1) An organizations' data demonstrate an increase in the number of patients falls.

The healthcare quality professional should recommend

A- Convening a focus group of medical staff to discuss fall risk
B- Revising the fall risk assessment tools
C- Sharing the data with the staff to provide feedback
D- Increasing staffing on weekends and nights
----------------------------------------------------------------------------------------------------------------------
2) The responsibility to promote organizational values and commitment among the
staff lies within:
A- Nurse executive and CEO
B- Nurse staff, senior management
C- Medical director,quality manager
D- Clinical,non-clinical leaders
----------------------------------------------------------------------------------------------------------------------
3) The quality improvement team finds high needles sticks in emergency
department. Who should the team share this information with?
A- ED staff
B- medical staff
C- medical executive committee
----------------------------------------------------------------------------------------------------------------------
4) A hospice agency conducted a satisfaction survey of all 200 patients currently
receiving pain management service. When asked if they were satisfied with their
pain management, 170 said "Yes" and 30 said "No". In this case, the healthcare
quality professional should:
A- Review all dissatisfied persons for similarities
B- Collect more data to ensure statistical significance
C- Discontinue monitoring because 85% satisfaction rate is excellent
D- Continue monitoring because 15% dissatisfaction rate is acceptable
----------------------------------------------------------------------------------------------------------------------
5) In continuous quality improvement programs, surveys are essential to
determine which of the following?
A- Population demographics
B- Customer needs
C- Performance standards
D- Effective managements
----------------------------------------------------------------------------------------------------------------------
6) Performance of RCA for a sentinel event provides all of the following except:

A- Identification of why the variance occurred

B- Recommendations for actions to prevent recurrence
C- Measurement strategies for each factor affecting the outcome
D- Continuous measurement to identify opportunities for
improvement
7) Which of the following is responsible for patient safety?
A- Senior leadership
B- Entire staff
C- Patient safety officer
D- Medical executive committee
----------------------------------------------------------------------------------------------------------------------
8- When considering the use of an external subject matter expert (SME), which of
the following is the characteristic most critical?
A- Leadership personal preference
B- Geographic location of the SME
C- Cost of SME service
D- References of the SME
----------------------------------------------------------------------------------------------------------------------
9- A health organization is becoming a member in a health plan. The most
important educative program to be delivered to the staff is
A- organizational change
B- conflict of interest
C- consumer needs
D- accreditation needs
----------------------------------------------------------------------------------------------------------------------
10- The best time for evaluating a quality improvement project is:
A- At the end of the project
B- Quarterly (quarter year)
C- Annually (calendar year)
----------------------------------------------------------------------------------------------------------------------
11- A policy for time-out in the OR was initiated in the first quarter. In the second
quarter the data has 40% compliance with all elements of the process. The first
step the quality council should take is to:
A-Examine if the policy is clear and user friendly
B- Ask the nurses to identify the non-compliant surgeons
C- Continue to audit to confirm that problems exist
D- Create a letter for CEO to send to all surgeons
----------------------------------------------------------------------------------------------------------------------
12- Effectiveness of performance improvement program best assessed by :
A) patient satisfaction
B ) staff competencies
C) guideline compliances
D) organizational culture
----------------------------------------------------------------------------------------------------------------------
13- Customer suggestions for new service are best used by the organization in
developing:
A- Staffing plan
B- Financial plan
C- Strategic plan
D- Performance improvement plan
----------------------------------------------------------------------------------------------------------------------

14- After significant unexpected event, an intensive analysis is performed to:

A. Understand the cause
B. Correct risk management data
C. Prevent the facility from law suit
D. Identify who made the error
----------------------------------------------------------------------------------------------------------------------
15-A credentialing committee has determined that a practitioner has significantly
higher rate of complications after surgeries than the practitioners peer. Which of
the following the committees do next?
A- Initiate a focused professional evaluation (FPPE).
B- Limit the practitioner’s current surgical privileges
C- Require the practitioner to attend continuing education
D- Continue ongoing professional practice evaluation
----------------------------------------------------------------------------------------------------------------------
16- The CEO has directed the quality improvement council to develop objectives to
meet an identified goal. When developing the objectives, the council should
remember to:
A- State the end result of that outcome
B- Keep the objective specific to the short term
C- Use the plan do check act (PDCA) for continuous improvement
D- Tie the objective to financial performance
----------------------------------------------------------------------------------------------------------------------
17- Decision by "consensus" means:
A- unanimous agreement
B- all support the decision
C- the agree of the majority
D- nobody agrees
----------------------------------------------------------------------------------------------------------------------
18- The best tool to begin investigate causes of laboratory labeling errors :
A- histogram
B- flowchart
C- affinity diagram
D- prioritization matrix
----------------------------------------------------------------------------------------------------------------------
19- Data gathering method includes all of the following except:
A- Measurement
B- Observation
C- Correlation
D- Interviewing
----------------------------------------------------------------------------------------------------------------------
20- One of the team members that keep members on track & focus on the process
is:
A- Leader
B- Facilitator
C- Time keeper
D- Recorder
----------------------------------------------------------------------------------------------------------------------

21- Once statistical control is established, the next step in continuous quality
improvement is to :
A. Slowly increase the rate of control monitoring
B. Rapidly increase the rate of control monitoring
C. Eliminate the need for rework
D. Improve the process by reducing variation
----------------------------------------------------------------------------------------------------------------------
22- For CQI to be successful who must be included in staff
A. administrator
B. person performing process(process owner)
C. quality management representative
D. department supervisor
----------------------------------------------------------------------------------------------------------------------
23- Asking your staff to recall an appropriate use of safety behavior ..... then
according to the Kirkpatrick's Four-Level of learning is it
1. Reaction level = happy or sad (satisfaction)
2. Learning level = gain in knowledge / skills
3. Behavior level = change in performance in practice
4. Result level = Impact on your organization
This is a change in behavior i.e. change in staff performance in practice

Ask staff recall of the appropriate use of safety behavior in which level:
A- Learning
B- Behavior
C- Reaction
D- Result
----------------------------------------------------------------------------------------------------------------------
24-A physician complain a nurse to quality manger that the nurse doesn’t do his
orders at time & ask him to tell the nurse manger. what should quality manger do
first for facilitating the communication ?
a- Tell the nurse manager as the physician asked.
b- Review the medical record for review eligibility
c- arrange meeting for physician & nurse manager
d- Tell the CEO
----------------------------------------------------------------------------------------------------------------------
25- Under conducting a sentinel event review, a RCA:
A- Provide judgment of staff behaviors
B- Requires team consensus
C- Identifies gaps in patient care processes
D- Proactively identifies causes & effects
----------------------------------------------------------------------------------------------------------------------
26-- The chief executive officer "CEO" of healthcare organization has requested a
recommendation for the most effective method of assessing the organization's
readiness to adopt CQI, which of the following methods should CPHQ recommend:
A- review aggregate results of employee performance appraisals
B- Hire a consultant to conduct personal interview of staff
C- Conduct leadership ''walk through'' of the organization
D- Administer surveys to evaluate organization culture
----------------------------------------------------------------------------------------------------------------------

27- Integration (link) between risk management and QM :

A- deal with attorney potentially compensable event
B- risk manager
C- prevent recurrence of occurrence
----------------------------------------------------------------------------------------------------------------------
28- In a large tertiary hospital, 10.3% of a general surgeon's cases in the last 3
months were associated with surgical site infections. The average surgical site
infection rate for the other general surgeon's was 4.8%. Working closely with the
Chief Medical Officer, the healthcare quality professional should :
A. compare the hospital's overall surgical site infection rate with local and national
data.
B. examine the surgeon's case-mix, risk-adjusted outcomes
and practice patternas
C. refer the surgeon's cases for peer review.
D. compare the surgeon's surgical site infection rate with that of surgeons in other
specialties
----------------------------------------------------------------------------------------------------------------------
29) to establish evidence based practice guideline, it is best to :
A. reply on subjective, expert opinion
B. review every possible intervention or treatment
C. include those who resist process
D. allow individual practitioner to make any exception to guideline
----------------------------------------------------------------------------------------------------------------------
30-Which of the following is the FIRST step in facilitating change in an
organization?
1. Review customer satisfaction surveys.
2. Get feedback from staff on the problems to be addressed.
3. Identify key people in the organization that should be involved.
4. Develop a performance improvement plan.
----------------------------------------------------------------------------------------------------------------------
31-Which of the following steps is most commonly omitted from the quality
assessment and improving?
A. Reporting results of studies in a timely manner.
B. Determining the effectiveness of actions taken
C. Defining criteria.
D. Delegating data collection activities
----------------------------------------------------------------------------------------------------------------------
32- A patient not given enough instruction on the care plan this is to be:
1. Transition care.
2. Case Management
3- medical coverage
4-reconciliation
----------------------------------------------------------------------------------------------------------------------
33- Continuous quality improvement efforts find problems in hospital admissions
to provide breakthrough ideas in admission, the quality improvement team seek
ideas from:
a-other hospital
B-previous lectures
C-automobile industry
d-hotel and resort industry
----------------------------------------------------------------------------------------------------------------------
34-A Performance improvement program for supervisors should include
A. Rapid cycle process
B. Results of FMEA
C. Budget variance reporting
D. Review of patient falls
----------------------------------------------------------------------------------------------------------------------
35- The consensus- building group of diverse stakeholders who reviews and
endorses measures for public reporting in the U.S is known as the :
A. Institute is medicine (IOM)
B. Agency for health care quality and research(AHRQ)
C. Center for Medicare and Medicaid services(CMS)
D. National quality forum(NQF)
----------------------------------------------------------------------------------------------------------------------
36- after PI team finish the program who will submit results to the GB
A. team leader
B. facilitator
C. recorder
D. any member
----------------------------------------------------------------------------------------------------------------------
37- Which of the following is the best example of applying cultural diversity
principle to patient safety?
A. Allowing parents to perform rituals for their ill child
B. Providing interpretive service to explain medical
procedures
C. Having the nutritionist discussion dietary preferences with the patients
D. Performing mandatory training on culture diversity for staff
----------------------------------------------------------------------------------------------------------------------
38- which of the following is the primary benefit of using external quality
consultants :
A. Bridging knowledge gaps.
B. clarifying mission and vision of the organization
C. Promoting effective communication.
D. Maintaining performance standards for the organization
---------------------------------------------------------------------------------------------------------------------
39-what is the highest weighted mean
a) mean 3 weighted mean 3.4>>>>( 3*3.4=10.2 )
b) mean 9 weighted mean 6.5>>>> ( 9*6.5=58.5 )
c) mean 6 weighted mean 9.2>>>> ( 6*9.2 =55.2 )
d) mean 2 weighted mean 2.3>>>> ( 2*2.3 = 4.6 )
or
Customer gives score to the criteria , What's the highest weight mean score :
(Exam)
Score mean - score weight
A- 3 - 0.9 (3x0.9 ) = 2.7
B- 4 - 0.8 (4x0.8) = 3.2
C- 5 - 0.7 (5x0.7 ) = 3.5
D- 6 - 0.3 (6x0.3 ) = 1.8
---------------------------------------------------------------------------------------------------------------------
40- After in-depth data analysis, there is evidence of over utilization of
computerized tomography to diagnose acute appendicitis. A team has been
formed to develop a performance improvement plan for emergency department
physicians. Which of the following leadership style is most effective to implement
best practice guidelines?
A. Laissez faire
B. Democratic
C. Participatory
D. Autocratic
---------------------------------------------------------------------------------------------------------------------
41- If the organization is committed to patient safety, the most important process is
A. allocating the financial resources to promote Quality activities.
B. establishing an anonymous reporting system for safety issues.
C. integrating patient safety findings into governance and
management activities.
D. delegating administrative responsibility to the evaluation team
---------------------------------------------------------------------------------------------------------------------
42-Patient safety officer developing safety plan and the following information was
provided:
- incident report data ,
-performance indicator ,
-customer complain data
- which of the following addition data need to write the safety plan :
A. Physician satisfaction and financial goals
B. Staff satisfaction and root cause analysis
C. Infection control data and accreditation result
D.The facility risk assessment and strategic goal
---------------------------------------------------------------------------------------------------------------------
43- how to link CQI activities to strategic goals?
open , communication
monitor indicators on goals
---------------------------------------------------------------------------------------------------------------------
44- If leadership is the critical success factor for an effective patient safety
program, what is the first key responsibility of leaders?
a. Provide resources.
b. Set strategic goals.
c. Establish the value system.
d. Designate a champion.
---------------------------------------------------------------------------------------------------------------------
45- A nurse receives a verbal order for medication from physician, the nurse
should :
A. Ask the medication from pharmacists
B. Neglect the order
C. Read the order back
D. Write and tell the order
---------------------------------------------------------------------------------------------------------------------
46- a hospital develop a software to help in define problem ,what from this choices
,we should mark the trigger as zero :
a-physician not comply to hand wash hygiene
b- not complete medical record
c-near miss error
d- d-threats of suicide
---------------------------------------------------------------------------------------------------------------------

47- A patient complain that there are an error in writing the bill , because two out of
three days of her stay in hospital due to her drug reaction, HQP should consider
that :
A-billing error
B-medication error
c- Unexpected adverse occurrence
d- admission error
---------------------------------------------------------------------------------------------------------------------
48-Pt complain foreign object ,when counting the instrument there is missed
instrument , when perform x-ray per policy there is nothing, after surgery it was
discovered :
A- Apologize to pt and family and reduce the cost of treatment
B- Review why the x-ray don’t visualize the object
---------------------------------------------------------------------------------------------------------------------
49- The best tool to begin investigate causes of laboratory labeling errors :
A. histogram
B. flowchart
C. affinity diagram
D. prioritization matrix
---------------------------------------------------------------------------------------------------------------------
50- A health care quality professional is attempting to refine the differences
between an organizations objective and the stakeholder needs. Which of the
following tools is most appropriate?
A. Kanab method
B. Gantt chart
C. Ishikawa diagram
D. Gap analysis
---------------------------------------------------------------------------------------------------------------------
51- LEAN rapid improvement :
kaizen
kanban
pokayoka
six sigma
---------------------------------------------------------------------------------------------------------------------
52- the main goal of patient safety is:
1-reduce financial loss
2- harm prevention for patients, visitors, staff
---------------------------------------------------------------------------------------------------------------------
53- To collect (qualitative) data :
A- Focus group
B- score questionnaire
C- Survey
---------------------------------------------------------------------------------------------------------------------

54-Even when appropriate processes are in place, (errors can occur).

Understanding this, Leader coordinating a patient safety program should focus on:
A- Patient surveys
B-Time constrains
C- Policies
D- Performance feedback
---------------------------------------------------------------------------------------------------------------------
55-Which of the following is true regarding medical errors :
A- prevented by review of evidence based practice
B- caused by gaps between patient expectation & practice
C- avoided by uniform practice
D- associated with process failures
---------------------------------------------------------------------------------------------------------------------
56- GRAPHS differs from narrative data, because it can demonstrate,
a.trend
b.analysis
---------------------------------------------------------------------------------------------------------------------
57-An important reason for monitoring near misses is to
A. Prevent negative publicity
B. Identify incompetent staff
C. Provide lessons to the staff
D. Support disciplinary action
---------------------------------------------------------------------------------------------------------------------
58-The role of a team facilitator is to focus on
A. Analyzing problems during meetings
B. The process
C. Generating and selecting solutions
D. The content
---------------------------------------------------------------------------------------------------------------------
59-For a reappointment process for surgeons, physicians-specific data has been
provided on the total number of admissions, procedures and discharges. Which of
the following additional information will be most useful in making the
reappointment decision
A. Wound infection rate, surgical complication rate, and
summary of peer review
B. Number of sentinel event, adverse drug reaction rate, & healthcare acquired
infection rate
C. Transfusion reaction rate, surgical complication rate, & adverse drug reaction
rate
D. Summary of peer review, transfusion reaction, & healthcare acquired infection
rate
---------------------------------------------------------------------------------------------------------------------
60-Traditionally, nursing staff has attributed increased medication error to short
staffing. following a quality improvement team evaluation of the medication
administration process, the most frequent causes of a wrong drug administration
was determined to be look alike packaging .staff acceptance of the finding an
example of a shift in
A. a paragon
B. paradox
C. primary memory
D. paradigm
---------------------------------------------------------------------------------------------------------------------

61-You are working as the hospital quality healthcare professional, a person came
to your office to monitor selected quality issues in your facility. What is the most
appropriate FIRST question you may address to that person :

A-Which area of compliance would you like to review.

B-Let us sit to schedule for your visits.
C-Can I see your ID please
---------------------------------------------------------------------------------------------------------------------
62-T-test used in :
A- difference between sample size variance
B- difference between occurrence of variables
C- difference between effect of two treatments
D- significance of treatment
---------------------------------------------------------------------------------------------------------------------
63) When review clinical competency of surgeon at the time of reappointment
A- group interview with practitioners
B- interview with the practitioner
C- quality professional review credential file
D- chief of surgery department review credential file
---------------------------------------------------------------------------------------------------------------------
64- A poster contain information will most effectively convey outcome information
to internal customers?

A- 2 Bar graphs showing the 2 unites with fewest number of falls over past year
B- (Patient fall decreased over 4 years) printed above a line graph showing
percentage of falls to patient days
C- Patient fall indicate downward trend. Go for team!
D- (Patient fall last year were 0.5% of patient days) printed to photograph of the
organization staff
---------------------------------------------------------------------------------------------------------------------
65-Which of the following is most useful in performing a morbidity/mortality review
A- nosocomial infection rate + preoperative mortality
B- inpatient mortality + admission
C- planned admission + …..
---------------------------------------------------------------------------------------------------------------------
66) Circular shape of data on scatter diagram indicate :
A- positive linear relationship
B- negative linear relationship
C- no relationship between the two variables
---------------------------------------------------------------------------------------------------------------------
67) upper control limit and lower of control chart detected by :
a-the actual performance of the process
b-what you want in future
c-external standard
---------------------------------------------------------------------------------------------------------------------

68) A source of infection was identified in the kitchens (a knife) and an

improvement plan was implemented in the kitchen to decrease infection but after 1
week it is not used . what is the 1st thing to do :
A- perform root cause analysis
B- detect (remove) the barriers for implementation
C- continuous review of the program
---------------------------------------------------------------------------------------------------------------------
69- To best evaluate Training:
A- patient satisfaction
B- staff competency
---------------------------------------------------------------------------------------------------------------------
70- The best the description of strategic plan :
A- organization vision
B- organization direction
---------------------------------------------------------------------------------------------------------------------
71-Patient refused to bill after surgery because of postoperative infection, This
infection is:
A- co-morbidities
B- complication
---------------------------------------------------------------------------------------------------------------------
72- Data over time best demonstrated in :
A- line (or Run chart "better" or Control chart "best")
B- pie
C- scatter diagram
---------------------------------------------------------------------------------------------------------------------
73 -Best disseminate quality in the org. :
A- Q. team
B- Senior leader
C- Quality professional
---------------------------------------------------------------------------------------------------------------------
74- The first thing in stratification random sample :
A- predetermined homogenous group traits
B- Choose clusters
---------------------------------------------------------------------------------------------------------------------
75-Dissemination of behavior pattern information with who affect the behavior of
the practitioner:
A. governing board
B. QM committee
C. practitioners
D. administration
-------------------------------------------------------------------------------------------------------------------
76- Physician profiling is reviewed at time of reappointment to:
Ensure practitioner competency
Compare practitioner to peers
Review number of complaints
-------------------------------------------------------------------------------------------------------------------
77) Customer survey give score of (1-5)(1 dissatisfaction & 5 very satisfied) found that
customer satisfaction of pain management .The benchmarking score is 3.2, what the QHP
do:
Design full pain management program
Educate pain management all over the organization
Link with medicine department
-------------------------------------------------------------------------------------------------------------------
78-Increase aggressive behavior of patient toward the staff in (a department) , what is the
appropriate action :
Focus group with the staff about that
Review restrain policy
-------------------------------------------------------------------------------------------------------------------
79- the purpose of ANALYSIS is…..
Identify problems to be improved
Differentiate between internal & external problems
-------------------------------------------------------------------------------------------------------------------
80- before peer review, data of LIPs, must be…
risk adjusted for severity of illness
-------------------------------------------------------------------------------------------------------------------
81- Facilitating a team in improvement of care level of health/ cognitive statue
quality facilitator should :
a. have knowledge in care levels
b. have knowledge in health and cognitive status
c. moderate group
-------------------------------------------------------------------------------------------------------------------
82-the not tangible result of risk management OR patient safety
A-peace that nothing harm me
B- Prevention of harm & injuries
-------------------------------------------------------------------------------------------------------------------
83-effective performance improvement results in:
Staff satisfaction, effective outcome, patient expectations are met
-------------------------------------------------------------------------------------------------------------------
84- to solve problem of in appropriate blood use in emergency:
inservice on emergency physicians
design procurmy program
-------------------------------------------------------------------------------------------------------------------
85) When 2 facilities have a network, what it is the most cost effective issue
increases the patient satisfaction of the services ?
a. when the patient don't have to repeat investigations in
other facility(duplication of efforts)
b. when his satisfaction survey results are collected from both facilities on the fly
c. when both facilities have equal staff competencies
d. when the network allow doctors to communicate through the internet
-------------------------------------------------------------------------------------------------------------------
86-before implementation patient safety program - to evaluate the culture
you can ask the following question:
A-if there were new nosocomial infection in the operating
room, yesterday
B-who made the last medical error
-------------------------------------------------------------------------------------------------------------------
87- patient death resulting from the nurse give him intravascular dose which was
for orally use only when RCA take place we knew that, there is nurse staff
shortening, so the nurse confused, so she used the oral dose for iv for the died
patient. what is our action, to solve this problem
labeling & writing on the syringes, ONLY FOR ORAL USE.
increase number of nurses
-------------------------------------------------------------------------------------------------------------------
88-Deploying a CQI team would be first approach in addressing which
A-Several patient complained their call lights not answered
during night shifts
B-Several physicians don't allocate enough time for procedures which booking
surgical cases
C- Finance billing outpatient procedures as ambulatory surgery
D- Results of preadmission testing for inpatient survey are unavailable 35% of time
causing delays
-------------------------------------------------------------------------------------------------------------------
89-An organization has established a culture of patient safety when
a- Reports of potential errors have decreased
b- Patient safety goals are implemented
c- Employee education is completed
d- Fear of retaliation is eliminated
-------------------------------------------------------------------------------------------------------------------
90-A trend analysis of incidents occurring in a healthcare facility should focus on
which of the following areas?
A. Case mix index and staffing patterns
B. Practitioner profile and diagnostic codes
C.Severity level and occurrence types
D. Timeliness of reporting and data accuracy
-------------------------------------------------------------------------------------------------------------------
91- A balanced score card for an organization is best described as
a- A graphic display of departmental performance
b- An integrated report showing the best performing teams
c- A representation of key performance indicators
d- A tool to reflect the priorities of the organization customers
-------------------------------------------------------------------------------------------------------------------
92- In a medical group of 70 physicians, there were 10000 patients in 4th quarter of
last year with 100 complaints, the 4th quarter of this year there were 60000 patients
with 360 complaints. The quality improvement team target was 5 complaints per
1000 patient. By analyzing these coordinates, what will be found?

A. The rate decreased and the goal is not reached.

B. The rate increased and the goal is reached
C. The rate decreased and the goal is already reached.
D. The rate increased and the goal is not reached
-------------------------------------------------------------------------------------------------------------------

93- Performance improvement plan (Order or Arrange) :

1-Gathering baseline data
2-Evaluate effectiveness & improvement
3-Make commitment
4-Implementation

A- 2- 1- 3 -4
B- 3-1- 4- 2
C- 1 – 2- 3 -4
D- 3 -4 -1 -2
-------------------------------------------------------------------------------------------------------------------
94- An organization leader has directed a Healthcare Quality Professional to
measure the success of a corrective action plan on patient care planning. The
organization leader wants to be at least 95 % confident of the accuracy of results.
The average daily census at the organization is 1000 patients. The most accurate &
efficient sampling technique for this study would be:
A- Review 100% of all active records on one day of past month
B-review 10% of all discharge records for the past quarter
C-estimate the percentage of records to be reviewed using an
accepted statistical formula appropriate for the population
D- Identify 30% of all records that failed preliminary care plan compliance review
-------------------------------------------------------------------------------------------------------------------
95- Healthcare quality professional has written patient safety plan that includes:
purpose, goals, objectives (scope & processes) . A review of outcomes data has
been completed, which of the following additional information should be in the
plan :

A- Disaster preparedness
B- Steps to improve patient satisfaction
C- Equipment management
D- Efforts to reduce harm
-------------------------------------------------------------------------------------------------------------------
96- Which of the following are attributes to culture of safety?
A- Transparency & increased patient acuity level
B- Error –proof environment & empowered staff
C- Empowered staff & transparency
D- Increased patient acuity level & error-proof environment
-------------------------------------------------------------------------------------------------------------------
97- Which Best enhance patient safety program
Online Staff survey
Barcode on supplies
Video patient monitoring
Electronic medical record
-------------------------------------------------------------------------------------------------------------------
98- Generic screening is a type of risk:
Identification
Evaluation
Reduction
Intervention
-------------------------------------------------------------------------------------------------------------------

99- The paradigm shift is:

A. change the reframe of thinking

B. improve the monitoring measures
C. increase the standards
D. use the recent in medicine and technologies
-------------------------------------------------------------------
100- To improve the effectiveness of the team u should include:
facilitator and recorder
delegate tasks
empower and training
-------------------------------------------------------------------------------------------------------------------
101- Of the followings NOT example for sentinel event :
A. PT attempt suicide
B. hemolytic TRANSFUSION reaction of blood
C. death of patient due to medication error
D. surgery on wrong part of the body (or right leg instead of left)
-------------------------------------------------------------------------------------------------------------------

102- When team of CQI formed to discuss restrain started to discuss claim issues
about the patient, the facilitator should
A. Redirect the group
B. Review ground rounds
C. Ask for the risk manager
-------------------------------------------------------------------------------------------------------------------
103- MEDIAN of 1,1,1,1,1,2,5,7,8,9
A-1
B-1.5
C-2
D-18
-------------------------------------------------------------------------------------------------------------------
104- primary function of rapid response team is
A. prevent and manage crisis in the emergency room
B. early intervention when patient condition change
C. manage critical patient conditions
-------------------------------------------------------------------------------------------------------------------
105- Where should the surgical "time out" for a total knee replacement occur?
Med/Surg unit
Preoperative holding area
Operating room
Post anesthesia care unit
-------------------------------------------------------------------------------------------------------------------
106- Which of the following tools is most appropriate for investigating the
relationship between two characteristics?
A. Scatter plot
B. Cause-and-effect diagram
C. Failure modes and effects analysis
D. Pareto chart
-------------------------------------------------------------------------------------------------------------------

107- FMEA uses which type of review?

Proactive
Retrospective
Concurrent
Recurrent
-------------------------------------------------------------------------------------------------------------------
108- cohesion will be which stage of team building
Forming
Storming
Norming
Performing
-------------------------------------------------------------------------------------------------------------------
109- Which of the following should be reported in occurrence report and shouldn`t
be included in the medical record of the patient:
Patient found on the floor with his left leg appearing to be rotated
Right knee surgery though intended is the left one
wrong dose of the intended drug
Wrong drug but recognized before the patient administration
-------------------------------------------------------------------------------------------------------------------
110- After brainstorming , which of the following should a quality improvement
team use to identify items that need immediate attention?
Cost – benefit analysis
Multi voting
Flow chart
Histogram
-------------------------------------------------------------------------------------------------------------------
111- What does AHRQ maintain
A. Accreditation
B. Clearinghouse for evidence based guidelines
-------------------------------------------------------------------------------------------------------------------
112- Which is best to do during the accreditation survey:
A. To assign a team to answer the questions asked by surveyors
B. To have a departmental director who know 3 standards about their concerned
departments
C. To educate all staff members the FAQs by the surveyors
-------------------------------------------------------------------------------------------------------------------
113- Measures of central tendency include mean and:
A. Median & mode
-------------------------------------------------------------------------------------------------------------------
114- The best tool to display stability of nosocomial infection rates over time is a
a- Run chart
b- Control chart
c- Histogram
d- Pareto chart

-------------------------------------------------------------------------------------------------------------------
115- Which one should be included when reporting PI to GB:
Team achievements
-------------------------------------------------------------------------------------------------------------------
116- Team building goals for the first meeting should include all of the following
except
A. Learning to work as a team.
B. Evaluating the project
C. Setting meeting ground rules
D. Getting to know one another
-------------------------------------------------------------------------------------------------------------------
117- Which is best solved by quality team:
A. System problem
B. Customer complains
C. Financial problem
D. Administrative problem
-------------------------------------------------------------------------------------------------------------------
118- QI program start on reality when{ different options}
a-the staff believe it is desired
b-staff be owners and start to participate
-------------------------------------------------------------------------------------------------------------------
119- The pharmacy unit reported that there is an increase in the use of expensive
drug ,as a quality professional, you should review:
A-effectiveness and efficiency of the drug
B-The process of prescribing and dispensing of this drug
C- Share data with peer from prescribing physician
-------------------------------------------------------------------------------------------------------------------
120-Pharmacy staff was informed health care professional that use expensive
drug has been increased over the last six month , which of the following would be
health care professional next step :
a. Collect data related to striating and monitoring the effective of the drug
b. Collect data related to the prescribing and dispensing
patterns of drug
c. Continue monitoring the pharmacy data and addition six month
d. Recommended to review of prescribing of Practitioner

-------------------------------------------------------------------------------------------------------------------
121- The best way to evaluate any team is by:
A. Learning and innovation
B. Quantifiable objectives
C. Members Satisfaction
D. Aligning the vision of the organization
-------------------------------------------------------------------------------------------------------------------
122-Which of the following should be reported in occurrence report and shouldn`t
be included in the medical record of the patient:
A- Patient found on the floor with his left leg appearing to be rotated
B- Right knee surgery though intended is the left one
C- wrong dose of the intended drug
D- Wrong drug but recognized before the patient
administration(near miss)
-------------------------------------------------------------------------------------------------------------------

123- As a quality manager to evaluate the effectiveness of dietary department you

review
A. The timeliness of diets delivered after physician orders
B. The appropriateness of the nurses' request to diet
C. The delivery of special diets ordered by physicians
D. Complication of the whole parental diet
-------------------------------------------------------------------------------------------------------------------
124- Which of the following are attributes to culture of safety?
A- Transparency & increased patient acuity level
B- Error –proof environment & empowered staff
C- Empowered staff & transparency
D- Increased patient acuity level & error-proof environment
-------------------------------------------------------------------------------------------------------------------
125- In any quality management approach, how can you best evaluate the
effectiveness of action taken?
a. Use the same performance measures to remonitor the
process.
b. Formulate a new special study to monitor the action.
c. Interview the staff involved in implementing the action plan.
d. Do nothing. Effectiveness is expected with well-planned action
-------------------------------------------------------------------------------------------------------------------
126- Conclusions in a statistical study are generalized to the
a- Sample
b- Mean
c- Subject
d- Population
-------------------------------------------------------------------------------------------------------------------
127- The responsibility for providing organizational direction for a facility
continuous quality improvement program frequently rests with the quality
a- Council
b- Teams
c- Leader
d- Facilitator
-------------------------------------------------------------------------------------------------------------------
128- Once statistical control is established, the next step in continuous quality
improvement is to
A. Slowly increase the rate of control monitoring
B. Rapidly increase the rate of control monitoring
C. Eliminate the need for rework
D. Improve the process by reducing variation
-------------------------------------------------------------------------------------------------------------------
129- A medication error is regarded as
A. Malpractice.
B. Purposeful.
C. Negligence.
D. Normal
-------------------------------------------------------------------------------------------------------------------

130- Patient safety is promoted in an organization through:

a) Willingness to pay overtime, open communication, and staff education
b) Reliable systems, open communication, and performance reviews
c) Encouragement to report errors, staff education, and
reliable systems
d) Performance reviews, encouragement to report errors, and willingness to pay
overtimes
-------------------------------------------------------------------------------------------------------------------
131- an organization that is committed to a culture of team-work, collaboration, and
adaptability is referred to as having
A. A learning culture
B. An open culture
C. A just culture
D. A reporting culture.
-------------------------------------------------------------------------------------------------------------------
132- The CEO has directed the quality improvement council to develop objectives
to meet an identified goal. When developing the objectives, the council should
remember to:
A-State the end result of that outcome
B- Keep the objective specific to the short term
C- Use the plan do check act (PDCA) for continuous improvement
D- Tie the objective to financial performance
-------------------------------------------------------------------------------------------------------------------
133- An effective risk-management program for a health care organization
emphasizes :
A. Harm prevention for patients, visitors, and staff
B. Reduction of financial losses
C. Staff training and education
D. Compliance with accrediting agency standards
-------------------------------------------------------------------------------------------------------------------
134- The consensus- building group of diverse stakeholders who reviews and
endorses measures for public reporting in the U.S is known as the
A. Institute is medicine (IOM)
B. Agency for health care quality and research(AHRQ)
C. Center for medicare and Medicaid services(CMS)
D. National quality forum(NQF)
-------------------------------------------------------------------------------------------------------------------
135- For a reappointment process for surgeons, physicians-specific data has been
provided on the total number of admissions, procedures and discharges. Which of
the following additional information will be most useful in making the
reappointment decision
A. Wound infection rate, surgical complication rate, and
summary of peer review
B. Number of sentinel event, adverse drug reaction rate, & healthcare acquired
infection rate
C. Transfusion reaction rate, surgical complication rate, & adverse drug reaction
rate
D. Summary of peer review, transfusion reaction, & healthcare acquired infection
rate
-------------------------------------------------------------------------------------------------------------------

136- A continuous quality improvement team has proposed a major change in the
billing process for home health service. Staff acceptance of the change is best
facilitated by :
A. Immediate implementation
B. Medical staff education
C. Long-range planning
D. A pilot project
-------------------------------------------------------------------------------------------------------------------
137- Responsibility of quality improvement teams include all of the following
except :
a- Defining the roles and duties of the members
b- Communicating results
c- Setting goals and timetable for the steps of the process
d- Establishing the need for the team
-------------------------------------------------------------------------------------------------------------------

138-Validity of measures is defined as:

A-Repeated measuring leads to the same results
B-Low in cost
C-Well understood
D-Measure what's intended to measure
-------------------------------------------------------------------------------------------------------------------
139-Integration of quality culture within an organization is best demonstrated by :
a) Leadership rounds, increase staff satisfaction, and positive
patient outcome
b) Physician competence, staff longevity, and high patient satisfaction scores
c) Mission and vision statements, high patient census, and government body
involvement
d) Reduce adverse outcome, culture of patient safety, and expansion of services

-------------------------------------------------------------------------------------------------------------------
140- Which of the following could be used as an outcome measure during
indicator development ?
a) Staff adherence to a standard of practice
b) Compliance rate for specific surgical procedure
c) Required diagnostic testing performed before medication was prescribed
d) Laboratory compliance with policy and procedure for drawing peak and through
levels

-------------------------------------------------------------------------------------------------------------------

141- Conclusions in a statistical study are generalized to the :

a- Sample
b- Mean
c- Subject
d- Population
-------------------------------------------------------------------------------------------------------------------

142- A Performance improvement program for supervisors should include

A- Rapid cycle process
B- Results of FMEA
C- Budget variance reporting
D- Review of patient falls

-------------------------------------------------------------------------------------------------------------------
143- An ambulatory outpatient care facility identifies an opportunity to improve the
turnaround time for reports of x-rays performed at a local hospital . which of the
following groups should be involved in the team to improve the process?
a- Primary care physician , clinic nurse and clinic administrator
b- Radiologist, primary care physician, and clinical medical record
c- Clerical, clinical , and administrative staff from both
facilities
d- Administrative representation from both facilities

-------------------------------------------------------------------------------------------------------------------

144- a large facility has fostered a culture of patient safety through staff education ,
support of process improvement ,department levels of implementation of non-
punitive approach to error reporting compliance with patient safety goals ranges
from 75-100% in assessing culture of patient safety cphq should:
a-survey of all employee &physician
b-survey patient last 6 months
c-review collected data through incident reporting
d-review postsurgical infection rate data
-------------------------------------------------------------------------------------------------------------------

145- BCMA eliminate errors in:(BCMA : Bar Code Medication Administration)

A- administration
B- dispensing
-------------------------------------------------------------------------------------------------------------------

146- A radiology department regularly monitors x-ray repeat/reject, timeliness of

report dictation, and patient waiting times. What component is missing in this
department's ongoing evaluation program
a. Appropriateness review.
b. Process evaluation.
c. Quality control.
d. Documentation analysis

-------------------------------------------------------------------------------------------------------------------

147- Patient safety program must include all of the following, but the most crucial
is:
a. Identified individual or group to manage the program.
b. Defined mechanisms for support of staff responsible for the occurrence of a
sentinel event.
c. Proactive risk reduction activities.
d. Reporting mechanism
-------------------------------------------------------------------------------------------------------------------
148- To insure that medication administration more safe, the steps of
administration should be :
A. More complex
B. More branched
C. More simple
D. More dependent on experience of staff
-------------------------------------------------------------------------------------------------------------------

149- Which of the following statements best defines a quality problem?

A. The gap between what is and what is expected by the customer.
B. The gap between what is and what is desired by the
organization.
C. The gap between what is and what is the benchmark.
D. The gap between what is and what is expected by accreditation bodies.

-------------------------------------------------------------------------------------------------------------------

150- Which of the following topics should be discussed a morbidity\mortality

conference?
a. number of nosocomial infections
b. patient morbidity at the time of admission
c. preoperative morbidity
d. number of admissions
-------------------------------------------------------------------------------------------------------------------
151- Situation- Background- Assessment- Recommendation(SBAR) is a :
a- Six sigma methodology
b- Method that measures process variation
c- Tools to improve communication caregivers
d- Software package used in quality improvement
-------------------------------------------------------------------------------------------------------------------

152- A small rural hospital wishes to evaluate customer satisfaction using a survey
. the organization has four patient care units, emergency department and
Ambulatory unit. Which of the following survey methods provides the most reliable
information?
a- A random sample of 5% of all annual discharges/visits
b- A random sample of 20% of annual discharges/visits per
unit
c- All discharges/visits of customers with a last name beginning with the letters
A-E
d- All discharges/visits in January and July
-------------------------------------------------------------------------------------------------------------------
153- The following patient safety data were obtained for a facility :
Wrong dose Wrong patient Wrong medication
ER 1 4 2
ICU 3 0 6
Medical unit 2 3 4
Surgical unit 3 6 0
Which of the following more likely used only one patient identifier?
a- Surgical unit
b- ICU
c- ER
d- Medical unit

-------------------------------------------------------------------------------------------------------------------
154- LEAN rapid improvement
kaizen
kanban
poka yoke
six sigma

-------------------------------------------------------------------------------------------------------------------
155- The best way to facilitate change within a healthcare organization is to

A. communicate through group meetings.

B. arrange presentations by senior leaders.
C. communicate through group e-mail.
D. involve the individuals directly affected by the change.
-------------------------------------------------------------------------------------------------------------------
156- In the following, "reviews" refers to utilization reviews, "FTE" refer to full time
equivalent employee, and "#" refers to the number. Consider the following
productivity data:
month # reviews/month # reviews/day # of files # reviews/FTE
JANUARY 6000 273 31 8.8
FEBRUARY 6600 330 33 10.0
MARCH 6888 313 31 10.1
APRIL 7322 333 32 10.4
MAY 8000 364 31 11.7
What is the approximate percentage of increase in productivity from January to
May ?
a- 1%
b- 3%
c- 20%
d- 33%
-------------------------------------------------------------------------------------------------------------------
157-A healthcare organization's strategic plan includes, as one of its objectives, a
customer satisfaction rating of at least 85% in each unit. The overall customer
satisfaction rating for the past quarter in 3 units are shown below.

Unit A — 88%
Unit B — 80%
Unit C — 62%
Which of the following should the quality professional recommend?

A- Provide incentives to the staff of Unit B and Unit C

B- Share Unit A's practices with the other units
C- Review the performance of the manager of Unit C
D- Change the target for customer satisfaction rating to 90%
-------------------------------------------------------------------------------------------------------------------

158- A curriculum developed by healthcare organization for staff education in

organizational change should include all of the following except:
a- Project and time management
b- The negotiating process.
c- Budgeting techniques.
d- Conflict resolution.
-------------------------------------------------------------------------------------------------------------------
159- The following information about falls is obtained from a facility with units that
have similar average daily census:
Unit A – 6%
Unit B -4%
UNIT C- 9%
Unit D- 8%
What additional information is most important to evaluate the cause of the falls?
a- Time of day
b- Compliance with fall protocol
c- Number of fall
d- Medication education
-------------------------------------------------------------------------------------------------------------------

160- When 2 facilities have a network, what is the most cost effective issue
increases the patient satisfaction of the services
A. When the patient don't have to repeat investigations in
other facility (remove duplication of efforts)
B. When his satisfaction survey results are collected from both facilities on the
fly
C. When both facilities have equal staff competencies
D. When the network allows doctors to communicate through the internet

-------------------------------------------------------------------------------------------------------------------
161- Which of the following can demonstrate multiple aspects of a practitioners
practice as required for renewal of clinical privileges?
a- Credentialing
b- Peer review
c- Privilege delineation
d- Practitioner profile
-------------------------------------------------------------------------------------------------------------------
162- Organizational leaders can best demonstrate commitment to a new quality
improvement initiative by
a- Offering solution to identified problems
b- Maintain performance appraisals for staff
c- Allocate resource for the process
d- Reviewing the quality improvement plan
-------------------------------------------------------------------------------------------------------------------

163- The responsibility for providing organizational direction for a facility

continuous quality improvement program frequently rests with the quality
a- Council
b- Teams
c- Leader
d- Facilitator
-------------------------------------------------------------------------------------------------------------------
164- An organization has established a culture of patient safety when :
a- Reports of potential errors have decreased
b- Patient safety goals are implemented
c- Employee education is completed
d- Fear of retaliation is eliminated
-------------------------------------------------------------------------------------------------------------------
165- A quality improvement manager received the results from the most recent
customer survey. Sixty percent of the residents in the nursing home have rated the
temperature of foods served as poor. Which of the following actions should be
taken first?
a- Call the dietitian and ask for an explanation
b- Set up a continuous monitor for review
c- Ignore the results and assess next quarter
d- Review previous results and assess tend

-------------------------------------------------------------------------------------------------------------------
166- A large facility has fostered a culture of patient safety through staff education,
support of process improvements at department level, and implementation of a
non -punitive approach to error reporting, compliance with patient safety goals
range from 75-100%. in assessing the culture of patient safety , the healthcare
quality professional should :
a- Survey patients from the last 6 months
b- Survey all employees and physicians
c- Review post-surgical infection rate data
d- Review data collected through incident reports
-------------------------------------------------------------------------------------------------------------------
167- The prevalence rate of a disease depend on the
a- Number of new cases and the population at risk
b- Incident rate and duration of the disease
c- Incident and change in the balance of etiological factors
d- Total number of cases and the population at risk
-------------------------------------------------------------------------------------------------------------------

177- The team approach in quality improvement activities is preferred when

a- Financial resources are scarce
b- The solution is evident
c- Data management is required
d- The process has many owner (or need diverse expertise)
-------------------------------------------------------------------------------------------------------------------
178- The medical record manager reports that authentication of verbal orders
occurs 25% of the time , as compared to a reported 85% in situations ,which of the
following is the initial action for the manager to take ?
A- Recommend continued measurement of the indicator.
B- Share the data with the medical staff
C- Organize a PI team
D- Recommend improvement strategies
-------------------------------------------------------------------------------------------------------------------
179- A health organization is becoming a member in a health plan. The most
important educative program to be delivered to the staff is :
a. organizational change
b. conflict of interest
c. consumer needs
d. accreditation needs
-------------------------------------------------------------------------------------------------------------------
180- When a surveyor reached for regulatory visit, the first question that the quality
professional will ask for is
A-Please let me see your identification.
B-Let us sit to schedule for your visits.
c-Which area of compliance would you like to review.
-------------------------------------------------------------------------------------------------------------------
181- When considering the use of an external consultant, which of the following
characteristics is most be evaluated:
A. Cost of consultant's services .
B. Geographic location of the consultant.
C. Leadership's personal preference.
D. References of the consultant(expertise & relationships)
-------------------------------------------------------------------------------------------------------------------
182- Even when appropriate process are in place, error can occur, understanding
this, leader coordinating any safety program should focus on:
a-patient survey
b-time constrain
c-policies
d-performance feed back
-------------------------------------------------------------------------------------------------------------------
183- After the team action the plan and implement it ,and analyze data shows not
reaching the target ,what is the next step on PDCA cycle is now should follow;
A- plan
B- do
C- Check
D- Act
-------------------------------------------------------------------------------------------------------------------
 184- Options of new service:

Options of new service BENEFITES (10) High cost( xxxx) Change implement $$$$
LESS BENEFITS (1) Low cost (x) Less change implement $

A 10 XXXX $$$$

B 8 XX $$$

C 5 X $$

which service do you advice to implement A ,B,C ?

answer: B (I think due to .. B=(8-2-3)=3 --- A=(10-4-4)=2 --- C=(5-1-3)=1)

NOT SURE ABOUT THIS QUESTION

-------------------------------------------------------------------------------------------------------------------

185

Answer C ( Problems associated with treatment, Pareto chart)

**2nd q: What is the rate of problems in March:

a-1%
b-2%
c-18%
d-20%
% of problems in march = ( Problems associated with treatment in march ) +
( Problems associated with history and physical in march ) + ( Misinterpreted x-
rays in march ) all divided by Charts reviewed for quality in march , % of
problems in march = ( 19 + 4 +8 ) / 1350 * 100 approximately equal 2%
 **3rd q: What is the additional information to be added to the report:

a-No. of incomplete medical record

b-No. of x-ray done
c-No. of inappropriate admission
d-TAT of lab

we measure the misinterpreted x-rays .. so, we need the whole no. of x-rays

-------------------------------------------------------------------------------------------------------------------

186- After surveying the patients for communication, comfort, convenience, caring
& cost...which of the following statements is true:

A-patients are dissatisfied with cost & most satisfied with Communication
B-patients are dissatisfied with cost & most satisfied with
Caring
-------------------------------------------------------------------------------------------------------------------
187- Complaint analysis is most useful identifying which of the following?
A. Adherence to standards
B. Quality of the services rendered
C. Competence of personnel
D. Customer expectations
-------------------------------------------------------------------------------------------------------------------
188- One way to measure clinical outcomes is through
A. Aggregate data review
B. Pareto charts
C. Pre-admission review
D. The number of healthcare contracts
-------------------------------------------------------------------------------------------------------------------

189- stratified sample :

a- geographical cluster
b- classification population according trait.
-------------------------------------------------------------------------------------------------------------------

190- which of the following is the most effective means of communicating

commitment to patient safety :
A. Articles by a CEO in the employee newsletter
B. Senior leaders having discussions on units with front line
staff
C. Posters and bulletin boards on units displaying up to date patient falls data
D. CEO Presenting most recent medication error rates to the governing body.
-------------------------------------------------------------------------------------------------------------------
191- Performance of RCA for a sentinel event provides all of the following except:
a- Identification of why the variance occurred
b- Recommendations for actions to prevent recurrence
c- Measurement strategies for each factor affecting the outcome
d- Continuous measurement to identify opportunities for
improvement
-------------------------------------------------------------------------------------------------------------------

192- unanimous agreement:

a- all agree about the decision
b- the agree of the majority
c- nobody agrees
-------------------------------------------------------------------------------------------------------------------
193- A healthcare quality professional is provided the data bellow:

What steps should be taken to (prioritize) area of concern :

a- Draw an affinity diagram and identify primary causes for delay
b- Prepare a pareto chart develop an action plan
c- Create an ishikawa diagrams and identify primary causes for delay
d- Develop a control chart and create an action plan

-------------------------------------------------------------------------------------------------------------------
194-In order to establish a safety culture within a healthcare organization, one of
the effective actions is to:
A. punish individual employees who commit medication errors.
B. adopt anonymous free reporting of errors and adverse
events.
C. segregate staff who commit errors to work in the same shifts.
D. abstain from intervention until a completion of one year to have an accurate
information about types and patterns of errors.
-------------------------------------------------------------------------------------------------------------------
195- if a facility intended to decrease resources to achieve goals the manager
decision is driven by :
a. Quality data
b. physician orders
c. consultants recommendation
-------------------------------------------------------------------------------------------------------------------
196-effectiveness of local flu vaccination program is best measured by :
a. local prevalence rate to local incidence rate
b. local vaccination rate to local prevalence
c. local prevalence rate to national one
d. national incidence rate to local incidence rate

-------------------------------------------------------------------------------------------------------------------

197-Which of the following make a successful focus group:

A. Small group
B. Include patient
C. Good moderator
D. Short duration

-------------------------------------------------------------------------------------------------------------------

198-Which of the following is the best example of applying cultural diversity

principle to patient safety?
A. Allowing parents to perform rituals for their ill child
B. Providing interpretive service to explain medical
procedures
C. Having the nutritionist discussion dietary preferences with the patients
D. Performing mandatory training on culture diversity for staff
-------------------------------------------------------------------------------------------------------------------

199-The first step in collecting meaningful data is

A. establishing the goals of data collection.
B. developing operational definitions.
C. planning for data consistency.
D. evaluating the resources available
-------------------------------------------------------------------------------------------------------------------

200-Leaders of a multi-hospital system are trying to prioritize the services to

introduce in the coming year based on their impact on the community. These
leaders, who work geographically apart, can arrive at a group consensus without
meeting face to face by
A. the nominal group technique.
B. the Delphi technique.
C. brainstorming.
D. a focus group
-------------------------------------------------------------------------------------------------------------------

201-The dimension of quality/performance that is addressed by introducing a rapid

response team in a hospital is
A. continuity of care.
B. efficiency.
C. effectiveness.
D. prevention and early detection.
-------------------------------------------------------------------------------------------------------------------

202-When developing department specific performance measures and indicators,

the quality manger as a consultant should :
A. Prioritize the quality indicators for selection by the department leader
B. Ensure that the numerator and denominator are clearly defined
C. Review the mission statement and seek physician input
D. Conduct a literature search and select quality indicators
-------------------------------------------------------------------------------------------------------------------

203-Which of the following is the most appropriate question to ask when reviewing
an organizations performance improvement (PI) plan?
A. "has the organization been successful in communicating the intent and
message of the PI plan to employees?
B. Are there sufficient organizational resources to support the PI plan?
C. Does the PI plan include statistical methods for monitoring change?
D. Is the PI plan consistent with the organization's mission
and strategic priorities?
-------------------------------------------------------------------------------------------------------------------

204-One way to measure clinical outcomes is through

A. Aggregate data review
B. Pareto charts
C. Pre-admission review
D. The number of healthcare contracts
-------------------------------------------------------------------------------------------------------------------
205-A primary purpose of an information management system is to allow an
organization to:
A. Save time
B. Centralize demographics
C. Reduce cost
D. Evaluate data
-------------------------------------------------------------------------------------------------------------------

206-Which of the following is example of outcome measure:

A .mortality rate.
B. average LOS.
C. medication dispensing rate.
D.lab specimen
-------------------------------------------------------------------------------------------------------------------

207- Which of the following is the best approach when implementing a National
Patient Safety Goal related to identifying potential errors in a patient's care,
treatment, and services?
A. providing the patient and family an opportunity to ask questions
B. having the patient provide return demonstration of the knowledge provided
C. showing a video to a patient and their family
D. giving both written and verbal instructions to a patient and
family
-------------------------------------------------------------------------------------------------------------------
208- To allow changes to be maintained, you should ensure the change in
A. The behavior of the staff . (sometimes : the culture within the
organization)
B. The hierarchy of the organization
C. The values within the organization
D. The reward system
-------------------------------------------------------------------------------------------------------------------

209- A healthcare organization is seeking accreditation. The first step the

healthcare quality professional should take is to
A.review the organization's bylaws, rules, and regulations.
B. becomes familiar with the appropriate standards.
C. establishes a quality assessment committee.
D. review the organization's policies and procedures
-------------------------------------------------------------------------------------------------------------------

210- One of the aims in the treatment of severe community-acquired pneumonia is

to maintain an oxygen saturation of >94% (or 88 - 92% in patients with chronic
obstructive airway disease). Ensuring adequate oxygenation for this condition is
A. process and outcome measure.
B. structure measure.
C. process measure.
D. outcome measure

-------------------------------------------------------------------------------------------------------------------

211- Negligence means a lack of proper care. In medical malpractice "proper care"
is determined by
A. medical peers
B. JCAHO standards.
C. jury of civilian peers.
D. tort law
-------------------------------------------------------------------------------------------------------------------

212- When there's uncertainty about the outcome of the process with presence of
guidelines and experienced staff, the process is considered as:
Complicated
Complex
Simple
Flexible
-------------------------------------------------------------------------------------------------------------------

213- The first step in the design process of a QI plan is :

A. determine the scope of the organization
B. make a cost-benefit analysis
C. establish performance objectives
D. establish the project goals
-------------------------------------------------------------------------------------------------------------------
214- (New) drug with good outcome but high side effect , physician and pharmacist
decide to add it to drug formula depend on which study
A. Random
B. Stratified
C. Prospective
D. Retrospective
-------------------------------------------------------------------------------------------------------------------
215- Organizational profitability is the difference between:
A. Reimbursement minus cost of service.
B. Reimbursement minus charges.
C. Fees minus cost.
D. Cost minus reimbursement
-------------------------------------------------------------------------------------------------------------------
216- To establish evidence-based practice guidelines, it is best to :
A. Rely upon subjective, expert opinion.
B. Review every possible intervention or treatment
C. Include those who resist the process.
D. Allow individual practitioners to make any exceptions to the guidelines
-------------------------------------------------------------------------------------------------------------------
217- an increase in the mortality rate of patients undergoing caesarean section was
detected, the collected data revealed that the increased rate returns to (one
gynecologist), assessment of his performance was recommended. Who in this
case is responsible for (analyzing the collected data) regarding the targeted
gynecologist performance:
A. The head of the gynecology department
B. the quality professional
C. A medical staff committee.
D. The peer review committees
-------------------------------------------------------------------------------------------------------------------

218- The determination of annual National Patient Safety Goals is linked to

reported
A. sentinel events.
B. adverse events.
C. core performance measures.
D. claims
-------------------------------------------------------------------------------------------------------------------
219- which Of the following management approaches, expecting ____ would be
MOST likely to harm-quality improvement initiatives.
a quick fix from quality improvement
CQI to save the organization money
organization-wide involvement in QI
role change throughout the organization
-------------------------------------------------------------------------------------------------------------------
220- Attempts to align financial incentives of purchasers, payers &providers with
provider performance on clinical process &outcome measures encourages
A. under-utilization
B. community backlash
C. over-utilization
D. reengineering
-------------------------------------------------------------------------------------------------------------------
221- A facility is providing a new service for patients with chronic pain .Which of
the following is the primary role of the healthcare quality professional in evaluating
this new service?
A. Comparing outcome to benchmark data
B. Evaluating cost benefit ratio
C. Assuring the staff is adequately trained
D. Developing performance monitoring criteria
-------------------------------------------------------------------------------------------------------------------
222- Quality improvement plan must be
A. Focused on organizational improvement.
B. Consistent with business goals and objectives.
C. Evolve the training plan of hospital
D. Ensure regular maintenance program
-------------------------------------------------------------------------------------------------------------------
223- Which tool(s) or measure(s ) or show summary of characteristics about
population :
A. frequency distribution
B. central tendency measures
C .flow charts
D. cause and effect charts
-------------------------------------------------------------------------------------------------------------------
224- Nurse in the post-operative found missed clamp, X-ray has done to the patient
was negative & the patient has no symptoms this occurrence is type of
A. Claim management
B. Potentially compensable event
C. malpractice from the nurse
D. Incompetent surgeon

-------------------------------------------------------------------------------------------------------------------
225- Which of the following best demonstrate use of the plan-do-check-act(PDCA)
performance improvement model?

A- Identify a problem, implement change, educate staff about the change and
rewrite policies and procedures to augment the change.
B. Collect baseline data, form a committee to develop the plan, validate audit data,
and formalize the change .
C. Prioritize opportunities for improvement, pilot the
improvement, compare pre and post implementation data, and
rollout to the entire organization.
D. Review current practice , from a multidisciplinary committee, schedule a
meeting to develop a plan , and determine actions to be taken
-------------------------------------------------------------------------------------------------------------------
226- An Organization ask a CPHQ to help in preparedness to survey of accrediting
body, the quality manager will first:
A. Assign a team for the survey
B. Arrange for mock survey
C. Educate staff about types of questions that may be asked.
D. Review the adherence of the organization to quality
standard of accreditation
-------------------------------------------------------------------------------------------------------------------
227- A healthcare quality professional has been asked to provide a report on the
rate of cesarean sections performed at a hospital over the past 5 years , which of
the following would be the best way to present the data?
a- Control chart
b- Pareto chart
c- Stratified histogram
d- Cause and effect diagram
-------------------------------------------------------------------------------------------------------------------
228- A performance improvement team aims to reduce the rate of post-surgical
infection rates in a small rural acute care facility. Which of the following should the
team use as a reference?
The post-surgical infection rates among individual surgeons.
Postoperative antibiotic use among the surgeons.
National benchmark post-surgical infection rates based on the most recent
research.
Post-surgical infection rates in similar facilities
-------------------------------------------------------------------------------------------------------------------
229- Which of the following concerns would be best solved by a QI team?
A. A system issue
B. A discipline problem
C. A customer complaint
D. A financial variance
-------------------------------------------------------------------------------------------------------------------
230- Which of the following is an appropriate criterion when using a Prioritization
Matrix to select an Electronic Medical Record (EMR) system?

A- Quick to implement
B- Availability of supporting hardware
C- Ease of data abstraction
D- Integration with existing billing system
-------------------------------------------------------------------------------------------------------------------

231- In order to facilitate development of strategic plan, what to consider first?

A. Cultural assessment, planning, implementation & evaluation
B. Risk management, gap analysis, identification of organization wide functions
C. Mission, vision, values , short & long term goals &
objectives
D. Creation of master plan, identify customers, goals & objectives
-------------------------------------------------------------------------------------------------------------------
232- In developing a performance improvement action plan the first tool to use is
A. control chart
B. interrelationship diagram
C. cause and effect diagram
D. pareto chart
-------------------------------------------------------------------------------------------------------------------
233- Data on medication errors at a facility over the past month are shown in the
table below:

Which unit is most likely to have the highest incidence of using only one patient
identifier?

A- Emergency Room
B- Intensive Care Unit
C- Medical Unit
D- Surgical Unit
-------------------------------------------------------------------------------------------------------------------
234- A licensed independent practitioner with admitting privilege at a hospital must
A. be a fully licensed physician.
B. be eligible for medical staff membership.
C. be a member of the medical staff.
D. have completed proctoring for any clinical privileges previously requested.
-------------------------------------------------------------------------------------------------------------------
235- The senior leaders of a hospital are prioritizing performance improvement
initiatives for the coming year. Which of the following tools will be most useful for
this purpose?
A. Pareto chart
B. Cause-and-effect diagram
C. Affinity diagram
D. Stratification

-------------------------------------------------------------------------------------------------------------------

236- The chart below shows the overall inpatient mortality at a hospital.

Based on the data, the healthcare quality professional should

A. report that overall inpatient mortality has improved and the improvement is
statistically significant.
B. conclude that inpatient mortality has increased overall.
C. conduct drill-down analysis.
D. continue to monitor inpatient mortality.
-------------------------------------------------------------------------------------------------------------------
237- The chart below shows the rate of Cesarean Sections in a hospital.

The healthcare quality professional should

A. continue monitoring the monthly rates of Cesarean Sections.
B. recommend a Cesarean Section audit by peer review.
C. review the policies and procedures for Cesarean Section.
D. review the antenatal care of women who had Cesarean Sections.
-------------------------------------------------------------------------------------------------------------------

238- In the second half of 2008, the inpatient fall rate at Hospital X was above 15
falls per 1000 patient-days. A multidisciplinary team commenced an initiative to
lower the rate of inpatient falls in February 2009. The historical average in the 10
years before 2008 was 6.6 falls per 1000 patient-days and the target for this
initiative was 5.0 falls per 1000 patient-days. The results of this improvement work
are shown in the graph below.

Which of the following is the most appropriate next step?

A. Stop monitoring patient falls.
B. Continue monitoring patient falls.
C. Continue the initiative to reduce the rate of patient falls further.
D. Lower the target.
-------------------------------------------------------------------------------------------------------------------
239- Which of the following tools is most appropriate for investigating the
relationship between two characteristics?
A. Scatter plot
B. Cause-and-effect diagram
C. Failure modes and effects analysis
D. Pareto chart
-------------------------------------------------------------------------------------------------------------------
240- Discharge planning should begin :
A. at the time of admission to the hospital.
B. after the patient's medical condition stabilizes and he is transferred from the
Intensive Care Unit to a medical ward.
C. after the physician writes the discharge planning order.
D. two days before the expected date of discharge.
-------------------------------------------------------------------------------------------------------------------
241- After administration of the flu vaccine, the quality professional measures how
many people caught influenza after administering the vaccine. in this case which
dimension she measures:
Efficacy
Effectiveness
Availability
Appropriateness
-------------------------------------------------------------------------------------------------------------------

242- When the organization motivates the finance system of healthcare

organization or using financial motivation it uses:
JCI standards
Leapfrog
Baldrige award
-------------------------------------------------------------------------------------------------------------------
243- What is the definition of median:
Average of data
frequent data
50th percentile of data
-------------------------------------------------------------------------------------------------------------------
244- There were a large number of late visits for home care. The quality
professional wants to talk to the home care nurse at this problem. What is the best
approach?
Explain the cause of the problem and ask for solution
Describe the problem and ask for feedback
Share his home care experience
-------------------------------------------------------------------------------------------------------------------
245- Which one should be included when reporting PI to GB:
Team achievements(sometimes graphs and tables)
Team minutes
Occurrence and incident reports
-------------------------------------------------------------------------------------------------------------------
246- If a hospital has a problem with multi-disciplinary teams performance during
CPR , what is the best method to assess the problem?
A. Observe the process.
B. Review the hospitals code policy.
C. Survey the staff.
D. Review medical record documents
-------------------------------------------------------------------------------------------------------------------
247- There was a diagram of bar chart analyzing the causes of surgeries delay
about 75% of the causes was surgeon delay and he asks about the next step to do:
FPPE for all surgeons
search the causes of the delay
inform the GB
-------------------------------------------------------------------------------------------------------------------
248- The Process Decision Program Chart (PDPC) is a combination of ____
and____ diagrams.
A. Fishbone; flow
B. Fishbone; GANTT
C. Fishbone; tree
D. GANTT; affinity
-------------------------------------------------------------------------------------------------------------------

249-Scenario of three questions the scenario discussing a physician profile:

Chart no. 1768 The surgery report is not sufficient

Chart no. 2867 The discharge report doesn`t completed

Chart no. 8675 The medical history not completed

Chart no.4756 Emergency privilege was acquired

Chart no.5678 There is prolonged LOS without reasons

What is the decision taken?

wait for the departmental action

ask for privilege for the surgeon

peer review

What other data should include?

length of stay of cases

no. of cases reviewed

rate of mortality among cases of this surgeon

What is the most apparent error of the surgeon?

not completed medical records

increased LOS among his pt

increased readmission

medication errors
-------------------------------------------------------------------------------------------------------------------
250) The difference between practice guidelines and clinical pathways is
A. Guidelines are recommendations and pathways are evidence based.
B. guidelines deal with one disease process and pathways deal with multiple.
C pathways deal with multiple steps and processes and
practices deal with one practice.
D. Practices deal with quality and pathways deal with safety.
-------------------------------------------------------------------------------------------------------------------
251- Medication reconciliation is
A. The reconciliation of duplicated dosage, frequency and discrepancies
B. The resolution of medication discrepancies in dose, frequency and therapeutic
duplication at time of discharge
C. The reconciliation of medication through the patient's
hospital stay
D. The clarification of patient's medication at time of discharge
-------------------------------------------------------------------------------------------------------------------
252- Medication reconciliation:
A- help in efficient use of medication
B- Identify discrepancies in meds
C- Identify and resolve med. Discrepancies
-------------------------------------------------------------------------------------------------------------------
253- Implementation of the medication reconciliation process require the
interdisciplinary effort of
A. Nurse, physicians, laboratory technicians and informatics
B. Nurse, physicians, pharmacists and informatics
C. Nurse, physicians, chaplains and informatics
D. Nurse, physicians, pharmacists and medical therapists
-------------------------------------------------------------------------------------------------------------------
254- Infection rate in practitioner A is higher than B The quality professional
should make :
A- FPPE
B- OPPE
C- DO NOTHING

-----------------------------------------------------------------------------------------------------------------
--
255- difference between FMEA and RCA
the answer is FMEA IS prospective and RCA is retrospective
-------------------------------------------------------------------------------------------------------------------
256- which of the following not stage in team dynamics:
A- conforming
B- norming
C- storming
D- performing
-------------------------------------------------------------------------------------------------------------------

257-

A. Approximately 95% failed to meet the stated objective

B. There is no problem since approximately 35% of health assessments are
completed
C. A significant number of terminations resulted from lack of completion of health
D. The provider is in significant compliance with the program

the objective is: complete assessment and result to be known prior to assumption
of duties, the graph showed 5% only completed prior to start, i.e, meet the
objective. That means that 95% not meet.
SO CORRECT ANSWER IS A
objective‫يعنى هم عاوزين الموظف يكمل الكشف الطبي قبل ما يبدا الوظيفة يبقي ده ال‬
%5 ‫ بس هم اللي عملوا المطلوب و النسبة بتاعتهم عند‬H ‫ تالقي عند‬graph‫بصي في ال‬

-------------------------------------------------------------------------------------------------------------------
258- The interrelationships between people, tools they use, the environment they
work in best describe the study of:
a-Human factors/ ergonomics
b- Environment factors
c- process mapping
d- work engineering
-------------------------------------------------------------------------------------------------------------------

259- which stage cause the team to dissolve prematurely

A- norming
B- performing
C- storming
-------------------------------------------------------------------------------------------------------------------
260- Successful development of clinical practice guidelines:
Physician involvement
Staff education
Quality improvement tools
Patient education
-------------------------------------------------------------------------------------------------------------------
261- Which of the following is the primary goal of risk management?
Identify high risk areas of the organization
Maintain an effective reporting system
Perform failure mode & effect analysis
Reduce financial loss within the organization
-------------------------------------------------------------------------------------------------------------------
262- An effective risk-management program for a health care organization
emphasizes
A. Harm prevention for patients, visitors, and staff
B. Reduction of financial losses
C. Staff training and education
D. Compliance with accrediting agency standards
-------------------------------------------------------------------------------------------------------------------
263- 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.
-------------------------------------------------------------------------------------------------------------------
264- The primary goal of quality/performance improvement is to improve
patient care processes.
patient safety.
patient outcomes.
patient satisfaction
-------------------------------------------------------------------------------------------------------------------
265- in postoperative assessment the nurse discovered that the surgeon has
replaced the wrong hip for a patient. This is considered:
sentinel event.
malpractice.
-------------------------------------------------------------------------------------------------------------------
266- a nursery home 60% of residents complained of food that was delivered
cold as a quality professional you should do:
A- Call dietercian and ask for explanation.
B- Review previous Results & trend data.
C- do nothing
-------------------------------------------------------------------------------------------------------------------

267- safe environment can be best achieved by involving:

a. Leaders and top management
b. Delegating the responsibility to a cross-functional team
c. Involving staff members organization wide in the safety
initiatives
d. Establishing a specified committee to review safety issues organization-wide
-------------------------------------------------------------------------------------------------------------------
268- CQI training implementation success is proven by
a. data satisfaction
b. staff competency
c. GB
d. organization culture
-------------------------------------------------------------------------------------------------------------------

269- LD style needed to make practice guideline

participatory
autocratic
diplomatic
-------------------------------------------------------------------------------------------------------------------
270- Which tool(s) or measure(s ) or show summary of characteristics about
population
A. frequency distribution
B .flow charts
C. cause and effect charts

-------------------------------------------------------------------------------------------------------------------
271- 50th percentile of data is the definition of :
A- Mode
B- Median
C- Mean

-------------------------------------------------------------------------------------------------------------------
272- Which of the following is most useful in performing a morbidity/mortality
review?
Physician profiling.
Autopsy results
Length of stay
Do-not-resuscitate policy
-------------------------------------------------------------------------------------------------------------------
273- Compare care relative to clinical pathway is a measure of:
A-variance
B-gap analysis
-------------------------------------------------------------------------------------------------------------------
274- Deploying a CQI team would be first approach in addressing which
A-Several patient complained their call lights not answered
during night shifts
B-Several physicians don't allocate enough time for procedures which booking
surgical cases
C- Finance billing outpatient procedures as ambulatory surgery
D- Results of preadmission testing for inpatient survey are unavailable 35% of time
causing delays.
-------------------------------------------------------------------------------------------------------------------

275- A performance improvement team has been created to examine infection rates
following surgery . Which of the following is the best reference for the team to
use?
a- Hospital infection rate following surgery among similar
facilities
b- Number of surgeries performed among similar facilities
c- Individual infection control rate for each surgeon
d- Postoperative antibiotic use among surgeons
-------------------------------------------------------------------------------------------------------------------
276- To meet centers of medicare and medicaid services requirements:
A- should accomplish a survey of CMS
b- accomplish a survey which will meet requirements of CMS
-------------------------------------------------------------------------------------------------------------------
277- Organization improvement plans will assign team when:
there is a lot of staff
turnover rate among stuff
lab deliver results late
-------------------------------------------------------------------------------------------------------------------
278- Surgeon do a colonoscopy done perforation to colon in surgery
Refer case to peer review
Remove his privilege
Initiate FPPE =Focused Professional Practice Evaluation
-------------------------------------------------------------------------------------------------------------------
279- BPOC serves to prevent medication errors in the:(BPOC = BCMA)
Administration phase"BPOC" Barcode Point of Care
Transcribing phase
Prescribing phase
Dispensing phase
-------------------------------------------------------------------------------------------------------------------
280- The measures most indicative of the IDS' ability to provide value to its
stakeholders are:
Improvement in patient outcomes and reduced costs of care
An annual report with a positive bottom line
Improvements in patient outcomes and patient satisfaction
Reduced costs of care and competitive pricing
-------------------------------------------------------------------------------------------------------------------
281- For a patient with insulin-dependent diabetes mellitus, which of the following
programs is the most appropriate to administer?
Disease management
Utilization management
Demand management
Risk management
-------------------------------------------------------------------------------------------------------------------
282- The organizations strategic goals are best linked to its performance
improvement activities by management
A. offering many performance improvement models from which each area can
choose.
B. assigning improvement models to areas as deemed appropriate by the key
leaders.
C. obtaining organizational consensus for continuous
improvement activities.
D. analyzing the goals and improvement activities of other similar organizations

-------------------------------------------------------------------------------------------------------------------

283- For which of the following is process capability BEST used?

A) identifying if a process is having the intended effect
B) focusing a team on the best thing to do
C) narrowing down options through a systematic approach of comparison
D) determining if a process meets established specifications
-------------------------------------------------------------------------------------------------------------------
284- Hospital A has recently merged with hospital B after 6 months it is noted that
hospital A has successfully transmitted their staff to new organizational values
while hospital B still struggle .hospital A success can best be attributed to :

Required adoption of new values by all staff

Support of both hospital's mission statements

Acceptance of new mission and vision statements

Integrating technology and database

-------------------------------------------------------------------------------------------------------------------
285- Which of the following statements and documents are most likely to reveal the
organization's underlying or true value system? :
a. Mission, ethics policy, strategic initiatives
b. Vision, ethics policy, corporate bylaws.
c. Values, QM/QI plan, utilization management plan.
d. Mission, Vision, Values
-------------------------------------------------------------------------------------------------------------------
286- The best way to evaluate effectiveness of performance improvement training
is through

self-assessment

participants' feedback

observed behavioural changes

post-test results

-------------------------------------------------------------------------------------------------------------------
287- All of the following conditions contribute to system improvement except :
Measuring performance of processes & their outcomes using valid statistics
methods
Taking action to improve the way the processes are designed & carried out
Studying & understanding the complex process that contribute to care
Identifying & Responding to individual performance issues
-------------------------------------------------------------------------------------------------------------------
288- Comparison of surgeon specific infection rate is example of :
A- Practitioner profiling
B- Root cause analysis
C- Practitioner credentialing
D- Incident analysis
-------------------------------------------------------------------------------------------------------------------
289- TQM leadership style is :
A- Autocratic
B- Participative
C- Laissez-faire

------------------------------------------------------------------------------------------------------------------

290- Strong corporate organization value

communicate core value ethics to the staff
-------------------------------------------------------------------------------------------------------------------
291- Sentinel event is a variation in :
A- Staffing
B- Process
C- Structure
D- Competency
-------------------------------------------------------------------------------------------------------------------
292- A sentinel event is regarded as a:
a. Common cause variation.
b. assignable variation.
c. Noise.
d. Random variation
-------------------------------------------------------------------------------------------------------------------
293- QP search on data of other facilities to improve providing of care , this
assessment method called :
A- Statistical analysis
B- Benchmarking
C- Gap analysis
D- outcome measurement
-------------------------------------------------------------------------------------------------------------------
294- Performance improvement team are used to :
A- Evaluate data
B- Root cause analysis
-------------------------------------------------------------------------------------------------------------------
295- use the following data to answer the following 2 Q:

Number of discharges 142

Number of procedures 100

Arthroscopies 20

Hip replacement 40

Surgical wound infections 32

Incomplete medical records 40

The rate of overall surgical wound infections:

a.32%.
b.23%.
c.30%
d.40%.

Overall surgical wound infection rate = (surgical wound infections/No. of

procedures) x 100 = (32/100) x 100 = 32%
B. The rate of overall delinquent medical record:(delinquent )
a.40%.
b.28%.
c.30%.
d.20%.
overall delinquent medical record = (Incomplete medical records /No. of
discharges) x 100 (40/142) x 100 = 28 %
-------------------------------------------------------------------------------------------------------------------
296- chart contain FMEA include 5 risks , risk 1 is high and risk 5 is low. Which one
to choose
A- Consider risk 5 is benchmark
B- Improve risk 1
-------------------------------------------------------------------------------------------------------------------
297- By forming a team After 1 month team attendance is declined , which stage of
team development :
A- Storming
B- Norming
C- Performing
-------------------------------------------------------------------------------------------------------------------
298- which of the following is the most effective means of communicating
commitment to patient safety?
Articles by a CEO in the employee news letter
Senior leaders having discussions on units with front line
staff
Posters and bulletin boards on units displaying up to date patient falls data
CEO Presenting most recent medication error rates to the governing body
-------------------------------------------------------------------------------------------------------------------
299- Ask staff to recall of the appropriate use of safety behavior in which level :
A- Learning
B- Behavior
C- Reaction
D- Result
-------------------------------------------------------------------------------------------------------------------
300- Performance of RCA for a sentinel event provides all of the following except:
A- Identification of why the variance occurred
B- Recommendations for actions to prevent recurrence
C- Measurement strategies for each factor affecting the outcome
D- Continuous measurement to identify opportunities for
improvement
-------------------------------------------------------------------------------------------------------------------
301- how can facilitator help team to analyze the data :
a-present it on graph
-------------------------------------------------------------------------------------------------------------------
302- To avoid medication errors the organization should:
A. use computerized dispensing system
B. single medical record system
C. improve the process
-------------------------------------------------------------------------------------------------------------------
303- Quality improvement strategic plan
A- Shows future direction of quality in org.
B- Asses opportunities to improvements
-------------------------------------------------------------------------------------------------------------------
304- After PI team finish the program who will write the report or "present the
results"
A- Team leader
B- Facilitator
C- Recorder
-------------------------------------------------------------------------------------------------------------------
305- After education of continuous quality improvement program to evaluate
effectiveness of the program :
A- Do pre & post education exam
B- Evidence that the staff begin continuous quality
improvement activities
C- Monitoring the previous performance of the staff
D- Review the attendance rate of the staff
-------------------------------------------------------------------------------------------------------------------
306- Which of the following is NOT a function of the facilitator on a quality
improvement team?
a- Keep the group focused on a central issues.
b- Tactfully prevent anyone from dominating the discussion.
c- Manage time
d- Keep minutes and records of the team’s effort
-------------------------------------------------------------------------------------------------------------------
307- The best tool to display stability of nosocomial infection rates over time is a
a- Run chart
b- Control chart
c- Histogram
d- Pareto chart
-------------------------------------------------------------------------------------------------------------------
308- Which of the following is an example of a leadership strategy to integrate the
patient safety program into healthcare organization overall performance
improvement system?
a- Evaluate training data to plan leadership retreats
b- Identify quarterly discharge rate for the organization
c- Conduct a root cause analysis to proactively identify risk
d- Use a system wide failure mode and effect analysis (FMEA)
-------------------------------------------------------------------------------------------------------------------
309- Practice guidelines should be based on :
A) Scientific evidence.
B) Computer generated Data.
C) Utilization review characteristics.
D) Senior consultant review
-------------------------------------------------------------------------------------------------------------------
310- Who is responsible of quality improvement within the organization?

A. Quality manger.
B. Frontline staff.
C. Everyone within the organization.
D. Chief Executive Officer
-------------------------------------------------------------------------------------------------------------------
311- Which is best to do during the accreditation survey (about staff knowledge):

To assign a team to answer the questions asked by surveyors

To have a departmental director who know 3 standards about their concerned

departments
To educate all staff members the FAQs by the surveyors
……………..

-------------------------------------------------------------------------------------------------------------------

312- In the following , "reviews" refers to utilization reviews, "FTE" refer to full time
equivalent employee , and "#" refers to the number. Consider the following
productivity data:

What is the approximate percentage of increase in productivity from January to

May?
A- 1%
B- 3%
C- 20%
D- 33%
-------------------------------------------------------------------------------------------------------------------
313
A. Continue to track and trend incident reports
B. Educate med/surgery Units on fall prevention
C. Review ICU fall protocol
D. Conduct further analysis of fall data
-------------------------------------------------------------------------------------------------------------------

314- When HCOs want to review their compliance with conditions of participations
of MCOs, what they should do:
Review performance of 12 months ago
Review weakness for more 12 months
Involve every department and service
-------------------------------------------------------------------------------------------------------------------
315- QI program start on reality when :
The staff believe it is desired
Staff be owners and start to participate
-------------------------------------------------------------------------------------------------------------------
316- Who assess the clinical competency of LIP for reappointment?
Governing board
CMO(Chief Medical Officer)
Quality director
Departmental director
-------------------------------------------------------------------------------------------------------------------
317- Which one of the following is not considered sentinel event:
Hemolytic transfusion reaction
Patient death after….
Suicide threat in psychiatric unit …
-------------------------------------------------------------------------------------------------------------------
318- Increase aggressive behavior of patient toward the staff in (a department) ,
what is the appropriate action HQP :
A- Focus group with the staff about that
B- Review restrain policy
-------------------------------------------------------------------------------------------------------------------
319- How to link CQI activities to strategic goals :
A- open free 2 ways communication
B- monitor indicators link to strategic goals
-------------------------------------------------------------------------------------------------------------------
320- After in-depth data analysis, there is evidence of over utilization of
computerized tomography to diagnose acute appendicitis. A team has been
formed to develop a performance improvement plan for emergency department
physicians. Which of the following leadership style is most effective to implement
best practice guidelines?
A. Laissez faire
B. Democratic
C. Participatory
D. Autocratic
-------------------------------------------------------------------------------------------------------------------
321- When describing continuous quality improvement (CQI) to a senior
administrator in a healthcare organization, which of the following is not a
component of CQI :
A. Analyzing clinical processes
B. Empowering all levels of employees to improve quality
C. Identifying individual practice patterns
D. Analyzing variation

-------------------------------------------------------------------------------------------------------------------

322- A healthcare quality professional is provided the data bellow:

CAUSES OF SURGICAL DELAYS;

What steps should be taken to (prioritize) area of concern :

a- Draw an affinity diagram and identify primary causes for delay
b- Prepare a pareto chart develop an action plan
c- Create an ishikawa diagrams and identify primary causes for delay
d- Develop a control chart and create an action plan
-------------------------------------------------------------------------------------------------------------------
323- An effective risk management program for a health care organization
emphasizes
A. Harm prevention for patients, visitors, and staff
B. Reduction of financial losses
C. Staff training and education
D. Compliance with accrediting agency standards
-------------------------------------------------------------------------------------------------------------------
324- Prioritization matrix , which to choose

Ch 1 (cost) Ch2 … Ch3 … Ch4 … total

A 10 20 70 50 +++

B 50 30 10 20 ++

C 20 100 30 10 +++

D 10 70 90 90 +++

+++++ calculate totals and choose the largest total

-------------------------------------------------------------------------------------------------------------------

325- The following table for the first three months last year:

What is the percentage of complications of inpatients for the month of March?

1%
2%
18%

19%

27/1350 *100 = 2%
-------------------------------------------------------------------------------------------------------------------
326- The organization apply immunization program for the local area of the
organization. To evaluate the effectiveness of the program :
A- Immunization rate + the incidence
B- The prevalence + the incidence
C- National and local immunization rate …
D- National prevalence + local prevalence
-------------------------------------------------------------------------------------------------------------------
327- 200 patients … 170 satisfied / 30 not satisfied. The role of cphq :
A- continuous review, 85% satisfied
B- no action only 15% dissatisfied
C- review the data for statistically significance
D- review all cases not satisfied to know unique cause
-------------------------------------------------------------------------------------------------------------------
328- When review clinical competency of surgeon at the time of reappointment :
A- group interview with practitioners
B- interview with the practitioner
C- quality professional review credential file
D- chief of surgery department review credential file
-------------------------------------------------------------------------------------------------------------------
329- A facilitator in a team meeting :
a. Participate in the discussion of topics
b. Change the topic of the meeting
c. Modulate the meeting
-------------------------------------------------------------------------------------------------------------------
330- Surgeon's cases associated with surgical site infections higher than The
average surgical site infection rate for the other surgeon's the 1st thing to do :
A- remove privileges of the surgeons
B- refer the surgeon's cases for peer review.
C- Evaluate by credentialing committee
D- Consult with department chairperson

-------------------------------------------------------------------------------------------------------------------

331- There are whistleblower allegation in a public report about the healthcare
organization , CEO first :
A- Inform GB and firing the staff who do that
B- go to the website and compare data on it with the internal data
C- Review the process and discuss with the staff if there is
any pressure on them
-------------------------------------------------------------------------------------------------------------------
332- Patient complain foreign object ,when counting the instrument there is missed
instrument , when perform x-ray per policy there is nothing, after surgery it was
discovered :"potentially compensable event"
A- Apologize to patient and family and reduce the cost of
treatment
B- Review why the x-ray don’t visualize the object
-------------------------------------------------------------------------------------------------------------------
333- You are preparing a report to present to the Public Health Council on the
declining rates of gonorrhea in your state in both men and women over the last 10
years. Which type of graph would best illustrate the data??
a. Bar chart
b. Histogram
c. Pie chart
d. Line graph
-------------------------------------------------------------------------------------------------------------------
334- Failure modes and effects analysis can be done :
A- from causes forward to effects.
B- from effects back to causes.
C- from causes forward to effects or from effects back to
causes.
D- by none of the above approaches.
-------------------------------------------------------------------------------------------------------------------
335- In preparing for a meeting, what should be sent to the team members in
advance?
A. Agenda with all attachments.
B. Agenda with key information requiring a decision at the
meeting.
C. Just the agenda, because members will lose the other information.
D. Agenda and the confidential information, because guests will attend the meeting
-------------------------------------------------------------------------------------------------------------------
336- After the team action the plan and implement it ,and made recommendation
,what next step on PDCA cycle is now should follow;
a. Plan
b. Do
c. Check
d. Act
-------------------------------------------------------------------------------------------------------------------
337- how to link CQI activities to strategic goals?
1: open free 2 ways communication
2:monitor indicators on goals
-------------------------------------------------------------------------------------------------------------------
338- A healthcare system has decided to centralize its credentialing departments.
What is the main purpose for doing so?
A- Streamline jobs
B- Reduce costs
C- Meet NCQA requirements
D- Eliminate duplication of credentialing
-------------------------------------------------------------------------------------------------------------------
339- An organizations data demonstrate an increase in the number of patients falls,
the healthcare quality professional should recommend :
a- Convening a focus group of medical staff to discuss fall risk
b- Revising the fall risk assessment tools
c- Sharing the data with the staff to provide feedback
d- Increasing staffing on weekends and nights
-------------------------------------------------------------------------------------------------------------------
340- Implementation of an influenza vaccination program for staff across multiple
sites should ideally be :
A- customized to be suitable to each site.
B- overseen by a single site champion.
C- carried out simultaneously.
D- standardized to unify evaluation metrics
-------------------------------------------------------------------------------------------------------------------
341- A chief quality officer has the responsibility for education and implementation
of a continuous quality improvement process. To affect cultural change,
administration must :
A. Believe the costs are justified by the benefits.
B. Be assigned as a member of a team.
C. Receive quarterly reports.
D. Limit training to managers and supervisors.
-------------------------------------------------------------------------------------------------------------------
342- Benchmarking is a tool that compares current performance with
A- performance of industry leaders.
B- performance in similar organizations.
C- performance goals.
D- all of the above
-------------------------------------------------------------------------------------------------------------------
343- In deciding to submit an application for an external quality award the first step
to determine if award criteria:
A. Are aligned with organization strategic plan
B. Are well written
C. Demonstrate excellence in quality
D. Are approved by the chief executive officer
-------------------------------------------------------------------------------------------------------------------
344- Who is responsible for the FPPE and OPPE in a healthcare organization?
A. Governing Body
B. Medical Staff
C. Chief Medical Officer
D. Team Leader
-------------------------------------------------------------------------------------------------------------------
345- When a Sentinel Event (SE) occurs, the Risk Manager initiates a Root Cause
Analysis (RCA). To appropriately evaluate the cause of an SE,
A. terminate all processes that led to the event until the RCA is completed.
B. start with the assumption that human error was the most likely cause of the SE.
C. leadership must participate in the RCA.
D. start the RCA immediately to appropriately deal with causality
-------------------------------------------------------------------------------------------------------------------
346- The facilitator in patient focus group should do first :
A. Choose homogenous group
B. Make ground rules
C. Make rapport with group
D. Instruct orders
-------------------------------------------------------------------------------------------------------------------
347- hospital-wide set of professional standards is important because it…
a. Reduces the waste of time and resources
b. Eliminates bottlenecks
c. Encourages duplication
d. Minimizes the need for communication
-------------------------------------------------------------------------------------------------------------------
348- A facility has medical staff consists of 5 internists , 3 neurologists , 2
pediatricians , and 1 dermatologist , who should make the peer review for the
dermatologist ?
a. the internist
b. chair of medical staff
c. peer from outside
d. the neurologist
-------------------------------------------------------------------------------------------------------------------
349- Critical data selection elements for focused review of appendectomy surgeon
A) appropriateness - admitting symptoms - pathology results
B- admitting diagnosis - pathology results - committee review
C) preoperative testing - surgeon - admitting diagnosis - age
D) LOS - diagnosis on admission - age – surgeon
-------------------------------------------------------------------------------------------------------------------
350- Which of the following monitors provides patient outcome information?
a. Healthcare-acquired infection rate
b. Nursing care documentation compliance
c. Antibiotic therapy discontinuation compliance
d. Equipment malfunction rate
-------------------------------------------------------------------------------------------------------------------
351-Hospital Utilization Management Plan generally includes provision for
a. Disaster planning.
b. Transition planning.
c. Quality planning.
d. Financial planning
-------------------------------------------------------------------------------------------------------------------
352- An organization leader has directed a healthcare quality professional to
measure the success of corrective actions plan on patient care planning ,the
organization leader wants to be at least 96% confident of the accuracy of the result
. the average daily census at the organization is 1,000 patients . the most accurate
and efficient sampling technique for this study would be to :
A – review 100% of all active records on one day of the past month.
B – review 10% of all discharge records for the past quarter.
C – estimate the percentage of records to be reviewed using
an accepted statistical formula appropriate for the population
D – identify 30% of all records that failed preliminary care plan compliance review.

-------------------------------------------------------------------------------------------------------------------

353- The first step in conducting an epidemiological study is to :

A – determine which statistical test to use .
B – formulate the question to be answered.
C – develop the data collection tool.
D – collect the data
-------------------------------------------------------------------------------------------------------------------
354- A healthcare quality professional is teaching staff members to respond to
patient complaints .which of the following is the most effective behavior when
dealing with angry patients?
A – terminate the conversation quickly.
B – ask the patient to calm down.
C – redirect the discussion.
D – acknowledge the patients feelings.
-------------------------------------------------------------------------------------------------------------------
355- A process indicator is defined as one that measures;
a- The appropriateness of the procedure or treatment.
b- An activity carried out to provide care or service.
c- Significant events that require further investigation.
d- Unexpected or negative variations.
-------------------------------------------------------------------------------------------------------------------
356- Using the 80/20 rule, 80% of the organization problems are issues related to :
a- Education
b- Performance
c- Staffing
d- Systems
-------------------------------------------------------------------------------------------------------------------
357- An organizations vision statement addresses :
a- How the organization will reach its goal
b- Where the organization will be in the future
c- What the organization budget will be
d- The standards of the organization
-------------------------------------------------------------------------------------------------------------------
358- In order to introduce performance improvement concepts throughout the
organization, a healthcare quality professional should consider implementing all of
the following steps except:
a- Distributing a newsletter containing applicable quality topics
b- Providing lectures regarding quality topics
c- Meeting with each department head on a regular basis
d- Mandating staff participation in self-study activities on
quality
-------------------------------------------------------------------------------------------------------------------
359- The major drawback of using raw numbers to present the result of quality
monitoring is that they :
a- Lack proper reference points for interpretation
b- Cannot be graphed
c- May be used for focused review
d- only measure compliance to established criteria

-------------------------------------------------------------------------------------------------------------------

360- Which of the following is an example of a leadership strategy to integrate the

patient safety program into healthcare organization overall performance
improvement system?
a- Evaluate training data to plan leadership retreats
b- Identify quarterly discharge rate for the organization
c- Conduct a root cause analysis to proactively identify risk
d- Use a system wide failure mode and effect analysis
-------------------------------------------------------------------------------------------------------------------
361- When introducing continuous quality improvement into organization , the
chief executive officer must first :
a- Assess the organization readiness for change
b- Obtain funding from the governing board
c- Educate supervisors in CPI principles
d- Reach consensus with the staff
-------------------------------------------------------------------------------------------------------------------
362- ―To Err is Human‖ ―Quality Chasm‖:
Joint commission (JC)
IHI
Institute of medicine (IOM)
-------------------------------------------------------------------------------------------------------------------
363- Most important in review physician profile:
Surgery case mix
Medical record completion
Blood utilization review
Fall rate review
-------------------------------------------------------------------------------------------------------------------
364- To obtain (direct contact) and (immediate feedback) from customer:
A- Focus group
B- Computer survey
C- Questionnaire
-------------------------------------------------------------------------------------------------------------------
365- Nurse receives call (complain), what she first do:
A- Read back and document
B- Call the physician and record the call
-------------------------------------------------------------------------------------------------------------------
366- Why prioritize process for improvement:
A- Not all processes need improvement
B- No resource for improve all process
C- Some improvement not meaningful
-------------------------------------------------------------------------------------------------------------------
367- To best evaluate learning program:
A- Observation of behavior change
B- Post test result
-------------------------------------------------------------------------------------------------------------------
368- To best evaluate effectiveness of training program:
A- Test result 80 % after the program
B- Test result 75 % after 6 months of the program
C- Practice what they learn
-------------------------------------------------------------------------------------------------------------------

369- When prepare pt for surgery, surgical site (incorrect), which identify it:
A- Surgical time out
B- Count equipment
C- Nurse assessment
-------------------------------------------------------------------------------------------------------------------
370- Old female admitted for hip replacement surgery, patient is identified, the
surgical site is mark incorrect and equipment the X-ray is presents a near miss
result of:
a- equipment check
b- Root cause analysis
c- Surgery time out
d- Informed consent
-------------------------------------------------------------------------------------------------------------------
371- The time of ―surgery time out‖:
A- Immediately before surgery
B- Before enter operation room
-------------------------------------------------------------------------------------------------------------------
372- To identify root cause, sequence of tools :
A- Flow chart, cause and effect, tree diagram
B- Flow chart, tree diagram, cause and effect
C- Tree diagram, cause and effect, flow chart
D- Tree diagram, flow chart, cause and effect
-------------------------------------------------------------------------------------------------------------------
373- Report about fall to GB contains:
A- Confidential code of nurse names
B- Codes of nurse names with the key in the report
-------------------------------------------------------------------------------------------------------------------
374- Critical value determined by:
A- The regulations and laws
B- Accrediting body
C- Organization
D- Literature
-------------------------------------------------------------------------------------------------------------------
375- Which department to review first:

Wrong pt identification wrong dose wrong drug

A- Medicine 2 3 4
 B- Urology 4 5 0

C- Obstetric 0 6 3

D- Surgery 1 2 3

-------------------------------------------------------------------------------------------------------------------
376- Informed consent:
A- Physician signature on treatment , complication, SE, alternative
B- Physician signature on discussion of treatment, complication, SE, alternative to
pt
C- Patient signature on treatment, complication, SE,
alternative
-------------------------------------------------------------------------------------------------------------------
377- To train employee on conflict resolution learn them :
Negotiation

-------------------------------------------------------------------------------------------------------------------

378- All of the following is positive patient outcome except:

A- Decreased complication.
B- Improved clinical & health status.
C- Reduced infection rate.
D- Decreased LOS
-------------------------------------------------------------------------------------------------------------------
379- The sample include all available data in the area is:
A. Quota
B. Convenience
C. Stratified random
D. Purposive
-------------------------------------------------------------------------------------------------------------------
380- Primary purpose of integration of financial & quality management:
A-develop physician profiles
B-Identify potential cash flow problem
C- Identify problem in resource management
D-Determine medical necessity of treatment
-------------------------------------------------------------------------------------------------------------------
381- The most common cause of medication error is:
A- Communication breakdown.
B- Computer system error.
C- Incompetent nurse
-------------------------------------------------------------------------------------------------------------------
382- Which of the following is applicable to everyone in health care facility:
A- Communication
B- Medication safety
C- Hand hygiene
D- Reconcile medication
-------------------------------------------------------------------------------------------------------------------
383- (Continuous Education Programs) is usually a function of which of the
following:
A- Human Resources
B- Quality improvement
C- UM
D- Budgeting
-------------------------------------------------------------------------------------------------------------------
384- Root cause analysis (RCA) should be performed:
A- Using a multidisciplinary team
B- Using practitioners who not involved in the event
C- Starting no earlier than 45 days after the event
-------------------------------------------------------------------------------------------------------------------
385- The indicator is driven from:
A- Standards of accrediting body
B- Community standards
C- Important aspects of care & service
-------------------------------------------------------------------------------------------------------------------

386- In an organization The expenses (N of patients=8000) = 120,000 $ , profit =

120,000 $ The organization want to increase expenses by 60,000 $ with the same
profit

How many patients should the organization increase:

1000
2000
3000
4000
-------------------------------------------------------------------------------------------------------------------

387- Consulting firm to evaluate performance improvement program, as a quality

professional what u should do first:

A- Schedule the program for the consulting firm.

B- Allow the consultant to establish the necessary goals for the project.

C- Ask the consultant for job description that s/he will follow.
D- Defer to the consultant regarding time frames and deadlines
-------------------------------------------------------------------------------------------------------------------

388- The most important in patient identification:

A- Barcode system
B- Computerized physician order entry

-------------------------------------------------------------------------------------------------------------------
389- The importance of ground rule:
A- Put in the first meeting to put frame for the relationship
between the members
-------------------------------------------------------------------------------------------------------------------
390- For variance interpretation the most suitable tool ;

A- Bar graph

B- Control chart
C- Run chart

D- Pie chart
-------------------------------------------------------------------------------------------------------------------
391- Compared data:

A. Bar graph
B. Control chart

C. Pareto chart
D. Histogram

-------------------------------------------------------------------------------------------------------------------
392- Sharing which data best supports risk prevention:

Monthly event/occurrence reporting

Root cause analysis
Failure mode and effects analysis
-------------------------------------------------------------------------------------------------------------------
393-A healthcare organization implementing ongoing performance improvement, which of
the following would most likely benefit the PI goals of the organization?
A- A system selected by middle & senior management resulting from proposals by
consultants
B-Cross functional processes evaluated by multidisciplinary
teams with support of management
C-Discrete systems relevant to & monitored by individual department
D- Comprehensive process developed, implemented & monitored by the QM
department
The wait time after 1y and 2 y:

A- The 2 line under control

B- The 2nd year wait time more than the 1st year due to decrease volume in these
year
-------------------------------------------------------------------------------------------------------------------

395- Problem solving, cross functional understanding, expanded area of expertise,

gain in status & power & increase span of knowledge are examples of

The benefits of teams

Resource requirements

Customer expectation

Strategic alliance
-------------------------------------------------------------------------------------------------------------------
396- Comparing Healthcare organizations by using medical error rates:
may present bias due to difference in reporting practices
provide best method for benchmarking patient safety
can't be performed by facilities less than 100 beds
must include minimum of 10 facilities
-------------------------------------------------------------------------------------------------------------------
397- Organizational continuing education needs are best identified through what
type of activities
UM
QI
Budgeting
HR
-------------------------------------------------------------------------------------------------------------------
398- Clinical pathway identifies all of the following except:
Patient satisfaction
Better & Best Practice
Cost survey
Outcome of processes
-------------------------------------------------------------------------------------------------------------------
399- The annual evaluation of QI process must

be accomplished by healthcare quality professional

document all problems identified in care / service

be based on organizational objectives

survey all departments & teams

-------------------------------------------------------------------------------------------------------------------

400- An effective risk management plan includes all of the following except:

description of educational programs

statement of purpose

description of reporting mechanisms

scope of the program

-------------------------------------------------------------------------------------------------------------------
401- Developing educational training program in QI , What component should be
included

quality definition & principles

performance appraisal results

discussion of incidents

Individual focus of activities

-------------------------------------------------------------------------------------------------------------------
402- In evaluating length of stay &outcome data on cardiac cathertization.
HealthCare quality professional identified direct relationship between Adverse
outcomes & physician practice pattern. This integrated approach involves
correlating

case/care management & finance

UM & QM
Finance & UM

Discharge planning & QI

-------------------------------------------------------------------------------------------------------------------
403- When choosing an outside consultant to lead employee focus groups, what
priority areas of expertise should CPHQ look for?
A- team development & management
B-Organizational assessment & change management
C-Group dynamics & facilitation
D-Organizational design & re-engineering
-------------------------------------------------------------------------------------------------------------------
404- In reviewing medical records in 1st& 2nd quarters of year

surgical time out performed 90 95

communication of critical results 91 95

pain score used 50 60

initial patient assessment performed 52 45

Which to be reviewed
initial patient assessment performed
-------------------------------------------------------------------------------------------------------------------
405- To assess culture:
A- Incident reports of all physicians & employees.
B- Facilitator expectation & records of team efforts.
C- Health insurance company contract.
-------------------------------------------------------------------------------------------------------------------
406- The greatest fear from using electronic medical record system

A-Data sabotage
B-Process reboot

-------------------------------------------------------------------------------------------------------------------

407- Organization committed to improving patient safety, Key areas to influence

change are
- Staff willingness to change, policies& procedures, redesign the structure &
improvement of morale.
- Structure, environment, equipment, process, application, leadership, culture.
- Medication delivery, structure, staff willingness to change, on-slip floors,
improvement of wards , environment
- Leadership ,culture ,policies& procedures ,staff incentives,
better lightening , evaluation of processes & Electronic
medical records
-------------------------------------------------------------------------------------------------------------------
408- Under conducting a sentinel event review, a RCA is:
Provide judgment of staff behaviors
Requires team consensus
Identifies gaps in patient care processes
Proactively identifies causes & effects.
-------------------------------------------------------------------------------------------------------------------
409- Quality improvement activities should be considered for all except:
A-Compatibility with facilities mission
B- Ease of development of data collection tool
C- Processes that are high volume for the facility
D- Findings from patient satisfaction surveys
-------------------------------------------------------------------------------------------------------------------
410- Choosing software for physicians, what is the role of healthcare quality
professional?
assess use of technology
Cost-benefit analysis
Focus group with end users
-------------------------------------------------------------------------------------------------------------------
411- Root cause analysis is done:
A- when adverse events occur
B- when there is a possible sentinel event
-------------------------------------------------------------------------------------------------------------------
412- Strong organization culture :
1- employees commitment to mission and vision
2- employees participate in CQI activities
3- leaders pass the organization values to staff

-------------------------------------------------------------------------------------------------------------------
413-appropriateness of appendectomy
A. preadmission test
B. pathology test
C. age
D. clinical test