CPHQ Quiz 2

An organization demonstrates the financial benefits of its performance improvement plan by

completing a cost-benefit analysis.
enlisting the Governing Board to establish the financial goals of the plan.
soliciting information from other organizations with similar plans.
itemizing areas where cost cutting could benefit each department.

When the CPHQ creates a Performance Improvement Team, it is inappropriate to

create a team with as many personnel as will participate—the more views the better.
choose members with complementary skills.
allow the team to work autonomously.
make the team accountable for its actions.

The CPHQ ensures the survey processes run smoothly by

informing the Governing Board of all steps during the preparation process.
collecting all necessary data.
utilizing the best methods, even if the costs exceed the budget.
allowing departments to establish their own processes to be integrated as needed.

Cost analysis involves cost allocation, in which costs are determined as direct or
indirect. Direct costs are to indirect costs as

departmental budget is to the organization’s mission
the organization’s mission is to departmental budget
out-patient costs are to in-patient costs
in-patient costs are to out-patient costs

When developing a departmental budget, which one of the following need not be considered?

Employee Satisfaction
Strategic Mission and Vision
Controlling costs
Developing Quantitative Plan Records

The CPHQ creates the most effective survey to assess customers’ needs and
expectations when he/she

determines what design (font size, colour, layout, etc.) complies with patients’ need
designs only closed-ended questions so that data can be quantified.
adjusts the projected findings to include lower completion rates.
targets the largest population served to get the most data.

Data definition is necessary for performance improvement. When measuring the
frequency and type of medication error, you must first

establish what is considered to be a medication error.
determine the need for measuring medication errors.
assemble a team familiar with those who make medication errors.
request data regarding medication errors committed recently.

When addressing specific issues regarding data definitions, consider the 2 Rs
(Recordability and Reliability), UV (Usability and Validity) and the 3 Ss, meaning

Severity, Specificity, Stratification
Sensitivity, Specificity, Structure
Sensitivity, Specificity, Stratification
Severity, Specificity, Structure

In data collection, Qualitative Data are to Quantitative Data as

opinions are to facts
fabrications are to designs
attitudes are to deeds
actions are to outcomes

Random Variation is to Special Cause Variation as

an expected outcome is to an adverse outcome.
Geriatrics is to Primary Care medicine.
tonsillectomy is to appendectomy
a sterile field is to an operating room

Which one of the following is not a way to promote organizational values and commitment among the staff?

Establish departmental goals as mandated by the governing agencies.
Assist teams to develop good listening and collaborative skills.
Build upon the beliefs of the staff to establish a mind-set for continuous improvement.
Encourage staff to create personal goals within the organizational Mission and Vision.

To establish priorities for process improvement activities,

defer or ignore single events.
work independently with subject matter experts (SMEs).
defer to the Governing Board for decisions regarding activities’ focus.
initiate more analysis of all issues to be considered.

An effective team leader delegates tasks. Failure to delegate

shows distrust for the team members’ abilities.
develops independence within the team.
allows team members to “pick up the slack” for the team leader.
enables trust to develop among all team members

The facilitator of a Performance Improvement Team

is not a member of the team.
relies on the team members to help each other to build their skills.
delegates the duty of summarizing the outcomes to the appropriate team member.
encourages the team members to consult with and coach each other.

As a member of a performance improvement team, you will

propose projects and recommend actions.
help select the other members of the team.
not be required to document the team’s activities
only be required to attend those meetings when you present data.

To develop organizational Performance Improvement training, you will not need to

review the success of training programs at other facilities.
perform a needs assessment and target organizational outcomes.
pre-test the trainees’ knowledge of targeted information
train other instructors or assistants.

Some indicators of poor team performance are poor communication, poor problem-solving, and lack of

interest in participation.
experience of the members.
affiliation with the Governing Board
concise statement of outcomes

To interpret performance/productivity reports, you must also understand process variation, which means

determining if data variations are within the acceptable range or are of concern.
developing variations of a specific data element to interpret the productivity.
designing processes that vary according to the subject parameters.
delaying determinations while all variations are processed.

When analysing complaints, the CPHQ would not

report to the Governing Board the details of all complaints.
establish a timeframe for complaint resolution.
review pertinent bylaws and regulations.
categorize complaints by type, department or area of concern

The CPHQ determines the staff member’s role in quality processes and incorporates
the outcomes from those processes when

performing employee Performance Appraisals using performance improvement data.
performing data-analysis evaluations using performance improvement data.
performing personnel hiring using performance improvement data.
performing hospital-wide department analyses using performance improvement data.

The Performance Improvement process requires identification of

issues that need to be tracked
patterns and trends of community care services
external benchmarks unrelated to the outcome data.
actions to be taken when improvement is not possible.

The CPHQ must integrate Quality findings into governance and management activities to

align payment/incentive systems, tying rewards to clinical objectives to improve care.
maintain the current governing system to provide a continuum of care.
establish administrative policies and procedures for governance and management.
re-write the bylaws to reflect current streams of data-inclusion.

The National Quality Forum (NQF) endorses safe practices to assess and develop organizational patient safety cultures. One of the most important elements needed to create the culture is

identifying safety risks and interventions to reduce events.
measuring patient satisfaction after a risk intervention
leadership from external suppliers assisting in the culture’s structure.
training patients to abide by the safety culture’s requirements.

Facilitating the development of a patient safety program requires a CPHQ to

identify an interdisciplinary group to manage the safety program.
define the scope of the team and administrative oversight
establish procedures for rapidly disseminating medical errors reports
outlining mechanisms to support the findings of sentinel event investigation

Which one of the following is not included in the Organization Plan?

Evacuation Plan
Mission and Vision statements
Explanation of the Governing Board’s responsibilities
Scope and Purpose

An example of integrated technology that enhances patient safety is RFI, which stands for

Radio frequency identification, a tracking system with embedded digital memory chips.
Radio frequency initiation, establishing when a procedure or activity begins.
Radio frequency implementation, recording when a process starts
Radio frequency introduction, tracking the beginning of a new safety activity.

When a patient safety goal is chosen for review, it is because

outcomes have not been determined.
monitoring was performed haphazardly.
outcomes show an opportunity for improvement.
monitoring yielded cross-streaming data.

That dimension of quality/performance that is dependent upon evaluation by the recipients and/or observers of care is

respect/caring.
safety.
continuity
availability

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

governing body.
quality improvement council.
chief executive officer.
medical/professional staff

The written evaluation should include

recommendations and resources required to implement them.
persons concerned about quality problems.
recommendations for staff salary raises.
only recommendations that fall within current budget constraints

.The term “performance,” as used in healthcare quality improvement activities, refers to

the effective execution of functions and processes.
an interactive series of process steps.
a statement of expectation.
a demonstration during accreditation survey.

The Critical Care QI Team is chartered to improve the admission process to the critical care units. One identified issue, based on preliminary data, relates to admissions by family practice physicians. The medical director drafts the performance measures and criteria for data collection. The critical care nurses collect the data, and the quality management department staff aggregates and displays the data for the team. What key step is missing?

Collaboration with the medical staff Executive Committee and family practice department
Approval of the project by the family practice department
Data collection and summarization by the medical staff
Preliminary information proving that assessment is needed

In writing a report for administration, such as that concerning an organization ethics concern, your best communication strategy is to

a. "bullet" the issues and ideas for resolution and make recommendations based on your summary of research.
b. provide issues, research, and all ideas for resolution, allowing the administrator to determine what is best.
c. summarize the concerns expressed throughout the organization, permitting the administrator to do his/her own research and resolution.
d. express just your own ideas on the issues and permit the administrator to do his/her own research and resolution.

The Performance Improvement Team uses tracer methodology to identify

a patient’s socio-economic status.
the continuum of care from admission to post-discharge.
treatment history through information recorded by the primary care physician and providers at other facilities.
a patients location status

The champions of the Performance Improvement Team

monitor of all of the team’s day-to-day activities.
review the team’s overall efforts and provide guidance and direction.
counsel, but are not accountable for the team’s efforts.
support, but require the team to keep all interested parties informed

The three models for case management are
A. Type of patient care, Focus of patient needs, and Professional discipline
B. Type of provider care, Focus of care, and Professional discipline
C. Type of patient care, Focus of provider, and Professional discipline
D. Type of provider care, Focus of patient needs, and Professional discipline

Type of patient care, Focus of patient needs, and Professional discipline
Type of provider care, Focus of care, and Professional discipline
Type of patient care, Focus of provider, and Professional discipline
Type of provider care, Focus of patient needs, and Professional discipline

A team is required to evaluate computer software for data collection, as

all areas of the organization are represented.
selection is based on the broad knowledge-base of the members.
those with minimal knowledge are balanced by very knowledgeable team members
organization-wide systems can be duplicated.

Which one of the following is not useful for identifying users’ computer software
needs?

Wish-List questionnaire
Assessment of other facilities’ satisfaction
Employee survey or checklist
Group meetings and brainstorming

The most important question to ask when choosing computer software is:

Will the program serve the organization for many years?
Does the program meet the organization’s requirements?
How long has the program been in use?
How many other organizations use the program?

After aggregating data, it is important to summarize the information with data-displays
so that it is

visually appealing and compelling.
meaningful to those analysing the outcomes.
understandable to all organization employees.
publishable to the general public and in compliance with HIPPA standards.

External benchmarking can be

useful because all institutions are different.
misleading because all institutions are different.
meaningful when different populations are sampled internally
misinterpreted because the data are so vast.

When interpreting outcome data, it is

possible to provide sufficient risk-stratification to validate the outcome data.
difficult to accurately attribute the data to one step in a process without further study.
unnecessary to consider external factors that might have affected the outcome.
only necessary to concentrate on the data, not the purpose of the data-review.

One of the core concepts of Continuous Quality Improvement (CQI) is

“If it isn't broke, don’t fix it.”
most processes can be improved.
problems relate to people.
variations should be taken by “leaps and bounds”.

As a CPHQ, you must communicate to all members of the organization the key concepts of quality care, which are:

Appropriate, Accessible, Competent, Coordinated, Effective, Efficient, Preventive, Respectful, Safe and Timely.
Appropriate, Accommodating, Competent, Coordinated, Efficient, Effective, and Secure.
Appropriate, Accessible, Committed, Coordinated, Efficient, Effective, and Secure.
Appropriate, Accommodating, Competent, Committed, Efficient, Effective, and Safe.

A CPHQ facilitates communication with accrediting and regulatory bodies by

personally partnering with all accrediting officials on the survey day.
preparing documentation to be submitted prior to an accreditation survey.
determining if regulatory bodies need to review infection rate data.
authorizing organizational transparency prior to an accreditation survey.

Developing clinical/critical pathways requires

utilizing the most common practices
multidisciplinary teams involved in direct patient care
additional staffing
narrowing the scope of an illness.

The four primary core criteria for credentialing and privileging are:

Licensure, Education, Competence, Interpersonal skills
Licensure, Education, Competence, Performance ability
Licensure, Education, Professionalism, Interpersonal skills
Licensure, Education, Interpersonal skills, Professionalism

Mortality reviews are a critical element of Risk Management and Quality Improvement, conducted to determine

if the practitioner(s) involved was/were appropriately licensed and credentialed.
if treatments and patient care were adequate and appropriate.
who was responsible for the mortality and what disciplinary actions need to be taken.
what the unit staff was doing at the time of the mortality.

The first assessment step the CPHQ makes to prevent risks to the patients, the staff, or the organization is to

evaluate the corrective actions
identify potential risks.
analyse the risks.
create an evaluation team.

The ADDIE Model of organizational Performance Improvement training outlines five steps for the development of instructional systems. The steps are:

Analysis, Development, Distribution, Initiation, Evaluation
Analysis, Design, Development, Implementation, Evaluation
Analysis, Design, Distribution, Initiation, Evaluation
Analysis, design

The CPHQ evaluates the Performance Improvement team to ensure it is effective and efficient. Three areas to evaluate are completion of assigned tasks, the ability of the team to cooperate and reach a consensus, and the

effectiveness of the team as a whole.
effectiveness of the individual team members.
efficiency of the team’s leader.
efficiency of the team’s facilitator

To interpret performance/productivity reports, you must have a thorough
understanding of

chart and graph data manipulation.
the organization and existing processes
the impact of denominators on variances
root-cause analysis results for data review

Performance Improvement data are used for credentialing and privilege-delineation.
The practitioner is evaluated on his/her

communication style and temperament.
adherence to federal, state and organizational standards.
cooperation, appropriateness, and staffing activities
concern about the well-being of patients in long-term care

Utilization management assessments measure

how practitioners utilize Performance Improvement data.
the use of services, procedures and facility resources
how employees utilize outcomes and manage daily responsibilities
the use of high-risk equipment and the level of risk.

JCAHO issues National Patient Safety Goals annually. Which one of the following is not a hospital goal?

Improve accuracy of patient identification with two identifiers
Improve communication among caregivers with standard abbreviations
Involve patients actively in their own care as a patient safety strategy
Reduce healthcare-associated infections by following WHO or CDC hand-washing guidelines

The most important components of a patient safety program are

links to external customers and suppliers based on outward data-structures.
a functional infrastructure with a leader, safety officer, teams and tracking mechanisms
procedures for data collection that use data-streaming and vertical stratification
reporting systems that allow for organizational transparency with all events.

The Institute for Healthcare Improvement (IHI) promotes better healthcare worldwide. To integrate IHI patient safety goals, an organization must

comply with regulations and abide by the tenets of IHI.
go to the IHI Internet site for information that may be free and can be downloaded.
join the IHI as a member-facility at the appropriate level of participation.
delegate members as liaisons to IHI for data distribution.

The “appropriateness” of care is

primarily a focus of utilization management.
a key dimension of quality care
equivalent to "case management.
the degree to which healthcare services are coherent & unbroken.

Which of the following key healthcare issues is more problematic for ambulatory care than for inpatient care?

reimbursement for care
access to specialty care
appropriateness of treatment setting
quality of care provided

Hospital medical/professional staff bylaws

relate only to members.
are subject to governing body approval
are required only if the staff is departmentalized
are required only if the facility is not incorporated.

One of your first key issues to determine when evaluating the current QM program is

the climate for change in each department and service.
the extent of leadership knowledge of and involvement in quality activities.
the operating budgets for the quality, utilization, and risk management departments
Responses to accreditation recommendations following the last two surveys.

Your initial report should be addressed to the

Quality Council.
Vice President, Administrative and Support Services.
CEO.
Board of Directors.

A key physician/licensed independent practitioner QM function is

researching criteria options for specialty-specific peer review.
determination of what constitutes a deviation from an accepted standard of care.
determination of data collection methodology for non-physician clinical reviewers
tabulation of peer review data for periodic committee reporting.

Of the following options, conclusions concerning a licensed independent practitioner’s care drawn from organizational quality/performance improvement activities would most likely be used during

case management.
reprivileging.
productivity management
initial credentialing.

The average between the highest and lowest measures is the

median
mean
mode
dispersion

Communication is enhanced by

generalizing.
attending.
using more words.
making immediate judgments

Wearing a conservative dark suit to an important governing board meeting is an example of which mode of communication?

Nonverbal
Symbolic
Gesturing
Acting out

The task of setting up an ambulatory care setting QM/QI program that focuses on “outcomes” as a measure of treatment effectiveness is difficult because

the patient remains in control of treatment.
patient care outcomes are determined by the payer.
there are no required medical records.
expected outcomes for ambulatory conditions are too obvious.

The organization’s strategic goals are best linked to its performance improvement
activities by management

offering many performance improvement models from which each area can choose.
assigning improvement models to areas as deemed appropriate by the key leaders.
obtaining organizational consensus for continuous improvement activities.
analysing the goals and improvement activities of other similar organizations.

To facilitate change within an organization, a CPHQ should

obtain reference information from other organizations.
maintain every aspect of the plan as long as it is in place.
participate in developing and improving a common vision of care.
keep the plan for each department confidential from the others.

A healthcare organization must have a Risk Management plan to obtain liability insurance. Which of the following lists is best for a Risk Management plan?

Statement of Purpose, Goals, Program Scope, Procedures, Design Mechanisms
Statement of Purpose, Goals, Design Mechanisms, Policies, Data Sources
Statement of Purpose, Goals, Program Scope, Policies, Data Sources and Evaluation
Statement of Purpose, Goals, Team Member Evaluations, Procedures, Data Sources

State and federal regulations require that performance improvement activities, records
and reports are kept confidential. HIPPA protects the patients’ right to privacy and
confidentiality, and the initials stands for

Health Information Portability and Accountability Act
Health Information Privacy and Accountability Act
Health Insurance Portability and Accountability Act
Health Insurance Privacy and Accountability Act

To maintain the confidentiality of performance improvement activities, records and
reports, all information regarding a specific patient’s identity may

only be revealed to the physicians and nurses assigned to the patient’s unit.
not be revealed to the attending physician.
not be included in distributed reports.
only be revealed to the attending physician and members of the clinical department.

Which three elements ensure successful implementation of computerized systems for
data collection and analysis?

Preparation, Timing, Supervision
Preparation, Transition, Supervision
Preparation, Training, Supervision
Preparation, Tracking, Supervision

Which one of the following is not the description of an analysis tool?

Pareto Chart: Illustrates common causes or sources of problems
Run Chart: Provides a running record of a process over time
Control Chart: Similar to the Run Chart, but includes a median data line
Scattergram: Graphically displays the relationship between two variables

The CPHQ uses a run chart or control chart to find trends within a process. A trend is
determined by

seven or more consecutive ascending or descending data points with 21 or more total points.
seven or fewer consecutive ascending or descending data points with 21 or more total points.
seven or more consecutive data points all above or all below the median or mean.
unrelated points indicating a special-cause variation.

In the Ishikawa Fishbone Diagram, users label methods, materials, and measurements
with an “M” and people, prices, and policies with a “P”. An “S” label represents:

Substitutions
Submissions
Surroundings
Statements

The CPHQ evaluates a study of the incidence of strokes (CVA) in women who take birth
control pills versus a control group who do not take birth control pills. The best
statistical technique for evaluating the study data is:

chi-square (X2)
regression analysis
t-test
scatter diagrams

Meaningful comparisons between service areas using internally gathered comparative
data do not require

uniform definitions that are consistent with CDC guidelines.
uniform collection protocols that ensure data are collected in the same way on all units.
increased risk when infection-rate data are higher interdepartmentally.
similar risk factors or stratified results to account for differences in risk factors.

What are the four primary types of events related to medical error?

Near-error, Unusual Activity, Sentinel, Adverse
Near-error, Unusual Activity, Sentinel, Anticipated Outcome
Near-error, Unsafe Activity, Sentinel, Adverse
Near-error, Unsafe Activity, Sentinel, Anticipated Outcome

To properly disseminate performance improvement information,

submit all reports need to all governing agencies.
it is unnecessary to secure sensitive information when it is distributed internally.
all staff members should have access to information with which they are involved.
it is necessary to include practitioner identifiers for proper evaluation

Organizational Transparency is the healthcare industry standard, meaning that

any governmental agency can view quality data at any time
the public has a right to view redacted quality improvement reports.
the price and quality of care are revealed so patients and staff have realistic expectations.
the details of all safety issues must be published as they occur.

Multivoting is a procedure to help prioritize and reach consensus when selecting process improvement activities. Which one of the following is not a component of Multivoting?

Review the list of items for redundancies and similarities.
Select a voting method, vote, and tally the results
Develop cross-streamed priorities for discussion and voting.
Repeat voting and discussion until the list is narrowed to important priorities.

To establish evidence-based practice guidelines, it is best to

rely upon subjective, expert opinion
review every possible intervention or treatment
include those who resist the process.
allow individual practitioners to make any exceptions to the guidelines.

When applying for an external quality award, like the Malcolm Baldrige National Quality Award, an organization can benefit

only if it wins the award.
by practicing the application process for any award
from the comprehensive review.
by receiving the 450 to 1,000 points awarded for process development

When coordinating quality improvement projects, a CPHQ will not

secure approval from the Governing Board.
assess the needs of the organization.
rely on the Quality Improvement design from other facilities.
clarify roles and responsibilities organization-wide.

Accreditation requires the CPHQ to develop training activities. The best way to prepare for an accreditation survey is by

developing materials that report on survey outcomes at nearby facilities.
delegating daily job requirements to focus on the creation of training
periodic assessments to evaluate compliance with standards.
create multiple teams so that each can brainstorm training for all of the standards

Customer satisfaction surveys are used to evaluate service, rather than clinical elements, because their limited scope does not include measuring the customer’s

degree of trust in the organization’s ability to provide adequate care.
unmet needs.
satisfaction with the results of invasive and non-invasive procedures.
priorities for service

Which one of the following is not a benefit of integrating the results of data analysis into the Performance Improvement process?

More effective staff utilization
Improved interdepartmental communication
Duplicating efforts by similar groups
Increased cost-effectiveness

To develop the organization’s patient safety culture, the CPHQ will not

establish a commitment for allocation of funds, personnel and resources.
develop strategic plans that promote patient safety.
evaluate patient safety scenarios based on data-stream priorities.
identify systemic processes that provide opportunities to improve patient safety.

Strategic goals and objectives relate to patient safety activities

in that the goals and objectives are organization-wide and static.
that are measured using upward and downward data-streaming
when coupled with more specific safety objectives.
and have been assessed by external data consultants

To integrate patient safety concepts within the organization

leaders must assign the appropriate significance to the organization as a whole
they must be identified as high-priority goals of Quality Management.
they must be evaluated outside of the Quality program as the highest priority.
accept that the concepts can only be intradepartmental-specific.

If the organization is committed to patient safety, the most important process is

allocating the financial resources to promote Quality activities
establishing an anonymous reporting system for safety issues.
integrating patient safety findings into governance and management activities.
delegating administrative responsibility to the evaluation team.

As a patient safety officer, the CPHQ coordinates the patient safety program by

delegating a liaison to external agencies and organizations
assigning coordinators for patient safety teams and for organization-wide training.
reviewing medical error information, including trends and patterns.
allocating funds for personnel to distribute and facilitate patient safety communication

When a Sentinel Event (SE) occurs, the Risk Manager initiates a Root Cause Analysis

terminate all processes that led to the event until the RCA is completed
start with the assumption that human error was the most likely cause of the SE.
leadership must participate in the RCA.
start the RCA immediately to appropriately deal with causality.

If, in the continuous quality improvement process, we increase our emphasis on customer satisfaction and outcomes of care, which two dimensions of quality/performance must be incorporated into all quality management activities?

Availability and respect/caring
Respect/caring and competency
Effectiveness and respect/caring
Continuity and competency

A hospital generally has a unique structure comprised of a “triangle.” Which three entities make up the triangle?

Governing body, administration, finance
Administration, department managers, medical staff
Governing body, administration/management, medical staff
Administration, medical staff, nursing

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

autocratic.
consultative
participatory
democratic.

The most effective way to ensure patient safety as a dimension of performance is to

sponsor a "hotline" for reporting problems.
focus on processes and minimize individual blame.
have leaders who commit to and foster a safe culture
encourage patients and families to identify risks.

The method of ordering data by listing all possible values, and all individuals receiving
each value, is called

the range
the standard deviation.
a simple frequency distribution
a grouped frequency distribution

When data has a range of values between the lowest and highest that is wide, but you
want to rank-order them, it is best to use a

line graph
simple frequency distribution
grouped frequency distribution
cumulative frequency distribution

The most accurate measure describing the amount of variability in a distribution is the

. variance.
range.
standard deviation.
dispersion.

Barriers to effective communication include

direct meaning and clear messages.
two-way, free flowing ideas.
judgments and assumptions
repetition and feedback .

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

delay the start of the meeting to avoid going back over the material.
confront the group with the possibility of changing the meeting time to accommodate the late arrive.
start the meeting on time and do not draw any attention to the late arrive.
interrupt the meeting to acknowledge the late arrival to the group.

One fundamental difference between monitoring product quality and service quality is based upon the fact that

a service is easier to measure and verify in advance.
a service is not perishable.
a service is more heterogeneous than an object.
there are more service delays than product delays.

The quality professional can best facilitate the development of a “quality culture” in the organization by

assessing the organization's readiness to commit to change.
preparing a long-range plan for cultural transformation.
encouraging leaders to commit to a culture of excellence
leading the cultural transformation redesign team.

As facilitator of the Performance Improvement Oversight Group, the CPHQ

reviews performance records of the possible group members.
discusses with supervisors the appropriateness of appointments.
establishes the group and finalizes the appointment of its members.
schedules regular meetings of the group, and documents and reports its activities.

When an expert consultant is hired to assist with the Performance Improvement project, the CPHQ should

allow the consultant to establish the necessary goals for the project.
ask the consultant for an itemized job description that s/he will follow.
defer to the consultant regarding time frames and deadlines.
provide the consultant with an organizational chart indicating lines of authority

When developing performance measures, first determine which data are needed for:

Strategic Planning, Outcomes Management, and Contractual Agreements
State and Federal Regulations, Performance Determinations, and Outcomes Management
State and Federal Regulations, Contractual Agreements, and Performance Determinations
Strategic Planning, State and Federal Regulations, and Contractual Agreements

An Incremental Cost-Effectiveness Ratio is

the equivalent ratio of mandatory costs and projected costs.
the result of a cost-utility analysis, but stated in ratio increments.
the same as a cost-effective analysis, but stated in ratio increments.
the difference between a cost change and an outcome change.

The CPHQ distributes the topics for discussion prior to a committee meeting. The pre-meeting packet should contain

the previous meeting’s Minutes for all those who are mentioned within the Minutes.
confidential reports with patient identifiers for the committee members.
unrestricted data regarding all organizational activities.
unrestricted data regarding items requiring a vote at the meeting.

What is the catalogue order the CPHQ uses to best coordinate inventory listings for
Information Management?

From point-of-entry departments to discharge-planning departments
Between departments caring for similar patient-care needs
Beginning with care units, then department, contracts, licensure and accreditation
Beginning with accreditation, then licensure, contracts, departments and care unit

When sampling a population for data collection, consider

the size of the sample — the larger, the better.
the time-period being sampled — the longer, the better.
if the collection mechanism is biased toward improving an outcome.
if the characteristics of the sample are the same as the target population

“Epidemiological Theory” in data collection and analysis means the relationship
between

. one epidemic and another.
the frequency and distribution of diseases to determine outbreak causes.
the etiology and cause of an epidemic.
the frequency and severity of a disease with regard to a specific population.

The CPHQ measures averages to locate the centre point in a data group. Which
statement is false?

Mean calculates the frequency a number occurs and gives the most valid picture.
Median calculates the average number
Variance measures the distance between the extreme numbers.
Standard Deviation is the square root of the variance.

Decision-making for improvement is best supported by interpreting data acquired
through analysis of

internal benchmarks.
external benchmarks
national standards.
indicators and outcomes.

If a problem arises involving patient care management, the first step is to

decide how to prevent a recurrence.
collect as much data as possible from those involved in the care.
distinguish the motives and intentions of all parties.
resolve the immediate problem.

Which of the following does not need to be included in performance improvement reports?

Reporting-Entity-Relevant Data
Department-Specific Data
Narratives of Procedures
National Data

Performance Improvement Action Plans and Projects require many development steps. After problem assessment and monitoring, prioritization, and team creation, implement the plan

immediately.
as broadly as possible
for an extended period of time
after training the affected staff.

The three types of outcome measures are:

Clinical, Customer Facilitating, Customer Satisfaction
Clinical, Customer Functioning, Customer Servicing
Clinical, Customer Facilitating, Customer Servicing
Clinical, Customer Functioning, Customer Satisfaction

The coordination of Quality Improvement processes and projects requires

building relationships with external suppliers and internal customers.
producing an internal action plan based on cost-streaming priorities.
staff education regarding the needs of the project and mandated efforts
securing support, resources and the approval of key administrative personnel.

Federal regulations require physician practitioners to be re-credentialed every two years after privileges are granted to them. Quality information is

provided to the organization for monitoring of practitioners.
gathered from other facilities were the practitioner is a member.
included information from the practitioner’s previous facilities.
integral for the evaluation of a practitioner’s competence

The systematic approach to medical record reviews requires

establishing a team to evaluate all records.
evaluating all medical records for accuracy and completeness.
the approval of HIPAA for review of confidential information.
planning and consistent standards for questionnaires and coding

After developing the organizational Performance Improvement training program, you will then provide the training, with your focus on

designing the program materials
teaching strategic organizational goals.
developing methods to measure outcomes
a pilot group and the members’ feedback

The effectiveness of Performance Improvement training can be measured most accurately

if more employees agree to take the training.
at the end of the development process
with the approval of the Governing Body.
when the learner outcomes are achieved.

The Practitioner Profile reappraises a caregiver’s performance and includes:

designated process variations for patient care.
established levels of organizational participation.
the practitioner’s compliance with organizational bylaws
individual and internally benchmarked healthcare-related infection rates.

Risk Management assessment is a primary concern during

day-to-day patient care activities.
evaluation of practitioners for credentialing and privileging.
invasive procedures because of the high-risk equipment
process evaluation and process improvement

An organization-wide early warning system should be in place to screen patients and identify

departments that carry the highest risk
high-risk incidents that occurred within the past 24 hours.
assessments that should be conducted when a risk incident occurs.
adverse patient occurrences and potentially compensable events. Risk Management is concerned with decreasing

Accreditation and regulatory recommendations should always be considered

the highest level of achievement for an organization.
when developing processes with data-stream analysis.
in the management of utilized resources for patient-care evaluations.
minimal, rather than optimal, standards for an organization

AHRQ-sponsored surveys facilitate assessing the organization’s patient safety culture. AHRQ stands for

the Administration of Healthcare Research and Quality
Administration
the Administration for Healthcare Resources and Quality
the Agency for Healthcare Research and Quality

Computerized physician order entry (CPOE) can enhance patient safety by

allowing physicians to enter orders in their personal style.
always maintaining stand-alone functionality so that data cannot be corrupted.
containing CDSS, meaning clinical diagnostic support system.
reducing the number of medication errors

The patient safety program is enhanced by computerized physician order entry (CPOE), electronic medical records (EMR), and

barcode administration of medication (BCAM).
CBMA
BMAC
barcode medication administration (BCMA).

Which one of the following is not a patient safety goal of the Joint Commission International (JCI)?

Remove concentrated electrolytes from patient care units
Surgery Checklist for proper documentation and working equipment
Pre-surgery checklist for correct patient, procedure and site
Establish communications relying on verbatim orders

Incident reports indicate a failure in the system; therefore, review of incident reports is an important part of Risk Management. What can be determined by an incident
review?

It is more time-consuming than medical record review
Only what might have been found within the patient record
All incidents have been reported
Where in the process the error occurred

A medication is ordered for a diabetic patient. Its capacity to improve health status, as a
dimension of quality or performance, is its

. effectiveness
potential.
appropriateness.
efficacy.

The key to creating sustained value in the organization is to

delegate policy-making and oversight to the quality council.
develop a strategy that derives from the vision, strategic goals, and cost-benefit analyses
adopt an organizational ethics policy and code linked to mission, vision, and values.
act on predictive performance measures aligned to strategic goals and department objectives

In evaluating the current QM program for strengths and weaknesses, it is NOT necessary to assess

strategic initiatives.
managed care contracts.
team minutes.
alternative QM software products.

The formal functions of management include all except

planning.
organizing
directing.
inspecting

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

Height and weight
Community-acquired and nosocomial infection rates
Surgical or emergency department response time
Patient visits in the months of May and June

In developing a program to evaluate the effectiveness of physician care, a primary care clinic would select which one of the following indicators?

The patients will express overall satisfaction with clinic facilities.
The contract lab will provide results within 24 hours of sample delivery.
The staff complies with all infection control policies and procedures.
Newly diagnosed hypertensive patients are controlled within 6 months.

No. of Questions	Mark Of Each Question	Duration	Min Passing Percentage
140	1	120 min	60%

CPHQ Quiz 2

Quiz Summary

Information

Results

Results

Categories

1. Question

2. Question

3. Question

4. Question

5. Question

6. Question

7. Question

8. Question

9. Question

10. Question

11. Question

12. Question

13. Question

14. Question

15. Question

16. Question

17. Question

18. Question

19. Question

20. Question

21. Question

22. Question

23. Question

24. Question

25. Question

26. Question

27. Question

28. Question

29. Question

30. Question

31. Question

32. Question

33. Question

34. Question

35. Question

36. Question

37. Question

38. Question

39. Question

40. Question

41. Question

42. Question

43. Question

44. Question

45. Question

46. Question

47. Question

48. Question

49. Question

50. Question

51. Question

52. Question

53. Question

54. Question

55. Question

56. Question

57. Question

58. Question

59. Question

60. Question

61. Question

62. Question

63. Question

64. Question

65. Question

66. Question

67. Question

68. Question

69. Question

70. Question

71. Question

72. Question

73. Question