النجاح الباهر 7
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النجاح الباهر 7
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7 النجاح
Important Questions of
Exam
March 2019
To have patient
Leadership Lesson
Just Culture Reporting
safety Commitment Learned
Case Management Process
Important areas of exam March 2019
Teams, everything related to team Leadership style
formation, evaluation, successful Role of senior manager
team , role of sponsor …ect ( communication)
Patient safety and patient center Alignment
care Risk management
FMEA Risk priorities
PDCA Survey for accreditation
Brainstorming External consultant
Affinity diagram Preparation for accreditation
Control chart Unannounced survey
JCI Human factor
Definition of paradigm shift Barcoding
Janett chart
1- Who achieves target of ( level 1) with 100$, and reward the
staff who achieves target of (level 2) with 200$. According to the
following table, who of the following staff will NOT take any
incentives? The staff who will reach level 1 will take 100$, and
who will reach level 2 will take 200$
Staff Staff Staff Staff Level of
#1 #2 #3 #4 achievement
a) Staff # 1 Level 1 Level 2
b) Staff # 2
Hand Hygiene 75% 60% 95% 80% 70% 90%
c) Staff # 3 Surgical 70% 60% 90% 80% 65% 85%
d) Staff # 4 check list
Guidelines 80% 70% 95% 90% 75% 95%
Answer is …….B
2- Hospital plan to applied telehealth program and need to
spread it among its facility, among who of the following need to
be added in the team to help in communicate it?
a) Adaptive audience
b) Local media
c) Legal legislation
Answer is …….A
3- In evaluating length of stay &outcome data on cardiac
catheterization. Healthcare quality professional identified direct
relationship between adverse outcomes & physician practice
pattern. This integrated approach involves correlating:
a) Case/care management & finance
b) UM&QM
c) Finance &UM
d) Discharge planning &QI
Answer is …….B
4- The role of a team facilitator is to focus on:
a) Analyzing problem during meetings
b) The process
c) Generating and selecting solutions
d) The content
Answer is …….B
5-Which area you are recommending first for improvement
action:
Unit Time Medication Medication
dispensing Administration a)Medication dispensing in
Observat 7am-7pm 30% 70% ICU and observation
ion
7pm-7am 10% 40% b) Medication
North2 7am-3pm 40% 20%
administration in ICU and
3pm-11pm 0% 10%
observation
11pm-7am 10% 10%
South 7am-7pm 40% 30%
c) Medication dispensing in
7pm-7am 20% 20% north 2 and observation
ICU 7am-7pm 50% 40% d) Medication
7pm-7am 30% 20%
administration in ICU and
south
Answer is …….B
6- According to the Law of Diffusion of Innovations, the highest
rate of rise in innovation diffusion occurs among the
a) innovators
b) early adopters
c) early majority
d) late majority
Answer is …….C
7- patient was about to under wrong test , this consider :
a) near miss
b) latent error
c) human factor error
Answer is …….A
8-Availability of hand sanitizer is an example of:
a) Structure measure
b) Process measure
c) Outcome measure
Answer is …….A
9-Recent patient satisfaction surveys demonstrated that the responses to
the following questions did not meet the 80% benchmark: based on these
results, which two performance improvement activities should the
organization focus on FIRST? Area of concern Satisfaction Importance
a) add magazine and music to the waiting The staff were having personal 40 70
area, monito staff conversations for conversation in my presence
appropriateness While waiting in the holding area, it is 33 46
important to be offered items such as
b) Provide educational sessions for staff to magazines or music, ect… for distraction
improve patient communication
skills ,renovate waiting area I found the physical environment pleasant 68 79
for example: uncluttered , appealing to
c) add magazine and music to the waiting look at, adequate space for privacy, ect.
area, ,renovate waiting area
d) Provide educational sessions for staff to The nursing staff reassured me that my 69 93
improve patient communication skills, family would be kept-up-to-date during
my surgical procedure
review with staff the appropriateness of
In the holding area, I felt comfortable 74 84
personal conversation in front of patients. enough to provide personal information
without worrying that everyone was
Answer is …….A listening
10-An employee health program includes a pre-employment health
assessment for all prospective employees who are asked to be completed
and the results should be known prior to assumption of duties. A
retrospective study of 200 records displayed in the following chart. Review
of this information indicators which of the following?
a) Approximately 95% failed to meet the
stated objectives
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
Answer is …….A
11- Internal customer in admission process ,or who is
considered the internal customer in an advanced nursing facility
a) nurse competing the initial assessment
b) family and patient
c) patient being admitted
Answer is …….A
12- An improvement project did not reach its outcome in
radiology CPHQ should recommend:
a) Review of statistical method used
b) Review of clinical indicators used
Answer is …….A
13- Which indicator can be considered most important for
radiology department
a) Timeout
b) Mammography turnaround reporting
c) Contrast induced complications
Answer is …….C
14- Physician with 10% unplanned admission CPHQ should:
a) Review unplanned with peer physicians
b) Conduct focused review for unplanned cases
c) Review both planned and unplanned cases
Answer is …….A
15- Education of new hiring the CPHQ should what:
a) Set content by type of attended staff
Answer is …….A
16- CPHQ wants to determine process measure to improve
wound care outcome, FIRST thing to do:
a) Three years prior best practice in wound care
b) Clinical trials in wound care
c) Search guidelines for wound care
d)Review clinical record for wound care sentinel
events
Answer is …….C
17-To protect practitioner performance data use:
A-Limiting access
B-obtaining proper consent to release.
C-having all staff sign a confidentiality agreement.
D-removingall patient and practitioner identifiers
from documents.
Answer is ……. A
18
Answer is …….D
19- A surgeon almost always operates on the wrong body part.
The best action is?
a) Temporary suspension till the investigation
finished
b) focused review of his cases
c) does nothing
OR another form
19-A surgeon almost operates on the wrong body part in good
patient safety culture . The best action is?
D) Reporting
Answer is …….A or D ( if without always )
20. Which of the following is true regarding medication errors:-
a) Associated with process failure
b) Prevented by review of evidence based practice
c) caused by gap between patients expectations and
practice
d) avoid by uniform practice
Answer is …….A
21.A surgeon almost always operates on the wrong body part.
The best action is?
a) Temporary suspension till the investigation
finished
b) focused review of his cases
c) does nothing
Answer is …….A
22.Which of the following is an example of patient-centered
care?
a) Bedside rounds
b) Using two patient identifications
c) Pre-printed discharge instructions
d) Age based dosing
Answer is …….A
23. Organization work on employee purchasing power
a) JCI
b) Leapfrog
Answer is …….B
24. For a run chart the Central Line is called :
a) Mode
b) Standard division
c) Median
d) Mean
Answer is …….C
25. Who is responsible about performance improvement plan:
a) Quality manager
b) Leaders
c) GB
d) CEO
Answer is …….B
26.Which tool results in major problems or issues need to be
addressed:
a) Affinity
b) Force field
c) Nominal group
d) Interrelationship diagram
Answer is …….C
27. Who is considered the internal customer in an advanced
nursing facility
a) nurse competing the initial assessment
b) family and patient
c) patient being admitted
Answer is …….A
28. By forming a team after 1 month team attendance is
declined, which stage of team development:
a) Storming
b) Norming
c) Performing
d) Norming
Answer is …….A
29. An employee health program includes a pre-employment
health assessment for all prospective employees who are asked
to be completed and the results should be known prior to
assumption of duties. A retrospective study of 200 records
displayed in the following chart. Review of this information
indicators which of the following?
a) Approximately 95% failed to meet the
stated objectives
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
Answer is …….A
30. An organization set a goal 90% of waiting time to be below
15 minuets , here is a 10 cases time 5,5,9,10,12,12,12,14,22,25
with average 12.6 min what to do?
a) Set a trigger at 80%
b) Review data with more than 15 minuets
c) Nothing, the target is met
d) No thing
Answer is …….B
31. Which area you are recommending first for improvement action:
Unit Time Medication Medication
dispensing Administrat
ion
a) Medication dispensing in
Observati 7am-7pm 30% 70%
on ICU and observation
7pm-7am 10% 40%
North2 7am-3pm 40% 20%
b) Medication administration
3pm-11pm 0% 10% in ICU and observation
11pm-7am 10% 10% c) Medication dispensing in
South 7am-7pm 40% 30% north 2 and observation
7pm-7am 20% 20%
d) Medication administration
ICU 7am-7pm 50% 40%
in ICU and south
7pm-7am 30% 20%
Answer is …….B
32. patient was about to under wrong test , this consider :
a) near miss
b) latent error
c) human factor error
Answer is …….A
33.Which
of the following is the major responsibility of senior
management regarding continuous quality improvement?
a) Communicate the organizational mission and
values.
b) Develop organization-wide training sessions.
c) Participate in Quality Council activities.
d) Conduct periodic reviews of the program
Answer is …….A
34. HCQ will participate in strategic planning, which of the
following will have the primary effect on performance
improvement goals:
a) Results of gap analysis
b) Report of competitor's activities
Answer is …….A
35. Choosing software for physicians, what is the role of
healthcare quality professional?
a) Assess use of technology
b) Cost-benefit analysis
c) Focus group with end users
Answer is …….C
36. Hospital plan applied telehealth program and need to
spread it among its facility, among who of the following need to
be added in the team to help in communicate it.
a) Adopter audiences
b) Local media
c) Legal legislation
Answer is …….A
36. There is new accreditation body , CPHQ first action is :
a) Check accreditation standards to check the
organization readiness.
b) Hire external consultant.
c) Standards education to staff.
Answer is …….A
37. The upper and lower control limits in control chart :
a) Used to identify the distribution of data.
b) Calculated by using the collected data
c) It is in threshold
Answer is …….B
38. A unit dose was prepared 2.5 ml and actually needed is
1ml and the rest was discarded the pharmacist asks the CPHQ
something to do about the excess inventory and decrease waste:
a) Six sigma
b) Lean
Answer is …….B
39. Characteristics about performance improvement:
a) Systematic
b) Timely
c) Autonomous
Answer is …….A
40. Joe Smith wants to study patient satisfaction in his
institution but wants to get the largest group possible so he
conducts his study in the local mall. His study might be criticized
not only for reaching individuals who are not patients, but also
that it is
a) Capitated
b) Non randomized
c) Randomized
d) Varied
Answer is …….B
41. Which indicator can be considered most important for
Radiology Department ?
a) Timeout
b) Mammography turnaround reporting
c) Contrast induced complications
Answer is …….C
42. Who is responsible for creating and monitoring the
implementation of improvement project work plan and time line
a) Sponsor
b) Team leader
c) Team facilitator
d) Quality council
Answer is …….B
43. In Culture of patient safety errors is regarded as?
a) Malpractice
b) Normal
c) Negligence
or
A medication error is regarded as ,,,,
a) Malpractice
b) purposeful
c) Negligence
D) Normal
Answer is …….B ……………… A
44. What is the tool used to display large amount of data
language in the group that have related topics
a- ishikawa
b- force field
C- affinity diagram
Answer is …….C
45. To assist physician to improve their performance with pay
for performance program, first begin with:
a) Obtain a copy of the physician measures.
b) Suggest educational program for the physician
c) Searching for benchmark data for physician
practice
Answer is …….A
46. An outbreak of measles in a school district resulted in 58
cases over a period of 5 months. Which of the following data
displays best illustrate the monthly occurrence of measles
a) Run chart
b) Pie chart
c) Gantt chart
d) Scatter diagram
Answer is …….A
47. Which of the following is the best tool to begin on
investigation into the causes of laboratory labeling error?
a) Affinity diagram
b) Prioritization matrix
c) Flow chart
d) Histogram
Answer is …….C
48. Empowerment give employees the opportunity to:
a) Solve problem
b) Make more money
c) Gain respect of peers
d) Achieve upward mobility
Answer is …….A
49. Quality improvement team outcomes are best evaluated by
which of the following?
a) Team leader
b) Senior leadership
c) PDCA process
d) Nominal group technique
Answer is …….C
50. Based on identified issues, a healthcare quality
professional examines 100% of one physician’s admission and only
20% of all other physicians’ admissions. This is best described as
a
a) Focused review
b) Prospective review
c) Retrospective review
d) Concurrent review
Answer is …….A
51. What sampling technique involve selecting the medical
record of every fifth patient undergoing cardiovascular bypass?
a) Convenience
b) Systematic
c) Stratified
d) Simple random
Answer is …….B
52. Which of the following sample techniques selects
participants based on their availability in a certain place during a
specific time frame?
a) Quota
b) Random
c) Volunteer
d) Convenience
Answer is …….D
53. A quality improvement manager must decide how to
present data that demonstrates the relationship between two
process characteristics. Which of the following data display
techniques is most appropriate?
a) Bar chart
b) Scatter diagram
c) Pareto chart
d) Line graph
Answer is ……. B
54.An outbreak clinic is attempting to measure the quality of a
newly developed diabetes disease management program. To
accomplish this laboratory results will be measured overtime .
The best way to display the data is to use a :
a) Gantt chart
b) Control chart
c) pareto chart
d) flow chart
Answer is …….B
55. A failure mode and effects analysis (FMEA) provides which
of the following types of review?
a) Proactive
b) Retroactive
c) Concurrent
d) Retroactive
Answer is …….A
56. Availability of hand sanitizer is an example of:
a) Structure measure
b) Process measure
c) Outcome measure
Answer is …….A
57. Physician with 10% unplanned admission CPHQ should:
a) Review unplanned with peer physicians
b) Conduct focused review for unplanned cases
c) Review both planned and unplanned cases
Answer is …….A
58-Replacing retrospective review with concurrent review is an
example of
A. a paradigm shift.
B. a process improvement.
C. an empowerment process.
D. productivity enhancement.
Answer is ……. A
59-To reduce the incidence of ventilator-associated pneumonia
(VAP) in a critical care unit, who should be included on a quality
improvement team?
A. Intensives , ICU nurse, and respiratory therapist
B. primary care physician, infection control nurse, and
surgeon
C. ICU manager, respiratory therapist, and pharmacist
D. pharmacist, intensivist , and infection control nurse
Answer is …….A
60-Quality improvement team progress is best evaluated by
which of the following?
A. team leader
B. senior leadership
C. PDCA process
D. nominal group technique
Answer is ……C
61- Which of the following is an example of patient-centered
care?
a- Bedside rounds
b- Using two patient identifications
c- Pre-printed discharge instructions
d- Age based dosing
Answer is …….A
62- A surgeon almost always operate on the wrong body part the
best action is
A-temporary suspension till the investigation finished
B-focused review of his case.
C-do nothing.
Answer is …….A
63- Which of the following is true regarding medical errors
A. associated with process failure
B. prevented by review of evidence based practice
C. caused by gap between patients expectations and
practice
D. avoided by uniform practice
Answer is …….A
20 March 2019
64- Publicly report measures are developed through a life cycle
in which of the following sequences
A- first year data collection, public comment,
evaluation
B- topic select, measure develop , public comment
C- measure developed, evaluation, topic selection
D- public comment, Measure developed, first year
data collection
Answer is …….B
65- New pediatric psychiatry will open in one year. The
utilization coordinator is responsible for developing the
utilization management progress. The programe success will
depend on which factor
A-obtaining approve from the chief psychiatry of
each stage
B- Provide education in service to all team member
involved
C- develop program and present it to approve
D-involving the team member in developing
programe
Answer is …….D
66- What is the best way to deal with conflict in a group?
A- A mandate
B- Assertiveness
C-“Smoothing”
D-Negotiation
Answer is …….D
67- Which one of the following reflect medication reconciliation?
A- write the accurate medication list and compare
with other list “to identify dose, name”
B-Consult the medical physician to validate patient
medication list
C-Writ the medication name, dose, frequency, rout
in the medical record
D .Identity and resolve discrepancies
لو االختيار دا موجود بيكون هوا الصح
Answer is …….B
68- Surgeon has 6.7% SSI in a specific procedure, while his
collogue has 3.3 % SSI for the same procedure.
The data was reviewed by the chair of the department, the
quality professional recommend:
A- RCA
B- Focus review
C- temporarily suspension the surgeon
D- stop the privilege of the doctor
Answer is …….2
69-Which of the following should be used to create ckinux
practice guide line
A- national norms
B-Population based standard
C- established criteria
D-evidence based literature
Answer is …….D
70- Primary consideration in selecting and evaluating criterion is
that it be
a- team approve by the quality
review committee
B- concerned with the cost of care
C- reflect the clinical practice
D-data that can be measured
Answer is …….D
71- Publicly report measures are developed through a life cycle
in which of the following sequences
A- first year data collection, public comment,
evaluation
B- topic select, measure develop , public comment
C- measure developed, evaluation, topic selection
D- public comment, Measure developed, first year
data collection
Answer is …….B
72- Healthcare quality professional is comparing healthcare
associated infection among hospital of varying sizes specialized
services and geographical region which of the following most
useful
A- readmission rate
B- Healthcare associated
pneumonia rates
C- risk adjustment rates
D- overall infection rates
Answer is …….C
73- New pediatric psychiatry will open in one year. The
utilization coordinator is responsible for developing the
utilization management progress.
The program success will depend on which factor
A- obtaining approve from the chief psychiatry of each
stage
B-Provide education in service to all team member
involved
C- develop program and present it to approve
D- involving the team member in developing program
Answer is …….D
74- Characteristic about performance improvement:
A. systematic
B. timely
C. autonomous
Answer is …….A
75-Quality council wants to evaluate team improvement for last
year. Which one you choose to improve?
Answer is ……. Productivity (the lowest one)
76-a unit dose was prepared 2.5 ml and actually needed is 1ml
and the rest was discarded the pharmacist asks the CPHQ
something to do about the excess inventory and decrease waste:
A- Six sigma
B- Lean
Answer is …….B
77-To set up on effective improvement project to prevent
employees from omitting:
1. Proactive risk management soft ware
to identify risks and automatic alarm to risk manager
2.A warning system that is contiguous and cues that
a wrong thing is about to occur
Answer is …….2
78- The upper and lower control limits in control chart :
A. Used to identify the distribution of data.
B. Calculated by using the collected data
C. It is in threshold
Answer is …….2
79- Joe Smith wants to study patient satisfaction in his
institution but wants to get the largest group possible so he
conducts his study in the local mall. His study might be criticized
not only for reaching individuals who are not patients, but also
that it is
A. Capitated
B. Non randomized
C. Randomized
D. Varied
Answer is …….B
80-When attendance declined after 2 months, in which stage are
they?
1- Storming
2- Forming
3- norming
Answer is …….1
81- Physician has 10 % unplanned admission , what CPHQ will do
A- Compare the unplanned admission with peer
physician
B- Review prior planned and unplanned admission for
that surgeon
c- focus review for the unplanned admission
d- report to GB
Answer is …….A
82- Facility has admission from different sources
20.000 home
10.000 physician referral
786 skilled nursing facility
50 others
What is the best tool to demonstrate the proportion of admission for each
source ?
A- Run
B- Histogram
C- Pareto
D- Control
Answer is …….C
83- Confidentiality of information is best accomplished by:
A-limiting access.
B-obtaining proper consent to release.
C-having all staff sign a confidentiality agreement.
D-removingall patient and practitioner identifiers
from documents.
Answer is …….A
84- Upper control limit & lower control limit is
a) derived from special cause variation
b) actual process measure
Answer is …….B
85- 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
Answer is …….A
86- The best definition of adverse event
A- Unintended and should be investigated
B- Avoidable and should be reported
C- Compensable event
Answer is …….A
87- The facilitator role in the team :
A- Focus in people
B- Focus on process
C- Focus on data
D- Follow time line
Answer is …….B
88- Which tool used to check process stability?
1- Run chart
2- Control Chart
Answer is …….2
89- In patient safety, errors are:
1- Normal
2- Negligence
3- Purposeful
4- Misconduct
Answer is …….1
90- Outpatient Surgery Center a assembled a quality council
from CEO, CFO and Medical Director , who should else be added:
1- Nursing Director
2- Safety Environment Supervisor
3- Head of HR
4- head of medical record
Answer is …….1
91-Which indicator can be considered most important for
Radiology?
a- Timeout.
b- Mammography turnaround reporting.
c- Contrast induced complications.
Answer is …….3
92- 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
Answer is …….A
93-Choosing software for physicians, what is the role of
healthcare quality professional?
A . assess use of technology
B . Cost-benefit analysis
C . Focus group with end users
Answer is …….C
94-Compare two facilities in many problem .the 2 facilities the
same in all those problems except falling rate what we will do
Review fall.
Answer is …….
95-The first task in a continuous quality improvement process
analysis to
a. Define problems arising within the system
b.Monitor the system to ensure no new problems
occur
c. Evaluate the effects of changes to the system
d-Separate external from internal problem
Answer is …….A
96- Display data for last year monthly:
A-histogram.
B-Pareto
Answer is …….A
97- Effectiveness of performance improvement program best
assessed by :
A) patient satisfaction
B) staff competencies
C) guideline compliances
D) organizational culture
Answer is …….A
98-Department manger wants to improve customer service, in
order to gain the support of the employee what should the
manager do FIRST:
A-Demonstrate need for change
B-Seek authorization from GB
C-empower employee
D-include customer service in performance review
Answer is …….A
99- The key element for safety medication management
A . Relying on barcode instead of two patient
identifiers
B.use standard method for medication
administration
C. restricting formulary generic drug
Answer is …….B
100-The first task in a continuous quality improvement process
analysis to
a. Define problems arising within the system
b. Monitor the system to ensure no new problems
occur
c. Evaluate the effects of changes to the system
d-Separate external from internal problem
Answer is …….A
101-Quality professional want to improve communication with
patient family , there are 3 problems faced him
“1” Patient family did not understand English
” 2” Difficulty in meeting treating physician
“3”
What he will do ???
A- Calculate RBN
B- Bring English translator
C- Convince patient family advisor
Answer is ……. A
102-
في تقليل االخطاء الدوائيه في:سؤال بيحكي عن دور منسق الجودة كان من ضمن االختيارات
المستشفى بعد ما جاءهم تقرير انها ارتفعت
A-drill
down data to identify a trend before making
recommendations.
B-conduct research to use BCMA.
C-assess staff competency for medication
administration.
Answer is …….A
103-Surgeon has 6.7% SSI in a specific procedure, while his
collogue has 3.3 %. The data reviewed by chair of the
department, the quality professional recommend:
1- Focus review
2- RCA
3- temporarily suspension the surgeon
4- stop the privilege of the doctor
Answer is …….1
104- Which of the following patient centered care the
percentage of
A-patient actively involvement
B- patient satisfaction survey
Answer is …….A
105-Leader of a project did a brain storming then he put the
ideas into (( Thematic)) group. What is the tool he used for this?
1- Affinity Diagram
2- Ishikawa
Answer is …….1
106-Leader of a project did a brain storming then he put the
ideas into (( Thematic)) group. What is the tool used after this?
1- Affinity Diagram
2- Ishikawa
Answer is …….2
107- Managed care peer review first obtain
A. confidentiality statement
B. clinical practice guideline
Answer is …….A
108-When a healthcare organization is contracting with an
outside provider for services, the subcontractor must:
A. provide a representative to the Quality Council.
B. Agreed upon performance expectations
C. have an active risk management program.
D. have a competitively priced service.
Answer is …….B
109- The main responsibility of QI program is to
A- establish target priorities
B- obtain customer satisfaction data
Answer is …….A
110-A group want to perform FMEA for improvement of patient
discharge. Quality improvement team found many problems
related to patient and family .What is next step for quality
improvement team?
1-consult family
2-observe patient discharge
3-calculate RPN
Answer is ……. 3
111- Which is best solved by quality team:
A. System problem
B. Customer complains
C. Financial problem
D. Administrative problem
Answer is …….A
112- Difference between research & CQI
1-withdraw outcome
2-data analyzed & displayed
3-identify RCA
Answer is …….3
113-Compliance with hand hygiene. Utilizing PDCA , the plan
step has been accomplished . They will use improvement using
Shewhart cycle, what is the next step:
1-collect data
2-simulate hand washing(proper hand hygiene)
3-review the observation of staff in hand washing.
Answer is …….2
114- The patient discharged without any counseling of his care, this
problem, concerned with:
A-medical coverage
B-case management
C-transition care
D-reconciliation
Or
When the patient didn't receive sufficient counseling in his case this is
1. Care transition
2. Case management
Answer is …….C ,,,,2
115-A Quality improvement team want to do FMEA for
improvement of patient discharge ,the team found many
problems related to patient and family. What is next step for
quality improvement team?
1-consult family
2-observe patient discharge
3-calculate RPN
Answer is …….3
116- The following technology has been used for patient safety?
A- BCMA
B- movable bedside barcode
Answer is …….B
117-The first task in a continuous quality improvement process
analysis to
a. Define problems arising within the system
b. Monitor the system to ensure no new problems
occur
c. Evaluate the effects of changes to the system
d-Separate external from internal problem.
Answer is …….A
118-
Difference between scientific method and quality
improvement:
A- Identify the rout cause of the result
B- Communicate outcome
Answer is …….A
119-Surgeon has 6.7% SSI in a specific procedure, while his
collogue has 3.3 %. The data reviewed by chair of the
department, the quality professional recommend:
1- Focus review
2- RCA
3- temporarily suspension the surgeon
4- stop the privilege of the doctor
Answer is …….1
120- Annual review of QI program done to :
1- effectiveness of the program
2- identify mission statement.
3- review/ identify scope of service
Answer is …….1
121-
Performance improvement program should be initiated
when:
a. Staff turnover is very high in certain units
b. Staff overtime is increasing
c. Staff wants new working schedule with4 days off
d. Data analyzer in lab is giving wrong results
Answer is …….A
Answer is …….B
122- There is new accreditation body , CPHQ first action is :
1- check accreditation standards to check the
organization readiness.
2- hire external consultant.
3- standards education to staff.
Answer is …….1
123-An emergency department’s quality improvement report for the first quarter
of the year showed the following:
In which of the following areas should the healthcare quality professional initiate
further
process analysis? And which tool can be used for data display?
A- Problems associated with treatment, flow chart.
B. Misinterpreted x-rays; control chart.
C. Problems associated with treatment; Pareto chart.
D. Misinterpreted x-rays; run chart
Answer is …….C
124-
Which of the following is the major responsibility of senior
management regarding continuous quality improvement?
A. Communicate the organizational mission and
values.
B. Develop organization-wide training sessions.
C. Participate in Quality Council activities.
D. Conduct periodic reviews of the program
Answer is …….A
125-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 is …….C
--- talk about safety culture ( long phrase)
- consider that sharp injuries as system failures
important q about the nurse and provider and staff
registration.
Best match roll:
2 answers far away
2 answers confusing ( first answer the provider is champion
and the quality Sp is facilitator and
The other answer: the staff nurse is team leader and quality
sp is process owner)
-- Def of Paradigm shift:
االختيارات كلها جديدة اول مرة اشوفها
-- an organization with notably fewer adverse events
reflects :
1- Effective risk management (my answer)
Def of histogram:
- distribution ( my answere)
- two variables
--- Affinety diagram (clear and simple) with key word
(thrematic groups)
--- the Q with long phrase and then asked about the tool to be
used in the first step :
- Flow chart
--- when the point is NOT Sp cause variation :
- when lies between ULC and LLC
autocratic leader :-
answer contains the one who takes the decision
alone and then tell the staff
2 Questions about
Range definition
Difference between high and law variances
حاجة ندرس بيها ال
Quality Improvement Ideas
Appropriateness of radiology care is evaluated by:
chief of radiology
Quality of care policy is ultimate responsibility of:
board of director
Medical director:
pass on commitment and value of understanding
For CQi to be successful who must be included in staff
A. administrator
B. person performing process
C. quality management representative
D. department supervisor
Answer is …….B
Who is responsible for providing CQI direction
A. facilitator
B. quality council
C. leader
D. team
Answer is …….B
Who is responsible for quality improvement within organization
A. quality manager
B. frontline staff
C. everyone within organization
D. chief executive office
Answer is …….C
Who is responsible for creating and monitoring the
implementation of improvement project work plan and time line?
A. sponsor
B. team leader
C. team facilitator
D. quality council
Answer is …….B
Who is ultimately responsible for the effective implementation
of the quality program:
a. Governing Body
b. CEO
c. All staff
d. The CFO
Answer is …….A
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
Answer is …….C
#march2018
Internal customer in admission process :
A. Nurse completing the initial assessment
B. Family and patient
C. Patient being admitted.
Answer is …….A
Whichof the following is the first step in facilitating change in
an organization?
a. Identify problems to be addressed in the
organization
b.Get feedback from staff on the problems to be
addressed
c. Identify key people in the organization who
should be involved
d. Develop a performance improvement plan
Answer is …….A
Whichof the following steps occurs first in facilitating change in
an organization?
a. Identify problem to be addressed in the
organization
b. Get feedback from management
c. Identify key people in the organization who
should be involved
d. Develop a performance improvement plan
Answer is …….A
Thebest way to facilitate change within a healthcare
organization is to
a. Involve the individuals directly affected by change
b. Communicate through group meeting
c. Arrange presentations by senior leaders
d. Communicate through group e – mail
Answer is …….A
Anambulatory / outpatient care facility identifies an
opportunity to improve the turnaround time for report of X- Rays
performed at a local hospital. Which of the following groups
should be involved in the team to improve the process
a. Administrative representative from both facilities
b.Primary care physician, clinical nurse, and clinical
administrators
c.Radiologist, primary care physician, and clinical
medical records
d.Clerical, clinical, and administrative staff from
both facilities
Answer is …….D
The prevalence rate of a disease depends on the
a. Incidence rate and duration of the disease
b. Number of new cases and population at risk
c. Total number of cases and the population at risk
d. Incidence and change in the in the balance of
etiological factors.
Answer is …….C
CPHQ believes that MARS infection rate is high what should CPHQ
first do?
السؤال االول معC .. a. Repeat data collection process to
ال يوجد داتا مؤكده في السؤال تشير إلى justify a new rate
انه فعال معدل الMARS عالي وانما هو
فقط اعتقاد من الCPHQ وطبعا هو مش B. form a multidisciplinary team
متخصص في مكافحة العدوى بالتالي عليه
انه يوجه اخصائي مكافحة العدوى عشان b. Conduct infection control practitioner
يزوده بالbenchmark وده الشى اللي to obtain benchmark data
ح يحدد فعال هل الrate ده عالي فعال وال
ال.. c. Inform risk manager to counsel staff
to following infection (follow infection
control policies)?
Answer is …….B ((( معتصم.ا(ستفتق((لبك ا((لمربع( ا((الخضر ب((ه( رأ(يد
Decrease variation……..possible scenarios
Theuse of clinical pathways and guidelines in hospitals should do
which of the following?
a. Minimize variation in patient care
b. Reduce length of stay
c. Improve patient satisfaction
d. Identify errors in patient care
Answer is …….A
Healthcare leaders are confronted with the challenge of
increasing quality while reducing costs. Which of the following
approaches best advances improvement efforts?
a. Support activities that improve outcome and
reduce variation
b. Incorporate customer satisfaction result into
quality initiative
c. Develop new services to increase revenues
Answer is …….A
In statistical process control, it is important first to:
a. Eliminate assignable causes of variation
b. Eliminate random causes of variation
c. Prioritization causes of variation
d. Eliminate all causes of variation
Answer is …….A
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
Answer is …….D
Which
of the following should be included with CEO, CFO,
MEDICALDIRECTOR in quality council team
a. Facilitator
b. director of nurse
Answer is …….B
Thereare 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
Answer is …….C
IHIGlobal Trigger Tool record reviewers found an unreported
case of a radiologist inadvertently causing a small pneumothorax
(collapsed lung) by incorrectly positioning a percutaneous small-
bowel feeding tube .
To whom should the reviewers report this finding?
A. Chief Medical Officer
B. Chief of Radiology
C. Risk Manager
D. Director of Quality
Answer is …….B
Which of the following is NOT a function of the facilitator on a
quality improvement team?
A. Keep minutes and records of the team's efforts.*
B. Keep the group focused on a central issue.
C. Tactfully prevent anyone from dominating the
discussion.
D. Manage time.
Answer is …….A
Whichof the following is an essential component in a
performance improvement report?
A. governing body approval
B. data analysis and display *
C. individual performance review
D. team composition and attendance
Answer is ……B
Inprofiling length-of-stay data for benchmarking, it is important
that data be
A. raw numbers.
B. equal numbers.
C. reported monthly.
D. severity adjusted. *
Answer is …….D
Whichof the following is the FIRST step in the strategic planning
process?
A. setting goals and objectives *
B. defining organizational structure
C. determining productivity indicators
D. establishing and controlling a budget
Answer is ……A
Theuse of clinical pathways and guidelines in hospitals should do
which of the following?
A. Minimize variation in patient care. *
B. Reduce length of stay.
C. Improve patient satisfaction.
D. Identify errors in patient care
Answer is …….A
A summary of antibiotic usage for the fourth quarter showed that
an internal medicine department did not meet pre-established
criteria in 82% of the patients reviewed. Following review, the
Pharmacy and Therapeutics Committee should recommend that
the results be shared first with the
A. Quality Council.
B. governing body.
C. utilization committee.
D. chief of the department.
Answer is …….D
Evaluation of the quality and appropriateness of patient care in
the radiology department is the responsibility of the
A. medical director of radiology. *
B. chief medical officer.
C. medical director of the quality department.
D. administrator of clinical services.
Answer is ……A.
Thebest 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 is …….A
Thebest approach for training staff about quality and patient
safety is to
A. require staff to complete mandatory online
training at convenient times.
B. develop posters and brochures that explain key
quality concepts and place them strategically
throughout the workplace.
C.conduct multidisciplinary interactive sessions
consistent with adult-learning principles. *
D.have the CEO meet with each department to
explain the department's role in quality and safety.
Answer is …….C
Thebest way to facilitate change within a healthcare
organization is to
A. involve the individuals directly affected by the
change. *
B. communicate through group meetings.
C. arrange presentations by senior leaders.
D. communicate through group e-mail.
Answer is …….A
Of the following possibilities, what is does the control chart below tell you
(CL = Center Line—either mean or median, depending on type of data; LCL
= 0)?
a. Three sentinel events occurred
since mid-2006 with effective
intervention.
b. Special cause variation occurred
with effective intervention in mid-
2007.
c. Falls are within control limits since
mid-2006.
d. Falls are out of control since mid-
2007.
Answer is …….B
Data on length of stay of 251 randomly-selected admitted patients are
summarized in the figure below
(Assume N = 251, and not N = 25 as stated in the figure.)
What should the next step be?
a- Investigate lengths of stay of 5
days.
b- Investigate lengths of stay of 6
days.
c- Investigate lengths of stay of 8
days.
d- Investigate lengths of stay of 9
days or more
Answer is ……A ((ا(ستفتق((لبك
The following data is being analyzed based on 6 months of
incident reports for falls in a facility with 10 ICU beds and 40
Med/Surg beds: Which of the following is the next step for the
healthcare quality
professional to pursue?
A. Continue to track and
trend incident reports.
B. Educate Med/Surg units
on fall prevention.
C. Review ICU fall protocol.
D. Conduct further analysis
of fall data.
Answer is …….D
Hospital A has recently merged with Hospital B. After 6 months it
is noted that Hospital A has successfully transitioned their staff
to new organizational values, while Hospital B still struggles.
Hospital A's success can best be attributed to
A. requiring adoption of new values by all staff.
B. support of both hospitals' mission statements.
C. acceptance of the new mission and vision
statements.
D. integrating technology and databases.
Answer is ……. C
An employee health program includes a pre-employment health
assessment for all prospective employees who are asked to be
completed and the results should be known prior to assumption
of duties. A retrospective study of 200 records displayed in the
following chart. Review of this information indicators which of
the following?
a) Approximately 95% failed to meet the
stated objectives
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
Answer is …….A
Which of the following are the first steps when preparing for an
initial accreditation or certification survey of an organization?
A. Review the standards and determine readiness. *
B.Appoint a survey coordinator and prepare a survey
agenda.
C. Hire a consultant and conduct a mock survey.
D. Assess staff knowledge and plan staff training.
Answer is ……A
When considering the use of an external subject matter expert
(SME), which of the following is most critical?
A. leadership's personal preference
B. geographic location of the SME
C. cost of the SME's services
D. references of the SME
Answer is ……D
When a healthcare organization is contracting with an outside
provider for services, the subcontractor must
A. provide a representative to the Quality Council.
B. meet all regulatory requirements. *
C. have an active risk management program.
D. have a competitively priced service.
Answer is …….B
Informed consent for hip surgery was obtained and documented
for an elderly patient. In the recovery room, a nurse discovered
the wrong hip had been replaced. A healthcare quality
professional should
A. conduct a failure mode and effects analysis
(FMEA).
B. initiate the disciplinary action process.
C. review the practitioner's qualifications and
licensure.
D. perform a root cause analysis.
Answer is ……D
A patient safety program can best be enhanced by which of the
following technologies?
A. computers on wheels at the patients' bedsides
B. barcode system for medication administration *
C. digital medication reference materials
D. online evidence-based medicine guidelines
Answer is ……B
A failure mode and effects analysis (FMEA) provides which of the
following types of review?
A. proactive
B. retrospective
C. concurrent
D. retroactive
Answer is …….A
Which of the following is the best example of use of human
factors engineering?
A. designing products to prevent tubing
misconnections
B. implementing a Kaizen process to reduce
inventory
C. eliminating waste through reduction in motion
D. using PDCA to improve compliance with hand
hygiene
Answer is …….A
A healthcare quality professional is attempting to refine the
differences between an organization's objectives and the
stakeholder needs. Which of the following tools is most
appropriate?
A. gap analysis
B. Ishikawa diagram
C. Gantt chart
D. Kanban method
Answer is …….A
Indeveloping a performance improvement action plan, which of
the following tools should be used FIRST?
A. control chart
B. cause and effect diagram
C. interrelationship diagram
D. Pareto chart
Answer is ……B
Aperformance improvement program for supervisors should
include
A rapid cycle process
B.results from FMEA
C.budget variance reporting
d.review of pt falls
Answer is ……A
Thenurse was hanging an IV pump to the patient. However, the
nurse was using the home base IV tube that was taken from
home. The serious incident was happen when the pump misplace
and inserted into incorrect tubing causing death to the patient.
The nurse denies that the tube was taken inside the delivery of
care. The scenario is known example of?
A. Incompetent Nurse
B. Near miss
C. Unexpected Event
D. Human factor
Answer is …….D
When a healthcare organization is contracting with an outside
provider for services, the subcontractor must:
A. provide a representative to the Quality Council.
B. Agreed upon performance expectations*
C. have an active risk management program.
D. have a competitively priced service.
Answer is …….B
How to embedded the quality principles in daily org activity
A. ad hoc team
B. Empower person to take decision
C. Appoint external consultant
Answer is ……B
Under the quality improvement paradigm which statement is
incorrect?
A- The focus is on the competency of individual
practitioners.
B- The focus is on the efficacy and effectiveness of
processes
C- The focus is on the patient
D- The focus is on organization performance
Answer is …….A
The paradigm shift is:
A- Chang the reframe of thinking
B- Improve the monitoring measures
C- Increase the standards
D- Use the recent in medicine and technologies
Answer is …….A
Replacingretrospective review with concurrent review is an
example of
A- A paradigm shift
B- A process improvement
C- An empowerment process
D- Productivity enhancement
Answer is …….A
Your medical group is merging with a larger regional medical
group the function of quality, utilization, and risk management
will be centralized at the regional level, but expanded at the
local level necessitating a change in staffing, position
descriptions, and processes. Such organizational change
represents: For profit organizational structure
A- Downsizing
B- A paradigm shift
C- Financial advantage
Answer is …….B
A paradigm shift in a process
A. Must be slow in progress in order to allow
healthcare providers to master the methodology in
stepwise fashion
B.Is a return back to an effective old system or a
new promising one
C. Is handling out financial issues to a third party
D. Focuses on educating staff how to handle stressful
situations effectively
Answer is …….B
A paradigm shift in a process
B.Is a return back to an effective old system or a
new promising one
Answer is …….B
Solicit input from member advocacy
اقرب سؤال للمحتوى ده في الموك
Incontinuous quality improvement programs, survey are
essential to determine which of the following?
Customer needs
Performance standards
Effective management
Population demographic
Answer is …….A
train your self او من ملف
As a result of the customer survey the mean score was calculated
with each item. Weight was applied to range each item in order
to importance to the customer. Which of the following the
highest weighted mean:
A. Mean 3and weight .9
B. Mean 4and weight .8
C. Mean 5 and weight .7
D. Mean 6 and weight .3
Answer is …….C
Unique activity of quality improvement
Display of dataا(حد ا((الختيارا(ت
اقرب سؤال للمعنى ده في الموك
One difference between continuous quality improvement and
traditional quality improvement assurance is the quality
improvement always:
A. Require the application of statistical process control
B. Exclude monitoring and evaluation of care provided
C. Focus on system or processes
D. Addresses potential problem
Answer is …….C
صياغة أخرى
The major difference between traditional quality assurance
activities and expanded quality improvement / performance
improvement activity is QI/PI focus on: ت
( )ج(ان
A- People and competency.
B- Analysis of data
C- Performance measures
D- System and processes
Answer is …….D
تدهور مستوى األداء
يشبه في مذكرة النجاح سؤال
Animprovement project did not reach its outcome in radiology,
CPHQ should recommended:
A- Review statistical methods used
B- Review KPI
Answer is …….A
SAMPLING
Every fifth or convenience or purposive الدكتور ذكر االختيارات
وجدت اكتر من سؤال بنفس االختيارات
The sampling of 5% or 30 cases , whichever is greater is example
of :
Convenience
Expert
Purposive
Quota
Answer is …….D
Delphi technique is a form of ……………sampling:
a. Convenience
b. Expert
c. Purposive
d. Quota
Answer is …….B
Sample include people available in certain time frame or the
sample include all available data in the area is:
Quota
Convenience
Stratified
Purposive
Answer is …….B
Hospital plan applied telehealth program and need to spread it
among its facility, among who of the following need to be added
in the team to help in communicate it.
A-Adaptor audiences
B-Local media
C-Legal legislation
Answer is …….A
#march2018
in last 3 months clinical outcome deteriorated, CPHQ should
1-investigate related process measures
improvement
مكتوبة كده بالنص
- 2continue to collect data
siginificantمع .. 1بما انه في الثالثة شهور االخيره في تدهور فده يعتبر
يخليني اتدخل واشوف الحاصل شنو في البروسس وما السبب deterioration
في عدم إحراز اي تقدم ..وطبعا اإلجابة 2خطأ النه مستحيل اقعد اتفرج واستمر في
😊 متابعة الوضع لحد ما نلبس في الحيط
Answer is …….A
The x organization decided to pay for performance for staff who reach
50% will receive 100$ and staff achieve 75% will receive 200$. Who
among the following staff will not able to receive the 50 or 75 pay for
performance?
A- Physician A
B- Nurse B
C- Assistant physician D
Answer is …….C
For a run chart the Central Line is called :
a) Mode
b) Standard division
c) Median
d) Mean
Answer is …….C
The role of a team facilitator is to focus on:
A-Analyzing problem during meetings
B-The process
C-Generating and selecting solutions
D-The content
Answer is …….B
A physician complains to a healthcare quality professional that the
nursing staff did not strictly follow orders for a patient. The physician
requests that the quality professional speak with the nurse manager.
To facilitate improved communication, the quality professional should
A.arrange a meeting with the physician and nurse
manager.
B.speak with the nurse manager on behalf of the
physician.
C. evaluate the patient outcome to determine
organizational risk.
D.review the patient record to determine legibility of the
physician's orders.
Answer is …….A
themost effective way for a healthcare quality professional to
communicate quality improvement activities to the medical staff
is by
Developing professional relationships
Inviting medical staff to an in-service on quality
tools
Evaluating physician participating on quality teams
Providing outcome data at medical staff meeting
Answer is …….D
Healthcare quality professional is comparing healthcare
associated infection among hospital of varying sizes specialized
services and geographical region which of the following most
useful
A- readmission rate
B- Healthcare associated pneumonia rates
C- risk adjustment rates
D- overall infection rates
معتصم. د......
واضح انه بيتكلم عن مقارنة بين عدة مستشفيات مختلفة من حيث الحجم
والتخصص والرقعة الجغرافية يبقى مهم جدا توحيد عوامل الخطورة
)risk adjustment rates( لمستشفياتاوالAA اAينهذهAAAب
Answer is …….C
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
Answer is …….B
CMSmade a survey to a health plan and discovered some
deteciencies regarding non adherence to infect control
measure(done by another body)organization should :
A-the organization should appeal because the
measures are not from CMS
B- charter a team to identify the current process and
relevant non adherent practices
C-Identify the deficiencies to put the organization
back in compliance
Answer is …….B
Adverse events is
A. avoidable
B. unexpected and should be investigated
Answer is …….B
Which of the following are measures of central tendency?
A. mean, median, and mode
B. standard deviation, variance, and standard error
C. grouped data, bell curve, and distribution
D. correlation, regression, and t-test
Answer is …….A
Whichof the following is used to summarize a characteristic in a
population?
A. frequency distribution
B. regression analysis
C. case control study
D. control chart
Answer is …….A
A quality improvement manager must decide how to present
data that demonstrates the relationship between two process
characteristics. Which of the following data display techniques is
most appropriate?
A. bar chart
B. scatter diagram
C. Pareto chart
D. line graph
Answer is …….B
Publiclyreport measures are developed through a life cycle in
which of the following sequences
A-first year data collection, public comment,
evaluation
B- topic select, measure develop , public comment
C- measure developed, evaluation, topic selection
D- public comment, Measure developed, first year
data collection
Answer is …….B
Answer is …….B
Healthcare leaders are confronted with the challenge of
increasing quality while reducing costs. Which of the following
approaches best advances improvement efforts?
A. Support activities that improve outcomes and
reduce variation.
B. Incorporate customer satisfaction results into
quality initiatives.
C. Increase charges and decrease costs.
D. Develop new services to increase revenues.
Answer is …….A
Training is being determined based on treatment record review
results. The following weighted results are available: Based on
these results, which of the following areas should take priority
for training?
A. assessment B. external communication
C. care plan D. progress notes
Answer is …….C
Compare two facilities in many problem .the 2 facilities the
same in all those problems except falling rate what we will do
Review fall.
Answer is …….
AnOrganization 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
Answer is …….A
A unit dose was prepared 2.5 ml and actually needed is 1ml and
the rest was discarded the pharmacist asks the CPHQ something
to do about the excess inventory and decrease waste:
A- Six sigma
B- Lean
Answer is …….B
Which area you are recommending first for improvement action:
Unit Time Medication Medication
a)Medication dispensing in
dispensing Administration
ICU and observation
Observat 7am-7pm 30% 70% b) Medication
ion
7pm-7am 10% 40%
administration in ICU and
North2 7am-3pm 40% 20%
observation
3pm-11pm 0% 10%
c) Medication dispensing in
11pm-7am 10% 10%
South 7am-7pm 40% 30% north 2 and observation
7pm-7am 20% 20% d) Medication
ICU 7am-7pm 50% 40%
administration in ICU and
7pm-7am 30% 20%
south
Answer is …….B
Which of the following is true regarding medication errors:-
a) Associated with process failure
b) Prevented by review of evidence based practice
c) caused by gap between patients expectations and
practice
d) avoid by uniform practice
Answer is …….A
Toreduce the incidence of ventilator-associated pneumonia
(VAP) in a critical care unit, who should be included on a quality
improvement team?
A. Intensives , ICU nurse, and respiratory therapist
B. primary care physician, infection control nurse, and
surgeon
C. ICU manager, respiratory therapist, and pharmacist
D. pharmacist, intensivist , and infection control nurse
Answer is …….A
Newpediatric psychiatry will open in one year. The utilization
coordinator is responsible for developing the utilization
management progress.
The programmed success will depend on which factor
A- obtaining approve from the chief psychiatry of each
stage
B-Provide education in service to all team member
involved
C- develop program and present it to approve
D- involving the team member in developing programme
Answer is …….D
Availability of hand sanitizer is an example of:
a) Structure measure
b) Process measure
c) Outcome measure
Answer is …….A
Whichof the following is NOT one of the performance
measures in The Joint Commission's core measure set for
perinatal care?
A.Antenatal steroids for births between 24 and 32
weeks of gestation.
B. Exclusive breastfeeding at hospital discharge.
C.Deep venous thrombosis prophylaxis for women
having a Cesarean birth.
D. Elective delivery prior to 39 weeks
Answer is ……C
Answer is …….
Birthinjuries, initial analysis revealed that, injuries back to one
practitioner. What is the next step?
A. Form team to investigate outcomes.
B. further analysis to the practitioner outcome.
C. continues to monitor practitioner outcomes.
Answer is ……B
TheCPHQ evaluates a study of the incidence of strokes (CVA) in
women who take birth control pills versus a control group who do
not take birth control pills. The best statistical technique for
evaluating the study data is:
A. chi-square (X2)
B. regression analysis
C. t-test
D. scatter Digrams
Chi-square is used with incidence rate
T-test is used with mean
Answer is ……A
which must be improved of 4
االرقام تقريبية ولكن بشكل عام هنالقي ال
Pre mature delivery
هي اسوأ المشاكل واالعلي بطريقة ملحوظة بعيدا عن ال
Benchmark
Score A B C D
Nurse staff Provider Registration Quality
staff professional
High
Low
Significant
What is the best match to role:
A- B is champion and D is facilitator
C & D دةAجابتينمستبعAإ
Answer is ……A
السؤال عن اول مشاكل يبدأ بحلها
واالختيارات
..كانت
1-
اولثAAAالثمشاكل
2-
اولاربع Aمشاكل
واالختيارات
التانية كانت بعيدة جدا
Answer is …….1
Definition of incidence rate:
Number of new cases of disease during specified
time interval over Summed person-years of
observation
Or
average population during time interval
2 question about critical index
Question about pareto
Dr almost operated on wrong site , in patient culture what should the Dr
doتAلخياراAAانمناA كreport
2 tables to calculate RPN
I doing PDCA, what is the step after pilot?
Check
االجابة هي....
A
Sequences of improvement process
A- Proposal, budget, plan and implement
( The other options don’t have plan)
Answer is …….A
The upper and lower control limits in control chart :
a) Used to identify the distribution of data.
b) Calculated by using the collected data
c) It is in threshold
Answer is …….B
A unit dose was prepared 2.5 ml and actually needed is 1ml and
the rest was discarded the pharmacist asks the CPHQ something
to do about the excess inventory and decrease waste:
a) Six sigma
b) Lean
Answer is …….B
Physicianturnover is high. What is the best tool to identify how
to reduce the rate?
A. Focus group
B. Cause and effect diagram
C. PDCA
Answer is …….B
In patient safety, errors are:
A- Normal
B- Negligence
C- Purposeful
D- Misconduct
Answer is …….A
In patient safety Medication errors is regarded as?
a) Malpractice
b) Normal
c) Negligence
Answer is …….B
43. In patient safety Medication errors is regarded as?
a) Malpractice
b) Normal
c) Negligence
or
A medication error is regarded as ,,,,
a) Malpractice
b) purposeful
c) Negligence
D) Normal
Answer is …….B ……………… A
Patient was about to under wrong test this consider
A- Near miss
B- Latent error
C- HF error
Answer is ……A
Whichof the following key healthcare issues is more problematic
for ambulatory care than for inpatient care?
A- Reimbursement for care
B- Access to specialty care.
C- Appropriateness of treatment setting.
D- Quality of care provided.
Answer is ……A
the hospital leader decided to use electronic system in
outpatient clinic in order to improve patient safety. Which of the
following can reflect it?
A- Decrease/ less oral communication, more on
electronic
B-The nurse cannot proceed with medication need /
required double check unless another nurse to login.
C- Decrease incident reported within the system
Answer is ……B
Staffin Laboratory are not using the eye goggle. What CPHQ
should do?
A-Inform the laboratory manager for doing the
appropriate action
Answer is …….A
Use the following data to answer the following:
I. The rate of overall surgical wound II. The rate of overall delinquent
infections: medical record:
a.32%. a.40%.
b.23%. b.28%.
c.30% c.30%.
d.40% d.20%.
Answer is …….A ,,, A
Which can promote team work ?
A. Leadership support
B. Identify overall objective
Answer is ……B
An employee health program includes a pre-employment health
assessment for all prospective employees who are asked to be
completed and the results should be known prior to assumption
of duties. A retrospective study of 200 records displayed in the
following chart. Review of this information indicators which of
the following?
a) Approximately 95% failed to meet the
stated objectives
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
Answer is …….A
Answer is …….D
Newpediatric psychiatry will open in one year. The utilization
coordinator is responsible for developing the utilization
management progress.
The programmed success will depend on which factor
A- obtaining approve from the chief psychiatry of each
stage
B-Provide education in service to all team member
involved
C- develop program and present it to approve
D- involving the team member in developing programme
Answer is …….D
Hospital plan applied telehealth program and need to spread it
among its facility, among who of the following need to be added
in the team to help in communicate it.
a) Adopter audiences
b) Local media
c) Legal legislation
Answer is …….A
The
administration desire to apply a new program TELEHEALTH ,
who should be participated in its application:
A. audio adopter
B. state legislation
C. local media
Answer is ……B
For a run chart the Central Line is called :
a) Mode
b) Standard division
c) Median
d) Mean
Answer is …….C
When is the data considered stable ?
a. All above the mean
b. All below the mean
C. Common cause variation
D. Special cause variation
Answer is ……C
Who is responsible for creating and monitoring the
implementation of improvement project work plan and time line
a) Sponsor
b) Team leader
c) Team facilitator
d) Quality council
Answer is …….B
Who achieves target of ( level 1) with 100$, and reward the staff
who achieves target of (level 2) with 200$. According to the
following table, who of the following staff will NOT take any
incentives? The staff who will reach level 1 will take 100$, and
who will reach level 2 will take 200$
Staff Staff Staff Staff Level of
#1 #2 #3 #4 achievement
a) Staff # 1 Level 1 Level 2
b) Staff # 2
Hand Hygiene 75% 60% 95% 80% 70% 90%
c) Staff # 3 Surgical 70% 60% 90% 80% 65% 85%
d) Staff # 4 check list
Guidelines 80% 70% 95% 90% 75% 95%
Answer is …….B
Which of the following is an example of patient-centered care?
a) Bedside rounds
b) Using two patient identifications
c) Pre-printed discharge instructions
d) Age based dosing
Answer is …….A
Organization work on employee purchasing power
a) JCI
b) Leapfrog
Answer is …….B
Availability of hand sanitizer is an example of:
a) Structure measure
b) Process measure
c) Outcome measure
Answer is …….A
Internal customer in admission process ,or who is considered the
internal customer in an advanced nursing facility
a) nurse competing the initial assessment
b) family and patient
c) patient being admitted
Answer is …….A
Whichindicator can be considered most important for radiology
department
a) Timeout
b) Mammography turnaround reporting
c) Contrast induced complications
Answer is …….C
Physician with 10% unplanned admission CPHQ should:
a) Review unplanned with peer physicians
b) Conduct focused review for unplanned cases
c) Review both planned and unplanned cases
Answer is …….A
Education of new hiring the CPHQ should what:
a) Set content by type of attended staff
Answer is …….A
CPHQ wants to determine process measure to improve wound
care outcome, FIRST thing to do:
a) Three years prior best practice in wound care
b) Clinical trials in wound care
c) Search guidelines for wound care
d)Review clinical record for wound care sentinel
events
Answer is …….C
In evaluating length of stay &outcome data on cardiac
catheterization. Healthcare quality professional identified direct
relationship between adverse outcomes & physician practice
pattern. This integrated approach involves correlating:
a) Case/care management & finance
b) UM&QM
c) Finance &UM
d) Discharge planning &QI
Answer is …….B
The role of a team facilitator is to focus on:
a) Analyzing problem during meetings
b) The process
c) Generating and selecting solutions
d) The content
Answer is …….B
Which area you are recommending first for improvement action:
Unit Time Medication Medication
a)Medication dispensing in
dispensing Administration
ICU and observation
Observat 7am-7pm 30% 70% b) Medication
ion
7pm-7am 10% 40%
administration in ICU and
North2 7am-3pm 40% 20%
observation
3pm-11pm 0% 10%
c) Medication dispensing in
11pm-7am 10% 10%
South 7am-7pm 40% 30% north 2 and observation
7pm-7am 20% 20% d) Medication
ICU 7am-7pm 50% 40%
administration in ICU and
7pm-7am 30% 20%
south
Answer is …….B
A quality improvement manager must decide how to present
data that demonstrates the relationship between two process
characteristics. Which of the following data display techniques
is most appropriate?
a) Bar chart
b) Scatter diagram
c) Pareto chart
d) Line graph
Answer is ……. B
When attendance declined after 2 months, in which stage are
they?
1- Storming
2- Forming
3- norming
Answer is …….1
There is new accreditation body , CPHQ first action is :
a)Check accreditation standards to check the
organization readiness.
b) Hire external consultant.
c) Standards education to staff.
Answer is …….A
The upper and lower control limits in control chart :
a) Used to identify the distribution of data.
b) Calculated by using the collected data
c) It is in threshold
Answer is …….B
A unit dose was prepared 2.5 ml and actually needed is 1ml and
the rest was discarded the pharmacist asks the CPHQ something
to do about the excess inventory and decrease waste:
a) Six sigma
b) Lean
Answer is …….B
Characteristics about performance improvement:
a) Systematic
b) Timely
c) Autonomous
Answer is …….A
Difference between research & CQI
1-withdraw outcome
2-data analyzed & displayed
3-identify RCA
Answer is …….3
Whichtool results in major problems or issues need to be
addressed:
a) Affinity
b) Force field
c) Nominal group
d) Interrelationship diagram
Answer is …….C
Thefollowing table present los in one hospital for 2 years. What you can
conclude and which tool you will use to display the data over the last two
years نترولAنفكشنكAالمتحاناAAياAAAجتف
A- LOS in second year increase and can be displayed by Pareto
B- LOS of stay in second year decrease and can be displayed by control
chart
C- LOS in second year decreased and can be displayed by Pareto
Answer is ……B
Anorganization set a goal 90% of waiting time to be below 15
minuets , here is a 10 cases time 5,5,9,10,12,12,12,14,22,25
with average 12.6 min what to do?
a) Set a trigger at 80%
b) Review data with more than 15 minuets
c) Nothing, the target is met
d) No thing
Answer is …….B
CPHQ believes that MARS infection rate is high what should CPHQ
first do?
السؤال االول معC .. a. Repeat data collection process to
ال يوجد داتا مؤكده في السؤال تشير إلى justify a new rate
انه فعال معدل الMARS عالي وانما هو
فقط اعتقاد من الCPHQ وطبعا هو مش B. form a multidisciplinary team
متخصص في مكافحة العدوى بالتالي عليه
انه يوجه اخصائي مكافحة العدوى عشان b. Conduct infection control practitioner
يزوده بالbenchmark وده الشى اللي to obtain benchmark data
ح يحدد فعال هل الrate ده عالي فعال وال
ال.. c. Inform risk manager to counsel staff
to following infection (follow infection
control policies)?
Answer is …….C ((ا(ستفتق((لبك
Responsibility of quality improvement plan
A. team
B. leaders
C. quality manger
D. Governing board
Answer is …….B
Score A B C D
Nurse staff Provider Registration Quality
staff professional
Perspective High High
By peers Low High
process Moderate Low
What is the best match to role:
A- B is champion and D is facilitator
B. C is facilitator and B is champion
C. B is facilitator and D is process owner
Answer is ……A
Thefirst task in a continuous quality improvement process
analysis to
a. Define problems arising within the system
b. Monitor the system to ensure no new problems
occur
c. Evaluate the effects of changes to the system
d-Separate external from internal problem.
Answer is …….A
Difference between scientific method and quality improvement:
A- Identify the rout cause of the result
B- Communicate outcome
Answer is …….A
Surgeon has 6.7% SSI in a specific procedure, while his collogue
has 3.3 %. The data reviewed by chair of the department, the
quality professional recommend:
a- Focus review
b- RCA
c- temporarily suspension the surgeon
d- stop the privilege of the doctor
Answer is …….A
Thereis a new(computerized/technical) system introduced to
the pharmacist to facilitate his work but the project has many
defects and the pharmacist refused to apply it so after that the
responsible for the project correct it and introduced it to the
pharmacy saying that it is now free of defects
What kind of improvement applied on the project
a- FEMEA
b- 6 sigma
Answer is …….B
Outpatient
Surgery Center a assembled a quality council from
CEO, CFO and Medical Director , who should else be added:
A- Nursing Director
B- Safety Environment Supervisor
C- Head of HR
D- head of medical record
Answer is …….A
Which tool used to check process stability?
A- Run chart
B- Control Chart
Answer is …….B
AnOrganization 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
Answer is ……A
Healthcareorganization 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
Answer is ……B
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
Answer is ……C
Themost important initial step in preparation for accreditation
survey is …
A. Ensure clinical competency
B. Provide teaching tools.
C. Standards education .
D. Quality improvement activities.
Answer is ……C
CEO
decides to have accreditation to the hospital after 18
months, what should he do
A. Communicate accreditation process to all staff
B. Hire external quality expert to give lectures
C. Make monthly newspaper
Answer is ……A
Inorder to facilitate development of strategic plan, what to
consider first?
a. Risk management, gap analysis, identification of
organization wide functions
b. Mission, vision, values , short & long term goals &
objectives
Answer is ……A
Quality professional want to improve communication with
patient family , there are 3 problems faced him
“1” Patient family did not understand English
” 2”Difficulty in meeting treating physician
“3”
What he will do
A- Calculate RPN
B- Bring English translator
C- Convince patient
family adviser
Answer is ……A
Facility has admission from different sources
20.000 home
10.000 physician referral
786 skilled nursing facility
50 others
What is the best tool to demonstrate the proportion of admission for each
source ?
A- Run
B- Histogram
C- Pareto
D- Control
Answer is …….C
The main responsibility of Q.I program is to:
A-establish target priorities
B-obtain customer satisfaction data
Answer is ……A.
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
Answer is …….B
Thereis a complain for patients or family regarding delay what is
the best action?
A/Discuss with the nurses involved
B/Report to the manager
C/Trend the delay data
Answer is ……C
Merge company and they want to improve the care, related to
rehabilitation center, home healthcare and other related
facilities
what is the first action?
community focus group
Answer is …….A
1-Which of the following is the FIRST step in facilitating change
in an organization?
a) Review customer satisfaction
surveys.
b) Get feedback from staff on the
problems to be addressed.
c) Identify key people in the
organization that should be
involved.
d)Develop a performance
improvement plan.
Answer is ……B
Which of the following is the first step in facilitating change in an
organization?
a. Identify problems to be
addressed in the organization
b. Get feedback from
management on the problems to be
addressed
c. Identify key people in the
organization who should be involved
d. Develop a performance
improvement plan
Answer is …….A
Which of the following is the FIRST step in the strategic planning
process?
A. Defining organizational structure.
B. Setting goals and objectives.
C. Determining productivity indicators.
D. Establishing and controlling a budget.
Answer is ……B
Organization work on employee purchasing power
a) JCI
b) Leapfrog
Answer is …….B
The prevalence rate of a disease depends on the
a. Incidence rate and duration of the disease
b. Number of new cases and population at risk
c. Total number of cases and the population at risk
d. Incidence and change in the in the balance of
etiological factors.
Answer is …….C
CMSmade a survey to a health plan and discovered some
deteciencies regarding non adherence to infect control
measure(done by another body)organization should :
A-the organization should appeal because the
measures are not from CMS
B- charter a team to identify the current process and
relevant non adherent practices
C-Identify the deficiencies to put the organization
back in compliance
Answer is …….B
Which of the following is true regarding medication errors:-
a) Associated with process failure
b) Prevented by review of evidence based practice
c) caused by gap between patients expectations and
practice
d) avoid by uniform practice
Answer is …….A
Publiclyreport measures are developed through a life cycle in
which of the following sequences
A-first year data collection, public comment,
evaluation
B- topic select, measure develop , public comment
C- measure developed, evaluation, topic selection
D- public comment, Measure developed, first year
data collection
Answer is …….B
Inprofiling length of stay data for benchmarking, it is important
that data be :
a. Raw number
b. Equal numbers
c. Reported monthly
d. Severity adjusted
Answer is …….D
Survey question Preparing employee for accreditation survey
first step
A. select standard to be taught
B. planning education program for staff
Answer is …….A
Adverse events is
A. avoidable
B. unexpected and should be investigated
Answer is …….B
For a run chart the Central Line is called :
a) Mode
b) Standard division
c) Median
d) Mean
Answer is …….C
A healthcare organization's strategic plan objectives include a
customer satisfaction rating of 85%. The following data are
available for three units: Which of the following should a
healthcare quality professional recommend?
A. Change the target to 90% satisfaction.
B. Share Unit A's practices with other units.
C. Provide incentives for the staff of Units B and C.
D. Review the performance of the manager of Unit C.
Answer is …….B
Which area you are recommending first for improvement action:
Unit Time Medication Medication
dispensing Administrat
ion
a) Medication dispensing in
Observati 7am-7pm 30% 70%
on ICU and observation
7pm-7am 10% 40%
North2 7am-3pm 40% 20%
b) Medication administration
3pm-11pm 0% 10% in ICU and observation
11pm-7am 10% 10% c) Medication dispensing in
South 7am-7pm 40% 30% north 2 and observation
7pm-7am 20% 20%
d) Medication administration
ICU 7am-7pm 50% 40%
in ICU and south
7pm-7am 30% 20%
Answer
is …….B
A quality improvement manager must decide how to present
data that demonstrates the relationship between two process
characteristics. Which of the following data display techniques is
most appropriate?
A. bar chart
B. scatter diagram
C. Pareto chart
D. line graph
Answer is …….B
which must be improved of 4
االرقام تقريبية ولكن بشكل عام هنالقي ال
Pre mature delivery
هي اسوأ المشاكل واالعلي بطريقة ملحوظة بعيدا عن ال
Benchmark
A failure mode and effects analysis (FMEA) provides which of the
following types of review?
a) Proactive
b) Retroactive
c) Concurrent
d) Retroactive
Answer is …….A
Why it is important to report or trend track near miss events?
A- Learning lesson to the staff
Answer is …….A
Opioid medication…
Who is the best to be included in the team?
A- Pain management specialist
Answer is …….A
The best way to conflict resolution is
A- ignore
B- negotiation
Answer is ……2.
Team members are divided about the next course of action in an
important project. It appears that the conflict is severe enough
to warrant intervention. Who is responsible for managing the
conflict?
A Sponsor or Team Leader
B Team Leader or Coach
C Coach or Sponsor
D Team Leader only
Answer is …….B
New Questions
Thereis merging between two organizations and in the meeting
the CEO made a plan for improvement and gave it to the CPHQ ,,
what is the key step for CPHQ to do
A) Make criteria for prioritization
B) brainstorm with front line staff
Answer is …….B
Integration of quality principles in the organization culture to
A. Ensure realization of organization's mission
B. Support implementation of improvement strategy
Answer is …….B
بس بطريقة تانية انو
Team did not achieve the results So it will be reflected in
A- The team satisfaction
B- Growth Productivity
C- Results
وخيار رابع بعيد
Answer is …….B
Training(educational) program based on assessment of
organizational patient safety culture done as below
Organization National average Target 90%
Team work ( work with others) 39% 87%
Managers take quick actions to improve safety 61% 63%
Staff feel free to discuses safety issues 37% 69%
Staff believe that reporting of errors don’t 35% 61.8%
harm them at all
A-Training managers about staff issues and decisions
B-Training staff on just culture
C-Training couch staff with prior risks unique to there
departments
Answer is …….B
Postoperative urinary tract infection decrease rate after using
new catheter:
A- trend data over another quarter
B- send the data to procurement
C- get a new catheter
D- find statistical significance for decrease
Answer is …….D
To facilitate change, you should focus on staff who are:
A. Perceptive of change
B. Attitude business usual
C. Unmotivated appearance
Answer is …….C
Effectiveness of performance improvement program best
assessed by :
A) patient satisfaction
B) staff competencies
C) guideline compliances
D) organizational culture
Answer is …….A
Questionabout for medical record documentation most suitable
data can be used for process review
a) clinical data
b)prospective review
c) retrospective review
d) administration claims
Answer is …….C
Cost analysis and appropriateness what type of process review :
a) clinical data
b) administration claims
c) prospective
d) retrospective
Answer is …….D
Medicationerrors with drug-drug interactions was 15.3 per 1000
admissions dispensing. Benchmark was 5
What is the best safety measure to do?
A. BCMA
B. CPOE
C. EMR
Answer is …….B
What is the most useful while comparing health acquired
infection among different facilities
Adjusted risk rates
Overall HAIs rates
Number HAIs after readmission
Number of HAIs
Answer is …….A
Performance training program Should include
A- Performance appraisal results
B- Basic quality principles and tool
C- Individual focus project or issues
Answer is …….B
A new risk manager discover areas of non compliance in one
performance improvement plan ..he discuss with the Quality
professional about the areas of non compliance in the plane ..
what should the Quality professional do
A-review the risk management committee summary
B-Act on the area of non compliance
Answer is …….B
Wedid a project and pilot it and the results was sustained for a
year what is the next based on rapid cycle improvement
A- Another pilot study
B- Publicly the results
C and d (( I can’t remember the other choices))
Answer is …….B
CEO asked CPHQ to provide report about organization's quarterly
publicated data cphqياغةAAقربصAا
A. data result case - significant opportunities and
intervention taken
B. summary dash board.....and involved
improvement initiatives
Answer is …….B
Thehospital considering changing the process of admission from
emergency department. To support patient safety when this
process deployed. What should the healthcare quality professional
during the redesign of the process?
a. Complete FMEA of the new process
b.Analysis incidents report of the last year PARETO
CHART
c. Examining the stability and variation of the new
process by using control chart
d. Conducting RCA to predict errors of the new process
Answer is …….A
InHigh mortality rate, post operative is most appropriate for
focus review :
A- Antibiotics pre and post utilization
B- Hospital acquired infection rate
C- Surgery cases
Answer is …….C
For preparing a clinical pathway, who is should be available:
A- Staff education
B- Case management leader
C- Physician
Answer is …….B
Organization with notable decrease incident- Adverse event “
organization considered.
A- High quality control
B- Effective risk management
C- High reliable organization
Answer is …….B
Answer is …….B
Answer is …….B
Answer is …….B
Answer is …….B
Answer is …….B
Answer is …….B
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