Certified Professional in Healthcare Quality Online Self-Assessment Examination

INDIVIDUAL FEEDBACK REPORT

X 1. Which of the following are essential functions of an infection control program?

A. risk management and surveillance

B.X prevention and education

C.√ surveillance and prevention

D. patient safety and risk

management

EXPLANATIONS:

A. Risk management is not an essential function of an infection control program.

B. Education is a component of prevention, but is not an essential function of an infection control program by
itself.

C. Two principal functions of infection control are surveillance and prevention.

D. Patient safety and risk management are not essential functions of an infection control program.

X 2. For a quality improvement team to deal effectively with conflict, it is important to appoint which of the following to its membership

A. risk manager

B.X human resources representative

C.√ facilitator

D. senior leader
 EXPLANATIONS:

A. A risk manager's role would not necessarily deal with conflict within a quality improvement
team.

B. A human resources representative handles staffing issues within a team, not necessarily
conflict.

C. A facilitator is an unbiased party that may help groups deal with conflict.

D. A senior leader's role would not necessarily deal with conflict within a quality improvement
team.

X 3. Which of the following accrediting bodies have deemed status with the Centers for Medicare and Medicaid Services (CMS)?

A.X 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)

EXPLANATIONS:

A. ISO is a quality control certification and it does not have deemed status.

B. Both of these organizations are accrediting bodies with deemed status from CMS.

C. NQF is a measurement consensus-building and endorsement group, not an accrediting

body.

D. The AMA is a professional society, not an accrediting body.

√ 4. A team has identified a process for improvement, selected examples of best practice performers, visited those sites, gathered all n
results. The most effective next step for the team is to

A. identify the next process to benchmark.

B.√ implement change at the team's site.

C. compare the results to historical data.

D. make the results public for others to use for

benchmarking.

EXPLANATIONS:

A. The first issue has not been resolved. It needs to be addressed before moving on to the next
process.

B. Implementation is the next step in the performance improvement cycle.

C. All necessary data have already been compiled.

D. The process has not been completed, so there is nothing to share at this point.

√ 5. Hospital A has recently merged with Hospital B. After 6 months, it is noted that Hospital A has successfully transitioned their staff
Hospital B still struggles. Which of the following is most likely the reason for Hospital A's success?

A. requiring adoption of new values by all staff.

B. support of both hospitals' mission statements.

C.√ acceptance of the new mission and vision

statements.
D. integrating technology and databases.
 EXPLANATIONS:

A. There is not enough information provided to show that the values were adopted by all staff.

B. Support of two mission statements could be confusing to staff and would not lead to an integrated
organization.

C. Acceptance of the new mission and vision statements demonstrates integration of the two facilities.

D. Values are not dependent on the integration of technology and databases.

√ 6. The concept of organizational responsibility is most important to the field of healthcare quality because it holds the organization re

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.

EXPLANATIONS:

A. Confidentiality of all documents is not the most important part of organizational responsibility.

B. Carrying adequate malpractice insurance is usually required, but is not the most important
aspect.

C. Maintaining quality of care is the ultimate responsibility of the governing body of an organization.

D. Conducting unbiased peer reviews is a process that helps identify deficiencies in care.

√ 7. Evaluating medication administration to reduce medical errors is an example of

 A. quality management.

B. resource management.

C.√ risk management.

D. financial management.

EXPLANATIONS:

A. Quality management involves the process of achieving organizational performance improvement

goals.

B. Resource management relates to the utilization of resources, but is unlikely to reduce medication
errors.

C. Improving patient safety, including error reduction, is the primary goal of risk management.

D. Financial management involves the process of achieving organizational financial goals.

√ 8. The Joint Commission (TJC) Standards and Elements of Performance are used

A.√ to define expectations for safety and quality care.

B. in place of Centers for Medicare and Medicaid Services (CMS) Conditions of

Participation.
C. to determine compliance with the Department of Health and Human Services (HHS).

D. to calculate pay-for-performance incentives or penalties.

EXPLANATIONS:

A. TJC Standards and Elements of Performance define performance standards that must be in place for an organization to provid
 B. CMS deems TJC to determine compliance with the Conditions of Participation using the accreditation Standards and Elements
Performance.

C. TJC Standards and Elements of Performance are not related to the Department of Health and Human Services Regulations.

D. Performance on TJC standards are not used to calculate pay-for-performance incentives/penalties.

√ 9. The primary reason healthcare organizations use benchmarking is to

A. comply with accreditation standards.

B.√ improve performance.

C. decrease risk to the organization.

D. provide risk adjustment.

EXPLANATIONS:

A. Benchmarking encompasses more than accreditation standards.

B. Benchmarking is a quality improvement process for comparing one organization's work practices against other similar organiz
incorporate best practices.

C. Decreasing risk to an organization can result from successful benchmarking, but is not the primary reason for benchmarking.

D. Risk adjustment is a technique used to take into account or to control the fact that different patients with the same diagnosis m
characteristics.

√ 10. Which of the following patient safety goals is applicable to everyone in a healthcare facility?

A. hand-off communication

B. medication safety
 C.√ hand hygiene

D. prevention of falls

EXPLANATIONS:

A. Hand-off communication is about communication among caregivers, not all healthcare

workers.

B. Medication safety primarily affects caregivers, not all healthcare workers.

C. Good hand hygiene is appropriate for everyone, whether in direct contact with patients or not.

D. Prevention of falls primarily affects caregivers, housekeeping, and maintenance.

√ 11. Meaningful quality process measures must be

A.√ relevant and valid.

B. publicly reported and explainable.

C. relevant and explainable.

D. valid and publicly reported.

EXPLANATIONS:

A. Data must be reproducible to be valid. For data to be reproduced, it should be relevant. Relevance of data is important because
process being measured.

B. See explanation A and D.

C. While the data must be relevant; if it is not valid, it is not meaningful.

 D. While the data must be valid, publicly reporting the data is not required.

X 12. Which of the following is the best way to determine if a quality improvement initiative is successful?

A. Present findings to the Quality Council.

B. Conduct a retrospective review.

C.√ Compare outcomes with pre-established goals.

D.X Survey patients and customers.

EXPLANATIONS:

A. Presenting findings to a Quality Council does not help determine whether an initiative is successful.

B. A retrospective review may not help determine if goals have been met.

C. Outcomes are evidence of having accomplished pre-established goals.

D. Surveying patients and customers is not the best way to determine whether an initiative is successful if it is not the outcome o
interest.

√ 13. Which of the following is essential to an effective Quality Council?

A.√ involvement of leadership

B. consultation of the legal advisor

C. participation of the strategic planning committee

D. direction from the organization's quality

department

EXPLANATIONS:
 A. Leadership involvement promotes an effective quality council through resource and support allocation to achieve
objectives.

B. A legal advisor is not commonly a member of a quality council.

C. A strategic planning committee is not commonly a component of a quality council.

D. The quality department may provide input, but not necessarily direction, to a quality council.

X 14. Based on identified issues, a healthcare quality professional examines 100% of one physician's admissions and only 20% of all oth
best described as

A.√ focused review.

B. prospective review.

C.X retrospective review.

D. ongoing review.

EXPLANATIONS:

A. A focused review is performed for a predetermined reason and is concentrated on a select sample of cases or data elements. C
usually based on internally identified problem areas or on external demands. Since the quality professional examined 100% of on
identified issues, a focused review is the best description of this case.

B. A prospective review is performed prior to care or practice. It is evident in the case above that the review was based on identifi
practice patterns.

C. The case above can be described as a retrospective review; however, a focused review is a more accurate answer since the qu
of a physician's admissions compared to 20% or all other physician's admissions.

D. Ongoing review is used for efficient and continual review of practitioner performance, and replaces the previous cyclical review
√ 15. 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

EXPLANATIONS:

A. Providing an education sheet without an opportunity for dialogue is not

sufficient.

B. Return demonstration is an evidence-based approach for learning.

C. Showing a video does not ensure that learning has occurred.

D. Delaying instruction until the patient reaches homecare is not appropriate.

X 16. A number of specialty and primary care clinicians have participated in several meetings to develop clinical practice guidelines for
team leader has moved the team through the actual guideline development. Which of the following sequences of steps should the
quality of care product evaluation phase?

A.X 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 the performance
review
 EXPLANATIONS:

A. See explanation C.

B. See explanation C.

C. Objectives must be defined

first.

D. See explanation C.

X 17. The following data are being analyzed based on 6 months of incident reports for falls in a facility with 10 ICU beds and 40 Med/Surg

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.X Form a team to change the ICU fall protocol.

D.√ Conduct further analysis of fall data.

EXPLANATIONS:

A. Action needs to be taken to investigate fall patterns because not enough information is provided from the above
data.

B. Education should be targeted toward identified issues after further analyzing the data.

C. Revision to the ICU fall protocol may be necessary, but the first step is to determine the cause of the falls.

D. The data need to be analyzed further to better understand causative factors.

X 18. A Quality Council has created a Patient Safety Council. The council is concerned that staff may see this as another program that h
schedules that will eventually go away. The best way for the organization to establish patient safety as an ongoing part of the orga

A.X display the number of incident reports monthly with lessons

learned.
B. identify the patient safety goals and how they will be monitored.

C.√ integrate patient safety into all employees' job expectations.

D. include a presentation on patient safety in employee orientation.

EXPLANATIONS:

A. Sharing risk data may help develop a patient safety program, but it will not change the culture of an organization.
 B. Identifying and monitoring goals is a necessary part of a patient safety program, but it will not change the culture of an
organization.

C. Including patient safety in the job expectations provides a mechanism to hold employees accountable.

D. Providing presentations on patient safety may be helpful, but is not the best way to change the culture of an organization.

√ 19. Which of the following is an example of a "never event" or sentinel event?

A. missed dose of an antibiotic

B. patient fall that results in a bruise

C. fever of 101.2 °F after a blood

transfusion
D.√ patient suicide in the psychiatric ward

EXPLANATIONS:

A. One missed dose of an antibiotic is not usually considered a sentinel event.

B. A bruise is usually not a sentinel event.

C. A fever alone is not a serious side effect of a blood transfusion.

D. A suicide in a healthcare facility is serious, preventable, and of concern to

all.

X 20. When a healthcare organization is contracting with an outside provider for services, the subcontractor must

A. provide a representative to the Quality

Council.
 B.√ meet all regulatory requirements.

C. have an active risk management program.

D.X have a competitively priced service.

EXPLANATIONS:

A. It is not necessary for a contract provider to be represented on the Quality

Council.

B. The outside provider must meet all regulatory requirements.

C. Having a risk management program is not a contractual requirement.

D. Competitive price may be a consideration but is not considered a "must."

√ 21. In evaluating long waiting times, a healthcare quality professional can best demonstrate components related to staffing, methods,
equipment by utilizing

A. a run chart.

B. a histogram.

C. a pie chart.

D.√ an Ishikawa diagram.

EXPLANATIONS:

A. Run charts are used to track data over time.

B. Histograms and bar charts are used to show distribution.

 C. Pie charts are used to compare parts of a whole.

D. An Ishikawa (cause and effect) diagram helps to analyze potential

causes.

√ 22. A root cause analysis revealed a patient in an acute psychiatric unit committed suicide by hanging himself with his shoelaces. To p
the most appropriate action is to institute

A. patient checks every 15 minutes.

B.√ a policy allowing only non-laced shoes.

C. a 24-hour video monitoring system.

D. a buddy system for the patients.

EXPLANATIONS:

A. Checking patients every 15 minutes may not prevent suicide.

B. This policy eliminates the object that was used to commit suicide and creates a safer
environment.

C. A monitoring system may not prevent suicide.

D. A buddy system may not prevent suicide.

X 23. A former patient emails an organization's chief executive officer complimenting the friendliness of the nurses while complaining th
To comply with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, what actions are needed?

A. Interview staff involved, track performance over time, and report to the Quality Council.

B.√ Investigate the complaint, write the patient, and report to the governing board.

C. Call the patient, put compliments in the nurses' personnel records, and report to the Quality Council.
 D.X Review the medical record, put compliments and complaints in the appropriate staff personnel records, and report to the gov
board.

EXPLANATIONS:

A. CMS does not require staff interviews or reporting to the Quality Council.

B. CMS requires that grievances be investigated and letters to the patient be written. CMS also requires that the governing board
grievances.

C. These actions are not required by CMS.

D. Of these responses, only reporting to the governing body is a CMS expectation.

X 24. Which of the following are the primary reasons for developing drug formularies?

A.√ manage pharmacy costs and promote patient safety

B.X 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

EXPLANATIONS:

A. A drug formulary is an approved list of medications, clinical indications, and doses that helps manage pharmacy costs and pa

B. Reduced medication errors may result from having a drug formulary, but it is not the primary reason for having one. It is also n
physicians.

C. A formulary may encourage the appropriate use of medications, but it is not intended to educate physicians.

D. A formulary is intended to promote patient safety, but the primary purpose is not intended to decrease food and drug interactio
√ 25. Which of the following sampling techniques involves selecting the medical record of every fifth patient undergoing cardiovascular

A. convenience

B.√ systematic

C. stratified

D. simple random

EXPLANATIONS:

A. Convenience sampling allows the use of any arbitrarily selected medical record and while selecting every fifth record may be c
the best answer.

B. Systematic sampling is the selection of every nth element from a population.

C. Stratified sampling allows for two or more populations, which is not appropriate in this situation.

D. Simple random sampling allows every record an equal chance of being selected.

X 26. A chief quality officer has the responsibility for education and implementation of a quality improvement process. To affect cultural
must

A. believe the costs are justified by the

benefits.
B.√ be a visible participant in the process.

C. receive quarterly reports.

D.X limit training to managers and supervisors.

EXPLANATIONS:
 A. For support and resources to be provided, the chief quality officer must believe the costs are justified in order to affect culture
change.

B. Administration and organization leaders, such as the chief quality officer, must be part of the effort to affect cultural change.

C. Receiving quarterly reports does not affect culture change.

D. Limiting training to certain staff members does not affect culture change.

√ 27. The concept of "patient safety" applies most appropriately to

A. environmental safety
measures.
B. serious patient injuries.

C. patient complaint management.

D.√ risk prevention.

EXPLANATIONS:

A. According to The Joint Commission and others, the physical environment is only one aspect of patient safety; therefore, this is

B. According to The Joint Commission and others, patient safety encompasses not only prevention of serious physical injury, bu
the performance of tasks or the physical environment; therefore, this answer is incomplete.

C. Complaint review and management may help to identify potential patient safety issues, but it is not a reliable method to improv

D. The Joint Commission defines safety as the degree to which the risk of an intervention (e.g., use of drugs, procedures) in the c
patient and other persons, including healthcare practitioners. Safety risks may arise from the performance of tasks, the structure
situations beyond the organization's control, such as weather. Therefore, risk prevention is the correct answer because it best en
while the other responses are limited to one area of patient safety.

X 28. A Quality Council has chartered a performance improvement team to reduce medication errors. The team has been meeting for sev
been very slow. Which of the following is the most important factor for the Quality Council to assess with the team leader?
 A.√ composition of the team

B. number of medication errors since team was

chartered
C. team members' ability to interpret graphs

D.X length of team meetings

EXPLANATIONS:

A. The composition of the team is the most important factor and is often the main cause of team failure. Having the right team in p
essential.

B. The number of medication errors is not relevant to the team's functionality.

C. Interpreting graphs is a skill the team needs, but it is not as important as having the right team members.

D. The length of team meetings may need to be examined, but is not the most important factor.

√ 29. An emergency department trends wait times from patient arrival to physician assessment. Data are reported using a run chart. Wh
true statistical increase in treatment delays?

A.√ 6 consecutive ascending data points

B. 7 consecutive descending data points

C. a zigzag pattern of 10 data points

D. data points close to the mean line

EXPLANATIONS:

A. A true statistical increase is indicated by 6 consecutive ascending data

 points.

B. Descending data points do not indicate an increase in this particular case.

C. A zigzag pattern of data points demonstrates variability in the data.

D. Data points close to the mean demonstrate minimal variation in the data.

√ 30. A facility decided to implement Standard Precautions 1 year ago, but compliance has been poor. In addition to assessing the caus
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 handwashing policies and procedures.

EXPLANATIONS:

A. Providing equipment does not necessarily improve compliance.

B. Including return demonstration in competency testing ensures that staff understand proper technique.

C. Showing a videotape does not necessarily improve compliance.

D. Reviewing and revising handwashing policies and procedures does not necessarily improve
compliance.

√ 31. A healthcare quality professional is developing a policy regarding access to physician quality files. In addition to the date and nam
information, which of the following should be included in the policy?
 A. permission from the applicable
physician
B.√ purpose of the request

C. approval from legal counsel

D. the department chair's approval

EXPLANATIONS:

A. Permission from the applicable physician is not an essential element to include as a requirement in this policy.

B. The high degree of sensitivity related to the evaluation of practitioner experience and outcomes dictates the need to answer qu
authority), when (to establish timing), why (to determine whether the access was valid and credible), and what (to establish the re
stated reason for access).

C. Approval from legal counsel is not an essential element to include as a requirement in this policy.

D. The department chair's approval is not an essential element to include as a requirement in this policy.

X 32. A performance improvement training program has been conducted. The healthcare quality professional has determined that impro
most likely cause for the lack of improvement would be that

A.√ organizational systems are inhibiting changes.

B. employees practice what they are trained to do.

C.X staff members thought the program was too

long.
D. the facilitator did not prepare agenda materials.

EXPLANATIONS:
 A. The most common failure of training programs is system challenges within the organization. There must be a culture that foste
within the organization.

B. Employees practicing what they are trained for would lead to improvement and is one of the intended outcomes of a training p

C. While the employees' perception about the program may be that it was too long, it would not be the sole reason that improvem
could help to improve future training programs within the organization.

D. The lack of agenda materials could have contributed to the lack of improvement, but would not be the sole cause.

√ 33. A Quality Council is preparing a patient safety plan. A key factor that needs to be considered for the long-term success of the patie

A. determine which patient safety goals need to be monitored.

B.√ involve the entire organization in the program.

C. review incident reports to identify what disciplinary action should

occur.
D. research how technology can be used to prevent errors.

EXPLANATIONS:

A. Patient safety goals must be monitored as part of the program, but are not as essential to the program's success as involving a
team.

B. The program must be organization-wide to be successful. It must include all members of the healthcare team.

C. Reviewing incident reports to identify what disciplinary action should occur would not be part of a patient safety program that
environment.

D. Technology may be very useful to the program, but it is not essential to its success.

√ 34. Two surveys were completed in a healthcare facility that showed conflicting results concerning patient satisfaction with food servi
independently designed and distributed by different departments within the facility. The healthcare quality professional should firs
 A. set up a quality improvement team to improve food
service.
B. redistribute the surveys to obtain a larger sample size.

C. design, distribute, and analyze a new survey instrument.

D.√ meet with the departments to review the survey

processes.

EXPLANATIONS:

A. The data must be analyzed before action steps can be taken.

B. A larger sample size may not be necessary.

C. The current surveys should be investigated before creating a new survey.

D. Reviewing the survey processes with the departments will help the understanding of the survey tools and the processes
used.

√ 35. The relationship between patient satisfaction and hours per patient day on a medical unit was found to be (r = 0.60, p < 0.05). What
two values?

A. 0.05

B. 0.36

C. 0.55

D.√ 0.60

EXPLANATIONS:
 A. See explanation D.

B. See explanation D.

C. See explanation D.

D. The correlation coefficient (r) is an index that ranges from -1.0 to 1.0 and reflects the extent of a linear relationship between two
coefficient is 0.60.

√ 36. Multidisciplinary quality improvement teams are beneficial because they

A. improve managerial control.

B. promote competition and pride among

members.
C.√ maximize expertise and perspectives.

D. authorize solutions to problems.

EXPLANATIONS:

A. Quality improvement teams do not affect managerial control.

B. Promoting competition is not a function of quality improvement teams.

C. A diverse team, including members with different experience and backgrounds, provides a broader knowledge base and
outcomes.

D. Authorizing solutions to problems is a function of management.

√ 37. The most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staff is b

A. developing professional relationships.

 B. inviting medical staff to an inservice on quality
tools.
C. evaluating physician participation on quality teams.

D.√ providing outcome data at medical staff meetings.

EXPLANATIONS:

A. Relationships are needed, but they are not the most effective way to communicate quality improvement
activities.

B. Inviting medical staff to an inservice does not ensure attendance.

C. Evaluating participation is not a communication tool.

D. Outcome data communicates objective feedback to medical staff.

√ 38. Benchmarking is based on identifying

A.√ best practices.

B. competition.

C. deficiencies.

D. statistical
control.

EXPLANATIONS:

A. Benchmarking is the comparison of results against a reference point, which is a best

practice.

B. See explanation A.
 C. See explanation A.

D. See explanation A.

√ 39. Clinical decision support systems can best support medication safety by alerting prescribers to

A. patient compliance and allergies.

B. the need for dose adjustments and patient weight changes.

C. drug interactions and patient weight changes.

D.√ allergies and drug interactions.

EXPLANATIONS:

A. Patient compliance is not part of a support system.

B. Dose adjustment and weight change alerts may be programmed, but are not the primary purpose of the system.

C. Patient weight change alerts may be programmed, but are not the primary purpose of the system.

D. A clinical decision support system involves a computerized medication management system that allows medication alerts to b
and drug interactions).

√ 40. Which of the following tools should be used to record patient and practitioner-specific data?

A. flowchart

B. graphs

C. histogram

D.√ spreadsheet
 EXPLANATIONS:

A. A flowchart shows a process.

B. Graphs are used to display, not record data, and there is not enough information provided to determine whether graphs could

C. Histograms are used to display, not record data, and there is not enough information provided to determine whether a histogra
used.

D. A spreadsheet allows for individualized data to be recorded.

X 41. Healthcare quality professionals can best communicate organizational values and commitment through

A. establishing a multidisciplinary task

force.
B.X disseminating monthly newsletters.

C. creating a mission statement.

D.√ leading by example.

EXPLANATIONS:

A. Establishing a task force does not communicate organizational values and is not ongoing.

B. Newsletters may be one way of communicating, but they are a passive form of communication.

C. A mission statement is a passive form of communication. Leading by example is the best way to communicate values stated in
mission.

D. Demonstrating and practicing expected values are the best ways to communicate organizational values.

X 42. 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.X Select key people in the organization to serve on the

team.
D. Develop a performance improvement plan.

EXPLANATIONS:

A. Performance improvement methodology includes identifying issues and/or problems before taking action.

B. Management feedback may be useful, but the problems should be identified first and feedback should be sought from all
stakeholders.

C. Selecting key people who should be involved is important, but those people cannot be selected until the problems have been
identified.

D. A performance improvement plan cannot be developed until the problems have been identified.

X 43. Replacing retrospective review with concurrent review is an example of

A.√ a paradigm shift.

B.X a process improvement.

C. an empowerment process.

D. productivity enhancement.

EXPLANATIONS:

A. A paradigm shift is a change in method or perspective.

 B. Switching from a retrospective to concurrent review represents a change that may or may not result in a process
improvement.

C. Empowerment typically gives the people involved the power to make decisions and is not related to the review process.

D. Switching to a concurrent review may or may not result in an increase in productivity.

√ 44. To be useful in preventing future error, a root cause analysis (RCA) should be performed

A. at least 45 days after the event.

B. using practitioners who were not involved in the

event.
C.√ utilizing a multidisciplinary team.

D. documenting opinion as well as facts.

EXPLANATIONS:

A. See explanation C.

B. See explanation C.

C. The principles surrounding a credible RCA are to perform them in a manner that is (1) timely, (2) factual and objective to avoid
disciplines to provide a "systems" perspective, and (4) accurate by gaining insights and firsthand accounts of those who were th

D. See explanation C.

X 45. A team approach to problem solving is most useful when

A. the organization's goals are unclear.

B.√ diverse areas of expertise are

 required.
C.X communication challenges exist.

D. required by a regulatory body.

EXPLANATIONS:

A. It is leadership's responsibility, not the team's responsibility, to clearly define organizational goals.

B. The make-up of a team that varies in perspective and experience provides a variety of skill sets that will help solve
problems.

C. Communication challenges may make working within a team more difficult.

D. A team approach to problem solving should not be dependent on regulatory requirements.

X 46. Patient satisfaction scores for a community hospital demonstrate multiple areas for improvement including a need to improve the
responsiveness to patient needs, and physician and nursing communication. Based on these results, which of the following shoul
professional also expect to find?

A. administration prioritizing and leading units to achieve organizational goals

B. unit managers who openly discuss patient satisfaction scores

C.√ units operating independently with little communication between units

D.X employee satisfaction scores in the 80th percentile compared to other peer
organizations

EXPLANATIONS:

A. Based on the information provided, leadership may not have prioritized these issues to achieve organizational
goals.
 B. There is not enough information provided to determine if managers are discussing patient satisfaction scores.

C. Responsiveness to patient needs requires effective communication between multiple units as well as staff.

D. Employee satisfaction does not necessarily correlate with these patient satisfaction scores.

√ 47. To reduce the incidence of ventilator-associated pneumonia (VAP) in a critical care unit, who should be included on a quality impro

A.√ intensivist, ICU nurse, and respiratory therapist

B. primary care physician, infection control nurse, and

surgeon
C. ICU manager, respiratory therapist, and pharmacist

D. pharmacist, intensivist, and infection control nurse

EXPLANATIONS:

A. Intensive-care medicine or critical-care medicine is concerned with the provision of life support or organ support systems in p
who usually require intensive monitoring. In this scenario, the healthcare quality professional should include staff that would mo
care of a patient with VAP. The involvement of the intensivist, ICU nurse, and respiratory therapist would be considered common
appropriate team to care for a patient with VAP.

B. While the primary care physician may be involved, it is not common practice for the infection control nurse/preventionist to be
patient with VAP.

C. While the ICU manager and pharmacist could be involved in the care of a patient with VAP, they would not be ideal members o

D. While the pharmacist, intensivist, and infection control nurse/practitioner could be part of the VAP quality improvement team, t
does not include the respiratory therapist or ICU nurse.

√ 48. Physician profiles should be reviewed at time of reappointment to

A.√ assess practitioner competency.

 B. compare the practitioner to their
peers.
C. review the number of complaints.

D. facilitate reappointment approval.

EXPLANATIONS:

A. Physician profiles demonstrate knowledge and skills through outcomes for individual practitioners.

B. Comparisons are a component of physician profiles, but are not the main reason they are reviewed for reappointment.

C. The number of complaints may be included in physician profiles, but this is not the main reason to review profiles.

D. Physician profiles can help facilitate the reappointment process, but demonstrating physician competency is the reason for re
profiles.

√ 49. Evaluating the time it takes a nurse to perform a procedure is known as which type of measure?

A. balancing

B.√ process

C. outcome

D. structure

EXPLANATIONS:

A. Balancing measures unintended consequences.

B. A process measure evaluates a system or process.

C. An outcome measure evaluates the overall result or impact of a process.

 D. Structural measures involve the resources available for medical care
delivery.

√ 50. Which of the following quality improvement principles is most important for management to emphasize?

A. staff orientation

B.√ customers' expectations

C. quarterly statistical
reports
D. team selection

EXPLANATIONS:

A. Staff orientation is only one component of quality improvement principles.

B. The basis of quality improvement is knowing what the customer needs and wants.

C. Quarterly statistical reports are only one component of quality improvement

principles.

D. Team selection is only one component of quality improvement principles.

√ 51. Which of the following is the first step in the strategic planning process?

A.√ setting goals and objectives

B. defining organizational structure

C. determining productivity indicators

D. establishing and controlling a budget

 EXPLANATIONS:

A. The strategic planning process is based on what the organization wants to achieve (i.e., goals and objectives). The quality prof
possibilities as first steps, but those were not presented in the options.

B. Organizational structure may not be a component of a strategic plan.

C. Productivity indicators are measures of the progress made toward the goals and objectives.

D. Budget determinations are made based on the goals and objectives.

√ 52. A failure mode and effects analysis (FMEA) is performed

A. to immediately investigate an incident that occurred.

B.√ as a preventative measure before an incident

occurs.
C. if the severity of an incident led to a patient death.

D. when there is a chance of an incident reoccurring.

EXPLANATIONS:

A. The FMEA process is performed before an incident occurs.

B. The FMEA process is a proactive, systematic method of identifying and preventing incidents from
occurring.

C. The FMEA process examines severity, but before an incident or a death occurs.

D. The FMEA process examines the likelihood of occurrence, but before an incident occurs.

√ 53. A Quality Council has created a failure mode and effects analysis (FMEA) team to examine the best method of preventing medicati
 new medication dispensing system. The team's first major task should be to

A. identify ways to detect the likelihood of the equipment breaking

down.
B.√ brainstorm on potential failure modes associated with equipment
use.
C. multi-vote on the severity of the potential equipment breakdowns.

D. develop a flow chart of how the equipment will be installed.

EXPLANATIONS:

A. Detecting a specific failure mode, such as equipment failure, is a step in an FMEA, but it is not the first major step.

B. In an FMEA, brainstorming potential failures is the first major step.

C. Multi-voting on the severity of a failure mode, such as an equipment breakdown, is a step in the FMEA process, but it is not the
step.

D. Developing a flow chart of how equipment will be installed is not a step in an FMEA.

√ 54. The use of clinical pathways and guidelines in hospitals should

A.√ minimize variation in patient

care.
B. reduce length of stay.

C. improve patient satisfaction.

D. identify errors in patient care.

EXPLANATIONS:
 A. The purpose of a clinical pathway and guideline is to standardize best practices.

B. Reduced length of stay may occur as a result of minimizing variation in patient care.

C. Improved patient satisfaction may occur as a result of minimizing variation in patient

care.

D. Identifying errors may occur as a result of minimizing variation in patient care.

√ 55. Standards of care based on the knowledge and research of recognized experts are known as

A. benchmarking.

B. generic screening.

C. pre-established criteria.

D.√ evidence-based guidelines.

EXPLANATIONS:

A. Although benchmarking may be used in establishing standards of care, it is a process, not a

standard.

B. Generic screening is used to establish triggers to identify potential problem areas.

C. Pre-established criteria may not be based on research.

D. Evidence-based guidelines are consensus driven and based on research or literature.

√ 56. Which of the following best describes an organizational vision statement?

A. It is used as a marketing strategy.

 B. It defines the structure of the institution.

C. It describes the organization's strategic

plan.
D.√ It reflects the organization's aspirations.

EXPLANATIONS:

A. The vision statement may be used for marketing purposes, but it does not
define marketing strategies.

B. The structure of the institution is not defined in the vision statement.

C. The strategic plan is not part of an organization's vision statement.

D. Vision is the image or description of what the organization desires to

become.

√ 57. A critically ill patient is admitted and requires a specialized procedure; however, the surgeon does not have privileges at the facilit
documents will be most helpful in identifying the course of action the hospital should take?

A. patient safety manual

B. risk management plan

C.√ medical staff bylaws

D. surgical policies and procedures

EXPLANATIONS:

A. See explanation C.

B. See explanation C.
 C. Medical staff privilege rules are defined in the medical staff
bylaws.

D. See explanation C.

√ 58. Quality improvement initiative progress is best evaluated by which of the following?

A. team leader

B. senior leadership

C.√ PDCA process

D. nominal group technique

EXPLANATIONS:

A. The team leader may be biased and is not the best source for team evaluations.

B. Senior leadership is not usually involved in evaluating a team.

C. The Plan, Do, Check, Act (PDCA) process is a comprehensive methodology used to conduct performance improvement activiti
progress.

D. The nominal group technique is a group decision-making process for generating a large number of ideas where each member
would not be helpful in evaluating team progress.

X 59. Leadership at a facility reviewed and revised business process activities. The activities, particularly those regarding staff layoffs, w
communicated, and implemented according to the plan. One year later, the business is stable but staff morale is very low. A health
asked to consult in determining where the effort went wrong. Based on the concepts of change theory, the cause is most likely

A. that the decision to revise business processes was a mistake.

 B.√ a failure to address the needs of the staff who were retained.

C.X leadership who are not properly trained in the change process.

D. a few disgruntled staff who are instigating dissension in the

ranks.

EXPLANATIONS:

A. There is not enough information to determine whether revising the business processes was a mistake.

B. Addressing the needs of the retained staff is important for staff morale and "buy-in," or ownership, of the change.

C. Improperly trained leadership may be a component of the issues, but not necessarily the cause of low staff morale.

D. Having disgruntled staff may be a component of the issues, but there is not enough information to determine whether this has
occurred.

√ 60. A facility has identified a trend of increased falls for patients aged 60 to 85 years. An effective fall prevention program should inclu

A. a fall protocol, restraint criteria, and a family sitter program.

B. restraint criteria, staff education, and a sedation protocol.

C. a patient assessment process, a family sitter program, and a sedation

protocol.
D.√ a patient assessment process, a fall protocol, and staff education.

EXPLANATIONS:

A. See explanation B.

B. According to the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation for hospitals and long-term ca
right to be free of restraints of any form (physical or drug) that are not medically necessary. Restraints should only be used when
 management have failed and there is a need to ensure the safety or well-being of the patient/resident. Restraints should not be us
prevention program.

C. According to the CMS Conditions of Participation for hospitals and long-term care, patients or residents have the right to be fre
(physical or drug) that are not medically necessary. Medications used to restrict the freedom of movement of a patient are consid
medically necessary for their condition. Therefore, any sedation protocol used as part of the falls prevention program would be c

D. The proper steps to reducing patient falls include assessing the risk for fall regularly during a patient stay, putting in place pro
results of the assessment, then conducting staff education to ensure these steps are implemented.

√ 61. The evaluation of the quality and appropriateness of patient care in the radiology department is the responsibility of the

A.√ medical director of radiology.

B. chief medical officer.

C. director of the quality

department.
D. administrator of clinical services.

EXPLANATIONS:

A. The medical director of a department has the chief responsibility for everything within that department (care, quality, technolog
etc.).

B. The chief medical officer is responsible for facility-wide medical staff operations.

C. The director of the quality department is responsible for activities within the quality department.

D. The administrator of clinical services is responsible for facility-wide clinical activities.

√ 62. Which of the following is an essential component in a performance improvement report?

 A. governing body approval

B.√ data analysis and display

C. individual performance review

D. team composition and attendance

EXPLANATIONS:

A. The governing body is accountable for the performance improvement program, but their approval is not a component of a perf
report.

B. Analysis and display of data are essential in a performance improvement report to assess progress towards goals/aims.

C. An individual performance review is not an essential part of a performance improvement report.

D. Team attendance is not included in a performance improvement report.

√ 63. A surgery department's monthly case review revealed 10 records meeting criteria and six additional records that did not meet the c
rate, the denominator is

A. 4.

B. 6.

C. 10.

D.√ 16.

EXPLANATIONS:

A. See explanation D.

B. See explanation D.
 C. See explanation D.

D. The denominator is the total of all of the medical records, which equals
16.

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