Question #1

A strategy used in brainstorming is that ideas are

A. prioritized as they occur.
B. all recorded.
C. discussed when they are mentioned.
D. progressively eliminated.
Hide correct answer

Question #2

Which of the following should a Quality Council provide to best ensure success of
performance improvement teams?

A. empowerment and training

B. indicators and a data analyst
C. standards and procedures
D. facilitator and recorder

Question #3
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, and ease of detection
B. probability, likelihood, and criticality
C. response, evidence, and outcome
D. effectiveness, risk, and priority

Question #4
Which of the following charts would most likely be used first in a root cause analysis?
A. Pareto
B. control
C. flow
D. Gantt

Question #5
A summary of antibiotic usage for the fourth quarter showed that an internal medicine
department did not meet pre-established criteria in 82% of the patients reviewed. Following
review, the pharmacy and therapeutics committee should recommend that the results be
shared first with the
A. utilization committee.
B. Quality Council.
C. governing body.
D. chief of the department

Question #6
When considering the use of an external subject matter expert (SME), which of the
following characteristics is most critical?
A. references of the SME
B. cost of the SME's services
C. geographic location of the SME
D. leadership's personal preference

Question #7
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

Question #8
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

Question #9
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 Centres for Medicare & Medicaid Services (CMS) survey.
D. a healthcare organization that passes Centres for Medicare & Medicaid Services (CMS)
survey.

Question #10
Random screening of new-borns 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 new-borns 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 new-borns with a family history of G6PD.

Question #11
Frequency distribution can best be displayed through use of
A. an interrelationship diagram.
B. a force field analysis.
C. a flow chart.
D. a histogram.

Question #12

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.

Question #13

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, and name of a medication administered to a patient in error
B. the patient found on the floor next to the bed with the patient's 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

Question #14
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.

Question #15

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.

Question #16
Staff has been trained and oriented on a new electronic incident reporting system. In the
past, staff could report anonymously. The new system requires staff to sign in with an
individualized username and password. Three months after implementation, there is a
sharp reduction in the number of reported incidents. Which of the following reasons for
underreporting of incidents is of greatest concern?
A. staff fears of negative consequences of reporting
B. time required to complete an incident report
C. incomplete understanding about required reporting
D. lack of knowledge about how to use the system

Question #17

The leader of a pain management performance improvement team has asked the Quality
Council to disband the team. The most important factor for the Quality Council to assess is
A. the amount of data the team has collected.
B. the effectiveness of the team leader and facilitator.
C. how well the team met the intended outcome.
D. the length of time the team has been together.

Question #18

Which of the following is the first step in preparing for an initial accreditation or certification
survey of an organization?
A. Assess staff knowledge and plan staff training.
B. Hire a consultant and conduct a mock survey.
C. Appoint a survey coordinator and prepare a survey agenda.
D. Review the standards and determine readiness.

Question #19

A failure mode and effects analysis (FMEA) provides which of the following types of
review?
A. retroactive
B. proactive
C. retrospective
D. concurrent

Question #20
Quality improvement teams go through stages of development. These team development
stages include all of the following EXCEPT
A. forming.
B. performing.
C. norming.
D. conforming.

Question #21
A physician who has a high inpatient mortality rate compared to others in a facility should
first be
A. suspended in the interest of patient safety.
B. counselled by the department chairperson.
C. evaluated by the credentialing committee.
D. subjected to a more in-depth review of cases.

Question #22
A medication error occurred resulting in a severe adverse outcome. In addition to informing
the patient and/or family, a healthcare quality professional should
A. implement new technology.
B. conduct a root cause analysis.
C. reassign the employees involved.
D. perform a regression analysis.

Question #23
To avoid misinterpreting variances, which of the following statistical tools should be used?
A. fishbone diagram
B. control chart
C. Pareto chart analysis
D. force field analysis

Question #24
Which of the following should be included in an annual performance improvement report to
a governing body?
A. team achievements
B. meeting minutes
C. incident/occurrence reports
D. physician peer reviews

Question #25
The quality improvement director is responsible for coordination of accreditation survey
activities. Responsibilities will most likely include
A. educating staff to all standards, writing the survey report, and completing the survey
application.
B. developing a protocol for a mock survey, conducting unannounced surveys, and
challenging the survey report.
C. facilitating self-assessments of compliance with standards, communicating new
requirements to pertinent parties, and distributing the agenda for the survey.
D. preparing for unannounced surveys, disseminating the survey report, and developing
new standards.

Question #26
A patient safety program can best be enhanced by which of the following technologies?
A. online evidence-based medicine guidelines
B. computers on wheels at the patients' bedsides
C. digital medication reference materials
D. barcode system for medication administration

Question #27
A healthcare provider recently conducted a customer satisfaction survey that focused on
the five key quality characteristics in the graph below:

By analysing the information, the provider can identify that customers were most
dissatisfied with
A. caring and most satisfied with cost.
B. cost and most satisfied with caring.
C. communication and most satisfied with comfort.
D. cost and most satisfied with communication.

Question #28
A culture of patient safety in an organization will have been successfully created when
A. staff members serve as safety advocates.
B. near miss reporting of safety issues declines.
C. a root cause analysis is performed regularly.
D. personal accountability is removed from the organization.

Question #29
A performance improvement training program for supervisors should include
A. review of patient falls.
B. results of a failure mode and effects analysis (FMEA).
C. budget-variance reporting.
D. rapid-cycle process.

Question #30
The primary purpose of risk management trend analysis is to
A. identify opportunities for improvements.
B. meet regulatory requirements.
C. provide required reports to liability carriers.
D. eliminate financial loss for organizations.

Question #31
In lean thinking, a process step is defined as "value added" if the
A. customer recognizes the value.
B. process owner recognizes the value.
C. process owner changes the value of the product.
D. customer corrects a mistake to add value.

Question #32
Facility A is investigating its medication administration time for a specific diagnosis.
Evidence-based guidelines indicate that administration of a particular drug within 30
minutes significantly improves patient outcomes. The national average is 32 minutes. The
average for Facility B is 28 minutes. If the average for Facility A is 35 minutes, Facility A
should
A. identify the average time of its competitors.
B. determine whether its rate is within one standard deviation of the national average.
C. contact Facility B to determine its practices.
D. decrease its rate to meet the national average.

Question #33
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. scatter diagram
B. Pareto chart
C. line graph
D. bar chart

Question #34
Team cohesion is established during which of the following stages of team growth?
A. storming
B. performing
C. norming
D. forming

Question #35
In the quality improvement process, performing a cost-benefit analysis would be most
useful in
A. designing solutions and controls.
B. checking performance.
C. analyzing process problems.
D. implementing solutions and controls.

Question #36
A 69-year-old female admitted for hip replacement is taken to surgery. The patient is
identified, the surgical site is marked incorrectly, and equipment/x-rays are present. A near
miss was most likely identified as a result of
A. a root cause analysis.
B. informed consent documentation.
C. a surgical team "time-out."
D. an equipment check.

Question #37
Which of the following obstetrical outcomes would result in a morbidity review?
A. post-delivery septicaemia
B. neonatal deaths
C. caesarean sections
D. normal deliveries

Question #38
Satisfaction surveys, focus groups, and complaint tracking are tools used to
A. understand customers' expectations.
B. develop clinical pathways/guidelines.
C. measure professional practice patterns.
D. benchmark satisfaction

Question #39
The phrase "reaching consensus" is often used in performance improvement. The term
consensus refers to
A. unanimous agreement
B. everyone being totally satisfied.
C. a majority vote of those present
D. support by all members.

Question #40
A physician complains to the healthcare quality professional that the nursing staff did not
strictly follow orders for a patient. The physician requests that the healthcare quality
professional speak with the nurse manager. To facilitate improved communication, the
healthcare quality professional should
A. review the patient record to determine legibility of the physician's orders.
B. speak with the nurse manager on behalf of the physician.
C. arrange a meeting with the physician and nurse manager.
D. evaluate the patient outcome to determine organizational risk.

Question #41
Human factors engineering is defined as the study of humans and their interaction with
A. medical technology and the organizational systems.
B. adverse events and latent errors.
C. demographics and the organization.
D. the tools they use and the environment.

Question #42
Which of the following action plans is the first step in correcting inappropriate blood usage
in an emergency department?
A. development of a new procurement procedure
B. improvements in documentation
C. elimination of wasted blood
D. in-service on blood usage for the physicians

Question #43
The target for performance improvement should be
A. policies and procedures.
B. employees.
C. systems.
D. standards and regulations.

Question #44
Which of the following are attributes of a culture of safety?
A. increased patient acuity level and error-proof environment
B. empowered staff and transparency
C. error-proof environment and empowered staff
D. transparency and increased patient acuity level

Question #45
Which of the following is most appropriate in preparation for an external survey of a
healthcare facility?
A. Set up teams to make a good showing for the survey.
B. Assign key staff to answer all questions.
C. Ask department heads to prepare a presentation for the survey team.
D. Educate staff about the types of questions they may be asked.

Question #46
A monitoring system is being designed in which data will be collected and compared to
criteria. Which of the following will best enhance the validity and reliability of the data?
A. providing a practice-based definition and specific instructions for each element
B. establishing criteria that are based on the most recent changes in medical science and
technology
C. using a computerized system to substitute data for missing responses
D. assigning one staff member to identify, collect, enter, and interpret all data

Question #47
In managed care, the most widely used performance measures are
A. Agency for Healthcare Research and Quality (AHRQ).
B. Healthcare Effectiveness Data and Information Set (HEDIS).
C. National Quality Forum (NQF).
D. Uniform Hospital Discharge Data Set (UHDDS).

Question #48
A serious event has occurred related to the timely notification of critical test results. The
root cause was traced to nursing difficulty with following the organizational policy. To
prevent a similar event from reoccurring, which of the following should be done next?
A. Continue to collect data as one event is insufficient to take action.
B. Refer the involved nurse to nursing peer review.
C. Review the policy with nursing representatives to identify ambiguities.
D. Educate nursing staff on the importance of timely notification of critical test results.

Question #49
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.

Question #50
When conducting a sentinel event review, a root cause analysis
A. proactively identifies causes and effects.
B. identifies gaps in patient care processes.
C. provides judgment of staff behaviors.
D. requires team consensus.

Question #51
Data collected about surgical cases shows significant delays. Further analysis shows the
following chart:

Which of the following should a healthcare quality professional do?

A. Perform a focused professional practice evaluation (FPPE) on every surgeon.
B. Ask the nurse manager to write a memo encouraging promptness.
C. Form a multidisciplinary team to develop recommendations for improvement.
D. Provide the service chief with further analyses of surgeon-specific data

Question #52

A new quality director has reviewed the information related to the Quality Council minutes
and notes the following:
- The council meets quarterly. Meetings last approximately two hours.
- The council roster includes all clinical department managers and the quality director.
Attendance ranges from 45-60%.
-The primary role of the council is to receive department quality reports, which are then
forwarded to the organization's governing body.
Based on the information above, which of the following actions is most appropriate?
A. Redefine the council's role to coordinate and prioritize quality activities.
B. Require departments to forward reports for review prior to the meetings.
C. Eliminate the council and directly report quality data to the governing body.
D. Switch to a monthly meeting with a new agenda format

Question #53
Which of the following graphs provides the best information for re-appointment/re-
evaluation of an individual physician? (Use the scroll bar to the right to scroll down as
needed)
A
B
C
D

Question #54
Informed consent for hip surgery was obtained and documented for an elderly patient. In
the recovery room, a nurse discovered the wrong hip had been replaced. A healthcare
quality professional should
A. perform a root cause analysis.
B. review the practitioner's qualifications and licensure.
C. initiate the disciplinary action process.
D. conduct a failure mode and effects analysis (FMEA).

Question #55
Which of the following actions would have the greatest impact in reducing harm?
A. increasing data collection frequency
B. forming a performance improvement team
C. improving interdisciplinary communication
D. revising the patient safety evaluation tool

Question #56
Which of the following is the major responsibility of senior management regarding
continuous quality improvement?
A. Communicate the organizational mission and values.
B. Develop organization-wide training sessions.
C. Participate in Quality Council activities.
D. Conduct periodic reviews of the program.

Question #57
A federally certified electronic health record (EHR) with the capacity for e-prescribing,
electronic exchange of health information, and submission of healthcare quality measures
meets
A. health privacy requirements.
B. bar-code technology specifications.
C. meaningful use requirements.
D. computer-based monitoring specifications.

Question #58
When developing a strategic plan that integrates patient safety, which of the following
factors is most critical?
A. cost-benefit of patient safety programs
B. culture of performance improvement
C. patient-to-staff ratio
D. resources for advanced technology

Question #59
Minimizing the chances of an adverse event reoccurring includes determining the primary
contributing factor by using
A. root cause analysis.
B. clinical pathways.
C. failure mode and effects analysis (FMEA).
D. force field analysis.

Question #60
The clinical competency of a physician is determined by
A. a committee of peers.
B. the hospital governing body.
C. a quality management committee.
D. the chief executive officer.

Question #61
When using cost-benefit analysis in decision making, it is important to remember that
A. qualitative and quantitative data should be used.
B. implementation costs are more important than return on investment.
C. return on investment should be at least 10 to 1.
D. consideration of the benefit is more important than cost.

Question #62
A hospital has recently moved to a paperless system. It is noted that some data is missing
from the obstetrics delivery record. A healthcare quality professional should recommend
A. providing a paper trail.
B. evaluating the computerized data entry process.
C. designating one data entry person per shift.
D. assessing the need for additional education.

Question #63
The perception of how an organization operates, including how employees relate to internal
and external customers, is the organizational
A. mission.
B. vision.
C. structure.
D. culture.

Question #64
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

Question #65
Balanced 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 effort

Question #66
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.

Question #67
The best way to evaluate the effectiveness of performance improvement training is through
A. observed behavioral changes.
B. participants' feedback.
C. post-test results.
D. self-assessments.

Question #68
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

Question #69
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.

Question #70
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

Question #71
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

Question #72
A valid data collection tool should incorporate
A. a reliable graphic presentation.
B. the definition of data elements.
C. allowance for variance of interpretation.
D. a minimum of 20 data elements.

Question #73
Leaders enhance employee commitment to organizational values by fostering which of the
following types of communication?
A. clear, written, top-down
B. timely, open, two-way
C. formal, electronic, "need to know"
D. face-to-face, oral, scheduled

Question #74
A healthcare quality professional wants to develop a continuous survey readiness model.
The initial step should be
A. selecting the standards to be taught.
B. establishing leadership accountability.
C. appointing a steering group.
D. planning education for the entire team.

Question #75
When errors are discovered, staff and supervisors best demonstrate a culture of safety by
A. planning which details of the error to disclose to senior leadership.
B. studying the process to understand the error.
C. performing a root cause analysis to determine which individuals were involved.
D. developing a plan for just-in-time training.

Question #76
After a significant unexpected event, an intense analysis is performed to
A. collect risk management data.
B. prepare the facility for a lawsuit.
C. understand the cause.
D. identify who made the error.

Question #77
Which of the following is the best example of an outcome measure?
A. laboratory turnaround
B. average length of stay
C. medication dispensing error
D. mortality rate

Question #78
A physician focus review was conducted following a postoperative surgical infection rate
increase. Thefollowing information was obtained:

Which of the following should be done next?

A. Suspend privileges for physician C.
B. Initiate peer review with physician C.
C. Initiate peer review with physician A.
D. Suspend privileges for physician A.

Question #79
Based on the principles from the Institute for Healthcare Improvement (IHI), who has the
ultimate responsibility for the effectiveness of quality improvement and patient safety
within
an organization?
A. chief executive officer
B. quality improvement director
C. medical director
D. governing body

Question #80
Which of the following is the best tool to begin an investigation into the causes of laboratory
labeling errors?
A. histogram
B. flow chart
C. affinity diagram
D. prioritization matrix

Question #81
Which of the following is the most effective way to integrate performance improvement
concepts throughout an organization?
A. quality teams
B. monthly lectures
C. continuous monitoring
D. quarterly newsletters

Question #82
Facility A is investigating its medication administration time for a specific diagnosis.
Evidence-based guidelines indicate that administration of a particular drug within 30
minutes significantly improves patient outcomes. The national average is 32 minutes. The
average for Facility B is 28 minutes. If the average for Facility A is 35 minutes, Facility A
should
A. identify the average time of its competitors.
B. determine whether its rate is within one standard deviation of the national average.
C. contact Facility B to determine its practices.
D. decrease its rate to meet the national average.

Question #83
A consulting firm has been selected by a facility's quality professional to assess the quality
improvement program. Before starting the assessment, the quality professional should
A. define expectations and outcomes.
B. develop potential action plans.
C. help the consulting firm to identify problem areas.
D. schedule the activities of the consulting firm.

Question #84
A facility is becoming part of a healthcare network. Which of the following employee
education programs is most important?
A. consumer expectations
B. organizational change
C. conflict resolution
D. quality teams

Question #85
In the process of strategic planning, an organization makes decisions about the future. A
basic component of the planning process is to
A. contract with a consulting firm to assist with the planning process.
B. determine organizational profitability during the most recent fiscal year.
C. examine both internal and external environments.
D. develop contractual relationships to enhance market share.

Question #86
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

Question #87
The primary purpose of integrating financial and quality management information is to
A. develop physician profiles.
B. identify potential cash flow problems.
C. determine medical necessity of treatment.
D. identify problems in resource management

Question #88
Which of the following topics are discussed at a morbidity and mortality conference?
A. planned readmissions and newborn mortality rates
B. healthcare-acquired infections and perioperative mortality
C. inpatient mortality and admissions
D. Cesarean section rates and number of physicians

Question #89
Which of the following is used to summarize a characteristic in a population?
A. control chart
B. case control study
C. regression analysis
D. frequency distribution

Question #90
The utilization management committee is reviewing length-of-stay data for a particular
procedure. In comparing data by physician, which of the following statistics would be most
useful?
A. range
B. correlation
C. mean
D. standard deviation

Question #91
For health information technology to be most effective in reducing harm, the technology
needs to be
A. numeric and easy to use.
B. integrated with clinical workflow.
C. able to correct claims data.
D. flexible and accessible.

Question #92
Healthcare leaders are confronted with the challenge of increasing quality while reducing
costs. Which of the following approaches will best advance improvement efforts?
A. Develop new services to increase revenues.
B. Increase charges and decrease costs.
C. Incorporate customer satisfaction results into quality initiatives.
D. Support activities that improve outcomes and reduce variation.

Question #93
A staff member reports that a colon perforation occurred during a colonoscopy. Which of
the following is a healthcare quality professional's next step?
A. Refer the case for peer review.
B. Review 100% of colonoscopy procedures.
C. Assign a proctor to the physician.
D. Modify the physician's privileges.

Question #94
Which of the following team members is responsible for keeping meetings focused?
A. time keeper
B. recorder
C. leader
D. facilitator

Question #95
Which of the following actions should the facilitator make the highest priority during the
customer focus group process?
A. generalizing the findings to the population
B. selecting a homogeneous group
C. providing written ground rules to the group
D. establishing rapport with the groupShow comments (1)
Question #96
The following data has been provided to a healthcare quality professional:

Which of the following is the best choice for beginning clinical-pathways implementation in
an organization?
A. total knee replacement
B. diabetes
C. gastroenteritis
D. heart failure

Question #97
An organization can best measure its effectiveness in meeting customer expectations by
A. using satisfaction data.
B. tracking length of stay.
C. benchmarking occupancy rates.
D. creating a run chart of complaints.

Question #98
Generic screening is an example of risk
A. identification.
B. prevention.
C. reduction.
D. evaluation.

Question #99
A hospice agency conducted a satisfaction survey of all 200 patients currently receiving
pain management services. When asked if they were satisfied with their pain management,
170 patients said yes and 30 said no. In this situation, a healthcare quality professional
should
A. review all dissatisfied responses for similarities.
B. discontinue monitoring because an 85% satisfaction rate is excellent.
C. continue monitoring because a 15% dissatisfaction rate is acceptable.
D. collect more data to ensure statistical significance.

Question #100
Results of physician practice pattern studies are most likely to promote behavior changes
when disseminated to the
A. practitioners.
B. governing body.
C. quality committee.
D. administration.

Question #101
The evolution of quality improvement in healthcare has shifted the primary focus from
performance of individuals to the performance of the
A. medical staff.
B. organization's systems.
C. governing body.
D. ancillary departments.

Question #102
Which of the following is always true regarding a sentinel event?
A. The findings must be reported to a regulatory body.
B. The occurrence requires an immediate investigative response.
C. The cause is established as a deviation from standards.
D. The incident is a result of a medical error.

Question #103
The primary purpose of an organization's quality improvement strategic plan is to
A. define the future direction for quality.
B. determine accountability for outcomes.
C. assess improvement opportunities.
D. explain the purpose of performance teams.
Question #104
A facility is becoming part of a healthcare network. Which of the following employee
education programs is most important?
A. consumer expectations
B. organizational change
C. conflict resolution
D. quality teams

Question #105
A healthcare quality professional has been asked to assess a facility's patient safety
culture. Which of the following should be targeted in a validated survey?
A. a random sample of leaders and staff
B. a stratified sample of physicians and nurses
C. all staff and physicians
D. all patients and their families

Question #106
A healthcare quality professional has been asked to examine a new method of reviewing
adverse eventsin an organization. It has been decided that a system of triggers will be
established to alert the QualityCouncil of a potential problem. The best example of a trigger
that should be setwith a threshold of zerois a
A. patient complaint regarding wait times.
B. medical record not completed by a physician.
C. staff member not using proper handwashing technique.
D. near miss from failure to perform a "time-out."

Question #107
Leadership can best integrate performance improvement within an organization through
A. multidisciplinary teams.
B. seminars.
C. newsletters.
D. focus groups.

Question #108
A healthcare network has implemented an electronic medical record system allowing data
to betransmitted, on demand, from one facility to another. Which of the following will best
promote both cost effectiveness and patient satisfaction?
A. eliminating the need for patients to hand-carry records
B. decreasing repeat tests when a patient is seen in more than one facility
C. increasing the security of confidential patient information
D. improving the accuracy of medication reconciliation
Question #109
Problem-solving, cross-functional understanding, expanded areas of expertise, gains in
status and power, and increased span of knowledge are examples of
A. the benefits of teams.
B. resource requirements.
C. customer expectations.
D. strategic alliances.

Question #110
Performing a root cause analysis of a sentinel/unexpected event provides all of the
following EXCEPT
A. recommendation for actions to prevent or decrease recurrence.
B. measurement strategies for each factor affecting the outcome.
C. continuous monitoring to identify opportunities for improvement.
D. identification of why the variance occurred.

Question #111
Which of the following adverse events is NOT considered a sentinel event?
A. hemolytic transfusion reaction
B. surgery on the wrong patient or body part
C. suicide threat by a patient in a confined 24-hour care setting
D. death due to a medication error

Question #112
A policy for "time-outs" in an operating room was initiated in the first quarter. The second
quarter data has demonstrated only 40% compliance with all elements of the process. The
first step the Quality Council should take is to
A. ask the nurses to identify non-compliant surgeons.
B. continue to audit to confirm that a problem exists.
C. create a letter for the chief executive officer to send to all surgeons.
D. examine if the policy is clear and user friendly.

Question #113
A healthcare entity initiating re-structuring must consider the impact on staff to ensure the
greatest opportunity for success by
A. selecting a consultant, conducting a needs assessment, and analyzing results.
B. developing policies to assist in the change process so that fear will be minimized.
C. planning carefully, communicating openly, and leading effectively.
D. defining the concepts of re-structuring to the staff and the community.

Question #114
During quality management data analysis activities, Pareto charts are most appropriately
used for
A. displaying trends overtime.
B. determining priorities among contributing factors.
C. determining cause and effect relationships.
D. displaying parts of a whole.

Question #115
A health plan is required to have a mechanism for members to submit complaints. Which of
the following actions must be included in the complaint analysis to ensure the plan makes
full use of this type of information?
A. Determine the date/time the complaint occurred and the person responsible.
B. Total each complaint category at least on an annual basis.
C. Review complaints to find system problems that can be improved.
D. Calculate the average number of complaints per office site.

Question #116
A healthcare quality professional is conducting a study to determine how many patients
contracted influenza after receiving flu shots. This study is evaluating
A. prevalence.
B. efficacy.
C. process.
D. appropriateness.

Question #117
One aspect of a quality process that integrates with risk management is the review and
evaluation of
A. adverse drug events.
B. accreditation survey reports.
C. encounter data.
D. case-mix analysis reports.

Question #118
An annual evaluation of a laboratory's quality program identified no opportunities for
improvement. Which of the following elements of the program should be reviewed?
A. frequency of data collection
B. performance indicators
C. format of data display
D. committee meeting attendance

Question #119
When examining the relationship between staff and patient outcomes, which of the
following would be most appropriate to assess?
A. occurrence reports and sentinel events
B. staff turnover and budget
C. overtime data and absenteeism rates
D. patient safety data and overtime data

Question #120
Which of the following principles applies to continuous quality improvement in an
organization?
A. Causes of non-conformance must be identified and corrected temporarily.
B. Systems, not poor job performance, are responsible for most problems.
C. Empowerment automatically occurs upon implementation of the program.
D. Twenty percent of trouble comes from 80% of the problems.

Question #121
The success of a performance improvement program will be most influenced by the
A. culture of the organization.
B. reliability of data management software.
C. educational preparation of quality leaders.
D. people skills of the facility leaders.