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CPHQ Quiz Bank. Exam Questions and answers, 100% Accurate, rated A+. Verified. Which of the following is NOT part of the seven steps to the Kubler Ross Change Curve model? A. shock B. experim... ent C. anger - ✔✔-A. anger All styles are important for different situations an organization may find itself in at any given point in time. Which of the following leadership styles is best when an organization is in crisis mode? A. autocratic B. empowering C. transactional D. transformational - ✔✔-A. Autocratic Quality Assurance - ✔✔-Measures compliance with standards Quality Control - ✔✔-Process of ensuring products and services meet consumer expectations Performance Improvement - ✔✔-Continuously improve processes to meet standards Quality Defect: Underuse - ✔✔-Failing to provide medically necessary care or follow evidence based medical practice Quality Defect: Overuse - ✔✔-Providing a drug or treatment without medical justification Quality Defect: Misuse - ✔✔-Medical errors in the provision of care DEFECT: Wrong site surgery A. Underuse Failing to provide medically necessary care or follow evidence based medical practice B. Overuse Providing a drug or treatment without medical justification C. Misuse Medical errors in the provision of care - ✔✔-C. Misuse DEFECT: Use of high tech imaging (MRI, CAT scan) when other diagnostic tests are sufficient A. Underuse Failing to provide medically necessary care or follow evidence based medical practice B. Overuse Providing a drug or treatment without medical justification C. Misuse Medical errors in the provision of care - ✔✔-B. Overuse DEFECT: Less than 10% of recommended women receive annual mammograms A. Underuse Failing to provide medically necessary care or follow evidence based medical practice B. Overuse Providing a drug or treatment without medical justification C. Misuse Medical errors in the provision of care - ✔✔-A. Underuse DEFECT: Nearly 10,000 pneumonia related deaths per year could be prevented with the administration of a vaccine A. Underuse Failing to provide medically necessary care or follow evidence based medical practice B. Overuse Providing a drug or treatment without medical justification C. Misuse Medical errors in the provision of care - ✔✔-A. Underuse DEFECT: Administering the wrong drug to a patient or resident A. Underuse Failing to provide medically necessary care or follow evidence based medical practice B. Overuse Providing a drug or treatment without medical justification C. Misuse Medical errors in the provision of care - ✔✔-C. Misuse DEFECT: Antibiotics prescribed for simple viral infection A. Underuse Failing to provide medically necessary care or follow evidence based medical practice B. Overuse Providing a drug or treatment without medical justification C. Misuse Medical errors in the provision of care - ✔✔-B. Overuse Vision - ✔✔-•Future goal •Commitment to both internal and external customer supplier relationships •Short, sustainable, patient centered Mission - ✔✔-•Reflects current state •Describes in broad terms organization purpose and role in the community •Based on data, program analysis and input from key stakeholders •Includes at minimum, commitment to quality, patient safety, patient care and need to serve the community Goals - ✔✔-•Support vision and mission •Overarching direction •Intangible improve team communication; reduce falls; patient satisfaction, build trust •Developed for units, departments •Hard to measure Objectives - ✔✔-•Specific, measurable actions or tasks taken to achieve goals •Include at a minimum: o Measurable o Timeline o Accountable party Data driven process - ✔✔-External analysis of customer needs in relation to demographics and regulations Analytical process - ✔✔-Internal services and functions SWOT analysis - ✔✔-Strengths, weaknesses, opportunities, threats Revisions - ✔✔-Mission, vision, goals, core values Ground it - ✔✔-o Priorities o Goals o Objectives Safety - ✔✔-patient, family, staff Communication - ✔✔-clinicians, non clinicians Regulatory - ✔✔-ongoing readiness Clinical quality measures - ✔✔-quality programs Quality improvement - ✔✔-evidence based practice Event tracking system - ✔✔-Risk management Strategic goals - ✔✔-•Use PI measures for business planning and resource allocation •Provide PI training By Laws - ✔✔-•Establish relationship between medical staff and board •Develop priorities with physicians Management roles - ✔✔-•Develop PI competencies •Empower staff and evaluate compliance Regulatory - ✔✔-•Root cause analysis •Action plans Focused Professional Practice Evaluation (FPPE) - ✔✔-Consistently implemented for all newly requested privileges Ongoing Professional Practice Evaluation (OPPE ) - ✔✔-•Process that supports early detection and response to performance issues •Applies to all practitioners granted privileges •Oral or written report •Dissatisfied with quality or processes of care •Patient, guardian, non union staff member •Written complaint - ✔✔-COMPLAINT •Formal written complaint •Union member - ✔✔-GRIEVANCE •Complaint or grievance found valid •Impartial review of the decision from a third party - ✔✔-APPEAL o Depends on personal charm o Limited effectiveness o Only relate to a one group of people - ✔✔-Charismatic Leader o Follows rules exactly o Expects everyone to follow the rules o Most conducive during critical times or cash flow o Not conducive to change or creativity o May engender respect - ✔✔-Bureaucratic Leader o Make decisions independently o Strictly enforces rules o Team often feels left out of decision making o Most effective in crisis situations o Difficulty with staff commitment - ✔✔-Autocratic Leader o Presents decisions to staff and seeks input and questions o Most effective when gaining staff commitment is critical to success - ✔✔-Consultative Leader People exercise skills and advance over time - ✔✔-Stable learning Culture People have valued skills transferable to other organizations - ✔✔-Independent Culture Strong identification and emphasis on seniority - ✔✔-Group Culture Frequent staff layoffs and reorganizations - ✔✔-Insecure Culture •Leader presents a potential decision •Leader makes final decision based on input from individuals or team - ✔✔-PARTICIPATORY LEADERSHIP •Leader takes complete control •Leader asks individual, employee and/or team to arrive at a solution •Leader usually makes the final decision - ✔✔-DEMOCRATIC LEADERSHIP •Leader exerts indirect control •Employees and teams make decisions independently •Leader has very little input in final decision - ✔✔-LAISSEZ FAIRE (FREE REIGN) o Force field of driving and restraining forces o Remove restraining forces o Unfreeze old beliefs refreeze new beliefs - ✔✔-Lewin Change Model o Seven key elements; start with leading change to anchoring change o Assess readiness and develop strategies to move toward readiness and "go" - ✔✔-Palmer Change Model o Five stage model o Progress and revert at any time o Not a linear model various stages of change accept as is - ✔✔-DeWeaver and Gillespie Change Model o Strong appreciation for human side o 10 stage model strategically or grassroots driven - ✔✔-Galpin's Human Side of Change Model o Ensure people fully accept change o Incorporate change into their belief system o Change is associated with the heart and emotions - ✔✔-Kotter's Heart of Change Model o Integrates individual behavioral change with organizational change o Six stages indicate individual's readiness to change behavior rather than process change o Works well with patients, individual staff members and providers - ✔✔-Prochaska's Transitional Model o Narrow focus o My way or the highway o Short term outcomes - ✔✔-Barrier to system change: Autocratic view o Unsure of ability to relearn new concepts, principles and procedures - ✔✔-Barrier to system change: Failure to adapt o Superficial or weak solutions about difficult problems o Problems still exist - ✔✔-Barrier to system change: Weak consensus o Nurse/doctor vs system and solution - ✔✔-Barrier to system change: Identification with role rather than purpose o Us vs them o Closed to change - ✔✔-Barrier to system change: Feelings of victimization o Already tried before o New direction requires new solutions - ✔✔-Barrier to system change: Relying too heavily on past A physician who has a high mortality rate compared to others in a facility should first be: A. Counseled by the department chairperson B. Evaluated by the ongoing professional practice evaluation (OPPE) and focused professional evaluation (FPPE) committee C. Suspended until further action can be determined in the interest of patient safety D. Subjected to more in depth review of cases - ✔✔-D. Subjected to more in depth review of cases To decrease costs, the hospital has hired outside consultants to perform many of its tasks. There are concerns the performance of many of the consultants does not meet the state's standards for the hospital's operation. What is the healthcare professional's role in this situation? A. Create simulated activities to test the consultants and see if they are meeting the standards B. Develop educational programs to assist the consultants and ensure the standards are met C. Supply the consultants with information about state standards and ensure full compliance D. Review activities of the consultants and report the results to the hospital administration - ✔✔-D. Review activities of the consultants and report the results to the hospital administration Which of the following should be included in an annual report to the governing body? A. Meeting minutes B. Team achievements C. Incident/occurrence reports D. Physician peer reviews - ✔✔-B. Team achievements Aside from the Chief Compliance Officer, who else might be responsible to establish and oversee processes to prevent or identify inaccurate billing practices or misbehavior that might result in errors being investigated as fraudulent practice? A. Chief Financial Officer and Chief Operations Officer B. Quality Professional and Risk Management Professional C. Chief Executive Office and Chief Medical Officer - ✔✔-B. Quality Professional and Risk Management Professional The activities of the Quality Improvement Organization (QIO) are known as the SoW, which stands for: A. Solicitation of Work B. Scope of Work C. Subcontract of Work - ✔✔-B. Scope of Work The purpose of developing a corrective action plan is to: A. Keep a record of actions B. Provide a reference point to look back on changes C. Will solve all problems associated with a survey issues D. Helps evaluate if changes are successful E. Promotes program improvement F. A, B, D and E only - ✔✔-F. A, B, D and E only The primary purpose of an emergency preparedness program is to A. Conduct evaluations of emergency training B. Provide evaluations of semiannual evacuation drills C. Prevent internal disasters that disrupt the facility's ability to provide care and treatment D. Manage the consequences of disasters that disrupt the facility's ability to provide care - ✔✔-D. Manage the consequences of disasters that disrupt the facility's ability to provide care Pharmacy and nursing are having difficulty developing an action plan for medication errors. Pharmacy states nursing causes most of the problems related to errors ; nursing states the opposite. What is the quality professional's role in this situation? A. Provide them with directives on how to solve the problem B. Facilitate discussion between the groups to enable them to assume ownership of their portions of the problem C. Assign the task to an uninvolved manager D. Refer the problem to the facility wide quality council - ✔✔-B. Facilitate discussion between the groups to enable them to assume ownership of their portions of the problem A hospital has implemented a quality program to improve the overall quality of patient care. The program is running over budget, so the board conducts a review of the program to see if it should continue. What is the quality professional's role in this? A. Prove to the administrative board the quality program should continue in the hospital B. Assist the board in making a final decision about the quality program C. Create a committee to review the quality program and develop a list of reasons to keep it D. Evaluate the financial benefits of the program and demonstrate these to the board - ✔✔-D. Evaluate the financial benefits of the program and demonstrate these to the board Which of the following processes is most cost effective in preventing unnecessary resource consumption in the hospital? A. Effective preadmission screening B. Accurate DRG assignment at admission C. Second opinions for all surgeries D. Preadmission insurance benefit denials - ✔✔-A. Effective preadmission screening What are the reasons for evaluating the results of quality improvement training? A. To improve future training B. To determine whether participants' and organization's needs were met C. To determine whether current training should be continued D. All the above - ✔✔-D. All the above Volatility in nursing workload is less likely to be reported than other sources of waste because: A. Nurses are unlikely to complain B. It can only be perceived using advanced metrics C. It is less observable D. It takes place infrequently - ✔✔-C. It is less observable The primary reason to analyze customer satisfaction surveys is to: A. Provide data for the quality improvement program B. Meet pay for performance requirements C. Identify how perceptions relate to services provided D. Assist with evaluation of employee performance - ✔✔-C. Identify how perceptions relate to services provided One important driver of patient dissatisfaction in health care over the past decade has been: A. Introduction of online services B. Lack of communication between physicians and patients C. Rise in income inequality D. Improvement of customer care in other service industries - ✔✔-A. Introduction of online services Health Care Impact from this Federal Regulation: •Hospitals participating in Medicare and offering emergency services must provide a medical screening exam when requested for examination/treatment for emergency medical condition (EMC), including active labor, regardless of patient's ability to pay •Hospital is required to provide stabilizing treatment for patients with EMC's •If hospital is unable to stabilize a patient or request is made to transfer, appropriate transfer will be implemented - ✔✔-Emergency Medical Treatment and Active Labor Act (EMTALA) Health Care Impact from this Federal Regulation: Protection of personal health information and provides patient rights - ✔✔-Health Insurance Portability and Accountability Act (HIPAA) Health Care Impact from this Federal Regulation: Established quality standards for labs, regardless of where test is done - ✔✔-Clinical Laboratory Improvement Amendments (CLIA) Health Care Impact from this Federal Regulation: •Comprehensive U.S. health insurance reforms •Transforms and modernizes the American health care system •New payment models with the goal to reward value and quality, not volume •Bundled payments, medical home models for primary care physicians, financial incentives to coordinate care •Includes accountable care organizations (ACO's) - ✔✔-Patient Protection and Affordable Care Act (PPACA) Affordable Care Act (ACA) Health Care Impact from this Federal Regulation: Impacts the way providers are reimbursed through merit based payment Incentives and alternative payment models (APMs), collectively referred to as quality payment programs (QPPs) - ✔✔-MACRA = Medicare Access and CHIP Reauthorization Act (CHIP = Medicaid = Children's Health Insurance Program) Network of health care providers that band together to provide the full continuum of health care services for patients. Receives a payment for all care provided to a patient and held accountable for the quality and cost of care. - ✔✔-Accountable Care Organization (ACO) Classification system that groups patients by diagnosis, type of treatment, age and other relevant criteria. Under the prospective payment system (PPS), hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual. - ✔✔-Diagnosis Related Group Series of programs created by health care payers comprised of incentives and reductions for payment (adjustments by CMS) - ✔✔-Incentive and Penalty Programs Health care delivery system organized to manage cost, utilization and quality. - ✔✔-Managed Care Private regulators as compared to federal or state regulators. The most well known is the American Medical Association (AMA) acts as an oversight for the medical profession to supplement government regulators. - ✔✔-Private Quasi Regulators Requirements issued by various governmental agencies to carry out the intent of legislation enacted by Congress, state legislatures and local authorities. Compliance with regulations is mandatory by law. - ✔✔-Regulations Official authorization or approval, recognition for conforming to standards or to recognize as outstanding - ✔✔-Accreditation Recognition for meeting special qualifications in a field - ✔✔-Certification A level of health care quality or attainment set by CMS for health care entities receiving reimbursement for Medicare/Medicaid patients - ✔✔-CMS Standards: CoPs Conditions of Participation CfC Conditions for Coverage Granted by CMS to accrediting organizations, to determine on CMS' behalf, if an organization evaluated by an accrediting organization is following corresponding Medicare regulations - ✔✔-Deeming Authority Mechanism to escalate crisis survey issues immediately to both state and federal agencies when the health and safety of individual(s) are at immediate risk - ✔✔-Immediate Jeopardy Administrative remedies and actions (e.g., exclusion, civil monetary penalties) available to the Office of Inspector General to deal with questionable, improper or abusive behaviors under the Medicare, Medicaid or state health programs - ✔✔-Sanctions When a complaint or grievance is found invalid by an organization, the complainant or griever asks for an impartial review of the decision from a third party - ✔✔-Appeal A specific oral or written report of lack of satisfaction with quality of care or processes of care by a patient, guardian, or non union staff member; a written complaint is the first step in a civil or criminal court proceeding - ✔✔-Complaint A formal written complaint about contract violation, quality of care, or financial issues by a union member - ✔✔-Grievance An examination of one practitioner by a like practitioner who has similar training, experience, and expertise. A peer review is triggered by a root cause analysis that indicates the need to focus on an individual, sometimes related to utilization review - ✔✔-Peer Review Designed for adult patients (18 and older) of hospital based emergency departments (ED) who are discharged to home (also known as "treat and release" visits), which account for about 90% of all ED visits - ✔✔-Emergency Department Consumer Assessment of Healthcare Providers and Systems (ED CAHPS) as of 2020 voluntary First national, standardized, publicly reported survey of patients' perspectives of hospitals; the survey is an instrument and data collection methodology for measuring patients' perceptions of their hospital experience - ✔✔-Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey mandatory Respectful care that is responsive to patient preferences, needs and values and ensures the patient's values guide all clinical decisions; meaningful interpersonal relationships honoring the whole person and family - ✔✔-Person and family centered care Tool used at the start or "fuzzy front end" of any new product, process or service to better understand the customers needs and wants - ✔✔-Voice of the customer (VOC) 5 HAI measures recalibrated PSI 90 score - ✔✔-Hospital Acquired Conditions Reduction Program (HAC) •Results can be reproduced when the test is repeated under the same conditions •Reliable measure is not always valid - ✔✔-Reliability •Measures exactly what it was intended to measure •Valid measure is generally reliable - ✔✔-Validity Meaningful quality measures must be: A. Relevant and valid B. Feasible and explainable C. Relevant and explainable D. Valid and feasible - ✔✔-A. Relevant and valid o Data must be reproducible to be valid o For data to reproduced, it should be relevant o Relevance of data is important because the data must relate to the quality process being measured When developing department specific measures and indicators, the quality professional should: A. Conduct a literature search and then select indicators B. Ensure the numerator and denominator are clearly defined C. Prioritize the quality indicators for selection by department leader D. Review the mission statement and seek input from key stakeholders - ✔✔-B. Ensure the numerator and denominator are clearly defined o In order to have reliable and valid data all data elements must be clearly defined from the start In conducting clinical research and selecting probability sample of adults that includes 20 of ages 18 39, 20 of ages 40 59, 20 of ages 60 and older, the type of sampling is: A. Cluster B. Systematic C. Stratified random D. Simple random - ✔✔-C. Stratified random o Homogenous groups, random sample from each group age groupings o Heterogeneous groups, from each cluster pick sample - ✔✔-Cluster o Population based on a certain order • E.g., Nine out of every 10 participants - ✔✔-Sample probability sampling o Each case has a random chance of selection - ✔✔-Simple random o Based on strategic plan o Performance measures on mission, vision, goals and objectives o Organization wide metrics: financial, customers, clinical, community, growth, education - ✔✔- Balanced scorecard o Overview of organization o Integrates key indicators (KPIs) o Running picture: organization, department, unit o Valuable: involves everyone, visual, effective and efficient, informs decision making - ✔✔-Dashboard Balanced scorecards are useful because they: A. Focus on the most significant strategic initiative B. Evaluate the pros and cons of the governing body's priorities C. Put strategy and vision at the center of an organization's effort D. Concentrate on the performance of individual units - ✔✔-C. Put strategy and vision at the center of an organization's effort Benchmarking is based on identifying which of the following? A. Best practices B. Competition C. Deficiencies D. Statistical control - ✔✔-A. Best Practices o Value of benchmarking •Better understand the competition and deficiencies using benchmarking data Relationship between two or more groups at different times - ✔✔-Bar Graph Impact of independent variable on dependent variable - ✔✔-Line Graph o Line graph or a trend chart that displays observed data in a time sequence - ✔✔-Run Chart What percentage an item pertains to the whole o Display percentages of proportional relationships within a group you are trying to compare that add up to 100% - ✔✔-Pie Chart 80% of effects come from 20% of causes - ✔✔-Pareto Principle: 80/20 rule This variation type is known as "noise" and is managed by making changes and is removed through management - ✔✔-Common Cause Variation This variation type is attributed to a single unusual circumstance. If you find it, remove it. - ✔✔-Special Cause Variation Six or more consecutive data points all above OR all below the median - ✔✔-Shift Seven or more consecutive data points in either ascending OR descending order - ✔✔-Trend Eight or more similar fluctuations - ✔✔-Pattern o Up and down variation, forming a sawtooth pattern with 14 successive data points o Suspect a systemic effect on the data o Common cause variation is shown as 4- 11 successive data points - ✔✔-Cycle o Data point unrelated to other points o Sentinel event o Special cause variation - ✔✔-Astronomical value: In evaluating long wait times, a quality professional can best demonstrate components related to staffing, methods, measures, materials and equipment by utilizing: A. Run chart B. Histogram C. Pie chart D. Ishikawa diagram - ✔✔-D. Ishikawa diagram o Bar graph of how often of the frequency of which something happens. Because frequency is a continuous variable, there will not be gaps between the bars like in a bar graph - ✔✔-Histogram o Shows the causes of an event o Each cause or reason for the imperfection is the source of a variation o Quality defect prevention, product design - ✔✔-Ishikawa Diagram (Kaoru Ishikawa 1968) An emergency department trends wait times from patient to physician assessment data are reported using a run chart. Which of the following demonstrates a true statistical increase in treatment delays? A. Six consecutive ascending data points B. Seven consecutive descending points C. A zigzag pattern of 10 data points D. Data points close to the mean line - ✔✔-A. Six consecutive ascending data points Several patients who received pacemakers in a hospital have complained that instead of feeling better, they feel worse. They have low energy and need long periods of rest after doing even a small task. Looking into this further, you discover the patient's doctor failed to adjust the pacemaker settings for each patient but gave all patients a pacemaker with factory settings. Once the pacemaker settings were readjusted to fit the patient's individual needs, the problem was resolved. Patients felt great and had more energy than ever. Which of the following describes this type of statistical variation among the patients: A. Common B. Random C. Special D. Continuous - ✔✔-C. Special (Random blip one time occurrence) The best tool to display stability of process rates over time is: A. Run chart B. Control chart C. Scattergram D. Pareto chart - ✔✔-B. Control chart Chart type that shows: o Shifts and trends in dat [Show More]

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