aaQ caD q Qq ‫ملف‬

‫املتشابهات‬
)1(

1-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

‫ في اخر امتحان ورد السؤال بصيغة‬suicide threat ‫ ولم يقل‬suicide attempt

Ans:B
take care : (if choices are : )
2- 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

Ans:A

1
======================================
SO:

Of the followings NOT example for sentinel event :

A. PT attempt suicide
B. hemolytic TRANSFUSION reaction (or drug)
C. death of patient due to medication error
D. surgery on wrong part of the body (or right leg
instead of left)
E. threaten to suicide within 24 after admit
F. hemolytic drug reaction
ANS: both E - F NOT example for sentinel event
==========================================
===

(2)

2
1-When an incident to patient is occurred, the appropriate action is:
A. Distract the attention of the patient, discuss the incidence with the staff and
make action plan
B. Distract the attention of the patient, make punishment on the responsible for
the incidence
C. Distract the attention of the patient and the staff and make an action plan
D. Make no action

2-When an incident to patient is occurring, the appropriate action is

A-Distract the attention ‫ رصف االنتباه‬of the patient, discuss the incidence with the
staff and make action plan
B-Discuss the incidence with the patient; make punishment on responsible for the
incidence
C-Discuss the incidence with the patient and the staff and make an action plan
D-Make no action

ANS:C
‫المعتزباهلل‬

‫اعتقد االوالني فيه غلطة‬

Ola
distraction to pt. attention ‫ايوه اعتقد كده عمرنا مابنعمل‬
C ‫والتاني‬
Mutasim
‫معتز‬.‫زي ماقال د‬
C ‫السؤال ده عنده صيغه واحده بس وهو الصيغه التانيه والصح فيها‬
‫اما السؤال االول فهو من تعديل من قاموا بجمع ملف المتشابهات والجود له وغير صحيح‬
‫ سؤال وورد فيه بالصيغه التانيه وال وجود للسؤال االول بالتعديالت المخله اللي ادخلت على‬1000 ‫ والسؤال مصدره االصلي هو ملف ال‬.
‫خيارات االجابات‬

=============================================
(3)

1- In the business cycle, the negative cash flow present in

which of the following stages:
A- Harvest stage

B- Growth stage

3
‫‪C- Maintenance stage‬‬
‫‪D- Gains stage‬‬

‫‪ANS:B‬‬
‫‪---------------------------------------------------------------‬‬
‫‪2- 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-None of the above‬‬

‫‪ANS:B‬‬

‫‪ B‬المعتزباهلل جاب هللا‬

‫‪Sem Sema‬‬
‫مش مقتنع‬

‫المعتزباهلل جاب هللا‬

‫بص يا باشا‬
‫دلوقتى فى اى مشروع فى الدنيا و لتكن مثال مستشفى اطفال‬
‫بتبدى فى االول تصرفى عالمشروع‬

‫المعتزباهلل جاب هللا‬

‫بتشترى االرض و بتبتدى تبنى و تجهزى االسرة و االجهزة و تعينى استاف و تعملى دعاية و تصرفي‬
‫دعاية‬

‫المعتزباهلل جاب هللا‬

‫كسبتى انتى دلوقتى تعريفة‬

‫المعتزباهلل جاب هللا‬

‫ال مكسبتيش لسة و حتى بعد ما بدأ يدخل لك فلوس من بعض حاالت الزال فى البداية نصاريفك اكتر‬
‫النك فى مرحلة نمو‬

‫المعتزباهلل جاب هللا‬

‫‪4‬‬
‫المعتزباهلل جاب هللا‬
‫حتى تتخطين ال‬breakeven point

‫المعتزباهلل جاب هللا‬

‫اقتنعت ؟‬

‫المعتزباهلل جاب هللا‬

=============================================
(4)

1- The percentage of early diagnosed breast cancer after using of new imaging
technique is considered:

A. Structure measure
B. Process measure
C. Outcome measure
D. Continuous measure

5
 ANS: C. Outcome measure

Mutasim Hakim

C ..
‫نسبة النساء اللي تم تشخيص المرض لديهم‬Outcome‫طبعا‬

The number of designated women receiving breast cancer screening

(mammograms) in the reporting year measures

a. process.
b. clinical outcome.
c. process outcome.
d. process and clinical outcome.

a. process.
‫علشان أوضح كومنت د بسنت ويكون باين المقصود‬
...
‫ده أحد األسئلة الىل أختلف مع إجابة جانيت فيها‬
C‫جانيت مجاوبة السؤال ده‬
Process outcome measure‫مفيش حاجة اسمها‬
AHRQ‫ ف‬process measure ‫ده مثال عن‬
..
A‫اإلجابة‬

6
----------------------------------------------------------------
2- The number of designated women receiving breast cancer
screening (mammograms) in the reporting year measures
a. process.
b. clinical outcome.
c. process outcome.

d. process and clinical outcome

ANS:C

=======================================================
(5)
1- 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?
‫الوطن المتعلق بسالمة المرض المرتبط‬
‫ي‬ ‫التال هو أفضل طريقة عند تنفيذ الهدف‬
‫ي‬ ‫أي من‬
‫بتحديد األخطاء المحتملة يف رعاية المريض وعالجه وخدماته؟‬

7
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

this question in mock 2008 no. ( 53 ) answered D)

---------------------------------------------------------------

A 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.

8
 Ans: b

2 -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. Have employees demonstrate the use of personal protective equipment (PPE) as
a part of staff competency
c. Show a videotape on Standard Precautions quarterly.
d. Review and revise hand washing policies and procedures

Ans: b
Hala Salha We don't choose A because we don't know if they have shortage in PPE supplies.
C is a part of the education but it is not sufficient enough to get the staff compliance.
The answer B because it seems that revision and education is needed for all staff.
D. No because they did not specify the fallouts about hand hygiene as amuck as it's important.
The answer is B because all staff needs intensive education to pull up the scores.

Marwa Elkhouly Return demonstration is a perfect way of communication to make sure they
understand the policies and implement it in a right way

‫ المعتزباهلل جاب هللا‬B because in practical education the most important in communication is to have
feed back

-------------------------------------------

1- A hospital is working to reduce readmissions. Which of the following is

the best approach to accomplish this goal?
A. giving an education sheet on patient medication to the patient and
family
B. having the patient provide return demonstration of the knowledge
provide
C. showing a video to a patient and their family
D. requesting the home health nurse provide patient instruction

9
ANS:B
‫ المعتزباهلل جاب هللا‬B

2.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
‫مالحظة‬

D‫ االجابة‬NPSG ‫فقط اللي مكتوب فيهم‬

Abdel Aziz Elbadry NPSG MUST BE IN written and verbal instructions NOT return
demonstration

Hala Salha D but A is important as well as we always can know more about our patients which
might help us prevent errors.

Mutasim Hakim
‫مع‬D ..
‫وانا فسرت في تعليقي ليه مش‬B ‫ اما‬.. A ‫فهي فقط تتحدث عن اتاحة الفرصه لطرح أسئلة وطبعا ده‬
‫مش كافي ابدا النه في اخطاء قد يقع فيها المريض دون ان يخطر بباله اصال السؤال عنه‬

10
1-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

ANS:A

For an insulin dependant diabetic patient, which of the following is the best -2
approach when implementing a National Patient Safety Goal related to
identifying potential errors in a patient’s care, treatment, and services?
A.Playing a video to the patient and accompanied family members.
B.providing both written and verbal instructions to the patient and family
members.
C. Letting the patient provide return demonstration of the knowledge
provided.
D.Allowing time for the patient and family an opportunity to ask questions
on administration technique.

ANS:B
‫تقديم كل من التعليمات الكتابية والشفهية للمريض وأفراد األرسة‬

11
 MOCK QUESTION‫المعتزباهلل جاب هللا‬

‫االول الزم تعرفى االسئلة المتشابهة فى النقطة ديه من المصدر االهم ليها و هو الموكات‬

‫المعتزباهلل جاب هللا‬

2 ‫ادى واحد منهم و اجابته‬
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

B.√ demonstrating understanding by return demonstration

‫المعتزباهلل جاب هللا‬

‫و ادى واحد تانى و اجابته‬return demo
A patient is being taught how to self-administer insulin. Which of the following is the BEST
method to assess this patient's understanding of the teaching?

A. return demonstration
B. patient satisfaction survey
C. family's ability to verbalize instructions
D. written pre- and posttest

A. return demonstration

‫المعتزباهلل جاب هللا‬

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

D. giving both written and verbal instructions to a patient and family

12
‫و اجابته ‪ THE FOURTH 2‬المعتزباهلل جاب هللا‬

‫‪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.‬‬

‫‪B. initiate return demonstration as a part of staff competency.‬‬

‫السؤال االصح كان فى الموكات و السؤال من ملف ال‪ 400‬سؤال د عماد و الحقيقة اننا ملزمين جدا جدا و ال مناقشة فى ذلك المعتزباهلل جاب هللا‬
‫باسئلة الموكات بصيغتها و اجابتها و السؤال ده واخد كوكتيل من اسئلة الموك فارجعى لالصل فيه و هو الموكات هتالقي واحد بيتكلم عن تطبيق‬
‫‪ RETURN DEMO‬لعالج السكر و هو ما يتفق مع نصف السؤال اللى هنا و اجابته فى الموك‬

‫المعتزباهلل جاب هللا‬

‫‪NPSG‬‬
‫بيتكلم عن اكتشاف االخطاء المحتملة فى العالج و ده كالمه كتير و مفيهوش تطبيق لذا االفضل فيه‬
‫انى اعتمد طريقتين للتواصل مكتوبة و منطوقة‬

‫المعتزباهلل جاب هللا‬

‫و ده نصف السؤال اللى هنا برضه‬

‫المعتزباهلل جاب هللا‬

‫و عليه فلما تالقي السؤال ده او ما يشبهه من فضلك ما تلخبطيش نفسك و ارجعى الى اسئلة الموك‬
‫النها المرجع االهم و اجابتها من وجهة نظر الجهة الممتحنة اجابة نموذجية‬

‫=================================================‬

‫)‪(6‬‬
‫‪1q‬عينات االحتمال ‪1- 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

‫إزالت المصادر المحتملة للتحيز ‪Ans >>C‬‬

‫‪13‬‬
Muhamad Shehata
.. ‫إنتي صح‬Other options are advantages of non- probability sample..

2-Sample results` are often more accurate than results based on

population because

a-sample could be studied more quickly than population

b-probability methods could be used to estimate the error in the resulting
statistics
c- studying sample is easier
d-possibility of bias when studying population

Mutasim Hakim
‫مع‬B..
‫ال‬sample results ‫ فعال احيانا تكون اكثر دقه النه مثال في ال‬probability method ‫ح االقي انه كل‬
‫واحد في ال‬population .. ‫عنده نفس الفرصه في ان يتم اختياره ضمن العينه العشوائية‬
‫اما االجابه‬D ‫ فهي في تقديري غير صحيحه النه عندما تدرس كل ال‬population ‫دون ان تلجأ الى‬
‫اختيار عينه فانه اليوجد مجال الي‬bias ‫ او تحيز النك ستاخذ كل ال‬population ‫ اذا‬.. ‫دون ان تتحيز ابدا‬
‫ال يوجد‬possibility of bias ‫ في دراسة كل ال‬population

‫يمكن استخدام أساليب االحتمال لتقدير الخطأ في اإلحصائيات الناتجة‬

==============================================================
(7)
1- 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

14
 Ans: A
===================================

2- 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.

Ans: A
===================================
3- 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.

Ans:D

d‫المعتزباهلل جاب هللا‬

Doaa ELhadad
. it is D .. the key word (safety) not found here.. if there is no safety it will be (financial)
regardless eliminate or reduce

Hany Mohamed The primary goal of RM is prevent harm then reduce financial loss so
it is D

‫من االخر لولقينا خيار‬

promote patient safety - or - Harm prevention
‫هنختاره‬
‫ يبقى‬.. ‫لوأل‬
reduce financial
==================================================
Risk control imposes providing mechanisms for:

a. Elimination of hazards that lead to risk occurrence

b. Prevention of recurrence of risk occurrences.

15
c. Minimizing the loss after risk occurrence
d. Dealing with the legal aspect of risk liabilities

‫القضاء على المخاطر التي تؤدي إلى حدوث خطر‬

16
==============================================================
(8)

1-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

ANS:D

========================================
2-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.

17
2. Conduct a cost-benefit analysis.
3. Analyze readmission rates with a run chart.
4. Continue to monitor length of stay rates

ANS:B
‫قم بإجراء تحليل للتكلفة والعائد‬

‫المعتزباهلل جاب هللا‬

‫االختيار علي هذه الصيغة‬B

‫علي الصيغة االخري‬D

==============================================================
(9)

1-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

18
=============================

Which of the following is the FIRST step in facilitating change in an

organization?
D- A. Review customer satisfaction surveys.
E- B. Take commitment from GB.
F- C. Identify key people in the organization that should be involved
G- D. Develop a performance improvement plan

‫المعتزباهلل جاب هللا‬

‫ الصيغة ديه فيها اختالف‬A

1-Which of the following is the FIRST step in facilitating change in an

organization?
a) Review customer satisfaction surveys.
b) Get feedback from staff on the problems to be addressed.
c) Identify key people in the organization that should be involved.
d) Develop a performance improvement plan.

19
Answer: A (according to tutor)
---------------------------------------------------------
2-The following is the First Step to facilitate a change in an organization?
A. Identify problems to be addressed in the organization.
B.Get feedback from staff on the problems to be addressed.
C.Identify key people in the organization who should be involved.
D. Develop a performance improvement plan

Review customer satisfaction surveys.

Identify problems to be addressed in the organization

Answer: A
---------------------------------------------------------

3-Which of the following is the FIRST step in facilitating change in an

organization?

A. Review customer satisfaction surveys.

B. Take commitment from GB.
C. Identify key people in the organization that should be involved.
D. Develop a performance improvement plan.

Answer: A

20
1- Which of the following steps occurs first in facilitating change in an
organization?
A. Identify problems to be addressed in the organization
B. Solicit feedback from management.
C. Select key people in the organization to serve on the team.
D. Develop a performance improvement plan

21
 Ans:A

Mutasim Hakim
.‫مع‬A ..
‫ياجماعه سؤال البوست ده هو سؤال الموك وال خالف ابدا على اجابته ومافي حد ح يغير اجابة سؤال‬
‫ وهي‬... ‫الموك‬A ..
Identify problems to be addressed in the organization

===========================

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

Ans: A
Mutasim Hakim
.. ‫عشان تسهل التغيير احسن طريقة انك تشرك الناس اللي ح تتأثر بالتغيير ده بشكل مباشر‬

==============================================================
(10)
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

ANS:D
==================================
The physical difference between quality assurance and continuous quality

22
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 B

ANS:B

==============================================================
(11)
Medication reconciliation is:
A. The reconciliation of duplicated dosage, frequency and discrepancies at
the ICU only ‫واخد بالك من االختالف‬
B. The resolutions of medication discrepancies in dose, frequency and
therapeutic duplication at time of discharge
C. The reconciliation of medications thrughout the patient’s hospital stay
D. The clarification of patient’s medications to the relatives at time of
discharge

Ans: C

23
- Medication reconciliation:
A- help in efficient use of medication
B- Identify discrepancies in meds ‫واخد بالك من االختالف‬
C- Identify and resolve med. Discrepancies

Ans: C

Implementation of the medication reconciliation process require the

interdisciplinary effort of
A. Nurse, physicians, laboratory technicians and informatics
B. Nurse, physicians, pharmacists and informatics
C. Nurse, physicians, chaplains and informatics
D. Nurse, physicians, pharmacists and medical therapists

Ans: B

24
==============================================================
(12)
1-A patient complain that there is an error in writing the bill , because two
out of three days of her stay in hospital due to anaphylaxis , HQP should
consider that :
A-billing error
B-medication error
c- Unexpected adverse occurrence
d- admission error

Ans: c

25
‫‪On discharge, the patient refuse billing because 2 out of 3 days of his stay in -3‬‬
‫‪the hospital is due to medication anaphylaxis. This occurrence is:‬‬

‫‪A. Billing error‬‬

‫‪B. Potentially compensable event‬‬
‫‪C. Nurse incompetence‬‬
‫‪D. Admission error‬‬

‫‪Ans: B‬‬

‫‪Mutasim Hakim‬‬

‫السؤال االول اخترنا ‪ C‬عشان هو بيسال اللي حصل للعيان ده ايه ومسالة انه ‪ medication error‬اجابه غير دقيقه الني لسه عايز اعرف‬
‫وبعدين ‪ ..‬يعني ‪ medication error‬مش كافيه بس لما اقول انه ده ‪ unexpected adverse occurrence‬وبالتعريف اللي انا‬
‫كاتبه فوق تبقي المساله واضحه ومحسومه ‪..‬‬

‫اما السؤال التاني ليه اخترنا ال ‪ PCE‬اخترنا اوال باالستبعاد ‪ By exclusion‬وثانيا عشان فعال ال‬
‫‪anaphylaxis‬اللي حصلت للعيان ده حدث يمكن جدا ان يؤدي لتعويض العيان ماديا او عينيا‪..‬‬

‫هو اي حدث ادى او متوقع ان يؤدي الى دفع ‪ PCEs‬برضو هنا بعتمد على صيغة السؤال شكلها ازااي وعلى العموم ال‬
‫تعويض للمريض سواء تعويض مادي او غيره اذا تم اللجوء للقضا ء‬

‫‪..‬‬

‫========================================‬

‫‪26‬‬
On discharge woman refuse billing because 2 out of 3 days of her stay in
the hospital is due to medication anaphylaxis ,pt complain from

unexpected adverse reaction

E. Billing error
F. Medication error
G. Admission error
Mutasim
‫الخيارات ناقصه الخيار الصح‬

Mutasim
‫بالضبط كده‬
unexpected adverse reaction ‫دي االجابه الصح‬

============================================================
(13)

In a culture of patient safety, the most appropriate surveillance to assess the

infection rate within the hospital is:
‫ر‬
‫األكث مالءمة لتقييم معدل اإلصابة داخل المستشف هو‬ ‫المراقبة‬

A. Total house surveillance

B. Targeted surveillance
C. Community surveillance
D. Prioritized surveillance
-------------------------------------------------------------------
In a culture of patient safety, the most appropriate surveillance to assess the
infection rate is
A-Total house surveillance?
B-Targeted,perioterized surveillance?
C-Community surveillance
D-None of the above

Mutasim Hakim

‫مع‬B..

27
‫ للحد من اللتهابات‬7 ‫ رقم‬goal ‫ تم تخصيص ال‬national pt safety goals ‫في اخر تحديث لل‬
‫المصاحبه للعمليات سواء الكبيره او الصغيره التي تتم في المستشفى ويتم ذلك عن طريق‬
targeted surveillance ‫نظام المراقبه المركز‬
==============================================================
(14)
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.

Ans : A

A chief quality officer has the responsibility for education and

implementation of a quality improvement process. To affect cultural
change, the chief quality officer must0

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.

Ans: B

28
 ======================================================
(15)
1- 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

ANS: D

recommendations ‫ انا بعمل ال‬check ‫الفكرة بالضبط زي ما قالوا الزمالء في خطوة ال‬
act .‫بتاعتي بعدها اتجه مباشرة لل‬

========================================

29
2-After the team action the plan and implement it ,and analyze data shows
not reaching the target ,what is the next step on PDCA cycle is now should
follow;
A- plan
B- do
C- Check
D- act

ANS: D

=============================================================
(16)
1) the pt discharged without any counseling of his care, this problem,
concerned with
a-medical coverage
b-case management
c-transition care
d-reconciliation

ANS:C

======================================
2) A patient not given enough instruction on the care plan this is to be:

30
1. Transition care.
2. Case Management
3- medical coverage
4-reconciliation

ANS: 2
Mutasim Hakim
.. 2 ‫ و‬.. C ‫مع‬
‫برضو مختلفين النه الصياغه مختلفه‬
‫السؤال االول بيسال عن لحظة خروج العيان ودي محطه معينه داخل المستشفى ومسئولية ال‬
.. transition care
case ‫ ودي مسئولية ال‬.. ‫السؤال التاني المريض لم يعطى فكره عن كامل الخطه العالجيه‬
. manager

==============================================================
(17)

which of the following best describes an organizational vision statement

A. It is used as a marketing strategy
B. It defines the structure of the institution
C. Describes the organization strategic plan
D. It reflects the organization aspirations

ANS:D..

Which of the following BEST describe an organization vision statement ?

A)it's used as a marketing strategy
B)it define the structure of the institution
C)it describe the organization strategic plan
D)it reflect the organization culture

31
======================================================

(18)
1. Who usually makes the final decision regarding credentialing in a
managed care organization?
a. Governing body
b. Credentialing committee
c. Quality improvement committee
d. Chief medical officer

ANS:B
-----------------------------------------
2-In a hospital accredited by The Joint Commission, ultimate
responsibility for all medical credentialing decisions lies with the
A governing body.
B medical staff department.
C Medical Executive Committee.
D credentialing committee.
ANS:A
----------------------------------------

32
3-Which of the following bodies is ultimately responsible for credentialing
in a hospital?
A. Chief Executive Officer
B. Chief Medical Officer
C. Governing Body
D. Credentialing Committee
ANS:C

Mutasim Hakim

B ‫السؤال االول مع‬

A ‫التاني مع‬
C ‫التالت مع‬
‫ بس زي‬Credentialing committee ‫ هو مسىولية ال‬Credentialing ‫برغم اقتناعي انه ال‬
Activities ‫ في كل ال‬GB ‫ دايما هي لل‬ultimate Accountability ‫ما نحن متفقين انه ال‬
‫وده النص من جانيت الطبعة الجديده‬

---------------------------------------------------------------------------------------------------
1. Who usually makes the final decision regarding credentialing in a
managed care organization?
a. Governing body
b. Credentialing committee
c. Quality improvement committee
d. Chief medical officer
..

ANS: B

33
2.Who makes the final decision regarding reappointment to the medical/
professional staff in a hospital?
a. Governing body
b. Medical staff executive committee
c. Credentialing committee
d. Medical staff as a whole

ANS:A

==========================================================
(19)

34
1- Which of the following issues might be most important to health
maintenance organizations HMO negotiating contracts with providers?

a. Quality/utilization capabilities, disclosure of data, reimbursement

b. Disclosure of data, practitioner credentialing, computer capabilities
c. Staffing, accreditation, reimbursement
d. Reimbursement, physician board certification, malpractice claims

ANS:A
================================================

‫ والسداد‬، ‫ والكشف عن البيانات‬، ‫ االستخدام‬/ ‫قدرات الجودة‬

2-Which of the following issues might be most important to a medical

group or IPA negotiating contracts with health plans?

a. Reimbursement, physician board certification, staffing

b. Data requirements, credentialing requirements, reimbursement
c. Credentialing requirements, computer capabilities, MCO accreditation
d. Data requirements, MCO accreditation, reimbursement

ANS:B
================================================
3-Which of the following issues might be most important to hospitals
negotiating contracts with health plans?
a. MCO accreditation, bylaws, medical staff practitioner credentialing
requirements
b. Staffing, reimbursement, confidentiality of peer review information
c. Computer capabilities, MCO accreditation, review requirements
d. Data requirements, confidentiality of peer review information,
reimbursement

ANS:D

35
 ‫‪Mutasim Hakim‬‬
‫مع ‪A B D‬‬
‫الفكره واحده في األسئلة الثالثه وتختلف اختالف بسيط باختالف الجهات المتفاوضه‬

‫في السؤال االول المفاوضات بين ال ‪HMOs‬من جهه وال ‪ providers‬من جهه ‪ ..‬واهم نقطه هنا‬
‫انه ال ‪ HMOs‬هو نظام تتحمل فيه ال ‪ .. HMOs‬كل ما يتعلق بالخدمه‬
‫‪.. Share both financial insurance and risk of service‬‬
‫عشان كده لما ال ‪ HMOs‬تتفاوض مع ال ‪ provider‬وهو مقدم الخدمه بيهمها ‪ ..‬الحاجات‬
‫المذكوره في ‪ A‬وهي مدي جودة الخدمه وارتباطبها بالموارد والمقدره على توفيرها وواالستخدام‬
‫االمثل لها وهل ال ‪ provider‬لديه فعال القدره على ذلك باالضافه طبعا الى ال ‪disclosure of‬‬
‫‪ data‬وهنا مهم لل ‪HMOs‬انه ال ‪ provider‬يفصح عن الداتا المتعلقه بكل الخدمه التى يقدمها‬
‫بحيث يتيح قدر من الشفافيه يسمح لل ‪MHOs‬اتخاذ القرار بالتعاقد معه ام ال ‪ ..‬وطبعا ال‬
‫‪ reimbursements‬ودي ثابته في كل المفاوضات وبين مختلف الجهات النها تمثل العائد المادي‬
‫له ‪..‬‬

‫السؤال الثاني ‪ ..‬هنا المفوضات بين ال ‪ medical group‬او ‪ IPA‬ودي طبعا ‪Individual‬‬
‫‪ .. Practitioner Association‬وده عباره عن جسم او مجموعه مكونه من عدة‬
‫‪ practitioners‬وتتفاوض مع ‪ health plan‬لتقديم خدمة ال ‪ insurance‬وحسب االجابه ‪ B‬طبعا‬
‫مهم الداتا المطلوبه ايه منهم ‪ data requirement‬وهنا تدرس ال ‪IPA‬نوع الداتا المطلوبه وكذلك‬
‫ال ‪ Credentialing requirements‬وكلها اشياء تخص ال ‪ physicians‬او ال‬
‫‪ practitioners‬زي ما هو سماهم ‪ ..‬واخيرا العضو الثابت في كل المفاوضات ال‬
‫‪.. reimbursement‬‬

‫السؤال الثالث ‪ ..‬وده مفاوضات بين ال ‪ hospital‬و ال ‪ health plan‬اللي ح تقوم بتقديم الخدمه‬
‫التامينيه للمرضى في المستشفى وطبعا زي ماهو واضح في االجابه ‪ D‬مهم بالنسبه للمستشفى‬
‫تعرف ايه الداتا اللي ح تطلبها ال ‪ .. health plan‬ومهم جدا للمستشفى سرية ملفات ومعلومات ال‬
‫‪ Peer review‬الخاصه بالمستشفى ‪ ..‬واخيرا زي ما في كل المفاوضات ال ‪reimbursements‬‬
‫‪..‬‬
‫اتمنى اكون قلت كالم معقول ‪....‬‬
‫==============================================================‬
‫)‪(20‬‬
‫‪1-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

‫‪ANS:C‬‬

‫‪36‬‬
===================================
Another question
2-Customer gives score to the criteria , What's the highest weight mean
score : (Exam)
Score mean - score weight
A- 3 - 0.9 (3x0.9/2) = 1.35
B- 4 - 0.8 (4x0.8/2) = 1.6
C- 5 - 0.7 (5x0.7/2) = 1.75 √
D- 6 - 0.3 (6x0.3/2) = 0.9
‫باختصاراضرب الرقمين وخدأ على نتيجة‬

37
Mutasim Hakim

.. C ‫مع‬
3.5 ‫ الناتج‬0.7 ×5 ‫ وهو‬.. ‫ ونختار اعلى حاصل ضرب‬weight ‫ في ال‬mean ‫ح نضرب ال‬
‫وهو االعلي‬

==============================================================
(21)
144- The pharmacy unit reported that there is an increase in the use of
expensive drug ,as a quality professional, you should review:
A-effectiveness and efficiency of the drug
B-The process of prescribing and dispensing of this drug
C- Share data with peer from prescribing physician

ANS:B

=========================
‫السؤال بصيغة أخرى‬
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

ANS:B

38
AadA local immunization rate to local incidence rate
==============================================================

(22)
1-Effectiveness of local flu vaccination program is best measured by :

a. local prevalence rate to local incidence rate

b. local vaccination rate to local prevalence
c. local prevalence rate to national one
d. national incidence rate to local incidence rate

A .. ‫مع‬
‫ى‬
‫ المهم هنا هو ال‬Outcome ‫ وال‬Outcome ‫ يبف هنا ح اشوف ال‬effectiveness ‫السؤال عن ال‬
‫ وطبعا الزم اعرف أنا طعمت كم من المستهدفي‬.. ‫وهو معدل وجود حاالت جديد‬incidence rate
‫المحىل ومعدل حدوث حاالت‬ ‫ ى‬Outcome.. ‫مؤرسات ال‬
‫يبف السؤال االول معدل التطعيم‬ ‫كواحد من ر‬
‫ي‬
‫جديده‬
ANS:A
2-The organization apply immunization program for the local area of the
organization. To evaluate the effectiveness of the program :
A- Immunization rate + the incidence
B- The prevalence + the incidence
C- National and local immunization rate …
D- National prevalence + local prevalence

‫بتاع اي مرض‬incidence ‫وال ال‬prevelance ‫انا باقيم البرنامج نفسه مش كفاءة التطعيم وبالتالي ماليش دعوه بال‬
ANS:A

39
3-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

ANS:D
4-Effectiveness of local flue 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

ANS:A

Mutasim Hakim A.. A ..D.. A

Enas Shalaby
‫بص يا دكتور من خالل فهمي المتواضع اول حاجة تعالى نتفق على حاجة اساسية في االربع اسئلة وهيا ان حصل‬
‫ تطعيم لمجموعة من الناس‬...
‫الحاجة التانية ناخد بعض التعريفات كدة مبدئيا قبل ما نبتدي نجاوب ونعرف الفرق بينهم‬
effectiveness = outcome = outcome of immunization
incidence = frequency of occurring NEW cases during period of time
prevalence = Describes what proportion of the population has the disease at
one specific point in time
‫يعني بغض النظر عن هو عندهم من المرض من زمان او لسة حاصله في التوقيت اللي بجمع فيه الداتا المهم انه وقت‬
‫جمع داتا المرض موجود عندهم يعني بقيس معدل انتشار المرض‬
‫واعتقد الصورة دي ممكن توضح الفرق‬

40
Enas Shalaby
‫ نبتدي بالسؤال التالت النه مختلف شكال وموضوعا‬.. ‫نبتدي ناخد االسئلة بالترتيب‬
‫وكمان بعد ما شرحنا التعريفات دي اصبحت االجابة عليه واضحة و صريحة ان االجابة‬
‫الرابعة هي الصحيحة‬
Q3 asks about the definition of prevalence rate so the answer will be total
number of cases and population at risk....

‫ التالت اسئلة واحد و بيسأل عن‬4 ‫ و‬2 ‫ و‬1 ‫السؤال رقم‬

effectiveness of immunization
‫الطبيعي ان النتيجة اللي متوقع اشوفها بعد التطعيم لمجموعة من الناس لما آجي‬
.. ‫ فرد‬100 ‫احسبها هشوف كام واحد أخد الجرعة بتاعة التطعيم دي ولو فرضنا انهم‬
‫ جاله مرض وبالتالي اقدر احسب كفاءة التطعيم‬100 ‫واحسب كم واحد من ال‬
% ‫بتاعي هتكون كام‬
incidence rate - immunization rate
‫ وتكون دي‬4 ‫ و رقم‬2 ‫وبالتالي هالقي االجابة دي موجودة واضحة في السؤال رقم‬
‫االجابة الصحيحة‬

‫ لكن االجابة بتاعتنا مش موجودة‬4 ‫ و‬2 ‫ بيسال نفس سؤال‬1 ‫نيجي للسؤال رقم‬
‫في االختيارات وبالتالي هنختار اجابة تانية تدينا نفس النتيجة اللي عاوزينها وهي‬
‫االجابة‬A
prevalence rate - incidence rate
‫يعني بقارن معدل حدوث حاالت جديدة بمعدل االنتشار الموجود وبالتالي اقيم‬
: ‫التطعيم المهم في النهاية انه‬
to measure outcome of vaccination , we must calculate the incidence rate

effectiveness of the flue vaccine program is best measured by....

1-local immunization rate to local incidence rate

2-local vacination rate to local prevelence
3-local prevelence rate to one national
4-national incident rate to ;ocal incident rate.

A
effectiveness of local flue vaccination program is best measured by :

a. local prevalence rate to local incidence rate

b. local vaccination rate to local prevalence
c. local prevalence rate to national one
d. national incidence rate to local incidence rate

41
A
==============================================================
255- After administration of the flu vaccine, the quality professional
measures how many people caught influenza after administering the
vaccine. in this case which dimension she measures:
A. Efficacy
B. Effectiveness
C. Availability
ANS:A

D. Appropriateness

=================
This choices changed in another Exam
1- Prevalence
2- Process
3- Appropriateness
4- Efficacy

by conclusion it is Efficacy in both ..

42
==============================================================
(23)
Sentinel event is a variation in :
A- Staffing
B- Process
C- Structure
D- Competenc

ANS:B
---------------------------------------------
A sentinel event is regarded as a:
a. Common cause variation
b. assignable variation.
c. Noise.
d. Random variation

ANS:B .‫اختالف قابل للتخصيص‬

Mutasim Hakim

With B
..
Assignable variation ( special cause , sentinel event ) describing the unusual event not
usually a part of the process and of course it's non-random caused by a single
identifiable factor with clearly defined characteristics

==============================================================
(24)
- 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

43
ANS:B
===================

240- 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

ANS:A

Mutasim Hakim
● In the first question the CPHQ should be familiar with the standards
first i.e just to have an idea about them ..
● In the seconed question as it's written very clear in JB that reviewing
the compliance with standards is a job of the TEAM so team should be
assigned first

Mutasim Hakim

‫ ومستحيل تغيب‬CPHQ ‫ مهمه جدا في امتحان ال‬accreditation ‫اسئلة السيرفي او ال‬

‫ اذا لم تكن‬Accreditation ‫ وفي خمسه اسئله مشهورين جدا عن ال‬.. ‫عن االمتحان‬
‫كلها موجوده في االمتحان فاثنين او ثالثه منها اكيد انهم سيكونوا موجودين ان شاء هللا‬
..
.. A ‫السؤال االول واجابته‬
‫ انه‬D ‫ واالجابة‬standards ‫الزم في االول نكون تيم عشان المراجعه الكامله بتاعة ال‬
‫ مش صحيحه النه ده شغل تيم كامل‬standards ‫الكواليتي بروفيشنال يعمل مراجعه لل‬
.. ‫عشان كده تكوين التيم اوال‬.. ‫مش شغله لوحده‬
‫وده السؤال‬
41

44
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

.. B ‫السؤال التاني واجابته‬

‫ يعني مجرد‬standards ‫ بال‬familiar ‫مطلوب من الكواليتي بروفيشنال فقط انه يكون‬
.. ‫ كامل زي السؤال السابق‬review ‫نظره مش‬
.. ‫وده السؤال‬
The first step the .healthcare organization is seeking accreditation A
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 committe
D. review the organization's policies and procedures

.. C ‫السؤال التالت واجابته‬

‫وده بيختلف عن االتنين اللي فاتو شويه انه اثناء السيرفي واالتنين السابقين كانوا قبل‬
‫ او‬accreditation ‫ ال‬during ‫السيرفي و المطلوب من الكواليتي بروفيشنال اثناء‬
‫ اللي‬frequently asked questios ‫ وهي ال‬FAQs ‫السيرفي عايزينه يدرس الناس ال‬
‫ وده السؤال‬.. surveyors ‫بيسالوها ال‬

:Which is best to do during the accreditation survey

A. To assign a team to answer the questions asked by surveyor

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

45
C
.. C ‫السؤال الرابع واجابته‬
‫ وهنا مهم جدا تدريس ال‬accreditation ‫وده برضو بيتكلم عن مرحلة التجهيز االولي لل‬
standards
.. ‫وده السؤال‬
… The most important initial step in preparation for accreditation survey is
A. Ensure clinical competenc
.B. Provide teaching tools
C. Standards education
D. Quality improvement activities

C
.
.. A ‫السؤال الخامس واجابته‬
‫ في‬CEO ‫هنا مش بيسال عن االستاندرز وال الكواليتي بروفيشنال وانما عن دور ال‬
.. ‫ شهر‬18 ‫ اللي ح يتم بعد‬Accreditation ‫توصيل وشرح معلومة ال‬
.. ‫وده السؤال‬
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
‫ودمتم_موفقين‬#
==============================================================
(25)
Performance Improvement data are used for credentialing and privilege-
delineation. The practitioner is evaluated on his/her
‫يتم تقييم الممارس‬. ‫يتم استخدام بيانات تحسي األداء يف عمليات االعتماد وتحديد االمتياز‬
‫ له‬/ ‫عىل‬
A. communication style and temperament.
B. adherence to federal, state and organizational standards.
C. cooperation, appropriateness, and staffing activities
D. concern about the well-being of patients in long-term care.

ANS:B

B. adherence to federal, state and organizational standards.‫المعتزباهلل جاب هللا‬

46
 ====================

An organization hires ‫ تعيي‬a 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

ANS:B ‫لتمرير مفاهيم تحسي الجودة لموظفيها‬

Ahmed Yassein
C ‫مستبعده تماما وال فيها جزء من الصح‬

Dr-Fares Younis
‫ السؤال عن أول حاجة ايه‬- ‫تيجي في المرحلة الثانية‬

====================
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

ANS:B

47
==============================================================
(26)
((Consensus)) = All support the decision …
(( Unanimous Agreement)) = All agree about the decision
===============================================
20- Decision by "consensus" means:
A- unanimous agreement
B- all support the decision
C- the agree of the majority
D- nobody agrees
ANS:B

48
Abdullah Al-Falah

A ‫ مش موجودة راح اختار‬B ‫لو‬

‫او‬

‫ بهذي الصيغة‬B ‫لو‬

Most support the decision

‫ برضو راح اختار‬A

Decision by "consensus" means:

A. unanimous agreement
B. most support the decision
C. the agree of the majority
D. all members are satisfied

ANS:A

49
 ‫‪unanimous agreement :‬‬
‫‪a- all agree about the decision‬‬
‫‪b- the agree of the majority‬‬
‫‪c- nobody agrees‬‬

‫‪ANS:A‬‬
‫========================‬
‫‪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

‫‪ANS:D‬‬
‫‪Mutasim Hakim‬‬
‫مع‪.. D .‬‬
‫في ال ‪:consensus‬‬
‫● اليوجد فيه تصويت ‪ voting‬ابدا ‪..‬‬
‫● ال مش كل واحد بيحصل على اللي هو عايزه‬
‫● ال مش كل الناس تاتي على الراي الصحيح وانما كل الناس تدعم الراى المتفق عليه‬
‫● اخيرا في ‪ D‬ودي الصح اي واحد من التيم بيكون فاهم ليه تم اتخاذ القرار ده وليه يعتبر االصلح‬
‫‪..‬‬
‫مع ‪.. D‬‬
‫احنا قلنا انه في ال ‪ decision by consensus‬مش الزم الكل يوافق ‪ ..‬بس اللي الزم انه كل حد‬
‫في التيم يكون عارف ليه تم اتخاذ القرار ده وليه هو االصلح من بين كل الخيارات ‪ ..‬االجابة ‪ C‬مش‬
‫صح عشان هو حدد فيها انه اخيرا كل الناس جات للقرار الصح ومش الزم القرار في حقيقة الوضع‬
‫يكون هو الصح المهم انه الكل معتقد ومؤمن انه االصلح ‪..‬‬

‫‪50‬‬
‫‪-------------------------------------------‬‬
‫‪Consensus does NOT mean:‬‬

‫‪• A unanimous vote‬‬

‫‪• Everyone getting what they want‬‬
‫‪• Everyone finally comes around to the "right" opinion‬‬
‫‪• Reaching a compromise‬‬

‫‪Consensus means:‬‬
‫‪• Everyone understands the decision and can explain why it's best‬‬
‫‪• Everyone can live with the decision‬‬

‫==============================================================‬
‫)‪(27‬‬
‫ل ‪TYPES OF MEASURES‬‬
‫موضوع ال ‪ types of measures‬حيوي جدا وغالبا بيكون حولها ‪ 4‬او ‪ 5‬اسئله في االمتحان‬
‫ولالسف الناس بتتلخبط فيهم ‪ ..‬عشان كده ح احاول اوضحهم بشكل مختصر ومبسط عشان نفهمهم‬
‫كويس‬
‫■ اوال ال ‪.. Structure‬‬
‫ياجماعه ال ‪ structure‬دي هي المصادر والبنيه التحتيه يعني اي حاجه في ‪environment‬‬
‫بتسهل وتعمل ‪ facilitation‬لتقديم الخدمه الصحيه ‪ ..‬وبمعني تاني هي كل المدخالت التي تجعل‬
‫المؤسسه قادره علي تقديم الخدمه ‪..‬‬
‫ال ‪organization capacity to provide care‬‬
‫ابتداء من الطبيب والممرضه ومرورا باالجهزه الطبيه وعدد الموظفين وساعات العمل المفروضه‬
‫والغرف اللي بيتقدم فيها الخدمه والسياسات بتاعة الخدمه ولحد الكرسي والسجل اللي بيتسجل فيه‬
‫‪ ..‬يبقي ال ‪ structure‬هي اسهل واحده فيهم ‪..‬‬
‫■ ثانيا ال ‪.. process‬‬
‫البروسس هو كل اجراء او خطوه يتم عملها بغرض الحصول علي ‪.. outcome‬‬
‫والبروسس تالت انواع‬
‫• ال ‪clinical process‬‬
‫وده اي شغل بيعمله الطبيب او الممارس للعيان وبرضو ردة فعل العيان للحاجه اللي عملها الطبيب‬
‫يعني الفحص اللي بيفحصه الطبيب للعيان ده بروسس وخطة العالج وطلب الفحوصات وتثقيف‬
‫المريض ومعالجة المضاعفات وحقن الدواء وحتى نسبة العيانين اللي بيتلقوا الخدمه حاليا ‪ ..‬كل ده‬
‫‪.. clinical process‬‬

‫‪51‬‬
 ‫• ال ‪care delivery process‬‬
‫ودي جزء منها متعلق بالخدمات اللي بتقدم بشكل غير مباشر للعيان زي التسجيل في السجالت او‬
‫تنظيف الغرف او تحويل العيان ‪ ..‬وجزء تاني متعلق بالسيستم زي نظام توزيع االدويه ‪..‬‬
‫• ال ‪.. administrative process‬‬
‫ودي كل االجراءات اللي بتتخدها االداره لتقديم الخدمه ‪..‬‬
‫■ ثالثا ال ‪.. Outcome‬‬
‫هنا بنتكلم عن نتائج ‪ end results‬للخدمه اللي قدمت ‪ ..‬وممكن نقسمها ل تالت انواع ‪..‬‬
‫• ال ‪clinical‬‬
‫وده اي شئ حصل في المدي القريب نتيجة الخدمه اللي قدمت للعيان يعني نسبة الوفايات ونسبة‬
‫المضاعفات وال ‪ adverse events‬كل دي ‪.. clinical outcome‬‬
‫• ال ‪.. functional‬‬
‫ودي الوظيفه الحياتيه للمريض علي المدي الطويل والحاله الصحيه والسلوكيه التي يمارس بها‬
‫نشاطه اليومي ‪..‬‬
‫• ال ‪perceived‬‬
‫ودي مدي تقدير العيان او اسرته للخدمه اللي قدمت زي ال ‪..pt & family satisfaction‬‬
‫وده مثال من ‪ 10‬اسئله علي نوعية االسئله بتاعتهم في االمتحان والحلول تحت ‪..‬‬
‫واللي جمع االسئله دي حبايبي د‪.‬فارس يونس ود‪.‬اشرف القناوي ‪..‬‬

‫‪1- A performance measure that records the number of well-child visits within the‬‬
‫‪first fifteen‬‬
‫‪months of life in the reporting year is a measure of‬‬
‫‪a. structure.‬‬
‫‪b. process.‬‬
‫‪c. outcome.‬‬
‫‪d. process and outcome.‬‬

‫‪1B‬‬
‫‪----------------------------------------------------------------------------------------------------‬‬

‫‪52‬‬
2- The performance indicator, “Total unscheduled inpatient admissions following
ambulatory procedure (within 48 hours)” is a measure of
a. structure.
b. process.
c. outcome.
d. process and outcome.

2C

-----------------------------------------------------------------------------------------------
3- The number of designated women receiving breast cancer screening
(mammograms) in the reporting year measures
a. process.
b. clinical outcome.
c. process outcome.
d. process and clinical outcome.

53
3C
-----------------------------------------------------------------------------------------------
4- Measuring the time it takes a nurse to perform a procedure addresses which of
the following
aspects of care?

A. monitoring
B. process
C. outcome
D. structure

4B
-----------------------------------------------------------------------------------------------
5- The number of productive hours worked by nursing staff with direct patient care
responsibilities per patient day is a
A- structural measure.
B- process measure.
C- outcome measure.
D- composite measure.

5A
----------------------------------------------------------------------------------------------------

54
6- One of the aims in the treatment of severe community-acquired pneumonia is to
maintain an oxygen saturation of >94% (or 88 - 92% in patients with chronic
obstructive airway disease). Ensuring adequate oxygenation for this condition is a
A. process and outcome measure.
B. structure measure.
C. process measure.
D. outcome measure.

6C
---------------------------------------------------------------------------------------------
7- In an improvement project to reduce the wait times in an Emergency Room, the
time taken to be assessed by a physician is
A- a process measure.
B- an outcome measure.
C- a structure measure.
D- not a suitable measure.

7A
----------------------------------------------------------------------------------------------------
8- In implementing a care bundle for the management of acute myocardial
infarction, the recording of the extent to which smoking cessation counseling is
provided is a measure of
A. structure.
B. process.
C. outcome.
D. process and outcome

8B
---------------------------------------------------------------------------------------------------

55
9-Monitoring phlebitis associated with IV insertions by nurses in the Surgic- al Intensive
Care Unit
addresses which focus?
‫ بواسطة الممرضات في وحدة العناية المركزة الجراحية‬IV ‫مراقبة التهاب الوريد المرتبط بإدخال‬
‫عناوين التي تركز‬

a. Outcome of care
b. Process of care
c. Structure of care
d. Administrative procedure

9A ..
---------------------------------------------------------------------------------------------------
10- Monitoring the specific organization and content requirements of a medical
record system is a review of which focus?
a. Outcome of care
b. Process of care
c. Structure of care
d. Administration of care

10C

Mutasim Hakim

1B .. 2C

3C .. 4B

5A .. 6C

7A .. 8B

9A .. 10C
1 ‫تفسير السؤال‬

56
 ‫تفسير السؤال ‪2‬‬

‫تفسير سؤال ‪3‬‬

‫السؤال ‪4‬‬
‫الفرق بين السؤال الرابع والخامس هو انه في السؤال الرابع احنا بنتكلم عن الوقت الدي تستغرقه‬
‫الممرضه الداء مهمه معينه وده بروسس مافي كالم ‪..‬‬
‫اما السؤال الخامس فالساعات المقصوده هي الساعات المقرر انجازها نظاما ( وطبعا ده حسب ال‬
‫‪ contract‬بتاعها ) من الممرضه مع كل مريض ‪ ..‬عشان كده دي ح نعتبرها ‪ structure‬زيها زي‬
‫ال ‪ policies‬اللي مكتوبه عندنا ‪..‬‬

‫تفسير السؤال الخامس‬

‫مع ‪.. A‬‬
‫السؤال ده كان عليه خالف كبير وناس كتير كان رايها انه المؤشر ده يمثل ‪ ( process‬وانا منهم )‬
‫باعتبار الكالم عن الساعات المنجزه حقيقة ‪.. productive hours‬مش الساعات المقرر انها‬
‫تشتغلها ‪ ..‬بس لما رجعت لمعرفة قياس المؤشر بتاع ال ‪ productive hours‬عند ال ‪National‬‬
‫‪ Quality Forum‬وطبعا بالشك هو جهه موثوق فيها جدا وال يختلف عليها اثنان ‪ ..‬وجدت انها‬
‫مصنفه على اساس ‪ structure‬بشكل ال لبس فيه ابدا عند ال ‪ .. NQF‬وبناء عليه فان اجابتي على‬
‫السؤال هي‪A .‬‬

‫تفسير السؤال ‪6‬‬

‫تفسير السؤال ‪8‬‬

‫ركزي هو بيسال عنه ايه ‪ ..‬ال ‪ key word‬هي ال ‪ recording‬يبقي التسجيل بتاع الى اي مدي ال‬
‫‪ counseling‬ده قدم ده اكيد بروسس‬
‫تفسير السؤال ‪9‬‬

‫‪57‬‬
 10 ‫تفسير السؤال‬

==============================================================

(28)
Facilitator ---focus on--> Process only
Leader .... ---focus on--> Process & Content
================
38- 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..

ANS:A
=================
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

58
ANS:B

Marwa El-shazly Facilitator is not a team member so focus genrally on process

A,c are details discussed by team members

================
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

ANS:A

======================
The healthcare quality professional's role in a quality improvement team
should least likely be
‫أخصائن جودة الرعاية الصحية يف فريق تحسي الجودة أقل‬
‫ي‬ ‫ينبغ عىل األرجح أن يكون دور‬
‫ي‬

1. team leader.
2. coordinator of the team process.
3. team member.
4. Facilitator

59
ANS:1

===========================
Primary role of the facilitator is to :
a) Design team structure
b) promote effective group dynamics.

July 2016
ANS:B

‫المعتزباهلل جاب هللا‬

B as in janet exactly in team roles

==============================================================

60
(29)
hospital purchases additional malpractice insurance and general tort
liability insurance prior to introducing a pediatric heart surgery program.
This is an example of
risk transfer.
risk avoidance.
risk reduction.
risk retention.

ANS:A
Mutasim Hakim
.. A ‫مع‬
‫المستشفى دي قبل ما تبدأ تقديم خدمة جراحة القلب لالطفال قررت تتعاقد مع شركة تأمين ضد‬
‫القضايا واألخطاء الطبيه يعني حولت الدفع في اي مخالفه طبيه الى جهه اخرى خارج المستشفى‬
‫ اي تحويل المخاطر‬risk transfer ‫ وده بالضبط ما يعرف بال‬externally funded ‫وده اللي هو‬
organization ‫الناتجه عن تقديم الخدمه الى جهه خارج ال‬

==============================================================
(30)
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.

ANS:C
============================================
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.

61
ANS:A
==============================================================
(31)
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

ANS:A

Hala Salha Cphq Exam the best outcome you can take to measure for ambulatory
services is the number of patients that get admitted to the hospital , means that référés
from outpatient to the hospital for emergency or severity .
======================
The performance indicator, “Total unscheduled inpatient admissions
following ambulatory procedure (within 48 hours)” is a measure of
48 ‫(ف غضون‬‫اإلسعاف ي‬
‫ي‬ ‫جمال القبول للمرض الداخليي غث المجدولي يف أعقاب اإلجراء‬
‫ي‬ ‫ا‬
‫ساعة) "هو مقياس‬
a. structure.
b. process.
c. outcome.
d. process and outcome

ANS:C

.==============================================================

(32)

62
The most important initial step in preparation for accreditation survey is …

A. Ensure clinical competency

B. Provide teaching tools.
C. Standards education.
D. Quality improvement activities.

ANS:C

..
Mutasim Hakim with C
I think in accreditation standards are the the corner stone and it includes clinical and nonclinical
issues of course , and i think this is why A is wrong because the clinical co mpetency is not
included in all parts of the accreditation

====================
When review clinical competency of surgeon at the time of reappointment :
A- group interview with practitioners
B- interview with the practitioner
C- quality professional review credential file
D- chief of surgery department review credential file

ANS:D

‫المعتزباهلل جاب هللا‬

‫علشان هو حدد الكفاءة و االولى هنا لقاء مع الرئيس المباشر اللى هيشغله و كمان االدري بالتخصص‬
‫هو رئيس القسم‬

====================

63
Who assess the clinical competency of LIP for reappointment?

‫ إلعادة التعيي؟‬LIP ‫الكفاءة الرسيرية من‬

A. Governing board
B. CMO (Chief Medical Officer)
C. Quality director
D. Departmental director

ANS:D

Mutasim Hakim

.. D ‫مع‬
‫ ان يقيم ال‬GB ‫ للممارس و ال يمكن لل‬clinical competency ‫رئيس القسم مسئول بشكل تام من تقييم ال‬
‫ لدا هو ابعد واحد عن االجابه‬clinical competency
‫ في التقييم ايضا‬CMO ‫وهناك دور مهم جدا لل‬

Enas Shalaby

‫اي حاجة تخص‬

evaluation or the assessment of competency of any staff member inside any
department is the responsibility of the department director
‫يعتي تقييم اداء اي موظف‬

‫ نفسه مين مسئول عنه هتكون االجابة‬reappointment ‫لكن لو بيسال عن قرار ال‬
Governing body

=========================================================
(33)
1- The best time for evaluating a quality improvement project is:
A. At the end of the project
B. Quarterly (quarter year)
C. Annually (calendar year)

64
ANS:B
Hala Salha B- quarterly so we can have sometime to monitor the improvement
projects progress. issues cannot be solved quickly , however, we don't want to wait too
long to evaluate.

======================
2- Best time to evaluate the performance improvement team is
A- When the goal is reached
B-At the end of the meeting
C-every quarter
D-Each year

ANS:C
Mutasim

Every quarter

==============================================================
(34)
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

ANS:B

65
 ===================
1-Health care organization is complex system. In complex system all of the
following are right except:
A-the interrelationships between agents are most important
B-The outcome is predictable ‫النتيجة قابلة للتنبؤ‬
C-dealing with complex system require understanding the bid picture
D-here's a high chance for variation that may be identified as error or
innovation

ANS:B
Mutasim Hakim
.. B ‫السؤال االول‬
Outcome ‫ هو من اعقد النظم والتي ال يمكن أبدا التنبؤ بال‬healthcare system ‫معروف انه ال‬
‫ معروف ومحدد مسبقا شكال‬product ‫ النه مقارنة بالجهات االخرى زي الصناعه مثال ال‬.. ‫بتاعها‬
pt ‫ هو صحة انسان و‬product ‫ او ال‬Outcome ‫ فانه ال‬healthcare ‫ اما في ال‬.. ‫وكيفا وكما‬
wellbeing

=============================================================
(35)

66
1- 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

-Intermittent, unpredictable, unstable, extrinsic and assignable

ANS:B
Mutasim Hakim
.. B
‫ بمعنى متقطع‬intermittent ‫ يعتبر‬common c.v ‫ وبعكس ال‬special cause variation ‫ال‬
‫ بمعنى غير متوقع‬unpredictable ‫ وكمان‬.. Common C.V ‫او غير موجود بشكل دائم زي ال‬
unstable ‫ وكمان هو‬.. ‫ والذي يحدث دائما‬common ‫النه الشئ الذي يمكن توقعه هو الشئ ال‬
‫ وكمان‬.. ‫ اللي بيكون ثابت في البروسس على مدى سنين او فترات طويله‬common ‫مش زي ال‬
‫ واخيرا‬.. common ‫ يعني قشري او خارجي وغير متجذر في اعماق البروسس زي ال‬extrinsic
‫ عايزه تولد‬lady ‫ لما تجي‬special cause ‫ مثال على‬.. ‫ بمعنى مميز وواضح جدا‬assignable ‫هو‬
‫ مزعج جدا‬special cause ‫في المستشفى والده طبيعه وتموت في الوالده نتيجة خطأ طبي مثال ده‬
.. ‫وواضح ومميز ونادر جدا‬

67
2- A common cause variation is:
a. An intrinsic, inliers, unpredictable, chronic variation.
b. The responsibility of the process owners.
c. Correctable by top management and the team.
d. An intrinsic, outlier, unpredictable, acute variation.

‫قابل للتصحيح من قبل اإلدارة العليا والفريق‬

ANS:C

==============================================================
(36)

68
- On presentation of the annual review to the governing body, the
following is important to include the presentation :
A- Graphs & tables
B- Minutes
C- Team achievement
D- Complaints

ANS:C

Which one should be included when reporting PI to GB

A- Team achievements
B- Team minutes
C- Occurrence and incident reports

ANS:A

Mutasim Hakim
‫مع‬A

==============================================================

69
(37)

‫ر‬
Prevention quality indicators are useful in ‫مؤرسات جودة الوقاية مفيدة‬
A. Monitoring of mortality rate for medical and surgical patients
B. Identifying avoidable intervention/admissions
C. Identifying preventable complications and iatrogenic events for pediatric
patients
D. Identifying potentially avoidable complications

ANS:B

‫ القبول الذي يمكن تجنبه\ تحديد التدخل‬.

Mutasim Hakim
.. B ‫مع‬
early intervention ‫ ودي اللي من خاللها بيتم ال‬prevention indicators ‫هنا السؤال عن ال‬
‫ عشان نقلل بقدر االمكان مسألة رجوعهم‬ambulatory ‫ من ال‬suspected cases ‫بالنسبه لل‬
‫للتنويم في المستشفى والكالم في الصوره بيوضح النقطه دي كويس‬

==============================================
Indicators designed to identify potentially avoidable complications
A. Prevention quality indicators
B. Inpatient quality indicators
C. Patient safety indicators
D. Pediatric quality indicators

70
ANS:C

Mutasim Hakim
‫مع‬C

==============================================================
(38)
Low medication error rate in a healthcare organization may be due to:
A. Highly developed culture of safety
B. Deficient reporting system
C. The staff is reluctant to report due to fear of reprisal
D. The organization failed to adopt a performance improvement approach
for error reduction

ANS:A

71
=============================================
To develop a culture of safety, it is first to:

A. Make it safe to make mistakes

B. Establish a punitive reporting system
C. Blame is enough
D. Focus efforts on individuals rather than system

‫اجعلها آمنة الرتكاب األخطاء‬

ANS:A
An organization has established a culture of patient safety when
A. fear of retaliation is eliminated.
B. reports of potential errors have decreased.
C. patient safety goals are implemented.
D. employee education is completed

ANS:A

72
‫‪High reporting of medical errors and near miss is a mirror of:‬‬
‫‪A. Defective quality of care‬‬
‫‪B. Feeling protected by a non-punitive culture‬‬
‫‪of medical errors reporting‬‬
‫‪C. Sophisticated system‬‬
‫‪D. Conflict of interest‬‬

‫الشعور بالحماية بواسطة ثقافة غث عقابية‬

‫من األخطاء الطبية اإلبالغ‬
‫‪ANS:B‬‬
‫‪Mutasim Hakim‬‬
‫‪.. B‬‬
‫لما تكون الناس بتسجل وتبلغ عن االخطاء بشكل عالي ده بيدل على انه الناس عندها احساس انها‬
‫محمية من العقاب نتيجة االبالغ عن الخطأ ودي الثقافة الرائعة المعدومة في منظومتنا الصحيه‬
‫لالسف وهي معاقبة وفصل وتشريد من يظهر االخطاء الى السطح‬

‫==============================================================‬
‫)‪)39‬‬

‫‪73‬‬
Who is responsible for providing organizational direction for a facility’s
continuous quality improvement?
A. Quality council
B. Facilitator.
C. Teams.
D. Leader.

Ans:a
Orgz guide>>>>>Q.council
Team guid>>>>>>Q. Leader
Team redirect during meeting >>>>facilitator
====================================

Mutasim Hakim
22 June

VERSION 1: For CQi to be successful, who must be included in staff

A. department supervisor
B.administrator
C. facilitator
D. Staff

answer: A
Version 2: For CQi to be successful who must be included in staff

A. administrator
B. person performing process
C. quality management representative
D. department supervisor

ANSWER: B
Version 3: who is responsible for providing CQI direction
A. facilitator
B. quality councel
C. leader
D. team

74
ANSWER : B
Version 4: who is responsible for quality improvement within organization

A. quality manager
B. frontline staff
C. everyone within organization
D. chief executive officer

ANSWER : C
Version 5: 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 councel

ANSWER : B
VERSION 6: Who is ultimately responsible for the effective implementation of the
quality program:

a. Governing Body
b. CEO
c. All staff
d. The CFO

ANSWER : A
VERSION 7: 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 practictioner to make any exception to guideline

75
ANSWER : C
Version 8: appropriateness of radiology care is evaluated by: chief of radiology
Version9 : quality of care policy is ultimate responsibility of: board of director
Version10: pass on commitment and value of understanding : medical director

‫ وال هما االتنين‬GOVERING BODY ‫ حتى لو كان فى ال‬BOARD ‫بالنسبه للسؤال التاسع بختار ال‬
‫حاجه واحده؟‬

Mutasim Hakim
governing body ‫ هو نفسه ال‬board of directors ‫ال‬

======================
CHAMPION ‫سؤال اخر عن‬

76
The roles and responsibilities of a Champion include all of the following
EXCEPT:
A.A Champion selects the Team Leader.
B.A Champion reviews team progress.
C.A Champion coordinates team logistics.??
D.A Champion assures the use of Six Sigma methods and tools

D.A Champion assures the use of Six Sigma methods and tools

If leadership is the critical success factor for an effective patient safety

program, what is the first key responsibility of leaders? .
A. Set strategic goals
B. Establish the value system
C. Designate a champion.
D. Provide resources

B. Establish the value system

Who has the responsibility of determining improvement priorities in a

healthcare organization?
A The Quality Council
B The Governing Body
C The Chief Executive Officer
D The Quality Director

77
ANS:A

Determining improvement priorities >> quality council

Final approval of improvement priorities >>> GB

========================
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
ANS:A

Mutasim Hakim
.. A ‫السؤال الخامس‬
‫ ممكن‬tool ‫ مافي‬.. ‫ يعني باريتو‬prioritization ‫اعتقد مش محتاجين نفسر اكتر من اننا نقول‬
pareto chart ‫يوضح لنا االولويات احسن من ال‬

====================================================
** Quality council :
1- providing organizational direction for a facility’s continuous quality
improvement
2- determining improvement priorities in a healthcare organization
** Senior leaders :
- prioritizing performance improvement initiatives
=======================================================
(40)

78
‫يصف تقييم االحتياجات التعليمية‬

The function which describes the assessment of educational needs is

a) Quality improvement
b) Utilization management
c) Risk management
d) Process map

ANS:A

Mutasim Hakim
‫مع‬A

=======================
(Continuous Developing Education Programs) is usually a function of
which of thefollowing :
A- Human Resources
B- Quality improvement
C- UM
D- Budgeting

Mutasim Hakim

.. B ‫مع‬
.. ‫ وهي طبعا مهمه جدا‬Developing ‫السؤال عندكم ناقص كلمة‬

‫السؤال كامل كالتالي‬-

79
In any hospital, developing (Continuous Education Programs) is usually a
function of which of the following departments?
a) Human Resources department.
b) Quality Management department.
c) Risk Management department.
d) Nursing department

ANS:B

In any hospital, PERFORMING (Continuous Education Programs) is usually a

function of which of the following departments
a) Human Resources department.
b) Quality Management department.
c) Risk Management department.
d) Nursing department

a) Human Resources department.

80
============================
A continuous quality improvement organization promotes vigorous
education and training/retraining in order to
A. restructure internal jobs.
B. reduce the need for competency testing.
C. promote harmony within the organization.
D. acquire new knowledge

ANS:D
Mutasim Hakim
.. D ‫السؤال االول‬
.. ‫ عشان الفكره هنا اكتساب علم ومهارات جديده‬.. D ‫كلنا متفقين علي‬

==============================================================
(41)
~~ BSC Balanced Score Card ~~
A balanced score card for an organization is best described as
A-A graphic display of departmental performance A
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

ANS:C

81
-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 .

d)review patient compliant .

ANS:A
Mutasim Hakim
.. A ‫السؤال االول مع‬
pt satisfaction ‫ موجود عنده وقالوا انه ال‬already ‫ النه‬C ‫ مش ح يسأل عن اللي مكتوب في‬GB ‫ال‬
‫ وهو هل في شكاوي وال ال عشان يتأكد‬D ‫ هو لو في شك ممكن يسال عن اللي مكتوب في‬%98 ‫ هي‬data
‫ بس طبعا انا بفترض انه اي داتا في السؤال هي داتا صحيحه وليست محل شك‬.. ‫ دي‬% 98 ‫من حقيقة ال‬
A ‫ عشان كده االجابه االصح هي‬..

82
=========================
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 th e
organization's performance
d) Each measure in the balanced score card has a target

ANS:C

83
==========================
In the Balanced Scorecard, the Perspective that measures human,
informational, and operational capital is

a. Operations/Internal.
b. Financial.
c. Innovation and Growth
d. Customer

ANS:C

84
=========================
In your capacity as the Director of Quality and Patient Safety at a 1600-bed
tertiary referral center, you are consulted to assist in the development of a
balanced scorecard.
In selecting measures for the scorecard, the "perspectives" commonly used
include all of the following EXCEPT
1. Financial.
2. External Business Processes
3. Customer.
4. Learning and Growth.

ANS:2
Mutasim Hakim
.. 2
INTERNAL business process ‫ وانما‬EXTERNAL business process ‫هو طبعا مش‬

The 4 classic "perspectives" of the balanced score card are: "Financial",

"Customer", "Internal Business Processes", and "Learning and Growth".

==========================

85
As a performance measurement system, the key value of the "balanced
scorecard" concept is its ability to

a. serve as a comparative "report card" with like organizations.

b. focus the organization on financial measures of survival and success.
c. encompass all the organization's clinical and non-clinical measures.
d. align measurement with the vision and strategy of the organization.

ANS:D

86
=========================
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

ANS:D

Tharwat Mahmoud
‫شكرا لك‬
‫ما فهمته هو التالى‬
‫ لوحة مراقبة االداء‬Dashboard

87
 ‫ كرت مراقبة تنفيذ الخطة االستراتيجية‬BSC
‫ خريطة تطبيق اال ستراتيجية‬Strategy Map
‫ شكرا لك‬.. ‫هل هذا المفهوم صح ام ال‬

Mutasim Hakim
‫ هي بالضبط لوحة العدادات اللي فيها كل االرقام قدامك واللي بتقولك‬dashboard ‫نعم بالضبط ياحبيب وال‬
‫ فهي فعال مراقبة تنفيذ الخطه االستراتيجيه من حيث ال‬BSC ‫ اما ال‬.. ‫في اللحظه دي انت موقفك ايه‬
‫ الخ‬.. Goals ‫ وال‬vision ‫ وال‬Mission

==============================================================
(42)
Time out :
Where ? : In OR "operating Room"
When ? : just before surgery
=================
Concerning the surgical "time-out", which of the following statements is
FALSE?
1. The surgical "time-out" reduces the risk of wrong-site surgery.
2. The surgical "time-out" reduces the risk of preventable surgical mistakes
other than wrong-site surgery.
3. The surgical "time-out" is a component of the World Health
Organization (WHO) Safe Surgery Checklist.
4. The surgical "time-out" requires involvement of the patient.

88
--------------------------------------------------------------------------
1- A company comprising 500 employees, negotiated the delivery of
comprehensive package of health services to its employees during the
coming year, to be paid as a fixed rate on monthly basis. This is mechanism
of payment is:
a. Case rate.
b. Per-diem charges.
c. Capped rate.
d. Capitation rate

89
ANS:D

Abdel Aziz Elbadry CASE RATE NEGOTIATION……. FOR ONE PERSON

Abdel Aziz Elbadry PER DIEM……. FOR ONE DAY

Abdel Aziz Elbadry CAPPED RATE….. FOR IMPORTANT PERSONS

‫يعنى ايه‬imp persons?

Abdel Aziz Elbadry

‫الناس المشهوريين او اللى وضعهم كويس‬

Abdel Aziz Elbadry ALSO CAPPED…… FOR DANGERIUS DISEASES

Abdel Aziz Elbadry CAPITATION…….. FOR HOMOGENEOUS LARGE NO. OF PERSONS

============================
2- The insurance mechanism which entails paying a fixed rate per visit by
the insured, while the insurer covers the rest of the required expenses
according to the care provided is:
a. Capitation.
b. Co-payment
c. Deductible.
d. Fee- for service.

ANS:B
============================

90
The capitation rate paid for a Medicare member is ____% of the adjusted -4
average per capita cost.
A. 100
B. 95
C. 75
D. 66

ANS:B
Mutasim Hakim B .. B
Medicare ‫ دي ثابته بتدفعها ال‬%95 ‫ وهو نسبة ال‬recall ‫لسؤال التاني ياحبيب سؤال‬
..‫العضائها وهي منظمة التامين الصحي االمريكي‬

==============================================================
(43)
1- "Occurrence reporting" is a type of
a. risk reduction
b. risk evaluation
c. risk identification
d. risk prevention

ANS:C
Mutasim Hakim
.. C
‫ ده واحد من الطرق اللي‬reporting ‫ يبقى ال‬.. ‫ بالشك‬risk ‫تسجيل االحداث هو لتحديد مواضع ال‬
‫ سواء للمرضى او‬harm ‫ لمعرفة مواضع الخلل والتي قد تتسبب في‬identification ‫بنعمل بيها‬
‫ على المؤسسه ككل‬financial risk ‫اسرهم او االستاف او حتى‬

===========================

91
2- which is the best tool used in "generic screening"?
a. medical record
b. claims data
c. incident report
d. performance indicators

ANS:A
Mutasim Hakim
.. A ‫مع‬
medical records ‫ اساسا هو بحث وتعقب في ال‬generic screening ‫ال‬

============================
3-What is true regarding patient safety indicators (PSIs) :
a. PSIs require manual data collection
b. PSIs are screening tools
c. PSIs focus on outpatient care
d. PSIs are tools used to monitor patients while they are in the hospital

92
ANS:B
Mutasim Hakim
B ..
‫ نقدر من خالله نتقصى عن ال‬screening tool ‫ هي بال شك‬pt safety indicators ‫طبعا ال‬
‫ اللي بتحصل للمرضى داخل المنشآت الصحية‬adverse events

==============================================================

(44)
1-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

ANS:A

Medication reconciliation:
A: help in efficient use of medication
B: Identify discrepancies in meds
C:Identify and resolve med. Discrepancies

Mutasim Hakim
.. A ‫السؤال االول اجابته‬
‫ جوه المستشفى وفي االبالغ لرئيس التيم عن‬safety ‫ مفيده في في متابعة ال‬PSIs ‫النه فعال ال‬
pt ‫ اما اعادة التعاقد فمؤشرات ال‬.. ‫االحداث المعينه وكمان متابعة االداء ومقارنته مع االستاندرز‬

93
 ‫ ال تتم على اساسها‬safety

‫😊)شال راس السؤال‬ ‫اما السؤال الثاني فهو غير صحيح اصال النه في شخص ( هللا يسامحه‬
‫ وده اخالل بمعايير السؤال‬.. ‫االول ولزقه في السؤال اللي مرفق في الصوره تحت ده‬

3- Patient safety indicators are developed by AHRQ are designed to be useful in

all of the following except

A.Collect patient safety data

B.Support root cause analysis
C.Monitor change initiatives post implementation
D. Monitoring of the staff performance

Patient safety Indicators

94
1.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

🔴 Answer: A
2.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

🔴 Answer: C
3.Prevention quality indicators are useful in

A. Monitoring of mortality rate for medical and urgical patients

B. Identifying avoidable intervention
C. Identifying preventable complications and iatrogenic events for pediatric
patients
D. Identifying potentially avoidable complication

🔴 Answer: B
4.Indicators designed to identify potentially avoidable complications are:

A. Prevention quality indicators

B. Inpatient quality indicators
C. Patient safety indicators
D. Pediatric quality indicators

🔴 Answer: C

95
==============================================================
(45)

96
The type and volume of patient admitted to treatment at hospital known as:

IF Type ANSWER Case mix TC

IF volume ANSWER Daily census VD

A.Case mix
B. Diagnosis-related group
C. Daily census
D. Patient acuity

ANS:C

97
=======================
2- Type and number of patients treated by a hospital is called :
A- DRGs
B- Case mix TC
C- case complexity
D- case severity

98
ANS:B
Dr-Fares Younis B

Abdeltawab Fathy
‫ يا د فارس؟‬case mix ‫يعني ايه‬

Dr-Fares Younis
The term Case mix refers to the type or mix of patients treated by a
hospital or unit. The term is often used to describe the billing system of the
hospital or unit, since the "cost per item" of healthcare is based on the
casemix.

====================
3- 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

ANS:D

Mutasim Hakim
.. D ‫مع‬
‫ ومش‬case mix ‫ وطبعا الصح‬case management ‫ مكتوب‬D ‫السؤال ده كنت بالقي الخيار‬
‫ لالسباب اللي ذكرتها زمان في التعليق المرفق‬case management ‫ممكن يكون‬

99
=====================

Case Mix
Managed care The characteristics–age, gender and health status–of the
population served by a health system or physician's office in a given period
of time, which are classified by disease, diagnostic or therapeutic
procedures performed, method of payment, duration of hospitalization,
and intensity and type of services provided; in the US, a hospital's CM is
based on the diagnosis-related groups
===========================
The Daily Census
is a database created by the MOHLTC using hospital monthly submissions
on their Daily Bed Census. It is the most definitive source of information
for patient volumes and related information. It includes the number of
admissions and separations, average length of stay, occupancy rates, as
well as the number of beds staffed and in operation

100
(46)
- Surgeon do a colonoscopy done perforation to colon in surgery :
A- Refer case to peer review
B- Remove his privilege
C- Initiate FPPE

ANS:A

101
Reporting that colon perforation occurred during colonoscopy which of the
following is the health care quality professional next step :
a. Notify physician privileges
b. Assign doctor for investigation
c. Define the case for peer review
d. View 100% colonoscopy procedure.

ANS:C
==============================================================
(47)
Evaluating medication administration to reduce medical errors is an example of:

A. Risk management.
B. Utilization management.
C. Quality management.
D. Financial management.

ANS:A
_____________________________________________________
2-Medication error rates are considered an indicator of which of the following
parameters?
A. Finance
B. Patients
C. Clinical process
D. Learning

ANS:C

102
==============================================================

For a patient with insulin-dependent diabetes mellitus, which of the following

programs is the most appropriate to administer?

Disease management
Utilization management
Demand management
Risk management

Disease management
(48)

103
‫‪Practice guidelines cannot help the physicians in:‬‬
‫‪A. Identifying the best practice‬‬
‫‪B. Saving money to the facility‬‬
‫‪C. Meeting patients expectations‬‬
‫‪D. Identifying errors in patient care‬‬

‫‪ANS:C‬‬

‫‪Mutasim Hakim‬‬
‫في التوضيح انا اتكلمت ليه االجابه ‪ C‬وليه مش ‪.. B‬‬
‫اما بالنسبه لالجابه ‪ A‬فهي مش صحيحه النه ال ‪ CPGs‬فعال بتخلي الطبيب يعرف ايه ال ‪best‬‬
‫‪ practice‬من خالل االلتزام الحرفي بماهو مكتوب في البرتكول العالجي ‪..‬‬
‫اما االجابه ‪ D‬مش صحيحه برضو النه ال ‪ CPGs‬ممكن تخلي الطبيب يعرف االخطاء في الخدمه اللي‬
‫قدمت للمريض النه بمراجعه بسيطه لل ‪ guidelines‬ومقارنتها بما تمت عليه الخدمه ح اقدر انا‬
‫كطبيب احدد فين كان الحياد عن ال ‪ guidelines‬وبالتالي فين الخطأ بالضبط‬

‫‪104‬‬
=======================================
The following is important in development of practice guidelines except
A. Evidence based researches
B. Experience of peers
C. Patient expectation
D. Clinical knowledge of peer physician

ANS:C
Mutasim Hakim
.. C ‫مع‬
‫ وعلي خبرة ال‬evidence researches ‫ ح اعتمد بشكل اساسي علي ال‬guidelines ‫عشان اعمل‬
‫ وكذلك حصيلتهم العلمية والمعرفية لكن توقعات واراء المرضى‬specialty ‫ في نفس ال‬peers
typical treatment for typical patient ‫ هي‬guidelines ‫التهمني كثيرا النه ال‬

----------------------------------------------------------------------------------
In development of the practice guidelines, the following is involved except:
A. Physician
B. Quality manger
C. Evidence based research
D. Nurses

ANS:B

Mutasim Hakim
.. B ‫مع‬
‫ في‬nurse‫ النه ال‬quality profitional ‫ اهم بكتير من وجود ال‬Nurse ‫طبعا ياحبيب وجود ال‬
‫ عكس اخصائي الجوده والذي من‬process owners ‫ تعتبر من ال‬guidelines ‫عملية وضع ال‬

105
CPHQ ‫الممكن جدا ان يكون تخصصه بعيد تماما عن الحقل الطبي كان يكون خريج تجاره مثال ولديه‬
.. ‫ اذا فالممرضه هي من ستكون مشاركتها اهم واكثر فائدة لخبرتها في هذا المجال‬..

==============================================================
(49)
When the team member start to interest in hearing each other and being
on focus on goals and to respect each other, this is the stage of:
A. Performing
B. Storming
C. Norming
D. Forming

ANS:C

====================================

106
Conflict management is a function of leader to manage team in certain
stage of its development. This stage is:
A. Storming
B. Norming
C. Adjourning
D. Forming

ANS:A
==============================================================
(50)
The utilization management committee for a large medical group is
concerned about mis utilization. Which data supports the concern?
a. Lab report delays .
b. Reduced pediatric hospitalization rates
c. Increased incidence of C-Sections
d. Reduced pediatric immunization rates

ANS:A

107
 ===================================
.The utilization management committee for a large medical group is
concerned about under utilization. Which data supports the concern?
a. Lab reports delays
b. Reduced paediatric hospitalization rates
c. Increased incidence of C-sections
d. Reduced paediatric immunization rates

ANS:D

OVER utilization...............Increased incidence of C-Sections

==============================================================
(51)
Hospital Utilization Management Plan generally includes provision for
a. Disaster planning.
b. Transition planning.
c. Quality planning.
d. Financial planning..

108
ANS:B
Mutasim Hakim
B ‫مع‬
JB CH3 Q14

========================
‫التخطيط لمواجهة الكوارث‬Patient safety ----> Disaster planning
Hospital Utilization Management ----> Transition (discharge) planning
==============================================================
(52)
The average between the highest and lowest measures is the
A-Median
B-Mean
C-Mode
D-Dispersion

ANS:B
THE difference between the highest and lowest measures is the
A-Median
B-Mean
C-Mode
D-Range

D-Range

109
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1- (difference) between highest and lowest --------> it is Range
2- (Average = mean) bet. highest and lowest -----> " " Mean

110