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HIT 201 > Final 2 > Flashcards

Final 2 Flashcards

1
Q

According to TJC standards, which of the following hospital committees would be responsible for overseeing the process of monitoring the quality of care provided by physicians that practice in the hospital?

A

medical staff executive committee

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2
Q

What do we call standards, that if met, allow a hospital to receive reimbursement for care provided to Medicare beneficiaries?

A

CoP-Conditions of Participation

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3
Q

According to the Pareto principle

A

20% of the sources of a problem are responsible for 80% of its effects

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4
Q

Of the following tools listed below, which one is used to plot the points for two variables that may be related to each other in some way?

A

Scatter diagram

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5
Q

As the HIM manager, you have been asked to provide a display showing the amount of time it took for 80 records to be pulled from the Emergency department. To report this information, what type of graph would be most effective?

A

histogram

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6
Q

What process assists a health care facility in continuously looking at the ways that problems develop and seeking ways to prevent problems from happening in the future?

A

performance improvement

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7
Q

What is the best tool for differentiating between common cause variation and special cause variation?

A

control chart

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8
Q

What feature is a trademark of an effective PI program?

A

a continuous cycle of improvement projects over time

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9
Q

Continuous Quality Improvement is best described by the following statements EXCEPT

A

corrective action targets clinicians more so than processes

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10
Q

Which of the following processes is mandatory for health care facilities?

A

licensure

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11
Q

A histogram is a valuable tool for representing

A

a frequency distribution with continuous-interval data

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12
Q

Reporting the number of incomplete charts over a 6-month period using a run or line chart will prove valuable in which of the following two ways

A

over time, the data can reveal trends and point out areas for improvement

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13
Q

Which quality management theorist focused on zero defects as the goal of performance improvement efforts?

A

Crosby

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14
Q

The quality improvement team for the HIM department meets to generate ideas to address physician complaints about missing dictation reports. What QI tool would prove useful in discussing various recommendations for solving this problem?

A

brainstorming

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15
Q

The health information reception desk is experiencing an huge influx of phone calls on Monday, Tuesday, and Wednesday mornings. This is creating a problem in getting requested patient information out within an acceptable time frame. The reception staff work group has agreed to start recording the reason for the phone calls for the next four weeks. They want to focus on solving the response-time problem by reducing the turnaround time for the largest category of phone calls. Which QI tool best supports this goal

A

Pareto chart

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16
Q

Which quality management theorist believed that merit raises, formal evaluations, and quotas established through benchmarking hinder worker productivity and growth

A

W. Edwards Deming

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17
Q

In the ACT phase of the PDCA method, what step can assist in implementing change in a department

A

all of the above

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18
Q

The Anesthesia Department is adding a new indicator to its plan. THe Chief Anesthesiologist has come to you, the Director of Quality Management, to help her design a data collection methodology. The two of you are now considering who will be doing the data collection. All of the following are factors in your deliverations EXCEPT

A

TJC standards and required characteristics

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19
Q

All of the following are QI activities that CMS focuses on except:

A

Pregnancies

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20
Q

All of the following are steps to consider when choosing a performance measure except:

A

collecting specific information

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21
Q

Brainstorming, affinity grouping, and nominal group techniques are tools and techniques used during PI initiatives to facilitate ________ among employees?

A

communication

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22
Q

DMAIC is part of which PI model?

A

Six Sigma

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23
Q

In the health care setting today, what is the most common PI model used?

A

PDCA

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24
Q

There are four levels in most healthcare systems and all require changes. Which system is the most important one to consider in any healthcare facility?

A

Level A-the patient

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25
Q

The process of comparing the outcomes of HIM abstracting functions at your facility with those of comparable departments of superior performance in other healthcare facilities to help improve accuracy and quality is referred to as

A

benchmarking

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26
Q

The local healthcare organization has contracted with ABC Labs, Inc. for all “after hours” lab services. This lab is located two blocks from the health care organization.
The process is as follows:
The samples are sent to the lab, via messenger. The ordering physician need the lab values back quickly in order to confirm CAP. At the off-site lab, the lab technician runs the tests, reviews the findings, and sends back a preliminary report to the ordering physician via the messenger. The desired turn-around time for this process is 4 hours or less.
The data on this process is as follows:
The number of after hours procedures performed per month and
the average turn-around time per month
Using this illustration above, which tool would best illustrate if a trend exists with regards to the timing of received reports over the course of 6 months?

A

run chart

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27
Q

Performance measure is a tool that provides an indication of an organization’s performance in relation to a specific process or outcome. What type of tool is this?

A

quantitative

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28
Q

Match the following definition to its proper term: “grants the healthcare organization legal authority to provide healthcare services within its scope of practice”.

A

Licensure

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29
Q

In the “plan” phase of PDCA, which activity is not included?

A

test the solution with a trail run

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30
Q

In the introduction there is a discussion regarding TJC and mandated data sets needing reported on. Within this section it speaks of core measures. What is a core measure?

A

a set of patient care characteristics that TJC and CMS have determined to reflect the quality of care an organization can provide for important diagnoses

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31
Q

What criteria is critical in selecting performance indicators for a health information management department?

A

the indicators must include the most important aspects of performance

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32
Q

What is another term for TQM in healthcare?

A

CQI

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33
Q

What type of environment is essential for implementing PI

A

shared leadership

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34
Q

Which PI theorist believes that performance improvement starts at the top and works it way down

A

Joiner

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35
Q

Which PI model was developed by Shewhart

A

PDCA

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36
Q

What type of review is used by an on-site survey team that permits assessment of operational systems of the healthcare organization and their processes in relation to the actual experience of selected patients currently under the healthcare organizations care

A

Tracer Methodology

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37
Q

This private, not-for-profit organization is dedicated to improving the quality of healthcare by assessing and reporting on the nation’s managed care plans. What organization is this?

A

NCQA

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38
Q

What is the name of the program that NCQA uses to compare the performance of managed healthcare plans

A

HEDIS

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39
Q

This credential is given to an organization tha tmeets a defined set of standards, some of which relate to performance management. Only organizations seeking this credential must comply with these mandates. What is the name of this credential?

A

Accreditation

40
Q

Which performance theorist defined the approaches to assessing quality in care by using measures that examine structure, processes and outcomes

A

Donabedian

41
Q

What QI toolbox technique gives each member of the team an opportunity to select the most important iedas from the affinity diagram?

A

Nominal Group Technique

42
Q

Which type of performance measure focuses on a way of delivering services that leads to a certain outcome?

A

process measure

43
Q

This PI model was introduced by TJC but is no longer mandatory to follow. What is the name of this PI model?

A

10-Step

44
Q

Who was the PI theorist who’s plan worked off of the idea of “no quotas, no merit raises”?

A

Deming

45
Q

This PI tool is used to gather data based on sample observations. What is the name of this PI tool?

A

check sheet

46
Q

What is the name of the chart shows the relationship of each part to the whole?

A

pie chart

47
Q

When creating the fishbone diagram, what is the first step you should do?

A

document an outcome/goal on the right side of the diagram at the end of the horizontal causal line

48
Q

In order to assure complete documentation of any type of event in the healthcare setting, Occurrence Screenings, Incident Reports, Event Reports and Hazard Surveillance Reports should be documented and filed in the

A

Risk Management Office

49
Q

The Utilization Review Coordinator reviews inpatient records at regular intervals to justify necessity and appropriateness of care to warrant further hospitalization. Which of the following utilization review activities is being performed?

A

concurrent review

50
Q

Which of the following established legal liability for hospitals in 1965?

A

Darling v. Charleston

51
Q

The ongoing review of clinical care to ensure the necessity and effectiveness of the services being provided to the patient is the definition for

A

case management

52
Q

Considering what you now know about incident reporting, when should an incident report be analyzed?

A

concurrently

53
Q

In healthcare, risk includes

A

any occurrence or circumstance that might result in loss

54
Q

All of the following are among Joint Commission’s initial core measure sets for hospitals EXCEPT

A

Diabetes

55
Q

The totality of healthcare services provided to a patient and his or her family is all setting, from the least extensive to the most extensive is the definition for

A

Continuum of care.

56
Q

What is another name for the fishbone diagram

A

A & C

57
Q

In the fishbone diagram, what is documented on the “head” of the fishbone?

A

effect, problem, or quality characteristic

58
Q

All of the following are core measures of ORYX we need to focus on except:
Answer

A

CA

59
Q

How many steps are there to determine the starting point for assessing customer service quality?

A

6

60
Q

HEDIS gathers data in the following area(s):

A

All of the above

61
Q

Most health care facilities use this type of screening criteria for UR purposes to determine the need for IP (inpatient) services and justification for continued stay

A

Serverity of illness/intensity of service

62
Q

The medical transcription improvement team wants to identify the cause of poor transcription quality. Which of the following QI tools from the toolbox will best assist the team in identifying the root cause of the problem

A

fishbone diagram

63
Q

When completing a RCA, how many steps must be completed?

A

4

64
Q

If TJC is made aware of a sentinel event that meets reportable criteria, how long does the healthcare organization have to prepare a root-cause analysis and action plan

A

within 45 day sof the event being aware of the event

65
Q

According to your reading, there are two documents important for managing risk exposure. One is the incident report, the other is the

A

patient’s health record

66
Q

Patient safety must be integrated into a healthcare organization’s

A

All of the above

67
Q

Customers receive products or services as a result of what type of process?

A

Organizational

68
Q

All of the following approaches assist UR in determining the nature and extent of required care except:

A

TPP reviews

69
Q

All of the following are types of vendors of patient satisfaction surveys except

A

NitPicker

70
Q

Sentinel events

A

must be reported to Joint Commission along with a root-cause analysis.

71
Q

Which accrediting body requires all accredited healthcare organizations to conduct RCA following any sentinel event?

A

TJC

72
Q

With blood usage review, the committee must watch all of the following when blood products are ordered except:

A

how many blood and blood products are ordered

73
Q

Quality assessment monitoring relies on what primary source document to conduct medical care evaluations?

A

Medical Record

74
Q

Surgical case review includes all of the following except:

A

cases with elements missing in the preoperative anesthesia consultation

75
Q

Risk management programs were introduced to reduce

A

malpractice suits against healthcare organizations and physicians

76
Q

What is ORYX

A

all of the choices

77
Q

Which system is one of the most complex healthcare processes and also one fraught with the greatest possibilities for error?

A

medication usage system

78
Q

This performance measure enables health care organizations to monitor a process to determine whether it is meeting requirements. What is the name of this performance measure?

A

Both A & B

79
Q

The following “sentinel events” must be available for Joint Commission review EXCEPT

A

Petechiae due to adverse drug reaction

80
Q

What is a fishbone diagram used for?

A

all of the above

81
Q

The quality review process of invasive and noninvasive procedures to ensure performance of appropriate procedure, preparation of patient, monitoring and postoperative care and education of patient describes which type of review?

A

surgical case review

82
Q

All of the following clinical finding represents SI indicators for the UR function for inpatient stay except:

A

PO antibiotics for 10 days

83
Q

The following organizations play a key role in the public-private partnership of the MBNQA except:

A

Board of Directors

84
Q

In the fishbone diagram, what is shown on the “bones” of the fishbone diagram?

A

cause(s) of the effect

85
Q

What is the name of the project management tool that is used in clinical process improvement to depict clinical guidelines or critical pathways in the treatment of common medical conditions

A

Gantt chart

86
Q

NPSG “7” relates to

A

Preventing infection

87
Q

Which quality customer service award identifies organizations that will serve as role models for other organizations

A

MBNQA

88
Q

The three major components of UM are

A

Utilization Review, Case Management, Discharge Planning

89
Q

What is the ultimate goal for P4P

A

providers are rewarded for meeting pre-established targets for delivery of healthcare that improve quality and efficiency

90
Q

The UR Coordinator reviews IP records a regular intervals to justify necessity and appropriateness of care to warrant further hospitalizations. Which of following UR activities is being performed?

A

Continued stay review

91
Q

All of the following are part of a successful CQA program except

A

the nursing department is not part of the CQA program

92
Q

NPSGs include all except

A

Over utilization of healthcare services

93
Q

Patient advocacy is usually

A

part of risk management

94
Q

As based in case law decisions and TJC standards, who is ultimately responsible to ensure quality and appropriateness of patient care in a health care facility?

A

governing body or board of trustees

95
Q

The Malcolm Baldrige National Quality Award has three sector-specific criteria. Which of the following is not one of the criteria?

A

all of them are included

96
Q

What does the abbreviation “P4P” mean?

A

Pay for Performance

HIT 201 (2 decks)

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