Module 13 Test- Quality and Performance Improvement (RHIA and RHIT) Flashcards
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 deliberations EXCEPT
the expertise of the staff.
the location of data.
Joint Commission standards and required characteristics.
quality management organizational model of the institution.
Joint Commission standards and required characteristics
If administrators of a home health agency wanted to measure the outcomes of adult patients receiving their agency’s services, which tool would they use?
HEDIS
QAI
OASIS
ORYX
OASIS
As director of the HIM department, you are asked to chair a committee that will review, select, and implement a CPOE system. The information has been collected, and you bring your committee together to prioritize their suggestions. This method of working with information is known as
correlation analysis.
force field analysis.
Delphi process.
nominal group technique.
nominal group technique
As an HIM coding supervisor, you are asked to compare the current coding process with a proposed concurrent coding process. What visual tool would be the best to identify all the logical steps and sequence of each procedure?
decision matrix
checksheet
flowchart
cause and effect diagram
flowchart
The performance tool shown above is used to provide structure by classifying information into smaller groups. What is the name of this chart/diagram?
arrow diagram
flowchart
matrix
affinity diagram
affinity diagram
Your hospital is required by the Joint Commission and CMS to participate in national benchmarking on specific disease entities for quality of care measurement. This required collection and reporting of disease-specific data is considered
a series of core measures.
an environment of care.
a group of sentinel events.
risk assessment.
a series of core measures
The hospital quality department adopted the Lean Management quality model using JIT, which ensures required process items and resources are
for the correct patient, using the correct procedure, at the correct site.
available at the right place and the right time.
automatically restocked to maintain a surplus.
always kept stocked in central processing.
available at the right place and the right time
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?
preadmission
retrospective review
continued stay review
admission review
continued stay review
Which of the following processes is mandatory for health care facilities?
AHA registration
licensure
certification
accreditation
licensure
The use of metrics to conduct root cause analysis that will facilitate changes throughout the organization can best be presented using a
flow chart.
scatter diagram.
fishbone diagram.
pie chart.
fishbone diagram
Eighty requests for records to be pulled for the emergency room were processed in January. From the histogram provided above, what was the most frequent amount of time taken to process a request?
21–30 minutes
1–10 minutes
31–40 minutes
11–20 minutes
11–20 minutes
Which of the following is a disadvantage of retrospective data collection?
Data are all available.
Reviewer bias is reduced.
Deficiencies in documentation can effect reimbursement.
Fewer data collectors are required.
Deficiencies in documentation can effect reimbursement
What feature distinguishes the nominal group technique (NGT) from brainstorming?
NGT uses a visual device like a flip chart to keep track of responses.
NGT draws responses from a large group of people.
NGT determines the importance of responses through a rating system.
NGT can be accomplished by mail.
NGT determines the importance of responses through a rating system
Surgical case review includes all the following EXCEPT
determination of surgical justification based on clinical indication(s) in cases where no tissue has been removed.
cases with elements missing in the preoperative anesthesia consultation.
cases with serious surgical complications or surgical mortalities.
cases where there is a significant discrepancy between preoperative, postoperative, and pathological diagnoses.
cases with elements missing in the preoperative anesthesia consultation.
A surgeon left a clamp in a patient, resulting in a return to the operating room. In an integrated organizational quality management model, all of the following entities would receive data about the investigation EXCEPT the
Credentials Committee.
Risk Management Program.
Tissue Committee.
Pharmacy and Therapeutics Committee.
Pharmacy and Therapeutics Committee
HEDIS gathers specific data on women’s health in which of the following areas?
severity of illness indicators
comprehensive diabetes care
average length of stay
prenatal care
prenatal care
HIPAA Security Component concerned with having a building alarm system installed would be a(n)
administrative safeguard.
physical safeguard.
organizational standard.
technical safeguard.
physical safeguard
As head of the performance improvement department, you are asked to evaluate patient satisfaction and offer recommendations for action. The performance tool shown above is used to graphically display the results. What is the name of this chart?
line chart
Pareto chart
run chart
bar chart
Pareto chart
As the new coding manager, you met with the coding staff to encourage feedback on ways to increase coding accuracy to meet established benchmarks. The coders provided feedback through brainstorming that you compiled on flipcharts and organized into categories. This is known as a(n)
cause-and-effect diagram.
affinity diagram.
nominal group technique.
flow process chart.
affinity diagram
The QI plan for your hospital requires each coder maintain a minimum of 94.5% accuracy in coding. You manage the coding department, and the past year’s average accuracy rating was 95.3%. The QI plan allows a standard deviation (SD) of ±2 against the minimum of 94.5% accuracy. Did your coding staff’s overall average meet within standard deviation range?
Yes, within ±2 above SD
Yes, within ±2 below SD
No, because it is > ±2 above SD
No, because it is > ±2 below SD
Yes, within ±2 above SD
What federal legislation passed in 1986 gave immunity from legal action to practitioners regarding some peer-review process activities?
Utilization Review Act
Healthcare Quality Improvement Act
Health Insurance Portability and Accountability Act (HIPAA)
Patient Protection and Affordable Care Act (PPACA)
Healthcare Quality Improvement Act
The HIM department frequently experiences a backlog in loose report filing. A quality improvement team is assembled to identify the outcome variables and the major or root causes. What visual QI tool is helpful to report the findings?
fishbone (cause and effect) diagram
run chart
PDCA method
scatter diagram
fishbone (cause and effect) diagram
Based on the graphic chart, which two areas should you recommend be acted upon first in order to address 80% of the patients’ complaints?
not enough information to determine
food and cleanliness
cleanliness and courtesy of staff
food and courtesy of staff
food and cleanliness
A histogram is a valuable tool for representing
a frequency distribution with continuous-interval data.
priorities in problem solving.
the root causes of a problem.
the solution to a problem.
a frequency distribution with continuous-interval data
What feature is a trademark of an effective PI program?
a one-time cure-all for a facility’s problems
a cost-containment effort
a continuous cycle of improvement projects over time
an unmanageable project that is too expensive
a continuous cycle of improvement projects over time
According to the HIPAA Privacy Rule, the following persons must adhere to the minimum necessary standard when releasing patient-specific information.
physicians
volunteers
employees
all members of the organization: clinicians, staff, and volunteers
all members of the organization: clinicians, staff, and volunteers
Refer to the Summary of Selected Blood Product Review table shown above. What percent of the fresh frozen plasma units met indications?
24%
7%
22%
76%
24%
What quality improvement (QI) tool uses criteria to weigh different alternatives? This display would assist in viewing all relevant information at the same time.
the PDSA method
a flowchart
a decision matrix
a customer satisfaction survey
a decision matrix
Continuous quality improvement is best described by the following statements EXCEPT
standards are defined, measured, and systematically applied.
all personnel support quality improvement efforts, including top management and the governing body.
corrective action targets clinicians more so than processes.
monitoring is ongoing with periodic feedback.
corrective action targets clinicians more so than processes
Refer to the Summary of Selected Blood Product Review table shown above. Which quality improvement function would prompt the production of the table?
blood usage review
pharmacy and therapeutics function
drug usage evaluation
medical record review
blood usage review
In the Act phase of the PDSA method, what step can assist in implementing change in a department?
distributing new policies and procedures to people affected by the changes and explaining the rationale for the changes
collecting data
analyzing data
preparing for implementation of the new strategy
distributing new policies and procedures to people affected by the changes and explaining the rationale for the changes
Referring to the case study below, what would you do as director of the quality department?
Upon Mary G’s arrival back in the department, give her a written warning.
Immediately dismiss Mary G upon her arrival back in the department.
Walk into Lucille’s room and state that Dr. Z is a fine surgeon and also advise Mary G to lower her voice.
Seek the advice of the facility’s legal counsel.
Immediately dismiss Mary G upon her arrival back in the department.
The Joint Commission recently surveyed an acute care hospital. The hospital just received the survey report and the accreditation decision. Which of the following categories should the hospital leaders address first?
Written Progress Reports
Requirements for Improvement
Grid Elements
Triennial Exception Rules
Requirements for Improvement
As director of the HIM department, it is your responsibility to reduce the turnaround time for your organization’s accounts receivable balance. The performance improvement tool shown above was used to add weights in order to prioritize ideas. What is it called?
precision matrix
force field analysis
fishbone diagram
flowchart
force field analysis
In quality review activities, departments are directed to focus on clinical processes that are
high risk.
low volume.
most commonplace.
expensive.
high risk
The primary advantage of concurrent quality data collection is that
staffing is decreased.
multiple chart reviews eliminate collector bias.
chart completion issues can be remedied promptly.
practitioners receive immediate feedback about patient processes and outcomes.
chart completion issues can be remedied promptly
The following legislation requires that patient-identifiable health information remains confidential and protected against unauthorized disclosure, alteration, or destruction.
HIPAA Security Rule
Privacy Act of 1974
Patient Care Act
Workman’s Compensation Act
HIPAA Security Rule
You sit on the quality improvement team for the nursing department that meets to generate ideas to address verbal order documentation problems about the “Read Back Verbal Order” policy. What QI tool would prove useful in sharing input and various recommendations for solving this problem?
flowchart
check sheet
brainstorming
scatter diagram
brainstorming
Which quality management theorist focused on the use of the PDCA cycle in continuous clinical quality management improvement efforts?
Peters
Crosby
Kaizen
Deming
Deming
You are determining the sample size for a quality study. Which of the following factors should you consider first?
personnel
cost
confidentiality of the record
size of the target population
size of the target population
The manager of the quality department is listing various sources of data. Which of the following data sources would be an example of an external source?
quality improvement organization (QIO) information
patient registration and admission, discharge, transfer (ADT) information
incident reports
emergency room logs
quality improvement organization (QIO) information
Physicians who are members of the Surgery Committee meet to review surgical cases referred for quality issues and deviations from standard care norms. This type of review in which a physician’s record is reviewed by his or her professional colleagues is known as
concurrent review.
incident screening.
peer review.
clinical pertinence review.
peer review
The medical malpractice crisis of the 1970s prompted the development of _____________________ in health care facilities.
quality improvement programs
risk management
financial analysis programs
utilization management
risk management
Reporting the monthly average turnaround time for the release of information (ROI) over a 6-month period using a run or line chart will reflect
trends and detect if improvements were made.
the quality of informed consents.
the quality of appropriate authorized consents.
the number of denied requests.
trends and detect if improvements were made
The credentialing process requires health care facilities to
review and file the provider’s application.?
query the NPDB to collect and report malpractice judgment and settlements.
interview previous patients.
watch the provider perform surgery.
query the NPDB to collect and report malpractice judgment and settlements
Which quality management theorist believed in the contrasting views of Theory X (presumed that workers disliked work) and Theory Y (assumed that under the right conditions, people would seek responsibility and be creative)?
Brian Joiner
Philip Crosby
Joseph Juran
Douglas McGregor
Douglas McGregor
Referring to the case study below, are the meeting minutes about the decisions regarding Dr. Z of the Department of Surgery and of the Executive Committee admissible in court?
No, the federal Freedom of Information Act and state “sunshine laws” protect peer review.
Yes, federal amendments to the Medicare Act require release of peer review.
Yes, state laws allow discovery of medical review committee records.
No, under state laws, records of medical review committees are not subject to introduction into evidence.
No, under state laws, records of medical review committees are not subject to introduction into evidence.
The Joint Commission has a standard stating that a hospital must plan and design information management processes to meet _____________ information needs.
internal
both internal and external
patient record
external
both internal and external
Patient mortality, infection and complication rates, adherence to living will requirements, adequate pain control, and other documentation that describe end results of care or a measurable change in the patient’s health are examples of
outcome measures.
incident reports.
threshold level.
sentinel events.
outcome measures
A culture and sensitivity report was returned to the inpatient unit of Brian Hospital. The sensitivity showed bacterial resistance to the current antibiotic the patient was receiving. The patient continued on the same antibiotic without improvement. A generic quality screen identified this case for review. At a minimum, which committee should review this case?
Safety Committee
Information Governance Committee
Surgical Case Review
Pharmacy and Therapeutics Committee
Pharmacy and Therapeutics Committee
