing policies and procedures.
***************************************************
advantages of probability samples includes:
a- depends on experts opinion
b- convenience , speed , lower cost
c- possible sources of bias removed
d- selection will be based on desired characteristics
***************************************************
An effective risk-management program for a health care organization
emphasizes
A. Harm prevention for patients, visitors, and staff
B. Reduction of financial losses
C. Staff training and education
D. Compliance with accrediting agency standards
***************************************************
Which of the following is the primary goal of risk management?
A. Identify and manage risks to promote patient safety
B. Maintain an effective incident reporting system.
C. Perform failure mode and effects analyses.
D. Eliminate financial loss associated with legal actions
***************************************************

Which of the following is the primary goal of risk management?

A. Identify the high risk areas of the organization.
B. Maintain an effective incident reporting system.
C. Perform failure mode and effects analyses.
D. Reduce financial loss associated with legal actions.
***************************************************
A utilization management department of a hospital has collected data on
length of stay and readmission rates. Compared to benchmarks, the length
of stay rates are higher and readmission are lower. Which of the following
is the next step?
A. Identify additional benchmarks to compare the data.
B. Conduct a cost-benefit analysis.
C. Display readmission rates with a run chart.
D. Investigate the length of stay rates
***************************************************
A utilization management department of a hospital has collected data on
length of stay and readmission rates. Compared to benchmarks, the length
of stay rates are higher and readmission rates are lower. Which of the
following is the next step?
1. Identify additional benchmarks to compare the data.
2. Conduct a cost-benefit analysis.
3. Analyze readmission rates with a run chart.
4. Continue to monitor length of stay rates
***************************************************
The following is the first step in facilitating change in an organization?
A. Review customer satisfaction survey
B. Get feedback from staff on problems to be addressed
C. Identify key people in the organization that should be involved
D. Develop a performance improvement plan

***************************************************
The best way to facilitate change within a healthcare organization is to:
A. Involve the individual directly affected by the change
B. Communicate through group meeting
C. Arrange presentation by senior leaders
D. Communicate through group e-mail
***************************************************
One major difference between traditional quality assurance and quality
improvement is that quality improvement:
A. Stresses peer review, while QA focuses on the customer
B. Focuses on the individual while QA focuses on the process
C. Stresses management by objective while QA stresses team management
D. Focuses on the process while QA focuses on individual performance
***************************************************
The physical difference between quality assurance and continuous quality
improvement is a shift focus from:
A. Retrospective review to concurrent screening
B. Individual faults to focus on customer satisfaction
C. Identify poor performance to good performance
D. Short term gain to long term one
***************************************************
A chief quality officer has the responsibility for education and
implementation of a continuous quality improvement process. To affect
cultural change, administration must
A. Believe the costs are justified by the benefits.
B. Be assigned as a member of a team.
C. Receive quarterly reports.
D. Limit training to managers and supervisors.

***************************************************
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.
***************************************************
After the team action the plan and implement it ,and made
recommendation ,what next step on PDCA cycle is now should follow;
a. Plan
b. Do
c. Check
d. Act
***************************************************
what is the highest weighted mean
a) mean 3 weighted mean 3.4
b) mean 9 weighted mean 6.5
c) mean 6 weighted mean 9.2
d) mean 2 weighted mean 2.3
***************************************************
Customer gives score to the criteria , What's the highest weight mean
score :
Score mean - score weight
A- 3 - 0.9
B- 4 - 0.8
C- 5 - 0.7
D- 6 - 0.3
***************************************************
Pharmacy staff was informed health care professional that use expensive
drug has been increased over the last six month , which of the following
would be health care professional next step :
a. Collect data related to striating and monitoring the effective of the drug
b. Collect data related to the prescribing and dispensing patterns of drug
c. Continue monitoring the pharmacy data and addition six month
d. Recommended to review of prescribing of Practitioner
***************************************************
Effectiveness of local flu vaccination program is best measured by
A. local Immunization rate to local incidence rate
B. local vaccination rate to local prevalence
C. local prevalence rate to one national
D. national incidence rate to local incidence rate
***************************************************
The prevalence rate of a disease depend on the
a- Number of new cases and the population at risk
b- Incident rate and duration of the disease
c- Incident and change in the balance of etiological factors
d- Total number of cases and the population at risk
***************************************************
Sentinel event is a variation in :
A- Staffing
B- Process
C- Structure
D- Competence
***************************************************

A sentinel event is regarded as a:

a. Common cause variation
b. assignable variation.
c. Noise.
d. Random variation
***************************************************
A healthcare organization is seeking accreditation. The first step the
healthcare quality professional should take is to
A. review the organization's bylaws, rules, and regulations.
B. becomes familiar with the appropriate standards.
C. establishes a quality assessment committee.
D. review the organization's policies and procedures
***************************************************
An Organization ask a CPHQ to help in preparedness to survey of
accrediting body, the quality manager will first:
A. Assign a team for the survey
B. Arrange for mock survey
C. Educate staff about types of questions that may be asked.
D. Review the adherence of the organization to quality standard of
accreditation
***************************************************
The most important initial step in preparation for accreditation survey is…
A. Ensure clinical competence
B. Provide teaching tools.
C. Standards education
D. Quality improvement activities.
***************************************************

An organization hires a quality professional to pass quality improvement

concepts to its staff. The first step the quality professional should do is to
a- Deliver lectures to the staff
b- Assess the present knowledge of the staff
c- Review the previous performance of the staff
d- Make interview with the staff
***************************************************
Which of the following could be used as an outcome measure during
indicator development ?
a) Staff adherence to a standard of practice
b) Compliance rate for specific surgical procedure
c) Required diagnostic testing performed before medication was prescribed
d) Laboratory compliance with policy and procedure for drawing peak and
through levels
***************************************************
In team decision making, consensus means
1. a unanimous vote.
2. everyone getting what they want.
3. everyone finally comes around to the "right" opinion.
4. everyone understands the decision and can explain why it is best
***************************************************
Decision by "consensus" means:
A- unanimous agreement
B- all support the decision
C- the agree of the majority
D- nobody agrees
***************************************************

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.
***************************************************
The role of a team facilitator is to focus on
A. Analyzing problems during meetings
B. The process
C. Generating and selecting solutions
D. The content
***************************************************
One of the team members that keep members on track and focus on the
process is
a. Leader
b. Facilitator
c. Quality manger
d. Minutes recorder
***************************************************
hospital purchases additional malpractice insurance and general tort
liability insurance prior to introducing a pediatric heart surgery program.
This is an example of
A. risk transfer.
B. risk avoidance.
C. risk reduction.
D. risk retention.
***************************************************

Comparison data is best displayed by

a. flowchart, cause and effect diagram, scatter diagram.
b. run chart, table, scatter diagram.
c. pie chart, control chart, Pareto chart.
d. flowchart, cause and effect diagram, affinity diagram.
***************************************************
Relationships are best displayed by a
a. flowchart, cause and effect diagram, or scatter diagram.
b. run chart, table, or scatter diagram.
c. pie chart, prioritization matrix, or Pareto chart.
d. flowchart, cause and effect diagram, or check sheet.
***************************************************
the best indicator used by an ambulatory setting to measure its outcome is
a- number of admissions to the hospital
b- number of surgeries
c- claims data
d- number of dispensed drugs
***************************************************
When there's uncertainty about the outcome of the process with presence
of guidelines and experienced staff, the process is considered as:
A. Complicated
B. Complex
C. Simple
D. Flexible
***************************************************

In special cause variation, the source of variation is:

A-Intermittent, unpredictable, chronic , extrinsic and assignable.
B-Intermittent, unpredictable, unstable, extrinsic and assignable
C-Intermittent, inliers, unstable, extrinsic and assignable.
D-Intermittent, unpredictable, unstable, and intrinsic and assignable
***************************************************
Indicators designed to identify potentially avoidable complications
A. Prevention quality indicators
B. Inpatient quality indicators
C. Patient safety indicators
D. Pediatric quality indicators
***************************************************
The senior leaders of a hospital are prioritizing performance improvement
initiatives for the coming year. Which of the following tools will be most
useful for this purpose?
1. Pareto chart
2. Cause-and-effect diagram
3. Affinity diagram
4. Stratification
***************************************************
A balanced score card for an organization is best described as
A-A graphic display of departmental performance
B-An integrated report showing the best performing teams
C-A representation (summary) of key performance indicators
D-A tool to reflect the priorities of the organization customers
***************************************************

healthcare quality program had prepared a balanced score card that

displayed patient satisfaction was 98%, financial target has been met ,
medication error had been increased by 30% and heart surgery rate
decreased 3% , what additional information the governing body may ask
for?
a) type of medication error.
b) heart surgery case.
c) patient satisfaction data.
d) review patient compliant .
***************************************************
Which of the following statements about the balanced scorecard is FALSE
a) It is a strategic performance management tool.
b) It presents a mixture of financial and non-financial measures.
c) The overall score on the balanced scorecard gives a summary of the
organization's performance
d) Each measure in the balanced score card has a target
***************************************************
The main difference between a dashboard and a scorecard is that…
a. A dashboard is only to be viewed by senior administrators
b. A scorecard includes performance measures from multiple departments
c. A dashboard only includes one measure of performance
d. A scorecard describes past performance, while a dashboard depicts
performance in real team
***************************************************
"Occurrence reporting" is a type of
a. risk reduction
b. risk evaluation
c. risk identification
d. risk prevention

***************************************************
Patient specific indicators are not useful for
A. Reappointments of practitioner
B. Monitoring safety
C. Reporting to a senior management team
D. Comparing performance to external standards
***************************************************
What are the two type (Level) of patient safety indicators (PSIs) :
A. Pediatric and Prevention
B. Inpatient and Pediatric
C. Provider and Area
D. safety and quality
***************************************************
Indicators designed to identify potentially avoidable complications are:
A. Prevention quality indicators
B. Inpatient quality indicators
C. Patient safety indicators
D. Pediatric quality indicators
***************************************************
The system that classifies people into homogenous groups, either by
disease, diagnostic or therapeutic procedures performed, method of
payment, duration of hospitalization or intensity and type of services
provided. This system means:
A. Demand management
B. Disease management
C. Utilization management
D. Case mix
***************************************************

The average between the highest and lowest measures is the

A-Median
B-Mean
C-Mode
D-Dispersion
***************************************************
The best way to evaluate effectiveness of performance improvement
training is through
A- self assessment
B- participants' feedback
C- observed behavioral changes that staff starting initiating PI processes
D- post-test results


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2021 ‫يناير‬ ‫الملف يخضع للتحديث المستمر‬

in project improvement , We pilot it in small scale and the results was

Aly amin WTE file Excellence 2021

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Aly amin WTE file Excellence 2021

Observation 7am-7pm 30% 70%

A healthcare organization's strategic plan objectives include a customer

A. Change the target to 90% satisfaction.

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Which of the following is the FIRST step in the strategic planning

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Quality professional want to improve communication with patient family

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By forming a team After 1 month team attendance is declined ( team

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Which indicator can be considered most important for radiology

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It's noticed that increase aggressive behavior among psychiatric patients ,

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Who is responsible for creating and monitoring the implementation of improvement

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Aly amin WTE file Excellence 2021

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When a healthcare organization is contracting with an outside provider for services,

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A poster contain information will most effectively convey outcome information to

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Aly amin WTE file Excellence 2021

Aly amin WTE file Excellence 2021

An employee health program includes a pre-employment health

A- Approximately 95% failed to meet the standard objectives.

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In which of the following areas should the healthcare quality professional

A. Problems associated with treatment, flow chart.

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a. Three sentinel events occurred since mid-2006 with effective intervention.

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The following data is being analyzed based on 6 months of incident reports

A. Continue to track and trend incident reports.

Aly amin WTE file Excellence 2021

Training is being determined based on treatment record review results.

The rate of overall surgical wound infections:

Aly amin WTE file Excellence 2021

A- LOS in second year increase and can be displayed by Pareto

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A. ( D ) Because higher severity

Aly amin WTE file Excellence 2021

Aly amin WTE file Excellence 2021

facility decided to implement Standard Precautions 1 year ago, but

Aly amin WTE file Excellence 2021

Which of the following is the primary goal of risk management?