Question 1

The following "sentinel events" must be available for Joint Commission review EXCEPT

Accepted Answer

The other options (infant abduction, rape, and surgery on wrong patient or body part) are considered sentinel events by The Joint Commission and are required to be reported for review. However, petechiae due to adverse drug reaction is not listed as a sentinel event by The Joint Commission.

Question 2

Quality requirements of providers participating in the Medicare program are found in all EXCEPT the

Accepted Answer

The ORYX initiative is a quality improvement program for hospitals and not a source for quality requirements for Medicare providers. Quality requirements for providers participating in the Medicare program can be found in the Conditions of Participation, Federal Register, and QIO regulations governing work scope.

Question 3

Which of the following is incorrect about the use of control charts?

Accepted Answer

The upper control limit is typically set at ±3 standard deviations, while the lower control limit is typically set at ±2 standard deviations. Therefore, statement D is incorrect as it says that the upper control limit is always ±1.8 standard deviations.

Question 4

Adding the UCL (upper control limit) and LCL (lower control limit) to the chart ?

Accepted Answer

The control chart is specifically designed to include the UCL and LCL, which are statistical measures that help identify whether a process is in control or not. The UCL and LCL represent the upper and lower thresholds for acceptable variation in the process being examined. Therefore, A is the best choice for this scenario.

Question 5

Historic accomplishments impacting quality in medical care include all EXCEPT

Accepted Answer

The implementation of OTRA (Organ Transplantation and Recovery Act) is not considered a historic accomplishment impacting the overall quality in medical care like the other options listed.

Question 6

The average percent of patients exceeding acceptable waiting time was 3.7% (see table for question number 91). The calculated UCL is 9.4. When you plot the upper and lower limits, what would you suggest as the reason for the June variation?

Accepted Answer

The fact that the calculated UCL is 9.4 suggests that there may have been a special cause variation in June, as the percent of patients exceeding acceptable waiting time was higher than usual. A special cause variation can occur due to a specific event or circumstance, rather than being within the normal range of common cause variation.

Question 7

The manager of a Health Information Department has many training and development methods available for the departmental and nondepartmental staff. Consider the following situation. The department's working hours are 8:00 AM to 6:00 PM. After 6:00 PM, if a record is needed in the emergency room for a possible readmission, the ER clerk has access to the HID in order to retrieve the record. On the occasions when the ER clerk has retrieved a record, she has left the department open, the records have been pulled and not replaced, and it appears as if the clerk was viewing records unnecessarily. What would be the best training or development method for the ER clerk in order to rectify this situation?

Accepted Answer

Receiving training directly from the supervisor of the files would be the most effective and efficient method in addressing the specific issues with opening the department and improper handling of records. This allows for immediate feedback and clarification on the correct procedures to follow. Additionally, it reinforces the importance of organizational policies and procedures as well as promoting accountability and responsibility for actions.

Question 8

Which department will most likely be responsible for taking corrective action regarding following quality indicator?

Accepted Answer

The answer of Which department will most likely be responsible...

Question 9

Which data bank is a result of HIPAA legislation?

Accepted Answer

The Health Care Integrity and Protection Data Bank (HIPDB) was established under HIPAA to combat fraud and abuse in health care.

Question 10

What is the best tool for differentiating between common cause variation and special ca variation?

Accepted Answer

Control charts are specifically designed to identify and differentiate between common cause variation and special cause variation. They help to show when a process is operating within its normal limits (common cause variation) or when there are specific factors affecting the process (special cause variation). Pareto charts, run charts, and scatter diagrams are useful tools in quality improvement and data analysis, but they do not specifically address the differentiation between common cause variation and special cause variation.

Question 11

The outpatient coding staff has been working to improve coding accuracy. The standard for the number of cases that must be coded has been raised four times in the past year. The staff states that "the more cases that must be coded, the greater the error rate will be for the corresponding time period." The department keeps statistics on both the numbers of cases coded and the corresponding error rate. What is the best QI tool for testing the coding staff's theory?

Accepted Answer

A scatter diagram is the best tool for testing the theory as it can show the relationship between the number of cases coded and the error rate, helping to identify any correlation between the two variables.

Question 12

Using the information in the table below, calculate the average percentage of patients for the entire year who waited longer than an acceptable amount of waiting time. (The sample size for each month's data is 100.)

Accepted Answer

To calculate the average percentage of patients who waited longer than an acceptable amount of waiting time, we need to add up the percentages for each month and divide by 12 (number of months in a year).

(2.9 + 3.5 + 4.2 + 2.7 + 3.6 + 3.9 + 2.8 + 3.2 + 3.6 + 3.8 + 3.6 + 3.9) / 12 = 44.9 / 12 = 3.74

Rounding off to one decimal place, we get the answer as 3.7%. Therefore, the best choice is C).

Question 13

You are the Quality Coordinator for the medical staff. Analyze the chart above and determine steps to be taken next.

Accepted Answer

The answer of You are the Quality Coordinator for the...

Question 14

All of the following are among Joint Commission's initial core measure sets for hospitals EX

Accepted Answer

The answer of All of the following are among Joint...

Question 15

An accreditation agency counterpart to the Joint Commission for managed care organizations is the

Accepted Answer

The NCQA (National Committee for Quality Assurance) is a non-profit accreditation agency that accredits managed care organizations, similar to how the Joint Commission accredits hospitals. The AHRQ (Agency for Healthcare Research and Quality) and AHCPR (Agency for Health Care Policy and Research) focus on healthcare research and quality improvement, while the IOM (Institute of Medicine) provides guidance and advice on healthcare policy and practice.

Question 16

Strong lateral relationships within a facility are most likely when

Accepted Answer

Strong lateral relationships occur when departments work together to achieve goals for the organization as a whole. When departments only focus on their own internal goals or avoid each other, lateral relationships are less likely to be strong. While inadequate vertical relationships may contribute to a lack of communication and collaboration, they are not the only factor in determining the strength of lateral relationships.

Question 17

All of the following data would appear on a "public accountability report card" EXCEPT

Accepted Answer

The average number of clinicians in the operating room during bypass surgery is not a commonly reported metric on a public accountability report card. The other options - average cost, customer satisfaction, and complication/death rate - are all typically included in such reports.

Question 18

The health information reception desk is experiencing a huge influx of phone calls on Monday, Tuesday, and Wednesday mornings. This is creating a problem in getting requested patient information out within an acceptable time frame. The reception staff work group has agreed to start recording the reason for the phone calls for the next 4 weeks. They want to focus on solving the response-time problem by reducing the turnaround time for the largest category of phone calls. Which QI tool best supports this goal?

Accepted Answer

A Pareto chart can be used to identify the largest category of phone calls and prioritize them for improvement. By addressing the top contributing factors, the reception staff can reduce the overall turnaround time for phone calls and improve efficiency.

Question 19

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?

Accepted Answer

The Pharmacy and Therapeutics Committee is the appropriate committee to review cases where bacterial resistance is encountered and the current antibiotic is not effective. This committee is responsible for reviewing and making recommendations on the appropriate use of antibiotics within the hospital to ensure optimal patient outcomes.

Question 20

The board of directors of a 400-bed women's hospital receives a report of key quality indicator results on a periodic basis. The report always includes the quarterly cesarean section rate and has for many years. This recent period they have seen a rise in the rate and want to know if this is significant. What is the best Q1 tool for this purpose?

Accepted Answer

A control chart is the best tool for this purpose as it shows the trend and variation in a process over time. The quarterly cesarean section rate can be plotted on a control chart to determine if the rise is statistically significant or within the normal variation of the process. A Pareto chart would only be useful if there were multiple factors contributing to the rise in the rate, a run chart would only show the trend over time without indicating if it is significant, and a scatter diagram would not be useful in this case as there is only one variable being analyzed.

Exam 1: Registered Health Information Administrator