1|Page
CPPS DOMAIN 4: MEASURING & IMPROVING
PERFORMANCE QUIZZES & ANS!!
In Dec 2012, Hospital A reports a C.diff infection rate
of 8% and begins a series of infection prevention
measures to reduce HAIs in general, including the use of
stronger antibacterial cleaners throughout the hospital
and a hand hygiene awareness campaign. In Dec 2013,
this hospital reports a C.diff infection rate of 4%. What
is the best conclusion that can be drawn from these
infection rates?
A. Hospital A was successful in reducing their C.diff
infection rate in 2013.
B. Hospital A reduced their C.diff rate, though one
cannot tell which intervention was most effective.
C. Multiple infection prevention efforts are needed to
drive down C.diff infection rates.
D. No conclusions can be drawn. - ....ANSWER ....✔✔
D. No conclusions can be drawn
The Board of Hospital A wants to know how Hospital A's
safety performance in CLABSI compares to that of other
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hospitals in their region. Which data display would best
inform them for that decision?
A. Control charts of overall infection rate by quarter for
the past two years for each hospital in the region.
B. A table indicating the CLABSI rates of all hospitals in
the region relative to NHSN benchmark for CLABSI
infections for the past two years.
C. A written report summarizing the current CLABSI
prevention protocols of each hospital in the region.
D. A table showing the number of CLABSIs in each
hospital in the region by quarter for the past two years.
- ....ANSWER ....✔✔ B. A table indicating the CLABSI
rates of all hospitals in the region relative to the NHSN
benchmark for CLABSI infections for the past two years.
A patient safety professional is monitoring indicent
reports submitted for near misses and minor events to
identify areas of potential patient safety risk. Over the
last few months there has been a steady decline in the
number of reports being submitted each week. There
have been some leadership changes, but the staff has
been stable with no major personnel issues. Which of the
following actions should be taken in response to this
change?
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A. Report the data as a positive trend and celebrate the
improved performance
B. Issue a message to the staff that failure to report can
lead to discipline
C. Continue to monitor for fluctuations, no action
required at this time.
D. Ensure reporting is being emphasized and feedback
on submitted reports is occurring. - ....ANSWER ....✔✔
D. Ensure reporting is being emphasized and feedback
on submitted reports is occurring.
An organziation has implemented measures to provide
preventative health screenings in an effort to prevent
disease, delay the onset of disease, keep diseases from
worsening, and reduce costs to healthcare. In order to
measure effectiveness of implemented interventions,
multiple measurements were analyzed. To best capture
process measurements, the team should capture data on:
A. The number of patients who reported adopting a
healthier lifestyle as a result of the screening
B. The number of patients whose pre-existing conditions
improved after having been screened
C. Costs to the organization pre and post
implementation of the health screenings
CPPS DOMAIN 4: MEASURING & IMPROVING
PERFORMANCE QUIZZES & ANS!!
In Dec 2012, Hospital A reports a C.diff infection rate
of 8% and begins a series of infection prevention
measures to reduce HAIs in general, including the use of
stronger antibacterial cleaners throughout the hospital
and a hand hygiene awareness campaign. In Dec 2013,
this hospital reports a C.diff infection rate of 4%. What
is the best conclusion that can be drawn from these
infection rates?
A. Hospital A was successful in reducing their C.diff
infection rate in 2013.
B. Hospital A reduced their C.diff rate, though one
cannot tell which intervention was most effective.
C. Multiple infection prevention efforts are needed to
drive down C.diff infection rates.
D. No conclusions can be drawn. - ....ANSWER ....✔✔
D. No conclusions can be drawn
The Board of Hospital A wants to know how Hospital A's
safety performance in CLABSI compares to that of other
,2|Page
hospitals in their region. Which data display would best
inform them for that decision?
A. Control charts of overall infection rate by quarter for
the past two years for each hospital in the region.
B. A table indicating the CLABSI rates of all hospitals in
the region relative to NHSN benchmark for CLABSI
infections for the past two years.
C. A written report summarizing the current CLABSI
prevention protocols of each hospital in the region.
D. A table showing the number of CLABSIs in each
hospital in the region by quarter for the past two years.
- ....ANSWER ....✔✔ B. A table indicating the CLABSI
rates of all hospitals in the region relative to the NHSN
benchmark for CLABSI infections for the past two years.
A patient safety professional is monitoring indicent
reports submitted for near misses and minor events to
identify areas of potential patient safety risk. Over the
last few months there has been a steady decline in the
number of reports being submitted each week. There
have been some leadership changes, but the staff has
been stable with no major personnel issues. Which of the
following actions should be taken in response to this
change?
, 3|Page
A. Report the data as a positive trend and celebrate the
improved performance
B. Issue a message to the staff that failure to report can
lead to discipline
C. Continue to monitor for fluctuations, no action
required at this time.
D. Ensure reporting is being emphasized and feedback
on submitted reports is occurring. - ....ANSWER ....✔✔
D. Ensure reporting is being emphasized and feedback
on submitted reports is occurring.
An organziation has implemented measures to provide
preventative health screenings in an effort to prevent
disease, delay the onset of disease, keep diseases from
worsening, and reduce costs to healthcare. In order to
measure effectiveness of implemented interventions,
multiple measurements were analyzed. To best capture
process measurements, the team should capture data on:
A. The number of patients who reported adopting a
healthier lifestyle as a result of the screening
B. The number of patients whose pre-existing conditions
improved after having been screened
C. Costs to the organization pre and post
implementation of the health screenings
