1) Based on the principles of the Institute for Healthcare Improvement (IHI), who has the ultimate responsibility for the effectiveness of quality improvement
and patient safety within an organization?

2) A root cause analysis team examined a serious medication error and recommended changes. Which of the following should be done next?

3) Measuring the time it takes a nurse to perform a procedure addresses which of the following aspects of care?

4) Failure modes can be prioritized by calculating the criticality index. Which of the following three categories are normally used to calculate a criticality index?

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

6) A hospital-wide medical record audit on documentation has been completed. The following table shows the compliance rate of documentation:

Which of the following is the next step?

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

8) A patient in an acute psychiatric unit committed suicide by hanging himself with his shoelaces. To prevent this from occurring again, the most appropriate action is to institute

9) 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?

10) To avoid misinterpreting variances, which of the following statistical tools should be used?

11) Data collected about surgical cases shows significant delays. Further analysis shows the chart:
Which of the following should a healthcare quality professional do first?

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

13) Based on identified issues, a healthcare quality professional examines 100% of one physician's admissions and only 20% of all other physicians' admissions. This is best described as a

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

15) In the context of quality awards, what role does organizational leadership play in strategic alignment?

16) A performance improvement training program has been conducted. The healthcare quality professional has determined that improvement has not occurred. The most likely cause for the lack of improvement would be that:

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

18) Which of the following scenarios best illustrates the principles of Lean management in healthcare delivery?

19) Which of the following is the primary goal of risk management?

20) Which of the following statements accurately reflects the nuanced role of utilization management (UM) in healthcare quality management?

21) A continuous quality improvement organization promotes vigorous education and training/retraining in order to:

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

23) The surgery department's monthly case review revealed 10 records meeting the criteria. Six records did not meet the criteria. In calculating the incidence rate, the denominator is

24) In continuous quality improvement programs, surveys are essential to determine which of the following?

25) Which of the following is an example of a "never event" or sentinel event?