Managing Quality and Safety

1. Which of the following best describes one of the main problems in ensuring quality for health care in the United States?

a.
Consumers believe American health care is high-quality and the best in the world.
b.
Every hospital and health care agency has its own approach to data collection and documentation.
c.
Finances are the basis of clinical decisions, not quality of care.
d.
We all agree on what quality is but not on how best to measure it.

ANS: B

Very little is known about quality of care in this country because a variety of definitions of quality are used and it is difficult to get comparable data from health care providers and agencies. Based on international comparisons, health care in the United States does not have the best statistics related to outcomes.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 289

2. A wealthy factory owner says, “I don’t care about the poor. I just want the best care available for me and my family. Why should I care whether other people get health care or not?” Which of the following would be the most appropriate response by the nurse?

a.
“If your employees are ill, who will do the work in your factory?”
b.
“You might catch a contagious disease from one of your employees.”
c.
“You have a moral obligation to help those less fortunate.”
d.
“Your personal insurance and tax costs will go up if your employees have to use community resources when they’re ill.”

ANS: D

Because the speaker’s primary concern is apparently money, an appropriate response must show that the factory owner will lose money if he doesn’t support the health of others in the community.

DIF: Cognitive Level: Apply (Application) REF: p. 289

3. Which of the following information can be gathered by reviewing a community health report card?

a.
Utilization of health care services in the community
b.
Demographic information of the community
c.
Leading causes of morbidity in a community
d.
Frequency of malpractice claims within a community

ANS: C

The term community health report card refers to different types of reports, community health profiles, needs assessments, scorecards, quality of life indicators, health status reports, and progress reports. Community health report cards can be a useful tool in efforts to help identify areas where change is needed, to set priorities for action, and to track changes in population health over time. The report card may be used to track leading causes of morbidity and mortality in a community, looking at trends over time to see if public health interventions have improved health care outcomes.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 289

4. Which of the following led to the development of the National Health Quality Improvement Act?

a.
A very famous movie and television star died as the result of a medical error.
b.
The number of malpractice claims had increased.
c.
Media such as films highlighted the reality of current medical care.
d.
Publicity about a few unfortunate cases caused consumers to become concerned.

ANS: B

In response to a growing number of malpractice claims in the United States, the National Health Quality Improvement Act of 1986 was established, which encouraged consumers to become informed about their practitioner’s practice record and created a national clearinghouse of information on provider malpractice records.

DIF: Cognitive Level: Remember (Knowledge) REF: p. 290

5. Which of the following describes the principal problem with early efforts at ensuring quality of care?

a.
No one knows how to measure quality care.
b.
Professionals resisted and sabotaged such efforts.
c.
Standards emphasized structure, not process.
d.
There were no standards as to what represented quality care.

ANS: C

Early efforts such as the National Health Quality Improvement Act of 1986 emphasized structure rather than process or outcome of care; hence, they did not really address the root issues of quality.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 290

6. An agency has not created a continuous quality improvement program. Which of the following actions should the agency take to help ensure quality care within the institution?

a.
Ensure appropriate policies and procedures are followed.
b.
Employ highly recommended and credentialed professionals to give care.
c.
Use administrative action to ensure that quality care is given to clients.
d.
Write quality care plans for the most typical problems of clients.

ANS: A

Quality assurance/quality improvement (QA/QI) programs remain the enforcers of standards of care for many agencies that have not elected to engage in a program of CQI. These activities are called assurance activities because they make certain that those policies and procedures are followed so that appropriate quality services are delivered.

DIF: Cognitive Level: Analyze (Analysis) REF: pp. 290-291

7. A home care nurse is encouraging the administration of the agency to increase their quality assurance efforts. Which of the following best describes a negative outcome from this activity?

a.
An agency deficiency may become visible.
b.
An individual may be found at fault and then become fearful of being involved.
c.
Some agency processes may be questioned.
d.
Employees at the agency will have to commit extra time to complete this process.

ANS: B

Total quality management/continuous quality improvement are concepts that give direction for managing a system of care, whereas quality assurance focuses on the care a client receives within the system. QA is concerned with the accountability of the provider. A major problem with quality assurance efforts, done by the quality assurance team, is that individuals may be found to be at fault and hence may be fearful of reporting problems or errors. Continuous quality improvement focuses on processes and possible deficiencies of the organization as a whole so that everyone is involved.

DIF: Cognitive Level: Apply (Application) REF: pp. 291-292

8. How does continuous quality improvement (CQI) differ from quality assurance?

a.
Quality assurance focuses on client care, whereas CQI focuses on system issues.
b.
Quality assurance focuses on system issues, whereas CQI focuses on individual client care.
c.
Quality assurance measures care at one point in time, whereas CQI is an ongoing issue.
d.
Quality assurance focuses on families, whereas CQI focuses on agency issues.

ANS: A

Total quality management and continuous quality improvement are concepts that give direction for managing a system of care, whereas quality assurance focuses on the care a client receives within the system.

DIF: Cognitive Level: Understand (Comprehension) REF: pp. 292, 301

9. Which of the following is accomplished through the use of traditional quality assurance?

a.
Implementation of new techniques to improve outcomes
b.
Implementation of appropriate interventions for diagnosed problems
c.
Implementation of change when measured performance does not meet standards
d.
Implementation of research findings to ensure appropriate clinical treatment

ANS: C

Traditional approaches to quality assurance are to focus on assessing or measuring performance, to ensure that performance conforms to standards, and to take action to bring about change when care does not meet standards.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 292

10. What is the primary goal of total quality management?

a.
To confirm the high standards desired in patient care
b.
To discover and correct errors in task completion
c.
To eliminate problems before negative outcomes occur
d.
To enable organizations to publicize their quality approach to patient care

ANS: C

The goal of TQM and CQI is to eliminate errors in the work process before negative outcomes occur rather than waiting until after the fact to correct individual performance; the focus is on problem prevention and continuous improvement.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 303

11. An agency is beginning to implement a general approach for quality improvement. Which of the following activities would the agency most likely implement?

a.
Customer satisfaction is assessed through the use of surveys provided to the client after each appointment.
b.
The health maintenance organization (HMO) provides incentives to personnel who complete in-house programs on customer service.
c.
The institution has received accreditation through The Joint Commission.
d.
The total quality improvement (TQI) team meets to examine how to make the registration process more efficient.

ANS: C

General approaches to quality improvement seek to protect the public by ensuring a level of competency among health care professionals. Examples are credentialing, licensure, accreditation, certification, charter, recognition, and academic degrees.

DIF: Cognitive Level: Apply (Application) REF: p. 292

12. The pharmacist sent up the wrong medication for the patient. The nurse filled out an incident report when the error was discovered. Which of the following best describes the likely outcome when the quality improvement team reviews the incident report?

a.
The nurse will receive a commendation for recognition of the error.
b.
The pharmacist will be disciplined.
c.
The pharmacist will be reported to the state pharmacy board.
d.
The CQI team will try to determine how the error occurred.

ANS: D

It is important for ongoing quality improvement not to blame or discipline those involved or to commend those who recognize a problem, but rather focus on what led to the error occurring. In quality improvement, people are asked to help identify problems and seek ways to improve system performance.

DIF: Cognitive Level: Apply (Application) REF: p. 294

13. A home health care agency has major problems but does not want consumers to know about these problems while the agency decides what should be done to improve them. Employees are not told to lie, but they are advised not to share information. Which of the following is the most likely outcome of this situation?

a.
As long as employees do not share what they know, the community will be uninformed.
b.
By law, comparative information will be available to the public via the Internet.
c.
Only a few informed persons will know about the problems.
d.
Secrecy will prevail unless the local newspaper does an investigative report.

ANS: B

In 2003 the Home Health Care Quality Initiative (HHQI) was developed by the USDHHS to provide consumers with data on the quality of home health services. Home Health Compare, posted on the Medicare website, is a home health report card available to consumers nationwide.

DIF: Cognitive Level: Apply (Application) REF: p. 295

14. The nurse admits uncertainty over how to address the needs of a group of clients. The long-term nurse in the area suggests that the nurse review published evidence-based clinical guidelines. How can the nurse know these guidelines are reliable?

a.
Because the agency supports their use
b.
Because the guidelines have been published
c.
Because the long-term nurse trusts them
d.
Because they are based on research and expert opinion

ANS: D

Evidence-based practice guidelines are protocols or statements of recommended practice developed by professional organizations and based on scientific clinical data and research as well as expert opinion from extensive clinical experience. Such guidelines help a clinician in decision making.

DIF: Cognitive Level: Apply (Application) REF: p. 295

15. The quality improvement team reviews the records of clients on a monthly basis to determine whether protocols for pain assessment were followed. Which of the following best describes this activity?

a.
Accreditation review
b.
Concurrent audit
c.
Retrospective audit
d.
Utilization review

ANS: C

The retrospective audit, or outcome audit, evaluates quality of care through appraisal of the nursing process after the client’s discharge from the health care system.

DIF: Cognitive Level: Apply (Application) REF: p. 296

16. The quality improvement team reviews the records of clients on a monthly basis to determine whether protocols for pain assessment were followed. Which of the following best describes the major drawback to the team’s approach?

a.
The client is no longer under the agency’s care.
b.
It is difficult to compare documentation of care to standards of care.
c.
Records can be inaccurate or incomplete.
d.
Team members may disagree on whether the standards of care were met.

ANS: A

With this approach, problems are identified only after clients have been discharged. Although the hope is that better care will be given to future clients, nothing can be done about the clients who received less than optimal care.

DIF: Cognitive Level: Apply (Application) REF: p. 296

17. A nurse is invited to join the utilization review team to help the agency avoid giving unnecessary care. Which of the following difficulties would the nurse most likely confront as client records are reviewed?

a.
Alternative care options rather than agency care are often encouraged.
b.
Not all clients fit the pattern and need more care than guidelines suggest.
c.
The nurse suggests the agency provide guidelines to professionals giving care.
d.
The agency is now accountable to its clients and their families.

ANS: B

The major disadvantage of utilization review is that not all clients fit the classic picture presented by the criteria used to determine approval or denial of care.

DIF: Cognitive Level: Apply (Application) REF: pp. 296-297

18. The staff was informed that a PRO (Professional Review Organization) would be making an unannounced visit in a few hours. Which of the following would the hospital nurse expect the PRO team to examine?

a.
Records of hospital admissions and scheduled procedures
b.
Nursing care plans of patients with unexpected problems (infections, falls)
c.
Discharge paperwork of patients discharged in the past 30 days
d.
Documentation of adherence to nursing standards of care

ANS: A

PROs are directed by the federal government to reduce hospital admissions for procedures that can be performed safely and effectively in an ambulatory surgical setting on an outpatient basis and to reduce inappropriate or unnecessary admissions or invasive procedures by specific practitioners or hospitals. Therefore, the PRO team would examine records to see whether the hospital admissions and all procedures performed were medically necessary.

DIF: Cognitive Level: Apply (Application) REF: p. 297

19. Which of the components of the PDCA model and Donabedian’s framework is the most crucial?

a.
Standard
b.
Outcome
c.
Process
d.
Structure

ANS: B

The PDCA model and Donabedian’s framework for evaluating health care programs, using the components of structure, process, and outcome, are useful in developing a quality assurance program. Outcome is the most important ingredient of a program, because it is the key to evaluation of providers and agencies by accrediting bodies, insurance companies, and Medicare and Medicaid through PROs, report cards, and other accrediting agencies.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 298

20. Stakeholders developing a new community-oriented clinic plan want to include a quality assurance (QA) program. Which of the following would be the first step in measuring the structure component?

a.
Criteria that will be used to measure quality
b.
Philosophy and objectives of the organization
c.
Requirements of accrediting agencies
d.
Standards the QA program wishes to achieve

ANS: B

The philosophy and objectives of an agency define the structural standards of the agency. Identification of standards and criteria for quality assurance begins with writing the philosophy and objectives of the organization.

DIF: Cognitive Level: Apply (Application) REF: p. 298

21. Which of the following best explains why evaluation of client outcomes resulting from nursing intervention is so difficult?

a.
Client records may not include appropriate data.
b.
Few tools exist to measure client outcomes.
c.
Many other factors can also affect client outcomes.
d.
Measuring client outcomes is extremely time consuming.

ANS: C

The major problem with outcome evaluation is determining which nursing care activities are primarily responsible for causing changes in client status. In nursing, many uncontrolled factors in the field, such as environment and family relationships, have an effect on client status.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 300

22. The management team of the Central County Community Health Agency wants to analyze the cost of homebound client services. Which of the following records are most likely to provide useful data?

a.
Clinical records
b.
Financial records
c.
Morbidity and mortality records
d.
Provider service records

ANS: D

The provider service records include information about the numbers of clinic clients seen daily, home visits made daily, transportation and mileage, the provider’s time spent with the client, and the amount and kinds of supplies used. The provider service record is completed on a daily basis by each provider and is summarized monthly and annually to indicate trends in health care activities and costs relative to personnel time, transportation, maintenance, and supplies. A clinical record is the client health record. This would contain health information for a single client, would not generally include clinic costs, and would be an inefficient source because it identifies service to only one individual. Financial records include extraneous items for the clinic as a whole. Extracting specific data will not be as easy, because they will be from the provider service record. Morbidity and mortality records would not be suitable in this instance.

DIF: Cognitive Level: Apply (Application) REF: p. 302

23. A nurse has identified a need to increase the quality assurance efforts within the home care agency. Which of the following has most likely occurred?

a.
Increased number of client complaints and injuries
b.
Increased costs of providing care
c.
Reduced number of incident reports
d.
Reduced government reimbursement (Medicare and Medicaid)

ANS: A

The types of problems that may lead to increased quality assurance efforts include client complaints, injury, or death, poor documentation of care, with subsequent denials of reimbursement by third-party payers, lack of or inefficient service, and concerns about client or staff safety.

DIF: Cognitive Level: Apply (Application) REF: p. 300

24. A nurse is implementing tertiary prevention strategies as part of the quality management process. Which of the following best describes a strategy the nurse would have used?

a.
All new employees complete a program on fire safety that details what to do in the event of a fire.
b.
At the yearly employee picnic, teams compete in putting out trash can fires and in racing while carrying mock victims, using safe evacuation techniques.
c.
After evaluation of response to an actual fire, new procedures implemented in the fire response protocol are distributed to employees.
d.
Mock fire drills are carried out twice a year to assess response and readiness in the event of a real fire.

ANS: C

Tertiary prevention involves activities that are carried out when evaluation indicates needed improvement. A program on fire safety is an example of primary prevention. The employee picnic activity and mock fire drills provide for evaluation of competency (screening) and are thus secondary prevention.

DIF: Cognitive Level: Analyze (Analysis) REF: p. 301

MULTIPLE RESPONSE

1. In which of the following ways does licensing differ from accreditation? (Select all that apply.)

a.
Licensing applies to the individual, whereas accreditation applies to a program.
b.
Licensing is required to practice, whereas accreditation is by choice.
c.
Licensing is required by state law, whereas accreditation is required by federal law.
d.
Licensing is required for all professions, whereas accreditation is only available for some.

ANS: A, B

Licensure controls entrance into a profession or occupation and is mandatory to practice. Accreditation is a voluntary or at least a quasi-voluntary approach used by institutions or programs. Licensure is based on state law, whereas accreditation is dependent upon professional standards. Although there are cost differences between licensure and accreditation, individuals pay for licensure, whereas agencies pay for accreditation.

DIF: Cognitive Level: Understand (Comprehension) REF: pp. 292-293

2. A nursing committee is responsible for evaluating the process of health care agency in their quality assurance efforts. Which of the following techniques would most likely be used by the committee members? (Select all that apply.)

a.
Client satisfaction survey data
b.
Confirmation of credentials of all health care providers employed
c.
Patient discharge data over the past one year
d.
Peer review committee audit

ANS: A, D

The primary approaches used for process evaluation are the peer review committee and the client satisfaction survey. The techniques used for process evaluation are direct observation, questionnaire, interview, written audit, and videotape of client and provider encounters. Once data are collected to evaluate nursing process standards, the peer review committee reviews the data to identify strengths and weaknesses in the quality of care delivered.

DIF: Cognitive Level: Apply (Application) REF: pp. 299-300