According to continuous quality improvement principles,

which of the following concepts is most important?

A. financial impact
B. constancy of purpose
C. resistance to change
D. performance of individuals

To avoid misinterpreting variances, which of the following

statistical tools should be used?

A. control chart
B. fishbone diagram
C. force field analysis
D. Pareto chart analysis
In the process of strategic planning, an organization makes
decisions about the future. A basic component of the
planning process is to

A. develop contractual relationships to enhance market share.

B. contract with a consulting firm to assist with the planning
process.
C. determine organizational profitability during the most recent
fiscal year.
D. examine both internal and external environments.

A root cause analysis team examined a serious medication

error and recommended changes. Which of the following
should be done next?

A. Random checks for compliance should be made by patient

safety staff.
B. The Quality Council should review medication errors
quarterly.
C. The process owner should implement and assess
effectiveness.
D. Monthly reports should be sent to the regulatory body.
When a team evaluating the use of restraints starts to
discuss a liability claim related to a patient, the facilitator
should

A. redirect the team.

B. consult the risk manager.
C. request the medical record.
D. review team ground rules.

The primary purpose of risk management trend analysis is

to

A. meet regulatory requirements.

B. provide required reports to liability carriers.
C. identify opportunities for improvements.
D. eliminate financial loss for organizations.
A Quality Council has examined data on patient falls and
determined that a comprehensive falls prevention program
is needed. The first step in increasing staff awareness of this
initiative is to

A. require staff to sign that they have read and understood the
falls policy.
B. use an educator to teach falls prevention.
C. share unit-specific data on falls.
D. conduct a medication review of patients who have fallen.

After in-depth data analysis, there is evidence of over

utilization of computerized tomography to diagnose acute
appendicitis. A team has been formed to develop a
performance improvement plan for emergency department
physicians. Which of the following leadership style is most
effective to implement best practice guidelines?

A. Laissez faire
B. Democratic
C. Participatory
D. Autocratic
A radiology department regularly monitors x-ray
repeat/reject, timeliness of report dictation, and patient
waiting times. What component is missing in this
department's ongoing evaluation program?

a. Appropriateness review.
b. Process evaluation.
c. Quality control.
d. Documentation analysis

To ensure that medication administration is more safe, the

steps of administration should be:

A. More complex
B. More branched
C. More simple
D. More dependent on experience of staff
Situation – Background – Assessment - Recommendation
(SBAR) is a:

a- Six sigma methodology

b- Method that measures process variation
c- Tools to improve communication between caregivers
d- Software package used in quality improvement

Which of the following can demonstrate multiple aspects of a

practitioners practice as required for renewal of clinical
privileges?

a- Credentialing
b- Peer review
c- Privilege delineation
d- Practitioner profile
Organizational leaders can best demonstrate commitment to
a new quality improvement initiative by

a- Offering solution to identified problems

b- Maintain performance appraisals for staff
c- Allocate resource for the process
d- Reviewing the quality improvement plan

One way to measure clinical outcomes is through:

A. Aggregate data review

B. Pareto charts
C. Pre-admission review
D. The number of healthcare contracts
Which of the following is example of outcome measure:

A. mortality rate.
B. average LOS.
C. medication dispensing rate.
D. lab specimen.

To allow changes to be maintained, you should ensure the

change in:

A. The behavior of the staff.

B. The hierarchy of the organization
C. The values within the organization
D. The reward system
To allow changes to be maintained, you should ensure the
change in:

A. Culture within the organization

B. The hierarchy of the organization
C. The values within the organization
D. The reward system

Negligence means a lack of proper care. In medical

malpractice, "proper care" is determined by

A. medical peers.
B. JCAHO standards.
C. jury of civilian peers.
D. tort law.
(New) drug with good outcome but high side effect,
physician and pharmacist decided to add it to drug formula
depending on which study :

A. Random
B. Stratified
C. Prospective
D. Retrospective

The responsibility to promote organizational values and

commitment among the staff lies within:

A- Nurse executive and CEO

B- Nurse staff, senior management
C- Medical director, quality manager
D- Clinical and non-clinical leaders
Performance of RCA for a sentinel event provides all of the
following except:

A- Identification of why the variance occurred

B- Recommendations for actions to prevent recurrence
C- Measurement strategies for each factor affecting the outcome
D- Continuous measurement to identify opportunities for
improvement

Policy for time-out in the OR was initiated in the first

quarter. In the second quarter, the data had 40%
compliance with all elements of the process. The first step
the quality council should take is to:

A- Examine if the policy is clear and user friendly

B- Ask the nurses to identify the non-compliant surgeons
C- Continue to audit to confirm that problems exist
D- Create a letter for CEO to send to all surgeons
After significant unexpected event, an intensive analysis is
performed to:

A. Understand the cause

B. Correct risk management data
C. Prevent the facility from law suit
D. Identify who made the error

Credentialing committee has determined that a practitioner

has significantly higher rate of complications after surgeries
than the practitioners peer. Which of the following the
committees do next?

A- Initiate a focused professional evaluation (FPPE).

B- Limit the practitioner’s current surgical privileges
C- Require the practitioner to attend continuing education
D- Continue ongoing professional practice evaluation
Data gathering method includes all of the following except:

A- Measurement
B- Observation
C- Correlation
D- Interviewing

The evolution of quality improvement in healthcare has

shifted the primary focus from performance of individuals
to the performance of the

A. medical staff.
B. governing body.
C. ancillary departments.
D. organization's systems.
Timeliness and compliance of documentation were discussed
at a multidisciplinary team meeting. To evaluate the
effectiveness of the team's action plan, which of the following
will provide the most useful information?

A. physician attendance
B. number of complaints
C. frequency of meetings
D. medical record review

Empowerment gives employees the opportunity to

A. solve problems.
B. make more money.
C. gain respect of peers.
D. achieve upward mobility.
Which of the following is the best example of use of human
factors engineering?

A. designing products to prevent tubing misconnections

B. implementing a Kaizen process to reduce inventory
C. eliminating waste through reduction in motion
D. improve compliance with hand hygiene

Leaders of a multi-hospital system are trying to prioritize

the services to introduce in the coming year based on their
impact on the community. These leaders, who work
geographically apart, can arrive at a group consensus
without meeting face to face by:

A. the nominal group technique.

B. the Delphi technique.
C. brainstorming.
D. a focus group
When developing department specific performance
measures and indicators, the quality manger as a consultant
should:

A. Prioritize the quality indicators for selection by the

department leader
B. Ensure that the numerator and denominator are clearly
defined
C. Review the mission statement and seek physician input
D. Conduct a literature search and select quality indicators

Which of the following is the most appropriate question to

ask when reviewing an organizations performance
improvement (PI) plan?

A. "has the organization been successful in communicating the intent

and message of the PI plan to employees?
B. Are there sufficient organizational resources to support the PI
plan?
C. Does the PI plan include statistical methods for monitoring
change?
D. Is the PI plan consistent with the organization's mission and
strategic priorities?
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

The following data has been provided to a healthcare quality

professional: Which of the following is the best choice for beginning
clinical-pathways implementation in an organization?

A. diabetes
B. total knee replacement
C. heart failure
D. gastroenteritis
Which of the following adverse events is NOT considered a
sentinel event?

A. death due to a medication error

B. suicide threat by a patient in a confined 24-hour care setting
C. surgery on the wrong patient or body part
D. hemolytic transfusion reaction

A healthcare quality professional has been asked to examine

a new method of reviewing adverse events in an
organization. It has been decided that a system of triggers
will be established to alert the Quality Council of a potential
problem. The best example of a trigger that should be set
with a threshold of zero is a

A. medical record not completed by a physician.

B. staff member not using proper hand washing technique.
C. near miss from failure to perform a 'time-out.'
D. patient complaint regarding wait times.
A quality improvement manager must decide how to present
data that demonstrates the relationship between two process
characteristics. Which of the following data display
techniques is most appropriate?

A. bar chart
B. scatter diagram
C. Pareto chart
D. line graph

In profiling length-of-stay data for benchmarking, it is

important that data be

A. raw numbers.
B. equal numbers
C. reported monthly.
D. severity adjusted.
Failure modes can be prioritized by calculating the
criticality index. Which of the following three categories are
normally used to calculate a criticality index?

A. probability, likelihood, and criticality

B. frequency, severity, and ease of detection
C. effectiveness, risk, and priority
D. response, evidence, and outcome

Upon completion of a performance improvement project,

who is the best person to compile and write a report?

A. quality manager
B. team leader
C. facilitator
D. recorder
A physician complains to a healthcare quality professional
that the nursing staff did not strictly follow orders for a
patient. The physician requests that the quality professional
speak with the nurse manager. To facilitate improved
communication, the quality professional should

A. arrange a meeting with the physician and nurse manager.

B. speak with the nurse manager on behalf of the physician.
C. evaluate the patient outcome to determine organizational risk.
D. review the patient record to determine legibility of the
physician's orders.

Which of the following is the best tool to begin an

investigation into the causes of laboratory labeling errors?

A. affinity diagram
B. prioritization matrix
C. flow chart
D. histogram