Deck 10: Performance Improvement and Project Management

Question 1

The term ______________ describes the results of a patient's treatment and is often used to judge quality.

A) benchmarking
B) sentinel event
C) affinity
D) outcome

Answer 1

outcome

Question 2

Which pattern of behavior might prompt a Quality Improvement Organization (QIO) review?

A) ordering x-rays instead of CT scans
B) rarely using CC or MCC codes
C) discharging patients too soon
D) taking too many transfers

Answer 2

discharging patients too soon

Question 3

What is the focus of quality improvement in health care?

A) the facility
B) the payer
C) the patient
D) the provider

Answer 3

the patient

Question 4

The assignment of deemed status grants Medicare COP certification when a facility is accredited by The Joint Commission or which other organization?

A) National Committee for Quality Assurance (NCQA)
B) National Integrated Accreditation for Health care Organizations (NIAHO)
C) Commission on Accreditation of Rehabilitation Facilities (CARF)
D) Health care Facilities Accreditation Program (HFAP)

Question 5

How does the American National Standards Institute (ANSI) promote quality?

A) by accrediting institutions of higher learning
B) by accrediting accreditation agencies
C) by accrediting hospitals
D) by accrediting standards developers

Question 6

Which is a component of the Total HAC Score under the CMS Hospital-Acquired Condition Reduction Program?

A) cases of urinary tract infections from catheters
B) cases of pneumonia from ventilators
C) cases of mumps
D) accidental needle sticks

Question 7

What is the source of data for the CMS Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey?

A) a random selection of discharged patients
B) providers with privileges at the institution
C) independent auditors
D) HIM department supervisors

Question 8

Which program provides a report that can be used by the hospital to initiate an internal review of overcoding, undercoding and other billing accuracy problems?

A) Program for Evaluating Payment Patterns Electronic Report (PEPPER)
B) Comprehensive Error Rate Testing (CERT) program
C) recovery audit contractor (RAC) program
D) Hospital Compare

Question 9

Which is an initiative to detect and prevent fraud?

A) Program for Evaluating Payment Patterns Electronic Report (PEPPER)
B) Comprehensive Error Rate Testing (CERT) program
C) QualityCheck
D) Hospital Compare

Question 10

Which process determines the facility's compliance with documentation standards?

A) Physician profile review
B) Record review
C) Medication review
D) PDSA

Question 11

A surgeon left a surgical instrument in a patient's abdomen. This is an example of a ______________ event, which should never occur.

A) sentinel
B) affinity
C) evidence-based
D) GANTT

Question 12

Who is responsible for the quality management theory that aims for zero defects from the standard?

A) Juran
B) Crosby
C) Deming
D) Donabedian

Question 13

What does Shewhart use to graph unacceptable variances in key process indicators?

A) GANTT chart
B) fishbone chart
C) process control chart
D) PERT chart

Question 14

What helps new team members get to know each other?

A) ice breakers
B) icebergs
C) decision matrices
D) root cause analysis

Question 15

In the fishbone diagram, what does the head of the fish represent?

A) the solution
B) the problem
C) the input
D) the purpose

Question 16

What does the PERT chart show?

A) the shortest possible time in which the project can be completed.
B) the longest possible time the project will take.
C) the number of people required to work on a project.
D) the unity of command within the project.

Question 17

Which is a characteristic of a GANTT chart?

A) upper and lower thresholds
B) standardized symbols showing an action
C) the display of factors that can change a variable
D) the sequence of events of a project

Question 18

A GANTT chart is useful during which process?

A) change management
B) project management
C) risk management
D) case management

Question 19

Which is a principle of change management?

A) a grassroots approach
B) identification of key stakeholders
C) communicating the need for change to all staff
D) preparing disciplinary action for those who resist

Question 20

Which statement is true of change management?

A) it happens organically
B) it is more difficult for senior staff
C) unexpected issues can arise
D) it usually involves staffing changes

Question 21

The Joint Commission's __________________ provide guidance or recommend procedures on issues like accurate patient identification, communication among health care providers, medicine safety, health care-associated infections, reduction of patient falls, and risk assessment.

Question 22

In CMS's Hospital Value-Based Purchasing Program, a hospital is reimbursed based on how much it improves from its _____________.

Question 23

A quality improvement effort regarding completion of the patient advance directive would require a(n) _______________ team, with members from different departments.

Question 24

A quality improvement effort to make batch scanning and indexing more efficient would require a(n) ___________ team of people from within the HIM department.

Question 25

A(n) __________ diagram is a method of grouping ideas based on relationships.

Question 26

In a(n) __________ group technique, group members offer solutions which are then ranked by favorability.