Which of the following action plans is the first step in correcting inappropriate blood usage in an emergency department?
A. in-service on ordering
... [Show More] blood usage for the physicians
B. elimination of wasted blood
C. improvements in documentation
D. development of a new procurement procedure
ANSWER
A. in-service on ordering blood usage for the physicians
Which of the following is most appropriate in preparation for an external survey of a healthcare facility?
A. Assign key staff to answer all questions.
B. Ask department heads to prepare a presentation for the survey team.
C. Educate staff about the types of questions they may be asked.
D. Set up teams to make a good showing for the survey.
ANSWER
C. Educate staff about the types of questions they may be asked.
The following table shows the percentage of hospital-acquired pressure ulcers: Which of the following
should the healthcare quality professional do next?
A. Implement a new pressure ulcer protocol.
B. Re-educate staff.
C. Continue to track and trend the data.
D. Conduct a focused analysis of pressure ulcer cases
ANSWER
D. Conduct a focused analysis of pressure ulcer cases
Leadership can best integrate performance improvement within an organization through:
A. multidisciplinary teams.
B. newsletters.
C. focus groups.
D. seminars.
ANSWER
A. multidisciplinary teams
(best integrate performance improvement by promoting an interdisciplinary approach to the process and including multiple subject matter experts.)
A medication error occurred and resulted in a severe adverse outcome. In addition to informing the
patient and/or family, a healthcare quality professional should:
A. perform a regression analysis.
B. implement new technology.
C. reassign the employees involved.
D. conduct a root cause analysis.
ANSWER
D. conduct a root cause analysis.
(exploration of system and process issues should be the primary function of a root cause analysis)
The primary purpose of an organization's quality improvement (QI) strategic plan is to:
A. determine accountability for outcomes.
B. assess improvement opportunities.
C. define the future direction for quality.
D. explain the purpose of performance teams
ANSWER
C. define the future direction for quality.
(This is a function of having a QI strategic plan.)
Which of the following are the first steps when preparing for an initial accreditation or certification survey
of an organization?
A. Review the standards and determine readiness.
B. Appoint a survey coordinator and prepare a survey agenda.
C. Hire a consultant and conduct a mock survey.
D. Assess staff knowledge and plan staff training.
ANSWER
A. Review the standards and determine readiness.
(These actions are part of the gap analysis, which establishes a good baseline to determine where to focus and how to prioritize efforts.)
The primary purpose of risk management trend analysis is to:
A. meet regulatory requirements.
B. provide required reports to liability carriers.
C. identify opportunities for improvements.
D. eliminate financial loss for organizations
ANSWER
C. identify opportunities for improvements.
(Risk management focuses on identification, assessment, and reduction of risk. The goal is to protect the organization from losses, the key component of which is proactive improvement to avoid and reduce risk.)
Which of the following elements must be present in order to evaluate the effectiveness of a healthcare
organization's quality improvement program?
A. quantifiable objectives
B. support from the medical staff
C. well-defined organizational structure
D. integrated data collection
ANSWER
A. quantifiable objectives
(To evaluate effectiveness, an organization must have quantifiable objectives in order to measure progress toward meeting goals)
Balanced scorecards are useful because they
A. focus on the most significant strategic initiative.
B. evaluate the pros and cons of the governing body's priorities.
C. put strategy and vision at the center of an organization's effort.
D. concentrate on the performance of individual units.
ANSWER
C. put strategy and vision at the center of an organization's effort.
(The balanced scorecard is a management framework that translates an organization's strategic objectives into a set of performance measures that are measured, monitored, and changed, if necessary, to ensure that organization's strategic goals are met.)
A t-test may be used to:
A. display the size of a sampling variation.
B. evaluate the effects of two different treatments.
C. evaluate differences among three or more treatments.
D. display a listing of the number of occurrences of a variable
ANSWER
B. evaluate the effects of two different treatments.
(A t-test is used to examine if the mean of two treatments are statistically different from one another)
Which of the following should a Quality Council provide to best ensure success of performance improvement teams?
A. facilitator and recorder
B. empowerment and training
C. indicators and a data analyst
D. standards and procedures
ANSWER
B. empowerment and training
Which of the following is the most effective way to integrate performance improvement concepts throughout an organization?
A. quarterly newsletters
B. monthly lectures
C. quality teams
D. continuous monitoring
ANSWER
C. quality teams
(Quality teams include participation by front-line staff, which allows direct integration of performance improvement into practice.)
The primary purpose of integrating financial and quality management information is to:
A. identify problems in resource management.
B. develop physician profiles.
C. identify potential cash flow problems.
D. determine medical necessity of treatment
ANSWER
A. identify problems in resource management.
(This ties financial impact to quality management.)
A group of pediatric patients diagnosed with cystic fibrosis is being studied. Their attitudes toward the disease have been measured each year for the past 4 years. The methodology used is an example of a:
A. cohort study.
B. regression analysis.
C. case-mix study.
D. cross-sectional analysis
ANSWER
A. cohort study
(analyzes a group with a specific characteristic, such as cystic fibrosis.)
A root cause analysis team examined a serious medication error and recommended changes. Which of
the following should be done next?
A. Random checks for compliance should be made by patient safety staff.
B. The Quality Council should review medication errors quarterly.
C. The process owner should implement and assess effectiveness.
D. Monthly reports should be sent to the regulatory body.
ANSWER
C. The process owner should implement and assess effectiveness.
(the recommended changes need to be assigned ownership.)
Which of the following is an example of information that should be included in an incident report, but should NOT be recorded in a patient's medical record?
A. the patient found on the floor next to the bed with the patient's right leg appearing to be rotated
B. the date, time, dose, and name of a medication administered to a patient in error
C. details concerning a medication preparation error discovered and corrected prior to administration
D. the patient's right knee replaced after consenting to replacement of the left knee
ANSWER
C. details concerning a medication preparation error discovered and corrected prior to administration
Based on the principles from the Institute for Healthcare Improvement (IHI), who has the ultimate responsibility for the effectiveness of quality improvement and patient safety within an organization?
A. quality improvement director
B. medical director
C. CEO
D. governing body
D. governing body
(This is the expectation of TJC and Centers for Medicare and Medicaid Services (CMS))
Which of the following charts will most likely be used first in a root cause analysis?
A. Gantt
B. Pareto
C. flow
D. control
D. control
(a tool to evaluate process)
A federally certified electronic health record (EHR) with the capacity for e-prescribing, electronic exchange of health information, and submission of healthcare quality measures meets:
A. bar-code technology specifications.
B. computer-based monitoring specifications.
C. meaningful use requirements.
D. health privacy requirements
C. meaningful use requirements.
Team cohesion is established during which of the following stages of team growth?
A. forming
B. storming
C. norming
D. performing
C. norming
(The team moves towards cohesion and collaboration during the norming stage.)
An annual evaluation of a laboratory's quality program identified no opportunities for improvement. Which of the following elements of the program should be reviewed?
A. performance indicators
B. format of data display
C. committee meeting attendance
D. frequency of data collection
A. performance indicators
When errors are discovered, staff and supervisors best demonstrate a culture of safety by
A. developing a plan for just-in-time training.
B. studying the process to understand the error.
C. planning which details of the error to disclose to senior leadership.
D. performing a root cause analysis to determine which individuals were involved.
B. studying the process to understand the error.
In lean thinking, a process step is defined as "value added" if the
A. customer recognizes the value.
B. customer corrects a mistake to add value.
C. process owner recognizes the value.
D. process owner changes the value of the product.
A. customer recognizes the value.
Customer value is the key concept of lean thinking and improvement efforts. [Show Less]