CPHQ Practice Test Verified Solutions 2024/2025, Exams of Nursing

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CPHQ Practice Test

Which of the following action plans is the first step in correcting inappropriate blood usage in an emergency department? A. in-service on ordering blood usage for the physicians B. elimination of wasted blood C. improvements in documentation D. development of a new procurement procedure - ✔ANSWER A. in-service on ordering blood usage for the physicians Which of the following is most appropriate in preparation for an external survey of a healthcare facility? A. Assign key staff to answer all questions. B. Ask department heads to prepare a presentation for the survey team. C. Educate staff about the types of questions they may be asked. D. Set up teams to make a good showing for the survey. - ✔ANSWER C. Educate staff about the types of questions they may be asked. The following table shows the percentage of hospital-acquired pressure ulcers: Which of the following should the healthcare quality professional do next? A. Implement a new pressure ulcer protocol. B. Re-educate staff. C. Continue to track and trend the data. D. Conduct a focused analysis of pressure ulcer cases - ✔ANSWER D. Conduct a focused analysis of pressure ulcer cases Leadership can best integrate performance improvement within an organization through: A. multidisciplinary teams. B. newsletters. C. focus groups. D. seminars. - ✔ANSWER A. multidisciplinary teams (best integrate performance improvement by promoting an interdisciplinary approach to the process and including multiple subject matter experts.) 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. - ✔ANSWER D. conduct a root cause analysis. (exploration of system and process issues should be the primary function of a root cause analysis) The primary purpose of an organization's quality improvement (QI) strategic plan is to: A. determine accountability for outcomes. B. assess improvement opportunities. C. define the future direction for quality. D. explain the purpose of performance teams - ✔ANSWER C. define the future direction for quality. (This is a function of having a QI strategic plan.) Which of the following are the first steps when preparing for an initial accreditation or certification survey of an organization? A. Review the standards and determine readiness. B. Appoint a survey coordinator and prepare a survey agenda. C. Hire a consultant and conduct a mock survey. D. Assess staff knowledge and plan staff training. - ✔ANSWER A. Review the standards and determine readiness. (These actions are part of the gap analysis, which establishes a good baseline to determine where to focus and how to prioritize efforts.) 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 - ✔ANSWER C. identify opportunities for improvements. (Risk management focuses on identification, assessment, and reduction of risk. The goal is to protect the organization from losses, the key component of which is proactive improvement to avoid and reduce risk.) Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization's quality improvement program? A. quantifiable objectives

B. support from the medical staff C. well-defined organizational structure D. integrated data collection - ✔ANSWER A. quantifiable objectives (To evaluate effectiveness, an organization must have quantifiable objectives in order to measure progress toward meeting goals) Balanced scorecards are useful because they A. focus on the most significant strategic initiative. B. evaluate the pros and cons of the governing body's priorities. C. put strategy and vision at the center of an organization's effort. D. concentrate on the performance of individual units. - ✔ANSWER C. put strategy and vision at the center of an organization's effort. (The balanced scorecard is a management framework that translates an organization's strategic objectives into a set of performance measures that are measured, monitored, and changed, if necessary, to ensure that organization's strategic goals are met.) A t-test may be used to: A. display the size of a sampling variation. B. evaluate the effects of two different treatments. C. evaluate differences among three or more treatments. D. display a listing of the number of occurrences of a variable - ✔ANSWER B. evaluate the effects of two different treatments. (A t-test is used to examine if the mean of two treatments are statistically different from one another) Which of the following should a Quality Council provide to best ensure success of performance improvement teams? A. facilitator and recorder B. empowerment and training C. indicators and a data analyst D. standards and procedures - ✔ANSWER B. empowerment and training Which of the following is the most effective way to integrate performance improvement concepts throughout an organization? A. quarterly newsletters B. monthly lectures C. quality teams D. continuous monitoring - ✔ANSWER C. quality teams

(Quality teams include participation by front-line staff, which allows direct integration of performance improvement into practice.) The primary purpose of integrating financial and quality management information is to: A. identify problems in resource management. B. develop physician profiles. C. identify potential cash flow problems. D. determine medical necessity of treatment - ✔ANSWER A. identify problems in resource management. (This ties financial impact to quality management.) A group of pediatric patients diagnosed with cystic fibrosis is being studied. Their attitudes toward the disease have been measured each year for the past 4 years. The methodology used is an example of a: A. cohort study. B. regression analysis. C. case-mix study. D. cross-sectional analysis - ✔ANSWER A. cohort study (analyzes a group with a specific characteristic, such as cystic fibrosis.) 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. - ✔ANSWER C. The process owner should implement and assess effectiveness. (the recommended changes need to be assigned ownership.) 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? A. the patient found on the floor next to the bed with the patient's right leg appearing to be rotated B. the date, time, dose, and name of a medication administered to a patient in error C. details concerning a medication preparation error discovered and corrected prior to administration D. the patient's right knee replaced after consenting to replacement of the left knee - ✔ANSWER C. details concerning a medication preparation error discovered and corrected prior to administration

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 - ✔D. governing body (This is the expectation of TJC and Centers for Medicare and Medicaid Services (CMS)) Which of the following charts will most likely be used first in a root cause analysis? A. Gantt B. Pareto C. flow D. control - ✔D. control (a tool to evaluate process) 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: A. bar-code technology specifications. B. computer-based monitoring specifications. C. meaningful use requirements. D. health privacy requirements - ✔C. meaningful use requirements. Team cohesion is established during which of the following stages of team growth? A. forming B. storming C. norming D. performing - ✔C. norming (The team moves towards cohesion and collaboration during the norming stage.) 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. performance indicators 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. - ✔B. studying the process to understand the error. In lean thinking, a process step is defined as "value added" if the A. customer recognizes the value. B. customer corrects a mistake to add value. C. process owner recognizes the value. D. process owner changes the value of the product. - ✔A. customer recognizes the value. Customer value is the key concept of lean thinking and improvement efforts. Generic screening is an example of risk A. evaluation. B. reduction. C. prevention. D. identification. - ✔D. identification Identification is the first step in disease management/risk management. One difference between continuous quality improvement and traditional quality assurance is that quality improvement always A. requires the application of statistical process control. B. excludes monitoring and evaluation of care provided. C. focuses on systems or processes. D. addresses potential problems. - ✔C. focuses on systems or processes. Quality improvement is focused on systems, processes, and groups to improve. Quality assurance is focused on monitoring problem areas or individuals. Statistical process control may be employed a tool to facilitate quality improvement, but is not a required component of quality improvement. 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. - ✔D. examine both internal and external environments. Includes an examination of internal strength and weaknesses, and external opportunities and threats. A healthcare entity initiating re-structuring must consider the impact on staff to ensure the greatest opportunity for success by A. defining the concepts of re-structuring to the staff and the community. B. planning carefully, communicating openly, and leading effectively. C. developing policies to assist in the change process so that fear will be minimized. D. selecting a consultant, conducting a needs assessment, and analyzing results. - ✔B. planning carefully, communicating openly, and leading effectively. these actions promote transparency and trust through communication and leadership. A hospital-wide medical record audit on documentation has been completed. The following table shows the compliance rate of documentation: 1st Qtr (Q1) & 2nd Qtr (Q2) Surgical "time-outs" performed: Q1 = 90% Q2 = 95% Communication of critical results: Q1= 91% Q2= 95% Pain score used: Q1= 50% Q2= 60% Initial patient assessment performed: Q1= 52% Q2= 45% Which of the following is the next step? A. Benchmark the compliance rates against another facility. B. Conduct training regarding pain score. C. Give data feedback on physician signature to the units. D. Conduct a focused review on the patient assessment process. - ✔D. Conduct a focused review on the patient assessment process. (A focused review of the patient assessment process should be prioritized because of low performance and decreased performance from Q1 to Q2.) The best way to evaluate the effectiveness of performance improvement training is through A. observed behavioral changes. B. self-assessments. C. participants' feedback. D. post-test results. - ✔A. observed behavioral changes. A physician who has a high inpatient mortality rate compared to others in a facility should first be

A. counseled by the department chairperson. B. reviewed by the credentialing committee. C. suspended in the interest of patient safety. D. evaluated via a more in-depth review of cases. - ✔D. evaluated via a more in-depth review of cases. 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. - ✔A. identify and resolve discrepancies. the definition of medication reconciliation is a process of identifying the most accurate list of all medications by comparing the medical record to an external list of medications. One aspect of a quality process that integrates with risk management is the review and evaluation of A. adverse drug events. B. encounter data. C. case-mix analysis reports. D. accreditation survey reports - ✔A. adverse drug events. Risk management has a role related to incident reporting. 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. - ✔B. Redefine the council's role to coordinate and prioritize quality activities. During quality management data analysis activities, Pareto charts are most appropriately used for

A. displaying parts of a whole. B. displaying trends over time. C. determining cause and effect relationships. D. determining priorities among contributing factors. - ✔D. determining priorities among contributing factors. Healthcare leaders are confronted with the challenge of increasing quality while reducing costs. Which of the following approaches best advances improvement efforts? A. Support activities that improve outcomes and reduce variation. B. Incorporate customer satisfaction results into quality initiatives. C. Increase charges and decrease costs. D. Develop new services to increase revenues. - ✔A. Support activities that improve outcomes and reduce variation. When choosing an outside consultant to lead employee focus groups, which of the following priority areas of expertise should a healthcare quality professional look for? A. team development and management B. organization assessment and change management C. group dynamics and facilitation D. organization design and re-engineering - ✔C. group dynamics and facilitation The primary role of a consultant who is leading focus groups is to facilitate interaction in the group dynamic. When considering the use of an external subject matter expert (SME), which of the following is most critical? A. leadership's personal preference B. geographic location of the SME C. cost of the SME's services D. references of the SME - ✔D. references of the SME The positive clinical reputation provides credibility support to the project. 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 - ✔B. constancy of purpose Which of the following is the best example of an outcome measure? A. availability of computers

B. pathway compliance C. mortality rate D. laboratory turnaround - ✔C. mortality rate An outcome measure is used to determine how the system or improvement project impacts the patient. 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: A. the length of time the team has been together. B. how well the team met the intended outcome. C. the effectiveness of the team leader and facilitator. D. the amount of data the team has collected. - ✔B. how well the team met the intended outcome. The decision to disband should be based upon how well the team has met the intended outcomes. Quality improvement team development stages include all of the following EXCEPT A. norming. B. forming. C. performing. D. conforming. - ✔D. conforming Which of the following actions has the greatest impact in reducing harm? A. revising the patient safety evaluation tool B. improving interdisciplinary communication C. forming a performance improvement team D. increasing data collection frequency - ✔B. improving interdisciplinary communication Improved communication has been proven to be a key factor in reducing harm. 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? A. claims management B. malpractice C. clinical incompetency D. potentially compensable event - ✔D. potentially compensable event

Although the clamp was not found, this has potential to become a compensable event. A potentially compensable event is an event for which there is risk of future claim or settlement. 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 - ✔A. control chart Control charts exhibit points between control limits, therefore displaying the variation. Which of the following team members is responsible for keeping meetings focused? A. time keeper B. facilitator C. recorder D. leader - ✔B. facilitator The facilitator facilitates and is responsible for team focus. 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? A. Evaluate compliance with the pathway. B. Correlate the pathway with staffing levels. C. Re-educate the staff on the purpose of the pathway. D. Continue to monitor, and collect additional data - ✔A. Evaluate compliance with the pathway. Evaluation of compliance with the proven (pathway) should be conducted first to see if that may be influencing the lack of change in the outcome. 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. - ✔A. redirect the team. Redirection is needed to move team back on topic and towards performance improvement effort.

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. - ✔C. contact Facility B to determine its practices. Sharing best practices is encouraged for process improvement. An organization can best measure its effectiveness in meeting customer expectations by A. analyzing satisfaction data. B. benchmarking occupancy rates. C. creating a run chart of complaints. D. tracking length of stay. - ✔A. analyzing satisfaction data. Satisfaction data evaluates customer satisfaction. A healthcare quality professional wants to measure the success of a corrective action plan with a 95% confidence level. The average daily census at the quality professional's organization is 1,000 patients. The best sampling technique for this study is to review: A. 10% of all discharge records for the past quarter. B. all active records on one day of the past month. C. 30% of records based on preliminary compliance review. D. the number of records needed using a statistical method. - ✔D. the number of records needed using a statistical method. the confidence level and interval would be determined through calculation. The quality improvement director is responsible for coordination of accreditation survey activities. Responsibilities will most likely include: A. facilitating self-assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda for the survey. B. educating staff to all standards, writing the survey report, and completing the survey application.

C. developing a protocol for a mock survey, conducting unannounced surveys, and challenging the survey report. D. preparing for unannounced surveys, disseminating the survey report, and developing new standards. - ✔A. facilitating self-assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda for the survey. These are essential functions for overseeing accreditation process. Minimizing the chances for an adverse event to reoccur includes determining the primary contributing factor by using: A. root cause analysis. B. force field analysis. C. clinical pathways. D. failure mode and effects analysis (FMEA). - ✔A. root cause analysis. as exploration of system and process issues should be primary in identifying root causes of error. 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. - ✔C. Review the policy with nursing representatives to identify ambiguities. The utilization management committee is reviewing length-of-stay data for a particular procedure. In comparing data by physician, which of the following statistics will be most useful? A. correlation B. range C. mode D. mean - ✔D. mean The mean is the statistical average in a data set. It is often used to describe average length of stay for comparison and is used with the standard deviation to understand the variability around the mean. Which of the following actions should a facilitator make the highest priority during the customer focus group process?

A. selecting a homogeneous group B. establishing rapport with the group C. providing written ground rules to the group D. generalizing the findings to the population - ✔B. establishing rapport with the group A facilitator must establish rapport in order facilitate the group towards outcomes. Satisfaction surveys, focus groups, and complaint tracking are tools used to A. benchmark satisfaction. B. develop clinical pathways/guidelines. C. understand customers' expectations. D. measure professional practice patterns - ✔C. understand customers' expectations. Surveys, focus groups, and complaints with or from customers can provide information directly from the customers regarding a variety of topics including customer expectations. In the quality improvement process, performing a cost-benefit analysis is most useful in A. checking performance. B. analyzing process problems. C. designing solutions and controls. D. implementing solutions and controls. - ✔C. designing solutions and controls. Cost-benefit analysis allows for financial controls to be considered towards outcome achievement. 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. examine if the policy is clear and user-friendly. Since process has changed, it is important to make sure it is clear and all understand. Deemed status refers to: A. a healthcare organization that passes a Centers for Medicare and Medicaid Services (CMS) survey. B. surveyors who work for both an accrediting body and a healthcare organization. C. physicians who have been reported to the National Practitioner Database.

D. accreditation equivalency with a Centers for Medicare and Medicaid Services (CMS) survey. - ✔D. accreditation equivalency with a Centers for Medicare and Medicaid Services (CMS) survey. CMS allows deemed status with meeting all conditions of participation requirements through Joint Commission Accreditation. 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 over time. The best way to display the data is to use a A. Gantt chart. B. control chart. C. Pareto chart. D. flow chart. - ✔B. control chart. A control chart is used to display data over time with upper and lower control limits to help monitor process variability. Performance improvement teams should always be required to A. evaluate data. B. include senior leadership. C. perform root cause analyses. D. write mission and vision statements. - ✔A. evaluate data. 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. - ✔A. arrange a meeting with the physician and nurse manager. Best answer to facilitate communication between parties 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. - ✔B. evaluating the computerized data entry process. Further analysis is necessary to determine the root causes of the missing data. The best reason to evaluate team meetings is to A. assess progress. B. rate leader performance. C. keep participants interested. D. assess accuracy of the minutes. - ✔A. assess progress. Assessing team progress is critical to determining whether the team is on track to meet established goals. 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. A target satisfaction rate of 90% has been set. In this situation, a healthcare quality professional should A. review all dissatisfied responses for similarities. B. collect more data to ensure statistical significance. C. discontinue monitoring because an 85% satisfaction rate is excellent. D. continue monitoring because a 15% dissatisfaction rate is acceptable. - ✔A. review all dissatisfied responses for similarities. The goal was not reached. Further examination of potential trends to identify opportunities for improvement is a component of continuous quality improvement The success of a performance improvement program will be most influenced by the A. reliability of data management software. B. educational preparation of quality leaders. C. culture of the organization. D. people skills of the facility leaders. - ✔C. culture of the organization. Significant factor that must be considered when implementing any program. 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. - ✔D. severity adjusted.

Benchmarking data should be severity adjusted to allow for meaningful comparisons while reducing bias and incorrect comparisons due to differences in the patient population across organizations A performance improvement (PI) training program for supervisors should include A. results of a failure mode and effects analysis (FMEA). B. budget-variance reporting. C. rapid-cycle process. D. review of patient falls. - ✔C. rapid-cycle process. This is a key fundamental "need to know" concept. 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. - ✔C. share unit-specific data on falls. characteristic of an effective team includes communication. 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. conduct a failure mode and effects analysis (FMEA). B. initiate the disciplinary action process. C. review the practitioner's qualifications and licensure. D. perform a root cause analysis. - ✔D. perform a root cause analysis. as exploration of a system and process issues should be primary in identifying root causes of error. Empowerment gives employees the opportunity to A. solve problems. B. make more money. C. gain respect of peers. D. achieve upward mobility. - ✔A. solve problems.

Empowerment is giving people autonomy and determination to enable people to overcome their sense of powerlessness and lack of influence, and to recognize and use their resources. 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 - ✔C. heart failure Physician champions are key in the development of clinical pathways. Heart failure should be prioritized because they not only have a champion but have data supporting the need for outcome improvements with LOS variance and a readmission rate of 10%. Which of the following sampling techniques selects participants based on their availability in a certain place during a specific time frame? A. quota B. random C. volunteer D. convenience - ✔D. convenience Selection based on convenience would help ensure selection based on time and place. 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? A. establishing criteria that are based on the most recent changes in medical science and technology B. using a computerized system to substitute data for missing responses C. assigning one staff member to identify, collect, enter, and interpret all data D. providing a practice-based definition and specific instructions for each element - ✔D. providing a practice-based definition and specific instructions for each element Data element definitions and instructions are essential in ensuring data validity and reliability. 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. - ✔A. integrated with clinical workflow. since staff at the line has to know how to use the tool with their daily work. When examining the relationship between staff and patient outcomes, which of the following is the most appropriate to assess? A. staff turnover and budget B. patient safety data and overtime data C. overtime data and absenteeism rates D. occurrence reports and sentinel events - ✔B. patient safety data and overtime data Using patient safety data and correlation to overtime data are appropriate indicators to identify a relationship between the two. Frequency distribution can best be displayed through use of A. a histogram. B. a flow chart. C. a force field analysis. D. an interrelationship diagram. - ✔A. a histogram. A histogram displays data in a bar chart by frequency distribution. 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. - ✔D. all recorded. Brainstorming is an idea generation tool intended to allow for all ideas to be considered without judgment, censoring, or prioritization. It is critical to the process that no ideas or participation is discouraged. All ideas should be recorded. A healthcare quality professional is conducting a study to determine how many patients contracted influenza despite receiving flu shots. This study is evaluating A. appropriateness. B. process. C. efficacy. D. prevalence. - ✔C. efficacy.

Efficacy measures the effectiveness or ability of the intervention (influenza vaccination) to achieve the desired results. 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 - ✔A. decreasing repeat tests when a patient is seen in more than one facility Decreasing the rate for repeating tests is the best way for a network to decrease cost and increase patient satisfaction. A valid data collection tool should incorporate A. a minimum of 20 data elements. B. a reliable graphic presentation. C. the definition of data elements. D. allowance for variance of interpretation. - ✔C. the definition of data elements. All data elements need to be defined to ensure data collection accuracy, reliability, and validity. Data collected about surgical cases shows significant delays. Further analysis shows the following chart: Which of the following should a healthcare quality professional do first? A. Perform a focused professional practice evaluation (FPPE) on every surgeon. B. Provide the service chief with further analyses of surgeon-specific data. C. Ask the nurse manager to write a memo encouraging promptness. D. Form a multidisciplinary team to develop recommendations for improvement. - ✔B. Provide the service chief with further analyses of surgeon-specific data. The quality professional should first notify the service chief so peer-to-peer feedback can be provided to the surgeon. 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 - ✔B. frequency, severity, and ease of detection these are the components of the criticality index. A staff member reports that a colon perforation occurred during a colonoscopy. Which of the following is a healthcare quality professional's next step? A. Review 100% of colonoscopy procedures. B. Refer the case for peer review. C. Modify the physician's privileges. D. Assign a proctor to the physician. - ✔B. Refer the case for peer review. It is a single episode which is appropriate for peer review. The phrase "reaching consensus" is often used in performance improvement. The term consensus refers to A. unanimous agreement. B. support by all members. C. everyone being totally satisfied. D. a majority vote of those present. - ✔B. support by all members. Consensus is general support from those concerned. Which of the following is always true regarding a sentinel event? A. The cause is established as a deviation from standards. B. The occurrence requires an immediate investigative response. C. The incident is a result of a medical error. D. The findings must be reported to a regulatory body. - ✔B. The occurrence requires an immediate investigative response. as a sentinel event should be as high a priority as a reactive response to a sentinel event. 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 - ✔B. organizational change

During times of significant change, it is critical to facilitate training on organizational change to set overarching organizational expectations and address culture changes before addressing quality teams, consumer expectations, or conflict resolution. When using cost-benefit analysis in decision-making, it is important to remember that A. consideration of the benefit is more important than cost. B. return on investment should be at least 10 to 1. C. implementation costs are more important than return on investment. D. qualitative and quantitative data should be used. - ✔D. qualitative and quantitative data should be used. In addition to quantitative data such as cost, qualitative information such as patient experience should be considered when performing a cost-benefit analysis. 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 - ✔C. flow chart a flow chart provides a picture of the separate steps of the labeling process in a sequential order When conducting a sentinel event review, a root cause analysis A. provides judgment of staff behaviors. B. identifies gaps in patient care processes. C. requires team consensus. D. proactively identifies causes and effects. - ✔B. identifies gaps in patient care processes. as a root cause analysis is a structured facilitated team process that identifies gaps in processes. The primary objective of the operational linkage between risk management and quality/performance improvement is to A. meet regulatory requirements. B. develop a plan of action for individual cases. C. develop a comprehensive plan to prevent future occurrences. D. alert the hospital attorney of a potentially compensable event - ✔C. develop a comprehensive plan to prevent future occurrences.

Expectation is to align quality and risk to address quality and safety activities. 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. - ✔D. organization's systems. The quality improvement concept focus is on systems and processes where individuals work, not individual performance. 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 - ✔B. scatter diagram A scatter diagram is used to depict the relationship between two variables. 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? A. gap analysis B. Ishikawa diagram C. Gantt chart D. Kanban method - ✔A. gap analysis Whenever there is an evaluation between current state and future state/requirements, gap analysis is the tool of choice. 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 handwashing technique.

C. near miss from failure to perform a 'time-out.' D. patient complaint regarding wait times. - ✔C. near miss from failure to perform a 'time-out.' this event should trigger further action by the Quality Council. A consulting firm has been selected by a healthcare Board of Directors to assess the quality improvement program. Before starting the assessment, the quality professional should first A. set up a project plan. B. develop potential action plans. C. define expectations and outcomes. D. design a dashboard. - ✔C. define expectations and outcomes. All answers could be done, however, expectations and outcomes should be established FIRST. 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. - ✔A. may present bias due to differences in reporting practices. Bias will be present if there are no standards for reporting. A patient safety program can best be enhanced by which of the following technologies? A. computers on wheels at the patients' bedsides B. barcode system for medication administration C. digital medication reference materials D. online evidence-based medicine guidelines - ✔B. barcode system for medication administration A technology that forces a double checking of patients against medication orders. Human factors engineering is defined as the study of humans and their interaction with A. the tools they use and the environment. B. medical technology and the organizational systems. C. adverse events and latent errors. D. patients and the organization. - ✔A. the tools they use and the environment. This is the most comprehensive definition of human factors engineering. Which of the following is used to summarize a characteristic in a population?

A. frequency distribution B. regression analysis C. case control study D. control chart - ✔A. frequency distribution A frequency distribution can be used to summarize data into categories; for example, we could summarize insurance type into Medicare, Medicaid and private insurance. Results of physician practice pattern studies are most likely to promote behavior changes when disseminated to the: A. practitioners. B. administration. C. governing body. D. quality committee. - ✔A. practitioners. Practitioners have vested interest in this information since the data is about them. Problem-solving, cross-functional understanding, expanded areas of expertise, and increased span of knowledge are examples of: A. strategic alliances. B. customer expectations. C. resource requirements. D. the benefits of teams. - ✔D. the benefits of teams. All of the above are key benefits of a performance improvement team 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' - ✔B. timely, open, two-way Best answer for leadership to have visibility and to promote engagement with staff. Which of the following obstetrical outcomes will result in a morbidity review? A. normal deliveries B. neonatal deaths C. post-delivery septicemia D. Cesarean sections - ✔C. post-delivery septicemia