A healthcare provider recently conducted a customer satisfaction survey that focused on the five key
quality characteristics in the graph below: By analyzing the information, the provider can identify that
customers were most dissatisfied with: - Cost and most satisfied with caring
Which of the following team members is responsible for keeping meetings focused? - The facilitator
facilitates and is responsible for team focus
The best way to evaluate the effectiveness of performance improvement training is through - Observed
behavioral changes: it demonstrates transfer of knowledge into practice
The best sampling technique for this case study is to review - The number of records needed using a
statistical method: the confidence level and interval would be determined through calculation
Which of the following is an example of Information that should be included in an incident report, but
should NOT be recorded in a patient's chart - Details concerning a medication preparation error
discovered and corrected prior to administration; as this information is a part of identifying the root
cause of the incident and not appropriate for the clinical medical record
The primary purpose of an organization's quality improvement (QI) strategic plan is to - Define the
future direction for quality; this is the function of having a QI strategic plan
A medication error occurred and resulted ion a severe adverse outcome. In addition to informing the
patient and/or family, a healthcare quality professional should - Conduct a root cause analysis;
exploration of the system and process issues should be the primary function of a root cause analysis
A federally certified electronic health record (EHR) with the capacity for e-prescribing, electronic
exchange of health information, and submission of healthcare quality measures meets - Meaningful use
requirements
Satisfaction Surveys, focus groups, and complaint tracking are tools used to - Understand customers
expectations; surveys, focus groups, and complaints with or from customers can provide information
directly from the customers regarding a variety of topics including customer expectations
,Deemed status refers to - Accreditation equivalency with a Centers for Medicare and Medicaid Services
(CMS) survey; CMS allows deemed status with meeting all conditions of participation requirements
through Joint Commission Accreditation
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? - 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
organizations's governing body. Based on the information above, which if the following actions is most
appropriate? - Redefine the council's role to coordinate and prioritize quality activities
Balanced scorecards are useful because they - Put strategy and vision at the center of an organization's
effort; the balanced scorecard is a management framework that translates an organization's strategic
objectives into a set of performance measures that are measured, monitored, and changed if necessary,
to ensure that organizations strategic goals are met
A root cause analysis team examined a serious medication error and recommended changes. Which of
the following should be done next - The process owner should implement and assess effectiveness; the
recommended changes need to be assigned ownership
Refer to the following control chart: In assessing the timeliness for the administration of antibiotics for
pneumonia, this control chart demonstrates - process of improvement
An organization can best measure its effectiveness in meeting customer expectations by - analyzing
satisfaction data; satisfaction data evaluates customer satisfaction
Based on the principles from the Institute for Healthcare Improvement (IHI), who has the ultimate
responsibility for the effectiveness of quality improvement and patient safety within an organization? -
governing body; this is the expectation of TJC and Centers for Medicare and Medicaid Services (CMS)
, Which of the following are the first steps when preparing for an initial accreditation or certification
survey of an organization - Review the standards and determine readiness.; These actions are part of the
gap analysis, which establishes a good baseline to determine where to focus and how to prioritize
efforts.
The primary purpose of integrating financial and quality management information is to - identifying
problems in resource management; this ties financial impact to quality management
Minimizing the chances for an adverse event to reoccur includes determining the primary contributing
factor by using - root cause analysis; as exploration of system and process issues should primary
identifying root causes of error
The utilization management committee is reviewing length-of-stay data for a particular procedure. In
comparing data by physician, which of the following statistics would be most useful - mean; the mean
statistical average in a data set. It is often used to described average length of stay for comparison and is
used with the standard deviation to understand the variability around the mean.
During quality management data analysis activities, Pareto chart are most appropriately used for -
determining priorities among contributing factors; pareto charts most appropriately assist to determine
priority using represented values
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? - Performance indicators; they
need to be reviewed for need for revision
When a team evaluating the use of restraints starts to discuss a liability claim related to a patient, the
facilitator should - redirect the team; redirection is needed to move team back on topic and towards
performance improvement effort
In the process of strategic planning, an organization makes decisions about the future. A basic
component of the planning process is to - examine both internal and external environments; includes an
examination of internal strength and weaknesses, and external opportunities and threats
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