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?
During a recent code blue situation at an organization, there was a delay in administering the defibrillator's shock, A root cause analysis found the delay was due to the fact that defibrillator pads available on the unit were not compatible with the unit's defibrillator Which of the following applications of human factors engineering could have prevented this delay?
An effective method to increase an organization’s board of directors engagement in patient safety is to
Which of the following is a key component in establishing a comprehensive populationhealth management program?
Which of the following is an example of a social determinant of health used to monitor a quality improvement initiative?
The following data are known:
Which ofthe following accurately describes this chart?
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?
Which of the following is essential for effective functioning of a Quality Council?
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?
The performance improvement team developed a prioritization matrix based on the identified improvement opportunities. Based on the information below, what would be the first improvement effort implemented?
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
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?
An organization Is looking for a creative approach at Improving heart failure outcomes to reduce readmissions. Several clinician's express concerns that nothing can be done to Improve this. Two clinicians recommend a set of clinical practiceguidelines recently developed by a specialty organization. Which of the following would the two clinicians be considered?
An acute care facility has established an outpatient heart failure clinic. Which of the following will best define the success of the program?
Which of the following tools will best help a quality professional to exhibit project activities and results?
Which of the following tools should be used to determine the root cause of variations in a process?
A hospitalized patient received a medication that was contraindicated based on their home medications. This should have been prevented by
The healthcare quality professional is engaged with a leadership team. Which of the following will best help to establish performance improvement opportunities?
In order to make effective long-term changes, performance Improvement emphasizes the need to study and understand
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?
How can a quality professional best engage stakeholders in the organization's quality efforts?
An internal customer of the admission process in a skilled nursing facility is the
What is the initial step an organization should take when the strategic goal of improving patient satisfaction has not been met?
Refer to the below medication administration audit:
Patient
Medication administered within 1 hour
Was the correct dosage of medication administered?
Were patient allergies confirmed prior to medication administration?
Was medication administration documented in the patient’s record?
Did the patient experience an adverse medication reaction?
A
Yes
Yes
Yes
Yes
Yes
B
Yes
Yes
No
Yes
Yes
C
No
Yes
Yes
Yes
No
D
Yes
Yes
Yes
No
No
Which patient’s record should the quality professional investigate first?
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?
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?
To effectively communicate performance indicator results, information should be disseminated to the
Prior to discharge, which of the following provides patient information to improve education for heart failure patients?
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?
Data from an incident reporting system compares incident rates for one facility to similar facilities:
After reviewing the graph, which of the following should be done first?
Ahospital is using the above chart to monitor the average length of stay (ALOS) for patients diagnosed with acute myocardial infarction (AMI). Which of the following conclusions should be made?
Which of the following regulatory agencies oversee development of electronic clinical quality measures (eCQMs)?
Which of the following actions best demonstrates that an organization has begun the work necessary to achieve the Malcolm Baldrige award?
Which of the following is the primary benefit of the initial phase brainstorming?
A healthcare quality professional Is assisting an organization with evaluating patient safety actions that will prevent errors of omission. Which of the following systems will most likely be effective?
A team has identified five opportunities for improvement related to patient wait times. Which of the following is the best tool for selecting the opportunity with the highest impact?
To best achieve a low rate of harm in spite of inherent risks in healthcare, an organization must:
In addition to being a good communicator, an essentialcharacteristic of a quality champion is:
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, whichconsistently reports 100% compliance. Which of the following steps should a healthcare quality professional take next?
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?
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 should a healthcare plan use to collect satisfaction data from its health plan members?
Which team role is responsible for maintaining improvements after the implementation of a quality initiative?
When recommending a quality improvement project, the quality professional must first consider
To integrate performance improvement with organization planning, there must be alignment between
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 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?
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:
Following the formation of a team, the success of the project will be most highly influenced by:
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 tools Is most effective in assisting an organization seeking to evaluate the current culture of safety?
An external audit of medical records was just completed. In order for the results to be shared with leadership, which of the following must be done?
A patient was found unresponsive on a medical-surgical floor. Upon review of the patient's medical record, it was found that the patient had accidentally been given two doses of a sedating agent that had not been ordered. Which of the following would have helped prevent this error?
A healthcare organization has experienced a recent increase in the number of falls with injury. A response by leadership that best demonstrates a safety culture is in place within the organization is to
Education sessions were held to improve bar code medication administration (BCMA) performance. Six months after completion of education, an analysis showed continued BCMA improvement. What is the key to sustaining this improvement?
A performance measure for Infection control such as the number of primary blood stream Infections per 1000 central line days Is an example of a
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
A healthcare quality professional receives complaints from numerous patients that the registration process is inefficient. Which of the following should be used to best identify customer expectations, perceptions, and improvement opportunities?
A clinic is implementing a new medication dispensing system. The vendors of three products are on site with staff interacting with the products prior to purchase. Which of the following best describes this type of safety intervention?
Which of the following is most effective to sustain knowledge gained from performance improvement training?
A quality professional needs to select a new project from a list of requests. An organization has determined that new projects should focus on patient safety and cost-reduction. Which tool would help Identify the project that best meets these criteria?
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
Which of the following actions will best promote organizational efficiency in managing quality improvement projects?
In a data set, the difference between the highest and lowest observed values is known as the
The collection, analysis, and Interpretation of data for planning, Implementing, and evaluating health programs is
The consensus-building group of diverse stakeholders who reviews and endorses measures for public reporting in the U.S. is known as the
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
A local health center is launching a community health assessment. What data is recommended to identify the potential needs of the population?
A home health agency has purchased an automated phone notification system to alert nurses that a patient has been discharged from a healthcare facility. The healthcare quality professional should complete which process as a next step?
Which of the following is the most effective means of communicating commitment to patient safety?
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?
A hospital received 50 Incident reports describing falls that occurred within aone-month period. Which of the following actions should be taken?
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
Based on the data below, which unit should the quality Improvement coordinator focus on?
Which initiative should a quality professional promote in an organization seeking to optimize value-based reimbursement?
Using the Information below, which patient population Is at the highest risk tor tailing?
Which of the following is the role a healthcare quality professional should play in strategic planning?
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 team has identified that labeled cutting boards are needed in a kitchen to decrease cross-contamination. After a new process has been implemented, it is discovered that the labeled cutting boards are not being used. Which of the following is the next action the team should take?
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
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 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 nursing director for a unit in a cancer hospital Is reviewing and assessing outcomes data in the followingscatter diagram:
The relationship between the incidence of infection and the decrease in staffing targets is
A surgeon has a surgical site infection rate of 6.7% for a particular procedure. The average infection rate for other surgeons performing the same procedure at this facility is 3.3%. After notifying the department chair of this situation, the quality professional should recommend
According to the Institute of Medicine’s (IOM) report, Crossing the Quality Chasm, which of the following is identified as one of the six aims for improvement?
Integration of a quality culture within an organization Is best demonstrated by
Which of the following is required for the successful development of clinical pathways?
A department director has been asked to compare the productivity of the department with the productivity of similar departments at other facilities. Which of the following Is the first step of this project?
An orthopedic surgery practice has been working on improving patient safety for the last 3 years. The following data table is available:
Which of the following is the most appropriate conclusion about patient safety outcomes?
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 quality professional was asked to assist with strategic planning. Which of the following should have the primary impact on the quality and performance improvement goals?
Data for an organization's annual Influenza vaccine administration yields the following results:
What is the median for the organization's annual vaccine count?
A CEO has directed a quality improvement council to develop objectives to meet an identified goal. When developing objectives, the council must remember to
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
An electronic medical records system was implemented in a department. Which of the following is the next step?
A hospital's quality professional notices a high 30-day readmission rate for patients with chronic obstructive pulmonary disease (COPD) exacerbation. What is the quality professional's next best step?
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 patient safety officer is developing a patient safety program. The following information has been reviewed:
Incident report data
Performance indicators
Customer complaintsWhich of the following additional information is needed prior to writing the patient safety plan?
A quality coordinator was asked to evaluate team effectiveness for a struggling quality improvement team. When interviewed about the team, members say they are frustrated because they do not know what the team is supposed to accomplish. Which of the following should be explored first?
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
The following information is available on a health system's performance dashboard:
Employee turnover decreased from 9% to 6%
Reporting of patient safety events and near misses increased 5%
Overall patient satisfaction increased from 58% to 61%Which of the following should the quality professional conclude as a result of this information?
Which of the following actions best illustrates an organization has begun the work necessary to achieve the Malcolm Baldrige Award?
A risk manager comes to the quality improvement (QI) professional and requests help to improve compliance with a corrective action plan. How can the QI professional help?
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 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?
When developing objectives for an educational program, the quality professional should recommend
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 of the following could be used as an outcome measure during indicator development?
The health quality professional recognizes that which of the following events should be reported to regulatory or accreditation organizations?
Which of the following is the most effective method to identify adverse events that cause harm to patients?
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?
Which of the following tools aids decision-making through organizing tasks, issues, or actions based on agreed-upon criteria?
Which of the following best describes the goal of the Healthy People Initiative?
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?
In aligning an organization's performance Improvement plan with strategic goals, a healthcare quality professional should consider
Which of the following Is an essential step in the strategic planning process?
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?
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?
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 is the best data source to assess an organization’s culture of safety?
An organization conducts daily briefing sessions. Which of the following questions demonstrates a culture of safety?
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?
Which of the following recommendations best supports effective transitions of care from hospital to home for patients?
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:
Which of the following should be used to show beginning and ending times for an activity along a timeline?
Using the data below, which issue would be identified as a priority for further performance improvement?
Issue
High Risk
High Strategic Priority
Cost
Customer Satisfaction
Quality Concern
Pressure Injuries
4
4
1
4
5
Medication Errors
3
1
2
1
5
Transfer to Higher Level of Care Within One Hour of Admission
2
5
4
1
3
Miscommunication of Abnormal Findings
4
3
5
1
4
A facility’s performance on a clinical outcome measure has deteriorated. The healthcare quality professional’s initial action should be to
Which of the following Is the best approach to prepare care team members tor Interacting with accreditation surveyors?
Within the strategic management process, which of the following actions is most relevant indetermining what projects are feasible for an organization?
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 is the key responsibility of a healthcare quality professional in all types of facilities and organizations?
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 managed care peer review committee should obtain which of the following first?
Following evaluation of the compounding process used by a pharmacy, the batch compounding consistently yields 12% more drug than Is needed. The excess Is stored until used or expired. Which of the following types of waste should be recorded when reporting this finding?
Priorities must be established for selecting processes for quality improvement because