The evolution of quality improvement in healthcare has shifted the primary focus from per-
formance of individuals to the performance of the
a. medical staff
b. governing body
c. ancillary departments
d. organization's systems - ANSWER d. organization's systems
The best way to evaluate the effectiveness of performance improvement training is through
a. observed behavioral changes
b. self-assessments
c. participants' feedback
d. post-test results - ANSWER a. observed behavioral changes
The primary objective of the operational linkage between risk management and quality/per-
formance improvement is to
a. meet regulatory requirements
b. develop a plan of action for individual cases
c. develop a comprehensive plan to prevent future occurrences
d. alert the hospital attorney of a potentially compensable event - ANSWER c. develop a
comprehensive plan to prevent future occurrences
The primary reason to analyze customer satisfaction surveys is to
a. provide data for the quality improvement program
b. meet pay-for-performance requirements
c. identify how perceptions relate to the services provided
1
,d. assist with evaluating employee performance - ANSWER c. identify how perceptions
relate to the services provided
Which of the following should a Quality Council provide to best ensure success of perfor-
mance improvement teams?
a. facilitator and recorder
b. empowerment and training
c. indicators and a data analyst
d. standards and procedures - ANSWER b. empowerment and training
Which of the following is the most effective way to integrate performance improvement con-
cepts throughout an organization?
a. quarterly newsletters
b. monthly lectures
c. quality teams
d. continuous monitoring - ANSWER c. quality teams
A critical difference between quality assurance (QA) and quality improvement is a shift in fo-
cus from
a. retrospective review to concurrent screening
b. nonclinical aspects to customer satisfaction
c. identifying poor performers to improving group performance
d. QA coordinators to teams - ANSWER c. identifying poor performers to improving group
performance
A clinical pathway on the management of hip fractures has been developed by a multi-disci-
plinary team and implemented in a large teaching hospital. After monitoring for 6 months,
the length of stay continues to exceed the guidelines. Which of the following should be the
next steps?
a. evaluate compliance with the pathway
2
,b. correlate the pathway with staffing levels
c. re-educate the staff on the purpose of the pathway
d. continue to monitor and collect additional data - ANSWER a. evaluate compliance with
the pathway
One difference between continuous quality improvement and traditional quality assurance is
that quality improvement always
a. requires the application of statistical process control
b. excludes monitoring and evaluation of care provided
c. focuses on systems or processes
d. addresses potential problems - ANSWER c. focuses on systems or processes
Which of the following sampling techniques selects participants based on their availability in
a certain plan during a specific time frame?
a. quota
b. random
c. volunteer
d. convenience - ANSWER d. convenience
The quality improvement director is responsible for coordination of accreditation survey ac-
tivities. Responsibilities will most likely include
a. facilitating self-assessments of compliance with standards, communicating new require-
ments to pertinent parties, and distributing the agenda for the survey
b. educating staff to all standards, writing the survey report, and completing the survey ap-
plication
c. developing a protocol for a mock survey, conducting unannounced surveys, and challeng-
ing the survey report
d. preparing for unannounced surveys, disseminating the survey report, and developing new
standards - ANSWER a. facilitating self-assessments of compliance with standards,
3
, communicating new requirements to pertinent parties, and distributing the agenda for the
survey
Frequency distribution can best be displayed through use of
a. a histogram
b. a flow chart
c. a force field analysis
d. an interrelationship diagram - ANSWER a. a histogram
An outpatient clinic is attempting to measure the quality of a newly developed diabetes dis-
ease management program. To accomplish this, laboratory results will be measured over
time. The best way to display the data is to use a
a. gantt chart
b. control chart
c. pareto chart
d. flow chart - ANSWER b. control chart
A valid data collection tool should incorporate
a. a minimum of 20 data elements
b. a reliable graphic presentation
c. the definition of data elements
d. allowance for variance of interpretation - ANSWER c. the definition of data elements
Balanced scorecards are useful because the
a. focus on the most significant strategic initiative
b. evaluate the pros and cons of the governing body's priorities
c. put strategy and vision at the center of an organization's effort
d. concentrate on the performance of individual units - ANSWER c. put strategy and vi-
sion at the center of an organization's effort
4
formance of individuals to the performance of the
a. medical staff
b. governing body
c. ancillary departments
d. organization's systems - ANSWER d. organization's systems
The best way to evaluate the effectiveness of performance improvement training is through
a. observed behavioral changes
b. self-assessments
c. participants' feedback
d. post-test results - ANSWER a. observed behavioral changes
The primary objective of the operational linkage between risk management and quality/per-
formance improvement is to
a. meet regulatory requirements
b. develop a plan of action for individual cases
c. develop a comprehensive plan to prevent future occurrences
d. alert the hospital attorney of a potentially compensable event - ANSWER c. develop a
comprehensive plan to prevent future occurrences
The primary reason to analyze customer satisfaction surveys is to
a. provide data for the quality improvement program
b. meet pay-for-performance requirements
c. identify how perceptions relate to the services provided
1
,d. assist with evaluating employee performance - ANSWER c. identify how perceptions
relate to the services provided
Which of the following should a Quality Council provide to best ensure success of perfor-
mance improvement teams?
a. facilitator and recorder
b. empowerment and training
c. indicators and a data analyst
d. standards and procedures - ANSWER b. empowerment and training
Which of the following is the most effective way to integrate performance improvement con-
cepts throughout an organization?
a. quarterly newsletters
b. monthly lectures
c. quality teams
d. continuous monitoring - ANSWER c. quality teams
A critical difference between quality assurance (QA) and quality improvement is a shift in fo-
cus from
a. retrospective review to concurrent screening
b. nonclinical aspects to customer satisfaction
c. identifying poor performers to improving group performance
d. QA coordinators to teams - ANSWER c. identifying poor performers to improving group
performance
A clinical pathway on the management of hip fractures has been developed by a multi-disci-
plinary team and implemented in a large teaching hospital. After monitoring for 6 months,
the length of stay continues to exceed the guidelines. Which of the following should be the
next steps?
a. evaluate compliance with the pathway
2
,b. correlate the pathway with staffing levels
c. re-educate the staff on the purpose of the pathway
d. continue to monitor and collect additional data - ANSWER a. evaluate compliance with
the pathway
One difference between continuous quality improvement and traditional quality assurance is
that quality improvement always
a. requires the application of statistical process control
b. excludes monitoring and evaluation of care provided
c. focuses on systems or processes
d. addresses potential problems - ANSWER c. focuses on systems or processes
Which of the following sampling techniques selects participants based on their availability in
a certain plan during a specific time frame?
a. quota
b. random
c. volunteer
d. convenience - ANSWER d. convenience
The quality improvement director is responsible for coordination of accreditation survey ac-
tivities. Responsibilities will most likely include
a. facilitating self-assessments of compliance with standards, communicating new require-
ments to pertinent parties, and distributing the agenda for the survey
b. educating staff to all standards, writing the survey report, and completing the survey ap-
plication
c. developing a protocol for a mock survey, conducting unannounced surveys, and challeng-
ing the survey report
d. preparing for unannounced surveys, disseminating the survey report, and developing new
standards - ANSWER a. facilitating self-assessments of compliance with standards,
3
, communicating new requirements to pertinent parties, and distributing the agenda for the
survey
Frequency distribution can best be displayed through use of
a. a histogram
b. a flow chart
c. a force field analysis
d. an interrelationship diagram - ANSWER a. a histogram
An outpatient clinic is attempting to measure the quality of a newly developed diabetes dis-
ease management program. To accomplish this, laboratory results will be measured over
time. The best way to display the data is to use a
a. gantt chart
b. control chart
c. pareto chart
d. flow chart - ANSWER b. control chart
A valid data collection tool should incorporate
a. a minimum of 20 data elements
b. a reliable graphic presentation
c. the definition of data elements
d. allowance for variance of interpretation - ANSWER c. the definition of data elements
Balanced scorecards are useful because the
a. focus on the most significant strategic initiative
b. evaluate the pros and cons of the governing body's priorities
c. put strategy and vision at the center of an organization's effort
d. concentrate on the performance of individual units - ANSWER c. put strategy and vi-
sion at the center of an organization's effort
4
