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You are overseeing quality assurance in a healthcare facility that recently implemented a new
medication dispensing system. After its adoption, several incidents were reported where
patients received incorrect medication dosages. As a CPHQ, what would be your primary course
of action? ✔Correct Answer-Implement additional safety checks within the medication
dispensing workflow.
What is the next step for a credentialing committee if it determines that a practitioner has a
significantly higher rate of complications after surgeries compared to their peers? ✔Correct
Answer-Initiate a focused professional evaluation ( FPPE)
A patient is scheduled for knee replacement surgery on their left knee. Before the procedure,
the surgical team marked the intended surgical site and conducts necessary preoperative
checks, including reviewing the patients medical records and performing imaging studies.
However, during the surgery, it is discovered that the procedure is being performed on the right
knee instead of the intended left knee. At which stage did the error most likely occur?
✔Correct Answer-surgery time out.
Total quality management philosophy assumes that: ✔Correct Answer-Most problems with
service delivery result from systems difficulties.
Which of the following is an example of a lagging indicator in healthcare quality?
a. nurse to patient ratio
b. hand hygiene compliance rate
c. patient satisfaction scores
d. length of stay in the emergency departmnet ✔Correct Answer-Length of stay in the
emergency department.
What does the Six Sigma methodology aim to achieve in healthcare quality improvement?
✔Correct Answer-Reduce process variation.
What should the quality manager do first when an organization requests assistance in preparing
for a survey by an accreditation body?
a. assign a team for the project
b. review the adherence of the organization to accreditation standards
c. arrange for a mock survey
d. educate the staff about the questions they will be asked ✔Correct Answer-Review the
adherence of the organization to accreditation standards.
Which of the following is the primary benefit of using external quality consultants?
,a. maintaining performance standards for the organization
b. clarifying the mission and vision of the organization
c. bridging the knowledge gaps
d. promoting effective communication ✔Correct Answer-Bridging the knowledge gaps.
When is the optimal time for evaluating a quality improvement project? ✔Correct Answer-
Upon project completion.
What is a key aspect of the strategy of brainstorming?
a. facilitation of discussion
b. idea generation
c. prioritization of issues
d. recording of ideas/issues ✔Correct Answer-Recording of ideas/issues
The term------ brings to mind the indicator panel on an automobile, which is most useful when
the car is moving as a way for the driver to monitor key performance metrics such as speed, fuel
leverage, engine performance, temperature and direction from digital display units. ✔Correct
Answer-Dashboard.
In a healthcare network comprising two facilities, which factor would most effectively enhance
patient satisfaction while optimizing costs?
a. minimizing the need for patients to undergo redundant medical tests when visiting different
facilities.
b. implementing a secure communication systems between healthcare providers across the
network.
c. streamlining the process for patients to transfer their medical records between the two
facilities.
d. ensuring that both facilities possess comparable levels of staff expertise and competency.
✔Correct Answer-Minimizing the need for patients to undergo redundant medical tests when
visiting different facilities.
What is the primary purpose of conducting a root cause analysis (RCA) in healthcare quality
improvement? ✔Correct Answer-To identify contributing factors to a problem.
Studies comparing self reports with proxy reports do not consistently support the hypothesis
that self reports are more accurate than proxy reports. However, conclusions drawn from
studies in which responses were verified using hospital and physician records show that, on
average: ✔Correct Answer-Health events are underreported in both populations.
Your hospital adopted a paperless system ( EMR), when applying for the program data was
missing from the surgical records your action as a CPHQ is:
a. assess the process of data entry in the system
b. assign one member of staff to enter the data
,c. conduct a root cause analysis to identifying the underlying reason for the missed data
d. educate the staff about the EMR ✔Correct Answer-Conduct a root cause analysis to
identifying the underlying reason for the missed data.
When reassessing the clinical competency of a physician during the reappointment process:
a. have a quality professional review the credential file
b. request the chief of the relevant department to review the file
c. perform the interview with the physician
d. conduct a group interview with practitioners ✔Correct Answer-perform an interview with
the physician.
What is the recommended course of action following a patient's death resulting from a
medication interaction?
a. conduct root cause analysis ( RCA)
b. initiate a cause and effect diagram
c. perform failure mode and effects analysis ( FMEA) ✔Correct Answer-Conduct a root cause
analysis ( RCA)
What is the initial stage in the strategic management process?
a. external and internal analysis
b. vision
c. setting measurable objectives
d. setting goals ✔Correct Answer-vision
Primary purpose of the integration of financial and quality management is: ✔Correct Answer-
identify problems in resource management.
Which areas should be the focus of a trend analysis of incidents within a healthcare facility?
a. case mix index and staffing patterns
b. timeliness of reporting and data accuracy
c. practitioner profile and diagnostic codes
d. severity level and occurrence types ✔Correct Answer-Severity level and occurrence types
During a team meeting focused on improving medication administration processes, the
discussion veers off track into concerns about patient billing errors. As the facilitator ,what
action should you take? ✔Correct Answer-Redirect the group to the original topic of
medication administration
The best way to evaluate any team is by:
a. member satisfaction
b. learning and innovation
c. aligning the vision of the organization
, d. quantifiable objectives ✔Correct Answer-quantifiable objectives
Which of the following is NOT a primary goal of healthcare quality improvement?
a. enhancing patient safety
b. increasing healthcare costs
c. enhancing patient satisfaction
d. improving patient outcomes ✔Correct Answer-increasing healthcare costs
When a surgeon perforates the colon during a colonoscopy, what is the appropriate course of
actions?
a. initiate FPPE (Focused professional practice evaluation)
b. remove his privilege
c. refer the case to peer review
d. conduct a root cause analysis ✔Correct Answer-conduct a root cause analysis.
How is a medication error typically viewed within the context of patient safety culture?
a. purposeful
b. malpractice
c. normal
d. negligence ✔Correct Answer-negligence.
Which quality indicator measures the ability of healthcare providers to deliver care in a timely
manner?
a. patient mortality rates
b. hospital acquired infection rates
c. average length of stay
d. wait times for appointments and process ✔Correct Answer-wait times for appointments
and procedures.
Which of the following is NOT a category of the Donabedian model for assessing healthcare
quality?
a. outcome
b. profitability
c. structure
d. process ✔Correct Answer-profitability
Who invented Donabedian model and what are the three categories? ✔Correct Answer-Dr.
Avedis Donabedian
Three main categories: structure, process and outcome
Which of the following is a primary function of a healthcare quality improvement committee?
a. identifying improvement opportunities