Quiz Questions Part 1 Flashcards by Renee Glaser

The act of granting a healthcare organization or an individual healthcare practitioner permission to provide services of a defined scope in a limited geographical area is called:

a. accreditation
b. licensure
c. approval
d. none of the above

Licensure

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This type of healthcare organization review is performed to fulfill legal or licensure requirements:

a. voluntary review
b. complimentary review
c. vocational review
d. compulsory review

Compulsory review

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Which of the following is the process of meeting a prescribed set of standards or regulations to maintain active accreditation, licensure, or certification status?

a. performance improvement
b. compliance
c. document review
d. deemed status

Compliance

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

a. accreditation
b. licensure
c. certification
d. approval

Accreditation

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The act of granting approval for a healthcare organization to provide services to a specific group of beneficiaries is called:

a. accreditation
b. licensure
c. certification
d. approval

Certification

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This organization has been responsible for accrediting healthcare organizations since the mid-1950s and determines whether the healthcare organization is continually monitoring and improving the quality of care it provides.

a. Commission on Accreditation of Rehabilitation Facilities
b. American Osteopathic Association
c. National Committee for Quality Assurance
d. Joint Commission on Accreditation of Healthcare Organizations

Joint Commission on Accreditation of Healthcare Organizations

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This accrediting body has become an alternative option for healthcare organizations because of its facility-friendly yet stringent annually occurring accreditation process.

a. American Osteopathic Association
b. DNV Healthcare
c. National Committee for Quality Assurance
d. Joint Commission on Accreditation of Healthcare Organizations

DNV Healthcare

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Every organization that provides services to Medicare and Medicaid beneficiaries must demonstrate its compliance with this set of standards:

a. Conditions of Participation
b. JCAHO accreditation
c. CARF accreditation
d. NCQA accreditation

Conditions of Participation

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An accrediting agency’s published rules, which serve as the basis for comparative assessment during the review or survey process is called _____.

a. Accreditation policies
b. Accreditation guides
c. Accreditation controls
d. Accreditation standards

Accreditation standards

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This type of healthcare organization review is conducted at the request of the healthcare facility seeking accreditation

a. Compulsory review
b. Vocational review
c. Voluntary review
d. Complimentary review

Voluntary review

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Data found on sites such as Hospital Compare use aggregated data to describe the experience of unique types of patients with one or more aspects of their care. What is this data collection called?

a. patient specific
b. aggregated
c. comparative
d. detailed

Comparative

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Which type of data collection summarizes the experience of many patients regarding a set of aspects of their care?

a. patient specific
b. aggregated
c. comparative
d. detailed

Aggregated

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What type of data collection pertains to the care services provided to each patient?

a. patient specific
b. aggregated
c. comparative
d. detailed

Patient specific

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Which of the following is NOT an organization currently collecting data on quality of healthcare?

a. AHRQ
b. CMS
c. IOM
d. AMCAS

AMCAS

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A report developed by a PI team on the occurrence of methicillin-resistant staph aureus infection in a neonatal ICU was subsequently used by the perinatal morbidity and mortality committee in a monthly review of infant morbidity. Access to this report was possible because it was housed in the organization’s :

a. computer hard drive
b. comparative performance data
c. PI data base
d. Information warehouse

Information warehouse

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TRUE/FALSE: This phase in the project life cycle begins with the determination that there is a gap between organization performance and expected outcomes is called initiation.

TRUE

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This phase in the project life cycle includes clear objectives, importance of the project and the expected outcome on the organization:

a. Initiation
b. Planning
c. Execution
d. Closure

Planning

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This phase in the project life cycle is where installation of equipment or construction begins, and any policy or procedure manuals should be prepared for distribution.

a. Initiation
b. Planning
c. Execution
d. Closure

Execution

An effective tool for planning and tracking the implementation of a project is the:

a. Gantt Chart
b. PERT chart
c. Flowchart
d. Pie chart

Gantt Chart

The stage of project team development in which team members work together easily is called:

a. Cautious affiliation
b. Competitiveness
c. Harmonious cohesiveness
d. Collaborative teamwork

Collaborative teamwork

TRUE/FALSE: Organization-wide strategic planning and planning for performance improvement are not interrelated activiites.

FALSE

Strategic planning may include SWOT analysis. What does SWOT represent?

Strengths, Weakness, Opportunities, and Threats

TRUE/FALSE: One possible criteria that is helpful in setting priorities for improvement opportunities is the degree to which patient safety is improved.

TRUE

TRUE/FALSE: In a healthcare organization’s performance improvement plan, data are systematically collected, aggregated and analyzed on an ongoing basis.

TRUE

TRUE/FALSE: High risk and low volume is one possible criteria that is helpful in setting priorities for improvement opportunites.

FALSE

TRUE/FALSE: PI Programs should be evaluated at least once every three years.

FALSE

TRUE/FALSE: One reason why PI programs are evaluated is to determine whether the organization's approach to designing, measuring, assessing, and improving its performance is planned, systematic and organization-wide.

TRUE

TRUE/FALSE: One component of an executive summary includes PI structure.

FALSE

TRUE/FALSE: PI programs are exclusive to clinical areas.

FALSE

TRUE/FALSE: PI teams should be assessed in an annual evaluation.

TRUE

Which of the following Joint Commission standards addresses how healthcare organizations must manage their information so that it can used to support high-quality and improved patient care? a. Data governance standards b. Performance improvement standards c. Information management standards d. Record of care standards

Information management standards

A report developed by a PI team on the occurrence of methicillin-resistant Staphylococcus aureus infection in a neonatal intensive care unit was subsequently used by the perinatal morbidity and mortality committee in a monthly review of infant morbidity. Access to this report was possible because it was housed in the organization’s a. Computer hard drive b. Information warehouse c. Comparative performance data d. PI database

Information warehouse

A(n) __________ is an open-structure database that is not dedicated to the software of a particular vendor or data supplier, in which data from diverse sources are stored so that an integrated, multidisciplinary view of the data can be achieved. a. Business intelligence b. Information warehouse c. Data repository d. Application program interface

Data repository

Community Hospital’s quality improvement department has collected data on their hospital-acquired infections (HAI). The QI department then reviews all cases to ensure that they meet the HAI criteria and removes any cases that do not fit. This process is an example of which component of the business intelligence life cycle? a. Analyze the data to discover trends b. Identify problems and opportunities c. Clean the data d. Acquire data

Clean the data

An accrediting agency’s published rules, which serve as the basis for comparative assessment during the review or survey process is called _____. a. Accreditation policies b. Accreditation guides c. Accreditation controls d. Accreditation standards

Accreditation standards

This type of healthcare organization review is conducted at the request of the healthcare facility seeking accreditation _____. a. Compulsory review b. Vocational review c. Voluntary review d. Complimentary review

Voluntary review

Which of the following is the process of meeting a prescribed set of standards or regulations to maintain active accreditation, licensure, or certification status? a. Compliance b. Deemed status c. Document review d. Performance improvement

Compliance

The forming stage of project team development in which team members tend to be very polite as they get to know one another is also called _____. a. Harmonious cohesiveness b. Competitiveness c. Collaborative teamwork d. Cautious affiliation

Cautious affiliation

This planning technique provides a structure that requires the project team to identify the order and projected duration of activities needed to complete a project: a. Pie chart b. PERT chart c. Gantt chart d. Flowchart

PERT chart

What is one way healthcare organizations can combat the resistance to change commonly experienced by employees during a transition? a. Communicate all aspects of the change with employees b. Communicate the change with high level leaders only c. Inform employees that change is happening without explanation d. Remain silent about the change until it is ready to be implemented

Communicate all aspects of the change with employees

A PI team has been tasked with implementing a workflow change in their hospital. The team has put together materials that describe the proposed improvement in great detail, including flowcharts to map out the new workflow. Which of Kotter’s accelerators to change is the team using to facilitate initiative? a. Create a sense of urgency b. Generate short-term wins c. Enable action by removing barriers d. Enlist a volunteer army

Create a sense of urgency

Employee __________ more readily occurs when employees are informed of the change and are educated on the reason for the change. a. Acknowledgement b. Buy-in c. Vision d. Reinforcement

Buy-in

A privilege applies to discussions and correspondence between persons with a certain type of relationship that has been recognized as needing confidentiality. Privileged information is not admissible at trial unless _____. a. The administrator waives the privilege b. The holder waives the privilege c. The judge waives the privilege d. The attorney waives the privilege

The holder waives the privilege