A continuous quality improvement

organization promotes vigorous education and

training/retraining in order to

A. restructures internal jobs.

B. reduce the need for competency testing.

C. promote harmony within the organization.

D. acquire new knowledge and new skills.

A continuous quality improvement
organization promotes vigorous education and
training/retraining in order to

A. restructures internal jobs.

B. reduce the need for competency testing.

C. promote harmony within the organization.

D. acquire new knowledge and new skills.

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 speaks unless directed by the team
leader.
D. be a front-line employee.
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 speaks unless directed by the team
leader.
D. be a front-line employee.
A patient is transferred to a neighboring hospital for a
magnetic resonance imaging (MRI) exam. Due to a
misinterpretation of orders, the procedure is performed
on the wrong part of the body. Which of the following
should the healthcare quality professional do?
A. Report this as a sentinel event to the transferring
hospital.
B. Do nothing since it happened at another facility.
C. Conduct an analysis to reduce future occurrences.
D. Recommend disciplinary action for the offenders.
A patient is transferred to a neighboring hospital for a
magnetic resonance imaging (MRI) exam. Due to a
misinterpretation of orders, the procedure is performed
on the wrong part of the body. Which of the following
should the healthcare quality professional do?
A. Report this as a sentinel event to the transferring
hospital.
B. Do nothing since it happened at another facility.
C. Conduct an analysis to reduce future occurrences.
D. Recommend disciplinary action for the offenders.
Which tool results in major problems or
issues need to be addressed:

A- affinity.

B- force field.

C- nominal group.

D- interrelationship diagram.
Which tool results in major problems or
issues need to be addressed:

A- affinity.

B- force field.

C- nominal group.

D- interrelationship diagram.
Waiting time is too long for lab reports. To
address causes of long time of reporting, use

A- value stream map.

B- spaghetti diagram.

C- run chart.

D- Gantt diagram.
Waiting time is too long for lab reports. To
address causes of long time of reporting, use

A- value stream map.

B- spaghetti diagram.

C- run chart.

D- Gantt diagram.
For revising hip replacement clinical
pathway, it is most important to consider

A- patient satisfaction.

B- patient expectations.

C- discharge disposition.
For revising hip replacement clinical
pathway, it is most important to consider

A- patient satisfaction.

B- patient expectations.

C- discharge disposition.
In assessing the timeliness for the administration of
antibiotics for pneumonia, this control chart demonstrates
A. process improvement. B. no process improvement.
C. evidence of a trend. D. evidence of an outlier.
In assessing the timeliness for the administration of
antibiotics for pneumonia, this control chart demonstrates
A. process improvement. B. no process improvement.
C. evidence of a trend. D. evidence of an outlier.
For organization seeking to Malcolm
Baldrige Award, the manager should

A- use a staff previously trained on Baldrige

award.

B- get within 12 months from application.

C- make a plan which may take several years.

For organization seeking to Malcolm
Baldrige Award, the manager should

A- use a staff previously trained on Baldrige

award.

B- get within 12 months from application.

C- make a plan which may take several years.

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. demonstrating understanding by return demonstration.

C. showing a video to a patient and their family.

D. requesting the home health nurse provide patient

instruction.
A 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. demonstrating understanding by return demonstration.

C. showing a video to a patient and their family.

D. requesting the home health nurse provide patient

instruction.
A number of specialty and primary care clinicians have participated in several
meetings to develop clinical practice guidelines for the management of diabetes.
The team leader has moved the team through the actual guideline development.
Which of the following sequences of steps should the team consider in
developing the quality of care product evaluation phase?

A. identify medical review criteria, identify sampling methods to be used, pilot

test.

B. identify populations covered by the guideline, identify the data sources,

conduct the review.

C. define objectives of the performance review, develop data collection form, pilot
test.

D. consider costs of the review, identify clinicians and sites of care, define
objectives of performance review.
A number of specialty and primary care clinicians have participated in several
meetings to develop clinical practice guidelines for the management of diabetes.
The team leader has moved the team through the actual guideline development.
Which of the following sequences of steps should the team consider in
developing the quality of care product evaluation phase?

A. identify medical review criteria, identify sampling methods to be used, pilot

test.

B. identify populations covered by the guideline, identify the data sources,

conduct the review.

C. define objectives of the performance review, develop data collection form, pilot
test.

D. consider costs of the review, identify clinicians and sites of care, define
objectives of performance review.
Which of the following is the next step for the healthcare quality
professional to pursue?
A. Continue to track and trend incident reports.
B. Educate Med/Surg units on fall prevention.
C. Form a team to change the ICU fall protocol.
D. Conduct further analysis of fall data.
Which of the following is the next step for the healthcare quality
professional to pursue?
A. Continue to track and trend incident reports.
B. Educate Med/Surg units on fall prevention.
C. Form a team to change the ICU fall protocol.
D. Conduct further analysis of fall data.
In evaluating long waiting times, a healthcare
quality professional can best demonstrate
components related to staffing, methods,
measures, materials, and equipment by utilizing.

A. a run chart.
B. a histogram.
C. a pie chart.
D. an Ishikawa diagram.
In evaluating long waiting times, a healthcare
quality professional can best demonstrate
components related to staffing, methods,
measures, materials, and equipment by utilizing.

A. a run chart.
B. a histogram.
C. a pie chart.
D. an Ishikawa diagram.
Which of the following are the primary reasons for
developing drug formularies?
A. manage pharmacy costs and promote patient
safety.
B. reduce medication errors and educate physicians.
C. encourage the appropriate use of medications and
educate physicians.
D. decrease food and drug interactions and promote
patient safety.
Which of the following are the primary reasons for
developing drug formularies?
A. manage pharmacy costs and promote patient
safety.
B. reduce medication errors and educate physicians.
C. encourage the appropriate use of medications and
educate physicians.
D. decrease food and drug interactions and promote
patient safety.
Which of the following sampling techniques
involves selecting the medical record of every fifth
patient undergoing cardiovascular bypass?

A. convenience.

B. systematic.

C. stratified.

D. simple random.
Which of the following sampling techniques
involves selecting the medical record of every fifth
patient undergoing cardiovascular bypass?

A. convenience.

B. systematic.

C. stratified.

D. simple random.
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. 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.

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. 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.

 Customers complained about admission
process. The best way to identify the
customer expectations is

a- focus group with patients.

b- focus group with admission staff.
c- telephone survey with pts.
d- survey of involved staff.
 Customers complained about admission
process. The best way to identify the
customer expectations is

a- focus group with patients.

b- focus group with admission staff.
c- telephone survey with pts.
d- survey of involved staff.
 To get senior management approval for
performance improvement project you should
provide:

A- software recommendations and plan

justification.

B- software recommendations and needed

resources.

C- proposed plan and needed resources.

 To get senior management approval for
performance improvement project you should
provide:

A- software recommendations and plan

justification.

B- software recommendations and needed

resources.

C- proposed plan and needed resources.

HIPAA ---- is used for protection of:

a- personal health information.

b- health plan information.

c- payer payment information.

HIPAA ---- is used for protection of:

a- personal health information.

b- health plan information.

c- payer payment information.

For a reappointment process for surgeons, physicians-specific data
has been provided on the total number of admissions, procedures
and discharges. Which of the following additional information will
be most useful in making the reappointment decision?
a. Wound infection rate, surgical complication rate, and summary of
peer review.
b. Number of sentinel event, adverse drug reaction rate, &
healthcare acquired infection rate.
c. Transfusion reaction rate, surgical complication rate, & adverse
drug reaction rate.
d. Summary of peer review, transfusion reaction, & healthcare
acquired infection rate.
For a reappointment process for surgeons, physicians-specific data
has been provided on the total number of admissions, procedures
and discharges. Which of the following additional information will
be most useful in making the reappointment decision?
a. Wound infection rate, surgical complication rate, and summary of
peer review.
b. Number of sentinel event, adverse drug reaction rate, &
healthcare acquired infection rate.
c. Transfusion reaction rate, surgical complication rate, & adverse
drug reaction rate.
d. Summary of peer review, transfusion reaction, & healthcare
acquired infection rate.
Which of the following accrediting bodies have deemed
status with the Centers for Medicare and Medicaid Services
(CMS)?

a. ISO Certification and The Joint Commission (TJC).

b. Det Norske Veritas (DNV) and the Healthcare Facility

Accreditation Program (HFAP).

c. The American Osteopathic Association (AOA) and the

National Quality Forum (NQF).

d. The American Medical Association (AMA) and Commission

Accreditation of Rehabilitation Facilities (CARF).
Which of the following accrediting bodies have deemed
status with the Centers for Medicare and Medicaid Services
(CMS)?

a. ISO Certification and The Joint Commission (TJC).

b. Det Norske Veritas (DNV) and the Healthcare Facility

Accreditation Program (HFAP).

c. The American Osteopathic Association (AOA) and the

National Quality Forum (NQF).

d. The American Medical Association (AMA) and Commission

Accreditation of Rehabilitation Facilities (CARF).
Positive correlation appears as:

A- points in a circular shape in the graph.

B-points in triangular shape.

C- increase in X-axis with an increasing in Y-axis.

D- increase in X-axis with a decreasing in Y-axis.

Positive correlation appears as:

A- points in a circular shape in the graph.

B-points in triangular shape.

C- increase in X-axis with an increasing in Y-axis.

D- increase in X-axis with a decreasing in Y-axis.

To be able to act calmly in sudden changes and
then bounce back to the normal state:

a- Disaster preparedness.

b- Resilience.

c- Strong personality.

d- Good attitude.
To be able to act calmly in sudden changes and
then bounce back to the normal state:

a- Disaster preparedness.

b- Resilience.

c- Strong personality.

d- Good attitude.
One aspect of a quality process that integrates
with risk management is the review and
evaluation of

a. adverse drug events.

b. encounter data.
c. case-mix analysis reports.
d. accreditation survey reports.
One aspect of a quality process that integrates
with risk management is the review and
evaluation of

a. adverse drug events.

b. encounter data.
c. case-mix analysis reports.
d. accreditation survey reports.
A hospital-wide medical record audit on documentation has been completed.
The following table shows the compliance rate of documentation: Which of
the following is the next step?

Compliance rate 1st quarter 2nd quarter

Surgical time out 90 95

Communication of critical 91 95
Result
Pain 50 60
Patient assessment 52 45

a. Benchmark the compliance rates against another facility.

b. Conduct training regarding pain score.

c. Give data feedback on physician signature to the units.

d. Conduct a focused review on the patient assessment process.

A hospital-wide medical record audit on documentation has been completed.
The following table shows the compliance rate of documentation: Which of
the following is the next step?

Compliance rate 1st quarter 2nd quarter

Surgical time out 90 95

Communication of critical 91 95
Result
Pain 50 60
Patient assessment 52 45

a. Benchmark the compliance rates against another facility.

b. Conduct training regarding pain score.

c. Give data feedback on physician signature to the units.

d. Conduct a focused review on the patient assessment process.

The concept of organizational liability is most
important to the field of healthcare quality because it
holds the organization responsible for
A. maintaining confidentiality of all documents.
B. requiring physicians to carry adequate malpractice
insurance.
C. maintaining a process to identify deficiencies in the
provision of care.
D. ensuring that peer review physicians have no conflict
of interest in cases being reviewed.
The concept of organizational liability is most
important to the field of healthcare quality because it
holds the organization responsible for
A. maintaining confidentiality of all documents.
B. requiring physicians to carry adequate malpractice
insurance.
C. maintaining a process to identify deficiencies in the
provision of care.
D. ensuring that peer review physicians have no conflict
of interest in cases being reviewed.
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. establishing criteria that are based on the most recent
changes in medical science and technology.
b. using a computerized system to substitute data for missing
responses.
c. assigning one staff member to identify, collect, enter, and
interpret all data.
d. providing a practice-based definition and specific instructions
for each element.
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. establishing criteria that are based on the most recent
changes in medical science and technology.
b. using a computerized system to substitute data for missing
responses.
c. assigning one staff member to identify, collect, enter, and
interpret all data.
d. providing a practice-based definition and specific instructions
for each element.