1) To develop a Performance Improvement Plan, the organization must

2) A Quality Council has created a Patient Safety Council. The council is concerned that staff may see this as another program that has been added to their
busy schedules that will eventually go away. The best way for the organization to establish patient safety as an ongoing part of the organization's culture is to

3) An organization hires a quality professional to pass quality improvement concepts to the staff. The first thing the quality professional should do

4) A balanced scorecard for an organization is best described as

5) A clinical pathway for the management of hip fractures has been developed by a multi-disciplinary team and implemented in a large teaching hospital. After
monitoring for 6 months, the length of stay continues to exceed the guidelines. Which of the following should be the next step?

6) A re-engineering effort occurred at a facility. The activities, particularly those regarding staff layoffs, were carefully planned, communicated, and implemented according to the plan. One year later, the business is stable but staff morale is very low. A healthcare quality professional has been asked to consult in determining where the effort went wrong. Based on the concepts of change theory, the cause is most likely

7) A team approach in quality improvement activities is preferred when

8) A critically ill patient is admitted and requires a specialized procedure; however, the surgeon does not have privileges at the facility. Which of the following documents will be MOST helpful in identifying the course of action the hospital should take?

9) Which of the following should a Quality Council provide to best ensure success of performance improvement teams?

10) A healthcare entity initiating re-structuring must consider the impact on staff to ensure the greatest opportunity for success by

11) The primary purpose of risk management trend analysis is to

12) Which of the following team members is responsible for keeping meetings focused?

13) An annual evaluation of a laboratory's quality program identified no opportunities for improvement. Which of the following elements of the program should be reviewed?

14) 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

15) Which of the following is the first step in implementing lean management effectively in a hospital?

16) Evaluation of the quality and appropriateness of patient care in the radiology department is the responsibility of the

17) Which of the following is an essential component in a performance improvement report?

18) The leader of a pain management performance improvement team has asked the Quality Council to disband the team. The most important factor for the Quality Council to assess is

19) Performance improvement teams should always be required to

20) Evidence of strong organization culture

21) Results of physician practice pattern studies are most likely to promote behavior changes when disseminated to the

22) The best reason to evaluate team meetings is to

23) 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?

24) The following information about patient falls is obtained from a facility with units that have a similar average daily census:
Unit A: 6%
Unit B: 4%
Unit C: 9%
Unit D: 8%
Which of the following additional information is most important to evaluate the cause of the falls?

25) A private insurer has contracts with two area hospitals. Hospital A is a 250- bed community facility and Hospital B is a 900-bed tertiary care center. It was
noted that costs were less at the tertiary care center. From a financial standpoint, the best option for the private insurer is to