Following the formation of a team, the success of the project will be most highly influenced by:

Data identify a need to reduce medication errors in an institution. When requesting support to form a medication error reduction team from executive leadership, a healthcare quality professional should demonstrate

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 the best way to evaluate the success of a performance improvement team?

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?

A sentinel event is a situation that reaches the patient and results in either a death, severe or temporary harm, or:

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?

Which of the following tools should be used to determine the root cause of variations in a process?

The main purpose of conducting tracers as a part ofcontinuous readiness is to

The preferred culture in promoting patient safety

The ultimate responsibility for ensuring and maintaining patient safety in a healthcare organization lies with the:

The consensus-building group of diverse stakeholders who reviews and endorses measures for public reporting in the U.S. is known as the

A healthcare quality professional is conducting a study to determine how many patients contracted influenza despite receiving flu shots. This study is evaluating

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?

A health system is designing a new wellness program and wants to incorporate social determinants of health. Which of the following should be considered?

An organization's culture is best assessed by examining the

After in-depth data analysis, there is evidence of overutilization of computerized tomography to diagnose acute appendicitis. A team has been formed to develop a performance improvement plan for emergency department physicians. Which of the following leadership styles is most effective to implement best practice guidelines?

A key concept in patient safety planning is to design procedures that

In a quality improvement team, the primary role of the facilitator Is to

A healthcare quality professional receives the following Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results:

Which of the following should be the next action by the professional?

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?

During the course of a root cause analysis, the team found the following Items contributed to the error:

• Fatigue and stress leading to Inattention

• Pressure to accomplish more tasks In the same amount of time

• The equipment was designed for right-handed staff

Which of the following best describe these types of causes?

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?

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 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

The quality professional reviews the following data:

[Data not provided in the document]

Which of the following is the next step?

A hospitalized patient received a medication that was contraindicated based on their home medications. This should have been prevented by

In a data set, the difference between the highest and lowest observed values is known as the

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?

What Is the Initial step the quality professional should take when the organization's performance on a patient satisfaction strategic goal Is below the desired performance?

The trend of a variable over time is best illustrated by a:

A Rapid Process Improvement Team began a new process on January 7 to reduce targeted events per bed day outcome. The team asked the quality analyst to help determine whether the new process was successful and should be continued. Based on the control chart the quality analyst produced, which of the following is the best conclusion?

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?

Which tool would be best suited to sequence interventions within a project?

When a team member fails to complete an assigned task, which aspect of team performance will most likely be affected?

Which of the following Is the best approach to prepare care team members tor Interacting with accreditation surveyors?

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?

Infection control risk assessments are performed to

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's leadership team has asked the quality professional to review alternative accreditation options for the organization. The quality professional recommends the:

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?

An organization that demonstrates a culture of safety

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?

Which performance improvement tool best evaluates care processes and transitions?

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?

Which of the following is most important to include in a project to reduce post-operative infections?

A public health agency is developing a proposal to provide free flu Vaccinations to anyone who requests one. Which of the following would be considered an intangible benefit?

An organization implemented a revised medication reconciliation process 21 months ago. The results of compliance with the revised process were recorded

on a statistical process control chart:

(Use the scroll bar to the right to scroll down as needed.)

Which of the following should be concluded by a performance improvement coordinator after evaluation of the control chart?

The quality improvement (QI) specialist recognizes that any documents related to medical peer review are:

Which of the following could be used as an outcome measure during indicator development?

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?

Priorities must be established for selecting processes for quality improvement because

A Lean improvement concept that represents rapid improvement is

The following data are known:

Which ofthe following accurately describes this chart?

A consistent and effective communication plan for a process improvement initiative facilitates

The collection, analysis, and Interpretation of data for planning, Implementing, and evaluating health programs is

A healthcare quality professional has been asked to assess afacility's patient safety culture. Which of the following should be surveyed?

A healthcare quality professional should determine that this process is:

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% |

Which of the following is an important characteristic of a performance indicator?

Which of the following is the most effective data display tool to demonstrate changes in monthly patient fall rates for the past fiscal year?

A quality professional has been asked to assist with prioritizing quality performance Initiatives In the surgery department. Given the Information In the matrix below, which of the following performance Initiatives should take priority?

Which of the following is one purpose of clinical pathways?

A quality professional is leading a rapid process improvement event to reduce central line infections. Which of the following actions should be taken?

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?

Hospitals must be in compliance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation in order to

Which of the following is the best tool to report process improvements to a quality committee?

A healthcare organization has been providing cardiac care to patients. Leaders areinterested in seeing how their outcomes compare with other organizations that are providing similar care. Which of the following types of programs should this organization consider participating in?

An example of a clinical care process measure is:

Which of the following tools depicts a sequence of events in a process?

The degree to which an instrument measures what it is intended to measure is known as

Which of the following is the most effective method to identify adverse events that cause harm to patients?

Which of the following is the most effective way to promote a safe transition of care to home for patients leaving a hospital?

Which of the following tools would be used to outline factors leading to a problem or desired outcome?

Which of the following is the best approach tomotivate stakeholders across the care continuum to take action?

An internal customer of the admission process in a skilled nursing facility is the

Which of the following tools aids decision-making through organizing tasks, issues, or actions based on agreed-upon criteria?

The study of clinic waiting times measures which of the following types of quality indicators?

The best means of reducing sentinel events In a care delivery system Is

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 root cause analysis is required after what type of occurrence?

Practice guidelines should be based on

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 quality professional was asked to assist with strategic planning. Which ofthe following should have the primary impact on the quality and performance improvement goals?

An organization recently lost its deemed status due to non-compliance with grievance process regulations. Which of the following standards would thequality professional research to identify grievance process requirements to correct the cited opportunities for improvement?

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?

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

A healthcare quality analyst compiles and analyzes data to facilitate performance improvement opportunities. The most suitable data review to proactively control cost would be which type of review process?

Cold-spotting involves identifying populations that

The health department cited a clinic for storing used instruments improperly. From aquality perspective, which of the following should be done first?

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?

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?

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?

An organization has Implemented a quality improvement project. The goal is a mean compliance rate of 90%. The results of observations are found in the table below:

Which focus area presents the greatest opportunity for the organization?

Which of the following identifies project deliverables as well as periods with simultaneously occurring activities?

Quality measures must be relevant, scientifically sound, and

Leadership wants to leverage technology as a strategy for improvement of patient safety. Which of the following best illustrates this is occurring?

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 national health plan has recently acquired a local health plan. At the year anniversary of the merger, the -local health plan staff still struggles with the transition to the new organizational values. Which of the following Is the most likely explanation for the difficulty?

An acute care facility has established an outpatient heart failure clinic. Which of the following will best define the success of the program?

Clinical staff at a hospital inconsistently document the fall risk assessment upon admission. What approach should the quality improvement professional recommend as a priority?

An organization with a focus on population health may use data to

A goal of measurement is to collect valid and reliable data that reflects

Which of the following is the best method of determining improvement priorities to benefit the health of the community?

A healthcare quality professional has been asked to evaluate the integrity of the data used for physician scorecards. When the data abstractors are asked to review physician A's charts, they each report back conflicting information on the physician’s performance. The results are as follows:

Abstractor 1: Compliance = 85%

Abstractor 2: Compliance = 75%

Abstractor 3: Compliance = 100%

This most likely indicates a problem with

A quality professional is reviewing identified deficiencies from a regulatory survey. Which of the following deficiencies should the quality professional prioritize for review?

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?

Patient complaints have been received regarding appointment time delays. Which of the following should be completed 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

Which of the following is the most effective method to identify adverse events that cause harm to patients?

Which of the following recommendations best supports effective transitions of care from hospital to home for patients?

Which of the following quality initiatives impacts an organization’s reimbursement?

Which team role is responsible for maintaining improvements after the implementation of a quality initiative?

The health quality professional recognizes that which of the following events should be reported to regulatory or accreditation organizations?

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 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 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?

Choosing a small number of items to represent characteristics of the whole is an example of

The design of a piece of equipment contributes to an error. Which of the following types of errors has occurred?

Which of the following is an example of improving primary prevention strategies?

Which of the following is the key responsibility of a healthcare quality professional in all types of facilities and organizations?

The most important determinant of quality improvement success is

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 risk manager comes to thequality improvement (QI) professional and requests help to improve compliance with a corrective action plan. How can the QI professional help?

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:

After a sentinel event, a root cause analysis (RCA) is performed. Which of the following should be included in the RCA?

Which of the following is an effective method to motivate employees to participate in performance Improvement?

A hospital wants to place increased emphasis on risk adjustment and cost as part of its innovation strategy. The quality leadership team recognizes that in order to appropriately identify severity of illness, they will need to work with providers and the

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?

The most important determinant of quality improvement success is

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?

Which of the following tools Is most effective in assisting an organization seeking to evaluate the current culture of safety?

Which of the following provides support and subject matter expertise (or organizations that self-report sentinel events?

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?

Which of the following best represents an "unsafe condition"?

Which of the following is an outcome indicator for a radiology unit?

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?

The data below shows 30-day readmission rates for heart failure patients by the primary language spoken and by gender with 95% confidence intervals in parentheses. Which group should be the priority target for reducing disparities in readmission rates?

During the initial quality improvement team meeting, ground rules should be established 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?

Which of the following best describes the goal of the Healthy People Initiative?

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?

The median is defined as the

Physician quality data reports for all credentialed physicians disseminated at regular Intervals, as generally mandated by accreditation standards, are called

A positive correlation is seen in a scatter diagram when

Survey preparation is initiated by a quality professional for an organization's annual three-year accreditation. The executive committee and department managers are given an organizational schedule for training and accreditation activities. Which of the following is the best tool to use to manage this initiative?

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?

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 wishes to develop an education plan for quality and patient safety. Based on adult learning principles, the plannededucation Is most likely to be effective when

The healthcare quality professional is tasked with monitoring the monthly fall rates. The fall rate that requires the most immediate investigation is

Which of the following Is true of a clinical pathway?

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?

Which of the following is required for the successful development of clinical pathways?

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?

When planning a healthcare organization’s performance improvement training, the curriculum is developed considering the needs of which groups?

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?

Even when appropriate processes are in place, errors can occur. Understanding this, leaders coordinating a patient safety program should focus on

To integrate performance improvement with organization planning, there must be alignment between

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?

Reviewing organizational priorities, addressing regulatory requirements, and identifying goals for the next year are important components in the development of which of the following?

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?

The benefits of performing a community health assessment include

An effective meeting requires which of the following?

The most important initial step in preparing for an accreditation survey is

Which of the following should a healthcare plan use to collect satisfaction data from its health plan members?

Performance Improvement plans are most successful when linked first with

Using the Information below, which patient population Is at the highest risk tor tailing?

Which of the following stages may cause continuous quality improvement teams to dissolve prematurely?

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?

An important responsibility of each team member working on a team project is to

The primary focus of Six Sigma methodology is

Recognition of the formal and informal structure of an organization is necessary when implementing a quality improvement program because

To effectively communicate performance indicator results, information should be disseminated to the

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

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:

A local health center is launching a community health assessment. What data is recommended to identify the potential needs of the population?

What is the first step in turning an organization’s long-term goals into an operational plan for improvement?

The quality improvement tool used to identify special-cause variation in a process is a:

Latent conditions can be described as

Which of the following are the three primary quality management activities?