Revision 2019

Leadership Commitment

1- Which of the following is most important to the successful implementation of

quality improvement activities?

a. Financial commitment and written quality management plan

b. Leadership commitment and organizationwide collaboration
c. Leadership commitment and financial commitment
d. Information management and department collaboration

2- Success of QI process depends on commitment of

a. Senior management
b. QM committee member
c. Middle management
d. Process owners

3- Impressed by what he saw at a healthcare conference, the Chief Executive

Officer decided to adopt Lean Six Sigma as the hospital's new approach to process
improvement. If the desired results are not achieved, which of the following is the
most likely reason for this?

A. Lack of understanding of Lean Six Sigma

B. Lack of top management support
C. Projects not linked to organizational goals and objectives
D. Inadequate focus on behavioral change to support process change

4- Which of the following is the FIRST step in facilitating change in an

organization?

A. Review customer satisfaction surveys.

B. Take commitment from GB.
C. Identify key people in the organization that should be involved
D. Develop a performance improvement plan

5- A healthcare organization wants to adopt concurrent review process instead of

retrospective review. To facilitate this changes the first to be inspired are
A-Leaders
B-Managers
C-Physician
D-Nurses

6- Organizational leaders can best demonstrate commitment to a new quality

improvement initiative by
A. reviewing the quality improvement plan.
B. offering solutions to identified problems.
C. allocating resources for the process.
D. maintaining performance appraisals for staff.

Leadership Role

7- Which of the following is the major responsibility of senior management

regarding continuous quality improvement?

A. Communicate the organizational mission and values.

B. Develop organization-wide training sessions.
C. Participate in Quality Council activities.
D. Conduct periodic reviews of the program

8- The quality professional can best facilitate the development of a "quality

culture" in the organization by

A. assessing the organization's readiness to commit to change.

B. preparing a long-range plan for cultural transformation.
C. encouraging leaders to commit to a culture of excellence.
D. leading the cultural transformation redesign team.

9- The responsibility to promote organizational values and commitment among the

staff lies within:

A- Nurse executive and CEO

B- Nurse staff, senior management
C- Medical director, quality manager
D- Clinical, non-clinical leaders

10- Within the context of total quality management philosophy, communication of

quality is

A. the responsibility of top management leaders.

B. delegated to the Quality Management Department.
C. an internal organizational, not community, issue.
D. independent of process budgets or costs

Leaders Safety

11- Safe environment can be best achieved by involving:

a. Leaders and top management

b. Delegating the responsibility to a cross-functional team
c. Involving staff member’s organization wide in the safety initiatives
d. Establishing a specified committee to review safety issues organization-wide

12- In order to ensure patient safety as a dimension of performance within a

healthcare facility, the most effective way is to:

A- Sponsor a toll-free line for reporting problems.

B- Focus on processes and minimize individual blame.
C- Have leaders who commit to and foster a safe culture.
D- Encourage patients and families to identify risks.

13- If leadership is the critical success factor for an effective patient safety
program, what is the first key responsibility of leaders?

a. Provide resources.
b. Set strategic goals.
c. Establish the value system.
d. Designate a champion.
14- Leaders' walk rounds are an effective opportunity to:

a. Focus front-line staff on safety issues.

b. Inspect the different departments in an informal way.
c. Discuss issues of concern to staff members.
d. Identify wrong doers.

15- Which of the following is the most effective means of communicating

commitment to patient safety?

A. Articles by a CEO in the employee newsletter

B. Senior leaders having discussions on units with front line staff
C. Posters and bulletin boards on units displaying up to date patient falls data
D. CEO Presenting most recent medication error rates to the governing body.

Leadership Styles

16- The leadership style that is said to motivate employees, and that optimizes the
introduction of change, is

A. autocratic
B. consultative
C. participatory
D. democratic

17- In participative management the manager

A. relinquishes decision-making responsibility to the staff

B. retains the final decision-making responsibility
C. presents a final decision to the staff
D. permits staff participation only with noncritical issues

18- In a crisis situation, when a manager must make a rapid decision, the most
effective leadership style is

A. consultative
B. participatory
C. autocratic.
D. democratic

Responsibilities

19- The member or group responsible for continuous improvement of organization

A- CEO
B- Quality council
C- Share holders
D- Governance board

20- The ultimate responsibility of implementation of quality relays on

A- CEO
B- Quality council
C- Share holders
D- Governance board

21- Who is responsible for developing vision for change:

A. CEO
B. Quality Council
C. Quality Leader
D. Quality Manager

22- The person/group legally responsible for maintaining quality patient care is the

A. governing body
B. quality improvement council
C. chief executive officer
D. medical/professional staff

23- Evaluation of the quality and appropriateness of patient care in the radiology
department is the responsibility of the
A. medical director of radiology.
B. chief medical officer.
C. medical director of the quality department.
D. administrator of clinical services.

Bylaws

24- The authority and responsibility of each level of the organization with respect
to quality management mechanisms must be specified in the

A. administrative policies and procedures

B. medical/professional staff bylaws
C. corporate bylaws
D. organizational plan for the provision of patient care

25- A critically ill patient is admitted and requires a specialized procedure;

however, the surgeon does not have privileges at the facility. Which of the
following documents will be MOST helpful in identifying the course of action the
hospital should take?

A. patient safety manual

B. risk management plan
C. medical staff bylaws
D. surgical policies and procedures

Culture

26- Organizational culture is best defined as:

A. assumptions about individuals and how work gets done

B. ethnic make-up of employees
C. provision of activities to employees such as National Nurses Week
D. professional development of employees

27- An organization that is committed to a culture of team-work, collaboration, and

adaptability is referred to as having

A. A learning culture
B. An open culture
C. A just culture
D. A reporting culture.

28- The chief executive officer "CEO" of healthcare organization has requested a
recommendation for the most effective method of assessing the organization's
readiness to adopt CQI, which of the following methods should CPHQ
recommend:

A- Review aggregate results of employee performance appraisals

B- Hire a consultant to conduct personal interview of staff
C- Conduct leadership ‘‘walks through'' of the organization
D- Administer surveys to evaluate organization culture

29- To allow change to be maintained, you should ensure the change in:

A. The culture within the organization

B. The hierarchy of the organization
C. The values within the organization
D. The reward system

30- Evidence of strong organization culture:

a- Employees commitment to mission and vision

b- Employees participate in CQI activities
c- Leaders pass the organization values to staff
d- Invite physicians to participate in quality activities

31- Education and training of all employees in quality management principles must
be done continuously in order to:

A- Prepare the staff for management positions

B- Motivate the staff around central theme of improvement
C- Document staff training to improve reimbursement rates
D- Train the staff to become technical and competent in their jobs

32- All of the following leads to powerful culture for quality improvement except

A- Consider sharing of the staff to quality activities at the time of reappointment.

B- Align reward to behavior support activities.
C- Face the resistance to quality by strict action.
D- Integrate quality improvement into strategic planning.

33- To enhance coping of the desired behavior by the employee, you should

A- punish the undesired behavior maker

B- Make rewards on the desired behavior
C- make the desired behavior appear as normal requirement and needs no
recognition
D- blame and train the undesired behavior maker

34- The most effective role of a healthcare quality professional as a facilitator of

change to quality culture in the organization is:

a. Education of leaders
b. Education of staff.
c. Evaluation of performance.
d. Designing processes.

35- 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.

36- Hospital A has recently merged with Hospital B. After 6 months it is noted that
Hospital A has successfully transitioned their staff to new organizational values,
while Hospital B still struggles. Hospital A's success can best be attributed to
A. requiring adoption of new values by all staff.
B. support of both hospitals' mission statements.
C. acceptance of the new mission and vision statements.
D. integrating technology and databases.
37- Healthcare quality professionals can best communicate organizational values
and commitment through
A. leading by example.
B. disseminating monthly newsletters.
C. establishing a multidisciplinary task force.
D. creating a mission statement.

38- A chief quality officer has the responsibility for education and implementation
of a continuous quality improvement (CQI) process. To affect cultural change,
administration must
A. believe the costs are justified by the benefits.
B. be assigned as a member of a team.
C. receive quarterly reports.
D. limit training to managers and supervisors.

39- A chief quality offer has the responsibility for education and implementation of
a quality improvement process. To affect cultural change, the chief quality officer
must
A. believe the costs are justified by the benefits.
B. be a visible participant in the process.
C. receive quarterly reports.
D. limit training to managers and supervisors.

40- When introducing continuous quality improvement (CQI) into an organization,

a chief executive officer must first
A. reach consensus with the staff.
B. educate supervisors in CQI principles.
C. obtain funding from the governing body.
D. assess the organization's readiness for change.

Culture (Safety)

41- Patient safety culture characterized by:

a- Competent staff
b- Anonymous reporting
c- Mutual trust
d- Self-directed teams

42- To develop a culture of safety, it is first to:

A. Make it safe to make mistakes

B. Establish a punitive reporting system
C. Blame is enough
D. Focus efforts on individuals rather than system

43- When developing a strategic plan with integration of patient safety, what is
considered to be crucial?

A- Culture of the performance improvement

B- Resources of the organization
C- Cost benefit analysis of patient safety program
D- Patient to staff ratio

44- High reporting of medical errors and near miss is a mirror of:

A. Defective system of quality

B. Feeling protected by a non-punitive culture of medical errors reporting
C. Sophisticated system
D. Conflict of interest

45- Voluntary reporting system may face under-reporting of incidents due to all of
the following except

A. Time constraints
B. Fear of shame
C. Developed safety culture
D. Blame litigation

46- Make it safe to make mistakes, Will:

A-Increase the learning state within organization
B-Increase the errors
C-Decrease the loyalty of the customers
D-Decrease the self-esteem of the staff

47- Which of the following is the best example of applying cultural diversity
principle to patient safety?

A. Allowing parents to perform rituals for their ill child

B. Providing interpretive service to explain medical procedures
C. Having the nutritionist discussion dietary preferences with the patients
D. performing mandatory training on culture diversity for staff

48- In order to establish a safety culture within a healthcare organization, one of

the effective actions is to:

A. punish individual employees who commit medication errors.

B. adopt anonymous free reporting of errors and adverse events.
C. segregate staff who commit errors to work in the same shifts.
D. abstain from intervention until a completion of one year to have an accurate
information about types and patterns of errors.

49- Which of the following are attributes to culture of safety?

A- Transparency & increased patient acuity level

B- Error –proof environment & empowered staff
C- Empowered staff & transparency
D- Increased patient acuity level & error-proof environment

50- An organization has established a culture of patient safety when

A. fear of retaliation is eliminated.

B. reports of potential errors have decreased.
C. patient safety goals are implemented.
D. employee education is completed.
51- A large facility has fostered a culture of patient safety through staff education,
support of process improvements at department levels, and implementation of a
nonpunitive approach to error reporting. Compliance with patient safety goals
ranges from 75-100%. In assessing the culture of patient safety, a healthcare
quality professional should

A. survey all employees and physicians.

B. survey patients from the last six months.
C. review data collected through incident reports.
D. review post-surgical infection rate data.

52- Staff has been trained and oriented on a new electronic incident reporting
system. In the past, staff could report anonymously. The new system requires staff
to sign in with an individualized username and password. Three months after
implementation, there is a sharp reduction in the number of reported incidents.
Which of the following reasons for underreporting of incidents is of greatest
concern?
A. staff fears of negative consequences of reporting
B. lack of knowledge about how to use the system
C. time required to complete an incident report
D. incomplete understanding about required reporting

53- 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.

Change Management

54- A continuous quality improvement team has proposed a major change in the
billing process for home health service. Staff acceptance of the change is best
facilitated by:
A. Immediate implementation
B. Medical staff education
C. Long-range planning
D. A pilot project

55- The senior leaders of a hospital have decided to adopt Lean methodology, to
which there is a large degree of resistance among the staff. Each of the following is
an effective strategy for change management except

A. explaining the benefits of the new methodology to individuals and groups.

B. conducting a large, multi-departmental project from the outset to create
participation and buy-in.
C. focusing on the system and processes instead of individuals.
D. rewarding efforts to implement the new methodology.

56- To establish evidence based practice guideline, it is best to

A. reply on subjective, expert opinion
B. review every possible intervention or treatment
C. include those who resist process
D. allow individual practitioner to make any exception to guideline

57- The followings can enhance the spread of the change in the organization
except:

A- Inclusion of the leaders in the planning process

B- Seeking input from the staff
C- Make punishments on errors related to the implementation of the change
D- Adopt open door policy

58- After in-depth data analysis, there is evidence of over utilization 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 style is most effective to implement best
practice guidelines?

A. Laissez faire
B. Democratic
C. Participatory
D. Autocratic

59- Which of the following steps occurs first in facilitating change in an

organization?
A. Identify problems to be addressed in the organization.
B. Get feedback from management.
C. Identify key people in the organization who should be involved.
D. Develop a performance improvement plan.

60- The best way to facilitate change within a healthcare organization is to

A. involve the individuals directly affected by the change.
B. communicate through group meetings.
C. arrange presentations by senior leaders.
D. communicate through group e-mail.

61- 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.

62- 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.
63- 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.

Constancy of Purpose & Determine your Goals

64- 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

65- 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.

Alignment

66- The Quality Management Cycle, based on Juran's Quality Trilogy (quality
planning, quality control, quality improvement)

A. excludes the lab's activities to monitor equipment.

B. requires a departmentalized approach to quality management.
C. encompasses only the nonclinical aspects of QM.
D. incorporates information from strategic planning.
67- Quality improvement plan must be first

A. Focused on organizational improvement.

B. Consistent with business goals and objectives.
C. Evolve the training plan of hospital
D. Ensure regular maintenance program

68- In deciding to submit an application for an external quality award the first step
to determine if award criteria:

A. Are aligned with organization strategic plan

B. Are well written
C. Demonstrate excellence in quality
D. Are approved by the chief executive officer

69- A quality professional in a home health agency is charged to develop a quality

management/ quality improvement strategy. Of the following steps, which should
be done first?

a. Develop strategic quality initiatives

b. Determine the roles of leaders in implementation
c. Draft the QM/QI plan for review by leaders
d. Review the organization's scope of care and service

70- Patient safety officer developing safety plan and the following information was
provided:
- Incident report data,
- Performance indicator,
- Customer complain data
- Which of the following addition data need to write the safety plan:

A. Physician satisfaction and financial goals

B. Staff satisfaction and root cause analysis
C. Infection control data and accreditation result
D. The facility risk assessment and strategic goal
71- Hospital leader asked the CPHQ to develop patient safety program, what
should he do

A. check the other hospital (in the same area) plans

B. make patient survey
C. search for scientific data on internet
D. identify the scope of service

72- Which of the following is the most appropriate question to ask when reviewing
an organization's performance improvement (PI) plan?
A. "Are there sufficient organizational resources to support the PI plan?"
B. "Does the PI plan include statistical methods for monitoring change?"
C. "Is the PI plan consistent with the organization's mission and strategic
priorities?"
D. "Has the organization been successful in communicating the intent and message
of the PI plan to employees?"

73- 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.

Learning and Education

74- Commitment of the governing body to quality improvement is essential for the
success of quality improvement activities. Quality professional can enhance the
board's commitment to quality by:

A- Assess knowledge and provide easily understood information

B- Ask them to make search on quality concepts
C- Provide them with materials to be studied on their own
D- Use of external educator
75- An organization hires a quality professional to pass quality improvement
concepts to the staff. The first thing the quality professional should do

A- Deliver lectures to the staff

B- Assess the present knowledge of the staff
C- Review the previous performance of the staff
D- Make interview with the staff

76- Teaching the use of QI tools is more effective when

A. All possible tool options are covered

B. Statistical process control is covered first
C. The team needing the tool is meeting together
D. Watching a videotape

77- Ask staff recall of the appropriate use of safety behavior in which level

A. Learning
B. Behavior
C. Reaction
D. Result

78- Measurement of effectiveness of a seminar delivered to the staff on new

methods for training asthmatic patients to use metered dose inhaler is best done by:

A. Satisfaction survey for the trainees

B. Tracking number of attendees
C. Incidence and severity of acute exacerbation
D. Satisfaction survey for the patients

79- After education of continuous quality improvement program to evaluate

effectiveness of the program:

A- Do pre & post education exam

B- Evidence that the staff begin continuous quality improvement activities
C- Monitoring the previous performance of the staff
D- Review the attendance rate of the staff
80- In order to introduce performance improvement concepts throughout the
organization, a healthcare quality professional should consider implementing all of
the following steps except

a- Distributing a newsletter containing applicable quality topics

b- Providing lectures regarding quality topics
c- Meeting with each department head on a regular basis
d- Mandating staff participation in self-study activities on quality

81- Developing educational training program in quality improvement, what

component should be included

A- Quality definition & principles

B- Performance appraisal results
C- Discussion of incidents
D- Individual focus of activities

82- A quality director is evaluating effectiveness of training for a healthcare

quality professional who recently attended a course on data analysis. Effective
learning can be best demonstrated when the learner

a. Develops a run chart showing falls data over time

b. Interprets a pie chart that displays falls by department
c. Builds a color-coded spreadsheet to report falls data
d. Discuss the implications of falls within the context of patient safety

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- A hospital is working to reduce readmissions. Which of the following is the

best approach to accomplish this goal?
A. giving an education sheet on patient medication to the patient and family
B. having the patient provide return demonstration of the knowledge provided
C. showing a video to a patient and their family
D. requesting the home health nurse provide patient instruction

85- The best approach for training staff about quality and patient safety is to
A. require staff to complete mandatory online training at convenient times.
B. develop posters and brochures that explain key quality concepts and place them
strategically throughout the workplace.
C. conduct multidisciplinary interactive sessions consistent with adult-learning
principles.
D. have the CEO meet with each department to explain the department's role in
quality and safety.

86- A performance improvement (PI) training program for supervisors should

include
A. results of a failure mode and effects analysis (FMEA).
B. budget-variance reporting.
C. rapid-cycle process.
D. review of patient falls.

System Focus

87- Mortality reviews are a critical element of risk management and quality
improvement, conducted to determine

A. if the practitioner(s) involved was/were appropriately licensed and credentialed.

B. if treatments and patient care were adequate and appropriate.
C. who was responsible for the mortality and what disciplinary actions need to be
taken
D. what the unit staff was doing at the time

88- Total quality management philosophy assumes that

A. most problems with service delivery result from systems difficulties

B. frequent inspection is necessary to improve quality.
C. most problems with service delivery result from difficulties with individuals.
D. top management leadership in quality activities disenfranchises employees.
89- All of the following conditions contribute to system improvement except
Measuring

A- Performance of processes & their outcomes using valid statistics methods

B- Taking action to improve the way the processes are designed & carried out
C- Studying & understanding the complex process that contributes to care
D- Identifying & responding to individual performance issues

90- A psychiatric hospital is reporting a significant level of patient aggression as a

quality professional the appropriate action to recommend is:

A- Generate a policy of restraining all patients

B- Switch from physical to chemical restrain
C- Adopt restrain free policy
D- Make a system of early identification of patient characteristics may be
indicative of aggression

91- 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.

Customer Focus

92- Complaint analysis is most useful identifying which of the following?

A. Adherence to standards
B. Quality of the services rendered
C. Competence of personnel
D. Customer expectations

93- The primary purpose of the survey is to measure

A. Patient expectations
B. Capacity of the process
C. Competence of the staff
D. Utilization appropriateness

94- Management using quality improvement principles should emphasize the

importance of

A. Staff orientation.
B. Customer expectations.
C. Quarterly statistical reports.
D. Team development.

95- Quality leadership, in contrast to management by results, starts with which of

the following?
A. profit and loss
B. return on investment
C. current products and services
D. customer needs and expectations

96- Management using quality improvement principles should emphasize the

importance of
A. staff orientation.
B. customers' expectations.
C. quarterly statistical reports.
D. team development.

97- 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.

Communication
98- Barriers to effective communication include

A. direct meaning and clear messages.

B. two-way, free flowing ideas.
C. judgments and assumptions
D. repetition and feedback .

99- A nurse receives a verbal order for medication from physician, the nurse
should

A. Ask the medication from pharmacists

B. Neglect the order
C. Read the order back
D. Write and tell the order

100- A poster contain information will most effectively convey outcome

information to internal customers?

A- 2 Bar graphs showing the 2 unites with fewest number of falls over past year
B- (Patient fall decreased over 4 years) printed above a line graph showing
percentage of falls to patient days
C- Patient fall indicate downward trend. Keep moving team!
D- (Patient fall last year were 0.5% of patient days) printed to photograph of the
organization staff

101- For which aspects of care are patient-reported measures most credible?

A Communication between providers

B Patient-provider interactions
C Adherence to clinical practice guidelines
D Appropriateness of therapy

102- 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'
Donabedian Framework

103- The quality improvement team finds high needles sticks in emergency
department. Who should the team share this information with?

A- ED staff
B- medical staff.
C- medical executive committee.
D- Quality council.

104- There were a large number of late visits for home care. The quality
professional wants to talk to the home care nurse at this problem. What is the best
approach?

A- Explain the cause of the problem and ask for solution

B- Describe the problem and ask for feedback
C- Share his home care experience
D- Blame her for this issue and require her justification

105- Customer survey gives score of 1-5 (1 dissatisfaction & 5 very satisfied)
found that customer satisfaction of pain management is 1.4, the benchmark score is
3.2, what the healthcare quality professional should recommend:

A- Design full pain management program

B- Educate pain management all over the organization
C- Link with internal medicine department
D- Continue measuring for customer satisfaction

106- The medical record manager reports that authentication of verbal orders
occurs 25% of the time , as compared to a reported 85% in situations ,which of the
following is the initial action for the manager to take ?

A- Recommend continued measurement of the indicator.

B- Share the data with the medical staff
C- Organize a PI team
D- Recommend improvement strategies

107- It's noticed that there is a significant increase in aggressive behavior among
psychiatric patients, what is the appropriate action:

A- Focus group with psychiatric department staff

B- Trend data over time
C- Review restrains policy
D- Use sedation for those patients

108- To effectively communicate performance indicator results, information

should be disseminated to the

A. Medical executive committee

B. Quality council
C. Entire staff
D. Department heads

109- Two surveys were completed in a healthcare facility that showed conflicting
results concerning patient satisfaction with food services. The two surveys were
independently designed and distributed by different departments within the facility.
The healthcare quality professional should FIRST

A. set up a quality improvement team to improve food service.

B. distribute the surveys to obtain a larger sample size.
C. design, distribute, and analyze a new survey instrument.
D. meet with the departments to review the survey processes.

110- 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.

111- An organization's data demonstrate an increase in the number of patient falls.

A healthcare quality professional should recommend
A. revising the fall-risk assessment tool.
B. convening a focus group of medical staff to discuss fall risks.
C. increasing staffing on weekends and nights.
D. sharing the data with the staff to provide feedback.

112- Nurse to patient ratio is an example of what type of measures?

A- Structure.
B- Process.
C- Outcome.
D- Monitoring.

113- In implementing a care bundle for the management of acute myocardial

infarction, the recording of the extent to which smoking cessation counseling is
provided is a measure of

A. Structure.
B. Process.
C. Outcome.
D. Process and outcome

114- The performance indicator, “Total unscheduled inpatient admissions

following ambulatory procedure (within 48 hours)” is a measure of

a. Structure.
b. Process.
c. Outcome.
d. Process and outcome.
115- Measuring the time it takes a nurse to perform a procedure addresses which of
the following aspects of care?

A. monitoring
B. process
C. outcome
D. structure

116- In health care organization, the quality department developed an indicator to

measure the commitment of the staff to myocardial infarction guidelines .This
indicator measure:
A. process
B. structure
C. culture
D. outcome

117- Which of the following monitors provides patient outcome information?

a. Healthcare-acquired infection rate

b. Nursing care documentation compliance
c. Antibiotic therapy discontinuation compliance
d. Equipment malfunction rate

118- Preliminary data shows increase medical errors in a unit. What should be
initially done?

A. Review technology and medication

B. Analyze the delivery process of care
C. Close the unit till change finishes
D. Ask for advice from other successful units

119- 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.

120- 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.

121- A policy for "time-outs" in an operating room was initiated in the first
quarter. The second quarter data demonstrated only 40% compliance with all
elements of the process. The first step the Quality Council should take is to
A. examine if the policy is clear and user-friendly.
B. ask the nurses to identify non-compliant surgeons.
C. continue to audit to confirm that a problem exists.
D. create a letter for the CEO to send to all surgeons.

TQM Concepts

122- To achieve excellence of care under TQM philosophy, healthcare

organizations must ensure:

A. Cautious use of minimal standards of care.

B. Meeting minimal standards of care.
C. Ignore minimal standards of care.
D. Working with minimal standards of care.

123- Which of the following management approaches would be MOST likely to

harm-quality improvement initiatives?

A- A quick fix from quality improvement

B- CQI to save the organization money
C- Organization-wide involvement in QI
D- Role change throughout the organization

124- The major difference between traditional "quality assurance" activities and
the expanded quality improvement/performance improvement activities is the
QI/PI focus on

A. people and competency.

B. analysis of data.
C. performance measures.
D. systems and processes

125- Under the quality improvement paradigm, which statement is incorrect?

a. The focus is on the competency of individual practitioners.

b. The focus is on the efficacy and effectiveness of processes.
c. The focus is on the patient.
d. The focus is on organization performance.

126- Incorporating TQM key concepts, compartmentalization of QM/QI activities

by organizational structure, i.e., by department or discipline, is

A. a weakness in implementing quality improvement.

B. the most efficient structure.
C. consistent with TQM philosophy.
D. important for preservation of medical staff autonomy.

127- When there's uncertainty about the outcome of the process with presence of
guidelines and experienced staff, the process is considered as:

A- Complicated
B- Complex
C- Simple
D- Flexible
128- Health care organization is complex system. In complex system all of the
following are right except:

A- The interrelationships between agents are most important

B- The outcome is predictable
C- Dealing with complex system require understanding the big picture
D- Here's a high chance for variation that may be identified as error or innovation

129- 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.

130- 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.
Key Dimensions

131- The perception of quality by a patient receiving care in an ambulatory

healthcare center is influenced most by

a. The physical environment.

b. Caring staff and physician.
c. New technology.
d. The physician's technical competence.

132- The dimension of quality/performance that is addressed by introducing a

rapid response team in a hospital is
A. Continuity of care.
B. Efficiency.
C. Effectiveness.
D. Prevention and early detection.
133- Which of the following is an example of patient-centered care?
a- Bedside rounds
b- Using two patient identifications
c- Pre-printed discharge instructions
d- Age based dosing

134- 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.

Strategic Planning

135- Customer suggestions for new service are best used by the organization in
developing:

A- Staffing plan
B- Financial plan
C- Strategic plan
D- Performance improvement plan

136- The mission statement of the organization describes

A. where the organization is going.

B. the purpose of the organization.
C. the strategic direction of the organization.
D. the long-term goals of the organization.

137- Strategic planning is best described as

A. a long-term focus, projecting the present into the future

B. a set of top-level performance measures
C. a statement of mission, vision, and values
D. an ongoing look into the future.

Guidelines

138- Practice guidelines should be based on:

A- Scientific evidence.
B- Computer generated Data.
C- Utilization review characteristics.
D- Senior consultant review

139- Standards of care based on the knowledge and research of recognized experts
are known as

A. benchmark data.
B. generic screens.
C. pre-established criteria.
D. evidence-based guidelines.

140- The use of clinical pathways and guidelines in hospitals should do which of
the following?

A. Minimize variation in patient care.

B. Reduce length of stay.
C. Improve patient satisfaction.
D. Identify errors in patient care.

PDCA

141- After the team action the plan and implement it, and analyze data shows not
reaching the target, what is the next step on PDCA cycle is now should follow;

A- plan
B- do
C- Check
D- Act
Lean
142- Lean strategy that means continuous incremental improvement:

A- kaizen
B- kanban
C- pokayoka
D- six sigma

143- When incorporating lean thinking into process improvement, the quality
professional teaches the team to

A. identify suppliers and their inputs.

B. focus on special cause variation.
C. consider the system's structure.
D. identify and eliminate wasteful steps.

Utilization Management

144- The key advantage of case management in managed care is

a. Control of clinical risk.

b. Control of hospital use.
c. Coordination of care.
d. Prevention of illness.

145- A patient not given enough instruction on the care plan this problem
concerned with:

A. Transition care.
B. Case Management
C. medical coverage
D .reconciliation

146- The patient discharged without any counseling of his care, this problem
concerned with

A. Transition care.
B. Case Management
C. medical coverage
D .reconciliation

147- Discharge planning should begin:

A. at the time of admission to the hospital.

B. after the patient's medical condition stabilizes and he is transferred from the
Intensive Care Unit to a medical ward.
C. after the physician writes the discharge planning order.
D. two days before the expected date of discharge.

148- In evaluating length of stay &outcome data on cardiac cathertization.

HealthCare quality professional identified direct relationship between adverse
outcomes & physician practice pattern. This integrated approach involves
correlating:

A- Case/care management & finance

B- UM & QM
C- Finance & UM
D- Discharge planning & QI

149- Attempts to align financial incentives of purchasers, payers &providers with

provider performance on clinical process &outcome measures encourages

A. under-utilization
B. community backlash
C. over-utilization
D. reengineering

150- The goal of an integrated service approach is to:

a. Reduce the cost of services

b. Increase the organization financial return.
c. Involve top management, leaders, and department managers in the process
d. Involve all working personnel in the process
151- A radiology department regularly monitors x-ray repeat/reject, timeliness of
report dictation, and patient waiting times. What component is missing in this
department's ongoing evaluation program?

a. Appropriateness review.
b. Process evaluation.
c. Quality control.
d. Documentation analysis

152- Hospital Utilization Management Plan generally includes provision for

a. Disaster planning.
b. Transition planning.
c. Quality planning.
d. Financial planning

Risk Management

153- Negligence means a lack of proper care. In medical malpractice "proper care"
is determined by:

a. Joint Commission standards.

b. Jury of civilian peers.
c. Tort law.
d. Medical peers.

154- An effective risk management plan includes all of the following except:
A) Description of educational programs
B) Statement of purpose
C) Description of reporting mechanisms
D) Scope of the program

155- On discharge, the patient refuses billing because 2 out of 3 days of his stay in
the hospital is due to medication anaphylaxis. This occurrence is:

A. Billing error
B. Potentially compensable event
C. Nurse Incompetence
D. Admission error

156- If your department has contract with another facility to provide a risky service
this is considered as

A- Risk shift
B- Risk adjustment
C- Claim against you from 3rd party
D- Negligence

157- "Occurrence reporting" is a type of

a. Risk reduction
b. Risk evaluation
c. Risk identification
d. Risk prevention

158- An effective risk-management program for a health care organization

emphasizes:

A. Harm prevention for patients, visitors, and staff

B. Reduction of financial losses
C. Staff training and education
D. Compliance with accrediting agency standards

159- Being immediately responsive and attentive to a family's concerns following a

patient's fall in the subacute care facility is:

a. Risk avoidance activity.

b. Loss prevention activity.
c. Risk shifting activity.
d. Loss reduction activity

160- A patient using a large exercise ball in outpatient rehabilitation fractures three
ribs when the ball bursts and she falls onto the floor. The risk manager tells the
patient that all costs of care will be covered. Of the following, this action best
represents risk

a. Avoidance or prevention
b. Assessment or analysis
c. Transfer or shifting
d. Handling or intervention

161- First task of a newly established quality council for implementation of safety

A- Provide protocols for rapid response teams

B- Assess preparedness and disaster plan
C- Prepare job description for quality council
D- Scan the environment for risks

162- 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.

163- Which of the following is the primary goal of risk management?

A. Identify the high risk areas of the organization.
B. Maintain an effective incident reporting system.
C. Perform failure mode and effects analyses.
D. Reduce financial loss associated with legal actions.

164- Which of the following is the primary goal of risk management?

A. Identify and manage risks to promote patient safety.

B. Maintain an effective incident reporting system.
C. Perform failure mode and effects analyses.
D. Eliminate financial loss associated with legal actions.
165- 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.
Sentinel Event

166- Which of the following is considered (0 % acceptance, 100 % analysis):

A. Occupancy report
B. Sentinel event
C. Cause and effect analysis
D. Cost benefit analysis

167- The determination of annual National Patient Safety Goals is linked to

reported

A. sentinel events.
B. adverse events.
C. core performance measures.
D. claims

168- Of the followings NOT example for sentinel event

A. Patient attempt suicide

B. patient fall results in bruises in tail bone
C. death of patient due to medication error
D. surgery on wrong part of the body

Analysis

169- Significant Deficiencies in the Provision of Care require:

A. Documentation.
B. Aggregation.
C. Intensive Analysis.
D. Initial Analysis
170- One way to measure a clinical outcome is through

A. Aggregate data review

B. Pareto charts
C. Pre-admission review
D. The number of healthcare contracts

171- A primary purpose of an information management system is to allow an

organization to:

A. Save time
B. Centralize demographics
C. Reduce cost
D. Evaluate data

172- A hospital has found that the performance of one of its department is
consistently below the expected standard. The hospital administration wants to
locate the source of the problems and see improvement in the department within
six months what is the health care Quality management professional role in this

A. Research the problems and develop a program that applies current standards to
the department
B. Recommend that the hospital replace the current administration of the
individual department
C. Advise that performance improvement team be assembled to review and address
the failings
D. Review the expected standards and submit these to the department for
immediate applications

Reporting

173- In compiling and writing performance improvements reports, which of the

following would not be included?

a- Project objective
b- Methodology
c- Meeting minutes
d- Improvement achieved
174- On presentation of the annual review to the governing body, the following is
important to include the presentation:

A- Graphs & tables

B- Minutes
C- Team achievement
D- Complaints

175- What to report to GB:

a- Details for all QI activities

b- Summary about results and outcomes for patients
c- Findings from peer review
d- Errors in staff documentation

176- In a high quality community hospital, a group of quality professionals

conducted a patient safety survey. As a hospital leader, you can guarantee that the
survey report may not contain data about:

A. The organization readiness

B. The impact of the patient safety intervention
C. The cost and the time spent in the survey
D. Benchmarking data about how well the organization is doing in establishing a
culture of safety

177- Which of the following is an essential component in a performance

improvement report?

A. governing body approval

B. data analysis and display
C. individual performance review
D. team composition and attendance

178- The major drawback of using raw numbers to present the results of quality
monitoring is that they
A. lack proper reference points for interpretation.
B. only measure compliance to established criteria.
C. cannot be graphed.
D. may be used for focused review.

179- Which of the following should be included in an annual performance

improvement report to a governing body?
A. meeting minutes
B. team achievements
C. physician peer reviews
D. incident/occurrence reports

Physician Monitoring

180- Most important in review physician profile:

A- Surgery case mix

B- Medical record completion
C- Blood utilization review
D- Fall rate review

181- Who is responsible for the FPPE and OPPE in a healthcare organization?

A. Governing Body
B. Medical Staff
C. Chief Medical Officer
D. Team Leader

182- A facility has medical staff consists of 5 internists, 3 neurologists, 2

pediatricians, and 1 dermatologist, who should make the peer review for the
dermatologist?

a. The internist
b. Chair of medical staff
c. Peer from outside
d. The neurologist

183- Physician is asked to review the appropriateness of care provided by another

physician. This process is called:

A. Initial review
B. Clinical peer review
C. Appeals considerations
D. Reappointment rules

184- When review clinical competency of surgeon at the time of reappointment:

A- group interview with practitioners

B- interview with the practitioner
C- quality professional review credential file
D- chief of surgery department review practitioner profile

185- Which of the following can demonstrate multiple aspects of a practitioners

practice as required for renewal of clinical privileges?

a- Credentialing
b- Peer review
c- Privilege delineation
d- Practitioner profile

186- A credentialing committee has determined that a practitioner has significantly

higher rate of complications after surgeries than the practitioners peer. Which of
the following the committees do next?

A- Initiate a focused professional evaluation (FPPE).

B- Limit the practitioner’s current surgical privileges
C- Require the practitioner to attend continuing education
D- Continue ongoing professional practice evaluation

187- A physician who has a high inpatient mortality rate compared to others in a
facility should first be
A. counseled by the department chairperson.
B. reviewed by the credentialing committee.
C. suspended in the interest of patient safety.
D. evaluated via a more in-depth review of cases.

188- 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.

Teams

189- Quality teams can be an important component in an organization quality

improvement as avenue (a way) for:
A. Credentialing and reappointment
B. Administrative support
C. Staff involvement
D. Reporting to the governing body.

190- Leadership can best integrate performance improvement within an

organization through
A. multidisciplinary teams.
B. newsletters.
C. focus groups.
D. seminars.

191- 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.

192- 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.

193- A team approach in quality improvement activities is preferred when

A. the process has many owners.
B. financial resources are scarce.
C. the solution is evident.
D. data management is required.

194- Quality improvement teams are beneficial because they

A. maximize expertise and perspectives.

B. promote competition and pride among members.
C. improve managerial control.
D. authorize solutions to problems.

195- For CQI to be successful who must be included in team

A. administrator.
B. person performing process
C. quality management representative.
D. department supervisor.

196- For continuous quality improvement team to be successful, who must be

included in the team?
A. Administrator.
B. Department supervisor.
C. Process Owners
D. Facilitator.

197- Which of the following actions is the most appropriate for the team leader to
take during the norming stage of team development:

A-fully utilize team member's skills, knowledge, and experience

B-represent, advocate for the team with other group and individuals
C-develop and implement agreements about how decisions are made and who
makes them
D-provide clear direction and purpose.

198- When the team members start to interest in hearing each other and being on
focus on goals and to respect each other, this is the stage of:

A. Performing
B. Storming
C. Norming
D. Forming

199- By forming a team After 1 month team attendance is declined , which stage of
team development:

A- Storming
B- Norming
C- Performing
D- Forming

200- Which stage cause the team to dissolve prematurely?

A- Norming
B- Performing
C- Storming
D- Conforming
201- Cohesion will be which stage of team building

A- Forming
B- Storming
C- Norming
D- Performing

202- At one of its meetings, the team has digressed from its original discussion.
Who is responsible for bringing the conversation back to the meeting agenda?

a) Team sponsor
b) Team leader
c) Team facilitator
d) Team members

203- The responsibility for providing organizational direction for a facility

continuous quality improvement program frequently rests with the quality

a- Council
b- Teams
c- Leader
d- Facilitator

204- Team charted in mental & psychiatry health to improve level of care, the
facilitator should be knowledgeable about

A. Mental& psychiatry health

B. Level of care
C. Moderate group teamwork
D. Assign tasks to team members

205- The healthcare quality professional's role in a quality improvement team

should least likely be

A. Team leader
B. Coordinator of the team process.
C. Team member.
D. Facilitator.

206- A facilitator`s best start with a team is to:

A- agree on meetings ground rules.

B- forming homogeneous team members
C- support team leader decisions.
D- set meeting agenda and priorities

207- The Board and Chief Executive Officer have renewed their commitment to
improving quality in Hospital X. Your primary role as the Director of Quality &
Patient Safety should be

A. Data Consultant.
B. Team Leader.
C. Facilitator.
D. Quality Champion.

208- Facilitating a team in improvement of care level of health/ cognitive statue

quality facilitator should:

a. Have knowledge in care levels

b. Have knowledge in health and cognitive status
c. Moderate group
d. Not a member

209- Team members are divided about the next course of action in an important
project. It appears that the conflict is severe enough to warrant intervention. Who is
responsible for managing the conflict?

A Sponsor or Team Leader

B Team Leader or Coach
C Coach or Sponsor
D Team Leader only

210- In an organizationwide QI model, the person or group usually accountable for

continuously assessing and improving performance at the department level is the
a. Cross-functional QI team.
b. Quality council.
c. Department director.
d. Department team.

211- Which of the following should a Quality Council provide to best ensure
success of performance improvement teams?
A. facilitator and recorder
B. empowerment and training
C. indicators and a data analyst
D. standards and procedures.

212- Responsibility of quality improvement teams include all of the following

except:

a- Defining the roles and duties of the members.

b- Communicating results.
c- Setting goals and timetable for the steps of the process.
d- Establishing the need for the team

213- The best way to evaluate any team is by:

A. Learning and innovation

B. Quantifiable objectives
C. Members Satisfaction
D. Aligning the vision of the organization

214- 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.
215- 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.

216- A meeting facilitator notices that the team has a tendency towards groupthink.
What is one structural way to correct this problem?

a. Meet late in the day

b. Meet more often
c. Break the group down into smaller subgroups
d. Have comments submitted in writing

217- In order to perform a task for which one is held accountable, there must be an
equal balance between responsibility and

A. Authority
B. Education
C. Delegation
D. Specialization

218- You lead one of the organization's strategic quality initiative teams. One of
your key members consistently arrives at least 15 minutes late. Your best approach
is to

a. Delay the start of the meeting to avoid going back over the material.
b. Confront the group with the possibility of changing the meeting time to
accommodate the late arriver.
c. Start the meeting on time and do not draw any attention to the late arriver.
d. Interrupt the meeting to acknowledge the late arrival to the group.

219- In preparing for a meeting, what should be sent to the team members in
advance?

a. Agenda with all attachments

b. Agenda with key information requiring a decision at the meeting
c. Just the agenda, because members will lose the other information
d. Agenda and the confidential information, because guests will attend the meeting

220- During patient focus group, the facilitator should do first:

A. Choose homogenous group.

B. Make ground rules.
C. Make rapport to the group.
D. Instruct orders.

221- When choosing an outside consultant to lead employee focus groups, what
priority areas of expertise should CPHQ look for?

A- Team development & management

B- Organizational assessment & change management
C- Improve Group dynamics & facilitation
D- Organizational design & re-engineering

222- Which of the following make a successful focus group?

A. Small group
B. Include patient
C. Short duration
D. Good moderator

223- 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

224- When choosing an outside consultant to lead employee focus groups, which
of the following priority areas of expertise should a healthcare quality professional
look for?
A. team development and management
B. organization assessment and change management
C. group dynamics and facilitation
D. organization design and re-engineering

225- After PI team finish the program who will submit results to the GB

A. team leader
B. facilitator
C. recorder
D. any member

Safety

226- When the health care delivered should not vary in Quality because of patient's
personal characteristics such as gender, ethnicity, geographic location, and
socioeconomic status; then this health care is

a- Safe.
b- Efficient.
c- Patient centered.
d- Equitable.

227- In response to public concern the institute of medicine, published the report
"crossing the quality chasm" The following are domains for health improvement
identified in the report except

A- safety.
B- patient-centeredness.
C- equity.
D- appropriateness.

228- Even when appropriate process are in place, error can occur, understanding
this, leader coordinating any safety program should focus on:
a- Patient survey.
b- Time constrain.
c- Policies.
d- Performance feedback

229- To best achieve low rate of harm in spite of inherent risks in healthcare, an
organization must;

a- Apply principles of high reliability

b- Adopt a zero tolerance for defect policy
c- Meet at least 95% of accreditation standards.
d- Employ effective physician leaders

230- Which of the following is true regarding medical errors

A. associated with process failure

B. prevented by review of evidence based practice
C. caused by gap between patients expectations and practice
D. avoided by uniform practice

231- The key to reliable, safe environment of patient care does not lie in exhorting
individuals to be more careful and try harder. It lies in:

A. Hiring high professionals for sensitive positions

B. High alert leaders and managers
C. Learning about causes of error and designing systems to prevent human error
whenever possible
D. Strict staff bylaws

232- An important reason for monitoring near misses is to

A. Prevent negative publicity

B. Identify incompetent staff
C. Provide lessons to the staff
D. Support disciplinary action
233- A CEO has challenged an organization to decrease the number of serious
safety events involving patients. The leaders have decided to review and assess
current processes to achieve this safety goal. A key element is to:

a. Ensure that the processes address prevention, detection and mitigation

b. Design processes to be reliably executed by the most experienced staff
c. Create new processes when possible
d. Use disciplinary actions to prevent errors from reoccurrences

234- Primary function of rapid response team is

a- Prevent and manage crisis in the emergency room

b- Early intervention when patient condition change
c- Manage critical patient conditions
d- Control patient safety issues

235- Healthcare quality professional has written patient safety plan that includes:
purpose, goals, and objectives. A review of outcomes data has been completed,
which of the following additional information should be in the plan:

A- Disaster preparedness
B- Steps to improve patient satisfaction
C- Equipment management
D- Efforts to reduce harm

236- Where should the surgical "time out" for a total knee replacement occur?

A- Med/Surg unit
B- Preoperative holding area
C- Post anesthesia care unit
D- Operating room

237- 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.

238- A Quality Council has decided that a Patient Safety Committee needs to be
established to oversee the patient safety program. The Quality Council has asked
this committee to prepare a Patient Safety Plan that would guide the program. A
key factor that needs to be considered for the long-term success of the patient
safety program is to

A. determine which patient safety goals need to be monitored.

B. involve the entire organization in the program.
C. review incident reports to identify where the errors are occurring.
D. research how technology can be used to prevent errors.

FMEA RCA

239- Determine process vulnerability

A- Flow chart
B- FMEA
C- RCA
D- PDCA

240- FMEA uses which type of review?

A- Concurrent
B- Retrospective
C- Proactive
D- Recurrent

241- A hospital considering changing the process of admission from emergency

department. To support patient safety when this process deployed. What should the
healthcare quality professional during redesign the process?
A. Complete FMEA of the new process
B. Analysis incidents reports of the last year using Pareto Chart
C. Examining the stability and variation of the new process by using control chart
D. Conducting RCA for predict errors of the new process

242- Under conducting a sentinel event review, a RCA:

A- Provide judgment of staff behaviors

B- Requires team consensus
C- Identifies gaps in patient care processes
D- Proactively identifies causes & effects

243- After significant unexpected event, an intensive analysis is performed to:

A. Understand the cause

B. Correct risk management data.
C. Prevent the facility from lawsuit.
D. Identify who made the error.

HFE

244- The interrelationships between people, tools they use, the environment they
work in best describe the study of:

a- Human factors/ ergonomics

b- Environment factors
c- Process mapping
d- Work engineering

Accreditation

245- A healthcare organization is seeking accreditation. The first step the

healthcare quality professional should take is to

A. review the organization's bylaws, rules, and regulations.

B. becomes familiar with the appropriate standards
C. establishes a quality assessment committee.
D. review the organization's policies and procedure.
246- To protect your organization against unannounced surveys the most important
to keep in your organization

A- Continuous readiness
B- All plans unannounced.
C- Patient medical records for 3 months only.
D- Copy of all incident reports.

247- Which of the following is most appropriate in preparation for an external

survey of a healthcare facility?
A. Assign key staff to answer all questions.
B. Ask department heads to prepare a presentation for the survey team.
C. Educate staff about the types of questions they may be asked.
D. Set up teams to make a good showing for the survey.

248- 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.

249- 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.
MIS

250- In a medical group of 70 physicians, there were 10000 patients in 4th quarter
of last year with 100 complaints, the 4th quarter of this year there were 60000
patients with 360 complaints. The quality improvement team target was 5
complaints per 1000 patient. By analyzing these coordinates, what will be found?

A. The rate decreased and the goal is not reached.

B. The rate increased and the goal is reached
C. The rate decreased and the goal is already reached
D. The rate increased and the goal is not reached

251- A health plan decides to use flu vaccine for the total population at their
services area. What is the intangible benefit from this decision?
A- Savings from treatment of non-infected people
B- Savings from decreased rate of infection in non-immunized people
C- Peace of mind as a result of lowest incidence of flu infection
D- Reduced hospitalization rate

252- Patient refused to bill after surgery because of postoperative infection, this
infection is:

A- Co-morbidities
B- Complication
C- Community acquired
D- Unpreventable

253- In an inpatient stay, specific patient conditions that are present on admission
and require treatment during the stay are called

a. Complications.
b. Comorbidities
c. Community-acquired.
d. Healthcare-associated.

254- In inpatient care, what is the key difference between a comorbidity and a
complication:
a. A comorbidity affects both treatment and length of stay.
b. A complication is not present at time of admission
c. A complication is preventable.
d. A comorbidity is not present at time of admission.

255- 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).

256- Deemed status refers to

A. a healthcare organization that passes a Centers for Medicare and Medicaid
Services (CMS) survey.
B. surveyors who work for both an accrediting body and a healthcare organization.
C. physicians who have been reported to the National Practitioner Database.
D. accreditation equivalency with a Centers for Medicare and Medicaid Services
(CMS) survey.

257- A federally certified electronic health record (EHR) with the capacity for e-
prescribing, electronic exchange of health information, and submission of
healthcare quality measures meets
A. bar-code technology specifications.
B. computer-based monitoring specifications.
C. meaningful use requirements.
D. health privacy requirements.

258- Medication reconciliation is a process intended to

A. identify and resolve discrepancies.
B. investigate formulary discrepancies.
C. increase use of electronic medication administration.
D. improve efficiency of medication administration.
259- 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.

260- 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.

261- In the quality improvement process, performing a cost-benefit analysis is

most useful in
A. checking performance.
B. analyzing process problems.
C. designing solutions and controls.
D. implementing solutions and controls.

262- When a healthcare organization is contracting with an outside provider for

services, the subcontractor must

A. provide a representative to the Quality Council.

B. meet all regulatory requirements.
C. have an active risk management program.
D. have a competitively priced service.

Consultant

263- Which of the following is the primary benefit of using external quality
consultants?

A. Bridging knowledge gaps

B. clarifying mission and vision of the organization.
C. Promoting effective communication.
D. Maintaining performance standards for the organization

264- 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

265- 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

Indicators

266- The ability of a data measurement tool to produce the same results over a
period of time is known as

a. sensitivity.
b. specificity.
c. validity.
d. reliability.

267- Sometimes, when developing indicators to measure performance, specific

criteria must be written to fully define the measure. This type of criteria facilitates
which step?

a. Intensive analysis.
b. Initial analysis.
c. Data aggregation.
d. Data collection.

268- Assuming the measurement instrument is reliable, which of the following

ensures that measurements are almost identical no matter who does the measuring?

A. One person taking all the measurements

B. An operational definition
C. Close supervision
D. Repeating the measurement for each observation

269- In any quality management approach, how can you best evaluate the
effectiveness of action taken?

a. Use the same performance measures to remonitor the process.

b. Formulate a new special study to monitor the action.
c. Interview the staff involved in implementing the action plan.
d. Do nothing. Effectiveness is expected with well-planned action

270- Validity of measures is defined as:

A-Repeated measuring leads to the same results

B-Low in cost
C-Well understood
D-Measure what's intended to measure

271- When facility make development of clinical indicator criteria, Healthcare

quality professional should:

A- Selecting indicators that are approved by accrediting organization

B- Selecting indicators that are approved by Payers
C- Develop criteria that reflect processes & outcomes
D- Prioritize indicators for selection by process owners

272- Which of the following is the best way to determine if a quality improvement
initiative is successful?
A. Compare outcomes with pre-established goals.
B. Conduct a survey of employees.
C. Present findings to the Quality Council.
D. Survey patients and customers.

273- When developing department-specific performance measures and indicators,

the quality manager as a consultant should

A. conduct a literature search and select quality indicators.

B. ensure that the numerator and denominator are clearly defined.
C. prioritize the quality indicators for selection by the department leader.
D. review the mission statement and seek physician input.

274- Which of the following elements must be present in order to evaluate the
effectiveness of a healthcare organization's quality improvement program?
A. quantifiable objectives
B. support from the medical staff
C. well-defined organizational structure
D. integrated data collection

Benchmark

275- The basic philosophy of benchmarking is

a. Eliminating the competition.

b. Finding best practice and incorporating it
c. Getting all processes under statistical control.
d. Eliminating process deficiencies.

276- A performance improvement team aims to reduce the rate of post-surgical

infection rates in a small rural acute care facility. Which of the following should
the team use as a reference?

A. The post-surgical infection rates among individual surgeons.

B. Postoperative antibiotic use among the surgeons.
C. National benchmark post-surgical infection rates based on the most recent
research.
D. Post-surgical infection rates in similar facilities

Balance Scorecard

277- Healthcare quality program had prepared a balanced score card that displayed
patient satisfaction was 98%, financial target has been met , medication error had
been increased by 30% and heart surgery rate decreased 3% , what additional
information the governing body may ask for?

a) Type of medication error

b) Heart surgery case.
c) Patient satisfaction data.
d) Review patient compliant

278- As a performance measurement system, the key value of the "balanced

scorecard" concept is its ability to

a. Serve as a comparative "report card" with like organizations.

b. Focus the organization on financial measures of survival and success.
c. Encompass all the organization's clinical and non-clinical measures.
d. Align measurement with the vision and strategy of the organization.

279- A balanced scorecard for an organization is best described as

A. an integrated report showing the best performing teams.

B. a tool to reflect the priorities of the organization's customers.
C. a representation of key performance indicators.
D. a graphic display of departmental performance.

280- Balanced scorecards are useful because they

A. focus on the most significant strategic initiative.

B. evaluate the pros and cons of the governing body's priorities.
C. put strategy and vision at the center of an organization's effort.
D. concentrate on the performance of individual units.
Data Collection

281- The most important time to collect and use data is

a. Before the QI project begins, to prove a problem exists.

b. During the QI project, to answer questions about cause.
c. During the QI project, to help prioritize the implementation of improvements.
d. After the implementation of the improvement, to maintain the gain.

282- If planning data collection for antibiotic use in urinary tract infection (UTI),
what should you do first?

a. Define UTI.
b. Define the population.
c. Determine which antibiotics to include.
d. Determine which sampling method to use.

283- Data gathering method includes all of the following except:

A- Measurement
B- Observation
C- Correlation
D- Interviewing

284- The first step in collecting meaningful data is:

A. Establishing the goals of data collection.

B. Developing operational definitions.
C. Planning for data consistency.
D. Evaluating the resources available

285- 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.
286- 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

287- The first step in conducting an epidemiological study is to

A. collect the data.

B. determine which statistical tests to use.
C. develop the data collection tool.
D. formulate the question to be answered.

Type of Data

288- Focus groups provide patient/customer input or feedback. What type of

information do they offer?

a. Qualitative.
b. Quantitative.
c. Measured.
d. Opinionated.

289- Which of the following may be considered examples of discrete variables?

a. Height and weight.

b. Community-acquired and nosocomial infection rates.
c. Surgical or emergency department response time.
d. Patient visits in the months of May and June.

Samples
290- A focused review of every other case seen in the Emergency Department on
June 2, is an example of which type of sampling?

a. Nonprobability quota.
b. Stratified random.
c. Systematic random.
d. Nonprobability purposive.

291- The stratified random sample is

A. Random sampling after dividing the population into groups

B. Portions of the population
C. Choosing subjects fulfill the criteria
D. sampling randomly

292- The sample include all available data in the area is:

A. Quota
B. Convenience
C. Stratified random
D. Purposive

293- A healthcare quality professional wants to measure the success of a corrective

action plan with a 95% confidence level. The average daily census at the quality
professional's organization is 1,000 patients. The best sampling technique for this
study is to review
A. 10% of all discharge records for the past quarter.
B. all active records on one day of the past month.
C. 30% of records based on preliminary compliance review.
D. the number of records needed using a statistical method.

Timelines

294- Prospective review may be beneficial unless

a. The patient is having elective total knee replacement.

b. The patient is being readmitted for bypass surgery following heart
catheterization
c. The patient was admitted through the Emergency Department for a fractured hip.
d. The patient is a member of a managed care organization

Tests

295- T-test used in:

A- Difference between sample size variance

B- Difference between occurrence of variables
C- Difference between effect of two treatments
D- Significance of treatment

296- When comparing averaged immunization data from two pediatric medical
groups, it is appropriate to use

a. Standard deviation.
b. A T-test.
c. A chi-square test.
d. Variance.

297- 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.

Data Sources

298- Data about the competitors may be obtained from all of the followings
sources except:

A- National standards
B- Individual customers
C- News media
D- Surveys performed by the local government
299- Information about customers can be obtained from all of the followings
except:

A- Complaint logs
B- Managerial observations
C- Satisfaction survey
D- Employee's opinions about customer's attitude

Central Tendency

300- The average between the highest and lowest measures is the

a. Median.
b. Mean.
c. Mode.
d. Dispersion.

301- Measures of central tendency include:

A. Median & mode & mean

B. Standard deviation and range.
C. Proportion and ratio.
D. Quartiles and Deciles.

302- In a normal probability distribution, the relationship among the median, mean
and mode is that:

A- They are all equal to the same value.

B- The median and mode have the same value but the mean is different.
C- The median always has the highest value.
D- The mean equals the sum of both the median and the mode.

303- The Body Mass Index (a measure of body fat) was measured in a group of
women attending a primary care clinic. The graph below summarizes the results.
Which of the following measures best summarizes the data?
A- Mean
B- Mode
C- Median
D- Range

Charts

304- Which of the following tools is most appropriate for investigating the
relationship between two characteristics?

A. Scatter plot
B. Cause-and-effect diagram
C. Failure modes and effects analysis
D. Pareto chart

305- Positive correlation appears as:

A- Points in a circular shape in the graph

B- Points in triangular shape
C- Increase in X-axis with an increasing in Y-axis
D- Increase in X-axis with a decreasing in Y-axis

306- Circular shape of data on scatter diagram indicate:

A- Positive linear relationship
B- Negative linear relationship
C- No relationship between the two variables
D- Special cause variation

307- Of the following, the best way for the Sunset Nursing Home to determine if a
nursing staff shortage might be related to an increase in the number of patient falls
is to perform a

a. Root cause analysis.

b. Staffing effectiveness survey.
c. Regression analysis
d. Events and causal factors analysis.

308- The use of regression analysis to help determine relationships between groups
of numbers is most closely associated with which graphic display technique?

a. Frequency distribution.
b. Scatter diagram.
c. Line graph.
d. Histogram.

309- The rate of increase or decrease in total medication errors over a six-month
period could best be displayed by the use of a

a. Frequency polygon.
b. Line graph.
c. Bar graph.
d. Cumulative frequency curve.

310- You are the quality professional for a large provider organization. You have
two sets of monthly utilization data—total costs and total reimbursements from
payers—for the last two years. Use this information to answer question:

To best display the data for the full two years, which of the following types of
graphic displays should you use?
a. Pie charts.
b. Bar charts.
c. Run charts.
d. Pareto charts.

311- The primary care clinic tracks callers’ telephone wait times as a recurring
performance measure twice a year. In the last two months, wait times have been
increasing. On the latest run chart, 8 consecutive data points all in ascending order,
with 21 total data points, represents a/an

a. Common cause variation.

b. Special cause variation.
c. Cyclical variation.
d. Astronomical value.

312- "Common causes" of problems in processes refer to

a. One-time situations.
b. Temporary situations.
c. Acute situations.
d. Chronic situations

313- Special cause variation is to the process:

A. random, extrinsic, outlier

B. assignable, intrinsic, noise
C. random, inlier, identifiable
D. assignable, extrinsic, outlier.

314- Which of the following charts is used to institute quality improvement &
monitor cost reduction on ongoing basis?

A- Pie chart
B- Control chart.
C- Pareto chart
D- Fishbone diagram

315- To avoid misinterpreting variances, which of the following statistical tools

should be used?
A. control chart
B. fishbone diagram
C. force field analysis
D. Pareto chart analysis

316- In analyzing data, the healthcare quality professional can minimize the risk of
interpreting noise as if it were a signal and minimize the risk of failing to detect a
signal when it is present by using a

A. run chart.
B. control chart.
C. specifying a target.
D. comparing data to average values.

317- A sentinel event is regarded as a:

a. Common cause variation.

b. Assignable variation.
c. Noise.
d. Random variation

318- In statistical process control, it is important first to

a. Eliminate assignable causes of variation.

b. Eliminate random causes of variation.
c. Prioritize causes of variation.
d. Eliminate all causes of variation.

319- A common cause variation is:

a. An intrinsic, inliers, unpredictable, chronic variation.

b. The responsibility of the process owners.
c. Correctable by top management and the team.
d. An intrinsic, outlier, unpredictable, acute variation

320- Once statistical control is established, the next step in continuous quality
improvement is to:

A. Slowly increase the rate of control monitoring

B. Rapidly increase the rate of control monitoring
C. Eliminate the need for rework
D. Improve the process by reducing variation

321- Measurement and assessment activities by the local Ambulatory Surgery

Center indicate that monthly surgical site postoperative infection rates have
increased over the past year. A comparison of the local Center's aggregated rate to
the other surgery centers in the same region, for like procedures, is best displayed
by the use of a

a. Bar graph.
b. Pie graph.
c. Grouped frequency distribution.
d. Line graph.

322- Which of the following graphs is most appropriate in displaying the root
causes of adverse events that have occurred in a hospital system over the past 10
years?

A. Histogram
B. Frequency polygon
C. Line chart
D. Bar chart

323- Which is the best graphic display to show proportion?

a. Pie chart.
b. Bar chart.
c. Run chart.
d. Pareto chart.
324- Which display is best to help the ambulatory clinic team decide which of 10
reasons for patient dissatisfaction to address this year?

a. Pie chart.
b. Bar chart.
c. Run chart.
d. Pareto chart.

325- The senior leaders of a hospital are prioritizing performance improvement

initiatives for the coming year. Which of the following tools will be most useful for
this purpose?

A. Pareto chart
B. Cause-and-effect diagram
C. Affinity diagram
D. Stratification

Tools

326- The best tool to begin investigate causes of laboratory labeling errors :

A- histogram
B- flowchart
C- affinity diagram
D- prioritization matrix

327- Leaders of a multi-hospital system are trying to prioritize the services to

introduce in the coming year based on their impact on the community. These
leaders, who work geographically apart, can arrive at a group consensus without
meeting face to face by:

A. the nominal group technique.

B. the Delphi technique.
C. brainstorming.
D. a focus group
1- B 42- A 83- A
2- A 43- A 84- B
3- B 44- B 85- C
4- B 45- C 86- C
5- A 46- A 87- B
6- C 47- B 88- A
7- A 48- B 89- D
8- C 49- C 90- D
9- D 50- A 91- C
10- A 51- A 92- D
11- A 52- A 93- A
12- C 53- C 94- B
13- C 54- D 95- D
14- A 55- B 96- B
15- B 56- C 97- C
16- C 57- C 98- C
17- B 58- C 99- C
18- C 59- A 100- C
19- B 60- A 101- B
20- D 61- D 102- B
21- B 62- A 103- A
22- A 63- C 104- B
23- A 64- C 105- C
24- C 65- C 106- B
25- C 66- D 107- A
26- A 67- B 108- C
27- A 68- A 109- D
28- D 69- D 110- C
29- A 70- D 111- D
30- A 71- D 112- A
31- B 72- C 113- B
32- C 73- A 114- C
33- B 74- A 115- B
34- A 75- B 116- A
35- C 76- C 117- A
36- C 77- A 118- B
37- A 78- C 119- B
38- A 79- B 120- A
39- B 80- D 121- A
40- D 81- A 122- A
41- C 82- B 123- A
124- D 165- C 206- A
125- A 166- B 207- C
126- A 167- A 208- C
127- B 168- B 209- B
128- B 169- C 210- C
129- C 170- A 211- B
130- C 171- D 212- D
131- B 172- C 213- B
132- D 173- C 214- B
133- A 174- C 215- A
134- C 175- B 216- D
135- C 176- C 217- A
136- B 177- B 218- C
137- D 178- A 219- B
138- A 179- B 220- C
139- D 180- B 221- C
140- A 181- B 222- D
141- D 182- C 223- B
142- A 183- B 224- C
143- D 184- D 225- A
144- C 185- D 226- D
145- B 186- A 227- D
146- B 187- D 228- D
147- A 188- B 229- A
148- B 189- C 230- A
149- D 190- A 231- C
150- A 191- D 232- C
151- A 192- A 233- A
152- B 193- A 234- B
153- D 194- A 235- D
154- A 195- B 236- D
155- B 196- C 237- A
156- A 197- A 238- B
157- C 198- C 239- B
158- A 199- A 240- C
159- D 200- C 241- A
160- D 201- C 242- C
161- D 202- C 243- A
162- C 203- A 244- A
163- D 204- C 245- B
164- A 205- A 246- A
247- C 287- D 327- B
248- A 288- A
249- A 289- D
250- A 290- C
251- C 291- A
252- B 292- B
253- B 293- D
254- B 294- C
255- B 295- C
256- D 296- B
257- C 297- B
258- A 298- A
259- B 299- D
260- A 300- B
261- C 301- A
262- B 302- A
263- A 303- C
264- B 304- A
265- D 305- C
266- D 306- C
267- D 307- C
268- B 308- B
269- A 309- B
270- D 310- C
271- C 311- B
272- A 312- D
273- B 313- D
274- A 314- B
275- B 315- A
276- D 316- B
277- A 317- B
278- D 318- A
279- C 319- C
280- C 320- D
281- A 321- A
282- A 322- D
283- C 323- A
284- A 324- D
285- C 325- A
286- D 326- B