Exam 17: Quality and Safety

Hospitals must submit specific quality performance data regarding Medicare patients or risk:

The Baldrige National Quality Award (BNQA) establishes a set of performance standards that define a total quality organization. The standards in areas of excellence include (select all that apply):

Which comment by the nurse manager would indicate that the hospital places a high value on patient safety?

Quality planning establishes the design of a product, service, or process that will meet customer, business, and operational needs to produce the product before it is produced. Quality planning follows a universal sequence of steps. List the universal sequence of steps in order. A) Identify customers and target markets. B) Discover hidden and unmet customer needs. C) Develop a service or product that exceeds customers' needs. D) Transfer these designs to the organization and the operating forces to be carried out. E) Translate these needs into product or service requirements: a means to meet their needs. F) Develop the processes that will provide the service, or create the product, in the most efficient way.

A type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of conditions or procedures is:

Mercy Hospital compares its surgical site infection rate to General Heart Hospital, which is known as a best-in-class hospital for its surgical site infection rates. Mercy Hospital studies General Heart Hospital's methods for reducing surgical site infection rates and uses that information to improve its own performance. This quality performance method is called:

Attributes of high-performance organizations (HPOs) include (select all that apply):

Which of the following are never events (select all that apply)?

A Healthcare Failure Modes and Effects Analysis (HFMEA) for a new bar-coding system is being conducted by an interdisciplinary team. List the steps of the HFMEA in the correct order. A) Identifying prevention strategies B) Endorsing action plans for implementation C) Assessing risk points within the process steps D) Flowcharting the steps of the process being studied E) Designing out the most critical of the potential failures F) Recommending process improvements for prevention of the failures G) Ranking key risk points in terms of their impact on the potential failure of the system H) Reporting action plans for implementing prevention strategies to the enterprise leaders

TJC requires accredited organizations to participate in their core measure initiative. The current core measure sets include (select all that apply):

Principles of a fair and just culture include (select all that apply):

Sentinel event alerts are published by TJC to do which of the following?

The improvement process in which an organization measures its strategies, operations, or internal process performance against that of best-in-class organizations within or outside its industry, determines how those organizations achieved their performance levels, and uses that information to improve its own performance is known as _____.

A successful enterprise risk management (ERM) program will (select all that apply):

"To provide the best care to every patient every day through integrated clinical practice, education, and research" is an example of a(n):

Which of the following responses from the nurse manager is consistent with a culture that promotes patient safety?

Responding to a code called in the psychiatric unit where she works, a staff nurse finds that a patient has committed suicide. The staff nurse correctly identifies this as a:

The risk manager wants to illustrate the causes that have been leading to an increase in patient misidentification. The most appropriate tool to use is a:

_____ is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

The purpose of a root-cause analysis (RCA) is to: