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An organization demonstrates the financial benefits of its performance improvement plan by
When the CPHQ creates a Performance Improvement Team, it is inappropriate to
The CPHQ ensures the survey processes run smoothly by
Cost analysis involves cost allocation, in which costs are determined as direct or
indirect. Direct costs are to indirect costs as
When developing a departmental budget, which one of the following need not be considered?
The CPHQ creates the most effective survey to assess customers’ needs and
expectations when he/she
Data definition is necessary for performance improvement. When measuring the
frequency and type of medication error, you must first
When addressing specific issues regarding data definitions, consider the 2 Rs
(Recordability and Reliability), UV (Usability and Validity) and the 3 Ss, meaning
In data collection, Qualitative Data are to Quantitative Data as
Random Variation is to Special Cause Variation as
Which one of the following is not a way to promote organizational values and commitment among the staff?
To establish priorities for process improvement activities,
An effective team leader delegates tasks. Failure to delegate
The facilitator of a Performance Improvement Team
As a member of a performance improvement team, you will
To develop organizational Performance Improvement training, you will not need to
Some indicators of poor team performance are poor communication, poor problem-solving, and lack of
To interpret performance/productivity reports, you must also understand process variation, which means
When analysing complaints, the CPHQ would not
The CPHQ determines the staff member’s role in quality processes and incorporates
the outcomes from those processes when
The Performance Improvement process requires identification of
The CPHQ must integrate Quality findings into governance and management activities to
The National Quality Forum (NQF) endorses safe practices to assess and develop organizational patient safety cultures. One of the most important elements needed to create the culture is
Facilitating the development of a patient safety program requires a CPHQ to
Which one of the following is not included in the Organization Plan?
An example of integrated technology that enhances patient safety is RFI, which stands for
When a patient safety goal is chosen for review, it is because
That dimension of quality/performance that is dependent upon evaluation by the recipients and/or observers of care is
The person/group legally responsible for maintaining quality patient care is the
The written evaluation should include
.The term “performance,” as used in healthcare quality improvement activities, refers to
The Critical Care QI Team is chartered to improve the admission process to the critical care units. One identified issue, based on preliminary data, relates to admissions by family practice physicians. The medical director drafts the performance measures and criteria for data collection. The critical care nurses collect the data, and the quality management department staff aggregates and displays the data for the team. What key step is missing?
In writing a report for administration, such as that concerning an organization ethics concern, your best communication strategy is to
The Performance Improvement Team uses tracer methodology to identify
The champions of the Performance Improvement Team
The three models for case management are
A. Type of patient care, Focus of patient needs, and Professional discipline
B. Type of provider care, Focus of care, and Professional discipline
C. Type of patient care, Focus of provider, and Professional discipline
D. Type of provider care, Focus of patient needs, and Professional discipline
A team is required to evaluate computer software for data collection, as
Which one of the following is not useful for identifying users’ computer software
The most important question to ask when choosing computer software is:
After aggregating data, it is important to summarize the information with data-displays
so that it is
External benchmarking can be
When interpreting outcome data, it is
One of the core concepts of Continuous Quality Improvement (CQI) is
As a CPHQ, you must communicate to all members of the organization the key concepts of quality care, which are:
A CPHQ facilitates communication with accrediting and regulatory bodies by
Developing clinical/critical pathways requires
The four primary core criteria for credentialing and privileging are:
Mortality reviews are a critical element of Risk Management and Quality Improvement, conducted to determine
The first assessment step the CPHQ makes to prevent risks to the patients, the staff, or the organization is to
The ADDIE Model of organizational Performance Improvement training outlines five steps for the development of instructional systems. The steps are:
The CPHQ evaluates the Performance Improvement team to ensure it is effective and efficient. Three areas to evaluate are completion of assigned tasks, the ability of the team to cooperate and reach a consensus, and the
To interpret performance/productivity reports, you must have a thorough
Performance Improvement data are used for credentialing and privilege-delineation.
The practitioner is evaluated on his/her
Utilization management assessments measure
JCAHO issues National Patient Safety Goals annually. Which one of the following is not a hospital goal?
The most important components of a patient safety program are
The Institute for Healthcare Improvement (IHI) promotes better healthcare worldwide. To integrate IHI patient safety goals, an organization must
The “appropriateness” of care is
Which of the following key healthcare issues is more problematic for ambulatory care than for inpatient care?
Hospital medical/professional staff bylaws
One of your first key issues to determine when evaluating the current QM program is
Your initial report should be addressed to the
A key physician/licensed independent practitioner QM function is
Of the following options, conclusions concerning a licensed independent practitioner’s care drawn from organizational quality/performance improvement activities would most likely be used during
The average between the highest and lowest measures is the
Communication is enhanced by
Wearing a conservative dark suit to an important governing board meeting is an example of which mode of communication?
The task of setting up an ambulatory care setting QM/QI program that focuses on “outcomes” as a measure of treatment effectiveness is difficult because
The organization’s strategic goals are best linked to its performance improvement
activities by management
To facilitate change within an organization, a CPHQ should
A healthcare organization must have a Risk Management plan to obtain liability insurance. Which of the following lists is best for a Risk Management plan?
State and federal regulations require that performance improvement activities, records
and reports are kept confidential. HIPPA protects the patients’ right to privacy and
confidentiality, and the initials stands for
To maintain the confidentiality of performance improvement activities, records and
reports, all information regarding a specific patient’s identity may
Which three elements ensure successful implementation of computerized systems for
data collection and analysis?
Which one of the following is not the description of an analysis tool?
The CPHQ uses a run chart or control chart to find trends within a process. A trend is
In the Ishikawa Fishbone Diagram, users label methods, materials, and measurements
with an “M” and people, prices, and policies with a “P”. An “S” label represents:
The CPHQ evaluates a study of the incidence of strokes (CVA) in women who take birth
control pills versus a control group who do not take birth control pills. The best
statistical technique for evaluating the study data is:
Meaningful comparisons between service areas using internally gathered comparative
data do not require
What are the four primary types of events related to medical error?
To properly disseminate performance improvement information,
Organizational Transparency is the healthcare industry standard, meaning that
Multivoting is a procedure to help prioritize and reach consensus when selecting process improvement activities. Which one of the following is not a component of Multivoting?
To establish evidence-based practice guidelines, it is best to
When applying for an external quality award, like the Malcolm Baldrige National Quality Award, an organization can benefit
When coordinating quality improvement projects, a CPHQ will not
Accreditation requires the CPHQ to develop training activities. The best way to prepare for an accreditation survey is by
Customer satisfaction surveys are used to evaluate service, rather than clinical elements, because their limited scope does not include measuring the customer’s
Which one of the following is not a benefit of integrating the results of data analysis into the Performance Improvement process?
To develop the organization’s patient safety culture, the CPHQ will not
Strategic goals and objectives relate to patient safety activities
To integrate patient safety concepts within the organization
If the organization is committed to patient safety, the most important process is
As a patient safety officer, the CPHQ coordinates the patient safety program by
When a Sentinel Event (SE) occurs, the Risk Manager initiates a Root Cause Analysis
If, in the continuous quality improvement process, we increase our emphasis on customer satisfaction and outcomes of care, which two dimensions of quality/performance must be incorporated into all quality management activities?
A hospital generally has a unique structure comprised of a “triangle.” Which three entities make up the triangle?
The leadership style that is said to motivate employees, and that optimizes the introduction of change, is
The most effective way to ensure patient safety as a dimension of performance is to
The method of ordering data by listing all possible values, and all individuals receiving
each value, is called
When data has a range of values between the lowest and highest that is wide, but you
want to rank-order them, it is best to use a
The most accurate measure describing the amount of variability in a distribution is the
Barriers to effective communication include
You lead one of the organization’s strategic quality initiative teams. One of your key
members consistently arrives at least 15 minutes late. Your best approach is to
One fundamental difference between monitoring product quality and service quality is based upon the fact that
The quality professional can best facilitate the development of a “quality culture” in the organization by
As facilitator of the Performance Improvement Oversight Group, the CPHQ
When an expert consultant is hired to assist with the Performance Improvement project, the CPHQ should
When developing performance measures, first determine which data are needed for:
An Incremental Cost-Effectiveness Ratio is
The CPHQ distributes the topics for discussion prior to a committee meeting. The pre-meeting packet should contain
What is the catalogue order the CPHQ uses to best coordinate inventory listings for
When sampling a population for data collection, consider
“Epidemiological Theory” in data collection and analysis means the relationship
The CPHQ measures averages to locate the centre point in a data group. Which
statement is false?
Decision-making for improvement is best supported by interpreting data acquired
through analysis of
If a problem arises involving patient care management, the first step is to
Which of the following does not need to be included in performance improvement reports?
Performance Improvement Action Plans and Projects require many development steps. After problem assessment and monitoring, prioritization, and team creation, implement the plan
The three types of outcome measures are:
The coordination of Quality Improvement processes and projects requires
Federal regulations require physician practitioners to be re-credentialed every two years after privileges are granted to them. Quality information is
The systematic approach to medical record reviews requires
After developing the organizational Performance Improvement training program, you will then provide the training, with your focus on
The effectiveness of Performance Improvement training can be measured most accurately
The Practitioner Profile reappraises a caregiver’s performance and includes:
Risk Management assessment is a primary concern during
An organization-wide early warning system should be in place to screen patients and identify
Accreditation and regulatory recommendations should always be considered
AHRQ-sponsored surveys facilitate assessing the organization’s patient safety culture. AHRQ stands for
Computerized physician order entry (CPOE) can enhance patient safety by
The patient safety program is enhanced by computerized physician order entry (CPOE), electronic medical records (EMR), and
Which one of the following is not a patient safety goal of the Joint Commission International (JCI)?
Incident reports indicate a failure in the system; therefore, review of incident reports is an important part of Risk Management. What can be determined by an incident
A medication is ordered for a diabetic patient. Its capacity to improve health status, as a
dimension of quality or performance, is its
The key to creating sustained value in the organization is to
In evaluating the current QM program for strengths and weaknesses, it is NOT necessary to assess
The formal functions of management include all except
Which of the following may be considered examples of discrete variables?
In developing a program to evaluate the effectiveness of physician care, a primary care clinic would select which one of the following indicators?