When considering the use of an external subject matter expert (SME), which of the
following is most critical?
A. leadership's personal preference
B. geographic location of the SME
C. cost of the SME's services
D. references of the SME - ANS-D. references of the SME
The positive clinical reputation provides credibility support to the project.
To avoid misinterpreting variances, which of the following statistical tools should be
used?
A. control chart
B. fishbone diagram
C. force field analysis
D. Pareto chart analysis - ANS-A. control chart
Control charts exhibit points between control limits, therefore displaying the variation.
An operating room circulating nurse reported that the instrument count indicated a
missing clamp. X-ray findings were negative, and the patient showed no adverse
effects. This occurrence is an example of
which of the following?
A. claims management
B. malpractice
C. clinical incompetency
D. potentially compensable event - ANS-D. potentially compensable event
Although the clamp was not found, this has potential to become a compensable event.
A potentially
compensable event is an event for which there is risk of future claim or settlement.
Training is being determined based on treatment record review results. The following
weighted results are available: Based on these results, which of the following areas
should take priority for training? (Image missing)
A. assessment
B. external communication
C. care plan
D. progress notes - ANS-C. care plan
When ranked by weight and non-compliance (weight*(100-%compliance)), care plan
,results in the highest weighted rank.
A healthcare entity initiating re-structuring must consider the impact on staff to ensure
the greatest opportunity for success by
A. defining the concepts of re-structuring to the staff and the community.
B. planning carefully, communicating openly, and leading effectively.
C. developing policies to assist in the change process so that fear will be minimized.
D. selecting a consultant, conducting a needs assessment, and analyzing results. -
ANS-B. planning carefully, communicating openly, and leading effectively
Best answer, these actions promote transparency and trust through communication and
leadership.
During quality management data analysis activities, Pareto charts are most
appropriately used for
A. displaying parts of a whole.
B. displaying trends over time.
C. determining cause and effect relationships.
D. determining priorities among contributing factors. - ANS-D. determining priorities
among contributing factors.
Pareto charts most appropriately assist to determine priority using represented values.
A clinical pathway on the management of hip fractures has been developed by a
multi-disciplinary team and implemented in a large teaching hospital. After monitoring
for 6 months, the length of stay continues to exceed the guidelines. Which of the
following should be the next step?
A. Evaluate compliance with the pathway.
B. Correlate the pathway with staffing levels.
C. Re-educate the staff on the purpose of the pathway.
D. Continue to monitor, and collect additional data. - ANS-A. Evaluate compliance with
the pathway.
Evaluation of compliance with the proven (pathway) should be conducted first to see if
that may be
influencing the lack of change in the outcome.
A new quality director has reviewed the information related to the Quality Council
minutes, and notes the following: - The council meets quarterly. Meetings last
approximately 2 hours. - The council roster
includes all clinical department managers and the quality director. Attendance ranges
from 45-60%. - The primary role of the council is to receive department quality reports,
,which are then forwarded to the organization's governing body. Based on the
information above, which of the following actions is most appropriate?
A. Require departments to forward reports for review prior to the meetings.
B. Redefine the council's role to coordinate and prioritize quality activities.
C. Switch to a monthly meeting with a new agenda format.
D. Eliminate the council and directly report quality data to the governing body. - ANS-B.
Redefine the council's role to coordinate and prioritize quality activities.
This is the best answer available.
An annual evaluation of a laboratory's quality program identified no opportunities for
improvement. Which of the following elements of the program should be reviewed?
A. performance indicators
B. format of data display
C. committee meeting attendance
D. frequency of data collection - ANS-A. performance indicators
Performance indicators need to be reviewed for need for revision.
The following table shows the percentage of hospital-acquired pressure ulcers: Which of
the following should the healthcare quality professional do next?
A. Implement a new pressure ulcer protocol.
B. Re-educate staff.
C. Continue to track and trend the data.
D. Conduct a focused analysis of pressure ulcer cases. - ANS-D. Conduct a focused
analysis of pressure ulcer cases.
Advanced-stage, hospital-acquired pressure ulcers are considered never-events.
Because this is a
significant patient safety issue, it is important to not delay analysis so that trends and
opportunities for
improvement can be determined.
Medication reconciliation is a process intended to
A. identify and resolve discrepancies.
B. investigate formulary discrepancies.
C. increase use of electronic medication administration.
D. improve efficiency of medication administration. - ANS-A. identify and resolve
discrepancies.
Correct; the definition of medication reconciliation is a process of identifying the most
accurate list of
all medications by comparing the medical record to an external list of medications.
, One difference between continuous quality improvement and traditional quality
assurance is that quality improvement always
A. requires the application of statistical process control.
B. excludes monitoring and evaluation of care provided.
C. focuses on systems or processes.
D. addresses potential problems - ANS-C. focuses on systems or processes
Quality improvement is focused on systems, processes, and groups to improve. Quality
assurance is
focused on monitoring problem areas or individuals. Statistical process control may be
employed a tool to
facilitate quality improvement, but is not a required component of quality improvement.
According to continuous quality improvement principles, which of the following concepts
is most important?
A. financial impact
B. constancy of purpose
C. resistance to change
D. performance of individual - ANS-B. constancy of purpose
This is the best answer
In lean thinking, a process step is defined as "value added" if the
A. customer recognizes the value.
B. customer corrects a mistake to add value.
C. process owner recognizes the value.
D. process owner changes the value of the product. - ANS-A. customer recognizes the
value.
Customer value is the key concept of lean thinking and improvement efforts.
One aspect of a quality process that integrates with risk management is the review and
evaluation of
A. adverse drug events.
B. encounter data.
C. case-mix analysis reports.
D. accreditation survey reports. - ANS-A. adverse drug events.
Risk management has a role related to incident reporting.
Which of the following action plans is the first step in correcting inappropriate blood
usage in an emergency department?
A. in-service on ordering blood usage for the physicians
B. elimination of wasted blood
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