1.

Failure Mode and Effects Analysis (FMEA) is performed

a) ‰ as a preventative measure before an incident occurs.
b) ‰ to immediately investigate an incident that occurred.
c) ‰ if the severity of an incident led to a patient death.
d) ‰ when there is a chance of an incident reoccurring.
2. Which one piece of information is the most useful to describe the age of population that is
served in an anticoagulation monitoring service clinic
a) ‰ t-test.
b) ‰ mean.
c) ‰ standard error of the mean (SEM).
d) ‰ chi square test.
3. The primary goal of risk management is to
‰ minimize financial loss associated with legal actions.
‰ perform Failure Mode and Effects Analyses (FMEA).
‰ maintain an effective and timely incident reporting system.
‰ identify the high risk areas of the organization.
4. All of the following are key aspects of quality EXCEPT:
‰ It depends upon customer perceptions.
‰ It does not change with time.
‰ It considers customers needs.
‰ It promotes high levels of precision.
5. Meaningful quality process measures must be
‰ feasible and explainable.
‰ relevant and explainable.
relevant and valid
6. Fall prevention programs should include all of the following EXCEPT:
‰ Assessment/reassessment criteria.
‰ An evidence-based risk assessment tool.
‰ Reimbursement criteria.
‰ Post fall assessment criteria.

7. Which one piece of information is the most usefull to describe the age of population that is
served in a vaccination clinic ?
‰ Pie chart.
‰ Radar chart.
‰ Gantt chart.
‰ Scatter plot.s
8. A healthcare quality professional has been asked to examine a new method of reviewing adverse
events in an organization. It has been decided that a system of triggers will be established to
alert the Quality Council of a potential problem. The best example of a trigger that should be set
with a threshold of zero is a

A. medical record not completed by a physician.

 B. staff member not using proper handwashing technique.
C. near miss from failure to perform a 'time-out.'
D. patient complaint regarding wait times.

9. Which of the following obstetrical outcomes will result in a morbidity review?

A. normal deliveries
B. neonatal deaths
C. post-delivery septicemia

D. Cesarean sections

10. An outpatient clinic is attempting to measure the quality of a newly developed diabetes
disease management program. To accomplish this, laboratory results will be measured over
time. The best way to display the data is to use a
A. Gantt chart.
B. control chart.
C. Pareto chart.
D. flow chart.

11. For a continuous quality improvement team to be successful, who must be included on the
team?

A. person performing the process

B. department supervisor
C. administrator
D. quality management representative

12. Human factors engineering is defined as the study of humans and their interaction with

A. The tools they use and the environment

B. medical technology and the organizational systems.
C. adverse events and latent errors.
D. patients and the organization.
13. A culture of patient safety in an organization will have been successfully created when

A. personal accountability is removed from the organization.

B. near miss reporting of safety issues declines.

C. staff members serve as safety advocates.

D. a root cause analysis is performed regularly.

14. Which of the following is used to summarize a characteristic in a population?

A. frequency distribution

B. regression analysis
C. case control study
D. control chart

15. A staff member reports that a colon perforation occurred during a colonoscopy. Which of
the following is a healthcare quality professional's next step?
A. Review 100% of colonoscopy procedures.
B. Refer the case for peer review.

C. Modify the physician's privileges.

D. Assign a proctor to the physician.

16. The phrase "reaching consensus" is often used in performance improvement. The term
consensus refers to
A. unanimous agreement.
B. support by all members.

C. everyone being totally satisfied.

D. a majority vote of those present.

17. A healthcare network has implemented an electronic medical record system allowing data to
be transmitted, on demand, from one facility to another. Which of the following will best
promote both cost effectiveness and patient satisfaction?
A. decreasing repeat tests when a patient is seen in more than one facility

B. eliminating the need for patients to hand-carry records

C. improving the accuracy of medication reconciliation
D. increasing the security of confidential patient information

18. When using cost-benefit analysis in decision-making, it is important to remember that

 A. consideration of the benefit is more important than cost.
B. return on investment should be at least 10 to 1.
C. implementation costs are more important than return on investment.
D. qualitative and quantitative data should be used.

19. A health plan is required to have a mechanism for members to submit complaints. Which of
the following actions must be included in the complaint analysis to ensure the plan makes
full use of this type of information?
A. Total each complaint category at least on an annual basis.
B. Calculate the average number of complaints per office site.
C. Review complaints to find system problems that can be improved.

D. Determine the date/time the complaint occurred and the person responsible.

20. A healthcare quality professional is conducting a study to determine how many patients
contracted influenza despite receiving flu shots. This study is evaluating
A. appropriateness.
B. process.
C. efficacy.

D. prevalence.

21. The perception of how an organization operates, including how employees relate to internal
and external customers, is the organizational
A. structure.
B. mission.
C. vision.
D. culture.

22. A consulting firm has been selected by a healthcare Board of Directors to assess the quality
improvement program. Before starting the assessment, the quality professional should first
A. set up a project plan.
B. develop potential action plans.
C. define expectations and outcomes.

D. design a dashboard.

23. When conducting a sentinel event review, a root cause analysis

 A. provides judgment of staff behaviors.
B. identifies gaps in patient care processes.

C. requires team consensus.

D. proactively identifies causes and effects.

24. Which of the following principles applies to continuous quality improvement in an

organization?

A. Twenty percent of trouble comes from 80% of the problems.

B. Systems, not poor job performance, are responsible for most problems.
C. Causes of nonconformance must be identified and corrected temporarily.
D. Empowerment automatically occurs upon implementation of the program.

25. The best reason to evaluate team meetings is to

A. assess progress.

B. rate leader performance.

C. keep participants interested.
D. assess accuracy of the minutes.

26. Which of the following is the primary benefit of using external quality consultants?

A. promoting effective communication

B. bridging knowledge gaps

C. maintaining performance standards for the organization

D. clarifying the mission and vision of the organization

27. Leaders enhance employee commitment to organizational values by fostering which of the
following types of communication?
A. face-to-face, oral, scheduled

B. timely, open, two-way

C. clear, written, top-down
D. formal, electronic, 'need to know'

28. The evolution of quality improvement in healthcare has shifted the primary focus from
performance of individuals to the performance of the

A. medical staff.
B. governing body.
C. ancillary departments.
 D. organization's systems.

29. A performance improvement (PI) training program for supervisors should include

A. Results of a failure mode and effect analysis (FMEA)

B. budget-variance reporting.
C. rapid-cycle process.
D. review of patient falls.

30. Performance improvement teams should always be required to

A. evaluate data.
B. include senior leadership.

C. perform root cause analyses.

D. write mission and vision statements.

31. The primary objective of the operational linkage between risk management and
quality/performance improvement is to
A. meet regulatory requirements.
B. develop a plan of action for individual cases.
C. develop a comprehensive plan to prevent future occurrences.

D. alert the hospital attorney of a potentially compensable event.

32. A quality improvement manager must decide how to present data that demonstrates the
relationship between two process characteristics. Which of the following data display
techniques is most appropriate?
A. bar chart
B. scatter diagram

C. Pareto chart
D. line graph

33. Failure modes can be prioritized by calculating the criticality index. Which of the following
three categories are normally used to calculate a criticality index?
 A. probability, likelihood, and criticality
B. frequency, severity, and ease of detection

C. effectiveness, risk, and priority

D. response, evidence, and outcome

34. Which of the following is always true regarding a sentinel event?

A. The cause is established as a deviation from standards.

B. The occurrence requires an immediate investigative response.
C. The incident is a result of a medical error.
D. The findings must be reported to a regulatory body.

35. A valid data collection tool should incorporate

A. a minimum of 20 data elements.

B. a reliable graphic presentation.
C. the definition of data elements.

D. allowance for variance of interpretation.

36. When examining the relationship between staff and patient outcomes, which of the
following is the most appropriate to assess?
A. staff turnover and budget
B. patient safety data and overtime data
C. overtime data and absenteeism rates
D. occurrence reports and sentinel events

37. Comparing healthcare organizations by using medical error rates

A. may present bias due to differences in reporting practices.

B. must include a minimum of 10 different facilities.

C. cannot be performed by facilities with less than 100 beds.
D. provides the best method for benchmarking patient safety.

38. The success of a performance improvement program will be most influenced by the

A. reliability of data management software.

B. educational preparation of quality leaders.
 C. culture of the organization.

D. people skills of the facility leaders.

39. Which of the following sampling techniques selects participants based on their availability in
a certain place during a specific time frame?
A. Quota
B. Random
C. volunteer
D. convenience

40. A hospital has recently moved to a paperless system. It is noted that some data is missing
from the obstetrics delivery record. A healthcare quality professional should recommend
A. assessing the need for additional education.
B. evaluating the computerized data entry process.

C. providing a paper trail.

D. designating one data entry person per shift.

41. A critical difference between quality assurance (QA) and quality improvement is a shift in
focus from

A. retrospective review to concurrent screening.

B. nonclinical aspects to customer satisfaction.

C. identifying poor performers to improving group performance.
D. QA coordinators to teams.

42. Which of the following is the best example of use of human factors engineering?

A. designing products to prevent tubing misconnections

B. implementing a Kaizen process to reduce inventory

C. eliminating waste through reduction in motion
D. using PDCA to improve compliance with hand hygiene

43. A hospice agency conducted a satisfaction survey of all 200 patients currently receiving pain
management services. When asked if they were satisfied with their pain management, 170
patients said yes, and 30 said no. A target satisfaction rate of 90% has been set. In this
situation, a healthcare quality professional should
A. review all dissatisfied responses for similarities.

B. collect more data to ensure statistical significance.

C. discontinue monitoring because an 85% satisfaction rate is excellent.
 D. continue monitoring because a 15% dissatisfaction rate is acceptable.

44. Informed consent for hip surgery was obtained and documented for an elderly patient. In the
recovery room, a nurse discovered the wrong hip had been replaced. A healthcare quality
professional should
A. conduct a failure mode and effects analysis (FMEA).
B. initiate the disciplinary action process.
C. review the practitioner's qualifications and licensure.
D. perform a root cause analysis.

45. A monitoring system is being designed in which data will be collected and compared to
criteria. Which of the following will best enhance the validity and reliability of the data?
A. establishing criteria that are based on the most recent changes in medical science and technology
B. using a computerized system to substitute data for missing responses
C. assigning one staff member to identify, collect, enter, and interpret all data
D. providing a practice-based definition and specific instructions for each element

46. Which of the following topics are discussed at a morbidity and mortality conference?
A. healthcare-acquired infections and perioperative mortality
B. planned readmissions and newborn mortality rates

C. Cesarean section rates and number of physicians

D. inpatient mortality and admissions

47. Timeliness and compliance of documentation were discussed at a multidisciplinary team

meeting. To evaluate the effectiveness of the team's action plan, which of the following will
provide the most useful information?
A. physician attendance
B. number of complaints
C. frequency of meetings
D. medical record review

48. A Quality Council has examined data on patient falls and determined that a comprehensive
falls prevention program is needed. The first step in increasing staff awareness of this
 initiative is to
A. require staff to sign that they have read and understood the falls policy.
B. use an educator to teach falls prevention.
C. share unit-specific data on falls.

D. conduct a medication review of patients who have fallen.

49. A physician complains to a healthcare quality professional that the nursing staff did not
strictly follow orders for a patient. The physician requests that the quality professional speak
with the nurse manager. To facilitate improved communication, the quality professional
should
A. arrange a meeting with the physician and nurse manager.
B. speak with the nurse manager on behalf of the physician.
C. evaluate the patient outcome to determine organizational risk.
D. review the patient record to determine legibility of the physician's orders.

50. The clinical competency of a physician is determined by

A. a committee of peers.s

B. the CEO.
C. the hospital governing body.
D. a Quality Management Committee.

51. Empowerment gives employees the opportunity to

A. solve problems.

B. make more money.

C. gain respect of peers.
D. achieve upward mobility.

52. Problem-solving, cross-functional understanding, expanded areas of expertise, and increased

 span of knowledge are examples of
A. strategic alliances.
B. customer expectations.
C. resource requirements.
D. the benefits of teams.

53. In managed care, the most widely used performance measures are

A. Uniform Hospital Discharge Data Set (UHDDS).

B. Healthcare Effectiveness Data and Information Set (HEDIS).
C. Agency for Healthcare Research and Quality (AHRQ).

D. National Quality Forum (NQF).

54. Upon completion of a performance improvement project, who is the best person to compile
and write a report?
A. quality manager
B. team leader

C. facilitator
D. recorder

55. For health information technology to be most effective in reducing harm, the technology
needs to be

A. integrated with clinical workflow.

B. able to correct claims data.
C. flexible and accessible.

D. numeric and easy to use.

56. A 69-year-old female admitted for hip replacement is taken to surgery. The patient is
identified, the surgical site is marked incorrectly, and equipment/x-rays are present. A near
miss was most likely identified as a result of

A. a surgical team 'time-out.'

B. informed consent documentation.

C. an equipment check.
D. a root cause analysis.
57. A strategy used in brainstorming is that ideas are
A. prioritized as they occur.
B. discussed when they are mentioned.
C. progressively eliminated.
D. all recorded.

58. A facility is becoming part of a healthcare network. Which of the following employee
education programs is most important?

A. quality teams
B. organizational change

C. consumer expectations
D. conflict resolution

59. Results of physician practice pattern studies are most likely to promote behavior changes
when disseminated to the
A. practitioners.

B. administration.
C. governing body.
D. quality committee.

60. Which of the following is the best tool to begin an investigation into the causes of laboratory
labeling errors?
A. affinity diagram
B. prioritization matrix
C. flow chart

D. histogram

61. In profiling length-of-stay data for benchmarking, it is important that data be

A. raw numbers.
B. equal numbers.
C. reported monthly.
D. severity adjusted.

62. A summary of antibiotic usage for the fourth quarter showed that an internal medicine
department did not meet pre-established criteria in 82% of the patients reviewed. Following
review, the Pharmacy and Therapeutics Committee should recommend that the results be
 shared first with the
A. Quality Council.
B. governing body.
C. utilization committee.
D. chief of the department.

63. Frequency distribution can best be displayed through use of

A. a histogram.

B. a flow chart.
C. a force field analysis.
D. an interrelationship diagram.

64. A healthcare quality professional is attempting to refine the differences between an

organization's objectives and the stakeholder needs. Which of the following tools is most
appropriate?

A. gap analysis

B. Ishikawa diagram
C. Gantt chart
D. Kanban method

65. A serious event has occurred related to the timely notification of critical test results. The
root cause was traced to nursing difficulty with following the organizational policy. To
prevent a similar event from reoccurring, which of the following should be done next?
A. Refer the involved nurse to nursing peer review.

B. Educate nursing staff on the importance of timely notification of critical test results.
C. Review the policy with nursing representatives to identify ambiguities.
D. Continue to collect data as one event is insufficient to take action.

66. A hospital-wide medical record audit on documentation has been completed. The following
table shows the compliance rate of documentation: Compliance Rate (%) Documentation: 1st
Qtr 2nd Qtr Surgical "time-outs" performed 90 95 Communication of critical results 91 95
Pain score used 50 60 Initial patient assessment performed 52 45 Which of the following is
the next step?

A. Benchmark the compliance rates against another facility

 B. Conduct training regarding pain score.
C. Give data feedback on physician signature to the units.
D. Conduct a focused review on the patient assessment process.

67. A t-test may be used to

A. display the size of a sampling variation.
B. evaluate the effects of two different treatments.

C. evaluate differences among three or more treatments.

D. display a listing of the number of occurrences of a variable.

68. The primary purpose of integrating financial and quality management information is to

A. identify problems in resource management.

B. develop physician profiles.

C. identify potential cash flow problems.
D. determine medical necessity of treatment.

69. An annual evaluation of a laboratory's quality program identified no opportunities for

improvement. Which of the following elements of the program should be reviewed?
A. performance indicators

B. format of data display

C. committee meeting attendance
D. frequency of data collection

70. Which of the following team members is responsible for keeping meetings focused?

A. time keeper
B. facilitator
C. recorder
D. leader

71. One aspect of a quality process that integrates with risk management is the review and
evaluation of

A. adverse drug events.

B. encounter data.
 C. case-mix analysis reports.
D. accreditation survey reports.

72. Facility A is investigating its medication administration time for a specific diagnosis. Evidence-based
guidelines indicate that administration of a particular drug within 30 minutes significantly improves
patient outcomes. The national average is 32 minutes. The average for Facility B is 28 minutes. If the
average for Facility A is 35 minutes, Facility A should

A. determine whether its rate is within one standard deviation of the national average.
B. decrease its rate to meet the national average.
C. contact Facility B to determine its practices.

D. identify the average time of its competitors.

73. Which of the following actions has the greatest impact in reducing harm?

A. revising the patient safety evaluation tool

B. improving interdisciplinary communication

C. forming a performance improvement team

D. increasing data collection frequency

74. In lean thinking, a process step is defined as "value added" if the

A. customer recognizes the value.

B. customer corrects a mistake to add value.

C. process owner recognizes the value.
D. process owner changes the value of the product.
75. Which of the following actions should a facilitator make the highest priority during the
customer focus group process?
A. selecting a homogeneous group
B. establishing rapport with the group

C. providing written ground rules to the group

D. generalizing the findings to the population
76. Leadership can best integrate performance improvement within an organization through
 A. multidisciplinary teams.

B. newsletters.
C. focus groups.
D. seminars.

77. After a significant unexpected event, an intense analysis is performed to

A. understand the cause.

B. collect risk management data.

C. prepare the facility for a lawsuit.
D. identify who made the error.

78. The utilization management committee is reviewing length-of-stay data for a particular
procedure. In comparing data by physician, which of the following statistics will be most
useful?

A. correlation
B. range

C. mode
D. mean

79. A root cause analysis team examined a serious medication error and recommended changes.
Which of the following should be done next?

A. Random checks for compliance should be made by patient safety staff.

B. The Quality Council should review medication errors quarterly.
C. The process owner should implement and assess effectiveness.

D. Monthly reports should be sent to the regulatory body.

80. The quality improvement director is responsible for coordination of accreditation survey
activities. Responsibilities will most likely include

A. facilitating self-assessments of compliance with standards, communicating new requirements to pertinent

parties, and distributing the agenda for the survey.
B. educating staff to all standards, writing the survey report, and completing the survey application.
 C. developing a protocol for a mock survey, conducting unannounced surveys, and challenging the survey
report.
D. preparing for unannounced surveys, disseminating the survey report, and developing new standards.

81. A clinical pathway on the management of hip fractures has been developed by a multi-
disciplinary team and implemented in a large teaching hospital. After monitoring for 6
months, the length of stay continues to exceed the guidelines. Which of the following should
be the next step?

A. Evaluate compliance with the pathway.

B. Correlate the pathway with staffing levels.

C. Re-educate the staff on the purpose of the pathway.
D. Continue to monitor, and collect additional data.
82. The primary purpose of risk management trend analysis is to

A. meet regulatory requirements.

B. provide required reports to liability carriers.

C. identify opportunities for improvements.
D. eliminate financial loss for organizations.

83. The best way to evaluate the effectiveness of performance improvement training is through

A. observed behavioral changes.

B. self-assessments.
C. participants' feedback.
D. post-test results.
84. During quality management data analysis activities, Pareto charts are most appropriately
used for

A. displaying parts of a whole.

B. displaying trends over time.
C. determining cause and effect relationships.
D. determining priorities among contributing factors.
85. When considering the use of an external subject matter expert (SME), which of the following
is most critical?

A. leadership's personal preference

B. geographic location of the SME
C. cost of the SME's services
D. references of the SME

86. Healthcare leaders are confronted with the challenge of increasing quality while reducing
costs. Which of the following approaches best advances improvement efforts?

A. Support activities that improve outcomes and reduce variation.

B. Incorporate customer satisfaction results into quality initiatives.

C. Increase charges and decrease costs.
D. Develop new services to increase revenues.
87. One difference between continuous quality improvement and traditional quality assurance is
that quality improvement always

A. requires the application of statistical process control.

B. excludes monitoring and evaluation of care provided.
C. focuses on systems or processes.

D. addresses potential problems.

88. Satisfaction surveys, focus groups, and complaint tracking are tools used to

A. benchmark satisfaction.
B. develop clinical pathways/guidelines.
C. understand customers' expectations.

D. measure professional practice patterns.

89. Which of the following action plans is the first step in correcting inappropriate blood usage
in an emergency department?

A. in-service on ordering blood usage for the physicians

B. elimination of wasted blood

C. improvements in documentation
D. development of a new procurement procedure

90. A healthcare entity initiating re-structuring must consider the impact on staff to ensure the
 greatest opportunity for success by

A. defining the concepts of re-structuring to the staff and the community.

B. planning carefully, communicating openly, and leading effectively.

C. developing policies to assist in the change process so that fear will be minimized.
D. selecting a consultant, conducting a needs assessment, and analyzing results.
91. A group of pediatric patients diagnosed with cystic fibrosis is being studied. Their attitudes
toward the disease have been measured each year for the past 4 years. The methodology used
is an example of a

A. cohort study.

B. regression analysis.
C. case-mix study.
D. cross-sectional analysis.
92. Which of the following are the first steps when preparing for an initial accreditation or
certification survey of an organization?

A. Review the standards and determine readiness.

B. Appoint a survey coordinator and prepare a survey agenda.

C. Hire a consultant and conduct a mock survey.
D. Assess staff knowledge and plan staff training.

93. A new quality director has reviewed the information related to the Quality Council minutes,
and notes the following: - The council meets quarterly. Meetings last approximately 2 hours.
- The council roster includes all clinical department managers and the quality director.
Attendance ranges from 45-60%. – The primary role of the council is to receive department
quality reports, which are then forwarded to the organization's governing body. Based on the
information above, which of the following actions is most appropriate?

A. Require departments to forward reports for review prior to the meetings.

B. Redefine the council's role to coordinate and prioritize quality activities.

C. Switch to a monthly meeting with a new agenda format.
D. Eliminate the council and directly report quality data to the governing body.

94. Team cohesion is established during which of the following stages of team growth?

A. forming
 B. storming
C. norming

D. performing
95. The leader of a pain management performance improvement team has asked the Quality
Council to disband the team. The most important factor for the Quality Council to assess is

A. the length of time the team has been together.

B. how well the team met the intended outcome.

C. the effectiveness of the team leader and facilitator.

D. the amount of data the team has collected.

99. An organization can best measure its effectiveness in meeting customer expectations by

A. analyzing satisfaction data.

B. benchmarking occupancy rates.

C. creating a run chart of complaints.
D. tracking length of stay.
100. According to continuous quality improvement principles, which of the following concepts is
most important?

A. financial impact
B. constancy of purpose

C. resistance to change
D. performance of individuals