Exam 3

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Question #1

What qualitative tool would be used by an improvement team to undercover the root cause of a performance problem?

A Pareto chart

B Stakeholder analysis

C Five Whys

D Flow chart

Question #2

An improvement team in a home health agency wants to streamline the process of discharging patients. The team identifies all the factors that will hinder the success of their improvement plans, as well as those factors that will increase the likelihood of success. The team is using what improvement tool?

A Force field analysis

B Lean thinking

C Pareto analysis

D Nominal group technique

Question #3

The hospital team charged with reducing the incidence of patient falls has selected four different patient care process changes that need to be implemented. What tool would the team use to document the tasks necessary for making these process changes?

A Storyboard

B Workflow diagram

C Deployment flow chart

D Planning matrix

Question #4

Staff in an ambulatory surgery center want to streamline the patient admission process. What performance improvement tool would they use to get a better understanding of how patients are currently admitted?

A Histogram

B Affinity diagram

C Stakeholder analysis

D Flowchart

Question #5

An improvement team in the emergency department brainstorms all factors that have an effect on how long patients wait before being seen by a physician. What performance improvement tool would be useful for categorizing the factors identified through this brainstorming activity?

A Five Whys

B Cause and effect diagram

C Workflow diagram

D Pareto chart

Question #6

What can cause data gathered through the use of patient satisfaction surveys to be unreliable?

A Survey is conducted online

B Questions are graded on a continuum

C Response rate is low

D Surveys are sent to a representative sample

Question #7

A hospital improvement team has brainstormed several potential solutions to the problem of high nursing staff turnover. What tool could the team use to select the solutions most likely to be successful?

A Decision matrix

B Flowchart

C Questionnaire

D Pareto analysis

Question #8

What reporting format is used to summarize the steps of a performance improvement project?

A Quality storyboard

B Detailed flowchart

C Gantt chart

D Balanced scorecard

Question #9

What is another name for a fishbone diagram?

A Force field diagram

B Cause and effect diagram

C Workflow diagram

D Affinity diagram

Question #10

The hospital respiratory therapy department is conducting a Six Sigma project for the purpose of reducing the incidence of missed treatments. The department’s medical director asks staff members to identify process changes that will result in fewer missed treatments. What qualitative improvement tool could the director use during this brainstorming session to narrow down potential solutions to those most likely to be successful?

A Nominal group technique

B Workflow diagram

C Planning matrix

D Cause and effect diagram

Question #11

To improve productivity in the hospital operating room, the manager wants to start scheduling elective surgeries on Saturday. What tool can the manager use to identify strategies for gaining support from individuals who may resist this change?

A Nominal group technique

B Stakeholder analysis

C Five Whys

D Pareto analysis

Question #12

A team in the hospital registration department is conducting a Lean project to reduce wasteful steps in the process of preregistering elective admissions. What qualitative improvement tool could the team use to better understand the movement of preadmission paperwork throughout the department?

A Multi-voting

B Workflow diagram

C Cause and effect diagram

D Staff survey

Question #13

What is an example of a quantitative improvement tool?

A Scatter diagram

B Cause and effect diagram

C Nominal group technique

D Decision matrix

Question #14

Staff members in the physical therapy department gather information about the reasons why patient treatments do not start at the scheduled time. They want to group the reasons for late treatment starts into related categories to identify commonalities. What performance improvement tool could be used to sort the reasons into similar categories?

A Force field analysis

B Flowchart

C Prioritization matrix

D Affinity diagram

Question #15

What is a step common to all performance improvement models?

A Evaluate special cause variation

B Measure success

C Identify customer expectations

D Prevent rework

Question #16

Achieving near-perfect quality is the primary goal of which performance improvement model?

A FOCUS-PDCA

B Six Sigma

C Lean

D Rapid cycle improvement

Question #17

What is the first question asked during a FOCUS-PDCA project?

A How will we know that a change is an improvement?

B Who are the key stakeholders?

C What process do we want to improve?

D What changes can we make that will result in improvement?

Question #18

A health maintenance organization conducted a study on outpatient treatment of patients with asthma. The need for a new asthma management protocol was identified, and it was developed. Now the protocol is being piloted by physicians at two primary care clinics. This project is in which phase of the Plan-Do-Study-Act improvement cycle?

A Do

B Act

C Study

D Plan

Question #19

During the Act phase of a PDSA project, if changes made to improve performance are found to be unsuccessful, what is the next step?

A Continue to monitor process performance.

B Start a different process improvement project.

C Repeat the project starting at the Plan phase.

D Add new members to the improvement project team.

Question #20

What improvement model originated in the Toyota automobile production system?

A Six Sigma

B Lean

C Focus-PCDA

D Baldrige

Question #21

For a healthcare process to achieve Six Sigma, what level of quality is expected?

A Minimal waste

B No variation

C Meets expectations

D Free of defects

Question #22

Eliminating wasteful inefficiencies in a process is the primary goal of which performance improvement model?

A Rapid cycle improvement

B Plan-Do-Study-Act

C Lean

D FADE

Question #23

The hospital has collected patient satisfaction data for more than one year. It is now time for strategic planning, and you’ve been asked to summarize the satisfaction data so senior leaders can establish two or three strategic objectives related to improving patient satisfaction. They want to focus on the vital few issues that cause the most problems. What type of graph would you use to provide senior leaders with the information they need?

A Radar chart

B Control chart

C Pie chart

D Pareto chart

Question #24

Statistical process control techniques can be applied to which type of graph?

A Pareto chart

B Line graph

C Histogram

D Scatter diagram

Question #25

Which of the following statements regarding control charts is TRUE?

A Time-series data are plotted on a control chart.

B A control chart is a good tool for displaying cause and effect.

C The Pareto principle is highlighted by the use of control charts.

D Control charts are used to reduce assignable variation.

Question #26

What type of data display uses symbols or colors to draw people’s attention to performance concerns?

A Pie chart

B Bar graph

C Dashboard

D Line graph

Question #27

When a data point on a control chart falls above the upper control limit, the process being measured is exhibiting what type of characteristic?

A Random variation

B Exceptional variation

C Special cause variation

D Common cause variation

Question #28

The clinic medical director wants to know if there is a correlation between the number of minutes patients must wait to see a physician and the time of day. Which graph would you use to display the data to help determine if a relationship exists between the two variables?

A Control chart

B Histogram

C Scatter diagram

D Pie chart

Question #29

Which graph is used to display the frequency distribution of measurement data?

A Scatter diagram

B Line graph

C Histogram

D Pie chart

Question #30

Tampering can occur when a manager reacts to performance measurement results without knowing how much natural performance variance occurs in the process.

A True

B False

Question #31

What is revealed by evaluating the difference between a department’s actual and expected performance?

A Performance trend

B Performance target

C Performance goal

D Performance gap

Question #32

What type of data display is commonly used to report performance measurement data over time?

A Histogram

B Pareto chart

C Scatter diagram

D Bar graph

Question #33

During which phase of quality management are raw data examined to draw conclusions about performance?

A Data analytics

B Performance measurement

C Goal setting

D Data mining

Question #34

Which of the following statements best represents the philosophy employed by the Pareto principle?

A Problems that have a measurable effect on patient outcomes should be corrected.

B The majority of quality defects are caused by a small percentage of identifiable problems.

C To achieve ideal performance, all quality problems should be investigated.

D Generally, 80% of quality problems are candidates for improvement actions.

Question #35

What is a publicly available source of comparative healthcare performance data?

A National Quality Forum

B Hospital Association Quality Measures

C Healthcare Cost and Utilization Project

D American Customer Satisfaction Index

Question #36

Which of the following formats can be used to display measurement data from different time periods?

A Pareto chart

B Scatter diagram

C Pie chart

D Tabular report

Question #37

Which of the following factors is NOT considered when selecting a format for displaying measurement data?

A The audience

B The need for improvements

C The information’s intended use

D The measurement time frame

Question #38

What group sponsors the National Guidelines Clearinghouse?

A National Quality Forum

B Centers for Medicare & Medicaid Services

C Agency for Healthcare Research and Quality

D The Joint Commission

Question #39

What type of healthcare organization uses measures found in the Healthcare Effectiveness Data and Information Set (HEDIS)?

A Health insurance plan

B Rehabilitation facility

C Urgent care clinic

D Home health agency

Question #40

Which of the following is a process measure of performance in a hospital intensive care unit?

A Percentage of patients on ventilators who develop pneumonia

B Percentage of patients not on ventilators who develop pneumonia

C Number of complaints received from family members

D Percentage of staff using hand cleaner when entering patient room

Question #41

The percentage of patients receiving home health services who develop a pressure ulcer is a measure of potentially avoidable events.

A False

B True

Question #42

What is the denominator for the performance measure “percentage of home health patients admitted to the hospital”?

A Total number of hospitalized patients

B Total number of home health patients not admitted to the hospital

C Total number of home health patients

D Total number of home health patients admitted to the hospital

Question #43

A performance measure is considered evidence based if it is derived from nationally recognized practice guidelines.

A False

B True

Question #44

Measures of clinical decision making often originate from medical license requirements.

A True

B False

Question #45

What document does The Joint Commission require hospitals create to describe each data element captured electronically?

A Measure specifications

B Data attributes

C Measure plan

D Data dictionary

Question #46

What is the data source for an e-measure?

A Paper records

B Excel spreadsheet

C Patient surveys

D Electronic database

Question #47

What federal act created incentives for hospitals and providers to adopt electronic health records?

A Medicare Access and CHIP Reauthorization

B National Quality Strategy

C Patient Protection and Affordable Care Act

D Health Information Technology for Economic and Clinical Health

Question #48

What statistic is used to report a measurement that is comparing two things (e.g., the actual number of hospital deaths as compared to the expected deaths)?

A Percentage

B Ratio

C Average

D Absolute number

Question #49

Which external group does NOT establish performance measurement requirements for healthcare organizations?

A National Quality Forum

B National Committee for Quality Assurance

C The Joint Commission

D Centers for Medicare & Medicaid Services

Question #50

What is a process measure of staff performance in a nursing home?

A Number of requests for equipment maintenance

B Number of records lacking documentation of resident’s allergies

C Percentage of residents developing a pressure ulcer

D Percentage of residents regularly participating in social activities

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