A reliable source to determine a practitioner's competency is

"The degree to which individuals and groups are able to obtain needed health services." is referred as:

Of a quality improvement perspective, the most desirable state is when:

Lean-Six Sigma is a performance improvement model that

Hospital mission statement

A collaborative team is required to improve the service in the emergency department of a community hospital. What are the essential steps for this team success?

In describing the spread of data, the range

Common cause variation in a specific program is

Medical staff credentialing is determined based on all the following considerations EXCEPT:

One distenct difference between traditional quality assurance (QA) and quality improvement (QI) is that QI

An individual is considered to be terminally ill, if their life expectancy is:

Replacing retrospective review with concurrent review is an example of

A hospital governing board addressed the quality council to adopt an action plan to reduce patients fall rate in medical/surgical wards. What is the initial step to be taken by the council when developing or modifying a fall prevention program?

Fall prevention programs should include all of the following EXCEPT:

Which of the following are the primary reasons for developing drug formularies?

Elements of Continuous quality improvement include all of the following EXCEPT:

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?

The following represents an essential element to an effective quality council:

To determine who are or might be involved in a sentinel event it would be most useful to create a

A released report reveals that apendectomy rate is 50% of new admissions to a male surgical ward. What data are most important to interprete the value of this report?

The number of physiotherapists in a community is an indicator of which quality principle?

All the following are considered basic components of managed care EXCEPT:

Compartmentalization of QM/QI activities by department or descipline when incorporating TQM key concepts within an organization is

A healthcare quality professional is developing a policy regarding access to physician quality files. In addition to the date and name of the person requesting the information, which of the following should be included in the policy?

Clinical guidelines

Performing a financial assessment to determine the patient's ability to pay for an actual or anticipated obligation is a critical task invovled in:

An effective quality improvement plans should have clearly defined

In accordance with FDA Categorization for Medications Safety in Pregnancy, which statement is true?

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

Amenities may cover areas as those mentioned below EXCEPT:

What is "iatrogenic illness" ?

Management by quality improvement principles should emphasize the importance of

The categorization of patients according to volume and severity to assess their nursing care requirements is known as:

The following tool is used primarily to record patient and practitioner specific data

When developing an organization's strategic planning for the coming five fiscal years, the following is most important to be put into consideration:

In the event of a fire staff should follow R.A.C.E. what does that acronym stand for?

Physician profiles are reviewed at time of reappointment to

The Institute of Medicine (IOM) believes that the following statement will improve the quality of care

Which of the following is an important criterion for evaluating a measure of quality?

The healthcare risk manager is usually responsible for claims administration. Which of the following is included in this process?

In the continuous quality improvement process, it is determined to increase emphasis on customer satisfaction and outcomes of care, which two dimensions of quality performance must be incorporated into all quality management activities?

Many scientifically sound practices are not used as often they should be, for example, biannual mammography screening in women between 40 to 69 years old has been proven beneficial and yet is performed less than 75% of the time. This underuse of resources can be categorized under:

Which of the following tools can most appropriatly be used to determine the relationship between two sets of data?

Which of the following performance improvement model has been created by Motorola incorporation:

The following is an example of a "never event" or sentinel event

Which of the following forms of healthcare professional regulation is the most stringent?

Process variance monitoring

The following is non-modifiable risk factors for coronary heart disease:

A case management department regularly monitors the number of inappropriate referrals, the timelines of discharge planning, and the number of days of discharge delays. What additional monitor should be added to evaluate the appropriateness of case management interventions?

When evaluating the components of an existing medication utilization system, priority attention should be given to those steps that:

Who is responsible for notifying Clinical Engineering of any incoming medical equipment (including loaner, demo and rental) in order to complete an acceptance inspection prior to initial use on a patient?

A measure used to determines, over time, the performance of functions, processes, activities is defined as a/an:

Conclusions from a licensed independent practitioner's profile would most likely be used during

The following best describes the successful outcome of the quality improvement process:

The following best describes an organization's vision statement

Which of the following issues might be most important to an organization or a medical group negotiating contracts with health plans?

The fact that many scientifically sound practices are not used as often they should be is an example of:

In an organization where the trust between administration and employees is doutfull, which of the following is the best way to conduct a survey to point out areas of staff dissatisfaction?

A complete episode of care that starts at a patient admission and followed up till the time of discharge may be described as a(an):

In order to establish a safety culture within a healthcare organization, one of the effective actions is to:

The following is important in development of practice guidelines EXCEPT:

A team of three nurses is found to study the effect of patient education on diabetic patients to improve blood glucose levels. 120 patients have been selected for the survey and divided into two equal groups, A and B. Group A was randomly selected to receive education and group B was kept without intervention. Pre and post tests have been made before and after the end of survey. After three months, the team collected the data and made the necessary analysis to

Which of the following are measures of central tendency?

Potential negative outcomes of a patient fall may include all of the following except

A paradigm shift in a process

The evaluation of the quality and appropriateness of patient care in the radiology department is the responsibility of the

In healthcare service, a multidisciplinary team can have the greatest control over the following factor:

Failure Mode and Effects Analysis

Clinical decision support systems can support medication safety by alerting prescribes to

The following type pf budgets allocates one major equipment to be purchased in the next year:

The following is NOT among the roles that pharmacy has in revenue cycle management

Incorporating annual performance measurement data into the scoring process for accreditation is useful for

The objective of adopting a nationwide or global uniformset of discharge data is to

External environmental analysis typically includes:

The leader of a quality improvement team needs to deal effectively with a conflict between two units, it is best to appoint which of the following to its membership?

In an (ICU) at 400-bed community hospital, the head of department was quoted as saying "We need to replace ventilator circuits for incubated patients on a daily basis because we thought this helped in preventing pneumonia, but evidence shows that the more we interfered with the device, the more often we risk introducing infection to our patients. It turns out that it is often better to leave it alone until it begins to become cloudy, then being replaced." What lesson did hospital staff learned from this experience?

A process that may include recredentialing, reprivileging, profiling, peer review, and reappointment is known as:

An immediate intervention in clinical care process is described as

Balanced Scorecard answers which questions?

Teams normally go through five stages of growth: Forming,____,____,____, and finally Adjourning.

In a set of data, the range of values between the lowest and highest that is wide, what is best to rank-order the data in a meaningful way?

In order to maintain link between Risk management and Utilization management activities, it is best to

P control charts can be used to:

To be usedful in preventing future error, a Root Cause Analysis (RCA) should be performed

(FOCUS) performance improvement model is

The three entities that are essential to make up hospital manpower structure are

Quality leadership, in contrast to management by results, starts with which of the following?

All the following categories are eligible for the Baldrige Award except:

Using the table from question (Q-232), What is tha ratio of units wasted to total units typed and cross-matched in July?

Eliminating and avoiding wastes equipment, supplies, energy, and time actualize which quality dimension?

Responsiveness to patients' preferences is translated into all of the following factors EXCEPT:

The medical director requested the quality manager to assign a staff member to assist in the development of a quality program for a newly established service. The following staff member is the most appropriate for this project development:

All of the following are presently components of National Quality Measures for Acute Myocardial Infarction (AMI) EXCEPT:

The term _____ is defined as "Performance probability of the priduct over its intended life and conditions"

The primary goal of risk management is to:

The process of obtaining, verification, and assessment of the qualifications of a healthcare practitioner to provide patient care or services in a healthcare organization is known as:

A drug addict overdosed himself with an illicit drug in a psychiatric ward. The patient was found comatosed by the attending nurse and the on-call physician was called. The patient has been treated and recovered and an incident report was done. What type of negligence did the attending nurse commit?

_____ is "A group decision-making technique designed to generate a large number of creative ideas through an interactive process".

When illustrated in a dashboard, quartiles are defines as

Clinical practice guidelines

In a diabetes care clinic, a nurses team in initiating a survey to determine the effect of education on effective diabetes control for a sample of 60 individuals. Patients are divided into two groups (A) and (B). Group A is assigned as the control group and group B for intervention. A pre test survey is conducted to

A utilization management department of a community hospital has collcted data on the length of stay and readmission rates. When compared to benchmarks, the length of stay rates are found to be higher and readmission rates are lower. Which of the following is the next step?

Summary statistical reports of quality data

Patient's personal,demographic and insurance information should occur during:

The following statement can be identified as the best one that represents an organization's big picture describing a desired end-state, general scope and not restrictive:

When a healthcare plan is provided to a member in exchange for a schedualed payment in advance of the service rendered, this is known as:

Managing a change in a procedure that is related to patient safety in a hospital is an integral part of

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

For a healthcare quality professional selecting a software for quality improvement activities in the hospital, it is essential to

A quality officer is reviewing comorbidities in an OB&Gynecology Department during the last quarter. Which of the following areas may represent a priority for an investgationl review?

Standards of care that are based on the knowledge, experience and research of recognized experts on specialized areas of the practice of medicine are known as:

The leadership style known to motivate employees, and optimizes the introduction of a change in an organization is

An example of hospital external customer is (are)

The major difference between "Quality Assurance QA" and "Quality improvement QI" is that QI focuses on

Which of the following population groups are NOT covered under the Medicare program?

Intensive analysis in quality improvement

The concept of "medical home" in managed care is

To achieve full compliance with the discontinuation of postoperative antibiotics within 24 hours, the best way is through

A fundamental difference between monitoring product quality and service quality is that

Which of the following is the fisrt step in the strategic planning process?

For a healthcare organization to be market oriented in order to maintain its growth, the following approach should be adopted:

Which of the following is an essential component in a performance improvement report?

"The process of taking a creative idea and turning it into a uesful product, service, or method of operation" mostly defines:

Extent to which a service achieves its intended outcomes in a real world environmen is known as:

Health care practitioners can effeciently apply time management techniques through:

Clinical privileging for clinicians

All the following phases are essential for team development EXCEPT:

Re-engineering can most appropriately be viewed as:

Which test is most commonly used to evaluate the reliability of a survey questionnaire?

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

It has been recommended by the upper management of a 450-bed hospital to develop a performance improvement action plan to address the growing and continuous customers complaints about long waiting times for their outpatient prescriptions to be filled by pharmacy. Which of the following quality improvement tools should be used FIRST to develop the action plan?

A new plan for Improving Prophylactic Perioperative Antibiotic Utilization is introduced in your Hospital System. A physician champion has been appointed to promote the success of this initiative. The main role of the physician champion is to

The following key healthcare issue is more difficult to establish for ambulatory care than for inpateint care:

Recent patient satisfaction surveys demonstrated that the responses to the following questions did not meet the 80% benchmark:

Based on these results, which two performance improvement activities should the organization focus on first?

Which of the following is a nominal variable?

A solid evidence of the incorporation of quality planning into the organization wide strategic planning process could be

The following has no role in the mark-up cost on pharmaceuticals:

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

Which of the following US acts forbids discrimination in hiring and employment based on race, religion, sex, and national origin?

"Infection rate after a cesaerian section shall be no more than 5%" is a statement that determines:

If you were comparing two treatments for which it is easy to arrive at evaluations of both their costs and consequences in monetary terms. Which method of economic evaluation would be best for comparing them?

A facility runs an established healthcare project that serves 8.000 patients per year with annual cost of 240.000$ and revenue of 360.000$. The administration decided to open a similar project in a less populated area with an initial annual cost of 60.000$. What is the number of patients needed to maintain the same profit rate?

You are doing research on hospital personnel including orderlies, technicians, nurses, pharmacists and doctors. You want to be sure you draw a sample that has cases in each of personnel categories. An appropriate sampling method would be:

On performing a financial analysis of a hospital, the following would not be considered direct costs

According to Joint Commission standards, an organization's safety program must include all of the following EXCEPT:

Implementation of computerized physician/provider order entry (CPOE) software application to replace handwritten orders represents which method of economic evaluation?

In strategic planning, external environmental analysis typically includes:

While interpreting results in a clinical trip, the P value determines the

Two hospitals A&B has recently been merged. After 8 months it has been noted that Hospital A has successfully transitioned their staff to new organization values, while Hospital B is still struggling. Hospital A' success can be best attributed to

All of the following are key aspects of quality EXCEPT:

Which of the following tools is used following a sentinel event?

The following is basically reviewed to determine the medical necessity and the appropriateness of service delivery in inpatient care:

Surgery 'Time out' is taken

Generally, large quality data sets are summarized using

The accounting department is trying to reduce the time between claims procession and payment made by a contracting insurance company. A flow chart has been recently completed. Which of the following tools would be best to use next?

Managers' options for change essentially fall into what three categories?

The overall coordinator responsible for the strategic planning process is

Which of the following institution/agency has introduced core measures to determine if healthcare institutions are in compliance with current standards in areas such as Acute myocardial infarction, Heart failure, Venous thromboembolism, Pregnance and related conditions and Nosocomial infections?

An annual revenue assessment has been established for a vaccination clinic. It was concluded that the net profit of the current year was 8000.00 $ compared to 6000.00 $ of the previous year. What is the percentage of profit increment?

A health care facility decided to implement Standard Precautions one year ago, but compliance has been poor. In addition to assessing the cause for poor compliance, the most effective way for the organization to improve compliance?

A team has identified a process for improvement, selected examples of best ptactice performers, visited those sites, gathered all necessary data, and compiled the results. The most effective next step for the team is to:

Records show that one surgeon's wound infection rate is 28%. Further examination of which of the following data will provide the most useful information in determining the cause of this surgeon's infection rate?

What is the initial step taken when developing a new program?

Quality improvement teams are beneficial because they

While implementing a new plan to improve current infection control procedures organization-wide, staff are expected to become supportive to the plan when the it is linked to

A healthcare professional is writing a report for administration concerning an organization's ethics concern, the best communication strategy is to

This individual developed "bar chart" techniques for activity schedualing

Joint Comission surveyors review organization's

The 1999 report "To Err is Human" by the Institute of Medicine (IOM):

Which of the following is NOT associated with the Baldrige Award?

Cost-Effectiveness

Baldrige Award's guidelines are not used to

Six Sigma performance improvement model

In which area within a healthcare facility, a JCI surveyor reviews and assesses the preventive services, diagnosis, and appropriateness and continuity of care provided to patients?

Each of the following actions is recommended by The Joint Commission to take place in patient handoff process EXCEPT:

The_____ leader makes decisions independently, and strictly enforces rules

Reporting of an event or occurance is an example of:

Percentages of a distribution of values that are equal to or below that number are known as

The following table represents two samples of two hospitals lower limb amputation monthly rates per 1,000 diabetic patients aged 60-70 years of age:

In analyzing the above data, it can be concluded that:

_____is accountable for the administration of the prophylactic preoperative dose of antibiotics.

Using the table from the previous question (Q-232), which aspect of blood utilization would you recommend first for further investigation?

Which of the following actions should a quality officer primarily undergo if he/she needs to overcome employee resistance during an organizational change?

Key elements when choosing a fall risk assessment tool include

Which of the following are managers who assume that the average employee enjoys work, seeks out responsibility, and is self-directed?

"A measure of the quality of attainment in meeting objectives" is the definition of

In healthcare, utilization management can be described as

A PERT chart or an arrow-type diagram represents a/an

Mission statement of an organization is set to describe

The philosophy of Total Quality Management (TQM) assumes that

The relationship between patient satisfaction and hours per patient day on a GOB unit was found to be (r=0.70,p < 0.05). What is the correlation between these two values?

Utilization review

What is best to reduce medication errors?

Next to implementing a new plan, a healthcare quality officer is recommended to

The following is used to relate interaction between equipment, methods, and customers

Your community hospital has coordinated with local municipality authority to convert a busy intersection to a roundabout (i.e., traffic circle) to alleviate long standing condestion, but after completion it was realized that large fire trucks cannot fit through the new configuration. This is an example of:

The following processes is the most cost-effective in preventing unnecessary resource consumption in the hospital:

Clinical microsystems

RN Lora measured the customer variable "feelings toward quality of provided care" with the categories very satisfied, satisfied, indifferent, dissatisfied, and very dissatisfied. RN Lora was using which the level of measurement?

Based on Juran's Quality Trilogy (quality planning, quality control, quality improvement), the Quality Management Cycle

Steps to developing a new service or program should occur in the following order:

The following is the First Step to facilitate a change in an organization

To apply for an external quality award, the first step is to

The following table demonstrates inpatient adverse events data in male internal medicine department in a general hospital for the first three months last year:

What is the percentages of complications of inpatients for the month of March?

Which of the following organization is the oldest accreditation organization for hospitals in USA?

If response rates are not within the threshold levels in an ongoing determined process, which of the following statistical methods can be used for quality improvement purpose?

The following are essential functions of an infection control program

An increased payment based on achievement of certain patient outcomes or standards of care is termed:

Successful continued positive impact of simulation programs depends on all the following actions EXCEPT:

Which of the following National Patient Safety Goals is applicable to everyone in a healthcare facility?

For an insulin dependant diabetic patient, which of the following is the best approach when implementing a National Patient Safety Goal related to identifying potential errors in a patient's care, treatment, and services?

Performance improvement activities should not consider

Communication has been identified by The Joint Commission (TJC) as a leading cause of medical errors. A staff nurse to safely take a medication order by telephone from a resident physician should

Four kinds of cost behaviors in cost accounting are:

In the patient schedualing process, who is not considered a customer?

More complex waiting line problems can almost always be handled by:

Which of the following statements concerning population-based conceptualization of health care quality is true?

Meaningful quality process measures must be:

A patient was discharged from the operating room when a surgical towel was left in the patient's body. The patient was readmitted for removal of the towel. Which of the following would most likely apply in this situation?

A facilitator's best start with a team is to

The establishment of a national database of the history of clinical privileges and professional liability claims may be mandated to

Benchmark reports of quality data

Obtaining patient's personal, demographic, insurance, and financial information should occur during:

Tho most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staff is by

Which of the following sets of data are discret variables?

In evaluating "long waiting times," a healthcare quality professional best demonstrates components related to staffing, methods, measures, materials, and equipment utilizing a

Human-generated data is less independent than machine data for all these reasons EXCEPT:

One method used to transfere risk from one party to another is:

During the profiling process, it was found that a surgeon's wound infection rate is 29% of operated patients. Further investigation of which of the following data will provide the most useful information in determining the cause of this surgeon's relatively infection high rate?

A set of binary data collected from a process records could include all of the following EXCEPT:

One of the greatest motivators for employees is :

The primary purpose of an emergency preparedness program is to

Effective communication is enhanced by

The three levels of management are:

For a community hospital, patient satisfaction scores demonstrate multiple areas needed for improvement including a need to improve attractiveness of the facility, responsiveness to patient needs, and physician and nursing communication. Based on these results, which of the following would the healthcare quality professional also will be expected to find?

Performance improvement of a process should depend on

The following is not included in both utilization management and quality management plans:

The most common measure describing the degree of variability in a distribution is

The term "performance" means

A syphgmomanometer was used to measure the blood pressure of a patient, at the first trial, the blood pressure was 115/70. Two minute later, the blood pressure of the same patient being measured by the same nurse and the result was 170/100. In terms of quality, this measurement tool can be described as:

The sequential and continual nature of the continuous improvement process is illustrated by the PDCA cycle. PDCA stands for:

In the below chart, what does the point B stands for ?

Some applications of International Classification of Diseases (ICD) code information include:

The following is the approach when implementing a National patient Safety Goal related to minimizing potential errors in a patient's care, treatment, and services?

Clinical privileging of a practitioner

To deploy a strategic plan throughout a healthcare organization, rank the following steps into the logical sequence.

1- Establishment of a focus on identifying customer needs.

2- Development of quality goals and strategies by top management.

3- Implementation of actions by all related departments.

4- Incorporation of set strategies into the annual business plan.

Your hospital is compaing its current practice with the that of the best facility in the area. This process is called

Positive patient related outcomes in radiology department may be exemplified as:

Which one piece of information is the most usefull to describe the age of population that is served in a vaccination clinic?

The most effective tool to improve communication between caregivers is known as: