question

Infection occurring in a patient in a hospital or healthcare setting in whom the infection was not present or incubaing at the time of admission.

answer

health care acquired

question

Infection that was present in the patient before he or she was admitted to a healthcare facility.

answer

community acquired

question

Cause and effect diagram is otherwise known as ____ diagram.

answer

fishbone

question

This technique structures the root cause inquiry and ensure that the investigators examine the situation from all perspectives; used most often in root cause analysis.

answer

cause and effect diagram

question

The four elements of the cause and effect diagram are:

answer

manpower, methods, material, machinery

question

The purpose of risk management is trying to identify organizational conditions that _______ before _____ happen.

answer

increase risk exposure, injury occurrences

question

If hospital does not submit proper response to sentinel event within 45 additional days, _____ may be impacted.

answer

accreditation decision

question

Four functions of risk management include risk:

answer

exposure or identification, analysis, treatment, evaluation

question

This function of risk management involves systematic means of identifying potential losses and requires an understanding of facility's business, legal, organizational, and clinical components.

answer

risk exposure or identification

question

This function of risk management involves identification of which risks should be proactively addressed and which risks are lower in priority.

answer

risk analysis

question

This function of risk management applies risk control and risk financing techniques to determine how a risk should be treated.

answer

risk treatment

question

Risk management technique that is aimed at preventing or reducing the chances and/or effects of a loss occurrence.

answer

risk control

question

Risk management technique that refers to the methods used to pay for the costs associated with claims and other expenses.

answer

risk financing

question

This function of risk management evaluates each piece of the process in order to determine whether objectives are being met.

answer

risk evaluation

question

The goal of the risk management team is to spot _____ and through an intensive investigative process, identify _____.

answer

patterns in incidents, problems or concerns

question

The risk management team is involved in investigating _____ and is usually directed by ____ from healthcare facility or contracted agency.

answer

incidents, legal support

question

Some risk management teams are active in _______ program, tracking ______ and acting as ______.

answer

patient advocacy, patient grievances, intermediary

question

Occurrences that do not necessarily affect an outcome but if they were to recur they would carry significant chance of being a serious adverse effect.

answer

near misses

question

To instill a drug into a body of a patient.

answer

administer

question

To issue a medical prescription for a patient.

answer

prescribe

question

To deliver controlled substances in some type of bottle, box or other container to a patient.

answer

dispense

question

Utilizing PI processes to identify and analyze medical errors, medication errors, and near misses is part of _______ step in building a safe medication management system.

answer

evaluation

question

Purchasing medications, determining the formulary, and evaluating medications is part of the _______ step in building a safe medication management system.

answer

select and procure

question

Storage, tracking, and record keeping of controlled medication in compliance with federal and state laws and in a way that ensure stability and safety is part of the ________ step in building a safe medication management system.

answer

proper and safe storage

question

Taking steps to reduce the potential for error or misinterpretation when orders are written or verbally communicated (e.g., training/orientation, policies/procedures) is part of ______ step in building a safe medication management system.

answer

order and transcribe

question

The pharmacist reviewing prescription orders for appropriateness to prevent prescribing, administration, pharmacy, and discharge errors is part of the ______ step in building a safe medication management system.

answer

prepare and dispense

question

Using two patient identifiers prior to giving patient medication, second checks, providing medication in ready to administer form, and maintaining an accurate medication record are all part of the ______ step in building a safe medication management system.

answer

medication administration

question

Assessing each patient's response to medication and effects of medication on patients are part of the ______ step in building a safe medication management system.

answer

monitoring

question

The five medication rights are right:

answer

patient, drug, dose, route, time

question

Security risks are greater in _____ areas, inpatient/outpatient _____ where _____, ___ which is high risk for _____, and ____ and ____ areas where ____ are collected.

answer

cash handling, pharmacies, drugs are stored, ER, violence, registration, clinic, copays

question

NPSG

answer

national patient safety goals

question

RACE

answer

rescue patient, activate alarm, confine fire, extinguish

question

PASS

answer

pull pin, aim nozzle, squeeze handle, spray base

question

MSDS

answer

material safety data sheet

question

CPOE

answer

computerized provider order entry

question

MAR

answer

medication administration record

question

MDS

answer

minimum data set

question

PCE

answer

potentially compensable event

question

HEDIS

answer

Healthcare Effectiveness Data and Information Set

question

OASIS

answer

Outcome and Assessment Information Set

question

Occurrences involving liability for injury or property loss are :

answer

potentially compensable events

question

FMEA

answer

failure mode and effects analysis

question

Technique for analyzing and predicting potential problems before they actually happen.

answer

FMEA

question

Nonreviewable sentinel event with potential for more serious consequences.

answer

near miss

question

Process used by Joint Commission to analyze organization's systems by following individual patients through the organization's healthcare process in sequence experienced by patient.

answer

tracer methodology

question

Most medical staff by laws require documentation of an H&P within ______ of admission or within ______ prior to admission.

answer

24 hours, 30 days

question

Which NPSGs are related to proper and safe usage of medications?

answer

identify patient correctly, use medicines safely, improve staff communication

question

______ is an important part of ensuring medication safety.

answer

medication reconciliation

question

FMEA is a _____ system, while RCA is a ____ system.

answer

prospective, retrospective

question

Documentation maintained on the hazardous materials used in a healthcare organization outlining the common chemical names, risks associated with material, flammability, reactivity, effects, description of protective clothing.

answer

material safety data sheet

question

What is the overall plan for the EOC?

answer

safety management program

question

Fire drills are conducted _____ for ____.

answer

quarterly, each shift

question

What are the four parts of hazard vulnerability planning activities?

answer

mitigation, preparedness, response, recovery

question

Tracer methodology is used in ______ process.

answer

joint commission onsite survey

question

Introduced by the Joint Commission, this initiative has evolved to include core measure sets based on services provided by the healthcare organization and is now required of Medicare participants by CMS.

answer

ORYX

question

What are the eight steps of decreasing risk exposure?

answer

plan and policies, teaching, occurrence reports, examine structure, identify patterns, patient advocacy, communicate information, insurance strategy

question

The five core measures related to adult cardiovascular/respiratory are:

answer

stroke, ami, heart failure, venous thromboembolism, pneumonia

question

The three core measures related to children are:

answer

childrens asthma, perinatal, immunization

question

The three core measures related to psycho-behavioral are:

answer

substance abuse, tobacco treatment, inpatient psychiatric

question

The three core measures related to hospital services:

answer

scip, hospital outpatient, emergency department

question

The seven steps to building a safe medication management system include:

answer

select and procure, proper and safe storage, order and transcribe, prepare and dispense, administration, monitoring, evaluation

question

In 1918, American College of Surgeons establishes _______.

answer

hospital standardization program

question

In 1952, _____ was formed.

answer

JCAH

question

In 2002, HCFA becomes _____.

answer

CMS

question

In 2003, JCAHO begins ____, ______, and ______.

answer

unannounced, tracer methodology, NPSGs

question

In 2009, _____ is passed.

answer

HITECH

question

Who is the father of TQM?

answer

Demming

question

Who adapted TQM to healthcare?

answer

Donabedian

question

What are the five organizations that make up JCAH?

answer

AMA, AC of Physicians AHA, Canadian Medical Association, ACS

question

What were Donabedian's four perspectives?

answer

structure, process, outcomes, cost

question

What are the three sets of Federal legislation enacted that will impact the healthcare system?

answer

ARRA, HITECH, ACA

question

The Hill Burton Act established funding to build ______ in engage for the hospital providing reasonable amount of _____ for residents who could not _____.

answer

new hospitals, free care, afford to pay

question

_____ receive a product or service as a result of an organizational process.

answer

customers

question

Processes identified as important are ________, _____, or _____.

answer

high or low volume, high risk, problem prone

question

Which organization established the minimum standard for hospitals?

answer

ACS

question

Which 1910 document exposed the unacceptable variation in and lack of basic standards in medical school curricula.

answer

Flexner report

question

Who are the four leaders in TQM?

answer

Demming, Crosby, Juran, Donabedian

question

Performance improvement is a _____ process.

answer

cyclical

question

The cyclical model is based on assumptions that PI activities will take place _____ and services, processes, and outcomes can always be _____.

answer

continually, improved

question

What are the 5 steps of the organization wide PI process?

answer

identify performance measures, measure performance, analyze and compare data, identify improvement opportunity, perform ongoing monitoring

question

A quantitative tool that provides an indication of an organization's performance in relation to a specified process or outcome.

answer

performance measure

question

A standard of performance or best practice.

answer

benchmark

question

In healthcare, this provides a indication of an organization's performance in relation to a specified process or outcome.

answer

performance measurement

question

Healthcare philosophies often focus on measuring performance in which three areas?

answer

systems, processes, outcomes

question

When organizations measure the foundations of caregiving, which include buildings, equipment, professional staff, appropriate policies, they are measuring ______.

answer

systems

question

When organizations measure the interrelated activities that promote effective and safe patient outcomes across services and disciplines within an integrated environment, they are measuring _____.

answer

processes

question

When organizations measure the final results of care, treatment, and services in terms of the patient's expectations, needs,and quality of life, which may be positive and appropriate or negative and diminishing, they are measuring _____.

answer

outcomes

question

______ is another means of identifying systems, processes, and outcomes for improvement.

answer

benchmarking

question

The systematic comparison of the products, services, and outcomes of one organization with those of a similar organization.

answer

benchmarking

question

Sometimes organization receive dramatic information about the ineffectiveness of a care process through a ______.

answer

sentinel event

question

An unexpected occurrence involving the death or serious physical or psychological injury, or risk thereof.

answer

sentinel event

question

High volume processes increase the risk of incidents through ________ of _____.

answer

sheer number, processes performed

question

Low volume processes increase the risk of incidents because they may be ______ or be ______ creating opportunity for _______ or ______.

answer

performed infrequently, unfamiliar to staff, increased errors, safety risks

question

Problem prone or high risk outcomes can result in _____ or ______ that might open organization to ______ or ______.

answer

patient injury, negative outcomes, malpractice suits, legal action

question

In this process, the leader solicits input from team members by going around the table and having each team member provide ideas.

answer

structured brainstorming

question

In this process, member of the team offer ideas as they come to mind.

answer

unstructured brainstorming

question

This technique is used to organize and prioritize ideas by agreeing on primary categories or groupings from the brainstorming session and then secondary ideas listed under each primary category.

answer

affinity diagram

question

This technique allows groups to narrow the focus of the discussion or to make decisions by giving each member of the team the opportunity to select the most important ideas from the affinity diagram.

answer

nominal group technique

question

After the team has been selected, ____ should be chosen.

answer

team leader

question

The team leader should be someone whom the team _______ as well as someone who is ______ and will take the initiative to _______ through _____.

answer

respects, organized, see the team, the process

question

The team leader is responsible for the ______ of the team's work.

answer

content

question

The purpose of the team facilitator is to serve as _______ to the team and ______ in _____ and in using ______.

answer

advisor, help the team, PI process, quality improvement tools

question

What are the five team roles?

answer

leader, facilitator, member, recorder, timekeeper

question

This team member keep minutes of the meeting, including any documentation required by the organization.

answer

recorder

question

This team member helps the team manage its time.

answer

timekeeper

question

This explains those issues the team was initiated to address, describe the team's goal or vision, and list the initial members of the team.

answer

team charter

question

The mission statement of a PI team should address process _______, ______ by process, _______ with process, and how well the process _____.

answer

to be improved, who is affected, problems, must function

question

The vision statement of a PI team describes what the initiative will_______ or ______, or it describes some ______ the PI will reach.

answer

look like, be in the future, milestone

question

The PI team must focus on _______ and acknowledge ______ to maintain their focus on implementing its vision of the desired outcome.

answer

what should be, what is

question

Categorical data including values assigned to name specific categories.

answer

nominal

question

Nominal data are usually displayed in _____.

answer

bar graphs

question

Ranked data used to express the comparative evaluation of various characteristics or entities.

answer

ordinal

question

Ordinal data is often measured with _____.

answer

likert scale

question

Ordinal data is best displayed in ____ and ____.

answer

bar graphs, pie charts

question

Numerical values that represent whole numbers.

answer

discrete data

question

Discrete data can be displayed in ____.

answer

bar graphs

question

_____ data assume an infinite number of possible values in measurements that have decimal values as possibilities.

answer

continuous

question

Weight, blood pressure, and temperature are _____ data.

answer

continuous

question

The number of times a score or value occurs in the data set.

answer

absolute frequency

question

The percentage of time that the characteristic appears.

answer

relative frequency

question

The arithmetic average of a distribution.

answer

mean

question

If the data are discrete, the means should be rounded to nearest _____; if the data are continuous, _____ or _____ can be reported.

answer

whole numbers, numbers with decimal fractions

question

The value in the middle of a data set.

answer

median

question

Charts and graphs make it easier to identify ____ and ____.

answer

trends, significant findings

question

_____ can be used to compare data sets from different years or over time to illustrate a trend in the data.

answer

graphs

question

These are used to display discrete categories such as gender or type of health insurance.

answer

bar graphs

question

These are used to identify problems or changes in a system or process and display data proportionally.

answer

histogram

question

Histograms display large amounts of ______.

answer

continuous data

question

Histograms show the _______ of occurrence.

answer

relative frequency

question

Histograms show the distribution of the ______ of the data in _____.

answer

absolute frequency, grouped intervals

question

A _____ can help the PI team focus problems and their causes and demonstrate which are most responsible for the problem.

answer

pareto chart

question

These are used to show the relationship of each part to the whole (i.e., percentages).

answer

pie charts

question

These summarize data according to categories.

answer

pivot tables

question

This is a simple plotted chart of data that shows the progress of the a process over time.

answer

line chart

question

This type of chart measures key processes over time and is used to determine whether variation is normal or a result of special circumstance.

answer

control

question

The normal variation, or the expected variance, is called _____.

answer

common cause variation

question

When a special circumstance or unexpected event occurs in the process, this will result in a ______.

answer

special cause variation

question

The upper and lower control limits are always _____ standard deviations above and below mean.

answer

2

question

Data points that lie outside upper or lower control limits may signal ______.

answer

special cause variation

question

Which method is used to record meeting minutes?

answer

CRAF

question

In documenting minutes, one should use the CRAF method. CRAF stands for:

answer

conclusions, recommendations, actions, follow up

question

This section of the minutes should document the results of the discussion and any decisions the group makes about future actions.

answer

conclusions

question

This section of the minutes should capture the team's plan for putting its decision into effect with justification points.

answer

recommendations

question

This section of the minutes documents who has been assigned to accomplish certain activities during the next work period.

answer

action

question

This section of the minutes documents whether the actions were accomplished and whether the group is ready to make decisions and recommendations for future activities.

answer

follow up

question

At a minimum, reports should be submitted to the organizations Performance Improvement and Patient Safety Council at least ______.

answer

quarterly

question

In storytelling, the team explains their work using _____.

answer

storyboards

question

This communication method is used to summarize an entire PI project in a graphic format.

answer

storyboards

question

Customer _______ must be identified and incorporated into the design or redesign of an effective process

answer

expectations

question

What are six aspects of quality that are important to customers and can be reported?

answer

reliability, responsiveness, assurance, empathy, features, perceived quality

question

Aspect of quality that describes the level at which an organization can provide and offered product or service when requested and as advertised.

answer

reliability

question

Aspect of quality that describes how an organizational staff responds to unanticipated service needs.

answer

responsiveness

question

Aspect of quality that describes the knowledge and courtesy of the staff that provide the goods and services.

answer

assurance

question

Aspect of quality that describes the staff's willingness to relate to its customers during the provider customer relationship as fellow human beings who have feelings and emotions.

answer

empathy

question

Aspect of quality the describes aspects of healthcare services that distinguish one organization from another or that add particular value in the customer's evaluation of an organization.

answer

features

question

Aspect of quality that consists of the organization's reputation for quality of its services and consumer reaction to these services and products based on their experiences.

answer

perceived quality

question

HCAPHS was developed by _____; data and outcomes from this measure are required to be submitted to ______.

answer

AHRQ, CMS

question

This satisfaction questionnaire is mailed to a sample of discharged hospital patients.

answer

HCAPHS

question

The totality of healthcare services provided to the patient and his or her family in all setting.

answer

continuum of care

question

The principal process by which organizations optimize the continuum of care for their patients is _____.

answer

case management

question

These individuals review the condition of patients to identify each patient's care needs and to integrate patient data with the patient's course of treatment.

answer

case managers

question

A multidisciplinary outline of anticipated care within an appropriate time frame to aid a patient in moving progressively through a clinical experience that ends in a positive outcome.

answer

critical pathway

question

When reviewing the progress of care, the ultimate goal is to maintain the patient in the ______ level of care based on her _____.

answer

least costly, assessed needs

question

A performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting requirements.

answer

indicator

question

Indicators may be established and implemented _____, _____ or _____.

answer

internally, externally, or generically

question

_____ indicators are usually developed by an interdisciplinary team made up of staff from across the organization and is developed to monitor specific processes within the organization.

answer

internal

question

_____ indicators are created by an organization outside the healthcare facility.

answer

external

question

_____ indicators have been developed by many of the same agencies for use across the continuum of care and in various regions in the country.

answer

generic

question

For a patient to meet the admission criteria in acute care settings, he or she must meet a clinical measure in ____ and ____ categories.

answer

intensity of service, severity of illness

question

This criteria refers to the type of services or care the patient requires.

answer

intensity of service

question

This criteria refers to how sick the patient is or what level of care the patient requires.

answer

severity of illness

question

The four core processes involved in care, treatment, and services to patients include ______, and _____, ____, and ______ care, treatment, and services

answer

assessing patient needs, planning, providing, coordinating

question

The ______ has become the model for the _____ of patient_____.

answer

care pathway, outline, progression of treatment

question

This sets the overall direction for care and defines the specific treatment and its timing and frequency.

answer

care pathway

question

This Joint Commission initiative has evolved to include core measures sets based on services the healthcare organization provides and is not also required of Medicare participants

answer

ORYX

question

The 14 ORYX core measures include:

answer

SCIP, stroke, AMI, heart failure, pneumonia, substance abuse, tobacco treatment, immunization, emergency department, perinatal, venous thromboembolism, children's asthma, hospital based inpatient psychiatric services, hospital outpatient department

question

In core process 3 (providing care), patient care is set by the _____ and provided by _____ of _____.

answer

care pathway, collaborative team, professionals

question

NPSGs states that _______ are used when administering medications, blood, or blood components and when collecting blood samples and other specimens.

answer

two patient identifiers

question

For blood product transfusion, the blood product is matched using either _____ process or ______.

answer

two person verification, automated technology

question

The cause of every transfusion reaction must be _____.

answer

investigated

question

For healthcare organizations to define optimal care, they must first establish _______.

answer

standards of care

question

The following are the eight NPSGs: identifying ______; improve _____; use ______; prevent _____; check patient ______; prevent patients from _____; prevent _____; identify patient ____.

answer

patient correctly, staff communication, medicines safely, infection, medicines, falling, bed sores, safety risks

question

The universal protocol for surgery requires the prevention of ___, ____, ____ surgery.

answer

wrong person, wrong site, wrong procedure

question

These attempt to standardize the care of a single condition across the entire country.

answer

clinical guidelines

question

This attempts to identify the care processes or interventions that achieve the best outcomes in different types of medical practice.

answer

evidence based medicine

question

Under this arrangement, providers are rewarded for meeting preestablished targets for delivery of healthcare services that improve quality and efficiency.

answer

pay for performance

question

The NCQA introduced the HEDIS data set in early 1990s. This is used as a means of gathering information about ____, ____, and _____ with managed care organizations and other health plans.

answer

care, outcomes, member satisfaction

question

HEDIS gathers data in measures of ____, _____, ____, ____, and _____.

answer

quality, access, membership, financial performance

question

Any sentinel event requires a credible ______ to be completed within ______.

answer

root cause analysis, 45 days

question

The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards.

answer

accreditation

question

State's act of granting a healthcare organization or an individual healthcare practitioner permission to provide services of a defined scope in a limited geographical area.

answer

licensure

question

Grants approval for a healthcare organization to provide services to a specific group of beneficiaries.

answer

certification

question

Healthcare organization must meet the federal _______ to receive funding through the Medicare and Medicaid programs.

answer

conditions of participation

question

Reviews that are performed to fulfill legal or licensure requirements.

answer

compulsory

question

Reviews that are conducted at the request of the healthcare facility seeking accreditation or certification.

answer

voluntary

question

The process of meeting a prescribed set of standards or regulations to maintain active accreditation, licensure, or certification status

answer

compliance

question

Which organization has been the most visible organization responsible for accrediting healthcare organizations?

answer

joint commission

question

Private, nonprofit organization committed to developing and maintaining practical customer-focused standards to help organization measure and improve quality, value, and outcomes of behavioral health and medical rehabilitation programs.

answer

CARF

question

CARF stands for:

answer

commission on accreditation of rehabilitation facilities

question

The primary initiative of this organization was to ensure that osteopathic students receive proper training in facilities that provided high quality care. Now they have developed standards for a variety of facilities.

answer

AOA

question

AOA stands for:

answer

American osteopathic association

question

This organization accredits managed care plans and managed behavioral health organization, and provides credentials verification for physician organizations.

answer

NCQA

question

NCQA stands for:

answer

national committee for quality assurance

question

NCQA uses _____ to accomplish assessments of managed health care plans.

answer

HEDIS

question

This organizations surveys and accredits ambulatory medical facilities and managed care organizations.

answer

AAAHC

question

AAAHC stands for:

answer

accreditation association for ambulatory health care

question

Agencies contracted by CMS that retrospectively review patient records to ensure that the care provided by practitioners meets the federal standards for medical necessity, level of care, and quality of care.

answer

quality improvement organizations

question

Which four organizations have deemed status?

answer

aaahc, aoa, carf, joint commission

question

An organization has _____ when CMS assumes that the organization meets the Conditions of Participation if it is currently accredited by the organization.

answer

deemed status

question

TJC survey process where patients are selected on the basis of the current census of patients that the organization identifies as typical of its case mix and follow their experience through the organization.

answer

tracer methodology

question

TJC may conduct ____ and ____ tracer activities as well as _____.

answer

patient, system, leadership interviews

question

During TJC tracer process, system tracers may include _____, ____ and _____ systems.

answer

medication management, data management, infection control

question

CMS is currently moving all long term care state survey agencies to a more data driven process using _____.

answer

quality indicator survey

question

Long term care site surveyors always look for evidence of three trigger issues. These are:

answer

high percentages of dehydration, decubitus ulcers in low risk residents, fecal impactation

question

The _____ determines whether residents in long term care have high percentages of dehydration, decubitus ulcers, and fecal impaction.

answer

facility quality indicator survey

question

With regard to long term care, this two staged survey process designed to produce a standardized resident centered, outcome oriented quality review.

answer

quality indicator survey

question

Which organization accredits psychiatric and rehabilitative care facilities?

answer

CARF

question

Five trigger issues for Joint Commission are:

answer

patient rights, communication, medication use, information management, general safety

question

The use of prevent and control measures to protect against possible exposure to infectious agents.

answer

standard precautions

question

Standard precautions require that caregivers be educated about proper _____ techniques and wear ____, ____, ____, and ___.

answer

hand washing, gloves, gown, masks, eye protection

question

This organization published a report on medical errors that sent shock waves through the American healthcare industry.

answer

IOM

question

Joint Commission accredited organizations do annual review to assure what?

answer

efficacy and efficiency

question

The capacity to produce the desired effect.

answer

efficacy

question

Having a direct causative effect.

answer

efficiency

question

_____ involves using data collection and analysis activities as management tools to improve the provision of services to specific healthcare population.

answer

quality improvement

question

The systematic investigation, including development, testing, evaluation designed to develop or contribute to generalizable knowledge.

answer

research

question

Which case set the precedent for hospital legal liability?

answer

Darling vs Charleston hospital

question

Accordance of permission by a healthcare organization to a licensed independent practitioner in a specific area of specialty.

answer

clinical privileges

question

Recredentialing occurs at least every ____.

answer

two years

question

Which websites must be queried during the credentialing and re-credentialing process?

answer

National practitioner data bank, healthcare integrity and protection data bank

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