Final 2

Question 1

According to TJC standards, which of the following hospital committees would be responsible for overseeing the process of monitoring the quality of care provided by physicians that practice in the hospital?

Answer 1

medical staff executive committee

Question 2

What do we call standards, that if met, allow a hospital to receive reimbursement for care provided to Medicare beneficiaries?

Answer 2

CoP-Conditions of Participation

Question 3

According to the Pareto principle

Answer 3

20% of the sources of a problem are responsible for 80% of its effects

Question 4

Of the following tools listed below, which one is used to plot the points for two variables that may be related to each other in some way?

Answer 4

Scatter diagram

Question 5

As the HIM manager, you have been asked to provide a display showing the amount of time it took for 80 records to be pulled from the Emergency department. To report this information, what type of graph would be most effective?

Answer 5

histogram

Question 6

What process assists a health care facility in continuously looking at the ways that problems develop and seeking ways to prevent problems from happening in the future?

Answer 6

performance improvement

Question 7

What is the best tool for differentiating between common cause variation and special cause variation?

Answer 7

control chart

Question 8

What feature is a trademark of an effective PI program?

Answer 8

a continuous cycle of improvement projects over time

Question 9

Continuous Quality Improvement is best described by the following statements EXCEPT

Answer 9

corrective action targets clinicians more so than processes

Question 10

Which of the following processes is mandatory for health care facilities?

Answer 10

licensure

Question 11

A histogram is a valuable tool for representing

Answer 11

a frequency distribution with continuous-interval data

Question 12

Reporting the number of incomplete charts over a 6-month period using a run or line chart will prove valuable in which of the following two ways

Answer 12

over time, the data can reveal trends and point out areas for improvement

Question 13

Which quality management theorist focused on zero defects as the goal of performance improvement efforts?

Answer 13

Crosby

Question 14

The quality improvement team for the HIM department meets to generate ideas to address physician complaints about missing dictation reports. What QI tool would prove useful in discussing various recommendations for solving this problem?

Answer 14

brainstorming

Question 15

The health information reception desk is experiencing an huge influx of phone calls on Monday, Tuesday, and Wednesday mornings. This is creating a problem in getting requested patient information out within an acceptable time frame. The reception staff work group has agreed to start recording the reason for the phone calls for the next four weeks. They want to focus on solving the response-time problem by reducing the turnaround time for the largest category of phone calls. Which QI tool best supports this goal

Answer 15

Pareto chart

Question 16

Which quality management theorist believed that merit raises, formal evaluations, and quotas established through benchmarking hinder worker productivity and growth

Answer 16

W. Edwards Deming

Question 17

In the ACT phase of the PDCA method, what step can assist in implementing change in a department

Answer 17

all of the above

Question 18

The Anesthesia Department is adding a new indicator to its plan. THe Chief Anesthesiologist has come to you, the Director of Quality Management, to help her design a data collection methodology. The two of you are now considering who will be doing the data collection. All of the following are factors in your deliverations EXCEPT

Answer 18

TJC standards and required characteristics

Question 19

All of the following are QI activities that CMS focuses on except:

Answer 19

Pregnancies

Question 20

All of the following are steps to consider when choosing a performance measure except:

Answer 20

collecting specific information

Question 21

Brainstorming, affinity grouping, and nominal group techniques are tools and techniques used during PI initiatives to facilitate ________ among employees?

Answer 21

communication

Question 22

DMAIC is part of which PI model?

Answer 22

Six Sigma

Question 23

In the health care setting today, what is the most common PI model used?

Answer 23

PDCA

Question 24

There are four levels in most healthcare systems and all require changes. Which system is the most important one to consider in any healthcare facility?

Answer 24

Level A-the patient

Question 25

The process of comparing the outcomes of HIM abstracting functions at your facility with those of comparable departments of superior performance in other healthcare facilities to help improve accuracy and quality is referred to as

Answer 25

benchmarking

Question 26

The local healthcare organization has contracted with ABC Labs, Inc. for all “after hours” lab services. This lab is located two blocks from the health care organization. The process is as follows: The samples are sent to the lab, via messenger. The ordering physician need the lab values back quickly in order to confirm CAP. At the off-site lab, the lab technician runs the tests, reviews the findings, and sends back a preliminary report to the ordering physician via the messenger. The desired turn-around time for this process is 4 hours or less. The data on this process is as follows: The number of after hours procedures performed per month and the average turn-around time per month Using this illustration above, which tool would best illustrate if a trend exists with regards to the timing of received reports over the course of 6 months?

Answer 26

run chart

Question 27

Performance measure is a tool that provides an indication of an organization's performance in relation to a specific process or outcome. What type of tool is this?

Answer 27

quantitative

Question 28

Match the following definition to its proper term: “grants the healthcare organization legal authority to provide healthcare services within its scope of practice”.

Answer 28

Licensure

Question 29

In the "plan" phase of PDCA, which activity is not included?

Answer 29

test the solution with a trail run

Question 30

In the introduction there is a discussion regarding TJC and mandated data sets needing reported on. Within this section it speaks of core measures. What is a core measure?

Answer 30

a set of patient care characteristics that TJC and CMS have determined to reflect the quality of care an organization can provide for important diagnoses

Question 31

What criteria is critical in selecting performance indicators for a health information management department?

Answer 31

the indicators must include the most important aspects of performance

Question 32

What is another term for TQM in healthcare?

Answer 32

CQI

Question 33

What type of environment is essential for implementing PI

Answer 33

shared leadership

Question 34

Which PI theorist believes that performance improvement starts at the top and works it way down

Answer 34

Joiner

Question 35

Which PI model was developed by Shewhart

Answer 35

PDCA

Question 36

What type of review is used by an on-site survey team that permits assessment of operational systems of the healthcare organization and their processes in relation to the actual experience of selected patients currently under the healthcare organizations care

Answer 36

Tracer Methodology

Question 37

This private, not-for-profit organization is dedicated to improving the quality of healthcare by assessing and reporting on the nation's managed care plans. What organization is this?

Answer 37

NCQA

Question 38

What is the name of the program that NCQA uses to compare the performance of managed healthcare plans

Answer 38

HEDIS

Question 39

This credential is given to an organization tha tmeets a defined set of standards, some of which relate to performance management. Only organizations seeking this credential must comply with these mandates. What is the name of this credential?

Answer 39

Accreditation

Question 40

Which performance theorist defined the approaches to assessing quality in care by using measures that examine structure, processes and outcomes

Answer 40

Donabedian

Question 41

What QI toolbox technique gives each member of the team an opportunity to select the most important iedas from the affinity diagram?

Answer 41

Nominal Group Technique

Question 42

Which type of performance measure focuses on a way of delivering services that leads to a certain outcome?

Answer 42

process measure

Question 43

This PI model was introduced by TJC but is no longer mandatory to follow. What is the name of this PI model?

Answer 43

10-Step

Question 44

Who was the PI theorist who's plan worked off of the idea of "no quotas, no merit raises"?

Answer 44

Deming

Question 45

This PI tool is used to gather data based on sample observations. What is the name of this PI tool?

Answer 45

check sheet

Question 46

What is the name of the chart shows the relationship of each part to the whole?

Answer 46

pie chart

Question 47

When creating the fishbone diagram, what is the first step you should do?

Answer 47

document an outcome/goal on the right side of the diagram at the end of the horizontal causal line

Question 48

In order to assure complete documentation of any type of event in the healthcare setting, Occurrence Screenings, Incident Reports, Event Reports and Hazard Surveillance Reports should be documented and filed in the

Answer 48

Risk Management Office

Question 49

The Utilization Review Coordinator reviews inpatient records at regular intervals to justify necessity and appropriateness of care to warrant further hospitalization. Which of the following utilization review activities is being performed?

Answer 49

concurrent review

Question 50

Which of the following established legal liability for hospitals in 1965?

Answer 50

Darling v. Charleston

Question 51

The ongoing review of clinical care to ensure the necessity and effectiveness of the services being provided to the patient is the definition for

Answer 51

case management

Question 52

Considering what you now know about incident reporting, when should an incident report be analyzed?

Answer 52

concurrently

Question 53

In healthcare, risk includes

Answer 53

any occurrence or circumstance that might result in loss

Question 54

All of the following are among Joint Commission’s initial core measure sets for hospitals EXCEPT

Answer 54

Diabetes

Question 55

The totality of healthcare services provided to a patient and his or her family is all setting, from the least extensive to the most extensive is the definition for

Answer 55

Continuum of care.

Question 56

What is another name for the fishbone diagram

Answer 56

A & C

Question 57

In the fishbone diagram, what is documented on the “head” of the fishbone?

Answer 57

effect, problem, or quality characteristic

Question 58

All of the following are core measures of ORYX we need to focus on except: Answer

Answer 58

CA

Question 59

How many steps are there to determine the starting point for assessing customer service quality?

Answer 59

6

Question 60

HEDIS gathers data in the following area(s):

Answer 60

All of the above

Question 61

Most health care facilities use this type of screening criteria for UR purposes to determine the need for IP (inpatient) services and justification for continued stay

Answer 61

Serverity of illness/intensity of service

Question 62

The medical transcription improvement team wants to identify the cause of poor transcription quality. Which of the following QI tools from the toolbox will best assist the team in identifying the root cause of the problem

Answer 62

fishbone diagram

Question 63

When completing a RCA, how many steps must be completed?

Answer 63

4

Question 64

If TJC is made aware of a sentinel event that meets reportable criteria, how long does the healthcare organization have to prepare a root-cause analysis and action plan

Answer 64

within 45 day sof the event being aware of the event

Question 65

According to your reading, there are two documents important for managing risk exposure. One is the incident report, the other is the

Answer 65

patient's health record

Question 66

Patient safety must be integrated into a healthcare organization’s

Answer 66

All of the above

Question 67

Customers receive products or services as a result of what type of process?

Answer 67

Organizational

Question 68

All of the following approaches assist UR in determining the nature and extent of required care except:

Answer 68

TPP reviews

Question 69

All of the following are types of vendors of patient satisfaction surveys except

Answer 69

NitPicker

Question 70

Sentinel events

Answer 70

must be reported to Joint Commission along with a root-cause analysis.

Question 71

Which accrediting body requires all accredited healthcare organizations to conduct RCA following any sentinel event?

Answer 71

TJC

Question 72

With blood usage review, the committee must watch all of the following when blood products are ordered except:

Answer 72

how many blood and blood products are ordered

Question 73

Quality assessment monitoring relies on what primary source document to conduct medical care evaluations?

Answer 73

Medical Record

Question 74

Surgical case review includes all of the following except:

Answer 74

cases with elements missing in the preoperative anesthesia consultation

Question 75

Risk management programs were introduced to reduce

Answer 75

malpractice suits against healthcare organizations and physicians

Question 76

What is ORYX

Answer 76

all of the choices

Question 77

Which system is one of the most complex healthcare processes and also one fraught with the greatest possibilities for error?

Answer 77

medication usage system

Question 78

This performance measure enables health care organizations to monitor a process to determine whether it is meeting requirements. What is the name of this performance measure?

Answer 78

Both A & B

Question 79

The following “sentinel events” must be available for Joint Commission review EXCEPT

Answer 79

Petechiae due to adverse drug reaction

Question 80

What is a fishbone diagram used for?

Answer 80

all of the above

Question 81

The quality review process of invasive and noninvasive procedures to ensure performance of appropriate procedure, preparation of patient, monitoring and postoperative care and education of patient describes which type of review?

Answer 81

surgical case review

Question 82

All of the following clinical finding represents SI indicators for the UR function for inpatient stay except:

Answer 82

PO antibiotics for 10 days

Question 83

The following organizations play a key role in the public-private partnership of the MBNQA except:

Answer 83

Board of Directors

Question 84

In the fishbone diagram, what is shown on the “bones” of the fishbone diagram?

Answer 84

cause(s) of the effect

Question 85

What is the name of the project management tool that is used in clinical process improvement to depict clinical guidelines or critical pathways in the treatment of common medical conditions

Answer 85

Gantt chart

Question 86

NPSG "7" relates to

Answer 86

Preventing infection

Question 87

Which quality customer service award identifies organizations that will serve as role models for other organizations

Answer 87

MBNQA

Question 88

The three major components of UM are

Answer 88

Utilization Review, Case Management, Discharge Planning

Question 89

What is the ultimate goal for P4P

Answer 89

providers are rewarded for meeting pre-established targets for delivery of healthcare that improve quality and efficiency

Question 90

The UR Coordinator reviews IP records a regular intervals to justify necessity and appropriateness of care to warrant further hospitalizations. Which of following UR activities is being performed?

Answer 90

Continued stay review

Question 91

All of the following are part of a successful CQA program except

Answer 91

the nursing department is not part of the CQA program

Question 92

NPSGs include all except

Answer 92

Over utilization of healthcare services

Question 93

Patient advocacy is usually

Answer 93

part of risk management

Question 94

As based in case law decisions and TJC standards, who is ultimately responsible to ensure quality and appropriateness of patient care in a health care facility?

Answer 94

governing body or board of trustees

Question 95

The Malcolm Baldrige National Quality Award has three sector-specific criteria. Which of the following is not one of the criteria?

Answer 95

all of them are included

Question 96

What does the abbreviation “P4P” mean?

Answer 96

Pay for Performance