Quality and Performance Improvement in Healthcare Practice Test

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• What is a key feature of a quarterly PI report?
• Which strategy uses value stream mapping and pull systems to improve patient flow in a hospital?
• Which statement describes run charts vs control charts?
• How can organizations sustain QI initiatives after initial successes fade?
• What type of external organizations often require evidence of performance improvement activities to prove compliance in healthcare?
• Besides the medical executive committee, which group should receive a PI progress report?
• What is the primary purpose of a control chart in a quality improvement effort?
• Which example best illustrates a process measure in quality improvement?
• How should a patient safety event reporting system maximize learning?
• A heart transplant procedure automatically triggers a quality review because it is a high-risk procedure with potential for a negative outcome. Identify the reason this procedure triggers automatic review.
• Which describes a process indicator for infection prevention and control?
• Which elements are essential in a measurement plan for a quality improvement project?
• Which characteristic indicates a High-Reliability Organization (HRO) in healthcare?
• Which cycle emphasizes iterative learning with study of data after each cycle?
• Regulatory and accreditation agencies require evidence of performance improvement activities to prove compliance.
• Which aspect distinguishes PDSA from PDCA?
• Which of the following is a common lever to improve HCAHPS scores?
• In CRAF minutes, which section documents who was assigned to accomplish which activities during the next work period?
• Which strategy effectively involves patients and families in improvement work?
• Forces in favor of change and those resisting change are analyzed through which analysis?
• Which statement best describes Lean Six Sigma?
• Which data type can take infinitely many values between any two measurements and often involves decimals?
• Which statement best describes the post-World War II change in healthcare delivery?
• Which statement correctly characterizes data-driven measurement in accreditation-driven QI programs?
• What is the primary distinction between common-cause and special-cause variation, and how do control charts help?
• Which statement about Lewin's change phases is true?
• Which quality improvement methodology uses statistics to measure variation in a process with the aim of producing error-free results?
• Which statement best describes medication safety improvements using QI methods?
• Which section of CRAF minutes captures the team's plan for putting its decision in effect, with justification points if necessary?
• Buy-in from employees tends to occur more readily when they are informed about the change?
• Which term best describes communicating PI progress to stakeholders in an accessible and engaging way?
• If a PI team wants to document decisions and actions from a meeting, which document should be used?
• Using the monthly readmission rates 3, 7, 4, 2, 0, 1, what is the median?
• A hospital being cited for not meeting a standard for timely operative report documentation presents the hospital with an ______.
• In a plan-do-study-act cycle for reducing readmissions, which activity corresponds to the 'Study' phase?
• Which data type assumes an infinite number of possible values in measurements that have decimal values as possibilities?
• The interrelated activities in healthcare organizations that promote effective and safe patient outcomes across services and disciplines within an integrated environment are included in which area of performance measurement?
• Which document communicates performance information that emphasizes the organization's mission within the community and its efforts to provide high-quality care?
• What method would best inform the board of directors about team-based PI activities?
• Not performing effective pre-authorization is associated with which outcome?
• When prioritizing interventions using an impact-effort framework, which approach is best?
• Which of the following tools may be used to summarize charges from a department?
• Which items are typically evaluated in a Measurement System Analysis (MSA)?
• A system in which purchasers hold providers of healthcare accountable for both the costs of healthcare and its quality is called __________.
• Which of the following describes the concept of focusing on safety by recognizing early warning signs to prevent adverse events in healthcare organizations?
• Which act related to reimbursement programs created the Quality Payment Program, shifting reimbursement to value, and what is its acronym?
• List the common data sources used in QI reporting (EHR data, claims data, patient-reported outcomes) and discuss their strengths and limitations.
• Before the improvements, what was the average OR suite turnover time?
• Which description best defines force-field analysis?
• Which of the following acts created the Quality Payment Program, changing reimbursement to incentivize value over volume?
• According to deference to expertise as a characteristic of a high-reliability organization, in a crisis the person with the greatest knowledge will most likely lead. Which role fits this description?
• Which term is used for data that expresses ranked order of items based on criteria?
• In a measurement-focused quality improvement project, which component ensures the credibility of the measurement system?
• After initial short-term gains in process change, a healthcare organization must maintain urgency to sustain progress. This best describes which accelerator of change?
• In a crisis, the person with the greatest knowledge of the situation will most likely be which role?
• What is the concept of standard work in healthcare QI?
• What practice helps ensure a dashboard supports decision-making without overload?
• In a hospital with many providers, reviewing 20 percent of each provider's inpatient admissions every other year reflects which sampling approach?
• In informing the board about PI progress, which presentation format is described as effective for broad audiences?
• What is the difference between root cause analysis (RCA) quality and a simple error counting approach, and how can reliability engineering improve it?
• Each healthcare organization must identify and prioritize which processes and outcomes to monitor based on the scope of care and services provided and ________.
• Which option best describes data visualization to avoid misinterpretation?
• What is data governance in healthcare quality improvement and why is data quality critical?
• Which performance improvement framework did University Hospital use to reduce OR turnover time?
• Which indicators are considered outcome indicators for infection control performance?
• Which tool is commonly used to recognize staff participation and accomplishments in PI activities?
• What are the key ethical considerations in quality improvement, particularly around patient data, consent, and balancing improvement with patient autonomy?
• Which statement about risk adjustment in safety-net settings is correct?
• In the 1700-1800s, which hospital became a model for the development of hospitals in other communities?
• If Sue has three children and Bob has two children, the value representing the number of children in their family is considered this type of data.
• Which statement describes ongoing evaluation of care processes and related costs to identify opportunities for improvement?
• What is the purpose of balancing measures in a QI project?
• A benefit of storytelling is that it documents team accomplishments over an extended period of time in an organized and succinct way.
• Which individual was instrumental in bringing attention to the formal training needs for nurses?
• Which approach helps reduce resistance to change by informing staff about the change?
• Which concept emphasizes anticipating and preventing errors by recognizing weak signals in complex systems?
• What type of data is ranked and expresses the relative evaluation of characteristics according to criteria?
• Which statement best contrasts regression and time-series analysis for evaluating the impact of an intervention on patient outcomes?
• Which statement best describes accreditation incentives in quality improvement?
• Which statement best describes the impact of an interprofessional QI team on project success?
• What is the role of safety-net providers in quality measurement, and how might their metrics differ from other settings?
• Explain the concept of cost of quality in a healthcare QI project, including prevention, appraisal, and failure costs, and how ROI is estimated.
• What is a normal emotional response to changes in job duties?
• What signals indicate an unusual shift in a U-chart or C-chart?
• Patient experience measures influence reimbursement how?
• Why is risk adjustment used when measuring infection prevention outcomes?
• When an employee's job duties or workflow change, is grief a possible reaction?
• Which type of data includes measurements such as weight, time, and temperature?
• Which statement best describes how reliability engineering contributes to quality improvement?
• Which aspect would be considered a structure measure in a quality improvement project?
• In Lewin's change model, during which phase does the change become the new normal?
• Which term describes communicating the organization's story to external audiences to convey quality improvements?
• What does comparing a hospital's medication error rate to the rate at similar regional centers illustrate?
• What process is being used by the PI team when they gather ideas by going around the table and no new ideas emerge after several rounds?
• How does health information technology (EHRs, decision support) support quality improvement, and what risks must be managed?
• Which of the following is an example of a balancing measure in a discharge-process quality improvement project?
• Which format is described as a powerful teaching tool that displays printed documents and graphs and recognizes staff participation?
• Which technique is central to Lean for identifying underlying causes of problems?
• Which term describes the process of comparing performance with peers from other organizations to identify relative standing?
• What is a key consideration when combining multiple data sources (EHR, claims, PROs) for quality reporting?
• What changes were implemented to improve the OR turnover time?
• The percentage of antibiotics administered immediately prior to open reduction internal fixation surgeries is an example of which type of performance measure?
• Which statement best describes the role of a standing PI committee in a healthcare organization?
• What are the IOM's core domains of quality and illustrate with a healthcare example for each?
• Performance improvement data collection results that fall outside the established ________ often trigger further study or more focused data collection on a performance measure.
• The foundations of care giving, which include buildings, equipment, professional staff, and appropriate policies, are included in which area of performance measurement?
• In a U-chart versus a C-chart, which control chart tracks defects per unit when sample sizes vary?
• Which of the following is often used as a powerful teaching and learning tool in quality improvement?
• Which statement best describes Joint Commission (JC) standards for quality improvement in healthcare?
• Sue's phase in which a long-standing, familiar practice becomes unsettled because the change requires advanced planning is called?
• In a quality improvement project, what is the purpose of balancing measures?
• The incidence of postoperative wound infections occurring in ORIF procedures in which antibiotics were and were not utilized is an example of which type of performance measure?
• Which statement best distinguishes Plan-Do-Study-Act (PDSA) cycles from DMAIC cycles in quality improvement?
• Which group is primarily responsible for governance and should receive PI progress updates?
• The practice of reporting patient outcomes to the Hospital Board of Trustees began at which hospital?
• Which practice supports successful implementation of standardized order sets in the EHR?
• Which metric is NOT part of the proposed COPD readmission initiative's metrics?
• What is a Failure Mode and Effects Analysis (FMEA) and how would you apply it to a new medication administration workflow?
• Which of the following is a HCAHPS improvement lever?
• If data on readmission rates are skewed, which measure of central tendency is most appropriate?
• Which term identifies a collection of methods PI teams can use to reach their goals?
• Joint Commission requires healthcare organizations to appoint a ________ group to oversee organization-wide performance improvement activities.
• To address this increased need for more hospitals closer to where patients lived, the US government __________.
• What outcome is associated with the use of effective pre-authorization?
• Which quality improvement methodology emphasizes reducing variation by using statistical tools to achieve near-perfect quality?
• What is a measurement system analysis (MSA) primarily concerned with?
• Which state was the first to pass legislation requiring nurses to be registered?
• What is the primary purpose of a performance improvement activity in healthcare?
• Which data should be included in equity-focused data collection to avoid biased conclusions?
• After the improvements, turnover time was reduced to what value?
• What is a key feature of interrupted time series analysis in evaluating an intervention?
• Which type of data comprises numerical values that represent whole numbers?
• Which data source would you use to support a QI initiative aimed at reducing COPD readmissions?
• A PI team wants to show a member who missed the previous meeting that he was informed about the data collection process. Which tool should they use?
• Which type of report is based on documented meeting minutes and should include summaries of data collection, conclusions, and recommendations?
• Organizations that pay close attention to weak signals of trouble to catch problems or errors in the earliest stage are applying the principles of __________.
• At a PI team meeting, after reporting data collection results, the team brainstormed solutions and decided how to correct the problem. Which PDCA step is this an example of?
• Which practice helps address missing data when evaluating equity in QI?
• Root-cause analysis is a key technique used in which quality improvement methodology?
• Which statement best describes incorporating equity into quality improvement initiatives?
• Which DMAIC phases are primarily involved in identifying root causes and testing solutions to reduce defects?
• Lewin's three phases of change are also referred to by which set of terms?
• The regular and frequent assessment of healthcare processes, their outcomes, and related costs is considered what concept?
• The final results of care, treatment, and services in terms of the patient's expectations, needs, and quality of life are included in which area of performance measurement?
• Which description best matches the steps in which focused data are collected and analyzed, changes are incorporated, the new process is implemented, and staff are educated about the new process?
• What are sentinel events in patient safety?
• A QI project charter should include which elements to set clear aims and scope?
• University Hospital's advertising campaign announcing care improvements and regional ranking is an example of which concept?
• What is the primary purpose of meeting minutes in PI discussions?
• Which option best describes dashboard design for decision support?
• In the PI process, which element was missed by the hospital contributing to claims denials?
• Which statement about strategic vision for change is true?
• Reliability versus validity: which statement correctly describes these concepts in measurement data?
• Explain Lean in healthcare and provide an example of a value stream map in a clinic.
• What approach should be used when investigating sentinel events?
• The Hill-Burton Act primarily supported which outcome in postwar healthcare?
• What is the role of safety culture surveys in quality improvement and how should results be used?
• How does Root Cause Analysis (RCA) differ from a blame-focused investigation, and what steps are typically included in an RCA workflow?
• Which data summarization tool groups data into categories and computes aggregates, commonly used for department charges?
• During a PI team meeting, the leader asked members to provide ideas on how to reduce the coding backlog, and the ideas were recorded on the whiteboard as they came up. What PI tool is being used?
• Which term identifies a variety of methods that PI teams can use to accomplish their goals?
• In CRAF minutes, which section documents whether actions were accomplished and whether the group is ready to make decisions and recommendations for further activities?
• Which is a common standing committee in healthcare organizations responsible for coordinating and reporting performance improvement activities?
• What is the purpose of benchmarking in healthcare quality improvement, and what are best practices to ensure fair comparisons?
• Which data display tool is used to display discrete categories?
• In stratified analysis to identify disparities, which variables are typically used?
• True or false: The three phases of change are distinct, non-overlapping steps?
• In a patient satisfaction survey, patients rate their level of satisfaction with the healthcare organization, from 1 to 5. What is this type of method called?
• What is a Fishbone (Ishikawa) diagram and how might it be used to analyze a spike in infection rates after surgery?
• A control chart for antibiotic prescribing quality is used. Which action corresponds to a signal?
• In healthcare quality improvement, which practice best ensures data visualization ethics?
• Which indicator is most informative for assessing transitions of care quality?
• Which of the following acts stimulated investment in the information systems infrastructure of professional practices, clinics, and hospitals?
• Which data type is best for recording counts of events, such as patient visits?
• A set of National Patient Safety Goals (NPSGs) that all institutions participating in accreditation must promote and train their healthcare providers to adhere to was developed by which of the following organizations?
• Which group should oversee organization-wide performance improvement activities?
• The number of children in a family is an example of which data type?