1) 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?

2) In developing a performance improvement action plan, which of the following tools should be used FIRST?

3) A performance improvement (PI) training program for supervisors should include

4) 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:

5) In the process of strategic planning, an organization makes decisions about the future. A basic component of the planning process is to

6) A patient safety program can best be enhanced by which of the following technologies?

7) Which of the following actions should a facilitator make the highest priority during the customer focus group process?

8) Barriers to effective communication include

9) Which of the following is the primary benefit of using external quality consultants?

10) The responsibility to promote organizational values and commitment among the staff lies within:

11) 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

12) Which of the following is always true regarding a sentinel event?

13) A team has identified a process for improvement, selected examples of best practice performers, visited those sites, gathered all necessary data, and compiled the results. The most effective next step for the team is to

14) When conducting a sentinel event review, a root cause analysis

15) The clinical competency of a physician is determined by

16) 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

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

18) The responsibility for providing organizational direction for a facility's continuous quality improvement program frequently rests with the quality

19) Quality improvement team outcomes are best evaluated by which of the following?

20) Which of the following is most useful in performing a morbidity/mortality review?

21) A rural healthcare facility is tackling increased patient complaints about long ED wait times by forming a multidisciplinary task force. Strategies include hiring more staff, revamping triage processes, and investing in advanced equipment, with ongoing performance monitoring for improvement. Which principles of Total Quality Management (TQM) are being demonstrated in the healthcare facility's approach to addressing long wait times in the ED?

22) After brainstorming, which of the following should a quality improvement team use to identify items that need immediate attention?

23) 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?

24) 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?

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