Reviewing organizational priorities, addressing regulatory requirements, and identifying goals for the next year are important components in the development of which of the following?
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?
Evaluating data to determine high utilizers ofemergency departments and their related characteristics is a strategy that can best help with
Which of the following is an example of improving primary prevention strategies?
Toassess compliance with quality standards, a healthcare organization needs
Which of the following identifies project deliverables as well as periods with simultaneously occurring activities?
Organizational leadership asks the healthcare quality professional to review patient identification safety events and develop an action plan. Which of the following steps is most effective for defining the problem?
Which of the following best describes the goal of the Healthy People Initiative?
The facility’s compliance rate on pain assessment is shown below:
Compliance Rate on Pain Assessment
January
February
March
Physicians
40%
50%
20%
Nurses
80%
75%
83%
Physical Therapists
60%
55%
50%
To improve performance, what should be done next?
A quality professional was asked to assist with strategic planning. Which ofthe following should have the primary impact on the quality and performance improvement goals?
A hospitalized patient received a medication that was contraindicated based on their home medications. This should have been prevented by
Which of the following would provide the best information to a Quality Council interested in evaluating the effectiveness of quality improvement teams that were chartered during the past year?
Which of the following is a healthcare quality professional’s key responsibility for supporting organizational quality governance?
A facility plans to provide a new specialty. Which of the following will best provide information on the effectiveness of the specialty?
The office manager of a primary careoffice 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:
Integration of a quality culture within an organization Is best demonstrated by
Which of the following actions will best promote organizational efficiency in managing quality improvement projects?
A healthcare quality professional can conclude that clinical performance measures in disease specific certification programs are best supported by the
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?
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?
An organization conducts daily briefing sessions. Which of the following questions demonstrates a culture of safety?
Prior to a regulatory or accreditation visit, a healthcare quality professional should:
The tool used to graphically rank causes from most significant to least significant by using a vertical bar graph is known as a
A CEO has directed a quality improvement council to develop objectives to meet an identified goal. When developing objectives, the council must remember to
Which team role is responsible for maintaining improvements after the implementation of a quality initiative?
A hospital collects patient satisfaction data by mailing surveys to patients discharged home and analyzes the responses they receive. What is the most significant limitation of this sampling methodology?
Which of the following elements of an audit for a primary care office provides information about patient safety?
A new urgent care clinic is setting up a quality management system. Which of the following is the bestchoice as a process measure to evaluate effective clinical care?
The quality improvement (QI) specialist recognizes that any documents related to medical peer review are:
Which of the following is the phase of D-M-A-I-C that is most suitable for ensuring the new process performance is sustained?
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%.
Reduce30-day readmissions from 20% to 15%.Which of the following key elements in aim development appears to have been lost after the training?
Which of the following is most effective to sustain knowledge gained from performance improvement training?
A healthcare quality professional is charged with facilitating a team. The goal of the team is to develop criteria for levels of care in behavioral/mental health. Which of the following is the most important characteristic of the facilitator?
A healthcare quality professional has been informed of a significant medication error resulting in patient harm. A multidisciplinary team should be selected to conduct a
What Is the Initial step the quality professional should take when the organization's performance on a patient satisfaction strategic goal Is below the desired performance?
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
A healthcare quality professional has been hired to assist a quality improvement team with data analysis. In an attempt to enhance the team’s analysis of the data, the quality professional should
A director at a large health system is tasked with building a new population health program. What is the director’s first step?
The collection, analysis, and Interpretation of data for planning, Implementing, and evaluating health programs is
Which of the following is most important to include in a project to reduce post-operative infections?
The ability to safely manage complex tasks in the face of time pressures, quickly identify and contain errors, and bounce back after stressful situations relates to organizational:
A healthcare quality professional, previously employed by a hospital, has been hired by an ambulatory surgery center to create a continuous readiness program. Both employers are Medicare certified and are accredited by the same accrediting organization. The healthcare quality professional should first
A healthcare quality professional Is doing a study in the emergency room. Every other patient admitted to the department Is Included in the sample. This sampling technique Is best described as
An organization has Just experienced a wrong site surgery. A quality leader was asked to conduct a review to understand how the process failed. The best quality Improvement tool to use In developing a shared understanding of the current process Is which of the following?
The healthcare quality professional has been asked to participate in the organizations population health program related to cost and utilization.
Based on this Information, what Is the next action the quality professional should take?
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?
A multidisciplinary team has been convened to review delays in laboratory turnaround time between the medicine clinic and the laboratory. The team's first step in evaluating the issue is to
Physician quality data reports for all credentialed physicians disseminated at regular Intervals, as generally mandated by accreditation standards, are called
Consider the following data set:
DRG | Reimbursement | Cost
079 | $4,500 | $15,000
089 | $6,800 | $23,500
127 | $3,500 | $25,000
468 | $8,200 | $12,500
475 | $12,000 | $40,000
Which of the following is the best way to illustrate the relationship between reimbursement and cost?
When reporting infection control indicators to a governing body, a healthcare quality professional should demonstrate improvement with which of the following tools?
Which of the following should be a part of an organization's program of continuous readiness for accreditation?
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?
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
When an identified solution requires significant change, the best tool to increase the likelihood of success is a:
Which of the following interventions has the greatest potential for positive impact due to its ability to address social determinants of health?
A quality professional is leading a rapid process improvement event to reduce central line infections. Which of the following actions should be taken?
A healthcare quality professional works in a primary care setting and has been asked to develop a patient safety program. The first step in program development is to
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?
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?
A quality professional's key role in a performance improvement team is to serve as a:
A healthcare organization wishes to develop an education plan for quality and patient safety. Based on adult learning principles, the plannededucation Is most likely to be effective when
An organization has identified an increase in safety events related to the treatment of patients who are unable to give consent. At the beginning of the improvement process, which of the following tools should the healthcare quality professional use to assist the team?
A quality improvement team develops a new procedure for improving timeliness in reporting urgent lab results to inpatient units. Prior to implementing the new procedure, the team wants to identify any potential deviations from the desired procedure. Which of the following tools should the team use to identify potential deviations?
A newpediatric 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?
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:
A nursing unit has collected the following data:
50 medical records reviewed
Nurse A
Nurse B
Doctor A
Doctor B
Timely initial assessment
45
40
10
25
Incomplete documentation
0
12
26
20
Which of the following is the best method to display this data?
In a data set, the difference between the highest and lowest observed values is known as the
A nursing home has established a quality indicator to accomplish a 5% reduction in falls. A guideline has been developed and implemented. After six months, the goal has not been reached. The next action steps should include
Which of the following payment systems carries the most financial risk for a provider?
A nurse inadvertently hung an IV medication on the wrong patient’s IV pump, but discovered the error prior to initiating the infusion. Patient harm was averted, and the nurse disclosed the error to a healthcare quality professional. The quality professional should
Which of the following would be the best methodology to reduce referral wait time?
An internal customer of the admission process in a skilled nursing facility is the
A healthcare quality professional is preparing a presentation related to incomplete documentation. According to principles of adult learning, the first step in preparing is to
Which of the following best describes the goal of the Healthy People Initiative?
An organization recently completed an analysis of safety events from the last year. The majority of events were related to the following:
• provider order transcription errors (5%)
• wrong medication given to the patient (12%)
• adverse reaction related to medication allergies (7%)
• Inappropriate medication dose administered (10%)
• delayed antibiotic administration (10%)
Which of the following would be most helpful to enhance patient safety In this organization?
Which of the following performance improvement models is at the core of the Institute for Healthcare Improvement (IHI) collaborative approach?
Patient complaints have been received regarding appointment time delays. Which of the following should be completed first?
A stated purpose of the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) public reporting is that accountable health care should:
The greatest motivator for organization leaders to use a balanced scorecard is that it
An organization is adopting Lean Six Sigma as their new performance improvement model. The best approach for providing training on the model is to
What is the first step in turning an organization’s long-term goals into an operational plan for improvement?
A long-term care facility has experienced an Increase in occupational Injuries among nursing staff and increased patient harm as aresult of unsafe patient handling. Which of the following is the best example of a human factors design solution this facility could Implement?
A patient safety program can best be enhanced by which of the following technologies?
When prioritizing quality improvement initiatives, which of the following should take the highest priority?
The purpose of considering social determinants of health during quality improvement activities is to achieve
A nursing unit has collected the following data:
Which of the following is the best method to display this data?
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?
Which of the following is the best tool to report process improvements to a quality committee?
Which of the following approaches best allows an agency to align Its activities with organizational goals?
Which of the following strategies promotes timely completion of a quality improvement project?
A managed care peer review committee should obtain which of the following first?
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?
An organization recently lost its deemed status due to non-compliance with grievance process regulations. Which of the following standards would thequality professional research to identify grievance process requirements to correct the cited opportunities for improvement?
Which of the following is the key responsibility of a healthcare quality professional in all types of facilities and organizations?
An emergency department's quality improvement report for the first quarter showed the following data:
Which of the following additional information should be included in this report for each month?
Which of the following is the best way to evaluate the success of a performance improvement team?
To best achieve a low rate of harm in spite of inherent risks in healthcare, an organization must:
The quality professional has been asked to perform chart audits on a population to assess how often hypertension is being addressed by clinicians when hypertensive patients presented to theclinic in the last year. The clinic has over 8,000 patients diagnosed with hypertension. Which of the following would be most appropriate for the quality professional to consider when selecting a sampling methodology?
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?
For which incident would a process improvement manager be required to perform a root cause analysis (RCA)?
Which Is a source of data tor analyzing staff flu vaccination trends for an accountable care organization?
Continued evaluation of a quality improvement initiative occurs within which of the following phases of the DMAIC process?
In aligning an organization's performance Improvement plan with strategic goals, a healthcare quality professional should consider
Multi-voting Is frequently used in which of the following steps of the quality Improvement process?
A goal of measurement is to collect valid and reliable data that reflects
Which of the following is the most effective data display tool to demonstrate changes in monthly patient fall rates for the past fiscal year?
A patient safety manager is asked to recommend the best action to reduce medication errors at a hospital. Which of the following is the most appropriate next step?
Which of the following stages may cause continuous quality improvement teams to dissolve prematurely?
A quality council reviewed the following results from a performance improvement project:
Diabetic retinal eye exams
Target
Q1
Q2
Q3
>80%
60%
58%
62%
Which of the following should happen next?
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 thefollowing responses by leadership is consistent with high-reliability principles?
Which performance improvement tool best evaluates care processes and transitions?
When implementing a new process or procedure, which of the following tools should be used to anticipate and prevent potential problems?
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:
Senior leadership is evaluating an organization’s progress toward achieving patient safety goals and has a goal of 100% compliance. Hand hygiene compliance is currently at 80%, and "time-out" compliance is at 90%. A healthcare quality professional should recommend
Which tool is used to identify, explore, and display the possible causes of a specific problem or condition?
Which of the following regulatory agencies overseedevelopment of electronic clinical quality measures (eCQMs)?
In preparation for a provider organization accreditation survey, the most effective method for identifying training needs for staff is
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?
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
In order to make effective long-term changes, performance Improvement emphasizes the need to study and understand
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?
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?
Recognition of the formal and informal structure of an organization is necessary when implementing a quality improvement program because
What is the initial step an organization should take when the strategic goal of improving patient satisfaction has not been met?
The quality director would like to prepare the team for the upcoming accreditation survey. Which of the following would ensure continuous team survey readiness?
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?
When recommending a quality improvement project, the quality professional must first consider
Which of the following tools aids decision-making through organizing tasks, issues, or actions based on agreed-upon criteria?
An organization has a three-year accreditation cycle. The highest priority for the first year of the cycle by the accreditation team is
Which of the following action plans contains all key components of a SMART goal to support a strategic plan initiative?
Leadership at a facility reviewed andrevised 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:
Which of the following leads to better population health management in older adults with chronic conditions?
A health system in an underserved area seeks to improve medication adherence in patients with hypertension. One of the barriers identified is patients with limited English proficiency. Which of the following solutions will best improve medication adherence?
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?
Clinical staff at a hospital inconsistently document the fall risk assessment upon admission. What approach should the quality improvement professional recommend as a priority?
A facility’s performance on a clinical outcome measure has deteriorated. The healthcare quality professional’s initial action should be to
An organization implemented a revised medication reconciliation process 21 months ago. The results of compliance with the revised process were recorded
on a statistical process control chart:
(Use the scroll bar to the right to scroll down as needed.)
Which of the following should be concluded by a performance improvement coordinator after evaluation of the control chart?
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?
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?
A behavioral health hospital implemented restraint audits in each of its nursing units. After two months of data collection, what should the healthcare quality professional do next?
To promote staff engagement In a new Initiative, educators should focus on staff
Which of the following is the best example of a non-value added step in the healthcare environment?
A department manager wants to improve customer service. In order to gain employee support, the manager should first
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?
Which of the following is the strongest intervention for preventing medication safety events?
Where in the process of ensuring correct surgery does a "time-out" take place?
An organization IsImplementing 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?
The culture of safety survey data below is collected from perioperative services. Which action should the healthcare quality professional recommend?