1) The primary objective of the operational linkage between risk management and quality/performance improvement is to

2) In conducting a multivote, all of the following steps are taken except

3) To be useful in preventing future error, a Root Cause Analysis (RCA) should be performed

4) A performance improvement team has been created to examine infection rates following surgery. Which of the following is the best reference for the team to use?

5) Standards of care based on the knowledge and research of recognized experts are known as

6) Which of the following adverse events is NOT considered a sentinel event?

7) The concept of organizational liability is most important in the field of healthcare quality because it holds the organization responsible for

8) A hospice agency conducted a satisfaction survey of all 200 patients currently
receiving pain management services. When asked if they were satisfied with their pain management, 170 patients said yes, and 30 said no. A target satisfaction rate of 90% has been set. In this situation, a healthcare quality professional should:

9) When a case manager wants to demonstrate length of stay data that depicts both common cause and special cause variation, which of the following should be used?

10) A consulting firm has been selected by a healthcare Board of Directors to assess the quality improvement program. Before starting the assessment, the
quality professional should first

11) Which of the following is the most appropriate question to ask when reviewing an organization's performance improvement (PI) plan?

12) A patient is transferred to a neighboring hospital for a magnetic resonance imaging (MRI) exam. Due to a misinterpretation of orders, the procedure is performed on the wrong part of the body. Which of the following should the healthcare quality professional do?

13) Meaningful quality process measures must be

14) What is the primary goal of alignment efforts in healthcare quality?

15) When developing department-specific performance measures and indicators, the quality manager as a consultant should

16) A new quality director has reviewed the information related to the Quality Council minutes and notes the following: - The council meets quarterly. Meetings
last approximately 2 hours. - The council roster includes all clinical department managers and the quality director. Attendance ranges from 45-60%. - The primary role of the council is to receive department quality reports, which are then forwarded to the organization's governing body. Based on the information above, which of the following actions is most appropriate?

17) Which of the following should be included in an annual performance improvement report to a governing body?

18) An effective facilitator should be skilled in process evaluation and the tools of performance evaluation, and must

19) Situation-Background-Assessment-Recommendation (SBAR) is a

20) Which of the following topics are discussed at a morbidity and mortality conference?

21) An emergency department tracks wait times from patient arrival to physician assessment. Data is reported using a run chart. Which of the following demonstrates a true statistical increase in treatment delays?

22) Which of the following are the first steps when preparing for an initial accreditation or certification survey of an organization?

23) The utilization management committee is reviewing length-of-stay data for a particular procedure. In comparing data by physician, which of the following statistics will be most useful?

24) One aspect of a quality process that integrates with risk management is the review and evaluation of

25) Evaluating medication administration to reduce medical errors is an example of