NAHQ Practice CPHQ Questions & Answers, 100% Accurate, rated A+

NAHQ Practice CPHQ Questions & Answers, 100% Accurate, rated A+ 1- In evaluating "long waiting times," a healthcare quality professional best demonstrates components related to staffing, methods, measures, materials ...

NAHQ Practice CPHQ Questions & Answers, 100% Accurate, rated A+ 1- In evaluating "long waiting times," a healthcare quality professional best demonstrates components related to staffing, methods, measures, materials, and equipment utilizing A. a run chart. B. a histogram. C. a pie chart. D. an Ishikawa diagram. - ✔✔-EXPLANATIONS: A. Run charts are used to track data over time. B. Histograms and bar charts are used to show distribution. C. Pie charts are used to compare parts of a whole. D. An Ishikawa (cause and effect) diagram helps to analyze potential causes. 2- Which of the following are the primary reasons for developing drug formularies? A. manage pharmacy costs, promote patient safety B. reduce medication errors, educate physicians C. encourage the appropriate use of medications, educate physicians D. decrease food and drug interactions, promote patient safety - ✔✔-EXPLANATIONS: A. A drug formulary is an approved list of medications, clinical indications, and doses that helps manage pharmacy costs and patient safety. B. Reduced medication errors may result from having a drug formulary, but is not the primary reason for having one. It is also not intended to educate physicians. C. A formulary may encourage the appropriate use of medications, but it is not intended to educate physicians. D. A formulary is intended to promote patient safety, but the primary purpose is not intended to decrease food and drug interactions. 3- Management using quality improvement principles should emphasize the importance of A. staff orientation. B. customers' expectations. C. quarterly statistical reports. D. team selection. - ✔✔-EXPLANATIONS: A. Staff orientation is only one component of quality improvement principles. B. The basis of quality improvement is knowing what the customer needs and wants. C. Quarterly statistical reports are only one component of quality improvement principles. D. Team selection is only one component of quality improvement principles. 4- Quality improvement teams are beneficial because they A. improve managerial control. B. promote competition and pride among members. C. maximize expertise and perspectives. D. authorize solutions to problems. - ✔✔-EXPLANATIONS: A. Quality improvement teams do not affect managerial control. B. Promoting competition is not a function of quality improvement teams. C. A diverse team, including members with different experience and backgrounds, provides a broader knowledge base and outcomes. D. Authorizing solutions to problems is a function of management. 5- Which of the following is an essential component in a performance improvement report? A. governing body approval B. data analysis and display C. individual performance review D. team composition and attendance - ✔✔-EXPLANATIONS: A. The governing body is accountable for the performance improvement program, but their approval is not a component of a performance improvement report. B. The report has no value without having the data displayed and analyzed. C. An individual performance review is not an essential part of a performance improvement report. D. Team composition and attendance are not usually included in a performance improvement report. 6- Which of the following is the primary goal of risk management? A. Identify and manage risks to promote patient safety. B. Maintain an effective incident reporting system. C. Perform failure mode and effects analyses. D. Eliminate financial loss associated with legal actions. - ✔✔-EXPLANATIONS: A. Improving patient safety is the primary goal of risk management. B. Incident reporting is a tool that may be used in risk management, but is not the primary goal. C. A failure mode and effects analysis is a proactive method used to help identify problems. D. Risk management programs help protect an organization from financial loss, but it is not the primary goal. 7- 7- The relationship between patient satisfaction and hours per patient day on a medical unit was found to be (r = 0.60, p < 0.05). What is the correlation between these two values? A. 0.05 B. 0.36 C. 0.55 D. 0.60 - ✔✔-EXPLANATIONS: A. See explanation D. B. See explanation D. C. See explanation D. D. The correlation coefficient (r) is an index that ranges from -1.0 to 1.0 and reflects the extent of a linear relationship between two data sets. The correlation coefficient is 0.60. 8- Hospital A has recently merged with Hospital B. After 6 months, it is noted that Hospital A has successfully transitioned their staff to new organizational values, while Hospital B still struggles. Hospital A's success can best be attributed to A. requiring adoption of new values by all staff. B. support of both hospitals' mission statements. C. acceptance of the new mission and vision statements. D. integrating technology and databases. - ✔✔-EXPLANATIONS: A. There is not enough information provided to show that the values were adopted by all staff. B. Support of two mission statements could be confusing to staff and would not lead to an integrated organization. C. Acceptance of the new mission and vision statements demonstrates integration of the two facilities. D. Values are not dependent on the integration of technology and databases. 9- For a quality improvement team to deal effectively with conflict, it is important to appoint which of the following to its membership? A. risk manager B. human resources representative C. facilitator D. senior leader - ✔✔-EXPLANATIONS: A. A risk manager's role would not necessarily deal with conflict within a quality improvement team. B. A human resources representative handles staffing issues, but not necessarily conflict, within a team. C. A facilitator is an unbiased party that may help groups deal with conflict. D. A senior leader's role would not necessarily deal with conflict within a quality improvement team. 10- A Failure Mode and Effects Analysis (FMEA) is performed A. to immediately investigate an incident that occurred. B. as a preventative measure before an incident occurs. C. if the severity of an incident led to a patient death. D. when there is a chance of an incident reoccurring. - ✔✔-EXPLANATIONS: A. The FMEA process is performed before an incident occurs. B. The FMEA process is a proactive, systematic method of identifying and preventing incidents from occurring. C. The FMEA process examines severity, but before an incident or a death occurs. D. The FMEA process examines the likelihood of occurrence, but before an incident occurs. 11- Which of the following best describes an organizational vision statement? A. It is used as a marketing strategy. B. It defines the structure of the institution. C. It describes the organization's strategic plan. D. It reflects the organization's aspirations. - ✔✔-EXPLANATIONS: A. The vision statement may be used for marketing purposes, but it does not define marketing strategies. B. The structure of the institution is not defined in the vision statement. C. The strategic plan is not part of an organization's vision statement. D. Vision is the image or description of what the organization desires to become. 12- The most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staff is by A. developing professional relationships. B. inviting medical staff to an inservice on quality tools. C. evaluating physician participation on quality teams. D. providing outcome data at medical staff meetings. - ✔✔-EXPLANATIONS: A. Relationships are needed, but they are not the most effective way to communicate quality improvement activities. B. Inviting medical staff to an inservice does not ensure attendance. C. Evaluating participation is not a communication tool. D. Outcome data communicates objective feedback to medical staff. 13- Quality improvement team progress is best evaluated by which of the following? A. team leader B. senior leadership C. PDCA process D. nominal group technique - ✔✔-EXPLANATIONS: A. The team leader may be biased and is not the best source for team evaluations. B. Senior leadership is not usually involved in evaluating a team. C. The Plan, Do, Check, Act process is a comprehensive methodology used to conduct performance improvement activities, including the analysis of progress. D. The nominal group technique is a group decision-making process for generating a large number of ideas where each member works individually. This technique would not be helpful in evaluating team progress. 14- To reduce the incidence of ventilator-associated pneumonia (VAP) in a critical care unit, who should be included on a quality improvement team? A. intensivist, ICU nurse, and respiratory therapist B. primary care physician, infection control nurse, and surgeon C. ICU manager, respiratory therapist, and pharmacist D. pharmacist, intensivist, and infection control nurse - ✔✔-EXPLANATIONS: A. Intensive-care medicine or critical-care medicine is concerned with the provision of life support or organ support systems in patients who are critically ill and who usually require intensive monitoring. In this scenario, the healthcare quality professional would involve staff that would most commonly be related to the care of a patient with VAP. The involvement of the intensivist, ICU nurse, and respiratory therapist would be considered common, and would comprise the ideal and appropriate team to care for a patient with VAP. B. While the primary care physician may be involved, it is not common practice for the infection control nurse/preventionist to be involved in the daily care of a patient with VAP. C. While the ICU manager and pharmacist could be involved in the care of a patient with VAP, they would not be ideal members of a quality improvement team. D. While the pharmacist, intensivist, and infection control nurse/practitioner could be part of the VAP quality improvement team, this response is not ideal as it does not include the respiratory therapist or ICU nurse. 15- A team has identified a process for improvement, selected examples of best practice performers, visited those sites, gathered all necessary data, and compiled the results. The most effective next step for the team is to A. identify the next process to benchmark. B. implement change at the team's site. C. compare results to historical data. D. make the results public for others to use for benchmarking. - ✔✔-EXPLANATIONS: A. The first issue has not been resolved. It needs to be addressed before moving on to the next process. B. Implementation is the next step in the performance improvement cycle. C. All necessary data have already been compiled. D. The process has not been completed, so there is nothing to share at this point. 16- A continuous quality improvement organization promotes vigorous education and training/retraining in order to A. restructure internal jobs. B. reduce the need for competency testing. C. promote harmony within the organization. D. acquire new knowledge and new skills. - ✔✔-EXPLANATIONS: A. The purpose of continuous quality improvement within an organization is to reduce risks and improve the quality of care and patient safety. Restructuring internal jobs would not be a result of a highly reliable organization with a continuous quality improvement program and processes. B. Continuous Quality Improvement (CQI) is a process of creating an environment in which management and workers strive to create constantly improving quality. A successful quality improvement program is one that inspires people to learn, but still requires competency testing. C. Promoting harmony is not a goal of continuous quality improvement. D. As the stem of the question identifies a component of continuous quality improvement as one that promotes education and training, this will yield new knowledge and skills. 17- Which of the following is essential to an effective quality council? A. involvement of leadership B. consultation of the legal advisor C. participation of the strategic planning committee D. direction from the organization's quality department - ✔✔-EXPLANATIONS: A. Leadership involvement promotes an effective quality council through resource and support allocation to achieve objectives. B. A legal advisor is not commonly a member of a quality council. C. A strategic planning committee is not commonly a component of a quality council. D. The quality department may provide input, but not necessarily direction, to a quality council. 18- A Quality Council has chartered a Failure Mode and Effects Analysis (FMEA) team to examine the best method of preventing medication errors after the installation of a new medication dispensing system. The team's first major task should be to A. identify ways to detect the likelihood of the equipment breaking down. B. brainstorm on potential failure modes of the equipment. C. multi-vote on the severity of the potential equipment breakdowns. D. develop a flow chart of how the equipment will be installed. - ✔✔-EXPLANATIONS: A. Detecting a specific failure mode, such as equipment failure, is a step in an FMEA, but it is not the first major step. B. In an FMEA, brainstorming potential failures is the first major step. C. Multi-voting on the severity of a failure mode, such a as equipment breakdown, is a step in the FMEA process; but it is not the first major step. D. Developing a flow chart of how equipment will be installed is not a step in an FMEA. 19- Based on identified issues, a healthcare quality professional examines 100% of one physician's admissions and only 20% of all other physicians' admissions. This is best described as a A. focused review. B. prospective review. C. retrospective review. D. concurrent review. - ✔✔-EXPLANATIONS: A. A focused review is performed for a predetermined reason and is concentrated on a select sample of cases or data elements. Case or data element selection is usually based on internally identified problem areas or on external demands. Since the quality professional examined 100% of one physician's admission based on identified issues, a focused review is the best description of this case. B. A prospective review is performed prior to care or practice. It is evident in the case above that the review was based on identified issues related to a physician's practice patterns. C. The case above can be described as a retrospective review; however, a focused review is a more accurate answer since the quality professional reviewed 100% of a physician's admissions compared to 20% or all other physician's admissions. D. A concurrent review is performed at the onset of and during care; there is no evidence in the case above that the review was performed at that time. 20- An emergency department tracks wait times from patient arrival to physician assessment. Data are reported using a run chart. Which of the following demonstrates a true statistical increase in treatment delays? A. 6 consecutive ascending data points B. 7 consecutive descending data points C. a zigzag pattern of 10 data points D. data points close to the mean line - ✔✔-EXPLANATIONS: A. A true statistical increase is indicated by 6 consecutive ascending data points. B. Descending data points do not indicate an increase in this particular case. C. A zigzag pattern of data points demonstrates variability in the data. D. Data points close to the mean demonstrate minimal variation in the data. 21- Which of the following are essential functions of an infection control program? A. risk management and surveillance B. prevention and education C. surveillance and prevention D. patient safety and risk management - ✔✔-EXPLANATIONS: A. Risk management is not an essential function of an infection control program. B. Education is a component of prevention, but is not an essential function of an infection control program by itself. C. Two principal functions of infection control are surveillance and prevention. D. Patient safety and risk management are not essential functions of an infection control program. 22- A surgery department's monthly case review revealed 10 records meeting criteria and six additional records that did not meet the criteria. In calculating the incidence rate, the denominator is A. 4. B. 6. C. 10. D. 16. - ✔✔-EXPLANATIONS: A. See explanation D. B. See explanation D. C. See explanation D. D. The denominator is the total of all of the medical records, which equals 16. 23- The concept of organizational liability is most important to the field of healthcare quality because it holds the organization responsible for A. maintaining confidentiality of all documents. B. requiring physicians to carry adequate malpractice insurance. C. maintaining a process to identify deficiencies in the provision of care. D. ensuring that peer review physicians have no conflict of interest in cases being reviewed. - ✔✔- EXPLANATIONS: A. Confidentiality of all documents is not the most important part of organizational liability. B. Carrying adequate malpractice insurance is usually required, but is not the most important aspect. C. Maintaining quality of care is the ultimate responsibility of the governing body of an organization. D. Conducting unbiased peer reviews is a process that helps identify deficiencies in care. 24- A root cause analysis revealed a patient in an acute psychiatric unit committed suicide by hanging himself with his shoelaces. To prevent this from occurring again, the most appropriate action is to institute A. patient checks every 15 minutes. B. a policy allowing only non-laced shoes. C. a 24-hour video monitoring system. D. a buddy system for the patients. - ✔✔-EXPLANATIONS: A. Checking patients every 15 minutes may not prevent suicide. B. This policy eliminates the object that was used to commit suicide and creates a safer environment. C. A monitoring system may not prevent suicide. D. A buddy system may not prevent suicide. 25- Patient satisfaction scores for a community hospital demonstrate multiple areas for improvement including a need to improve attractiveness of the facility, responsiveness to patient needs, and physician and nursing communication. Based on these results, which of the following should the healthcare quality professional also expect to find? A. administration prioritizing and leading units to achieve organizational goals B. unit managers who openly discuss patient satisfaction scores C. units operating independently with little communication between units D. employee satisfaction scores in the 80th percentile compared to other peer organizations - ✔✔- EXPLANATIONS: A. Based on the information provided, leadership may not have prioritized these issues to achieve organizational goals. B. There is not enough information provided to determine if managers are discussing patient satisfaction scores. C. Responsiveness to patient needs requires effective communication between multiple units as well as staff. D. Employee satisfaction does not necessarily correlate with these patient satisfaction scores. 26- A team approach to problem solving is most useful when A. the organization's goals are unclear. B. diverse areas of expertise are required. C. communication challenges exist. D. there are ample resources within the organization. - ✔✔-EXPLANATIONS: A. It is leadership's responsibility, not the team's responsibility, to clearly define organizational goals. B. The make-up of a team that varies in perspective and experience provides a variety of skill sets that will help solve problems. C. Communication challenges may make working within a team more difficult. D. A team approach to problem solving should not be dependent on the amount of resources. 27- A performance improvement training program has been conducted. The healthcare quality professional has determined that improvement has not occurred. The most likely cause for the lack of improvement would be that A. organizational systems are inhibiting changes. B. employees practice what they are trained to do. C. staff members thought the program was too long. D. the facilitator did not prepare agenda materials. - ✔✔-EXPLANATIONS: A. The most common failure of training programs is system challenges within the organization. There must be a culture that fosters safety as a priority for everyone within the organization. B. Employees practicing what they are trained for would lead to improvement and is one of the intended outcomes of a training program. C. While the employees' perception about the program may be that it was too long, it would not be the sole reason that improvement did not occur. This information could help to improve future training programs within the organization. D. The lack of agenda materials could have contributed to the lack of improvement, but would not be the sole cause. 28- A facility has identified a trend of increased falls for patients aged 60 to 85 years. An effective fall prevention program should include A. a fall protocol, restraint criteria, and a family sitter program. B. restraint criteria, staff education, and a sedation protocol. C. a patient assessment process, a family sitter program, and a sedation protocol. D. a patient assessment process, a fall protocol, and staff education. - ✔✔-A. See explanation B. B. According to the CMS Conditions of Participation for hospitals and long-term care, patients or residents have the right to be free of restraints of any form (physical or drug) that are not medically necessary. Restraints should only be used when other less restrictive forms of management have failed and there is a need to ensure the safety or well-being of the patient/resident. Restraints should not be used as part of a routine falls prevention program. C. According to the CMS Conditions of Participation for hospitals and long-term care, patients or residents have the right to be free of restraints of any form (physical or drug) that are not medically necessary. Medications used to restrict the freedom of movement of a patient are considered a restraint when not used as medically necessary for their condition. Therefore, any sedation protocol used as part of the falls prevention program would be considered a restraint. D. The proper steps to reducing patient falls include assessing the risk for fall regularly during a patient stay, putting in place protocols to reduce falls based on the results of the assessment, then conducting staff education to ensure these steps are implemented. 29- A Quality Council has chartered a performance improvement team to reduce medication errors. The team has been meeting for several months and progress has been very slow. Which of the following is the most important factor for the Quality Council to assess with the team leader? A. composition of the team B. number of medication errors since team was chartered C. team members' ability to interpret graphs D. frequency of team meetings - ✔✔-EXPLANATIONS: A. The composition of the team is the most important factor and is often the main cause of team failure. Having the right team in place is essential. B. The number of medication errors is not relevant to the team's functionality. C. Interpreting graphs is a skill the team needs, but it is not as important as having the right team members. D. The frequency of meetings may need to be examined, but is not the most important factor 30- A number of specialty and primary care clinicians have participated in several meetings to develop clinical practice guidelines for the management of diabetes. The team leader has moved the team through the actual guideline development, and is now concentrating on the "evaluation of quality-ofcare" phase. Which of the following sequences of steps should the team consider in developing the evaluation phase? A. identify medical review criteria, identify sampling methods to be used, define objectives of the performance review, pilot test B. develop data collection form, identify populations covered by the guideline, identify the data sources, conduct the review C. define objectives of the performance review, identify populations covered by the guideline, develop data collection form, pilot test D. consider costs of the review, identify clinicians and sites of care, define objectives of the performance review, develop data collection form - ✔✔-EXPLANATIONS: A. See explanation C. B. See explanation C. C. Objectives must be defined first. D. See explanation C. 31- Evaluating medication administration to reduce medical errors is an example of A. quality managemen