Question 1

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

Accepted Answer

Licensure is mandatory for healthcare facilities as it is a legal requirement to operate as a healthcare provider. Accreditation and certification are voluntary processes that healthcare facilities can undergo to demonstrate their commitment to quality care. AHA registration is not a mandatory process.

Question 2

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

Accepted Answer

According to case law decisions and Joint Commission standards, the governing body or board of trustees is ultimately responsible for ensuring the quality and appropriateness of patient care in a healthcare facility. While the CEO and medical staff play important roles in this process, the governing body holds the ultimate responsibility and authority for overseeing the facility's operations and ensuring that patients receive safe and effective care. The hospital attorney may provide legal guidance, but they are not primarily responsible for ensuring the quality of patient care.

Question 3

As Director of the HIM department, you are asked to chair a committee that will recommend pharmacy information system. The information has been collected, and you bring your committee together to prioritize their suggestions. This method of working with information known as

Accepted Answer

The method described is the nominal group process, which is a structured group decision-making technique that involves generating and prioritizing ideas. Force field analysis is a method that identifies the driving and restraining forces for a particular change. Delphi process involves expert input through a series of surveys or questionnaires. Correlation analysis is a statistical method for analyzing the relationships between variables.

Question 4

What QI tool uses criteria to weigh different alternatives? This display would assist in viewing all relevant information at the same time.

Accepted Answer

A decision matrix uses criteria to weigh different alternatives and allows for all relevant information to be viewed at the same time. The PDSA method is a continuous improvement model, a flowchart is a visual representation of a process, and a customer satisfaction survey is a tool for gathering feedback from customers.

Question 5

As Director of the HIM department, it is your responsibility to reduce the turnaround time for your organization's accounts receivable balance. The following performance improvement tool was used to add weights in order to prioritize ideas. What is it called?

Accepted Answer

The answer of As Director of the HIM department, it...

Question 6

The following performance tool is used to provide structure by classifying information into smaller groups. What is the name of this chart/diagram?

Accepted Answer

The description provided fits the characteristics of an affinity diagram, which is used for organizing large amounts of ideas or data into groups based on their relationships or similarities. A flowchart is used to represent a process or workflow, a matrix organizes data into rows and columns, and an arrow diagram shows the flow and sequence of tasks or activities.

Question 7

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

Accepted Answer

A run or line chart can display the number of incomplete charts over time, which is useful in identifying trends and areas where improvement is needed. The chart would not provide information about how far service goes, customer satisfaction related to transcription errors, or office morale and productivity.

Question 8

Surgical case review includes all the following EXCEPT

Accepted Answer

Surgical case review includes all aspects of the surgical process, including determination of surgical justification, evaluation of discrepancies in diagnoses, and review of serious complications or mortalities. However, missing elements in the preoperative anesthesia consultation would fall under the purview of anesthesia case review, not surgical case review.

Question 9

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?

Accepted Answer

Brainstorming is a QI tool used to generate a wide range of ideas and solutions for a problem, making it suitable for addressing physician complaints about missing dictation reports.

Question 10

As head of the Performance Improvement Department, you are asked to evaluate pati satisfaction and offer recommendations for action. The following performance tool is used graphically display the results. What is the name of this chart?

Accepted Answer

The chart in question displays the frequency of patient satisfaction ratings, which is a common use case for a Pareto chart. This type of chart would allow the Performance Improvement Department to identify the most common causes of dissatisfaction among patients and prioritize areas for improvement. The other chart options (line chart, bar chart, run chart) may be useful for other types of data analysis, but would not be the best choice in this case.

Question 11

Physicians who are members of the Surgery Committee meet to review surgical cases referred f quality issues and deviations from standard care norms. This type of review in which physician's record is reviewed by his or her professional colleagues is known as

Accepted Answer

Peer review is the process in which professionals within the same field or specialty evaluate and review the work of their colleagues. In this case, physicians are reviewing the records of their fellow physicians in order to identify quality issues and deviations from standard care norms. The purpose of this review is to improve the quality of care provided to patients and to maintain professional standards within the medical field.

Question 12

Patient mortality, infection and complication rates, adherence to living will requiremen adequate pain control, and other documentation that describe end results of care or a measura change in the patient's health are examples of

Accepted Answer

Outcome measures are assessments of the end results of care and can include patient mortality, infection and complication rates, adherence to living will requirements, adequate pain control, and other documentation that describe a measurable change in the patient's health. Threshold level refers to a level at which an action is taken, and sentinel events and incident reports are types of adverse events that occur in healthcare settings.

Question 13

As a HIM coding supervisor, you are asked to compare the current coding process with proposed concurrent coding process. What visual tool would be the best to identify all the logical steps and sequence of each procedure?

Accepted Answer

A flowchart is the best visual tool to identify all the logical steps and sequence of each procedure. It allows for a clear visualization of the coding process and can easily highlight areas where the proposed concurrent coding process differs from the current process. A decision matrix is typically used to evaluate and compare multiple options, a cause and effect diagram is used to identify potential causes of a problem, and a run chart is used to track data over time.

Question 14

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?

Accepted Answer

The fishbone (cause and effect) diagram is the most helpful tool for identifying the major or root causes of the backlog in loose report filing. This tool allows the quality improvement team to visualize the possible causes and their relationships to the outcome variable. The PDCA method is a cyclical problem-solving process that could be used to implement solutions identified by the fishbone diagram. A run chart could be useful to track progress after implementing solutions. A scatter diagram is helpful to identify relationships between two variables.

Question 15

What feature is a trademark of an effective PI program?

Accepted Answer

An effective PI program is characterized by a continuous cycle of improvement projects over time. This means that the program is ongoing and constantly seeking ways to improve processes and outcomes, rather than being a one-time fix or an unmanageable project that is too expensive. Cost-containment may be a goal of the program, but it is not necessarily a trademark of effectiveness.

Question 16

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

Accepted Answer

Crosby was a quality management theorist who emphasized the importance of preventing defects rather than just detecting and fixing them. He advocated for a Zero Defects approach, which aimed for the complete elimination of defects and errors in products and processes.

Question 17

What action(s) would assist the manager of a medical record department in improving customer perception of the quality of services provided by the department?

Accepted Answer

To improve customer perception, the manager of a medical record department should identify specific customer needs in order to design value-added services. This shows a focus on meeting the needs of the customer and providing additional benefits beyond basic services. Setting a 2-week turnaround time for all dictated reports may be beneficial for efficiency but does not directly address customer needs. Refusing to fax patient information may protect confidentiality but could also inconvenience customers who require timely access to their records. Requiring physicians and hospital staff to retrieve their own medical records may result in increased efficiency for the department, but does not necessarily improve customer perception.

Question 18

Strictly from a quality standpoint, which of the following organizations was a forerunner of the evaluation of medical care?

Accepted Answer

The Joint Commission on Accreditation of Health care Organizations (Joint Commission) was established in 1951 to evaluate and accredit hospitals. It is the oldest and most widely recognized organization for the accreditation of health care organizations in the United States.

Question 19

Joint Commission requires that medical record review be performed to evaluate adequacy, accuracy, completeness, and quality of documentation

Accepted Answer

Joint Commission requires ongoing medical record review to ensure that documentation is accurate, complete and of high quality. This is done to improve patient care and safety.

Question 20

Eighty (80) requests for records to be pulled for the emergency room were processed in January. From the histogram provided, what was the most frequent amount of time taken to process a request?

Accepted Answer

The tallest bar on the histogram falls within the range of 11-20 minutes, indicating that this was the most frequent amount of time taken to process a request.

Exam 1: Registered Health Information Administrator