Question1: In an aging population, one of the challenges associated with the use of practice guidelines is
Question2: Care that does not vary in quality because of gender, ethnicity, geographic location, or socioeconomic status is said to be
Question3: Practice guidelines should be based on
Question4: Over the past 2 months, a trend has been detected in medication errors. The preferred method of presenting data to the nursing Quality Council will identify the nurse by:
Question5: Which of the following best represents an "unsafe condition"?
Question6: An orthopedic surgery practice has been working on Improving patient safety for the last 3 years. The following data table is available:
Which of the following Is the most appropriate conclusion about patient safety outcomes?
Question7: Based on the chart below, implementing which of the following technologies may have the greatest impact on reducing adverse events related to medication processes?
Question8: Which of the following is the strongest intervention for preventing medication safety events?
Question9: The primary reason to use a critical path is to
Question10: Choosing a small number of items to represent characteristics of the whole is an example of
Question11: A provider's Ongoing Professional Practice Evaluation (OPPE) profile is shown below. In this organization, if a provider partially meets or does not meet performance expectations, they are referred to peer review for a Focused Professional Practice Evaluation (FPPE).
Fully Meets: >80% of measures at threshold
Meets: 65% to 80% of measures at threshold
Partially Meets: 40% to 64% of measures threshold
Does Not Meet: <40% of measures at threshold
After reviewing this provider's overall profile, what should the healthcare quality professional suggest?
Question12: Secondary prevention IsPrimarilyIntended to
Question13: An organization Is Implementing a new electronic medical record and has employed a project manager. At the first meeting, the project manager observes the following:
* The team estimates It Is one-fourth finished with Identifying benchmark organizations.
* Team members have not yet begun to identify the current state.
- They are halfway through collecting public data, which puts them slightly behind schedule for that task.
Which of the following tools should the quality Improvement project manager recommend?
Question14: Identification of quality Improvement opportunities can best be Identified through
Question15: Which tool is used to identify, explore, and display the possible causes of a specific problem or condition?
Question16: When reporting infection control indicators to a governing body, a healthcare quality professional should demonstrate improvement with which of the following tools?
Question17: A Lean improvement concept that represents rapid improvement is
Question18: Analysis of the following wound infection rate control chart shows which of the following?
Question19: What tool displays performance outside of expected values to merit a deeper analysis?
Question20: A healthcare quality professional led a process improvement project to decrease the elapsed time for the stroke protocol. Which of the following tools will best help the quality professional to exhibit project activities and results?
Question21: An organization is shifting paradigms from top-down leadership to participatory management. The process of moving forward includes the four identified phases below:
gathering baseline data
evaluating effectiveness and improvement
making the commitment
implementing the program
Which of the following is the most logical sequence for these phases?
Question22: An organization notices an Increase In medication errors In threepatient care areas. Which ofthe following concepts will be most effective when Improving medication administration workflows?
Question23: A home health agency's Performance Improvement Committee has decided to base staff educational programs on aggregated occurrence report data. Due to budgetary and time constraints, not every area identified from the data can be addressed. Which of the following would be most useful to the committee in determining their educational targets?
Question24: A performance improvement team is looking at data from similar medical centers to improve patterns of care.
This method of assessment is known as:
Question25: A performance Improvement team has been meeting to examine delays in getting admissions from the emergency room to the nursing units. After six months of collecting data, the upper control limit was ISO minutes, and the lower control limit was 60 minutes. The next month's data shows a time of 155 minutes. The team should understand that this represents what type of variation?
Question26: A healthcare quality professional receives complaints from numerous patients that the registration process is inefficient. Which of the following should be used to best identify customer expectations, perceptions, and improvement opportunities?
Question27: Which of the following should the team do next?
Question28: Leadership at a facility reviewed and revised business process activities following staff layoffs. The activities were carefully planned, communicated, and implemented according to the plan. One year later, the business is stable but staff morale is very low. Based on the concepts of change theory, this is most likely due to:
Question29: Which of the following is a privacy breach according to HIPAA?
Question30: A provider's Ongoing Professional Practice Evaluation (OPPE) profile is shown below. In this organization, if a provider partially meets or does not meet performance expectations, they are referred to peer review for a Focused Professional Practice Evaluation (FPPE).
Fully Meets: >80% of measures at threshold
Meets: 65% to 80% of measures at threshold
Partially Meets: 40% to 64% of measures threshold
Does Not Meet: <40% of measures at thresholdAfter reviewing this provider's overall profile, what should the healthcare quality professional suggest?
Measure
Performance
Threshold
Direction
Timely Medical Record Documentation
95%
90%
Higher
Readmission Rate
13%
10%
Lower
Surgical Site Infection Rate
9%
5%
Lower
Use of Pre-procedure timeouts
100%
100%
Higher
Patient Experience Score (Top Box)
94%
80%
Higher
Clinical Pathway Adherence
81%
70%
Higher
Question31: A continuous survey readiness program requires which ofthe following?
Question32: To best achieve a low rate of harm in spite of inherent risks in healthcare, an organization must:
Question33: Medication reconciliation Is described as
Question34: An interdisciplinary learn met to review readmission rates at a health system. Issues were identified with communication across care providers. The team is interested in improving the coordination of care process and is now reviewing four candidates to serve in the role of process champion:
Of the four candidates, which represents the most effective choice to serve as a process champion?
Question35: A Pharmacy and Therapeutics Committee has reviewed the following control chart for presentation to a governing body:
Which of the following conclusions is most appropriate?
Question36: Which of the following is the best disease management approach to reduce hospitalizations for patients with high blood pressure?
Question37: The most important determinant of quality improvement success is
Question38: Which of the following is the best example of mistake-proofing?
Question39: The ultimate responsibility for ensuring and maintaining patient safety in a healthcare organization lies with the:
Question40: When analyzing nominal data, the quality professional uses a bar chart to display
Question41: An internal customer of the admission process in a skilled nursing facility is the
Question42: A pulmonologist is gathering social determinants of health data from their patients. Which of the following best explains the purpose of collecting this data?
Question43: The design of a piece of equipment contributes to an error. Which of the following types of errors has occurred?
Question44: Before patient outcome data can be used for benchmarking, the data should be
Question45: An organization wants to promote Six Sigma across its enterprise with all staff members having general exposure to Six Sigma methods. Which of the following best differentiates the role of the various belts?
Question46: A quality improvement team has been trained on writing SMART aim statements. Below are the team's aim statements:
* Reduce adverse drug events in critical care by 10% within 12 months.
* Reduce the time from 911 call to intervention for cardiac complaints by 15%.
* Reduce 30-day readmissions from 20% to 15%.Which of the following key elements in aim development appears to have been lost after the training?
Question47: While auditing a medical chart for breast cancer screening compliance using HEDIS, a quality professional questioned whether a patient's last screening fell within the lookback period. Where should the quality professional look to ensure compliance?
Question48: A department analyzed Its process for distributing paychecks to employees. The analysis showed there were multiple checkpoints tor approval, delays In processing of the checks, and errors that caused extra work for staff. Which of the following types of waste were identified during the analysis?
Question49: Which of the following payment systems carries the most financial risk for a provider?
Question50: Which of the following is most important to include in a project to reduce post-operative infections?
Question51: Based on the chart below, which of the following should be addressed first?
Question52: An ambulatory care practice has reviewed data to identify patients with multiple visits to the emergency room within the last six months. The population health management technique for this type of data review is called
Question53: A hospital wants to place increased emphasis on risk adjustment and cost as part of its innovation strategy.
The quality leadership team recognizes that in order to appropriately identify severity of illness, they will need to work with providers and the
Question54: A researcher decides to look at every fourth patient admitted each day and record if the IV is properly labeled, starting with a randomly selected patient. This is known as which of the following types of random selection?
Question55: Which of the following is the best strategy to increase a community's annual influenza vaccination rate?
Question56: A patient safety manager provided training on hand hygiene guidelines. The clinical manager Is confident that staff are following the guidelines. Which of the following Is the best method to evaluate the current compliance with the guidelines?
Question57: The chart below reflects the 12-week period following implementation of a new electronic health record (EHR) at an outpatient clinic.
Based on the information above, which of the following conclusions can be drawn?
Question58: During a recent code blue situation at an organization, there was a delay in administering the defibrillator's shock, A root cause analysis found the delay was due to the fact that defibrillator pads available on the unit were not compatible with the unit's defibrillator Which of the following applications of human factors engineering could have prevented this delay?
Question59: A pulmonologist is gathering social determinants of health data from their patients. Which of the following best explains the purpose of collecting this data?
Question60: What is the primary purpose of a balanced scorecard?
Question61: A healthcare quality professional identifies a statistically significant difference in uncontrolled hypertension between its African American and Caucasian populations. What is the next best step?
Question62: To maintain continuity, let's assume a question aligned with CPHQ domains, such as:
What is a key step in sustaining a performance improvement initiative?
Question63: Which of the following is an important characteristic of a performance indicator?
Question64: A team using the PDSA process is at the Study phase of the project. A quality professional assists the team by using which of the following tools?
Question65: A strategy to address social determinants of health would be to
Question66: The purpose of considering social determinants of health during quality improvement activities is to achieve
Question67: A healthcare organization has two years of data on infection rates by month. Which of the following process tools would be best to use for analyzing this data?
Question68: A quality Improvement team has Identified specific changes to Implement for a quality Improvement Initiative. As the next step, the team would like to establish a concrete timeline for implementation. Which of the following is the best tool to use for this step?
Question69: A healthcare quality professional Is facilitating the establishment of a Quality Council for an outpatient surgery center. The following positions have been selected for membership: medical director, CEO. and CFO.
Which of the following Is the most appropriate Individual to add?
Question70: The following hospital Medicare readmission findings are available:
Based on the provided information and an understanding of factors that drive readmissions, the hospital should first
Question71: Which initiative should a quality professional promote in an organization seeking to optimize value-based reimbursement?
Question72: An organization with a focus on population health may use data to
Question73: Data from an incident reporting system compares incident rates for one facility to similar facilities:
After reviewing the graph, which of the following should be done first?
Question74: An organization Is tracking Infection rates to determine the benchmarks for the next fiscal year. The team Is analyzing the data for Infection rates. Which key variables are missing to interpret the graph?
Question75: A patient sustained a skull fracture as a result of an attack by another patient. A risk manager initiates a root cause analysis. Which of the following is the intended outcome of the investigation?
Question76: Multi-voting Is frequently usedinwhich of the following steps of the quality Improvement process?
Question77: Which of the following is an example of collaboration for optimal care transitions?
Question78: Which initiative should a quality professional promote in an organization seeking to optimize value- based reimbursement?
Question79: A Quality Council has received the following requests for establishing performance improvement teams:
* Maintenance: Overtime reductions
* Dietary: Meal delivery process
* Housekeeping: Room turnaround times
* Biomedical: Identification of malfunctioning equipment
* Human Resources: Competency assessments
Which of the following should the Quality Council do first?
Question80: During which phase of DMAIC does the quality manager decide which priorities to focus on?
Question81: An increased number of outpatient surgery patients present to the emergency department with complaints of pain. Which would be the best strategy to address these occurrences?
Question82: Risk management identified claims for events that were not reported through the incident reporting system.
Which of the following actions should be leadership's initial priority?
Question83: An organization should establish a cross-functional quality improvement team when
Question84: Which of the following actions best illustrates an organization has begun the work necessary to achieve the Malcolm Baldrige Award?
Question85: Over the past 2 months, a trend has been detected in medication errors. The preferred method of presenting data to the nursing Quality Council will identify the nurse by
Question86: Leadership at an outpatient multi-specialty clinic is working toward becoming a high-reliability organization.
In the past week, there have been three medication errors with high-risk medications in the procedure area.
Which of the following responses by leadership is consistent with high-reliability principles?
Question87: Which of the following is a social determinant of health?
Question88: A facility Is reviewing their quality program for compliance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. Which of the following Is the most Important factor in program compliance?
Question89: A hospital's leadership team has asked the quality professional to review alternative accreditation options for the organization. The quality professional recommends the:
Question90: A hospital Is anticipating an accreditation survey In the next four months, and the quality director forms a team to ensure compliance with current requirements. This indicates the hospital Is
Question91: Recognition of the formal and informal structure of an organization is necessary when implementing a quality improvement program because
Question92: Following evaluation of the compounding process used by a pharmacy, the batch compounding consistently yields 12% more drug than Is needed. The excess Is stored until used or expired. Which of the following types of waste should be recorded when reporting this finding?
Question93: Key stakeholders for process improvement are selected during which phase of the Plan-Do-Study-Act (PDSA) model?
Question94: Which of the following is one purpose of clinical pathways?
Question95: A team wants to select a group of patients to measure satisfaction with care. Which of the following is an example of probability sampling?
Question96: The performance improvement team developed a prioritization matrix based on the identified improvement opportunities. Based on the information below, what would be the first improvement effort implemented?
Question97: A national health plan has recently acquired a local health plan. At the year anniversary of the merger, the - local health plan staff still struggles with the transition to the new organizational values. Which of the following Is the most likely explanation for the difficulty?
Question98: An ambulatory pulmonary division is in the finalphase of a DMAIC project. The division head asked the team to present the performance of the project. Which chart demonstrates that change has occurred over time and the process has limited variation?
Question99: An interdisciplinary team met to review readmission rates at a health system. Issues were identified withcommunication across care providers. The team is interested in improving the coordination of care process and is now reviewing four candidates to serve in the role of process champion:
Of the four candidates, which represents the most effective choice to serve as a process champion?
Question100: Six months after implementing a new cardiac rehabilitation program, an organization notes many patients that meet criteria are not enrolled. Which of the following is the most effective strategy to increase the enrollment rate?
Question101: Cold-spotting involves identifying populations that
Question102: To assist a primary care physician to improve their performance on a pay-for-performance program, the quality professional should begin with
Question103: During the course of a root cause analysis, the team found the following Items contributed to the error:
* Fatigue and stress leading to Inattention
* Pressure to accomplish more tasks In the same amount of time
* The equipment was designed for right-handed staff
Which of the following best describe these types of causes?
Question104: In reviewing information offered by the Agency for Healthcare Research and Quality (AHRQ), the quality improvement (QI) specialist recognizes that the three broad aims pursued by the National Quality Strategy are
Question105: Leadership is trying to set SMART goals as part of the annual quality plan. Which of the following meets this framework?
Question106: A healthcare quality professional has been asked to evaluate the integrity of the data used for physician scorecards. When the data abstractors are asked to review physician A's charts, they each report back conflicting information on the physician's performance. The results are as follows:
Abstractor 1: Compliance = 85%
Abstractor 2: Compliance = 75%
Abstractor 3: Compliance = 100%
This most likely indicates a problem with
Question107: Using the data below, which issue would be identified as a priority for further performance improvement?
Issue
High Risk
High Strategic Priority
Cost
Customer Satisfaction
Quality Concern
Pressure Injuries
4
4
1
4
5
Medication Errors
3
1
2
1
5
Transfer to Higher Level of Care Within One Hour of Admission
2
5
4
1
3
Miscommunication of Abnormal Findings
4
3
5
1
4
Question108: A quality professional is leading a team that was recently formed to identify ways to decrease length of stay.
The team members have started arguing with each other over whose approach is best. Each team member thinks the team should focus on a different part of the patient journey first, and members are not listening to each other. Which of the following should the team leader do?
Question109: Which of the following Is an essential stepinthe strategic planning process?
Question110: A quality improvement coordinator is asked to develop a training session on team facilitation based onadult learning principles. Which of the following would be the best approach to include?
Question111: An employee health program includes a pre-employment health assessment for all prospective employees.
The assessment is to be completed, and the results known prior to the assumption of duties. A retrospective study of 200 employees resulted in the information displayed in the following chart:
Review of this information indicates which of the following?
Question112: The following data are known:
Which ofthe following accurately describes this chart?
Question113: Education sessions were held to improve bar code medication administration (BCMA) performance. Six months after completion of education, an analysis showed continued BCMA improvement. What is the key to sustaining this improvement?
Question114: When recommending a quality improvement project, the quality professional must first consider
Question115: When allocating limited resources to meet strategic objectives, management decisions should be driven by
Question116: Which of the following best describes how a quality professional should conduct an organizational assessment to ensure safe transitions of care?
Question117: Annual evaluation of a quality Improvement process must
Question118: A quality professional Is the leader of a teaminthe storming phase of development Which of the following should the quality professional be prepared to do?
Question119: The primary objective of the project charter is to
Question120: A quality professional was asked to assist with strategic planning. Which of the following should have the primary impact on the quality and performance improvement goals?
Question121: A physician's profile shows a 4%readmissionrate following outpatient gallbladder surgery, which Is significantly higher than the rate for their peers.
What action should the quality professional take next?
Question122: A goal of measurement is to collect valid and reliable data that reflects
Question123: A physician challenges the number of healthcare-acquired infections reported for orthopedic surgery. Which of the following will be most effective in demonstrating the validity of the information?
Question124: A performance improvement coordinator is having difficulty keeping a new team focused on its goal of decreasing patient waiting times. To understand why the team process is not working, the team leader should initially assess the
Question125: Anemergency department's quality improvement report for the first quarter showed the following data:
What was the approximate overall problem rate for March?
Question126: Data for an organization's annual Influenza vaccine administration yields the following results:
What is the median for the organization's annual vaccine count?
Question127: A healthcare organization has recently launched a diabetes center of excellence to address the needs of its patients with advanced diabetes. The implementation of this program would fall into which of the following types of prevention?
Question128: An outbreak of measles in a school district resulted in 58 cases over a period of 5 months. Which of the following data displays best illustrates the occurrence of student measles by month?
Question129: A study was performed to compare quality outcomes between case/care managed groups and non-case/care managed groups tor elective coronary artery bypass. The results are as follows:
What is the median length of stay (or non-case/care managed patients?
Question130: Which tool would be best suited to sequence interventions within a project?
Question131: Which of the following is the best example of population health management?
Question132: Which of the following is the best example of applying cultural diversity principles to patient safety?
Question133: A surgeon left a sponge in one patient, resulting in a multi-million dollar lawsuit. The organization immediately changed the operating room procedure so that after every surgery, patients receive an x-ray before leaving the operating room. Which of the following should the organization have done prior to changing the procedure?
Question134: A recent Journal article has Identified three new patient safety Initiatives. When reviewing these Initiatives, the first action of a healthcare quality professional Is to
Question135: Senior leaders of a managed care organization have consulted a healthcare quality professional on the purchase of a clinical data management software system to support performance improvement. Which of the following should be considered first?
Question136: The quality Improvement (Ql) specialist recognizes that any documents related to medical peer review are
Question137: Complaint analysis is most useful in identifying which of the following?
Question138: A nursing director for a unit in a cancer hospital Is reviewing and assessing outcomes data in the followingscatter diagram:
The relationship between the incidence of infection and the decrease in staffing targets is
Question139: When reviewing the outcome measures of five regional psychiatric centers, variables such as illness severity, comorbid psychiatric and medical diagnoses, and substance-use issues are identified. Which of the following methods best controls for these variables?
Question140: Which of the following tools is most useful for an organization to complete prior to implementation of a new device for administration of intravenous chemotherapy?
Question141: Which of the following is the best way to evaluate the success of a performance improvement team?
Question142: A new pediatric psychiatric unit will open in one year. The utilization coordinator is responsible for developing the utilization management program. The program's success will depend on which of the following factors?
Question143: Which of the following is a social determinant of health?
Question144: Which of the following is an example of addressing a social determinant of health to improve outcomes in patients with type 2 diabetes?
Question145: A consistent and effective communication plan for a process improvement initiative facilitates
Question146: The consensus-building group of diverse stakeholders who reviews and endorses measures for public reporting in the U.S. is known as the
Question147: An organization has Implemented a quality improvement project. The goal is a mean compliance rate of 90%.
The results of observations are found in the table below:
Which focus area presents the greatest opportunity for the organization?
Question148: A multi-disciplinary team meets with the goal of reducing Infections In an ambulatory surgery center The group Is struggling to gain focus and come to agreement completing an Ishlkawa diagram. What Is the most likely cause for this challenge?
Question149: When developing objectives for an educational program, the quality professional should recommend
Question150: A positive correlation is seen in a scatter diagram when
Question151: Which of the following is an example of a structural measure?
Question152: A CEO and chief nursing officer have requested a new quality initiative to reduce patient falls. One of the first steps in starting this new quality Improvement Initiative should include
Question153: Which of the following is essential for effective functioning of a Quality Council?
Question154: Who is responsible for aligning resources and ensuring accountability in an improvement project?
Question155: Which of the following would be the best methodology to reduce referral wait time?
Question156: After in-depth data analysis, there is evidence of overutilization of computerized tomography to diagnose acute appendicitis. A team has been formed to develop a performance improvement plan for emergency department physicians. Which of the following leadership styles is most effective to implement best practice guidelines?
Question157: When implementing a new process or procedure, which of the following tools should be used to anticipate and prevent potential problems?
Question158: An organization Is looking for a creative approach at Improving heart failure outcomes to reduce readmissions. Several clinician's express concerns that nothing can be done to Improve this. Two clinicians recommend a set of clinical practice guidelines recently developed by a specialty organization. Which of the following would the two clinicians be considered?
Question159: Organizations with a positive safety culture are best characterized by
Question160: An organization has a goal to increase profitability of services covered under bundled payments. Which of the following aspects of quality should a healthcare quality professional recommend as a starting point for an analysis?
Question161: A physician, who is not a member of the peer review committee, requests the minutes of the last peer review committee meeting. The healthcare quality professional should respond to this request by:
Question162: In a regression analysis, which of the following is the best description of a dependent variable?
Question163: Which of the following tools depicts a sequence of events in a process?
Question164: Where in the process of ensuring correct surgery does a "time-out" take place?
Question165: Benchmark is a term used to describe
Question166: A home healthcare organization is looking to identify third-party endorsed outcome measures for the following areas:
* improvement in medication management
* improvement in ambulation
* improvement in painWhich organization can best provide this information?
Question167: A quality improvement professional believes that their MRSA facility rates are high. What should the quality improvement professional do first?
Question168: The quality improvement program is effective when the organization
Question169: A healthcare quality professional is looking at a control chart and notices that last November the number of admissions for flu symptoms exceeded the upper control limit. This most likely represents:
Question170: Which of the following strategies promotes timely completion of a quality improvement project?
Question171: An organization is implementing a palliative care unit. As part of the planning and implementation processes, the board authorizes the following:
* Learning visits with existing programs to obtain information about best practices
* Formal training of all staff assigned to the unit in the principles of palliative care
* The development of a balanced scorecard to monitor program performance The actions of the board best illustrate
Question172: Which of the following is a primary intervention for type 2 diabetes?
Question173: The main goal of a clinical pathway/guideline Is lo
Question174: A director at a large health system is tasked with building a new population health program. What is the director's first step?
Question175: In recent months, the amount of time It takes for Insurance claimsto be submitted has increased significantly, resulting in the hospital not being paidina timely manner. Which of the following Is the quality professional's best course of action?
Question176: A healthcare system has multiple medical clinics across a large geographic area. What is the best way to deliver education to assure continuous survey readiness?
Question177: Which of the following elements of an audit for a primary care office provides information about patient safety?
Question178: The preferred culture in promoting patient safety
Question179: Patient complaints have been received regarding appointment time delays. Which of the following should be completed first?
Question180: The office manager of a primary care office reviewed the performance of the providers and noted that one provider has not been completing depression screenings consistently for patients in the previous month. The manager's next action is to:
Question181: A health system successfully recruited patients to participate in a newly launched smoking cessation program, but attendance at follow-up visits is low among the Hispanic/Latino community. Which of the following interventions would benefit the program?
Question182: Which of the following regulatory agencies oversee development of electronic clinical quality measures (eCQMs)?
Question183: Which of the following data sources can be used to assess a population's health status?
Question184: Even when appropriate processes areinplace, errors can occur. Understanding this, leaders coordinating a patient safety program should focus on
Question185: A healthcare quality analyst compiles and analyzes data to facilitate performance improvement opportunities.
The most suitable data review to proactively control cost would be which type of review process?
Question186: The health quality professional recognizes that which of the following events should be reported to regulatory or accreditation organizations?
Question187: The most important determinant of quality improvement success is
Question188: A healthcare quality professional Is assisting an organization with evaluating patient safety actions that will prevent errors of omission. Which of the following systems will most likely be effective?
Question189: Which of the following is an example of active surveillance?
Question190: Prior to the implementation of a new electronic health record (EHR), a facility charters a failure mode and effects analysis (FMEA) team. After mapping out the process for creating a new patient chart, the next step should be to:
Question191: The benefits of performing a community health assessment include
Question192: Four surgical centers formed a collaboration to reduce post-operative infection rates. The goal was to reduce infection rates by 20% from baseline.
Which center met the goal?
Question193:
Question194: A hospital quality team notices there is an increased number of falls in the inpatient stroke unit. Which of the following is the best method to analyze the issue?
Question195: Which of the following is the best example of a non-value added step in the healthcare environment?
Question196: A quality professional's key role in a performance improvement team is to serve as a:
Question197: A performance improvement team has been examining delays in getting admissions from the emergency department (ED) to the coronary care unit. The team has collected data and determined that a significant number of delays are occurring because cardiologists are not consulting on their patients in the ED in a timely manner. The best way to communicate this information to the cardiologists is to:
Question198: Which of the following is most relevant to addressing social determinants of health?
Question199: Which of the following tools aids decision-making through organizing tasks, issues, or actions based on agreed-upon criteria?
Question200: Using clinical guidelines based on scientific evidence will most likely
Question201: A quality professional is leading a rapid process improvement event to reduce central line infections. Which of the following actions should be taken?
Question202: A quality professional is creating a training session for clinical leaders about quality improvement. Which of the following should be incorporated into the training?
Question203: In an improvement project to improve clinic flow, a spaghetti chart is best used to:
Question204: Which of the following technology enhancements will help the hospital most accurately identify hospital- acquired condition rates?
Question205: The quality improvement (QI) specialist recognizes that any documents related to medical peer review are:
Question206: A healthcare quality Improvement team is working on an action plan to address medication system defects.
Based on the data from the chart below, what would be the next step?
Question207: The data below shows 30-day readmission rates for heart failure patients by the primary language spoken and by gender with 95% confidence intervals in parentheses. Which group should be the priority target for reducing disparities in readmission rates?
Question208: Which of the following characteristics are most appropriate for a physician champion of healthcare quality?
Question209: A CEO has directed a quality improvement council to develop objectives to meet an identified goal. When developing objectives, the council must remember to
Question210: A healthcare organization had three medication incidents associated with narcotics. None of the events led to permanent loss of function or death, but could be considered near misses. Which of the following would be the best tool to use to identify influencing factors?
Question211: Team effectiveness can best be evaluated by
Question212: The strategic plan for an organization calls for expansion of information technology. The following information is available:
If equal weight is given to each consideration, which of the following options should be the primary choice?
Question213: Which of the following identifies project deliverables as well as periods with simultaneously occurring activities?
Question214: Which of the following actions will best promote organizational efficiency in managing quality improvement projects?
Question215: Which of the following leads to better population health management in older adults with chronic conditions?
Question216: An electronic medical records system was implemented in a department. Which of the following is the next step?
Question217: To gauge community perceptions regarding a hospital's response to a pandemic, the healthcare quality professional uses a random number generator to select 1,000 phone numbers and collect survey responses from the first 300 of those phone numbers where the call is answered. All calls are made between 9:00 am and
5:00 pm. This data collection approach is limited because:
Question218: When prioritizing quality improvement initiatives, which of the following should take the highest priority?
Question219: Accountability for quality ultimately rests with the
Question220: An example of a clinical care process measure is:
Question221: Reviewing organizational priorities, addressing regulatory requirements, and identifying goals for the next year are important components in the development of which of the following?
Question222: A provider requests to see the peer review file on another provider in their department. What is the healthcare quality professional's most appropriate response?
Question223: A patient safety program can best be enhanced by which of the following technologies?
Question224: A clinic is implementing a new medication dispensing system. The vendors of three products are on site with staff interacting with the products prior to purchase. Which of the following best describes this type of safety intervention?
Question225: In addition to being a good communicator, an essential characteristic of a quality champion is:
Question226: An organization has implemented a quality improvement project. The goal is a mean compliance rate of 90%.
The results of observations are found in the table below:
Which focus area presents the greatest opportunity for the organization?
Question227: Infection control risk assessments are performed to
Question228: Which of the following is most effective to sustain knowledge gained from performance improvement training?
Question229: The purpose of patient safety goals is to
Question230: An organization has compiled the scatter plots below:
Based on these plots, which of the following conclusions can be made by the quality professional?
Question231: The quality director would like to prepare the team for the upcoming accreditation survey. Which of the following would ensure continuous team survey readiness?
Question232: Which performance improvement tool best evaluates care processes and transitions?
Question233: An organization's nursing units report the following needlestick injuries:
Unit
# Needlestick Injuries
# Admissions
A
2
1,000
B
12
800
C
5
752
Which response by leadership demonstrates a culture of safety?
Question234: The control chart above indicates which of the following?
Question235: A Pareto chart can be used to
Question236: Members of a performance improvement team voice complaints about not having as much decision-making authority as they expected. Which of the following should be developed to decrease the likelihood of such complaints?
Question237: Which of the following Is the best example of effective learning in a learning organization?
Question238: Which of the following technology enhancements will help the hospital most accurately identify hospital- acquired condition rates?
Question239: A 300-bed healthcare organization has decided to apply for accreditation with a new accreditation body. The accreditation readiness coordinator should first
Question240: Which of the following is a key component in establishing a comprehensive populationhealth management program?
Question241: A Rapid Process Improvement Team began a new process on January 7 to reduce targeted events per bed day outcome. The team asked the quality analyst to help determine whether the new process was successful and should be continued. Based on the control chart the quality analyst produced, which of the following is the best conclusion?
Question242: Which of the following approaches best allows an agency to align Its activities with organizational goals?
Question243: A local health center is launching a community health assessment. What data is recommended to identify the potential needs of the population?
Question244: Which of the following is the most proactive approach to quality improvement?
Question245: Establishing a culture of safety begins with having the right
Question246: An effective meeting requires which of the following?
Question247: Which of the following is true of a clinical pathway?
Question248: Which of the following best describes the goal of the Healthy People Initiative?
Question249: Which of the following Is an example of active surveillance?
Question250: A hospital has just implemented a physician order entry system. Three days into implementation, the users begin having major technical issues with the system. The nurse manager instructs staff to submit troubleshooting requests to the help desk. This is an example of which high-reliability principle?
Question251: A surgeon has a surgical site infection rate of 6.7% for a particular procedure. The average infection rate for other surgeons performing the same procedure at this facility is 3.3%. After notifying the department chair of this situation, the quality professional should recommend
Question252: Which of the following actions demonstrate an organization working towards a just culture?
Question253: The most important component of a successful performance improvement program is:
Question254: Which of the following is the quality professional's first step prior to implementing a new infection prevention protocol in the clinic?
Question255: Priorities must be established for selecting processes for quality improvement because
Question256: A hospital received 50 Incident reports describing falls that occurred within aone-monthperiod. Which of the following actions should be taken?
Question257: An organization recently lost its deemed status due to non-compliance with grievance process regulations.
Which of the following standards would the quality professional research to identify grievance process requirements to correct the cited opportunities for improvement?
Question258: The collection, analysis, and Interpretation of data for planning, Implementing, and evaluating health programs is
Question259: After a sentinel event, a root cause analysis (RCA) is performed. Which of the following should be included in the RCA?
Question260: Which of the following measures would best evaluate the health of a metropolitan area?
Question261: Which of the following represents a medically underserved population?
Question262: An organization has established an ambulatory diabetic management program. Which of the following will best define a successful outcome of the program?
Question263: Which of the following is true regarding critical values?
Question264: Based on the data below, which unit should the quality Improvement coordinator focus on?
Question265: Which of the following approaches to training for a new quality and performance improvement initiative is most likely to succeed based on adult learning principles?
Question266: Several leaders in a healthcare facility have differing opinions regarding the pursuit of alternative certifications and recognitions. The Chief Quality Officer (CQO) has opted to retain an external quality consultant to determine relevance, appropriateness, and readiness for an alternative certification. The most appropriate role for an external consultant is to
Question267: Which of the following is the best tool to report process improvements to a quality committee?
Question268: A hospital has been experiencing a significant Increaseinthe number of medication errors. The hospital's governing board has adopted barcoding technology with electronic documentation at the point of care. Which of the following medication errors will most likely be reduced by the Implementation of this technology?
Question269: A quality professional needs to select a new project from a list of requests. An organization has determined that new projects should focus on patient safety and cost-reduction. Which tool would help Identify the project that best meets these criteria?
Question270: During development of a clinical pathway, a quality professional should
Question271: Which of the following is the key responsibility of a healthcare quality professional in all types of facilities and organizations?
Question272: Physician and nursing director compensation for a busy emergency department is tied to aggressive door-to- disposition times. Staff workarounds save time but have increased the potential for errors. Which of the following best describes this situation?
Question273: Ongoing practitioner practice evaluation (OPPE) Is used for which of the following?
Question274: A root cause analysts (RCA) was conducted tor an event related to a delayed high-priority alarm response.
Alarm fatigue was determined to be a root cause. Which of the following Is the most appropriate first Intervention?
Question275: A long-term care facility Is Interested in analyzing data to determine If there Is arelationship between the number of medications residents are prescribed and the number of falls the residents experience. Which of the following quality tools Is most appropriate to help the long-term care facility understand the data?
Question276: A risk manager comes to thequality improvement (QI) professional and requests help to improve compliance with a corrective action plan. How can the QI professional help?
Question277: A focused professional practice evaluation (FPPE) Is Initiated
Question278: The median is defined as the
Question279: Refer to the below medication administration audit:
Patient
Medication administered within 1 hour
Was the correct dosage of medication administered?
Were patient allergies confirmed prior to medication administration?
Was medication administration documented in the patient's record?
Did the patient experience an adverse medication reaction?
A
Yes
Yes
Yes
Yes
Yes
B
Yes
Yes
No
Yes
Yes
C
No
Yes
Yes
Yes
No
D
Yes
Yes
Yes
No
No
Which patient's record should the quality professional investigate first?
Question280: To determine the success of a transfusion quality improvement project, a healthcare quality professional should:
Question281: When compared to the scientific method, which of the following activities is unique to the quality improvement process?
Question282: An initial step to address health disparities within a population is to:
Question283: The upper and lower limits on a control chart are:
Question284: Population health care management programs are designed to
Question285: Which of the following Is the best approach to prepare care team members tor Interacting with accreditation surveyors?
Question286: A skilled nursing facility has implemented a process to address delays in diagnostic test result availability to the ordering provider. Which of thefollowing measurements will best document improvement in this process?
Question287: Prior to discharge, which of the following provides patient information to improve education for heart failure patients?
Question288: Which of the following statements most accurately describes health literacy?
Question289: A key concept in patient safety planning is to design procedures that
Question290: Which of the following is a healthcare quality professional's key responsibility for supporting organizational quality governance?
Question291: The quality manager needs to identify a set of process measures to improve wound care outcomes. The first step should be to
Question292: X quality professional is reviewing medication adherence data for patients with type 2 diabetes. Based on the table below, which neighborhood should be prioritized for additional interventions?
| Percent of Patients with Type 2 Diabetes Not Taking Medications for 30+ Days | | --- | --- | | Neighborhood | Year 1 | Year 2 | | A | 5% | 10% | | B | 43% | 42% | | C | 20% | 40% | | D | 38% | 44% |
Question293: A department manager wants to improve customer service. In order to gain employee support, the manager should first
Question294: Which of the following interventions has the greatest potential for positive impact due to its ability to address social determinants of health?
Question295: An improvement team is presented with the following information and tasked with deciding which improvement methodology would be most appropriate:
Medication Physician Order to Medication Arrival on Unit
Time in Minutes: Median: 45, Average: 44.3, Goal: 30
Staff Comments:
"The process is too complicated."
"Why do I need to enter the order into two different systems? There are lots of non-value added steps."
"We are constantly waiting for the medication to be delivered from the pharmacy, which delays patient care.
Why can't we access this medication directly on the floor?"
"The pharmacy overproduces this medication in large batches, which goes wasted."Based on the information available, which of the following methodologies is most appropriate to address the concerns about the process?
Question296: After much planning and preparation, a healthcare quality professional believes the organization is ready to move forward with the process of achieving recognition through a program that highlights their achievements in nursing excellence. Which of the following distinctions is most appropriate for the organization to pursue?
Question297: The degree to which an instrument measures what it is intended to measure is known as
Question298: A customer complains to the health care quality professional about a service in the organization. Which of the following actions should be taken first?
Question299: Survey preparation is initiated by a quality professional for an organization's annual three-year accreditation.
The executive committee and department managers are given an organizational schedule for training and accreditation activities. Which of the following is the best tool to use to manage this initiative?
Question300: A nurse working a second overtime shift accidentally administered an oral medication via the patient's IV line. The facility reported this to the accrediting body as a sentinel event. Which of the following is the best solution to prevent this error from happening again?
Question301: Which of the following is an example of a social determinant of health used to monitor a quality improvement initiative?
Question302: The initial step in clinical pathway development is review of
Question303: Which of the following organizations is a deemed status provider for hospital CMS participation?
Question304: Which of the following recommendations best supports effective transitions of care from hospital to home for patients?
Question305: During analysis of patient falls, a quality professional notes that there has been an increase in the fall rate over the last 3 months. What other data should be analyzed first to determine potential causes?
Question306: Which of the following actions will most effectively promote safety activities within an organization?
Question307: Which of the following best describes the purpose of the nominal group technique?
Question308: Which of the following actions target social determinants of health in an improvement project on asthma control?
Question309: A hospital's quality professional notices a high 30-day readmission rate for patients with chronic obstructive pulmonary disease (COPD) exacerbation. What is the quality professional's next best step?
Question310: An organization decides to transition from a departmental quality assurance model to a multidisciplinary quality improvement model. The first step to ensure successful change is to:
Question311: A team has been working together for six months to improve a patient outcome, and the desired result has not been achieved. An assessment of team effectiveness was conducted and revealed the following:
The healthcare quality professional should recommend
Question312: A quality professional within a seven-hospital system is asked to evaluate the number of quality staff working at the quality professional's hospital. The seven hospitals are all similar with equivalent volume of work. The average staffing is 1 staff/100 beds. This individual's hospital ratio is 0.7 staff/100 beds. Which of the following should the quality professional do first?
Question313: Which of the following is the most effective way to promote a safe transition of care to home for patients leaving a hospital?
Question314: Which of the following tools would be used to outline factors leading to a problem or desired outcome?
Question315: An organization that demonstrates a culture of safety
Question316: A healthcare quality professional can conclude that clinical performance measures in disease specific certification programs are best supported by the
Question317: The staff in the outpatient department complete the morning schedule at varied times. There are multiple factors in the variation such as number of patients, complexity of the cases, and the number of cancellations.
To identify common-cause variation affecting the completion of the morning schedules, what type of chart should be utilized?
Question318: Which of the following is most important for healthcare organizations to improve population health by reducing readmission rates?
Question319: In aligning an organization's performance Improvement plan with strategic goals, a healthcare quality professional should consider
Question320: Leadership at an outpatient multi-specialty clinic Is working toward becoming a high-re I lability organization. In the past week, there have been three medication errors with high-risk medications in the procedure area. Which of the following responses by leadership Is consistent with high-reliability principles?
Question321: A hospital installed a new patient safety event reportingsystem. During the failure modes and effects analysis (FMEA), decreased use of the system and complexity of reporting were identified as potential failures. What should the team use to determine which failure mode to address first?
Question322: A health system is designing a new wellness program and wants to incorporate social determinants of health.
Which of the following should be considered?
Question323: A chart used to display the expected range of variation in a stable process is called a
Question324: During a risk assessment, It Is noted that a unit manager and start feel there Is a high risk of aggressive patient behavior toward unit start Which of the following steps should a healthcare quality professional take first?
Question325: A rapid cycle model for improvement derived from the Deming model encompassing the feedback loop of planning, implementing, and evaluating a rapid test of change would best be described by which of the following acronyms?
Question326: When working with a new quality Improvement team, the quality professional should stress the importance of