CPHRM Quality Improvement 2 — Questions and Answers
Question 1: Which quality improvement methodology uses Define, Measure, Analyze, Improve, and Control phases?
- PDSA Cycle
- Six Sigma DMAIC (Correct answer)
- Lean Manufacturing
- Root Cause Analysis
Correct answer: Six Sigma DMAIC
Six Sigma uses the DMAIC framework to systematically reduce defects and variation in processes.
Question 2: A hospital notices catheter-associated urinary tract infections (CAUTIs) increasing. The FIRST step in a quality improvement initiative should be:
- Implement a new protocol immediately
- Benchmark against national CAUTI rates
- Collect baseline data to understand current performance (Correct answer)
- Discipline nursing staff involved in care
Correct answer: Collect baseline data to understand current performance
Collecting baseline data is the essential first step to understand the scope of the problem before implementing changes.
Question 3: Failure Mode and Effects Analysis (FMEA) is best described as a:
- Reactive tool used after an adverse event occurs
- Proactive tool used to identify potential failure points before they occur (Correct answer)
- Statistical method for analyzing outcome data trends
- Accreditation requirement for sentinel event reporting
Correct answer: Proactive tool used to identify potential failure points before they occur
FMEA is a proactive risk assessment technique that identifies potential failure modes and their effects before harm occurs.
Question 4: Which of the following is an example of a structure measure in healthcare quality?
- Patient mortality rate
- Average length of hospital stay
- Nurse-to-patient staffing ratio (Correct answer)
- Percentage of patients receiving discharge education
Correct answer: Nurse-to-patient staffing ratio
Structure measures assess organizational attributes like staffing ratios, equipment, and facilities rather than processes or outcomes.
Question 5: A 'never event' in healthcare quality improvement refers to:
- Any event that rarely occurs in clinical practice
- A serious, largely preventable adverse event that should never occur (Correct answer)
- An event that is never reported to regulatory authorities
- A near-miss event with no patient harm
Correct answer: A serious, largely preventable adverse event that should never occur
Never events are serious, preventable patient safety events that should not occur if evidence-based preventive measures are in place.
Question 6: The primary purpose of a control chart in quality improvement is to:
- Identify the root cause of a specific adverse event
- Distinguish between common cause and special cause variation (Correct answer)
- Rank problems by frequency and cumulative impact
- Map the sequence of steps in a clinical process
Correct answer: Distinguish between common cause and special cause variation
Control charts use statistical control limits to determine whether variation in a process is due to common causes or special causes requiring investigation.
Question 7: Which accreditation body requires healthcare organizations to conduct a thorough and credible root cause analysis following a sentinel event?
- Centers for Medicare and Medicaid Services (CMS)
- The Joint Commission (TJC) (Correct answer)
- Agency for Healthcare Research and Quality (AHRQ)
- National Committee for Quality Assurance (NCQA)
Correct answer: The Joint Commission (TJC)
The Joint Commission requires organizations to perform a root cause analysis and develop an action plan after a sentinel event occurs.
CPHRM Quality Improvement 2
Which quality improvement methodology uses Define, Measure, Analyze, Improve, and Control phases?