1) A physician who has a high inpatient mortality rate compared to others in a facility should first be

2) To reduce the incidence of ventilator-associated pneumonia (VAP) in a critical care unit, who should be included on a quality improvement team?

3) Impressed by what he saw at a healthcare conference, the Chief Executive Officer decided to adopt Lean Six Sigma as the hospital's new approach to process improvement. If the desired results are not achieved, which of the following is the most likely reason for this?

4) The most effective way for a healthcare quality professional to communicate quality improvement activities for the medical staff is by:

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

6) Which of the following is the best example of the use of human factors engineering?

7) The staff has been trained and oriented on a new electronic incident reporting system. In the past, staff could report anonymously. The new system requires staff to sign in with an individualized username and password. Three months after implementation, there is a sharp reduction in the number of reported incidents. Which of the following reasons for underreporting of incidents is of greatest concern?

8) Which of the following action plans is the first step in correcting inappropriate blood usage in an emergency department?

9) In profiling length-of-stay data for benchmarking, it is important that data be

10) A chief quality offer has the responsibility for the education and implementation of a quality improvement process. To affect cultural change, the chief quality officer must

11) Timeliness and compliance of documentation were discussed at a multidisciplinary team meeting. To evaluate the effectiveness of the team's action plan, which of the following will provide the most useful information?

12) Empowerment gives employees the opportunity to

13) A policy for "time-outs" in an operating room was initiated in the first quarter. The second quarter data demonstrated only 40% compliance with all elements of the process. The first step the Quality Council should take is to:

14) A Quality Council has examined data on patient falls and determined that a comprehensive fall prevention program is needed. The first step in increasing staff awareness of this initiative is to

15) Medication is ordered for a diabetic patient. Its capacity to improve health status, as a Dimension of quality or performance, is it

16) A healthcare quality professional is conducting a study to determine how many patients contracted influenza despite receiving flu shots. This study is evaluating

17) Incorporating TQM key concepts, compartmentalization of QM/QI activities by organizational structure, i.e., by department or discipline, is

18) Which of the following charts will most likely be used first in a root cause analysis?

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

20) An organization has established a culture of patient safety when

21) Which of the following are essential functions of an infection control program?

22) Which of the following is the best example of an outcome measure?

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

24) Which of the following obstetrical outcomes will result in a morbidity review?

25) Which of the following is used to summarize a characteristic in a population?