CPHQ Questions 2 PDF

CPHQ QUESTIONS 2 The "appropriateness" of care is a. primarily a focus of utilization management. b. a key dimension of quality care. c. equivalent to "case management." d. the degree to which healthcare services are coherent & unbroken Janet - CH 1 - Concepts A medication is ordered for a diabe...

CPHQ QUESTIONS 2 The "appropriateness" of care is a. primarily a focus of utilization management. b. a key dimension of quality care. c. equivalent to "case management." d. the degree to which healthcare services are coherent & unbroken Janet - CH 1 - Concepts A medication is ordered for a diabetic patient. Its capacity to improve health status, as a dimension of quality or performance, is its a. effectiveness. b. potential. c. appropriateness. d. efficacy. - Keyword (Capacity)  Efficacy Janet - CH 1 - Concepts That dimension of quality/performance that is dependent upon evaluation by the recipients and/or observers of care is a. respect/caring. b. safety. c. continuity. d. availability Janet - CH 1 - Concepts 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? a. Availability and respect/caring b. Respect/caring and competency c. Effectiveness and respect/caring d. Continuity and competency - Keyword (Outcome)  Effectiveness Janet - CH 1 - Concepts Which of the following key healthcare issues is more problematic for ambulatory care than for inpatient care? a. reimbursement for care b. access to specialty care c. appropriateness of treatment setting d. quality of care provided Janet - CH 1 - Concepts Incorporating TQM key concepts, compartmentalization of QM/QI activities by organizational structure, i.e., by department or discipline, is a. a weakness in implementing quality improvement. b. the most efficient structure. c. consistent with TQM philosophy. d. important for preservation of medical staff autonomy. Janet - CH 1 - Concepts One fundamental difference between monitoring product quality and service quality is based upon the fact that a. a service is easier to measure and verify in advance. b. a service is not perishable. c. a service is more heterogeneous than an object. d. there are more service delays than product delays. Janet - CH 1 - Concepts The quality professional can best facilitate the development of a “quality culture” in an organization by A. assessing the organization’s readiness to commit to change. B. designing a long range plane for cultural transformation. C. encouraging leaders to commit to a culture of excellence. D. leading the cultural transformation redesign team. Janet - CH 1 - Concepts 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 a. the patient remains in control of treatment. b. patient care outcomes are determined by the payer. c. there are no required medical records. d. expected outcomes for ambulatory conditions are too obvious Janet - CH 1 - Concepts In developing a program to evaluate the effectiveness of physician care, a primary care clinic would select which one of the following indicators? a. The patients will express overall satisfaction with clinic facilities. b. The contract lab will provide results within 24 hours of sample delivery. c. The staff complies with all infection control policies and procedures. d. Newly diagnosed hypertensive patients are controlled within 6 months Janet - CH 1 - Concepts The Quality Management Cycle, based on Juran's Quality Trilogy (quality planning, quality control, quality improvement) a. excludes the lab's activities to monitor equipment. b. requires a departmentalized approach to quality management. c. encompasses only the nonclinical aspects of QM. d. incorporates information from strategic planning Janet - CH 1 - Concepts The perception of quality by a patient receiving care in an ambulatory healthcare center is influenced most by a. the physical environment. b. caring staff and physician. c. new technology. d. the physician's technical competence Janet - CH 1 - Concepts Total quality management philosophy assumes that a. most problems with service delivery result from systems difficulties b. frequent inspection is necessary to improve quality. c. most problems with service delivery result from difficulties with individuals. d. top management leadership in quality activities disenfranchises employees Janet - CH 1 - Concepts Outside the United States, most industrialized nations offer which type of healthcare insurance? a. Universal coverage b. Employer-based coverage c. Managed care d. Managed competition Janet - CH 1 - Concepts That function in the Juran’s Quality Management Cycle that includes the initial analysis of Data / information is a. quality planning. b. quality initiatives. c. quality control/measurement. d. quality improvement. Quality Control  Initial Analysis Quality Improvement  Intensive Analysis Janet - CH 1 - Concepts A potential conflict between the philosophy of total quality management and quality improvement in healthcare is the challenge in Deming's Principles to a. eliminate numerical goals for management. b. cease dependence on inspection. c. constantly improve every process. d. break down barriers between staff areas/departments Janet - CH 1 - Concepts The most basic components of managed care include all except a. prepaid financing. b. comprehensive services at multiple levels and settings. c. controlled access to services. d. broad choice of providers. Janet - CH 1 - Concepts What is the most important relationship between structure, process, and outcome as types of indicators of quality? a. Interdependent: Structure directly affects both process and outcome. b. Causal: Structure leads to process and process leads to outcome. c. Relational: Useful for comparisons, but not causal d. There is no relationship; they are categories used to group indicators. Janet - CH 1 - Concepts Physicians working with health maintenance organizations (HMOs) in the U.S. may be organized in any of the following models except [Not for CPHQ Exam] a. staff. b. network. c. broker. d. independent practice association Janet - CH 1 - Concepts Continuous quality improvement efforts find problems in hospital admission.To provide breakthrough ideas in admission , the quality team seeks ideas from : A. other hospitals B. previous lecture C. automobile industry C. hotel and resort industry Janet - CH 1 - Concepts Which of the following best describes the successful outcome of the quality improvement process? a. Customer satisfaction b. Enhanced communication c. Employee empowerment d. Improved statistical data Janet - CH 1 - Concepts Monitoring the specific organization and content requirements of a medical record system is a review of which focus? a. Outcome of care b. Process of care c. Structure of care d. Administration of care Janet - CH 1 - Concepts The major difference between traditional "quality assurance" activities and the expanded quality improvement/performance improvement activities is the QI/PI focus on a. people and competency. b. analysis of data. c. performance measures. d. systems and processes Janet - CH 1 - Concepts Monitoring phlebitis associated with IV insertions by nurses in the Surgical Intensive Care Unit addresses which focus? a. Outcome of care b. Process of care c. Structure of care d. Administrative procedure Janet - CH 1 - Concepts The centerpiece of "outcomes management" in healthcare is a. the measurement of the patient's functionality and quality of life. b. morbidity and mortality. c. data reliability. d. financial impact Janet - CH 1 - Concepts "Common causes" of problems in processes refer to a. one-time situations. b. temporary situations. c. acute situations. d. chronic situations Janet - CH 1 - Concepts Review of the timeliness of high risk screening for diabetes addresses which focus? a. Outcome of care b. Process of care c. Structure of care d. Administrative procedure Janet - CH 1 - Concepts The concept of risk management in U.S. healthcare [Not for CPHQ Exam] a. began in 1965 as a consequence of Medicare/Medicaid legislation. b. is in conflict with the goals of a seamless continuum of care and utilization management. c. permits an organization to ignore threats associated with increased corporate liability. d. developed as a result of increased physician malpractice liability costs. Janet - CH 1 - Concepts Under the quality improvement paradigm, which statement is incorrect? a. The focus is on the competency of individual practitioners. b. The focus is on the efficacy and effectiveness of processes. c. The focus is on the patient. d. The focus is on organization performance Janet - CH 1 - Concepts Within the context of total quality management philosophy, communication of quality is a. the responsibility of top management leaders. b. delegated to the Quality Management Department. c. an internal organizational, not community, issue. d. independent of process budgets or costs. Janet - CH 1 - Concepts The doctrine of "charitable immunity" or "innkeeper policy" for a healthcare provider organization has been replaced by [Not for CPHQ Exam] a. ostensible agency. b. "borrowed servant." c. corporate liability. d. tort liability. Janet - CH 1 - Concepts In managed care, the most common form of reimbursement for primary care physicians is a. straight salary. b. capitation without withholds. c. capitation with withholds. d. discounted fee-for-service. Janet - CH 1 - Concepts The probability that each step in a process will occur as it needs to occur is known as a. predictability. b. reliability. c. dependability. d. consistency Janet - CH 1 - Concepts A healthcare organization’s liability for the negligence of its employees is known as the doctrine of [Not for CPHQ Exam] a. respondeat superior. b. res ipsa loquitur. c. ostensible agency. d. quid pro quo. Janet - CH 1 - Concepts Organizational "culture" most often refers to a. the ethnicity of the organization's employees and licensed independent practitioners. b. assumptions about people and how work gets done. c. the efforts to reach out to the diverse groups in the community. d. the scheduled social and cultural events within the organization. Janet - CH 1 - Concepts Liability for the conduct of independent practitioners acting as representatives of the healthcare organization is known as [Not for CPHQ Exam] a. respondeat superior. b. duty of care. c. ostensible agency. d. tort liability Janet - CH 1 - Concepts Prospective payment systems provide reimbursement that is a. based on actual costs. b. based on charges. c. determined prior to care rendered. d. determined by the number of members served per year Janet - CH 1 - Concepts Applying the Pareto Principle in quality improvement is a. prioritizing process issues. b. tracking and measuring process effectiveness. c. providing meaningful data to support strategic objectives. d. prioritizing patient outcome issues. Janet - CH 1 - Concepts Special cause variation is to the process: a. random, extrinsic, outlier b. assignable, intrinsic, noise c. random, inlier, identifiable d. assignable, extrinsic, outlier Janet - CH 1 - Concepts "Managed competition" in healthcare most often refers to a. healthcare providers administered by competing management companies. b. healthcare providers competing by type of specialty. c. grouped healthcare providers competing within a geographic region. d. managed care organizations. Janet - CH 1 - Concepts The key goal of reengineering is to a. improve care processes. b. satisfy the customer. c. position for change. d. redesign the organization Janet - CH 1 - Concepts Steven Strong, 60, is recuperating from a total hip replacement procedure following a fall and fracture. He has a history of diabetes and heart disease and had an angioplasty just 2 months ago. He had been fully self-sufficient until the fall. The hospital has a new "Transitional Care Center" to which total joint replacement patients are transferred for postoperative physical therapy. The hospital is part of an integrated delivery system serving the community across the continuum of care. Use this information to answer questions I-41 and I-42: The integrated delivery system represents what type of healthcare system?. Subacute b. Horizontal c. Vertical d. Acute Janet - CH 1 - Concepts Steven Strong, 60, is recuperating from a total hip replacement procedure following a fall and fracture. He has a history of diabetes and heart disease and had an angioplasty just 2 months ago. He had been fully self-sufficient until the fall. The hospital has a new "Transitional Care Center" to which total joint replacement patients are transferred for postoperative physical therapy. The hospital is part of an integrated delivery system serving the community across the continuum of care. Use this information to answer questions I-41 and I-42: As part of the integrated delivery system, the Transitional Care Center will best meet Steve Strong's needs through a. case management b. continued physical therapy in the home c. diabetic disease management d. home evaluation through occupational therapy prior to discharge Janet - CH 1 - Concepts When common cause process variation is identified, the goal of quality improvement is to a. promote compliance with established procedure or protocol. b. eliminate the variation. c. improve practitioner competency. d. reduce variation sufficiently to produce stability Janet - CH 1 - Concepts In an inpatient stay, specific patient conditions that are present on admission and require treatment during the stay are called a. complications. b. comorbidities. c. community-acquired. d. healthcare-associated Janet - CH 1 - Concepts The interdisciplinary team is charged with creating a new admission process that will radically reduce current delays and wait times. The team is looking for a. continuous quality improvement b. systems thinking c. breakthrough improvement d. process reliability Janet - CH 1 - Concepts According to performance data, medications are not getting to patients in a timely manner. The front-line team has identified a five-step process and is intent on improving reliability. Use this information to answer questions I-46 and I-47 If the reliability rating for each of the steps in the process is 99%, 95%, 95%, 90%, and 93%, what is the probability of the entire process succeeding? a. 75% b. 80% c. 94% d. 95% Janet - CH 1 - Concepts According to performance data, medications are not getting to patients in a timely manner. The front-line team has identified a five-step process and is intent on improving reliability. Use this information to answer questions I-46 and I-47 Improvements are implemented and a performance measure is established for each of the five Steps in the process. The team is excited about the possibility of 100% reliability. One additional performance measure that would be best at measuring the goal would be a. # patients meeting one key step measure ÷ total # patients in sample b. # patients with all measures met ÷ total measures X # of patients c. total measures met ÷ total measures X # of patients d. # patients with all measures met ÷ total # patients in sample Janet - CH 1 - Concepts Surgical removal of the wrong body part is an example of [Not for CPHQ Exam] a. res gestae. b. non compos mentis. c. res ipsa loquitor. d. res judicata Janet - CH 1 - Concepts Healthcare quality professionals facilitating the assessment of the impact of the organization's culture on quality should evaluate, at the very least, the organization's degree of compliance with: a. the budget b. mission and vision statements c. the strategic plan d. policies and procedures Janet - CH 1 - Concepts Sunshine Community Medical Center is merging with three other hospitals and their IPAs and home health agencies to form the Sunshine Healthcare Network. The new integrated delivery system's vision is to create a seamless continuum of care within the region represented by their communities. The healthcare quality professional is part of a team working on the redesign of the quality management programs into an integrated systemwide quality strategy. Consider this scenario in answering questions I-50 through I-55 The systemwide merger and redesign best meets the definition of a. restructuring. b. rightsizing. c. downsizing. d. reengineering Janet - CH 1 - Concepts Sunshine Community Medical Center is merging with three other hospitals and their IPAs and home health agencies to form the Sunshine Healthcare Network. The new integrated delivery system's vision is to create a seamless continuum of care within the region represented by their communities. The healthcare quality professional is part of a team working on the redesign of the quality management programs into an integrated systemwide quality strategy. Consider this scenario in answering questions I-50 through I-55 The organizations involved in the redesign must each commit to a. preserving their culture. b. incremental change. c. fundamental change. d. their own leaders. Janet - CH 1 - Concepts Sunshine Community Medical Center is merging with three other hospitals and their IPAs and home health agencies to form the Sunshine Healthcare Network. The new integrated delivery system's vision is to create a seamless continuum of care within the region represented by their communities. The healthcare quality professional is part of a team working on the redesign of the quality management programs into an integrated systemwide quality strategy. Consider this scenario in answering questions I-50 through I-55 The success of the integrated quality strategy effort is dependent on the team's understanding of the need to a. include representatives from all current QI teams on the redesign team. b. implement one structure throughout the system. c. redesign QM processes in all the organizations. d. solicit input from all identified stakeholders. Janet - CH 1 - Concepts Sunshine Community Medical Center is merging with three other hospitals and their IPAs and home health agencies to form the Sunshine Healthcare Network. The new integrated delivery system's vision is to create a seamless continuum of care within the region represented by their communities. The healthcare quality professional is part of a team working on the redesign of the quality management programs into an integrated systemwide quality strategy. Consider this scenario in answering questions I-50 through I-55 To create a seamless continuum of care, the Sunshine Healthcare Network will first seek to a. consolidate locations b. integrate financial planning, information systems, marketing c. expand technology at all locations d. focus on incremental process improvements. Janet - CH 1 - Concepts Sunshine Community Medical Center is merging with three other hospitals and their IPAs and home health agencies to form the Sunshine Healthcare Network. The new integrated delivery system's vision is to create a seamless continuum of care within the region represented by their communities. The healthcare quality professional is part of a team working on the redesign of the quality management programs into an integrated systemwide quality strategy. Consider this scenario in answering questions I-50 through I-55 The key leadership skills needed for redesign efforts include a. communication, negotiation, systems thinking. b. communication, contracting, democratic style. c. planning, measurement, analysis. d. planning, finance, systems thinking.. Janet - CH 1 - Concepts Sunshine Community Medical Center is merging with three other hospitals and their IPAs and home health agencies to form the Sunshine Healthcare Network. The new integrated delivery system's vision is to create a seamless continuum of care within the region represented by their communities. The healthcare quality professional is part of a team working on the redesign of the quality management programs into an integrated systemwide quality strategy. Consider this scenario in answering questions I-50 through I-55 In an integrated delivery system, the success of the quality strategy is most dependent on the effectiveness of the a. information system. b. QI team process. c. case management process. d. patient care management system. Janet - CH 1 - Concepts In inpatient care, what is the key difference between a comorbidity and a complication: a. A comorbidity affects both treatment and length of stay. b. A complication is not present at time of admission. c. A complication is preventable. d. A comorbidity is not present at time of admission Janet - CH 1 - Concepts Oceanview Health System (OHS), consisting of two hospitals, long-term care, home health agency, and large multispecialty medical group, is beginning a reengineering effort due to a recent merger, decreasing reimbursement, and increasing operating costs. The leaders are committed to being a "learning organization" and to adopting a "systems thinking" philosophy, as a way to survive in the fastchanging healthcare marketplace. Use this information to answer questions I-57 and I-58 In evaluating their system's structure, OHS leaders must include a. bylaws, organizational chart, community assessment. b. budgets, process flows, quality improvement plan. c. locations, budgets, incentives. d. interrelationships, decisions, attitudes Janet - CH 1 - Concepts Oceanview Health System (OHS), consisting of two hospitals, long-term care, home health agency, and large multispecialty medical group, is beginning a reengineering effort due to a recent merger, decreasing reimbursement, and increasing operating costs. The leaders are committed to being a "learning organization" and to adopting a "systems thinking" philosophy, as a way to survive in the fastchanging healthcare marketplace. Use this information to answer questions I-57 and I-58 After first describing the problem, the best way to look at "patterns of behavior" over time is to use a. story telling and "The Five Whys." b. brainstorming and constructing gap hypotheses. c. line graphs and story telling. d. Pareto charts and brainstorming Janet - CH 1 - Concepts In statistical process control, it is important first to a. eliminate assignable causes of variation. b. eliminate random causes of variation. c. prioritize causes of variation. d. eliminate all causes of variation Janet - CH 1 - Concepts Sunshine Healthcare Network is trying to adapt to new contracting arrangements that will reduce applicable reimbursements by at least nine percent. In response, leaders approve a strategic initiative to redesign administrative processes, including all quality management/ improvement activities, in order to eliminate any unnecessary steps, forms, and staff responsibilities and become as efficient as possible. The philosophy that best supports this specific initiative is a. systems thinking. b. lean thinking. c. continuous quality improvement. d. reengineering. Janet - CH 1 - Concepts In the transition from quality assurance to quality management/quality improvement, which of the following emphases has resulted in the most significant benefit? a. Focusing primarily on process rather than individual performance b. Focusing on organization wide rather than clinical processes c. Organizing activities around patient flow rather than department or discipline d. Initiating more prospective rather than retrospective improvement efforts Janet - CH 1 - Concepts Your medical group is merging with a larger regional medical group. The functions of quality, utilization, and risk management will be centralized at the regional level, but expanded at the local level, necessitating changes in staffing, position descriptions, and processes. Such organizational change represents a. for-profit organizational structure b. downsizing c. a paradigm shift d. financial advantage Janet - CH 1 - Concepts Attempts to align the financial incentives of purchasers, payers, and providers with provider performance on clinical process and outcome measures could encourage a. underutilization. b. community backlash. c. overutilization. d. reengineering Janet - CH 1 - Concepts After defining "internal" and "external" customers, your organization is making a master-list of each type of customer before initiating a major change process. Of the following, which is the best next question to ask of staff? a. Who do you receive services from? b. Who in your work day do you serve? c. Which patients receive your services? d. How do you know a customer from a supplier? Janet - CH 1 - Concepts When incorporating lean thinking into process improvement, the quality professional teaches the team to a. identify suppliers and their inputs. b. focus on special cause variation. c. consider the system's structure. d. identify and eliminate wasteful steps Janet - CH 1 - Concepts Process indicator is defined as one that measures; A. Significant events that require further investigation B. An activity carried out to provide care or service C. Unexpected or negative variation D. The appropriateness of the procedure or treatment Janet - CH 1 - Concepts Performance Improvement data are used for credentialing and privilege-delineation. The practitioner is evaluated on his/her A. communication style and temperament. B. adherence to federal, state and organizational standards. C. cooperation, appropriateness, and staffing activities D. concern about the well-being of patients in long-term care Janet - CH 1 - Concepts The following is basically reviewed to determine the medical necessity and the appropriateness of service delivery in inpatient care: A. Admission review. B. Diagnosis-related group (DRG) validation. C. Procedure review. D. Quality audits Janet - CH 1 - Concepts The role of the Utilization Management include all except A. Care coordination and after care planning B. Review: medical necessity and appropriateness C. Resource allocation: timeliness, efficiency and cost Janet - CH 1 - Concepts When evaluating how many people in her facility's managed care plan were able to receive the flu shot. , under Dimensions of Performance A. appropriateness B. availability C. effectiveness D. efficacy Janet - CH 1 - Concepts Critical data selection elements for focused review of appendectomy surgeon : A) appropriateness - admitting symptoms - pathology results B) admitting diagnosis - pathology results - committee review C) preoperative testing - surgeon - admitting diagnosis - age D) LOS - diagnosis on admission - age – surgeon Janet - CH 1 - Concepts The most important patient safety issue to a utilization reviewer is a. timeliness of treatment. b. medical necessity for treatment. c. correct assignment of diagnosis or procedure code. d. appropriateness of healthcare setting. Janet - CH 1 - Concepts A radiology department regularly monitors x-ray repeat/reject, timeliness of report dictation, and patient waiting times. What component is missing in this department's ongoing evaluation program? A. Appropriateness review. B. Process evaluation. C. Quality control. D. Documentation analysis Janet - CH 1 - Concepts Zero waste in particular equipment, supplies, ideas and energy means: A. Effectiveness B. Efficiency C. Appropriateness D. Equity Zero Waste  Resource  Efficiency Janet - CH 1 - Concepts Appropriateness of appendectomy: A. preadmission test B. pathology test C. age D. Clinical test Janet - CH 1 - Concepts After administration of flu vaccine. quality professional measures how many people caught influenza after administering the vaccine. Which dimension she measured? A. Prevalence b. process c. appropriateness D. Efficacy Janet - CH 1 - Concepts A quality manager is determining how many patients still became sick from influenza after receiving flu shots at his facility. Which dimension of performance is he evaluating? A. Appropriateness B. Effectiveness C. Efficacy D. Safety Janet - CH 1 - Concepts 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 A. efficacy. B. effectiveness. C. safety. D. appropriateness Janet - CH 1 - Concepts For which aspect of care are patient-reported measures most credible? A. Communication between providers B. Patient-provider interactions C. Adherence to clinical practice guidelines D. Appropriateness of therapy Janet - CH 1 - Concepts Among the following factors, nurse response to alerts by a computerized drug utilization review system is LEAST likely to be associated with A. the number of alerts. B. the appropriateness of alerts. C. a perception that the system is unhelpful and annoying. D. the patient's primary medical condition Janet - CH 1 - Concepts Several leader in the health care facilities have differing opinion regarding the pursuit of alternative of certification and recognition the chief of quality was alleged to hire an external quality consultation and determine performance for Appropriateness and readiness for alternative certification ,the first most appropriate role for external consultant is : a. Uncover opportunities for improvement with in the facility b. Support the chief of quality choices for alternative certification c. Take the final decision about the certification selected d. Alleviate the facility goals and stakeholder input Janet - CH 1 - Concepts A social service department regularly monitors the number of inappropriate referrals, the timeliness of discharge planning, and the number of days of discharge delays. What additional monitor should be added to evaluate the appropriateness of social service interventions? A. Inadequacy of documentation in progress notes B. Attainment of social service goals C. Timeliness of referrals to social services D. Number of social service referrals from nursing Janet - CH 1 - Concepts The primary purpose of the survey is to measure A. Patient expectations B. Capacity of the process C. Competence of the staff D. Utilization appropriateness Janet - CH 1 - Concepts For CQi to be successful, who must be included in staf A. department supervisor B. administrator C. facilitator D. Staff Janet - CH 1 - Concepts For CQi to be successful who must be included in staff A. administrator B. person performing process C. quality management representative D. department supervisor Janet - CH 1 - Concepts who is responsible for providing CQI direction A. facilitator B. quality council C. leader D. team Janet - CH 1 - Concepts Who is responsible for quality improvement within organization A. quality manager B. frontline staff C. everyone within organization D. chief executive officer Janet - CH 1 - Concepts Who is responsible for creating and monitoring the implementation of improvement project work plan and time line? A. sponsor B. team leader C. team facilitator D. quality council Janet - CH 1 - Concepts Who is ultimately responsible for the effective implementation of the quality program: a. Governing Body b. CEO c. All staff d. The CFO Janet - CH 1 - Concepts To establish evidence based practice guideline, it is best to A. reply on subjective, expert opinion B. review every possible intervention or treatment C. include those who resist process D. allow individual practitioner to make any exception to guideline Janet - CH 1 - Concepts Quality and technical performance refers to how well current scientific medical knowledge and technology are combined in a given situation to produce the best possible outcome. This joined combination is usually assessed in terms of: a. Appropriateness of therapy and other medical interventions are applied. b. The quality of interpersonal relationships. c. Timeliness and accuracy of the diagnosis. d. Both answers A and C are correct. Janet - CH 1 - Concepts Crossing the Quality Chasm provided a blueprint for the future that classified and unified the components of quality through six aims for improvement, chain of effects, and simple rules for redesign of healthcare. The six aims for improvement, viewed also six dimensions of quality. Which of the following is out of those dimensions? A. Safe B. Efficient C. Effective Care Centered (Patient Centered) is included in D. Care centered STEEP but NOT included within Key Dimensions of Quality Janet - CH 1 - Concepts Joint commission empowers customers by providing education materials as navigational aids for complex healthcare systems, like: A. Dimensions of quality B. Deming’s points of quality revolution C. Patient safety goals D. The “Speak Up” campaign Janet - CH 1 - Concepts Systems thinking can facilitate the quality professional's teaching of the structure Process Outcome paradigm. Which of the following statements best links systems with the paradigm? a. All systems are complex and open. b. The system's output has multiple dimensions. c. The design of the system produces the output. d. Systems are composed of people, machines, processes, and data. Janet - CH 1 - Concepts Which of the following situations best describes the term “Misuse” of Resources at healthcare facilities? a) Patients receive appropriate medical services that are provided poorly, exposing them to added risks of preventable complications. b) Patients undergo treatment or procedures from which they do not benefit. c) Patients do not receive beneficial health services. d) None of the above Janet - CH 1 - Concepts Mortality reviews are a critical element of Risk Management and Quality Improvement, conducted to determine A. if the practitioner(s) involved was/were appropriately licensed and credentialed. B. if treatments and patient care were adequate and appropriate. C. who was responsible for the mortality and what disciplinary actions need to be taken. D. what the unit staff was doing at the time Janet - CH 1 - Concepts Healthcare purchasers and payers are demanding that providers demonstrate their ability to provide high quality patient care at fair prices. Specifically, they are seeking: A. Objective evidence that hospitals and other healthcare organizations manage their costs well B. Current performance C. Baseline information D. Objective evidence that hospitals and other healthcare organizations satisfy their customers and have desirable outcomes Janet - CH 1 - Concepts A healthcare facility has committed to improving the overall quality of care for patients and their families during their stay at the facility. Among these goals in improved quality of care are the goal of increased safety, better nutrition, and staff friendliness. The role of the CPHQ in improving quality of care includes all of the following EXCEPT: A. Providing each department of the facility with friendly reminders about patient safety B. Creating a disciplinary process for staff members who fail to treat patients in a friendly way C. Researching and providing the facility with different options to improve food choices D. Developing an educational program to help staff members interact appropriately with patients Janet - CH 1 - Concepts The CPHQ must integrate Quality findings into governance and management activities to A. align payment/incentive systems, tying rewards to clinical objectives to improve care. B. maintain the current governing system to provide a continuum of care. C. establish administrative policies and procedures for governance and management. D. re-write the bylaws to reflect current streams of data-inclusion Janet - CH 1 - Concepts The Chief Executive Officer of an acute care facility wishes to know the difference between Total Quality Management (TQM) and Six Sigma. The healthcare quality professional should inform him that: A. TQM can be implemented on its own while the benefits of Six Sigma can only be realized when it is combined with Lean methods. B. TQM loosely monitors progress toward goals whereas Six Sigma ensures that investment in quality produces the expected return. C. TQM focuses on compliance with performance standards. Six Sigma focuses on world class performance. D. TQM is a management philosophy whereas Six Sigma is a tool to reduce variation in a product or process Janet - CH 1 - Concepts Total Quality Management (TQM) can affect all of the following significant changes in organizational functions EXCEPT: A. Diminishing of the top management role. B. An emphasis on customer satisfaction. C. Reducing the hierarchical structure. D. An emphasis on individuals involvement in process management and continuous improvement. Janet - CH 1 - Concepts Walter Shewhart's causes of variation led him to develop methodology to chart the process and quickly determine when a process is " Out of Control". This ongoing measurement and analysis is known as A. SPC Statistical process control (SPC). B.RCA c. FMEA D. TQM Janet - CH 1 - Concepts Which of the following element must be present in order to evaluate effectiveness of healthcare organization quality improvement program A. Integrated data collection. B. Quantified objective C. Well defined organization culture. D. Well educated medical staff. ‫وجود هدف محدد على أساسه نقيم مشروع الجودة اللي اتعمل‬ Janet - CH 1 - Concepts In health care organization, the quality department developed an indicator to measure the commitment of the staff to myocardial infarction guidelines.This indicator measure: a. process b. structure c. culture d. outcome Janet - CH 1 - Concepts In one of the first class high quality hospitals in Newcastle, Ministry of Health yield a survey about what is the impact of safe culture of work on the caregivers? As a quality man, What is not expected to find in the final report of the survey? A. The staff did not worry that their mistakes will be reported in their personnel file. B. The staff belief that their weakness points will not be used against them. C. The highest percentage of staff reported that no significant adverse events had occurred in their setting during the past 12 months. D. Low average composite score involved questions related to non-punitive response to error Janet - CH 1 - Concepts Healthcare quality professionals facilitating the assessment of the impact of the organization's culture on quality should evaluate, at the very least, the organization's degree of compliance with: a. the budget b. mission and vision statements c. the strategic plan d. policies and procedures Janet - CH 1 - Concepts All of the following are ways through which any organization leadership can enhance the spread of "quality culture" within the organization EXCEPT a) Develop mission and vision statements. b) Assign quality professionals to lead the process of cultural transformation c) Adopt flexible management styles. d) Develop quality initiatives Janet - CH 1 - Concepts Evidence Based Quality Management promotes. a. Culture of Excellence b. Culture of free from Medical & Medication Errors c. Culture of cooperation d. Culture of No punishment Janet - CH 1 - Concepts During a surgical procedure, a small medical implement was left inside a patient. The follow-up surfer to remove the implement is an example of... A. Quality improvement B. Quality control C. Quality assurance D. Total quality Janet - CH 1 - Concepts Just Culture means A. Culture of no abuse B. Blame free culture C. Quality culture D. A culture of timeliness Janet - CH 1 - Concepts 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 A. identifying safety risks and interventions to reduce events. B. measuring patient satisfaction after a risk intervention. C. leadership from external suppliers assisting in the culture’s structure. D. training patients to abide by the safety culture’s requirements Janet - CH 1 - Concepts The most effective role of a healthcare quality professional as a facilitator of change to quality culture in the organization is: a. Education of leaders b. Education of staff. c. Evaluation of performance. d. Designing processes Janet - CH 1 - Concepts Best to ensure success of quality improvement in the organization: a- Education level of quality leaders b- People skills of facility leaders c- Culture of the organization Janet - CH 1 - Concepts The way to emphasize the importance of learning from mistakes and near misses in order to reduce errors in the future is known as: A. Root cause analysis. B. Meetings. C. Fair and just culture. D. High quality of care Janet - CH 1 - Concepts Joe Smith wants to study patient satisfaction in his institution but wants to get the largest group possible so he conducts his study in the local mall. His study might be criticized not only for reaching individuals who are not patients, but also that it is a) capitated b) nonrandomized c) randomized d) varied Janet - CH 1 - Concepts A large facility has fostered a culture of patient safety through staff education, support of process improvements at department level, and implementation of a non -punitive approach to error reporting, compliance with patient safety goals range from 75-100%. in assessing the culture of patient safety , the healthcare quality professional should : a- Survey patients from the last 6 months b- Survey all employees and physicians c- Review post-surgical infection rate data d- Review data collected through incident reports Janet - CH 1 - Concepts  A patient with no prior history of major medical problems was admitted for an elective cholecystectomy. On the second postoperative day, the patient started to experience pain at the operative site and high fevers. Blood cultures were positive for Escherichia coli and other investigations confirmed the presence of a surgical site infection. The patient died of overwhelming septicaemia in the Intensive Care Unit 7 days after his operation. From a quality standpoint, this case is best classified as a A. clinical mishap. B. adverse event. C. never event. D. sentinel event. Sentinel Event = healthcare-associated infection associated with a death or permanent disability Adverse Event = healthcare-associated infection Medical or Clinical Mishap = occurs when "injury or damage is caused by mischance or accident, unexpected and undersigned". Janet Never Events - CH (by NQF) = are grouped into six categories: surgical, product or device, patient 1 - Concepts protection, care management, environmental, and criminal. The incident described in this question Which of the following is most likely to be a benefit of concurrent ambulatory surgical case review? A. Decreased medical record review at discharge B. An increase in the number of cases failing screening criteria C. An increase in reviewer competence D. Decreased employee turnover Janet - CH 1 - Concepts The performance indicator, “Total unscheduled inpatient admissions following ambulatory procedure (within 48 hours)” is a measure of a. structure. b. process. c. outcome. d. process and outcome. Janet - CH 1 - Concepts The number of designated women receiving breast cancer screening (mammograms) in the reporting year measures a. process. b. clinical outcome. c. process outcome. d. process and clinical outcome Janet - CH 1 - Concepts Measuring the time it takes a nurse to perform a procedure addresses which of the following aspects of care? A. monitoring B. process C. outcome D. structure Janet - CH 1 - Concepts The number of productive hours worked by nursing staff with direct patient care responsibilities per patient day is a A- structural measure. B- process measure. C- outcome measure. D- composite measure Janet - CH 1 - Concepts One of the aims in the treatment of severe community-acquired pneumonia is to maintain an oxygen saturation of >94% (or 88 - 92% in patients with chronic obstructive airway disease). Ensuring adequate oxygenation for this condition is a A. process and outcome measure. B. structure measure. C. process measure. D. outcome measure Janet - CH 1 - Concepts In an improvement project to reduce the wait times in an Emergency Room, the time taken to be assessed by a physician is A- a process measure. B- an outcome measure. C- a structure measure. D- not a suitable measure ‫وقت االنتظار ده‬..... ‫قياس وقت انتظار المريض في الطوارئ حتي يتم تقييمه بواسطة الطبيب‬.‫ بدون شك‬process ‫هو‬ Janet - CH 1 - Concepts In implementing a care bundle for the management of acute myocardial infarction, the recording of the extent to which smoking cessation counseling is provided is a measure of A. structure. B. process. C. outcome. D. process and outcome * Recording (Keyword)  Process Janet - CH 1 - Concepts A healthcare quality professional can best display the distribution of 48 data points on waiting times in an ambulatory care clinic using a A. stem-and-leaf plot. B. bar chart. C. scatter diagram. D. run chart. Janet - CH 1 - Concepts A small, rural hospital wishes to evaluate customer satisfaction using a survey. The organization has four patient care units, an emergency department, and an ambulatory unit. Which of the following survey methods provides the most reliable information? A. a random sample of 20% of annual discharges/visits per unit. B. a random sample of 5% of all annual discharges/visits. C. all discharges/visits in January and July. D. all discharges/visits of customers with a last name beginning with the letters A-E. Janet - CH 1 - Concepts Deploying a CQI team would be first approach in addressing which A- Several patient complained their call lights not answered during night shifts B- Several physicians don't allocate enough time for procedures which booking surgical cases C- Finance billing outpatient procedures as ambulatory surgery D- Results of preadmission testing for inpatient survey are unavailable 35% of time causing delays. Janet - CH 1 - Concepts An ambulatory outpatient care facility identifies an opportunity to improve the turnaround time for reports of x-rays performed at a local hospital. Which of the following groups should be involved in the team to improve the process? A. administrative representatives from both facilities B. primary care physician, clinic nurse, and clinic administrator C. radiologist, primary care physician, and clinic medical records D. clerical, clinical, and administrative staff from both facilities Janet - CH 1 - Concepts Pre-authorization is required for all of the following except a. Inpatient acute care. b. Ambulatory care. c. Rehabilitation. d. Psychiatric care. Janet - CH 1 - Concepts Which of the following is NOT true regarding the JCAHO's no smoking policy? A. Exceptions to the prohibitions are usually determined by licensed, independent practitioners. B. Social rehabilitation settings may not require a licensed independent practitioner’s order. C. Exceptions are allowed in hospital-sponsored ambulatory care areas. D. Exceptions are not allowed in adolescent and child patient care areas Janet - CH 1 - Concepts It is difficult to predict outcomes of care in A. ambulatory care B. hospice care C. intensive care D. emergency care Janet - CH 1 - Concepts the best indicator used by an ambulatory setting to measure its outcome is A. number of admissions to the hospital b- number of surgeries c- claims data d- number of dispensed drugs Janet - CH 1 - Concepts Which of the following group is least likely to report errors? A. Primary care physician B. Support staff C. Independent contractor D. Nurses Janet - CH 1 - Concepts An improvement team is implementing a care bundle to improve care for community-acquired pneumonia (CAP). After 12 months, the team has achieved 96.1% overall reliability. Which of the following is the BEST measure of the team's performance in implementing the care bundle going forward? a. Individual process measures b. Composite process measure c. All-or-nothing process measure d. Inpatient deaths due to CAP Janet - CH 1 - Concepts A hospital generally has a unique structure comprised of a "triangle." Which three entities make up the triangle? a. Governing body, administration, finance b. Administration, department managers, medical staff c. Governing body, administration/management, medical staff d. Administration, medical staff, nursing Janet - CH 2 - Leadership Autocratic leadership A- make decision and announce them B- limiting setting interfering in decision Janet - CH 2 - Leadership The leadership style that is said to motivate employees, and that optimizes the introduction of change, is a. autocratic. b. consultative. c. participatory. d. democratic Janet - CH 2 - Leadership The key to creating sustained value in the organization is to a. delegate policy-making and oversight to the quality council. b. develop a strategy that derives from the vision, strategic goals, and cost-benefit analyses. c. adopt an organizational ethics policy and code linked to mission,vision, and values. d. act on predictive performance measures aligned to strategic goals and department objectives. Janet - CH 2 - Leadership The person/group legally responsible for maintaining quality patient care is the a. governing body. b. quality improvement council. c. chief executive officer. d. medical/professional staff. * Keyword for Governing Body: Legally – Final – Ultimate …. Janet - CH 2 - Leadership Hospital medical/professional staff bylaws a. relate only to members. b. are subject to governing body approval. c. are required only if the staff is departmentalized. d. are required only if the facility is not incorporated. Janet - CH 2 - Leadership "Organization-wide functions" refer to a. key governance, management, clinical, and support activities. b. functions of the governing body. c. cross-functional team activities. d. legal and fiduciary obligations to patients. Janet - CH 2 - Leadership The authority and responsibility of each level of the organization with respect to quality management mechanisms must be specified in the a. administrative policies and procedures. b. medical/professional staff bylaws. c. corporate bylaws. d. organizational plan for the provision of patient care. Janet - CH 2 - Leadership In participative management the manager a. relinquishes decision-making responsibility to the staff. b. retains the final decision-making responsibility. c. presents a final decision to the staff. d. permits staff participation only with noncritical issues Janet - CH 2 - Leadership Which of the following statements refers only to strategic planning and not to the former traditional "master planning"? a. Planning focuses primarily on producing new services. b. Planning begins with the statement of mission. c. Planning is an integral part of management. d. Planning ignores the political environment of the organization Janet - CH 2 - Leadership The best evidence of the incorporation of quality planning into the organizationwide strategic planning process might be a. successful quality initiatives. b. the organizationwide plan for provision of patient care. c. the quality management/quality improvement plan. d. the quality management/quality improvement budget Janet - CH 2 - Leadership Which of the following is the best way to determine if a quality improvement initiative is successful? A. Present findings to the Quality Council. B. Conduct a retrospective review. C. Compare outcomes with pre-established goals. D. Survey patients and customers Janet - CH 2 - Leadership Strategic planning is best described as a. a long-term focus, projecting the present into the future. b. a set of top-level performance measures. c. a statement of mission, vision, and values. d. an ongoing look into the future Janet - CH 2 - Leadership Which of the following best describe vision statement? A. It is used as a marketing strategy B. It is define the structure of the institution C. It describe organization strategic plans D. It reflect the organization culture Janet - CH 2 - Leadership Which of the following is most important to the successful implementation of quality improvement activities? a. Financial commitment and written quality management plan b. Leadership commitment and organizationwide collaboration c. Leadership commitment and financial commitment d. Information management system and department collaboration Janet - CH 2 - Leadership The mission statement of the organization describes a. where the organization is going. b. the purpose of the organization. c. the strategic direction of the organization. d. the long-term goals of the organization Janet - CH 2 - Leadership You have joined the newly merged Preferred Health, a for-profit integrated delivery system (IDS), as Vice President for Quality. You are responsible for reengineering or otherwise integrating the QM/QI function across the provider network. Based on your understanding of systems, corporate culture, ethics, quality, leadership's influence, and strategic planning, answer questions II-14 through II-17: Which of the following statements and documents are most likely to reveal the organization's underlying or true value system? a. Mission, ethics policy, strategic initiatives b. Vision, ethics policy, corporate bylaws c. Values, QM/QI Plan, utilization management pland. Mission, vision, values d. Mission, Vision, Values Janet - CH 2 - Leadership You have joined the newly merged Preferred Health, a for-profit integrated delivery system (IDS), as Vice President for Quality. You are responsible for reengineering or otherwise integrating the QM/QI function across the provider network. Based on your understanding of systems, corporate culture, ethics, quality, leadership's influence, and strategic planning, answer questions II-14 through II-17: In working with the hospitals and physician practice groups (medical groups and IPAs) on QM/QI redesign, one of the important tasks to accomplish first will be to a. evaluate current compliance with data collection and reporting. b. develop a draft corporate QM/QI plan for the providers to review and revise as necessary. c. establish a cross-functional planning team. d. commit physician leaders to participate in the planning phase. Janet - CH 2 - Leadership You have joined the newly merged Preferred Health, a for-profit integrated delivery system (IDS), as Vice President for Quality. You are responsible for reengineering or otherwise integrating the QM/QI function across the provider network. Based on your understanding of systems, corporate culture, ethics, quality, leadership's influence, and strategic planning, answer questions II-14 through II-17: The best way to incorporate the concept of alignment into reengineering is to: a. learn the organizational structure of each provider organization. b. have one QM/QI Plan document for the IDS. c. evaluate the QM/QI initiatives of each provider organization in the light of corporate strategic goals. d. create a centralized database that assures the security, confidentiality, and accuracy of all QM/QI reports Janet - CH 2 - Leadership You have joined the newly merged Preferred Health, a for-profit integrated delivery system (IDS), as Vice President for Quality. You are responsible for reengineering or otherwise integrating the QM/QI function across the provider network. Based on your understanding of systems, corporate culture, ethics, quality, leadership's influence, and strategic planning, answer questions II-14 through II-17: Of the following, the measures most indicative of the IDS' ability to provide value to its stakeholders are a. improvements in patient outcomes and reduced costs of care. b. an annual report with a positive bottom line. c. improvements in patient outcomes and patient satisfaction. d. reduced costs of care and competitive pricing. Janet - CH 2 - Leadership You are going to make major changes in the billing system in the organization. To increase the acceptance of the staff to change: A. medical staff education. B. long range plan C. pilot project Janet - CH 2 - Leadership A team has been selected from all linked services in several healthcare organizations in the WeCare Healthplan [MCO] network to address information management. The term that best describes such a team is a. departmental. b. service-line. c. interdepartmental. d. cross-functional. Janet - CH 2 - Leadership In an organizationwide QI model, the person or group usually accountable for continuously assessing and improving performance at the department level is the a. cross-functional QI team. b. quality council. c. department director. d. department team. Janet - CH 2 - Leadership Strategic leadership is linked to success in meeting a. budget requirements. b. intended objectives. c. governing body policy. d. contract requirements Janet - CH 2 - Leadership In a crisis situation, when a manager must make a rapid decision, the most effective leadership style is a. consultative. b. participatory. c. autocratic. d. democratic Janet - CH 2 - Leadership In the "quality-based strategic planning" model a. representatives from each active QI team form the strategic planning team. b. the steering council leads strategic planning as an ongoing activity. c. licensed independent practitioners lead the strategic planning effort and formulate the performance measures. d. input from management and staff is the key assessment activity. Janet - CH 2 - Leadership  As a performance measurement system, the key value of the "balanced scorecard" concept is its ability to a. serve as a comparative "report card" with like organizations. b. focus the organization on financial measures of survival and success. c. encompass all the organization's clinical and non-clinical measures. d. align measurement with the vision and strategy of the organization ttps://www.youtube.com/watch?v=AdXt8BfiGJg Janet - CH 2 - Leadership Which of the following statements about the balanced scorecard is FALSE a) It is a strategic performance management tool. b) It presents a mixture of financial and non-financial measures. c) The overall score on the balanced scorecard gives a summary of the organization's performance d) Each measure in the balanced score card has a target Janet - CH 2 - Leadership In the Balanced Scorecard, the Perspective that measures human, informational, and operational capital is a. Operations/Internal. b. Financial. c. Innovation and Growth. d. Customer. Janet - CH 2 - Leadership healthcare quality program had prepared a balanced score card that displayed patient satisfaction was 98%, financial target has been met , medication error had been increased by 30% and heart surgery rate decreased 3% , what additional information the governing body may ask for? a) type of medication error b)heart surgery case. c)patient satisfaction data. d)review patient compliant Janet - CH 2 - Leadership The best way to facilitate leadership education about the role of ethics in the organization is to understand that a. each leader's personal value system drives decision making. b. the organization's written Code of Ethics drives decision making. c. the organization can have both good and bad ethics. d. accountability for organizational ethics is primarily internal, not public. Janet - CH 2 - Leadership Leadership during a lengthy period of crisis in the organization is a. based on the leader's position in the organization. b. a participative activity performed by anyone committed to lead. c. dependent on a set of personal characteristics. d. an autocratic style with decisions made solely by the leader. Janet - CH 2 - Leadership Having management pay attention to workers’ activities results in a. Decreased anxiety b. Decreased productivity c. Increased anxiety d. Increased productivity Janet - CH 2 - Leadership You are new to your position as Director of Healthcare Quality. You know you need to identify the “quality champions” who can help lead the quality strategy you are asked to implement. Use this information to answer questions II-27 and II-28: You understand that the most effective quality champions are a. the strategic decision makers. b. participants on the QI Council. c. committed to the mission, vision, and values. d. governing body members active in the community Janet - CH 2 - Leadership You are new to your position as Director of Healthcare Quality. You know you need to identify the “quality champions” who can help lead the quality strategy you are asked to implement. Use this information to answer questions II-27 and II-28: In the clinical arena, which of the following criteria is most consistent with your understanding of a key quality champion? a. Long-term relationship with the organization b. Experience with data analysis c. A leadership position d. Best practices Janet - CH 2 - Leadership In the "language" of strategic planning, the "strategies" of the organization can also be called a. objectives. b. critical success factors. c. goals. d. the dashboard Janet - CH 2 - Leadership The organization's governing body and CEO are being urged to make a commitment to a culture of quality. The ideal role of the healthcare quality professional is to serve as the: a. quality champion. b. facilitator. c. visionary. d. data expert. Janet - CH 2 - Leadership An acute care facility has found that the incidence rate of pressure ulcer cases, although low, is not as low as the incidence rate reported by comparable organizations. Because the incidence of pressure ulcers may detract from the organization's reputation for giving good care, management decides to take this matter seriously and assigns a project manager and analyst. On review of the records, the project team decides that the existing policy is the right one and something is going wrong in the implementation. Which of the following options is most appropriate? A. Develop a new policy. B. Failure modes and effects analysis. C. Root cause analysis. D. Review the data on pressure ulcers. Janet - CH 2 - Leadership You have just taken a new position as QM Director at the 350-bed Sunshine Community Medical Center in San Diego County, California. You report to the Vice President, Administrative and Support Services. Your first responsibility is to provide administration with an evaluation and recommendations concerning the current status of the quality management program. Use this information to answer the following: One of your first key issues to determine when evaluating the current QM program is a. the climate for change in each department and service. b. the extent of leadership knowledge of and involvement in quality activities. c. the operating budgets for the quality, utilization, and risk management departments. d. Responses to accreditation recommendations following the last two surveys Janet - CH 3 – Systems Management You have just taken a new position as QM Director at the 350-bed Sunshine Community Medical Center in San Diego County, California. You report to the Vice President, Administrative and Support Services. Your first responsibility is to provide administration with an evaluation and recommendations concerning the current status of the quality management program. Use this information to answer the following: In evaluating the current QM program for strengths and weaknesses, it is NOT necessary to assess a. strategic initiatives. b. managed care contracts. c. team minutes. d. alternative QM software products Janet - CH 3 – Systems Management You have just taken a new position as QM Director at the 350-bed Sunshine Community Medical Center in San Diego County, California. You report to the Vice President, Administrative and Support Services. Your first responsibility is to provide administration with an evaluation and recommendations concerning the current status of the quality management program. Use this information to answer the following: The written evaluation should include a. recommendations and resources required to implement them. b. persons concerned about quality problems. c. recommendations for staff salary raises. d. only recommendations that fall within current budget constraints Janet - CH 3 – Systems Management You have just taken a new position as QM Director at the 350-bed Sunshine Community Medical Center in San Diego County, California. You report to the Vice President, Administrative and Support Services. Your first responsibility is to provide administration with an evaluation and recommendations concerning the current status of the quality management program. Use this information to answer the following: Your initial report should be addressed to the a. Quality Council. b. Vice President, Administrative and Support Services. c. CEO. d. Board of Directors Janet - CH 3 – Systems Management The formal functions of management include all except a. planning. b. organizing. c. directing. d. inspecting Janet - CH 3 – Systems Management A large emergency department (ED) reduced its average length of stay for discharged patients from 130 minutes to 1 hour with a goal to improve patient satisfaction. How best might the ED know the changes were also effective financially, as part of a cost-benefit analysis? a. Decreased staffing and decreased costs b. Increased staffing and increased net revenue c. Increased patient volume and increased net revenue d. Increased patient volume and increased staffing Janet - CH 3 – Systems Management Which of the following issues might be most important to health maintenance organizations negotiating contracts with providers? a. Quality/utilization capabilities, disclosure of data, reimbursement b. Disclosure of data, practitioner credentialing, computer capabilities c. Staffing, accreditation, reimbursement d. Reimbursement, physician board certification, malpractice claims Janet - CH 3 – Systems Management Which of the following issues might be most important to a medical group or IPA (independent practice association) negotiating contracts with health plans? a. Reimbursement, physician board certification, staffing b. Data requirements, credentialing requirements, reimbursement c. Credentialing requirements, computer capabilities, MCO accreditation d. Data requirements, MCO accreditation, reimbursement Janet - CH 3 – Systems Management Which of the following issues might be most important to hospitals negotiating contracts with health plans? a. MCO accreditation, bylaws, medical staff practitioner credentialing requirements b. Staffing, reimbursement, confidentiality of peer review information c. Computer capabilities, MCO accreditation, review requirements d. Data requirements, confidentiality of peer review information, reimbursement Janet - CH 3 – Systems Management A quality professional in a home health agency is charged to develop a quality management/ quality improvement strategy. Of the following steps, which should be done first? a. Develop strategic quality initiatives b. Determine the roles of leaders in implementation c. Draft the QM/QI plan for review by leaders d. Review the organization's scope of care and service Janet - CH 3 – Systems Management Which of the following is not relevant to include in both utilization management and quality management plans? a. Confidentiality policy b. Process for appealing treatment denials c. Conflict of interest policy d. Provision for annual program evaluation Janet - CH 3 – Systems Management The principle underlying the selection of an organizationwide quality council is a. one oversight body b. leadership control c. one cross-functional team d. elimination of department/service quality control Janet - CH 3 – Systems Management Why should a UM Plan include a conflict of interest statement? a. To provide for unbiased decisions b. To prevent economic credentialing c. To provide for security and integrity of information d. To provide immunity for physician reviewers Janet - CH 3 – Systems Management The term "corporate compliance plan" refers to the healthcare organization’s a. licensure survey corrective action plan. b. annual financial audits. c. program to prevent fraud and abuse. d. agreement to collect HEDIS® data. Healthcare Effectiveness Data and Information et (HEDIS) Janet - CH 3 – Systems Management A hospital Utilization Management Plan generally includes provision for a. disaster planning. b. transition planning. c. quality planning. d. financial planning Janet - CH 3 – Systems Management The managed care organization’s use of a 24-hour nurse-staffed telephone hotline to inform member/patient callers of care options and provide self-management education is a type of: a. preauthorization. b. case management. c. disease management. d. demand management. Janet - CH 3 – Systems Management The key advantage of case management in managed care is a. control of clinical risk. b. control of hospital use. c. coordination of care. d. prevention of illness. Janet - CH 3 – Systems Management The practical motivation for American Healthplan HMO to develop a disease management system based on practice guidelines and clinical paths is a. capitation. b. healthcare reform. c. collection of HEDIS® data for NCQA. d. its mission as a health maintenance organization. Janet - CH 3 – Systems Management An 85-year-old woman is admitted through the Emergency Department with a fractured right hip. When should discharge planning begin? a. After surgery, once the physical therapist has done an assessment b. When the physician writes a discharge planning order c. At time of admission to the acute hospital d. When the decision is made concerning the next level of care Janet - CH 3 – Systems Management As Director of Quality Resource Management for an integrated delivery system, you have been asked to provide information prior to renegotiation of a contract with a national Preferred Provider Network. What data will be most helpful? a. Reimbursement minus charges b. Reimbursement minus costs c. Charges minus reimbursement d. Charges minus costs Janet - CH 3 – Systems Management Negligence means a lack of proper care. In medical malpractice "proper care" is determined by a. Joint Commission standards. b. jury of civilian peers. c. tort law. d. medical peers. Janet - CH 3 – Systems Management The written scope of care and service of a healthcare organization is best described as a. a plan describing the linkages between care processes and outcomes. b. the delineated activities performed by governance, management, clinical, and support personnel. c. a logical sequence of operations to be performed to care for and serve delineated populations of patients. d. an interactive series of steps, processes, functions, and systems Janet - CH 3 – Systems Management Being immediately responsive and attentive to a family's concerns following a patient's fall in the subacute care facility is a. loss reduction activity. b. loss prevention activity. c. risk shifting activity. d. risk avoidance activity. Janet - CH 3 – Systems Management The utilization management committee for a large medical group is concerned about underutilization. Which data supports the concern? a. Lab report delays b. Reduced pediatric hospitalization rates c. Increased incidence of C-Sections d. Reduced pediatric immunization rates Janet - CH 3 – Systems Management The key issue in integrating the functions of utilization management, quality management, and clinical risk management revolves around a. consolidation of leadership. b. information management. c. control by the quality council. d. cross-training staff. Janet - CH 3 – Systems Management Your freestanding Radiology Center did 200 outpatient CT scans each of the last two years. The average reimbursement rate has decreased from $200 to $150. The scanner and room need repairs estimated at $100,000. There are two other CT scanners in your immediate vicinity. The most likely decision resulting from a cost-benefit analysis would be to a. quit doing CT scans. b. repair the scanner. c. contract with a competitor for referral fees. d. market heavily and postpone the repairs for 6 months. Janet - CH 3 – Systems Management According to Total Quality Management principles, managers should a. lead with autocratic decision making. b. communicate successes or failures only to the boss. c. lead with participative decision making. d. focus on short term financial impact of quality improvement techniques. Janet - CH 3 – Systems Management Sunshine Community Medical Center had begun performing angioplasty procedures for cardiac patients in anticipation of providing cardiovascular surgery services. The administration then failed to negotiate a contract with the cardiac surgery team of physicians. The hospital and its cardiologists then negotiated an exclusive contract with another hospital in the area to refer all cardiac patients needing angioplasty to that facility. This action constitutes a. risk retention. b. risk avoidance. c. risk shifting. d. risk prevention. Janet - CH 3 – Systems Management Community case management and disease management programs make the most economic sense for which type of reimbursement? a. Fee-for-service b. Shared capitation c. Discounted fee-for-service d. Diagnosis-related group Janet - CH 3 – Systems Management Your hospital case management program monitors length of stay (LOS) by condition. LOS for four conditions has decreased slightly each of the last six quarters. To evaluate cost and quality of care impact, you recommend which measures? a. Denials, comparison with previous two years LOS, readmissions b. Staff productivity changes, reimbursement, LOS at next level of care c. Reimbursement, comparison with conditions with increasing LOS, denials d. Outcome of transition plan, reimbursement, readmissions Janet - CH 3 – Systems Management In revising the Utilization Management (UM) Plan, which of the following is most important to consider? a. External UM contract requirements b. Accreditation survey results impacting UM c. UM performance measure results d. Clinical pathway length of stay variances Janet - CH 3 – Systems Management In your organization, Quality Management (QM) and Risk Management (RM) are separate departments. As QM Director, you recognize the importance of linking with Risk Management to prevent or reduce risk and maximize patient safety. Use this information to answer questions: How can Quality Management link with Risk Management on peer review cases? a. Provide information about peer review actions b. Provide information about patient occurrences c. Provide aggregate occurrence data d. Meet with RM Director regularly in confidence Janet - CH 3 – Systems Management In your organization, Quality Management (QM) and Risk Management (RM) are separate departments. As QM Director, you recognize the importance of linking with Risk Management to prevent or reduce risk and maximize patient safety. Use this information to answer questions: Of the following, sharing which data best supports risk prevention? a. Annual practitioner profiling b. Monthly event/occurrence reporting c. Root cause analysis d. Failure mode and effects analysis Janet - CH 3 – Systems Management In your organization, Quality Management (QM) and Risk Management (RM) are separate departments. As QM Director, you recognize the importance of linking with Risk Management to prevent or reduce risk and maximize patient safety. Use this information to answer questions: One of the three aspects of quality discussed in Chapter I concerns "perceptive quality," the perspective of the recipient or observer of care. Of the following options, how might this aspect of quality best be utilized in linking the QM and RM goals? a. Involve the patient in ideas to improve safety. b. Teach the patient self-care. c. Involve the physician in ideas to improve safety. d. Teach the staff effective hand-washing Janet - CH 3 – Systems Management Comprehensive Health integrated delivery system IDS) consisted of four acute care hospitals, a behavioral health center, two long-term care facilities, and an ambulatory surgery center. One year ago, after cost- benefit analysis, the IDS added a home health agency, with investments in a building, staff, marketing, computer system, and other equipment and materials. Tracking expenses and revenue over time, when would you expect a return on investment (ROI)? a. After two years b. At the break-even point c. When revenue consistently exceeds expenses d. When patients consistently use agency services Janet - CH 3 – Systems Management Most commonly the primary purpose for incident/occurrence reporting is to a. record infection rates. b. identify medication errors. c. identify adverse patient events. d. identify patient grievances Janet - CH 3 – Systems Management At Sunshine Community Medical Center, occurrence forms are sent directly to the risk manager, who summarizes the data and submits quarterly reports of the prior quarter’s data (totals and some rates) to administration and the governing body. Use this information to answer questions: Why might this process be considered inadequate, based on PI process principles? a. The process does not include priorities for data collection. b. The report does not include data collection tools. c. The report does not include claims information. d. The process does not trend the data over time. Janet - CH 3 – Systems Management At Sunshine Community Medical Center, occurrence forms are sent directly to the risk manager, who summarizes the data and submits quarterly reports of the prior quarter’s data (totals and some rates) to administration and the governing body. Use this information to answer questions: What is another reason this process should be improved? a. Occurrence indicators should first be approved. b. The process is not collaborative with other PI activities. c. There is no cost data included in the report. d. The process does not identify responsibility for investigating the occurrence Janet - CH 3 – Systems Management Over the last few months, the organization has experienced several adverse events concerning trips and falls on the grounds outside, although without serious injury to date. Use this information to answer questions What can the Quality Professional do to best facilitate risk reduction? a. Coordinate a failure mode and effects analysis. b. Coordinate a root cause analysis. c. Recommend new lighting for the areas involved. d. Research the events to identify a pattern. Janet - CH 3 – Systems Management Over the last few months, the organization has experienced several adverse events concerning trips and falls on the grounds outside, although without serious injury to date. Use this information to answer questions Which of the following offers the best rationale for the Quality Professional’s involvement in this situation? a. Successful prework improves team efficiency. b. Successful proactive improvement activities improve processes. c. Successful improvement activities reduce costs. d. Successful reactive improvement activities minimize recurrence. Janet - CH 3 – Systems Management Your organization has approved a new strategic initiative that will change a key clinical service in which a sentinel event occurred. When is it most important for leaders to participate? a. During the design process b. During intensive analysis c. When approving the planned improvement d. When reviewing the effectiveness data Janet - CH 3 – Systems Management One of the best ways for a patient safety program to be effective is to provide anonymity in a. root cause analysis. b. individual case review. c. occurrence/incident reporting. d. decision making Janet - CH 3 – Systems Management In a cost-benefit analysis of a bar-code medication administration system, implemented as part of a patient safety program, which of the following would be the best indicator of success: a. A decrease in adverse drug events from dispensing errors b. A decrease in adverse drug events from administering errors c. A decrease in total medication errors d. A decrease in total adverse drug events Janet - CH 3 – Systems Management As part of the program to improve patient safety, you will make many core process changes, including changes to improve the organizational culture as it relates to patient safety. The percentage of staff reporting a positive safety climate measures a. the outcome of educational efforts. b. the attitude of staff toward leadership. c. the effectiveness of the program. d. the results of a process change. Janet - CH 3 – Systems Management If leadership is the critical success factor for an effective patient safety program, what is the first key responsibility of leaders? a. Provide resources. b. Set strategic goals. c. Establish the value system. d. Designate a champion. Janet - CH 3 – Systems Management The determination of annual National Patient Safety Goals is linked to reported a. sentinel events. b. adverse events. c. core performance measures. d. claims. Janet - CH 3 – Systems Management Nurses and pharmacists are encouraged to report medication errors upon first knowledge of occurrence. What is the most important thing the organization can do to support them in this effort? a. Instill a culture of accountability. b. Instill a culture of no blame. c. Provide computerized physician order entry. d. Provide adequate nurse staffing. Janet - CH 3 – Systems Management A patient using a large exercise ball in outpatient rehabilitation fractures three ribs when the ball bursts and she falls onto the floor. The risk manager tells the patient that all costs of care will be covered. Of the following, this action best represents risk a. avoidance or prevention b. assessment or analysis c. transfer or shifting d. handling or intervention Janet - CH 3 – Systems Management The term "performance,” as used in healthcare quality improvement activities, refers to a. the effective execution of functions and processes. b. an interactive series of process steps. c. a statement of expectation. d. a demonstration during accreditation survey Janet - CH 4 – Performance Improvement Process A key physician/licensed independent practitioner QM function is a. researching criteria options for specialty-specific peer review. b. determination of what constitutes a deviation from an accepted standard of care. c. determination of data collection methodology for non-physician clinical reviewers. d. tabulation of peer review data for periodic committee reporting Janet - CH 4 – Performance Improvement Process 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? a. Collaboration with the medical staff Executive Committee and family practice department b. Approval of the project by the family practice department c. Data collection and summarization by the medical staff d. Preliminary information proving that assessment is needed Janet - CH 4 – Performance Improvement Process 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 a. case management. b. re-privileging. c. productivity management. d. initial credentialing. Janet - CH 4 – Performance Improvement Process The most effective way to ensure patient safety as a dimension of performance is to a. sponsor a "hotline" for reporting problems. b. focus on processes and minimize individual blame. c. have leaders who commit to and foster a safe culture. d. encourage patients and families to identify risks. Janet - CH 4 – Performance Improvement Process The responsibility to reduce risks of endemic and epidemic healthcare associated infection is vested in a. the organization. b. an interdisciplinary committee. c. a qualified infection control practitioner. d. the attending physician Janet - CH 4 – Performance Improvement Process A trend has developed over the past year indicating that an internal medicine physician has significant difficulty treating patients with out-of-control diabetes who are admitted for inpatient care. Peer review of cases, along with meetings with the physician, has continued for ten (10) months. Which of the following is now the best action option to correct this performance problem? a. A letter from the department chair or medical director b. A medical education program about diabetic management c. Required consultation for all diabetic patients d. Summary suspension of admitting privileges Janet - CH 4 – Performance Improvement Process In any quality management approach, how can you best evaluate the effectiveness of action taken? a. Use the same performance measures to remonitor the process. b. Formulate a new special study to monitor the action. c. Interview the staff involved in implementing the action plan. d. Do nothing. Effectiveness is expected with well-planned action Janet - CH 4 – Performance Improvement Process The Baldrige Health Care Criteria for Performance Excellence establish standards for a. corporate compliance. b. a certification. c. an accreditation. d. an award. Janet - CH 4 – Performance Improvement Process Based on most quality improvement standards, those responsible to prioritize data collection to monitor organizationwide performance are a. the quality council. b. the leaders. c. those most knowledgeable about the process. d. those most experienced with statistical analysis. Janet - CH 4 – Performance Improvement Process The phrase "intensive analysis," as used in quality/performance improvement a. applies only to peer review. b. is an automatic indication of a problem. c. means the trigger is never set at 0%. d. includes all defined sentinel events Janet - CH 4 – Performance Improvement Process Occurrence or event reporting is an example of a. peer review. b. root cause analysis. c. generic screening. d. special study. Janet - CH 4 – Performance Improvement Process Which of the following is NOT a requirement for an organizationwide QM Program? a. Quality management activities include the use of performance measures in peer review activities. b. Peer review problems are resolved and opportunities for improvement are taken. c. Reports to the governing body include the findings from peer review activities. d. The effectiveness of the program, including peer review, is evaluated Janet - CH 4 – Performance Improvement Process An orthopedic surgeon in a surgical group refuses to accept his postoperative site infection data and high rate for joint cases over the last year. What could the QM professional try next to convince him? a. Present the data to all the orthopedic surgeons using practitioner names. b. Do nothing with the surgeon; continue to measure. c. Have peers outside the group review all the surgeon's cases. d. With the medical director, show the surgeon the data compared to peers Janet - CH 4 – Performance Improvement Process The Medicine Department at Sunrise Community Hospital has decided to add indicators to measure performance for ten diagnoses not previously assessed. How can you best help the department prioritize? a. Just say no b. Provide cost per case data c. Provide volume and complication data d. Provide liability claims data Janet - CH 4 – Performance Improvement Process When the surgeons at Sunrise Ambulatory Surgery Center determine that action must be taken to resolve scheduling problems in the operating room, the first task should be to a. write a letter to each surgeon involved. b. form a team of interested surgeons. c. refer the issue to administration. d. refer the issue to an interdisciplinary QI team Janet - CH 4 – Performance Improvement Process According to QI process theory and quality/performance improvement standards, it is best to select a quality improvement project that a. is the chief executive officer's ongoing quality or cost concern. b. is limited in scope and time to provide quick feedback. c. has the greatest potential to improve patient outcome. d. has the greatest potential to save the organization money Janet - CH 4 – Performance Improvement Process The Wellness Medical and Health Center uses a multi-level medical record review system to monitor clinical care that cannot be evaluated through their electronic data systems. Nurses, other clinical staff, health information management staff, and physicians participate. Physicians usually do all except: a. review/confirm variations in trend data. b. review selected cases to confirm noncompliance with criteria. c. provide oversight monitoring of non-physician clinical reviewers. d. screen cases for peer review Janet - CH 4 – Performance Improvement Process In setting up an outcome-oriented study of appendectomies, it is most important to look at [Probably not for CPHQ Exam due to clinical knowledge required] a. admitting diagnosis, surgeon, pathology report, condition at discharge. b. patient age, admitting physician, history and physical, length of stay. c. admitting diagnosis, discharge diagnosis, discharge instructions, discharge disposition. d. history and physical, operative report, progress notes, nursing notes. Janet - CH 4 – Performance Improvement Process A freestanding Radiology Service Center’s indicators include the measurement of patient wait times, timeliness of reports, timely follow-up on abnormal reports, and response time to urgent exam calls, as well as individual practitioner data. The information is collected by staff, using various data collection tools. The QM professional aggregates it quarterly and year-to-date, reports it to the administrative and medical directors, and disseminates the report to all medical groups and other providers with whom they have contracts. Use this information in answering questions Considering total quality management (TQM) philosophy and continuous quality improvement (CQI) process, who is most responsible for the effective implementation of quality management activities in the Radiology Service Center? a. Quality professional and medical director b. Council of organization leaders c. Governing board d. Physicians Janet - CH 4 – Performance Improvement Process A freestanding Radiology Service Center’s indicators include the measurement of patient wait times, timeliness of reports, timely follow-up on abnormal reports, and response time to urgent exam calls, as well as individual practitioner data. The information is collected by staff, using various data collection tools. The QM professional aggregates it quarterly and year-to-date, reports it to the administrative and medical directors, and disseminates the report to all medical groups and other providers with whom they have contracts. Use this information in answering questions The identified indicators measure a. structure. b. process. c. outcome. d. competency Janet - CH 4 – Performance Improvement Process A freestanding Radiology Service Center’s indicators include the measurement of patient wait times, timeliness of reports, timely follow-up on abnormal reports, and response time to urgent exam calls, as well as individual practitioner data. The information is collected by staff, using various data collection tools. The QM professional aggregates it quarterly and year-to-date, reports it to the administrative and medical directors, and disseminates the report to all medical groups and other providers with whom they have contracts. Use this information in answering questions Which step is missing from this QM process? a. Indicator development b. Data collection c. Analysis by peers d. Reporting Janet - CH 4 – Performance Improvement Process Prospective review may be beneficial unless a. the patient is having elective total knee replacement. b. the patient is being readmitted for bypass surgery following heart catheterization. c. the patient was admitted through the Emergency Department for a fractured hip. d. the patient is a member of a managed care organization Janet - CH 4 – Performance Improvement Process Accreditation credentialing requirements generally include a. appointment to the appropriate category based on activity. b. current adequate malpractice insurance coverage. c. compliance with policies and procedures. d. history of loss of, or limitation of, privileges to practice. Janet - CH 4 – Performance Improvement Process All quality improvement approaches or models include the following mechanisms except a. developing strategic goals. b. prioritizing problems/projects. c. collecting and analyzing data. d. taking action to improve Janet - CH 4 – Performance Improvement Process 26. Who usually makes the final decision regarding credentialing in a managed care organization? a. Governing body b. Credentialing committee c. Quality improvement committee d. Chief medical officer Janet - CH 4 – Performance Improvement Process Who makes the final decision regarding reappointment to the medical/ professional staff in a hospital? a. Governing body b. Medical staff executive committee c. Credentialing committee d. Medical staff as a whole Janet - CH 4 – Performance Improvement Process Which of the following is an untrue statement concerning licensed independent practitioners in hospitals? a. Any licensed independent practitioner is potentially eligible for medical/professional staff membership. b. Licensed independent practitioners who are not members of the medical/professional staff may treat patients. c. All licensed independent practitioners must be credentialed and privileged in order to treat patients. d. Nonphysician licensed independent practitioners practice with supervision within licensure limits. Janet - CH 4 – Performance Improvement Process The main goal of measurement in performance improvement is to a. provide specifications for processes needing redesign. b. keep track of process and practitioner variances. c. collect accurate data reflecting actual performance. d. establish benchmarks for the improvement process Janet - CH 4 – Performance Improvement Process Reappointment to an organized medical/professional staff generally includes all except a. reappraisal by uniform criteria. b. reappraisal annually. c. review of current competency. d. approval by the governing body. Janet - CH 4 – Performance Improvement Process The primary purpose of generic screening is to a. identify adverse occurrences as early as possible. b. provide data for practitioner reappraisal. c. identify common-cause variation. d. trend occurrence data over time Janet - CH 4 – Performance Improvement Process Risk management in an organization is most effective when it is a. responsible for sentinel event root cause analysis. b. incorporated into organization wide safety management. c. integrated with organizationwide performance improvement. d. the responsibility of the clinical performance improvement teams Janet - CH 4 – Performance Improvement Process In managed care, the responsibility for ensuring validation of credentials of licensed independent practitioners rests with the a. contracted medical group. b. centralized verification organization. c. managed care organization. d. provider services committee Janet - CH 4 – Performance Improvement Process In a managed care organization (MCO), an appeal following a denial of care or benefits a. may be reviewed by an independent external review process. b. is a formal grievance filed by a patient. c. is limited to insurance coverage issues. d. may be reviewed by a patient advocacy group process Janet - CH 4 – Performance Improvement Process Root cause analysis is the most appropriate PI process for a. determining costs/benefits. b. evaluating dental care. c. analyzing sentinel events. d. performing peer review. Janet - CH 4 – Performance Improvement Process Community Hospital has four urologists in the specialty, all of whom share a practice. When a new solo practice urologist arrives and receives membership in the medical staff, and then concerns arise as to quality of surgical care, the best way to avoid conflict of interest issues is to a. have each urologist sign a confidentiality agreement. b. have each urologist review the cases and issues independently. c. have only the one urologist who is head of the group handle the entire review. d. have a urologist from outside the group conduct the review. Janet - CH 4 – Performance Improvement Process Hospital infection control policies generally require a. 100% concurrent surveillance for healthcare associated infection tracking. b. periodic monitoring (cultures) of staff and equipment for AIDs. c. coordination of activities in patient care, ancillary, and support services. d. that the infection control committee be a medical staff committee. Janet - CH 4 – Performance Improvement Process The appraisal of individual practitioner performance in healthcare, beyond minimum standards and criteria, is known as a. continuous quality improvement. b. intensive analysis. c. perceptive quality. d. peer review. Janet - CH 4 – Performance Improvement Process What of the following is the greatest benefit of concurrent clinical review? a. Ability to focus review on prioritized performance measures b. Ability to review outcomes of care and processes c. Timely assessment at the onset of care for continuity d. Timely intervention to reduce risk of adverse outcomes Janet - CH 4 – Performance Improvement Process In conjunction with hospital credentialing, clinical privileges are granted a. only to members of the medical/professional staff. b. to all employees performing clinical procedures. c. to all licensed independent practitioners. d. only to active members of the medical/professional staff Janet - CH 4 – Performance Improvement Process The most important patient safety issue to a utilization reviewer is a. timeliness of treatment. b. medical necessity for treatment. c. correct assignment of diagnosis or procedure code. d. appropriateness of healthcare setting Janet - CH 4 – Performance Improvement Process Patients are a key customer in performance improvement. Of the following,