* A hospital has recently moved to a paperless system.

It is noted that
some data is missing from the obstetrics delivery record. A healthcare
quality professional should recommend

A. assessing the need for additional education.

B. evaluating the computerized data entry process.
C. providing a paper trail.
D. designating one data entry person per shift.

* A facility is becoming part of a healthcare network. Which of the

following employee education programs is most important?

A. quality teams
B. organizational change
C. consumer expectations
D. conflict resolution

* A valid data collection tool should incorporate

A. a minimum of 20 data elements.

B. a graphic presentation.
C. the definition of data elements.
D. allowance for variance of interpretation.

* Comparing healthcare organizations by using medical error rates

A. may present bias due to differences in reporting practices.

B. must include a minimum of 10 different facilities.
C. cannot be performed by facilities with less than 100 beds.
D. provides the best method for benchmarking patient safety.
* For health information technology to be most effective in reducing
harm, the technology needs to be

A. integrated with clinical workflow.

B. able to correct claims data.
C. flexible and accessible.
D. numeric and easy to use.

* Medication errors with drug-drug interactions was 15.3 per 1000

admissions dispensing, Benchmark was 5. What is the best safety
measure to do?

A. BCMA

B. CPOE

C. EMR

d. CDSS

* Utilization management need to produce report of Cost, Effectiveness

and Appropriateness of care. What is the most suitable review
approach?

A - prospective
B - retrospective
C - clinical data
D - administration claims
* To facilitate change in your organization, you should focus on staff
who are:

A. perceptive of change
B. attitude business usual
C. unmotivated appearance
d. motivated appearance

* Healthcare organization had high rate of post-operative urinary tract

infection. After change to new urinary catheter, the rate decreased. As a
CPHQ you should :

A- trend data over another quarter

B- send the data to procurement
C- get a new catheter
D- find statistical significance for decrease
 Medication
Unit Time Medication Administration
dispensing errors Errors
Observation 7am-7pm 30% 70%
7pm-7am 10% 40%
North2 7am-3pm 40% 20%
3pm-11pm 0% 10%
11pm-7am 10% 10%
South 7am-7pm 40% 30%
7pm-7am 20% 20%
ICU 7am-7pm 50% 40%
7pm-7am 30% 20%

* Which area you are recommending first for improvement action:

a) Medication dispensing in ICU and observation
b) Medication administration in ICU and observation
c) Medication dispensing in north 2 and observation
d) Medication administration in ICU and south
* A healthcare organization's strategic plan objectives include a
customer satisfaction rating of 85%. The following data are available
for three units: Which of the following should a healthcare quality
professional recommend?

A. Change the target to 90% satisfaction.

B. Share Unit A's practices with other units.
C. Provide incentives for the staff of Units B and C.
D. Review the performance of the manager of Unit C.

* For a run chart which is tracking the Central Line infection, the
central line is called :
a- Mode
b- Standard deviation
c- Median
d- Mean

* Based on the principles from the Institute for Healthcare

Improvement (IHI), who has the ultimate responsibility for the
effectiveness of quality improvement and patient safety within an
organization?

A. quality improvement director

B. medical director
C. CEO
D. governing body
* Medication reconciliation is a process intended to

A. identify and resolve discrepancies.

B. investigate formulary discrepancies.
C. increase use of electronic medication administration.
D. improve efficiency of medication administration.

* When errors are discovered, staff and supervisors best demonstrate a

culture of safety by

A. developing a plan for just-in-time training.

B. studying the process to understand the error.
C. planning which details of the error to disclose to senior leadership.
D. performing a root cause analysis to determine which individuals were
involved.

* Which of the following charts will most likely be used first in a root
cause analysis?

A. Gantt
B. Pareto
C. flow
D. control
* A serious event has occurred related to the timely notification of
critical test results. The root cause was traced to nursing difficulty with
following the organizational policy. To prevent a similar event from
reoccurring, which of the following should be done next?

A. Refer the involved nurse to nursing peer review.

B. Educate nursing staff on the importance of timely notification of critical
test results.
C. Review the policy with nursing representatives to identify ambiguities.
D. Continue to collect data as one event is insufficient to take action.

* A policy for "time-outs" in an operating room was initiated in the first

quarter. The second quarter data demonstrated only 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 non-compliant surgeons.
C. continue to audit to confirm that a problem exists.
D. create a letter for the CEO to send to all surgeons.

* A healthcare network has implemented an electronic medical record

system allowing data to be transmitted, on demand, from one facility to
another. Which of the following will best promote both cost effectiveness
and patient satisfaction?

A. decreasing repeat tests when a patient is seen in more than one facility
B. eliminating the need for patients to hand-carry records
C. improving the accuracy of medication reconciliation
D. increasing the security of confidential patient information
* The clinical competency of a physician is determined by

A. a committee of peers.
B. the CEO.
C. the hospital governing body.
D. a Quality Management Committee.

* A 69-year-old female admitted for hip replacement is taken to

surgery. The patient is identified, the surgical site is marked incorrectly,
and equipment/x-rays are present. A near miss was most likely
identified as a result of

A. a surgical team 'time-out.'

B. informed consent documentation.
C. an equipment check.
D. a root cause analysis.

* Leaders enhance employee commitment to organizational values by

fostering which of the following types of communication?

A. face-to-face, oral, scheduled

B. timely, open, two-way
C. clear, written, top-down
D. formal, electronic, 'need to know'

* A strategy used in brainstorming is that ideas are

A. prioritized as they occur.

B. discussed when they are mentioned.
C. progressively eliminated.
D. all recorded.
* 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

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

data be

A. raw numbers
B. severity adjusted.
C. equal numbers.
D. reported monthly.

* Publicly report measures are developed through a life cycle in which

of the following sequences

A- first year data collection, public comment, evaluation

B- topic select, measure develop , public comment
C- measure developed, evaluation, topic selection
D- public comment, Measure developed, first year data collection

* Which of the following should be used to create clinical practice

guideline :

A- national norms
B- Population based standard
C- established criteria
D- evidence based literature
* Primary consideration in selecting and evaluating criterion is that

a- it is approved by the quality review committee

B- it is concerned with the cost of care
C- it reflects the clinical practice
D- data can be measured

* Surgeon has 6.7 % SSI in a specific procedure, while his colleague has
3.3% SSI for the same procedure. the data was reviewed by the Chair of
department; the Quality Professional Recommend ?
1- RCA
2- Focus review
3- Temporarily Suspension the surgeon
4. Stop the privilege of the first doctor.

* CPHQ wants to determine process measure to improve wound care

outcome, FIRST thing to do:

a- Three years prior best practice in wound care

b- Clinical trials in wound care
c- Search guidelines for wound care
d- Review clinical record for wound care sentinel events
* A new quality director has reviewed the information related to the
Quality Council minutes, and notes the following: - The council meets
quarterly. Meetings last approximately 2 hours. - The council roster
includes all clinical department managers and the quality director.
Attendance ranges from 45-60%. – The primary role of the council is to
receive department quality reports, which are then forwarded to the
organization's governing body. Based on the information above, which
of the following actions is most appropriate?

A. Require departments to forward reports for review prior to the meetings.

B. Redefine the council's role to coordinate and prioritize quality activities.
C. Switch to a monthly meeting with a new agenda format.
D. Eliminate the council and directly report quality data to the governing
body.

* An annual evaluation of a laboratory's quality program identified no

opportunities for improvement. Which of the following elements of the
program should be reviewed?

A. performance indicators
B. format of data display
C. committee meeting attendance
D. frequency of data collection
* A medication error occurred and resulted in a severe adverse
outcome. In addition to informing the patient and/or family, a
healthcare quality professional should

A. perform a regression analysis.

B. implement new technology.
C. reassign the employees involved.
D. conduct a root cause analysis.

* Facility A is investigating its medication administration time for a

specific diagnosis. Evidence-based guidelines indicate that
administration of a particular drug within 30 minutes significantly
improves patient outcomes. The national average is 32 minutes. The
average for Facility B is 28 minutes. If the average for Facility A is 35
minutes, Facility A should

A. determine whether its rate is within one standard deviation of the national
average.
B. decrease its rate to meet the national average.
C. contact Facility B to determine its practices.
D. identify the average time of its competitors.