The greatest motivator for organization leaders to use a balanced scorecard is that it

A graph shows a 50% complication rate for appendectomies. Which of the following would be most important to assist the reader in interpreting the data?

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?

An effective way of keeping participants engaged in a meeting is

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 tools is most useful for an organization to complete prior to implementation of a new device for administration of intravenous chemotherapy?

Establishing a culture of safety begins with having the right

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?

Supporting patients through longitudinal care plans is the guiding principle of:

Which of the following is an example of an alternative payment model (APM)?

A healthcare organization has decided that the healthcare qualityprofessional will provide performance improvement training to all supervisors. The first step is to

The culture of safety survey data below is collected from perioperative services. Which action should the healthcare quality professional recommend?

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?

How can a quality professional best engage stakeholders in the organization's quality efforts?

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?

An annual evaluation of a radiology department's quality improvement program did not identify any opportunities for improvement. The healthcare quality professional should recommend a review of:

Priorities must be established for selecting processes for quality improvement because

Accountability for quality ultimately rests with the

Which of the following tools will best help a quality professional to exhibit project activities and results?

A root cause analysis is required after what type of occurrence?

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

The following data are known:

Which ofthe following accurately describes this chart?

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

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

A root cause analysis (RCA) was conducted for an event related to a delayed high-priority alarm response. Alarm fatigue was determined to be a root cause. Which of the following is the most appropriate first intervention?

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?

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?

Using clinical guidelines based on scientific evidence will most likely

Which of the following infection prevention techniques represents a human factors engineering solution?

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 recent Journal article has Identified three new patient safety Initiatives. When reviewing these Initiatives, the first action of a healthcare quality professional Is to

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?

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?

Organizations with a positive safety culture are best characterized by

A team wants to select a group of patients to measure satisfaction with care. Which of the following is an example of probability sampling?

When developing objectives for an educational program, the quality professional should recommend

Which performance improvement tool best evaluates care processes and transitions?

An organization Is evaluating the data used to measure compliance with medication reconciliation by clinic. Three abstractors have been assigned to collect the data. The compliance data by abstractor and unit are below:

Based on this table, which of the following Is the best next step to evaluate accuracy andreliability ol the data?

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?

As part of survey preparation, a quality professional follows the experience of care for several patients throughout the organization. This is an example of using

Which of the following approaches best allows an agency to align Its activities with organizational goals?

A hospital received 50 Incident reports describing falls that occurred within aone-month period. Which of the following actions should be taken?

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

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

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?

A hospital installed a new patient safety event reportingsystem. During the failure modes and effects analysis (FMEA), decreased use of the system and complexity of reporting were identified as potential failures. What should the team use to determine which failure mode to address first?

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?

Which of the following measures would best evaluate the health of a metropolitan area?

Evaluating data to determine high utilizers of emergency departments and their related characteristics is a strategy that can best help with

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

A healthcare quality professional led a process improvement project to decrease the elapsed time for the stroke protocol. Which of the following tools will best help the quality professional to exhibit project activities and results?

Sentinel events are most often the result of variations in:

Analysis of the following wound infection rate control chart shows which of the following?

One of the first steps in preparing for an organizational accreditation survey Is to have a quality professional

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

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?

Secondary prevention Is Primarily Intended to

Which of the following is the best example of a patient-centered approach in healthcare?

To determine how much variability in a process Is due to random variation and how much Is due to unique events, the most appropriate tool would be a

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

Team effectiveness can best be evaluated by

A provider requests to see the peer review file on another provider in their department. What is the healthcare quality professional’s most appropriate response?

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

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 the clinic 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?

When working with a new qualityImprovement team, the quality professional should stress the importance of

Which management accountability action should be Implemented to ensure continuous readiness tor accreditation survey?

Managed care outcomes related to HEDIS measures are most commonly obtained through

Which of the following should be a part of an organization's program of continuous readiness for accreditation?

A Quality Council has received the following requests for establishing performance improvement teams:

Maintenance: Overtime reductions

Dietary: Meal delivery process

Housekeeping: Room turnaround times

Biomedical: Identification of malfunctioning equipment

Human Resources: Competency assessments

Which of the following should the Quality Council do first?

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

Which of the following methods best links performance improvement activities with organizational strategic goals?

Leadership is trying to set SMART goals as part of the annual quality plan. Which of the following meets this framework?

Which of the following should be used to show beginning and ending times for an activity along a timeline?

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?

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

A facility plans to provide a new specialty. Which of the following will best provide information on the effectiveness of the specialty?

A hospital has just implemented a physician order entry system. Three days into implementation, the users begin having major technical issues with the system. The nurse manager instructs staff to submit troubleshooting requests to the help desk. This is an example of which high-reliability principle?

Which of the following presents a set of high-level measures grouped into learning and growth, customer, internal business, and financial?

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?

Which of the following is the best example of population health management?

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?

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?

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?

Annual evaluation of a quality Improvement process must

Which of the following best describes how a quality professional should conduct an organizational assessment to ensure safe transitions of care?

Which of the following is the role a healthcare quality professional should play in strategic planning?

The expectation to maintain continuous survey readiness must be supported and driven by the

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

When reporting infection control indicators to a governing body, a healthcare quality professional should demonstrate improvement with which of the following tools?

The most important determinant of quality improvement success is

A strategy to address social determinants of health would be to

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

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?

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

Infection control risk assessments are performed to

The desired outcome of peer review Is to

The chart below reflects the 12-week period following implementation of a new electronic health record (EHR) at an outpatient clinic.

Based on the information above, which of the following conclusions can be drawn?

A healthcare quality professional is looking at a control chart and notices that last November the number of admissions for flu symptoms exceeded the upper control limit. This most likely represents:

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?

An organization is adopting Lean Six Sigma as their new performance improvement model. The best approach for providing training on the model is to

Which of the following is the best disease management approach to reduce hospitalizations for patients with high blood pressure?

Which of the following would be the best methodology to reduce referral wait time?

An outpatient medical clinic wants to test whether a relationship exists between two factors: lack of available transportation and the number of times patients do not keep appointments. Which of the following tools should be used?

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 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

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?

A healthcare organization has recently launched a diabetes center of excellence to address the needs of its patients with advanced diabetes. The implementation of this program would fall into which of the following types of prevention?

A performance improvement team has been examining delays in getting admissions from the emergency department (ED) to the coronary care unit. The team has collected data and determined that a significant number of delays are occurring because cardiologists are not consulting on their patients in the ED in a timely manner. The best way to communicate this information to the cardiologists is to:

Which of the following actions will most effectively promote safety activities within an organization?

Evaluating data to determine high utilizers ofemergency departments and their related characteristics is a strategy that can best help with

In statistics, the p-value provides the data user with

An organization conducts daily briefing sessions. Which of the following questions demonstrates a culture of safety?

In addition to being a good communicator, an essentialcharacteristic of a quality champion is:

Prior to the implementation of a new electronic health record (EHR), a facility charters a failure mode and effects analysis (FMEA) team. After mapping out the process for creating a new patient chart, the next step should be to:

The control chart above indicates which of the following?

An employee health program includes a pre-employment health assessment for all prospective employees. The assessment is to be completed, and the results known prior to the assumption of duties. A retrospective study of 200 employees resulted in the information displayed in the following chart:

Review of this information indicates which of the following?

When recommending a quality improvement project, the quality professional must first consider

An organization has established an ambulatory diabetic management program. Which of the following will best define a successful outcome of the program?

Which of the following technology enhancements will help the hospital most accurately identify hospital-acquired condition rates?

Senior leadership is evaluating an organization’s progress toward achieving patient safety goals and has a goal of 100% compliance. Hand hygiene compliance is currently at 80%, and "time-out" compliance is at 90%. A healthcare quality professional should recommend

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

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?

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 of the following will help determine the health status of a defined population?

A healthcare quality professional Is facilitating the establishment of a Quality Council for an outpatient surgery center. The following positions have been selected for membership: medical director, CEO. and CFO. Which of the following Is the most appropriate Individual to add?

A 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?

Which of the following is used to assess points of vulnerability within a process?

Benchmark is a term used to describe

The main goal of a clinical pathway/guideline Is lo

A healthcare quality professional's initial step in the creation of a patient safety program is to

The primary objective of the project charter is to

Cold-spotting involves identifying populations that

A nursing unit has collected the following data:

Which of the following is the best method to display this data?

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

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

A multidisciplinary team completed a quality improvement project and wants to evaluate the team’s performance. Which of the following is most helpful?

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 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 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 payment systems carries the most financial risk for a provider?

Each provider in a primary care practice has the potential of earning a $20,000 bonus based on individual performance on select Healthcare Effectiveness Data and Information Set (HEDIS) indicators as outlined below:

Based on this information, which of the following conclusions is accurate?

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

The most effective method of communicating compliance with clinical practice guidelines is to disseminate results to

The following hospital Medicare readmission findings are available:

Based on the provided information and an understanding of factors that drive readmissions, the hospital should first

The preferred culture in promoting patient safety

A performance improvement team was formed to reduce the inappropriate ordering of two expensive lab tests. The goal was to reduce the rate of inappropriate ordering of Test A by 20% and Test B by 5%. The results of the pilot group showed a 30% drop in Test A orders and a 3% drop in Test B orders. What additional information would be of most benefit to gain final administrative approval to implement the change organization-wide?

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?

A healthcare quality professional, previously employed by a hospital, has been hired by an ambulatory surgery center to create a continuous readiness program. Both employers are Medicare certified and are accredited by the same accrediting organization. The healthcare quality professional should first

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

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 purpose of sentinel event review of never events is to

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

A Lean improvement team is examining potential improvements to room layout to reduce waste. Which of the following is the best tool to identify the baseline distance staff travel through the day to gather the materials they need to perform their job tasks?

An organization has a three-year accreditation cycle. The highest priority for the first year of the cycle by the accreditation team is

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 recent journal article has identified three new patient safety initiatives. When reviewing these initiatives, the first action of a healthcare quality professional is to:

Which of the following is true of a clinical pathway?

An improvement team is presented with the following information and tasked with deciding which improvement methodology would be most appropriate:

Medication Physician Order to Medication Arrival on Unit

Time in Minutes: Median: 45, Average: 44.3, Goal: 30

Staff Comments:

"The process is too complicated.”

"Why do I need to enter the order into two different systems? There are lots of non-value added steps.”

"We are constantly waiting for the medication to be delivered from the pharmacy, which delays patient care. Why can't we access this medication directly on the floor?”

"The pharmacy overproduces this medication in large batches, which goes wasted.”Based on the information available, which of the following methodologies is most appropriate to address the concerns about the process?

Which of the following tools is most appropriate to analyze a medication administration process?

Which of the following is a primary intervention for type 2 diabetes?

Which of the following is an example of a structural measure?

A hospital quality team notices there is an increased number of falls in the inpatient stroke unit. Which of the following is the best method to analyze the issue?

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 performance improvement team is looking at data from similar medical centers to improve patterns of care. This method of assessment is known as:

An orthopedic surgery practice has been working on Improving patient safety for the last 3 years. The following data table is available:

Which of thefollowing Is the most appropriate conclusion about patient safety outcomes?

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?

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 would best facilitate the development of priorities?

Which of the following is true regarding critical values?

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:

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?

At what step in the DMAIC process should a healthcare quality professional complete a gap analysis?

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 healthcare quality professional can conclude that clinical performance measures in disease specific certification programs are best supported by the

Which of the following regulatory agencies oversee development of electronic clinical quality measures (eCQMs)?

Which type of data could best be used to help identify health-determinant information in apatient population?

Which of the following is most effective to sustain knowledge gained from performance improvement training?

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?

The quality director would like to prepare the team for the upcoming accreditation survey. Which of the following would ensure continuous team survey readiness?

Which of the following data sources can be used to assess a population's health status?

To best achieve a low rale of harm In spite of Inherent risks In healthcare, an organization must

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?

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:

What tool displays performance outside of expected values to merit a deeper analysis?

An example of a safety practice that allows any worker to speak up when a rule is not being followed is:

Quality measures must be relevant, scientifically sound, and

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

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

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?

Care that does not vary in quality because of gender, ethnicity, geographic location, or socioeconomic status is said to be

An organization's preventable fall goal is not to exceed greater than 25% of its total falls. Which units below meet this goal?

Performance Improvement plans are most successful when linked first with

Which of the following most accurately describes medication reconciliation?

Four surgical centers formed a collaboration to reduce post-operative infection rates. The goal was to reduce infection rates by 20% from baseline.

Which center met the goal?

Which of the following strategies promotes timely completion of a quality improvement project?