A newpediatric psychiatric unit will open in one year. The utilization coordinator is responsible for developing the utilization management program. The program's success will depend on which of the following factors?
An interdisciplinary learn 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 facility Is reviewing their quality program for compliance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. Which of the following Is the most Important factor in program compliance?
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?
A director at a large health system is tasked with building a new population health program. What is the director’s first step?
Evaluating data to determine high utilizers ofemergency departments and their related characteristics is a strategy that can best help with
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?
An effective method to increase an organization’s board of directors engagement in patient safety is to
Which of the following is the appropriate group to review care delivered by an individual physician to a patient who suffered a serious adverse event?
The healthcare quality professional is tasked with monitoring the monthly fall rates. The fall rate that requires the most immediate investigation is
Which initiative should a quality professional promote in an organization seeking to optimize value-based reimbursement?
Which of the following is the most effective method to identify adverse events that cause harm to patients?
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
The quality manager needs to identify a set of process measures to improve wound care outcomes. The first step should be to
Prior to implementing a new patient service, the healthcare quality professional should recommend
When reporting infection control indicators to a governing body, a healthcare quality professional should demonstrate improvement with which of the following tools?
Which of the following should a healthcare plan use to collect satisfaction data from its health plan members?
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 data sources can be used to assess a population's health status?
A healthcare organization had three medication incidents associated with narcotics. None of the events led to permanent loss of function or death, but could be considered near misses. Which of the following would be the best tool to use to identify influencing factors?
The quality manager needs to identify a set of process measures to improve wound cate outcomes. The firststep should be to
In preparation for a provider organization accreditation survey, the most effective method for identifying training needs for staff is
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?
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?
Which of the following is the key responsibility of a healthcare quality professional in all types of facilities and organizations?
A healthcare quality professional's initial step in the creation of a patient safety program is to
A performanceimprovement specialist at an ambulatory surgery center is facilitating a Plan-Do-Study-Act Cycle (PDSA) process to improve the rate of hand hygiene amongst surgical post-recovery staff to 90% or above. Data from the past 12 months are as follows:
Baseline: 60% compliance
Q1: 87% compliance
Q2: 79% compliance
Q3: 91% compliance
Q4: 72% compliance
The specialist is preparing to discuss aggregate results with the Quality Committee. To most accurately convey the results, the specialist highlights the
Physician quality data reports for all credentialed physicians disseminated at regular Intervals, as generally mandated by accreditation standards, are called
For which incident would a process improvement manager be required to perform a root cause analysis (RCA)?
To effectively communicate performance indicator results, information should be disseminated to the
Which of the following is an example of a social determinant of health used to monitor a quality improvement initiative?
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?
Which of the following regulatory agencies oversee development of electronic clinical quality measures (eCQMs)?
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?
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?
Which Is a source of data tor analyzing staff flu vaccination trends for an accountable care organization?
To promote staff engagement In a new Initiative, educators should focus on staff
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?
Ongoing practitioner practice evaluation (OPPE) Is used for which of the following?
When working with a new qualityImprovement team, the quality professional should stress the importance of
A healthcare quality professional Is doing a study in the emergency room. Every other patient admitted to the department Is Included in the sample. This sampling technique Is best described as
A hospital received 50 Incident reports describing falls that occurred within aone-month period. Which of the following actions should be taken?
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 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?
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?
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?
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 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?
Which of the following actions best demonstrates that an organization has begun the work necessary to achieve the Malcolm Baldrige award?
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?
One of the first steps in preparing for an organizational accreditation survey Is to have a quality professional
In a healthcare organization Implementing ongoing performance Improvement (PI), which of the following will most likely benefit the PI goals of the organization?
The clinic has a goal to reduce the Healthcare Effectiveness Data and Information Set (HEDIS) measure of ' the percent of diabetic patients with a HgA1c greater than 9.0% for accreditation. Who should be Included on the quality Improvement team?
While the use of technology may result in fewer medical errors. In order for this strategy to be most effective. It should be supported by
In aligning an organization's performance Improvement plan with strategic goals, a healthcare quality professional should consider
Which of the following is an effective method to motivate employees to participate in performance Improvement?
Which of the following Is the best example of effective learning in a learning organization?
Multi-voting Is frequently used in which of the following steps of the quality Improvement process?
A quality improvement professional believes that their MRSA facility rates are high. What should the quality improvement professional do 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?
A healthcare quality professional has identified a gap In practice from regulatoryrequirements. The quality professional should
A study was performed to compare quality outcomes between case/care managed groups and non-case/care managed groups tor elective coronary artery bypass. The results are as follows:
What is the median length of stay (or non-case/care managed patients?
An organization has compiled the scatter plots below:
Based on these plots, which of the following conclusions can be made by the quality professional?
A quality Improvement team has Identified specific changes to Implement for a quality Improvement Initiative. As the next step, the team would like to establish a concrete timeline for implementation. Which of the following is the best tool to use for this step?
A hand surgeon is referred for peer review for a case of a wrong-site surgery. Which of the following professionals would be the best choice as a member of the peer review committee?
Which of the following Is the best approach to prepare care team members tor Interacting with accreditation surveyors?
When developing objectives for an educational program, the quality professional should recommend
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:
Choosing a small number of items to represent characteristics of the whole is an example of
Which of the following actions will best promote organizational efficiency in managing quality improvement projects?
Continued evaluation of a quality improvement initiative occurs within which of the following phases of the DMAIC process?
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 is an example of collaboration for optimal care transitions?
When an identified solution requires significant change, the best tool to increase the likelihood of success is a:
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?
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:
Medical staff monitoring indicators are best developed through a collaborative effort between the hospital's quality management professionals and the:
Ahealthcare quality professional has the following data on a hospital's surgical site infection rates:
Procedure
Hospital Infection Rate
95% Confidence Interval
State Mean Infection Rate
Total Hip Replacement
0.4%
0.2%-0.6%
0.9%
Total Knee Replacement
1.1%
0.8%-1.2%
1.0%
ACL Reconstruction
1.5%
1.4%-1.6%
1.5%
Total Shoulder Replacement
1.3%
1.0%-1.6%
0.9%
Which procedure is the best area for focused quality improvement?
In an improvement project to improve clinic flow, a spaghetti chart is best used to:
Which of the following conclusions might be drawn from failure mode and effects analysis (FMEA)?
Which of the following is the best way to evaluate the success of a performance improvement team?
To determine the success of a transfusion quality improvement project, a healthcare quality professional should:
Based on this matrix, which of the following ideas should the team address first?
Which of the following characteristics are most appropriate for a physician champion of healthcare quality?
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?
Which of the following best describes how a quality professional should conduct an organizational assessment to ensure safe transitions of care?
Which initiative should a quality professional promote in an organization seeking to optimize value-based reimbursement?
Which of the following recommendations best supports effective transitions of care from hospital to home for patients?
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?
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?
Which of the following is the most effective way to promote a safe transition of care to home for patients leaving a hospital?
Prior to discharge, which of the following provides patient information to improve education for heart failure patients?
Which of the following is an example of using human factors engineering to improve patient safety?
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 pulmonologist is gathering social determinants of health data from their patients. Which of the following best explains the purpose of collecting this data?
The quality improvement (QI) specialist recognizes that any documents related to medical peer review are:
Which of the following should be used to show beginning and ending times for an activity along a timeline?
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 ability to safely manage complex tasks in the face of time pressures, quickly identify and contain errors, and bounce back after stressful situations relates to organizational:
A 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 stages may cause continuous quality improvement teams to dissolve prematurely?