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Effective Leadership Styles and Organizational Culture in Healthcare, Exams of Nursing

The various leadership styles and organizational cultures that can be effective in healthcare settings. It discusses the importance of gaining staff commitment, the characteristics of different leadership approaches (participatory, democratic, and laissez-faire), and the impact of federal regulations like emtala and hipaa on healthcare operations. The document also covers key quality improvement concepts such as accreditation, certification, conditions of participation, and performance improvement measures. By analyzing this document, students can gain insights into the complex interplay between leadership, organizational culture, and regulatory compliance in the healthcare industry. The information provided can be useful for understanding the challenges and best practices in managing healthcare organizations, as well as preparing for related exams, assignments, or research projects.

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Download Effective Leadership Styles and Organizational Culture in Healthcare and more Exams Nursing in PDF only on Docsity! CPHQ CERTIFICATION EXAM NEWEST ACTUAL EXAM QUESTIONS AND DETAILED CORRECT ANSWERS WITH RATIONALES (VERIFIED ANSWERS) | 2025 1. A hospital has implemented a quality program to improve the overall quality of patient care. It has discovered, however, that the program is running over budget, so the hospital administrative board conducts a review program to see if it should move forward with the program. What is the healthcare quality professional's role in this situation? A. Create a committee to review the quality program and develop a list of reasons to keep the program B. prove to the board that the quality program should continue C. assist the board in making a final decision about the quality program D. evaluate the financial benefits of the program and demonstrate these to the board Correct Answer D. Evaluate the financial benefits of the program and demonstrate these to the board 2. A hospital has discovered the performance of one of its departments is consistently below the expected standards. The hospital administration wants to locate the source of the problems to see improvement in the department within six months. What is the healthcare quality professionals role? A. Research the problems and develop a program that applies current standards to the department B. Recommend the hospital replace the current administration of the individual department C. advise a performance improvement team to be assembled to review and address the shortcomings D. review the expected standards and submit these to the department for immediate action Correct Answer C. Advisor performance improvement team to be assembled to review and address the shortcomings 3. A physician who has a high mortality rate compared to others in a facility should first be: A. counseled by the department chair person B. evaluated by the ongoing professional practice evaluation (OPPE) and focused professional evaluation (FPPE) committee C. suspended until further action can be determined in the interest of patient safety D. subjected to more in-depth review of cases Correct Answer D. Subjected to more in-depth review of cases 4. A healthcare quality professional has all the following responsibilities toward improving patient safety except: A. Helping develop a patient safety program B. Incorporating new technology into a patient safety program C. appoint a supervisor for a patient safety program 10. Which of the following is not one of the Institute for healthcare improvements (IHI) identified Triple Aims? A. Population health B. experience of care C. per capita cost D. joy of work Correct Answer D. joy of work 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. Correct Answer D. accreditation equivalency with a Centers for Medicare and Medicaid Services (CMS) survey. (Explanation: A. This is not necessary to pass a CMS survey to obtain deemed status. B. Deemed status has no relation with a surveyor's employment status. C. Deemed status is not related to physicians. D. CMS allows deemed status with meeting all conditions of participation requirements through Joint Commission Accreditation.) 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 Correct Answer D. governing body (Explanation: A. The quality improvement director has a key role in facilitation and operations of the QIPS program, but is generally not the ultimate responsible individual. B. Same as A; provides input and facilitates interactions between medical staff and operations. C. Same as A; provides input and facilitates interactions throughout the organization. D. This is the expectation of TJC and Centers for Medicare and Medicaid Services (CMS).) 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. Correct Answer A. facilitating self-assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda for the survey. EXPLANATION: A. These are essential functions for overseeing accreditation process. B. Writing survey reports is not in scope of the work, but the role of a surveyor. The other items could be part of their responsibility. C. Conducting unannounced surveys is not in scope of the work; that is a surveyor function. The other items could be part of their responsibilities. D. Developing standards is not a function of their work, but of the accreditation organization. The other items could be part of their responsibilities. 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. Correct Answer D. evaluated via a more in-depth review of cases. EXPLANATION: A., B., and C. These steps cannot be done until the physician is subjected to a more in-depth review. D. Required to make a determination based on quantity of cases and quality 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 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. Correct Answer C. Educate staff about the types of questions they may be asked. EXPLANATION: A. Survey process may involve all staff, so to assign certain staff might not be the best strategy. B. May be an element for survey preparation, but not the best answer. C. Best answer; survey process will involve all staff. D. May be an element for survey preparation, but not the best answer. 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. Correct Answer A. observed behavioral changes. EXPLANATION: All of these are methods to evaluate effectiveness of performance improvement training. However, observed behavioral change is the best method as it demonstrates transfer of knowledge into practice. 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. Correct Answer D. determining priorities among contributing factors. EXPLANATION: A. Pareto charts are more dynamic than just display of parts of a whole project. B. Pareto charts do not show trends. C. Pareto charts do not show cause and effect. D. Pareto charts most appropriately assist to determine priority using represented values. 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 Correct Answer A. performance indicators EXPLANATION: A. Performance indicators need to be reviewed for need for revision. B. Format is not related. C. Attendance does not tie back to indicators. D. Frequency is one of the concepts related to data collection, but not related to elements. 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 Correct Answer C. mortality rate EXPLANATION: A. This is a structure measure. B. This is a process measure. C. An outcome measure is used to determine how the system or improvement project impacts the patient. D. This is a process measure. 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. Correct Answer D. the number of records needed using a statistical method. EXPLANATION: A. This may not provide a relative sampling. B. Sampling is not correct. C. There is not enough data to determine if sampling is relative. and training are much more likely. Restraint equipment has been designed to be very safe when it is used correctly. When used improperly, restraint equipment can be deadly. It should be noted that most root cause analyses indicate problems in multiple areas. Which of the following procedures is NOT a good way to mitigate injury: A. maintaining a ready supply of antidotes to high-risk medications. B. simulation training. C. programming equipment to shut off in the event of a crisis. D. requiring employees to practice crisis response. Correct Answer C. programming equipment to shut off in the event of a crisis. EXPLANATION: Programming equipment to shut off in the event of a crisis is not a good way to mitigate injury. Equipment should be programmed to default to the least harmful setting, but in many cases shutting off is as harmful as operating incorrectly. For instance, a respirator should never default to an "off" position. All the other answer choices represent excellent strategies for mitigating injury. Which of the following is NOT part of the seven steps to the Kubler Ross Change Curve model? A. shock B. experiment C. anger Correct Answer A. anger All styles are important for different situations an organization may find itself in at any given point in time. Which of the following leadership styles is best when an organization is in crisis mode? A. autocratic B. empowering C. transactional D. transformational Correct Answer A. Autocratic Quality Assurance Correct Answer Measures compliance with standards Quality Control Correct Answer Process of ensuring products and services meet consumer expectations Performance Improvement Correct Answer Continuously improve processes to meet standards Quality Defect: Underuse Correct Answer Failing to provide medically necessary care or follow evidence based medical practice Quality Defect: Overuse Correct Answer Providing a drug or treatment without medical justification Quality Defect: Misuse Correct Answer Medical errors in the provision of care DEFECT: Wrong site surgery A. Underuse Failing to provide medically necessary care or follow evidence based medical practice B. Overuse Providing a drug or treatment without medical justification C. Misuse Medical errors in the provision of care Correct Answer C. Misuse DEFECT: Use of high tech imaging (MRI, CAT scan) when other diagnostic tests are sufficient A. Underuse Failing to provide medically necessary care or follow evidence based medical practice B. Overuse Providing a drug or treatment without medical justification C. medical justification C. Misuse Medical errors in the provision of care Correct Answer B. Overuse Vision Correct Answer •Future goal •Commitment to both internal and external customer supplier relationships •Short, sustainable, patient centered Mission Correct Answer •Reflects current state •Describes in broad terms organization purpose and role in the community •Based on data, program analysis and input from key stakeholders •Includes at minimum, commitment to quality, patient safety, patient care and need to serve the community Goals Correct Answer •Support vision and mission •Overarching direction •Intangible improve team communication; reduce falls; patient satisfaction, build trust •Developed for units, departments •Hard to measure Objectives Correct Answer •Specific, measurable actions or tasks taken to achieve goals •Include at a minimum: o Measurable o Timeline o Accountable party Data driven process Correct Answer External analysis of customer needs in relation to demographics and regulations Analytical process Correct Answer Internal services and functions SWOT analysis Correct Answer Strengths, weaknesses, opportunities, threats Revisions Correct Answer Mission, vision, goals, core values Ground it Correct Answer o Priorities o Goals o Objectives Safety Correct Answer patient, family, staff Communication Correct Answer clinicians, non clinicians Regulatory Correct Answer ongoing readiness Clinical quality measures Correct Answer quality programs Quality improvement Correct Answer evidence based practice Event tracking system Correct Answer Risk management Strategic goals Correct Answer •Use PI measures for business planning and resource allocation •Provide PI training By Laws Correct Answer •Establish relationship between medical staff and board •Develop priorities with physicians Management roles Correct Answer •Develop PI competencies •Empower staff and evaluate compliance Regulatory Correct Answer •Root cause analysis •Action plans Focused Professional Practice Evaluation (FPPE) Correct Answer Consistently implemented for all newly requested privileges Ongoing Professional Practice Evaluation (OPPE ) Correct Answer •Process that supports early detection and response to performance issues •Applies to all practitioners granted privileges •Oral or written report •Dissatisfied with quality or processes of care •Leader usually makes the final decision Correct Answer DEMOCRATIC LEADERSHIP •Leader exerts indirect control •Employees and teams make decisions independently •Leader has very little input in final decision Correct Answer LAISSEZ FAIRE (FREE REIGN) o Force field of driving and restraining forces o Remove restraining forces o Unfreeze old beliefs refreeze new beliefs Correct Answer Lewin Change Model o Seven key elements; start with leading change to anchoring change o Assess readiness and develop strategies to move toward readiness and "go" Correct Answer Palmer Change Model o Five stage model o Progress and revert at any time o Not a linear model various stages of change accept as is Correct Answer DeWeaver and Gillespie Change Model o Strong appreciation for human side o 10 stage model strategically or grassroots driven Correct Answer Galpin's Human Side of Change Model o Ensure people fully accept change o Incorporate change into their belief system o Change is associated with the heart and emotions Correct Answer Kotter's Heart of Change Model o Integrates individual behavioral change with organizational change o Six stages indicate individual's readiness to change behavior rather than process change o Works well with patients, individual staff members and providers Correct Answer Prochaska's Transitional Model o Narrow focus o My way or the highway o Short term outcomes Correct Answer Barrier to system change: Autocratic view o Unsure of ability to relearn new concepts, principles and procedures Correct Answer Barrier to system change: Failure to adapt o Superficial or weak solutions about difficult problems o Problems still exist Correct Answer Barrier to system change: Weak consensus o Nurse/doctor vs system and solution Correct Answer Barrier to system change: Identification with role rather than purpose o Us vs them o Closed to change Correct Answer Barrier to system change: Feelings of victimization o Already tried before o New direction requires new solutions Correct Answer Barrier to system change: Relying too heavily on past A physician who has a high mortality rate compared to others in a facility should first be: A. Counseled by the department chairperson B. Evaluated by the ongoing professional practice evaluation (OPPE) and focused professional evaluation (FPPE) committee C. Suspended until further action can be determined in the interest of patient safety D. Subjected to more in depth review of cases Correct Answer D. Subjected to more in depth review of cases To decrease costs, the hospital has hired outside consultants to perform many of its tasks. There are concerns the performance of many of the consultants does not meet the state's standards for the hospital's operation. What is the healthcare professional's role in this situation? A. Create simulated activities to test the consultants and see if they are meeting the standards B. Develop educational programs to assist the consultants and ensure the standards are met C. Assign the task to an uninvolved manager D. Refer the problem to the facility wide quality council Correct Answer B. Facilitate discussion between the groups to enable them to assume ownership of their portions of the problem A hospital has implemented a quality program to improve the overall quality of patient care. The program is running over budget, so the board conducts a review of the program to see if it should continue. What is the quality professional's role in this? A. Prove to the administrative board the quality program should continue in the hospital B. Assist the board in making a final decision about the quality program C. Create a committee to review the quality program and develop a list of reasons to keep it D. Evaluate the financial benefits of the program and demonstrate these to the board Correct Answer D. Evaluate the financial benefits of the program and demonstrate these to the board Which of the following processes is most cost effective in preventing unnecessary resource consumption in the hospital? A. Effective preadmission screening B. Accurate DRG assignment at admission C. Second opinions for all surgeries D. Preadmission insurance benefit denials Correct Answer A. Effective preadmission screening What are the reasons for evaluating the results of quality improvement training? A. To improve future training B. To determine whether participants' and organization's needs were met C. To determine whether current training should be continued D. All the above Correct Answer D. All the above Volatility in nursing workload is less likely to be reported than other sources of waste because: A. Nurses are unlikely to complain B. It can only be perceived using advanced metrics C. It is less observable D. It takes place infrequently Correct Answer C. It is less observable The primary reason to analyze customer satisfaction surveys is to: A. Provide data for the quality improvement program B. Meet pay for performance requirements C. Identify how perceptions relate to services provided D. Assist with evaluation of employee performance Correct Answer C. Identify how perceptions relate to services provided One important driver of patient dissatisfaction in health care over the past decade has been: A. Introduction of online services B. Lack of communication between physicians and patients C. Rise in income inequality D. Improvement of customer care in other service industries Correct Answer A. Introduction of online services Health Care Impact from this Federal Regulation: •Hospitals participating in Medicare and offering emergency services must provide a medical screening exam when requested for examination/treatment for emergency medical condition (EMC), including active labor, regardless of patient's ability to pay •Hospital is required to provide stabilizing treatment for patients with EMC's •If hospital is unable to stabilize a patient or request is made to transfer, appropriate transfer will be implemented Correct Answer Emergency Medical Treatment and Active Labor Act (EMTALA) Health Care Impact from this Federal Regulation: Protection of personal health information and provides patient rights Correct Answer Health Insurance Portability and Accountability Act (HIPAA) Health Care Impact from this Federal Regulation: Established quality standards for labs, regardless of where test is done Correct Answer Clinical Laboratory Improvement Amendments (CLIA) Recognition for meeting special qualifications in a field Correct Answer Certification A level of health care quality or attainment set by CMS for health care entities receiving reimbursement for Medicare/Medicaid patients Correct Answer CMS Standards: CoPs Conditions of Participation CfC Conditions for Coverage Granted by CMS to accrediting organizations, to determine on CMS' behalf, if an organization evaluated by an accrediting organization is following corresponding Medicare regulations Correct Answer Deeming Authority Mechanism to escalate crisis survey issues immediately to both state and federal agencies when the health and safety of individual(s) are at immediate risk Correct Answer Immediate Jeopardy Administrative remedies and actions (e.g., exclusion, civil monetary penalties) available to the Office of Inspector General to deal with questionable, improper or abusive behaviors under the Medicare, Medicaid or state health programs Correct Answer Sanctions When a complaint or grievance is found invalid by an organization, the complainant or griever asks for an impartial review of the decision from a third party Correct Answer Appeal A specific oral or written report of lack of satisfaction with quality of care or processes of care by a patient, guardian, or non union staff member; a written complaint is the first step in a civil or criminal court proceeding Correct Answer Complaint A formal written complaint about contract violation, quality of care, or financial issues by a union member Correct Answer Grievance An examination of one practitioner by a like practitioner who has similar training, experience, and expertise. A peer review is triggered by a root cause analysis that indicates the need to focus on an individual, sometimes related to utilization review Correct Answer Peer Review Designed for adult patients (18 and older) of hospital based emergency departments (ED) who are discharged to home (also known as "treat and release" visits), which account for about 90% of all ED visits Correct Answer Emergency Department Consumer Assessment of Healthcare Providers and Systems (ED CAHPS) as of 2020 voluntary First national, standardized, publicly reported survey of patients' perspectives of hospitals; the survey is an instrument and data collection methodology for measuring patients' perceptions of their hospital experience Correct Answer Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey mandatory Respectful care that is responsive to patient preferences, needs and values and ensures the patient's values guide all clinical decisions; meaningful interpersonal relationships honoring the whole person and family Correct Answer Person and family centered care Tool used at the start or "fuzzy front end" of any new product, process or service to better understand the customers needs and wants Correct Answer Voice of the customer (VOC) 5 HAI measures recalibrated PSI 90 score Correct Answer Hospital Acquired Conditions Reduction Program (HAC) •Results can be reproduced when the test is repeated under the same conditions •Reliable measure is not always valid Correct Answer Reliability •Measures exactly what it was intended to measure •Valid measure is generally reliable Correct Answer Validity Meaningful quality measures must be: C. Put strategy and vision at the center of an organization's effort D. Concentrate on the performance of individual units Correct Answer C. Put strategy and vision at the center of an organization's effort Benchmarking is based on identifying which of the following? A. Best practices B. Competition C. Deficiencies D. Statistical control Correct Answer A. Best Practices o Value of benchmarking •Better understand the competition and deficiencies using benchmarking data Relationship between two or more groups at different times Correct Answer Bar Graph Impact of independent variable on dependent variable Correct Answer Line Graph o Line graph or a trend chart that displays observed data in a time sequence Correct Answer Run Chart What percentage an item pertains to the whole o Display percentages of proportional relationships within a group you are trying to compare that add up to 100% Correct Answer Pie Chart 80% of effects come from 20% of causes Correct Answer Pareto Principle: 80/20 rule This variation type is known as "noise" and is managed by making changes and is removed through management Correct Answer Common Cause Variation This variation type is attributed to a single unusual circumstance. If you find it, remove it. Correct Answer Special Cause Variation Six or more consecutive data points all above OR all below the median Correct Answer Shift Seven or more consecutive data points in either ascending OR descending order Correct Answer Trend Eight or more similar fluctuations Correct Answer Pattern o Up and down variation, forming a sawtooth pattern with 14 successive data points o Suspect a systemic effect on the data o Common cause variation is shown as 4- 11 successive data points Correct Answer Cycle o Data point unrelated to other points o Sentinel event o Special cause variation Correct Answer Astronomical value: In evaluating long wait times, a quality professional can best demonstrate components related to staffing, methods, measures, materials and equipment by utilizing: A. Run chart B. Histogram C. Pie chart D. Ishikawa diagram Correct Answer D. Ishikawa diagram o Bar graph of how often of the frequency of which something happens. Because frequency is a continuous variable, there will not be gaps between the bars like in a bar graph Correct Answer Histogram o Shows the causes of an event o Each cause or reason for the imperfection is the source of a variation o Quality defect prevention, product design Correct Answer Ishikawa Diagram (Kaoru Ishikawa 1968) An emergency department trends wait times from patient to physician assessment data are reported using a run chart. Which of the following demonstrates a true statistical increase in treatment delays? A. Six consecutive ascending data points B. Seven consecutive descending points C. A zigzag pattern of 10 data points D. Data points close to the mean line Correct Answer A. Six consecutive ascending data points Several patients who received pacemakers in a hospital have complained that instead of feeling better, they feel o This challenging situation affects the patient outcomes. Consistently poor working conditions can be recognized as part of the variable outcome of patient care. In beginning and implementing a new initiative, a process champion should be selected. Which of the following is not a best process champion? A. People willing to work on an improvement effort B. Individuals who are ready and willing to move forward C. Any manager in the organization D. Physician champion Correct Answer C. Any manager in the organization All the following represent essential performance improvement measures in a health care facility EXCEPT: a. Evaluating productivity of employee activities against established standards b. Reviewing the effectiveness of technology that is applied within the facility c. Using historical data to consider the current outcome patterns of the facility d. Comparing the performance of the facility to that of similar facilities Correct Answer c. Using historical data to consider the current outcome patterns of the facility One consequence of the implementation of Lean Six Sigma practices in a hospital would be: a. Reduction of inventory b. The creation of systems for verifying orders c. Reduction in staff d. Reduction in manufacturing costs Correct Answer a. Reduction of inventory 3. To deal with volatile workloads, a lab creates a fast track for samples that need to be processed immediately. One common result of this strategy is: a. Average lead times will be reduced b. The lab will stop having bottlenecks c. Technicians will become confused d. The portion of samples placed in fast track will steadily increase Correct Answer d. The portion of samples placed in fast track will steadily increase 4. Before the start of a PI process, the health care quality professional should do all the following EXCEPT: a. Develop outcome measures to determine the results of the PI process b. Assist in developing projects for PI teams to complete during the process c. Create educational opportunities for employees and staff members to learn about and apply PI results d. Participate in establishing priorities for activities that will occur during the PI process Correct Answer C. Create educational opportunities for employees and staff members to learn about and apply PI results 5. Which of the following is the primary responsibility of the health care quality professional in linking risk management with overall PI goals: a. Complete a risk management assessment and integrate the assessment with PI activities b. Detail risk prevention activities and identify opportunities for refining PI goals c. Review major causes of risk in the facility and develop a PI program to reduce or eliminate them d. Assemble a PI team to address potential risk and present the administration with recommended changes Correct Answer a. Complete a risk management assessment and integrate the assessment with PI activities 6. A health care facility is pleased with the results of the teams the quality professional has facilitated. Employee productivity has improved and the facility would like to quantify the improvements. How might the health care quality professional assist in this process? a. Develop a plan for adding the PI findings and activities to employee evaluations b. Create a rewards hierarchy for each employee who participated in a PI team c. Generate an annual bonus plan that provides an incentive to employees who participated on a PI team d. Assist in sending personalized message to employees who were part of a PI team Correct Answer a. Develop a plan for adding the PI findings and activities to employee evaluations 7. To evaluate the activities of a PI team, the health care quality professional should do all the following EXCEPT: a. Create a training program for the PI team b. Offer feedback to the members of a PI team c. Analyze the productivity reports of a PI team D. The patient's right knee replaced after consenting to replacement of the left knee. Correct Answer administered to a patient in error. C. Details concerning a medication preparation error discovered and corrected prior to administration. Which of the following actions has the greatest impact in reducing harm? A. Revising the patient safety evaluation tool B. Improving inter-disciplinary communication C. Forming a performance improvement team D. Increasing data collection frequency Correct Answer B. Improving inter-disciplinary communication 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 counsel should review medication errors quarterly C. The process owner should implement and assess effectiveness D. Monthly reports should be sent to the regulatory body Correct Answer C. the process owner should implement and assess effectiveness 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 Correct Answer D. Potentially compensable event 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 Correct Answer A. Adverse drug events 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 Correct Answer C. Identify opportunities for improvements 1. In order to perform a task for which one is held accountable, there must be an equal balance between responsibility and: A. Authority B. education C. delegation D. specialization Correct Answer A. Authority 2. When the hospital leader ship team decides on strategy, the information should be shared with: A. Employees, patients and the community B. Employees only C. Employees and patients only D. No one Correct Answer A. Employees, patients and the community 3. Which of the following is not part of the seven steps to the Kubler Ross change curve model? A. Denial B. decision C. shock D. experiment E. anger F. frustration G. integration Correct Answer C. Shock 4. Leadership styles are often presented within the context of the approaches to decision-making and problem-solving as well as specific approaches used to influence change. All styles are important for different situations and organization may find it self in at any given point in time. Which of the following leadership styles is best when in organization is in crisis mode? A. Autocratic B. participative C. empowering D. transactional E. Transformational Correct Answer A. Autocratic D. availability of information. Correct Answer C. physical environment EXPLANATION: An RCA of inpatient suicides would be most likely to discover problems with the physical environment. Staffing levels, staff orientation, and the availability of information also may contribute to suicide, but the physical environment is much more likely to be involved. Of course, most root cause analyses reveal that there are multiple factors involved in incidents of patient suicide. If an at-risk patient is left unattended and has an adverse response to medication, this is known as a(n): A. sentinel event B. near miss C. initiator D. slip Correct Answer A. sentinel event EXPLANATION: An example of a sentinel event is an unattended and at-risk patient's adverse response to medication. A sentinel event is an adverse occurrence that is not in the normal progression of a patient's illness. The death of a patient from lunch cancer would not be considered a sentinel event, for example. However, an adverse drug event is considered a sentinel event, even if the patient is risk. Whenever a sentinel event occurs, the healthcare facility should perform an RCA. Refer to the following control chart: In assessing the timeliness for the administration of antibiotics for pneumonia, this control chart demonstrates: A. process improvement. B. no process improvement. C. evidence of a trend. D. evidence of an outlier. Correct Answer A. process improvement. A. Eight points below the control limit indicate a positive shift in the problem (special cause variation). B. See explanation for A. C. Based on statistical process control rules, this is a shift, not a trend. D. An outlier would either be above or below the control limits. 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 Correct Answer A. control chart A. Control charts exhibit points between control limits, therefore displaying the variation. B. Fishbone diagrams identify cause and effect of a problem. C. Force field analysis helps look at the project and analyzes all the reasons impacting a change. D. Pareto charts display and help determine priority. Which of the following graphs provides the best information for re-appointment/re-evaluation of an individual physician? A. Complications as a percentage of inpatient discharges. B. Total Complications. C. Total Discharges. D. Complications as a percentage of inpatient discharges (Compares physician to specialty) Correct Answer D. Complications as a percentage of inpatient discharges (Compares physician to specialty) EXPLANATION: A. This chart doesn't compare the physician. B. This chart doesn't compare the physician. C. This chart doesn't show data over time. D. This chart includes the best information to compare using time. 24. A hospital-wide medical record audit on documentation has been completed. The following table shows the compliance rate of documentation: • Compliance Rate (%) • Documentation: 1st Qtr 2nd Qtr • Surgical "time-outs" performed 90 95 • Communication of critical results 91 95 • Pain score used 50 60 • Initial patient assessment performed 52 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. Correct Answer D. Conduct a focused review on the patient assessment process. Explanation: 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. Correct Answer C. put strategy and vision at the center of an organization's effort. EXPLANATION: A. There may be some sort of visual display to highlight most significant strategic initiative, but the intent of the scorecard is to highlight multiple objectives of the organization. B. Not in scope of a balanced scorecard. C. 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. D. The intent is to have a visual display of the entire organization's progress, not individual units. 29. 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. Correct Answer C. contact Facility B to determine its practices. EXPLANATION: Facility A is aware their average is low. There is no reason for additional calculations. Decreasing rates is the result. Sharing best practices is encouraged for process improvement. Progress is not gained from focusing on competitors' rates. 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. Correct Answer C. designing solutions and controls. EXPLANATION: A. Cost-benefit analysis is not used for checking performance alone. B. Cost-benefit analysis is more financial in nature. C. Cost-benefit analysis allows for financial controls to be considered towards outcome achievement. D. Implementation would follow the cost-benefit analysis. 31. A healthcare provider recently conducted a customer satisfaction survey that focused on the five key quality characteristics in the graph below: By analyzing the information, the provider can identify that customers were most dissatisfied with A. cost and most satisfied with caring. B. communication and most satisfied with comfort. C. cost and most satisfied with communication. D. caring and most satisfied with cost. Correct Answer A. cost and most satisfied with caring. EXPLANATION: From the graph above, cost has the largest percent of customers reporting they are disappointed. Caring has the largest percent of customer reporting they are delighted. 32. 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. Correct Answer A. cohort study. A. Cohort study analyzes a group with a specific characteristic, such as cystic fibrosis. B. Regression analysis looks at the relationship among variables. This study is looking at a single variable: attitudes toward disease. C. Case-mix study is more definitive and would require more analysis of each case within the study. This study is looking at a qualitative measure and does not require a quantitative analysis. B. Staff members do not always check or know how to access records from areas outside their own practice. C. A lack of centralized information storage. D. Different computer systems do not communicate. Correct Answer All of the above. Using information to determine actions is the definition of A. data B. information C. decisions Correct Answer C. Decisions Data aggregated, displayed and analyzed for a specific purpose is the definition of A. data B. information C decision Correct Answer B. Information The two types of categorical data are: A.nominal & ordinal B. interval & ratio Correct Answer A.Nominal & Ordinal The two types of continuous data are A. nominal and ordinal B. qualitative and quantitative C. interval and ratio Correct Answer C. Interval and ratio Frequency distribution can best be displayed through the use of: A. An interrelationship diagram B. a force field analysis C. a flow chart D. a histogram Correct Answer D. a histogram It is not possible to estimate the probability that every element has been included is the definition of: A. Probability sampling B. non-probability sampling Correct Answer B. non- probability sampling Every element in the population has an equal or random chance of being selected is the definition of A. probability sampling B. non-probability sampling Correct Answer A. probability sampling Apply data to situations: how many patients had surgery this month? What data would you use for this situation? A. Categorical B. continuous Correct Answer A. Categorical Apply data to some situations: the patient's temperature was 103°F. He was medicated with Tylenol and his temperature came downTo 101°F. What data would you use for this situation. A. categorical B. Continuous Correct Answer B. Continuous All the following represent essential performance improvement measures in a healthcare facility except: A.evaluating productivity of employee activities against established B. reviewing the effectiveness of technology in the facility C. using historical data to consider the current outcome patterns of the facility D. comparing the performance of the facility to that of similar facilities Correct Answer C. Using historical data to consider the current outcome patterns of the facility One consequence of the implementation of lean six Sigma practices in a hospital would be A. reduction of inventory B. the creation of systems for verifying orders C. reduction in staff D. reduction in manufacturing costs Correct Answer A. reduction of inventory To deal with volatile workloads a lab creates a fast track for samples that need to be processed immediately. One common result of the strategy is A. average lead times will be reduced B. the lab will stop having bottlenecks C. technicians will become confused D. the portion of samples placed in Fastrack will steadily increase Correct Answer D. the portion of samples placed in Fastrack will steadily increase Before the start of a PI project the Health Care Quality Professional should do all of the following except A. develop outcome measures to determine the results of the PI project B.assist in developing projects for PI teams to complete during the project D taking part as a member of the PI teams Correct Answer C. removing members from the PI teams During a surgical procedure a small piece of medical equipment was left inside a patient and a second surgery was needed to remove the equipment. This is an example of A. quality improvement B. quality control C. quality assurance D. total quality Correct Answer C. quality assurance When considering the use of external subject matter expert which of the following is most critical? A. leaderships personal preference B. geographical location of the SME C. cost of the SME's services D. references of the SME Correct Answer D. references of the SME 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. the elimination of wasted blood C. improvements in documentation D. development of a new procurement procedure Correct Answer A. in-service on ordering blood usage for the physicians Quality improvement team development stages include all of the following except A. norming B. forming C. performing D. conforming Correct Answer D. Conforming When choosing an outside consultant to lead employee focus groups which of the following priority areas of expertise should've Health Care Quality professional look for? A. team development and management B. organization assessment and change management C group dynamics and facilitation D organization design and reengineering Correct Answer C group dynamics and facilitation 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 counsel 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 Correct Answer B. How well the team met the intended outcome 36. 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 Correct Answer A. performance indicators Explanation: Performance indicators need to be reviewed for need for revision. B. Format is not related. C. Attendance does not tie back to indicators. D. Frequency is one of the concepts related to data collection, but not related to elements. 37. Training is being determined based on treatment record review results. The following weighted results are available: Based on these results, which of the following areas should take priority for training? A. assessment B. external communication C. care plan D. progress notes Correct Answer C. care plan Explanation: When ranked by weight and non-compliance (weight*(100- %compliance)), care plan results in the highest weighted rank. 38. 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 C. Same as A; provides input and facilitates interactions throughout the organization. D. This is the expectation of TJC and Centers for Medicare and Medicaid Services (CMS). 41. 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. Correct Answer A. Support activities that improve outcomes and reduce variation. EXPLANATION: A. Best action since this will effect multiple domains within quality, including safety, effectiveness, and efficiencies. B. Impacts one domain of quality, but not all. C. Not impactful for quality. D. Not impactful for quality. 42. 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. Correct Answer A. observed behavioral changes. EXPLANATION: All of these are methods to evaluate effectiveness of performance improvement training. However, observed behavioral change is the best method as it demonstrates transfer of knowledge into practice. 43. 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 Correct Answer B. empowerment and training EXPLANATION: A. These are important roles to have, but not the best answer. B. This is the best answer. These are two key elements for ensuring success for the teams. C. May be a function or work of the team with the data analyst; there are no guarantees that these items will directly contribute to the success of the teams. D. The presence of these items are important, but not factors that will guarantee success. 44. 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. Correct Answer B. planning carefully, communicating openly, and leading effectively. EXPLANATION: A. Not the best answer. B. Best answer, these actions promote transparency and trust through communication and leadership. C. Policies will not help at this point. D. Not the best answer. The organization would have already completed the needs assessment and analyzed the result prior to the restructuring. 45. Which of the following are the first steps whenpreparing for an initial accreditation or certification survey of an organization? 48. 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. Correct Answer C. focuses on systems or processes. EXPLANATION: 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. 49. 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 Correct Answer B. improving interdisciplinary communication EXPLANATION: A. A safety tool may not be utilized constantly and accurately. B. Improved communication has been proven to be a key factor in reducing harm. C. Performance improvement items are not always focused on reducing harm. Other focus areas may be efficiency, financial, etc. D. Data collection does not reduce harm independently. 50. 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. Correct Answer A. redirect the team. EXPLANATION: A. Redirection is needed to move team back on topic and towards performance improvement effort. B. This would be done following meeting. C. This is not an applicable action. D. This should be done at the start of the meeting. 51.Would you use Categorical or Continuous data for the following situation: How many patients had surgery this month? Categorical Continuous Correct Answer EXPLANATION: A. CATEGORICAL Categorical - remember this is COUNT - and the two types of categorical data are (1) Nominal (2) Ordinal Continuous - remember this is MEASURED - and the two types of continuous data are (1) Interval (2) Ratio There are two types of data (1) Categorical and (2) Continuous. The distinction between categorical and continuous data is critical because quality performance improvement work involves both types of data and their associated statistics. It is one of the most significant sources of confusion for people new to quality performance improvement work and data analysis. 52. Would you use Categorical or Continuous data for the following situation: A patient's temperature was 103 degrees. You medicated with Tylenol and his temperature came down to 101 degrees. Categorical Continuous Correct Answer B. Continuous EXPLANATION: A. Categorical - remember this is COUNT - and the two types of categorical data are (1) Nominal (2) Ordinal B. Continuous - remember this is MEASURED - and the two types of continuous data are (1) Interval (2) Ratio There are two types of data (1) Categorical and (2) Continuous. The distinction between categorical and continuous data is critical because quality performance improvement work involves both types of data and their associated statistics. It is one of the most significant sources of confusion for people new to quality performance improvement work and data analysis. Pilot Data Collection; Verify and Correct Monitor Performance Correct Answer 57. True or False? There are two types of sampling. With Probability Sampling, every element in the population has an equal or random chance of being selected. A. True B. False Correct Answer True 58. True or False? There are two types of sampling, Probability and Nonprobability Sampling. With Nonprobability Sampling, it is NOT possible to estimate the probability that every element has been included A. True B. False Correct Answer True 59. There are three types of probability sampling types. The following scenario is an example of which probability sampling type? Put all names in a hat, pull one for a door prize. Hint: Each individual in the population has an equal chance to be chose Simple Random Sampling Systemic Sampling Stratified Random Sampling Correct Answer Simple Random Sampling 60. There are three types of probability sampling types. The following scenario is an example of which probability sampling type? Every Fifth Patient. Hint: After random selection of first case, draw every nth case from population Simple Random Sampling Systemic Sampling Stratified Random Sampling Correct Answer Systemic Sampling 61. There are three types of probability sampling types. The following scenario is an example of which probability sampling type? Patients with a particular disease. Hint: The population is divided into groups; each member of the group has an equal probability of being selected Simple Random Sampling Systemic Sampling Stratified Random Sampling Correct Answer Stratified Random Sampling