NAHQ CPHQ Dumps Questions Answers
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NAHQ CPHQ Frequently Asked Questions
NAHQ CPHQ Sample Questions
Question # 1
The upper and lower limits on a control chart are:
A. Used to display the distribution of data.
B. The same as thresholds.
C. Used to determine if the long-range average is changing.
D. Statistically calculated from the related data.
Question # 2
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. flow chart
B. stakeholder analysis
C. PERT chart
D. force field analysis
Question # 3
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?
A. Self-study course of online modules and quizzes
B. Lecture series allowing for either in-person or virtual attendance
C. Reading material assignment with attestation of completion
D. Series of sessions with both classroom and simulation exercise time
Question # 4
A physician group with a patient population of 10,000 during the fourthquarter of a year reviewed 100 complaints regarding access to specialty care. During the fourth quarter of the next year, the patient population had grown to 60,000 with 360 complaints regarding access to specialty care. The group has a target goal of five complaints per 1,000 patients. Which of the following should a healthcare quality professional conclude based on the data?
A. The rate of complaints has increased and has exceeded the target.
B. The rate of complaints has decreased, and the target has been reached.
C. The rate of complaints has increased, but remains within the target range.
D. The rate of complaints has decreased, but the target has not been reached.
Question # 5
An acute care facility has established an outpatient heart failure clinic. Which of the following will best define the success of the program?
A. Decreased readmission rate
B. Increased patient satisfaction
C. Increased compliance with post-discharge plan
D. Decreased serious adverse events
Question # 6
Which of the following is the most effective method to identify adverse events that cause harm to patients?
A. benchmarking
B. conducting a failure mode and effect analysis
C. using patient satisfaction surveys
D. employing tiiyu.fi tools
Question # 7
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?
A. collection of bacterial hand cultures
B. direct observation of staff
C. calculation of Infection rates compared to a baseline
D. a test with a passing score of 98%
Question # 8
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?
A. There are team members who are absent.
B. The group has completed performing phase of development
C. The charter did not provide a specific problem statement.
D. The sponsor Is disengaged with the project
Question # 9
Which of the following Is true of a clinical pathway?
A. depicted using a value stream map
B. limited to one patient care setting
C. used to reduce variations in care
D. required for accountable care organizations
Question # 10
Which of the following is an example of addressing a social determinant of health to improve outcomes in patients with type 2 diabetes?
A. Educating patients on blood sugar monitoring
B. Addressing clinical risk factors for type 2 diabetes
C. Targeting interventions to age groups with poor diabetes control
D. Working with local food pantries to improve access to healthy foods
Question # 11
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. Evaluate data for an additional quarter to determine if the disparity persists.
B. Host a community health fair that provides free blood pressure monitors.
C. Partner with local community leaders to develop a community garden to improve nutrition.
D. Invite patients with uncontrolled blood pressure to attend a focus group to discuss barriers.
Question # 12
Which of the following is the most effective method for communicating an organization’s quality improvement efforts?
A. Report results of key quality measures at quarterly staff meetings
B. Instruct staff to review hospital’s performance data on the Medicare website
C. Email the quality improvement committee meeting minutes to all staff
D. Send updated scorecards that show the results of key indicators
Question # 13
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. Uncover other opportunities for improvement within the facility
B. Support the CQO’s choice for alternative certification
C. Evaluate the facility’s needs, goals, and stakeholder input
D. Determine the final certification selection
Question # 14
The main goal of a clinical pathway/guideline Is lo
A. assist in documentation of care.
B. document practitioner variances.
C. guide the patient's care toward identified outcomes.
D. ensure precise treatment plans are followed.
Question # 15
Which of the following would be the best source for the performance improvement manager to use to externally benchmark the occurrence of central line infections?
A. National Institutes of Health (NIH)
B. National Healthcare Safety Network (NHSN)
C. National Quality Forum (NQF)
D. Agency for Healthcare Research and Quality (AHRQ)
Question # 16
Which of the following population health strategies is most likely to improve rural patient access to mental healthcare services?
A. Apply a patient-centered medical home model to support care coordination.
B. Educate about health insurance exchanges to increase patient knowledge.
C. Partner with a health system to implement a telemedicine program.
D. Develop a health coaching service to promote behavior modification.
Question # 17
X quality professional is reviewing medication adherence data for patients with type 2 diabetes. Based on the table below, whichneighborhood 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% |
A. Neighborhood A
B. Neighborhood B
C. Neighborhood C
D. Neighborhood D
Question # 18
Cold-spotting involves identifying populations that
A. engage in high-risk behaviors.
B. lack access to healthcare or other community support.
C. receive care through state and federally funded programs.
D. utilize healthcare services frequently.
Question # 19
Prior to discharge, which of the following provides patient information to improve education for heart failure patients?
A. Insurance claims data
B. Patient satisfaction surveys
C. Electronic health records
D. Heart failure registry
Question # 20
Which of the following is the best method to achieve a reduction in medical errors?
A. Establish disciplinary measures for clinical practitioners who commit errors
B. Encourage patients, families, and staff to report actual and potential errors
C. Counsel employees to be more careful when providing care
D. Change the process for reporting medical errors within the organization
Question # 21
Which of the following tools depicts a sequence of events in a process?
A. Pareto diagram
B. Flowchart
C. Run chart
D. Scatter diagram
Question # 22
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?
A. Team A
B. Team B
C. Team C
D. Team D
Question # 23
A recent survey indicated that results of performance improvement projects are not being shared throughout the organization. Which of the following is the most effective method to improve dissemination of results?
A. Publish results in a peer-reviewed journal
B. Present results at department staff meetings
C. Report results to the Quality Council
D. E-mail results to management staff
Question # 24
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:
A. Use teach-back to establish an understanding of the patient’s medication plan.
B. Evaluate patient barriers to obtaining medications.
C. Complete medication reconciliation prior to discharge.
D. Provide printed medication information for the patient to take home.
Question # 25
A total joint replacement program is adding one outcome measure. Which of the following is the most appropriate?
A. Preoperative bathing compliance
B. Medication reconciliation compliance
C. Board certification of orthopedic surgeons
D. Surgical site infection rate
Question # 26
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. Disseminate the results to nursing staff.
B. Continue monitoring for another quarter.
C. Create an action plan with the department leaders.
D. Hire a pain management specialist.
Question # 27
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
A. a coding system with the key attached to the report.
B. initials.
C. name.
Question # 28
An important responsibility of each team member working on a team project is to
A. complete assignments between meetings.
B. investigate the existing data on the project.
C. review team progress periodically.
D. teach skills to the team during meetings.
Question # 29
A multidisciplinary team is focused on safe patient transfers to a long-term care facility and is conducting a failure mode and effects analysis (FMEA). Which of the following should be the first step?
A. Identify failure modes and causes
B. Analyze incident report data
C. Calculate the risk priority number
D. Determine the steps in the process
Question # 30
The following table shows survey results for three clinics within an organization: Measure (per 1,000 visits unless noted) Clinic A Clinic B Clinic C Target Complaints 16 12 8 < 5 Compliments 8 14 9 > 10 Wait time (average minutes) 20 18 18 < 15 Based on these findings, the organization should:
A. Continue to track and trend results.
B. Enforce a complaint training program.
C. Provide training on decreasing wait times.
D. Identify customer service strategies.
Question # 31
A healthcare quality professional receives the following data on causes of surgical delays: Cause Jan Feb Mar Incomplete paperwork 7 3 6 Surgeon unavailable/late 10 4 7 Anesthesia late 3 3 3 Surgical instruments incomplete 6 1 7 Pre-op lab results missing 2 4 7 Blood not available 1 0 2 Patient not NPO 7 4 6 What steps should be taken to prioritize areas of concern?
A. Prepare a Pareto chart and develop an action plan
B. Develop a control chart and create an action plan
C. Create an Ishikawa diagram to identify primary causes
D. Draw a histogram and analyze causes
Question # 32
During the initial quality improvement team meeting, ground rules should be established to nes
A. Educate the team about pathways/guideli
B. Help team members relate to patient needs
C. Agree how meetings will be conducted
D. Eliminate the need for meeting minutes
Question # 33
Each department in a hospital self-monitors and reports hand hygiene data each quarter. Results typically fall within the 58-72% range, with the exception of Respiratory Therapy, which consistently reports 100% compliance. Which of the following steps should a healthcare quality professional take next?
A. Provide remedial hand hygiene training for the lowest scoring departments.
B. Recognize the Respiratory Therapy department for its outstanding compliance.
C. Validate that the Respiratory Therapy results are accurate.
D. Require departments not achieving at least 95% compliance to develop corrective action plans.
Question # 34
The primary reason to use a critical path is to
A. Change third party reimbursement
B. Improve the delivery of service
C. Develop mandated contracts
D. Decrease incident reports
Question # 35
Managed care outcomes related to HEDIS measures are most commonly obtained through
A. claims data.
B. satisfaction survey results.
C. grievances.
D. medical records.
Question # 36
Which of the following is the best method of determining improvement priorities to benefit the health of the community?
A. Focus group interviews
B. Needs assessment survey
C. Windshield survey
D. Census data review
Question # 37
When a team member fails to complete an assigned task, which aspect of team performance will most likely be affected?
A. Satisfaction of the team member
B. Individual growth
C. Productivity and results
D. Storming and norming
Question # 38
Which of the following tools is most appropriate to analyze a medication administration process?
A. Flow chart
B. Pareto chart
C. Bar graph
D. Fishbone diagram
Question # 39
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. Request Information on the cost per patient for those discharged to skilled nursing facilities.
B. Request Information on total number of patients discharged to each location for both quarters.
C. Analyze the appropriateness of discharges to Inpatient rehabilitation centers.
D. Analyze the cost differences between patients discharged to home and skilled nursing facilities.
Question # 40
A patient safety program should be aligned with which of the following?
A. Public reporting
B. Third-party payors
C. Organizational core values
D. Patient satisfaction surveys
Question # 41
Which of the following quality improvement tools can best demonstrate length-of-stay data?
A. Run chart
B. Pareto chart
C. Flowchart
D. Gantt chart
Question # 42
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?
A. Ask participants to practice facilitation with the group during class.
B. Ask participants to study facilitation techniques after class.
C. Teach all the concepts and test participants at the end of class.
D. Teach the basic concepts and handout printed slides for participants to refer to after class.
Question # 43
A quality professional Is the leader of a team in the storming phase of development Which of the following should the quality professional be prepared to do?
A. Direct and provide role clarification.
B. Be willing to share leadership responsibilities.
C. Redirect conflict to energize the team.
D. Move to a more supportive leadership style.
Question # 44
What should a chief medical officer (CMO) do to avoid groupthink within a team?
A. Explore the reason for strong cohesion.
B. Encourage dissenting opinions.
C. Train members in teamwork.
D. Schedule frequent meetings.
Question # 45
In statistics, the p-value provides the data user with
A. An index of data reliability
B. A level of significance
C. A measure of central tendency
D. A degree of deviation
Question # 46
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. complete a literature search.
B. survey patients.
C. visit similar organizations.
D. define the scope.
Question # 47
A chart used to display the expected range of variation in a stable process is called a
A. Scattergram
B. Histogram
C. Run chart
D. Control chart
Question # 48
Which of the following conclusions might be drawn from failure mode and effects analysis (FMEA)?
A. Key factors were identified, and corrective action plans were created.
B. Actions were taken to address baseline performance and monitored for sustainment.
C. Risks were identified and prioritized, and action plans were developed.
D. Special causes were identified, and variation was reduced.
Question # 49
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. Immediate implementation
B. Medical staff education
C. Long-range planning
D. A pilot project
Question # 50
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. The end users’ feedback related to the software
B. The cost of the software
C. The ability to integrate with existing information systems
D. The organization’s goals for the system
Question # 51
Which of the following leads to better population health management in older adults with chronic conditions?
A. Better clinical research around chronic diseases
B. Comprehensive assessment of patients' health conditions
C. Improving relationships between providers and patients
D. Teaching patients how to access their patient portal
Question # 52
Which of the following could be used as an outcome measure during indicator development?
A. laboratory compliance with policy and procedure for drawing peak and trough levels
B. staff adherence to a standard of practice
C. required diagnostic testing performed before medication was prescribed
D. complication rate for a specific surgical procedure
Question # 53
Which of the following actions demonstrate an organization working towards a just culture?
A. Repeating safety culture assessments on a regular basis
B. Creating a balance between accountability and improving unsafe systems
C. Prioritizing evaluation of safety events that reach the patient
D. Balancing culture and lessons learned to create high reliability
Question # 54
Leadership is trying to set SMART goals as part of the annual quality plan. Which of the following meets this framework?
A. Decrease nosocomial infections by 40% in patient care areas
B. Decrease readmission rates to the general medicine floors by the end of the fourth quarter
C. Decrease negative survey results in the radiology department by 20% by the end of the second quarter
D. Decrease falls with injury in the ICU by 15% by the end of the second quarter
Question # 55
The quality improvement program is effective when the organization
A. Rewards behavior that supports quality improvement
B. Passes an accreditation survey
C. Has a written quality plan approved by the board
D. Develops quality improvement teams
Question # 56
Which of the following is the best method for determining improvement priorities to benefit the health of the community?
A. Census data review
B. Needs assessment survey
C. Windshield survey
D. Focus group interviews
Question # 57
When planning a healthcare organization’s performance improvement training, the curriculum is developed considering the needs of which groups?
A. Senior leaders, middle managers, and frontline staff
B. Insurance companies, Medicare, and Medicaid
C. Licensure, certification, and accrediting agencies
D. The governing body and external stakeholders
Question # 58
Which of the following Is the best approach to prepare care team members tor Interacting with accreditation surveyors?
A. Review patient records proactively.
B. Summarize and discuss past survey findings.
C. Brief them on survey activities and what questions to expect.
D. Provide techniques to defer surveyor questions to leaders.
Question # 59
Which tool should be used to determine how data changes over time?
A. Histogram
B. Control chart
C. Frequency plot
D. Stratification chart
Question # 60
Which of the following represents a medicallyunderserved population?
A. high risk obstetric patients in the third trimester
B. families with a household size greater than 7.2
C. patients living within S miles of an urban area
D. patients living below the Income poverty line
Question # 61
Leadership has selected a team to address barriers to filling prescriptions. Prior to finalization of the charter, what necessary step must be completed?
A. Begin data collection.
B. Create a flow chart.
C. Define outcome variables.
D. Evaluate outcome results.
Question # 62
Which tool Is used to Identify resources needed to complete a project?
A. control chart
B. cause-and-effect diagram
C. SIPOC diagram
D. value stream man
Question # 63
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?
A. automated dispensing machine
B. verbal order read-back
C. bar code medication administration
D. computerized provider order entry
Question # 64
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 inpainWhich organization can best provide this information?
A. Leapfrog Group
B. The Joint Commission (TJC)
C. URAC
D. National Quality Forum (NQF)
Question # 65
Which of the following tools should be used to select an option from a group of alternatives?
A. Affinity diagram
B. Histogram
C. Prioritization matrix
D. Gantt chart
Question # 66
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?
A. Physician A
B. Physician B
C. Nurse Practitioner C
D. Physician Assistant D
Question # 67
A physician's profile shows a 4% readmission rate following outpatient gallbladder surgery, which Is significantly higher than the rate for their peers. What action should the quality professional take next?
A. Report the surgeon to the medical board.
B. Review the physician's privileges against the procedures performed.
C. Compare the physician's readmission rate with peer physicians.
D. Review a sample of recent individual cases of the physician's readmissions.
Question # 68
A department manager wants to improve customer service. In order to gain employee support, the manager should first
A. Include customer service in performance reviews
B. Demonstrate the need for change
C. Seek authorization of the governing body
D. Empower the employees
Question # 69
An example of a clinical care process measure is:
A. Patient experience
B. Administration of beta blocker
C. Case mix mortality
D. 30-day readmission rate
Question # 70
Within the strategic management process, which of the following actions is most relevant indetermining what projects are feasible for an organization?
A. Performing a stakeholder analysis
B. Identifying strategic opportunities and threats
C. Reviewing resources, capabilities, and core competencies
D. Completing a community health needs assessment
Question # 71
Criteria used to evaluate a team’s performance generally include productivity, individual growth, and:
A. Leadership
B. Attendance
C. Satisfaction
D. Acquiescence
Question # 72
Which of the following statements most accurately describes health literacy?
A. maintains an individual health perspective
B. designs care around the needs of the patient
C. changes health behaviors and decisions
D. emphasizes people's ability to understand health information
Question # 73
A team adopted a solution to a recentproblem of not having the correct supplies at the start of a procedure. A new workflow has been in place for two weeks. This morning, a physician complained that the setup is still missing key supplies, despite the new workflow. Which phase of the Plan-Do-Study-Act (PDSA) model should the team revisit?
A. Plan
B. Do
C. Study
D. Act
Question # 74
Which of the following actions target social determinants of health in an improvement project on asthma control?
A. scheduling follow-up visits at time of discharge for high-risk asthmatic patients
B. mapping asthma patient zip codes against environmental air quality data
C. stratifying prevalence of asthma in the community by age and gender
D. measuring medication adherence to asthma treatment guidelines
Question # 75
Multi-voting Is frequently used in which of the following steps of the quality Improvement process?
A. identifying root causes
B. speculating on problem causes
C. prioritizing Improvement opportunities
D. Implementing solutions and controls
Question # 76
An orthopedic surgeon performed surgery on the wrong finger. After the case, the surgeon took full responsibility, disclosed the error to the patient, and discussed the event with the Chief of Surgery. The Chief of Surgery believed the error occurred because the splint was not removed for preoperative site marking. The surgeon stated, “I have learned from the situation and will never repeat it.” Neither believed further analysis or action was needed. The healthcare quality professional should conclude that:
A. No one was harmed and the surgeon’s accountability was consistent with just culture.
B. The Chief of Surgery demonstrated hindsight bias and minimized the situation.
C. Rapid identification of the root cause and learning dispersion reflected the approaching stage of high reliability.
D. The patient disclosure and discussion with the Chief of Surgery potentiate litigation risk.
Question # 77
Integration of quality principles into an organizational culture is important because these principles:
A. Determine leadership and accountability skills
B. Create a sense of urgency for improvement
C. Support implementation of improvement strategies
D. Ensure the realization of the organizational mission
Question # 78
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?
A. variation, overproduction, and over processing
B. defects, waiting, and over processing
C. waiting. Inventory, andtransportation
D. Inventory, variation, and motion
Question # 79
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. antibiotic usage by the orthopedic department
B. criteria used to classify infections
C. start time of antibiotics for each patient
D. infection control procedure manual
Question # 80
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?
A. lost specimen rate
B. turnaround time
C. average length of stay
D. provider satisfaction
Question # 81
When recommending a quality improvement project, the quality professional must first consider
A. when and how the project outcomes will be measured.
B. how the project aligns with the organization's strategic goals.
C. who will provide the resources for the quality project.
D. what departments and stakeholders need to be engaged.
Question # 82
A treatment center has experienced an increasing number of adverse medication safety events. Review of the data shows a medication error rate for drug–drug interactions of 15.7 per 1,000 medications dispensed. The organizational goal is less than 5 per 1,000, and ultimately 0. Which of the following solutions is most appropriate to consider?
A. Computerized order entry
B. Human factors engineering
C. Electronic medical record implementation
D. Barcode medication administration
Question # 83
After a sentinel event, a root cause analysis (RCA) is performed. Which of the following should be included in the RCA?
A. Implementing process redesign
B. Reporting event to the accrediting body
C. Retraining of individuals involvedThe facility’s compliance rate on pain assessment is shown below:Compliance Rate on Pain AssessmentJanuaryFebruaryMarchPhysicians40%50%20%Nurses80%75%83%Physical Therapists60%55%50%To improve performance, what should be done next?
D. Disseminate the results to nursing staff.
E. Continue monitoring for another quarter.
F. Create an action plan with the department leaders.
G. Hire a pain management specialist.
Question # 84
Which of the following is an effective method to motivate employees to participate in performance Improvement?
A. Host regular town hall meetings.
B. Display a success storyboard in the employee break room.
C. Highlight successes real time in huddles.
D. Provide mandatory training on an annual basis.
Question # 85
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?
A. Prepare a business case to present to the quality professional’s manager
B. Create a bonus structure with human resources for a reward program for expanded work tasks
C. Include the staffing issue as an item on the next hospital's quality committee meeting
D. Meet with the hospital's governing body to discuss the staffing needs
Question # 86
Which of the following is the best strategy for executive leaders to improve patient safety within an organization?
A. Model Just Culture practices.
B. Counsel staff involved in errors.
C. Implement leadershiprounds.
D. Support a blameless environment.
Question # 87
In an improvement project to improve clinic flow, a spaghetti chart is best used to:
A. Analyze the suppliers, inputs, processes, outputs, and customers.
B. Identifyredundancies and wasted movement.
C. Determine the strengths, weaknesses, opportunities, and threats of a process.
D. Display the hierarchy of subtasks required to achieve an objective.
Question # 88
In developing a peer review program, the quality professional has identified an audit tool for chart review, determined the top five diagnoses, and formed a peer review committee. As part of the implementation process, the quality professional should next provide the committee:
A. Training on how to conduct peer review and the elements of a peer review program
B. An implementation timeline to develop the peer review program
C. The results of the chart review of the top five diagnoses
D. The case charts for peer review after determining which diagnoses to review
Question # 89
A key concept in patient safety planning is to design procedures that
A. meet the needs of individual departments.
B. standardize patient care practices.
C. make errors non-transparent.
D. prevent all occurrences.
Question # 90
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. Measure
B. Analyze
C. Improve
D. Control
Question # 91
A recent analysis reveals that reimbursement projection Is being negatively Impacted by post-surgicalrespiratory failure rates. What Is the first step to address this issue?
A. Conduct focused professional practice evaluation (FPPE) on the surgeons in the organization.
B. identify a team leader and facilitator to Implement a quality Improvement project.
C. Conduct a focus group with the anesthesiologists and nurse anesthetists.
D. Obtain a list of the patients Identified by this code and conduct a retrospective review.
Question # 92
A goal of measurement is to collect valid and reliable data that reflects
A. actualperformance.
B. targeted performance.
C. potential performance.
D. desired performance.
Question # 93
A healthcare quality professional has identified sepsis as a high-volume, high-cost patient condition. After 12 months of initiating a sepsis care bundle, the following length-of-stay (LOS) data was analyzed: Length of Stay for Sepsis Diagnosis Month Previous Year Current Year Jan 3 2 Feb 5 6 Mar 8 6 Apr 12 5 May 9 8 Jun 14 4 Jul 8 8 Aug 8 8 Sep 12 9 Oct 6 6 Nov 8 10 Dec 9 6 The governing body has asked for a report on the outcome. Which of the following should be reported and how?
A. There has been an average LOS increase; present using a side-by-side bar graph
B. There has been an average LOS decrease; present using a side-by-side Pareto chart
C. There has been an average LOS decrease; display with a control chart
D. There has been an average LOS increase; display with a run chart
Question # 94
Continued evaluation of a quality improvement initiative occurs within which of the following phases of the DMAIC process?
A. Measure
B. Analyze
C. Improve
D. Control
Question # 95
Which of the following is the most effective method to identify adverse events that cause harm to patients?
A. benchmarking
B. using patient satisfaction surveys
C. conducting a failure mode and effectsanalysis
D. employing trigger tools
Question # 96
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. elimination of wait time from the pharmacy
B. Improvement of staff training on safe medication practices
C. delivery of medications in batches each shift
D. design of mistake-proof systems
Question # 97
Which of the following infection prevention techniques represents a human factors engineering solution?
A. antibacterial soap
B. motion-sensor faucets
C. antimicrobial stewardship
D. instrument sterilization
Question # 98
Leadership wants to leverage technology as a strategy for improvement of patient safety. Which of the following best illustrates this is occurring?
A. A decrease is noted in the number of adverse events reported in the electronic incident reporting system.
B. Staff are unable to move past a required double check without a second staff member using their log-in.
C. There is an increase in workarounds recorded by the barcode medication administration system (BCMA).
D. There is less oral communication of the team, replaced by communication in the electronic medical record.
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