CPHQ Quiz 1

Which of the following should a Quality Council provide to best ensure success of
performance improvement teams?

Failure modes can be prioritized by calculating the criticality index. Which of the following three categories are normally used to calculate a criticality index?

When considering the use of an external subject matter expert (SME), which of the
following characteristics is most critical?

Comparing healthcare organizations by using medical error rates

Staff has been trained and oriented on a new electronic incident reporting system. In the
past, staff could report anonymously. The new system requires staff to sign in with an
individualized username and password. Three months after implementation, there is a
sharp reduction in the number of reported incidents. Which of the following reasons for
underreporting of incidents is of greatest concern?

A culture of patient safety in an organization will have been successfully created when

The primary purpose of risk management trend analysis is to

In lean thinking, a process step is defined as “value added” if the

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?

In the quality improvement process, performing a cost-benefit analysis would be most
useful in

Which of the following obstetrical outcomes would result in a morbidity review?

The phrase “reaching consensus” is often used in performance improvement. The term
consensus refers to

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 two 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?

Informed consent for hip surgery was obtained and documented for an elderly patient. In
the recovery room, a nurse discovered the wrong hip had been replaced. A healthcare
quality professional should

A federally certified electronic health record (EHR) with the capacity for e-prescribing,
electronic exchange of health information, and submission of healthcare quality measures
meets

Minimizing the chances of an adverse event reoccurring includes determining the primary
contributing factor by using

The clinical competency of a physician is determined by

The best way to evaluate the effectiveness of performance improvement training is through

A healthcare quality professional is attempting to refine the differences between an
organization’s objectives and the stakeholder needs. Which of the following tools is most
appropriate?

Which of the following is the most effective way to integrate performance improvement
concepts throughout an organization?

A consulting firm has been selected by a facility’s quality professional to assess the quality
improvement program. Before starting the assessment, the quality professional should

A facility is becoming part of a healthcare network. Which of the following employee
education programs is most important?

A staff member reports that a colon perforation occurred during a colonoscopy. Which of
the following is a healthcare quality professional’s next step?

An organization can best measure its effectiveness in meeting customer expectations by

Generic screening is an example of risk

A hospice agency conducted a satisfaction survey of all 200 patients currently receiving
pain management services. When asked if they were satisfied with their pain management,
170 patients said yes and 30 said no. In this situation, a healthcare quality professional
should

Results of physician practice pattern studies are most likely to promote behaviour changes
when disseminated to the

The primary purpose of an organization’s quality improvement strategic plan is to

A facility is becoming part of a healthcare network. Which of the following employee
education programs is most important?

Leadership can best integrate performance improvement within an organization through

Problem-solving, cross-functional understanding, expanded areas of expertise, gains in
status and power, and increased span of knowledge are examples of

A healthcare quality professional is conducting a study to determine how many patients
contracted influenza after receiving flu shots. This study is evaluating

One aspect of a quality process that integrates with risk management is the review and
evaluation of

When examining the relationship between staff and patient outcomes, which of the
following would be most appropriate to assess?

The success of a performance improvement program will be most influenced by the

External customer-supplier relationships are important but often cannot be controlled
by the organization. Which one of the following tools best clarifies and improves those
relationships?

Achievable goals and measurable objectives support the Mission and Vision
Statements. Objectives are to goals as

The Laissez-faire leadership style is characterized by

The PDCA Performance Improvement Model is a method of continuous quality
improvement to resolve specific situations rather than organization-wide problems.
PDCA stands for

A strategy used in brainstorming is that ideas are

For a continuous quality improvement team to be successful, who must be included on the team?

A failure mode and effects analysis (FMEA) provides which of the following types of
review?

A medication error occurred resulting in a severe adverse outcome. In addition to informing
the patient and/or family, a healthcare quality professional should

To avoid misinterpreting variances, which of the following statistical tools should be used?

A culture of patient safety in an organization will have been successfully created when

Which of the following action plans is the first step in correcting inappropriate blood usage
in an emergency department?

Which of the following are attributes of a culture of safety?

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?

In managed care, the most widely used performance measures are

When conducting a sentinel event review, a root cause analysis

When developing a strategic plan that integrates patient safety, which of the following
factors is most critical?

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

An operating room circulating nurse reported that the instrument count indicated a missing
clamp. X-ray findings were negative, and the patient showed no adverse effects. This
occurrence is an example of which of the following?

Which of the following elements must be present in order to evaluate the effectiveness of a
healthcare organization’s quality improvement program?

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

A valid data collection tool should incorporate

When errors are discovered, staff and supervisors best demonstrate a culture of safety by

Which of the following is the best tool to begin an investigation into the causes of laboratory labelling errors?

Which of the following topics are discussed at a morbidity and mortality conference?

For health information technology to be most effective in reducing harm, the technology
needs to be

The evolution of quality improvement in healthcare has shifted the primary focus from
performance of individuals to the performance of the

Which of the following is always true regarding a sentinel event?

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?

During quality management data analysis activities, Pareto charts are most appropriately
used for

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?

Which of the following principles applies to continuous quality improvement in an
organization?

One standard element of organization-wide strategic planning is

It is important to identify customer-supplier relationships to improve methods, to meet
customers’ needs, and to increase internal awareness. Which of the following is the
best example of a horizontal internal customer-supplier relationship?

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
established core measures to determine if healthcare institutions comply with current
standards. Currently, core measure relate to which of the following conditions?

Management must establish lines of authority and transparent accountability. Which
of the following entities is responsible for all patient care rendered?

The FOCUS Performance Improvement Model is an incomplete process if it is not
combined with

To develop a Performance Improvement Plan, the organization must

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

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
would provide the most useful information?

Deemed status refers to

A clinical pathway on the management of hip fractures has been developed by a multi-
disciplinary team and implemented in a large teaching hospital. After monitoring for 6
months, the length of stay continues to exceed the guidelines. Which of the following
should be the next step?

The leader of a pain management performance improvement team has asked the Quality
Council to disband the team. The most important factor for the Quality Council to assess is

Which of the following should be included in an annual performance improvement report to
a governing body?

The quality improvement director is responsible for coordination of accreditation survey
activities. Responsibilities will most likely include

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

Team cohesion is established during which of the following stages of team growth?
storming

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 physician complains to the healthcare quality professional that the nursing staff did not
strictly follow orders for a patient. The physician requests that the healthcare quality
professional speak with the nurse manager. To facilitate improved communication, the
healthcare quality professional should

The target for performance improvement should be

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?

Medication reconciliation is a process intended to

Which of the following actions would have the greatest impact in reducing harm?

Balanced scorecards are useful because they

When a team evaluating the use of restraints starts to discuss a liability claim related to a
patient, the facilitator should

Which of the following is the best example of use of human factors engineering?

After a significant unexpected event, an intense analysis is performed to

In the process of strategic planning, an organization makes decisions about the future. A
basic component of the planning process is to

The utilization management committee is reviewing length-of-stay data for a particular
procedure. In comparing data by physician, which of the following statistics would be most
useful?

Performing a root cause analysis of a sentinel/unexpected event provides all of the
following EXCEPT

Which of the following adverse events is NOT considered a sentinel event?

A healthcare entity initiating re-structuring must consider the impact on staff to ensure the
greatest opportunity for success by

A health plan is required to have a mechanism for members to submit complaints. Which of
the following actions must be included in the complaint analysis to ensure the plan makes
full use of this type of information?

Effective leaders must be consistent and

Which of the following is not important to the development of an organization’s Mission
Statement?

The Ernst and Young 7-step IMPROVE (Identify, Measure, Prioritize, Research, Outline,
Validate, Execute ) model is simplified. IMPROVE is most effective for

Which one of the following is/are not a national or international excellence/quality
model(s)?

A summary of antibiotic usage for the fourth quarter showed that an internal medicine
department did not meet pre-established criteria in 82% of the patients reviewed. Following
review, the pharmacy and therapeutics committee should recommend that the results be
shared first with the

Random screening of new-borns by the neonatology department has confirmed a high
incidence of glucose insufficiency (G6PD) in the local population. Management believes
that the cost of testing all new-borns would be too high. Which of the following should the
healthcare quality professional suggest?

Frequency distribution can best be displayed through use of

Which of the following is an example of information that should be included in an incident
report, but should not be recorded in a patient’s medical record?

An outpatient clinic is attempting to measure the quality of a newly developed diabetes
disease management program. To accomplish this, laboratory results will be measured
overtime. The best way to display the data is to use a

Which of the following is the first step in preparing for an initial accreditation or certification
survey of an organization?

Quality improvement teams go through stages of development. These team development
stages include all of the following EXCEPT

A physician who has a high inpatient mortality rate compared to others in a facility should
first be

A patient safety program can best be enhanced by which of the following technologies?

A performance improvement training program for supervisors should include

Satisfaction surveys, focus groups, and complaint tracking are tools used to

Human factors engineering is defined as the study of humans and their interaction with

Which of the following is most appropriate in preparation for an external survey of a
healthcare facility?

Which of the following is the major responsibility of senior management regarding
continuous quality improvement?

When using cost-benefit analysis in decision making, it is important to remember that

The perception of how an organization operates, including how employees relate to internal
and external customers, is the organizational

Leaders enhance employee commitment to organizational values by fostering which of the
following types of communication?

A healthcare quality professional wants to develop a continuous survey readiness model.
The initial step should be

Which of the following is the best example of an outcome measure?

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 organisation?

The primary purpose of integrating financial and quality management information is to

Which of the following is used to summarize a characteristic in a population?

Healthcare leaders are confronted with the challenge of increasing quality while reducing
costs. Which of the following approaches will best advance improvement efforts?

Which of the following team members is responsible for keeping meetings focused?

Which of the following actions should the facilitator make the highest priority during the
customer focus group process?

A healthcare quality professional has been asked to assess a facility’s patient safety
culture. Which of the following should be targeted in a validated survey?

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 zeroes a

A policy for “time-outs” in an operating room was initiated in the first quarter. The second
quarter data has demonstrated only 40% compliance with all elements of the process. The
first step the Quality Council should take is to

Strategic quality planning promotes quality improvement throughout the organization
and has at its core TQM, which stands for

A Vision Statement is directed at the organization’s stakeholders (e.g., patients, staff,
community, etc.) and states

Voluntary accreditation is a primary requirement for most healthcare organizations.
The most important aspect to consider when evaluating each type of accreditation is

Which one of the following is not an issue that must be resolved when developing a
Performance Improvement Plan?