An organization conducts daily briefing sessions. Which of the following questions demonstrates a culture of safety?
When analyzing nominal data, the quality professional uses a bar chart to display
Which of the following is most important to include in a project to reduce post-operative infections?
A quality director has been tasked with the responsibility for education and implementation of a new process improvement initiative. To affect the needed change in culture, the quality director should
Which of the following actions best demonstrates that an organization has begun the work necessary to achieve the Malcolm Baldrige award?
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?
Which of the following methods best links performance improvement activities with organizational strategic goals?
The hospital administration has requested data to support an initiative to reduce barriers to healthcare In the community. Which of the following Information Is most appropriate for the quality professional to provide for initial planning?
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?
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:
To integrate performance improvement with organization planning, there must be alignment between
A group of clinical staff has identified a new opportunity for improvement. The group is ready to identify a sponsor, and a meeting has been scheduled with the Chief Medical Officer to discuss the possibility for them to serve as the sponsor. What sponsor task should be discussed during the meeting?
A pay-for-performance structure includes a payout based on achieving the NCQA Quality Compass® 50th Percentile, plus an additional bonus for achieving the NCQA Quality Compass® 75th Percentile. Individual performance on measures is as follows:
NCQA Measure
Physician A
Physician B
Nurse Practitioner C
Physician Assistant D
50th Percentile
75th Percentile
Diabetic Retinal Eye Exam
75%
80%
60%
63%
65%
70%
Nephropathy
53%
43%
50%
48%
50%
52%
HbA1c Testing
76%
80%
52%
70%
72%
76%
Which provider will not earn pay-for-performance based on reaching either the NCQA Quality Compass® 50th or 75th percentile?
Which of the following quality Improvement Tools Is best for riskassessment of a new or modified process?
Which of the following will help determine the health status of a defined population?
A home health agency’s Performance Improvement Committee has decided to base staff educational programs onaggregated 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?
Which of the following is the best disease management approach to reduce hospitalizations for patients with high blood pressure?
When implementing a new process or procedure, which of the following tools should be used to anticipate and prevent potential problems?
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?
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:
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
The degree to which an instrument measures what it is intended to measure is known as
Which of the following actions will most effectively promote safety activities within an organization?
A hospital is considering changing the process of admissions from the emergency department. To support patient safety when this new process is deployed, the healthcare quality professional should suggest which of the following actions during the design stage of the process?
The best indication of how well staff members apply the performance improvement (PI) process after completing a PI training course is:
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?
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?
An effective method to increase an organization’s board of directors engagement in patient safety is to
Which of the following is the best data source to assess an organization’s culture of safety?
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?
Which of the following regulatory agencies overseedevelopment of electronic clinical quality measures (eCQMs)?
A customer complains to the health care quality professional about a service in the organization. Which of the following actions should be taken first?
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
A healthcare organization has Introduced an Initiative to Increase lung cancer screenings for Itspatient population with a history of smoking. This screening would fall into which of the following types of prevention?
Which of the following tools will best help a quality professional to exhibit project activities and results?
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
Evaluating data to determine high utilizers ofemergency departments and their related characteristics is a strategy that can best help with
When recommending a quality improvement project, the quality professional must first consider
Which of the following is the role a healthcare quality professional should play in strategic planning?
Which of the following is an example of using human factors engineering to improve patient safety?
A healthcare quality professional has identified a gap In practice from regulatoryrequirements. The quality professional should
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 hospital's leadership team has asked the quality professional to review alternative accreditation options for the organization. The quality professional recommends the:
An extended carefacility measures the percent of time a comprehensive exam is completed within 96 hours of admission. This is an example of which of the following types of measure?
Integration of a quality culture within an organization Is best demonstrated by
Which performance improvement tool best evaluates care processes and transitions?
What is the first step in turning an organization’s long-term goals into an operational plan for improvement?
When an identified solution requires significant change, the best tool to increase the likelihood of success is a:
Leadership is trying to set SMART goals as part of the annual quality plan. Which of the following meets this framework?
Which of the following payment systems carries the most financial risk for a provider?
A department manager wants to improve customer service. In order to gain employee support, the manager should first
Which of the following is the best strategy to increase a community's annual influenza vaccination rate?
When developing objectives for an educational program, the quality professional should recommend
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
Which of the following is the best approach tomotivate stakeholders across the care continuum to take action?
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:
One of the first steps in preparing for an organizational accreditation survey Is to have a quality professional
A healthcare quality professional can conclude that clinical performance measures in disease specific certification programs are best supported by the
A team has completed several tests of change and has arrived at a recommendation. In order to facilitate change, which of the following should occur first?
An improvement project was implemented to expand utilization of primary care services in a rural area where only 5% of residents sought primary care. The team established a goal of 20% of residents using primary care. The table below shows the results for the four months following implementation of the improvement:
% Residents Using Primary Care
Time | %
Baseline | 5%
Month 1 | 15%
Month 2 | 20%
Month 3 | 21%
Month 4 | 22%
Which of the following should the quality professional recommend to the organization?
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?
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?
Choosing a small number of items to represent characteristics of the whole is an example of
Identification of quality Improvement opportunities can best be Identified through
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?
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
Which of the following best describes the goal of the Healthy People Initiative?
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?
A chart used to display the expected range of variation in a stable process is called a
A healthcare quality professional is organizing a team to address accuracy of the admission source data collection element. Accuracy of this data element impacts exclusions for various quality scores. The following teams have been proposed:
Team
Sponsor
Leader
Members
A
Chief Financial Officer
Director of Quality
Case Manager, Registration Staff, Coding Manager
B
Chief Executive Officer
Director of Finance
Staff Nurse, Hospitalist, Coding Manager
C
Chief Nursing Officer
Director of Health Information Management
Coding Manager, Emergency Dept. Nurse, Intensivist
D
Chief Medical Officer
Director of Case Management
Clinical Documentation Specialist, Case Manager, Emergency Dept. Intensivist
Which team is most appropriate to address this issue?
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?
An emergency department's quality Improvement report for the first quarter showed the following data:
What was the approximate overall problem rate for March?
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?
An example of a safety practice that allows any worker to speak up when a rule is not being followed is:
Which of the following represents an unintended consequence of payer-driven quality initiatives?
There has been an increase in readmissions and chart reviews show that it is related to medication non-adherence post-discharge. To improve medication adherence, the quality professional recommends staff:
Continued evaluation of a quality improvement initiative occurs within which of the following phases of the DMAIC process?
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?
For which incident would a process improvement manager be required to perform a root cause analysis (RCA)?
The chairperson of the governing body has requested an annual report on improvements in patient care. The report should include
Which of the following types of surveillance refers to relying on another person to report a safety concern?
A pulmonologist is gathering social determinants of health data from their patients. Which of the following best explains the purpose of collecting this data?
Which of the following characteristics best describes a learning organization?
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?
The quality professional reviews the following data:
[Data not provided in the document]
Which of the following is the next step?
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:
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
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?
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?
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?
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:
Which of the following would be the best methodology to reduce referral wait time?
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?
A healthcare organization has decided that the healthcare qualityprofessional will provide performance improvement training to all supervisors. The first step is to
A recent analysis reveals that reimbursement projection is being negatively impacted by post-surgical respiratory failure rates. What is the first step to address this issue?
The healthcare quality professional is engaged with a leadership team. Which of the following will best help to establish performance improvement opportunities?
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?
A performance Improvement team has been formed and assigned to reduce wait time from clinic check-In to seeing a provider. Which tool would be most useful for the team to create at the first meeting?
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?
Based on the chart below, implementing which of the following technologies may have the greatest impact on reducing adverse events related to medication processes?
An orthopedic surgery practice has been working on Improving patient safety for the last 3 years. The following data table is available:
Which of thefollowing Is the most appropriate conclusion about patient safety outcomes?
Which of the following is the quality professional's first step prior to implementing a new infection prevention protocol in the clinic?
An organization's preventable fall goal is not to exceed greater than 25% of its total falls. Which units below meet this goal?
Which of the following Is the best example of effective learning in a learning organization?
Through routine collection of incident reports, an increase in medication errors was noted over a period of 6 months on 2 nursing units. Which of the following is the best method of displaying the data to illustrate this finding?
Where in the process of ensuring correct surgery does a "time-out" take place?
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
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 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 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?
In a data set, the difference between the highest and lowest observed values is known as the
Ahospital has been experiencing a significant Increase in the 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?
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?
A Lean improvement team is examining potential improvements to room layout to reduce waste. Which of the following is the best tool to identify the baseline distance staff travel through the day to gather the materials they need to perform their job tasks?
Which of the following is the most effective way to promote a safe transition of care to home for patients leaving a hospital?
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 order to make effective long-term changes, performance Improvement emphasizes the need to study and understand
Which of the following provides support and subject matter expertise (or organizations that self-report sentinel events?
Hospitals must be in compliance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation in order to
The safety reporting system being used by an organization cannot produce reports or information in a usable format. After evaluating the existing system and other products on the market, which of the following should the quality professional do before making recommendations to leadership?
Which of the following stages may cause continuous quality improvement teams to dissolve prematurely?
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?
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?
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?
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?
When reporting infection control indicators to a governing body, a healthcare quality professional should demonstrate improvement with which of the following tools?
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?
Which of the following is most relevant to addressing social determinants of health?
A performance Improvement team has been meeting to examine delays in getting admissions from theemergency 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?
Anemergency department's quality improvement report for the first quarter showed the following data:
What was the approximate overall problem rate for March?
Which of the following tools should be used to determine the root cause of variations in a process?
Which of the following Is an algorithm that Is designed to classify patients according to their acuity?
Which of the following process improvement training methods would be effective to support a continuous survey readiness program?
Which of the following quality improvement tools is best suited for communicating the scope of a proposed quality improvement project?
A continuous quality improvement team has proposed a major change in the billing process for home health service. Staff acceptance of the change is best facilitated by:
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?
A nursing unit has collected the following data:
Which of the following is the best method to display this data?
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
Which of the following quality initiatives impacts an organization’s reimbursement?
Supporting patients through longitudinal care plans is the guiding principle of:
Which of the following is an effective method to motivate employees to participate in performance Improvement?
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
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?
Priorities must be established for selecting processes for quality improvement because
A quality professional is leading a rapid process improvement event to reduce central line infections. Which of the following actions should be taken?
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?
An organization identified the need to improve the flow of admitted patients from the emergency department (ED) to the inpatient unit. The following individuals have been selected to be a part of the team:
Based on this matrix, which of the following ideas should the team address first?
A hospital is working to decrease the length of stay for inpatients on a surgical unit. Which of the following should be measured to document aspects of the process that are non-value added?
An organization notices an Increase In medication errors In three patient care areas. Which of the following concepts will be most effective when Improving medication administration workflows?
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?
Which of the following best describes how a quality professional should conduct an organizational assessment to ensure safe transitions of care?
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 shouldinitially assess the
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
A performance improvement council has been directed to set up a communication plan for spreading an innovative telehealth program throughout the healthcare system. Which of the following groups must the council include in the communication plan?
In preparation for a provider organization accreditation survey, the most effective method for identifying training needs for staff is
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?
A root cause analysis (RCA) was conducted for 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?
Which of the following is a regulatory requirement to be undertaken by nonprofit hospitals?
Which of the following tools aids decision-making through organizing tasks, issues, or actions based on agreed-upon criteria?
Analysis of the following wound infection rate control chart shows which of the following?
The ultimate responsibility for ensuring and maintaining patient safety in a healthcare organization lies with the:
Which of the following is the best tool to report process improvements to a quality committee?
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 should be a part of an organization's program of continuous readiness for accreditation?
A healthcare quality professional identifies a need to improve compliance with colon cancer screening among primary care patients. Which of the following interventions should be used?