CPHQ Quiz 5

External customer-supplier relationships are important but often cannot be controlled by the organization. Which one of the following tools best
clarifies and improves those relationships?

Satisfaction Surveys
Announcements of Organizational Changes
Restructuring of the Company’s Organizational Chart
Employee Evaluations

Achievable goals and measurable objectives support
the Mission and Vision Statements. Objectives are to
goals as

rungs are to a ladder
inches are to a foot.
gloves are to a sterile field.
plates are to serving food.

The Laissez-faire leadership style is characterized by

few accomplishments due to lack of guidance during decision-making.
employees who are more committed to solutions because of the free-rein environment.
allowing participants to suggest solutions, but the leader makes the final decision.
time-consuming compromises that are unsatisfactory to all involved.

The PDCA Performance Improvement Model is a
method of continuous quality improvement to resolve
specific situations rather than organization-wide
problems. PDCA stands for

Plan, Do, Check, Act.
Plan, Delegate, Chart, Account.
Plan, Do, Check, Account.
Plan, Delegate, Check, Act.

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

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’ needs.
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. (Record ability and
Reliability), UV (Usability and Validity) and the 3 Ss,
meaning

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

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.

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

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

A. 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.

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.

For which of the following scenarios would an uncontrolled before-and-after evaluation design be most appropriate?

1. Evaluating the effectiveness of a one-day training course for nurses on infection prevention and control.
2. Evaluating the effectiveness of a four-week educational program for nurses to prevent back injury.
3. Evaluating the effectiveness of a training program for nurses to prevent patient slips and falls after an unusually high rate of patient falls in the preceding 12 months.
4. Evaluating the effectiveness of an Acute Myocardial Infarction (AMI) care bundle in reducing inpatient AMI mortality.

A patient diagnosed with hepatocellular carcinoma is receiving a novel chemotherapeutic agent based on promising preliminary data from clinical trials and the absence of other viable treatment options. The dimension of quality for which the medication was chosen is its

efficacy.
effectiveness.
safety.
appropriateness.

Which of the following is the most effective way to prevent accidental intravenous administration of epidural bupivacaine (a local anaesthetic) due to epidural catheters being inadvertently attached to intravenous lines?

Redesigning epidural catheters so that they cannot be attached to an intravenous line.
Regular reminders to doctors and nurses to be careful when administering epidural bupivacaine.
Affixing stickers that state epidural catheters are for epidural use only.
Training of doctors and nurses.

Which of the following is a healthcare-associated infection?

A patient who was admitted for the treatment of acute myocardial infarction and who had three positive urine cultures all isolating Pseudomonas aeruginosa. The patient did not have an indwelling urinary catheter.
A patient who was admitted with fever and cough, and was diagnosed with severe Pseudomonas aeruginosa pneumonia.
Cytomegalovirus infection in a new-born that was diagnosed 36 hours after birth.
A 65-year old man who was admitted for elective bowel surgery and developed shingles 48 hours after his operation.

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
A. shows distrust for the team members’ abilities.
B.
C.

D.

. 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
A. propose projects and recommend actions.
B.
C.D.

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

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

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.

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.

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

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

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

Achievable goals and measurable objectives support the Mission and Vision
Statements. Objectives are to goals as

rungs are to a ladder
inches are to a foot.
gloves are to a sterile field.
plates are to serving food.

In a successful lean healthcare facility, the largest costs related to quality will be incurred by…

Preventive efforts
Internal failures
Assessment programs
External failures

One standard element of organization-wide strategic
planning is

determining the future implications of the services offered by other healthcare facilities.
analysing internal services and community needs
adopting the fiscal and ethical standards of the corporate model.
adopting the strategic plans of successful organizations

It is important to identify customer-supplier
relationships to improve methods, to meet customers’
needs, and to increase internal awareness. Which of
the following is the best example of a horizontal
internal customer-supplier relationship?

Administrators-Board of Directors
Administrators-Nursing Executives
Directors of Nursing-Charge Nurses
Charge Nurses-Registered Nurses with BSNs

The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) established core measures to
determine if healthcare institutions comply with
current standards. Currently, core measure relate to
which of the following conditions?

Acute Pyelonephritis
Pneumonia
Thoracic Surgery
Vaginal Birth After Caesarean Section (VBAC)

Management must establish lines of authority and
transparent accountability. Which of the following
entities is responsible for all patient care rendered?

Medical Staff’s Executive Committee and Officers
Board of Directors
Vice President of Patient Care (or equivalent)
Administration, including but not limited to Chief Executive and Chief of Operations

The FOCUS Performance Improvement Model is an
incomplete process if it is not combined with

the mission and vision statements.
the PDCA Performance Improvement Model.
internal and external customer-supplier relationship evaluations.
an evaluation of the fiscal benefits of the quality improvement program.

To develop a Performance Improvement Plan, the
organization must

perform a Root-Cause Analysis to determine what needs to be improved
design the process and the plan, and then plan for the implementation.
review plans and goals from other organizations.
evaluate the costs for each department’s involvement

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.

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

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

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.

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?

“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.

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.

The performance improvement model adopted by any healthcare organization should include all of the following, EXCEPT

a focus on prioritized areas.
the PDCA cycle.
use of statistical and analytical tools.
action for improvement.

Following a non-fatal overdose of intravenous heparin (a blood thinner) in a 43 year old man in a cardiac care unit, which of the following is LEAST like to prevent the occurrence of a similar event?

Requiring an additional member of the clinical team to check all intravenous administrations of heparin.
Taking disciplinary action against any nurse found to have administered an incorrect dose of medication.
Introducing a combined heparin order form and documentation tool.
Encouraging low molecular weight heparin (administered subcutaneously) in lieu of intravenous heparin.

External benchmarking can be

useful because all institutions are different.
misleading because all institutions are different.
C. 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

The systematic approach to medical record reviews
requires
A. establishing a team to evaluate all records.
B.

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.

The first assessment step the CPHQ makes to prevent
risks to the patients, the staff, or the organization is to
A. B.C. D.

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

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.

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

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

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

When is the best time to discuss the results of a meeting exit survey?

Immediately upon receiving the responses
At the beginning of the next meeting
Via email in the interim before the next meeting
These results should not be discussed

Effective leaders must be consistent and

focus on a person’s errors for correction.
provide critiques of performance with discipline.
show by example with explanations.
determine each team member’s weak points.

The Organizational Culture comprises the attitudes,
beliefs, and behaviours of those involved in the
organization. The four basic types of Organizational
Cultures are Stable-Learning, Group, Independent,
and

Dependent.
Secure.
Insecure
Environmental.

Which of the following is not important to the
development of an organization’s Mission Statement?

Statement of the Organization’s Function
Outline of the Organization’s Purpose
Delineation of the Organization’s External Customer Relationships
Explanation of the Organization’s Role within the Community

The Ernst and Young 7-step IMPROVE (Identify,
Measure, Prioritize, Research, Outline, Validate,
Execute ) model is simplified. IMPROVE is most
effective for

an inexperienced team because of its simplicity
teams who only deal with the data collections elements of the process.
teams who have experience with quality improvement processes.

Which one of the following is/are not a national or
international excellence/quality model(s)?

Baldrige Award Criteria for Process Management and Results
International Standards Organization Standard for Quality Management
Centre for Disease Control Quality Improvement Monitoring Programs
United States Federal Quality Improvement Programs

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
A. B. C.
D.

obtain reference information from other organizations.
maintain every aspect of the plan as long as it is in place.
Centre for Disease Control Quality Improvement Monitoring Programs
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

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

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

Healthcare workers should perform hand hygiene

before entering a patient's room.
before entering a patient's room and again immediately before touching a patient.
after touching a patient's bedside table.
after leaving a patient's room.

Effective quality management in healthcare requires leaders who are

well-respected clinicians.
department chairs.
committed to the organization's mission, vision and values.
members of the Quality Council.

A healthcare quality professional is conducting a study to examine the relationship between cigarette smoking and unanticipated admission to the Intensive Care Unit (ICU). All patients were categorised as being current smokers or non-smokers (the latter category included ex-smokers). The patients were also categorised as having been admitted to the ICU unexpectedly or not.
Assuming the expected value in any category is greater than 20, the most appropriate statistical test is the

t-test
z-test
chi-squared test
eye-ball test

On which of the following is internal benchmarking most dependent?

Validity
Sensitivity
Reliability
Accuracy

A laissez-faire leadership style

is preferred in Total Quality Management (TQM).
involves the leader/manager providing regular feedback to let employees know how well they are doing.
involves no decisions by the leader/manager.
involves the leader/manager presenting a tentative decision, receiving feedback from the group, and then making the final decision.

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.

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. B
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.

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, Development, Distribution, Implementation, Evaluation

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

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

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

Strategic quality planning promotes quality
improvement throughout the organization and has at
its core TQM, which stands for

Total Quality Monitoring.
Theoretical Quality Management.
Team Quality
Total Quality Management.

A Vision Statement is directed at the organization’s
stakeholders (e.g., patients, staff, community, etc.)
and states

what services are integral to the organization’s current functions.
how management envisioned the organization’s past contributions to stakeholders.
how management envisions the organization’s role within the current community.
management’s commitment to stakeholders regarding future goals.

Voluntary accreditation is a primary requirement for
most healthcare organizations. The most important
aspect to consider when evaluating each type of
accreditation is

the frequency of participation in accreditation evaluations/surveys
the reputation of the accrediting organization and the public’s familiarity with it
the cost-effectiveness of participation.
the programs offered and the accreditor’s commitment to improvement

Which one of the following is not an issue that must
be resolved when developing a Performance
Improvement Plan?

Assign key leaders at all levels of responsibility within the organization
Determine consistent terminology for documenting planned activities
Allocate personnel to the Quality Council to oversee activities required in the plan
Create an Oversight Group of the Governing Board to supervise the Quality Council

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.

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

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 units

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.

Transparent communication with patients and families after a serious clinical adverse event

1. reduces patient satisfaction.
2. increases the risk of litigation.
3. improves patient satisfaction but increases the risk of medico-legal claims.
4. improves patient satisfaction and reduces the risk of medico-legal claims.

The Model for Improvement, developed by Associates in Process Improvement,

is identical to the PDSA cycle.
may be applied in only a limited number of clinical areas.
may replace Lean Six Sigma that an organization is using.
is used to accelerate improvement.

After a comprehensive review of the benefits and risks, a hospital’s Board of Directors decided to cease the oncology service within the next 6 months. This is an example of

risk avoidance.
risk prevention.
risk shifting.
risk financing.

As the Director of Quality & Patient Safety, you introduced the Institute for Healthcare Improvement (IHI)) Global Trigger Tool for measuring adverse events about 2 months ago. You now intend to present data collected using this tool to the hospital’s Board of Directors, most of whom are laypersons. Which of the following measures will you choose to present your findings?

Adverse events per 1,000 patient-days
Adverse events per 100 admissions
Adverse events per 1,000 admissions
Percent of admissions with an adverse event

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
A. D.

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.

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.

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

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

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

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

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

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.

In your capacity as the Director of Quality at an 800-bed multidisciplinary hospital, you are consulted on how best to reduce complication rates while reducing length of stay and cutting overall costs for total hip replacement.
Provided none of the following has already been attempted, the best option is

to identify the causes for the unacceptable complication rates, high lengths of stay and rising costs related to total hip replacement.
a clinical pathway.
to analyse the data and confirm that total hip replacement is associated with unreasonable rates of complications, and higher-than-expected lengths of stay and costs.
to review, and revise if necessary, all existing policies and procedures for total hip replacement.

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

CPHQ Quiz 5

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