1-Comparing outcomes in services with two similar hospitals is done as an example

of:
A Peer review.
B Benchmarking.
C Best practice.
D. Outsourcing

2-Pediatric psychiatric will open soon. As a utilization management officer what will
you do to ensure success:
-Make plan and show it to staff.
B -Involve team members

3-The primary reason healthcare organizations use benchmarking is to

A. comply with accreditation standards.
B. improve performance.
C. decrease risk to the organization.
D. provide risk adjustment.

4-The best tool to display stability of process rates over time is a

A. run chart.
B. histogram.
C. Pareto chart.
D. control chart.

5-To know the root cause of variance

A-ischkawa diagram
B-schwert diagram

6-To know if there is special cause or common cause

-run chart
-control chart

7-a complication is not present at time of admission (Answer : B)

8-In team decision making, consensus means>>>> (Answer :1-A /2-A)

9-risk retention.

(Answer : C)

(Answer : A)
10-“To Err Is Human” report was published by
Institute of Healthcare Improvement (IHI)
Institute of (IOM)

11- the facilitator

Moderate Team (Answer :1-C /2-D)

12-The surgical "time-out" reduces the risk of preventable surgical

mistakes (Answer :D)
13-autocratic leadership
[Link]. leadership
)31-31 ‫(كل األسئلة الخاصة بالسؤالين‬

(Answer :B)

(Answer :C)

(Answer :D)

(Answer :C)

(Answer :C)

(Answer :C)
15-Human factors

(Answer :C)

(Answer :C)

(Answer :A)

(Answer :D)
16-human factor engineering with infection control
A-antimicrobial soap
B-antimicrobial stewardship
C-motion sensor faucet ???
D-instrument sterilization

17-example of human factor engendering for decrease risk:

A-double check for insulin dose
B-decrease medicine mistakes in pharmacy
C- environmental services remove full sharp containers ???
D-placement of disinfectant gel in service place

18-When considering the use of an external subject matter expert (SME), which of
the following is the characteristic most critical

(Answer :D)
19-random sample

(Answer :A)

(Answer :C)

(Answer :C)

(Answer :A)
20-Problem solving, interdisciplinary thinking, conflict management and broad span
of expertise are examples of
a-team benefits
b-strategic alliance
c-leadership styles
21-The best indicator used by an ambulatory setting

(Answer :A)

22-A credentialing committee has determined that a practitioner has significantly

higher rate of complications after surgeries than the practitioners peer. Which of the
following the committees do next?

(Answer :A)
 23-Medication reconciliation is?
)‫(جميع األسئلة‬
[Link] reconciliation is:
A. The reconciliation of duplicated dosage, frequency and discrepancies at the
ICU only
B. The resolutions of medication discrepancies in dose, frequency and
therapeutic duplication at time of discharge
C. The reconciliation of medications throughout the patient’s hospital stay
D. The clarification of patient’s medications to the relatives at time of discharge

[Link] reconciliation:
A- help in efficient use of medication
B- Identify discrepancies in medication
C- Identify and resolve medication Discrepancies

[Link] of the medication reconciliation process require the

interdisciplinary effort of
A. Nurse, physicians, laboratory technicians and informatics
B. Nurse, physicians, pharmacists and informatics
C. Nurse, physicians, chaplains and informatics
D. Nurse, physicians, pharmacists and medical therapists

[Link] of the following is LEAST likely to reduce rehospitalization among

patients with congestive heart failure (CHF)?
[Link] patients before discharge on their diagnosis, medications, and
follow-up with physicians.
[Link] the geographic mean length of stay for the DRG.
[Link] reconciliation.
D.A telephone call by a nurse from the discharging hospital soon after
discharge

[Link] is not useful in making medication reconciliation successful?

[Link] education
[Link] between staff and patient
[Link] reconciliation errors part of staff reappointment process
[Link] measurement by reliable measures

24-FMEA provides which of the following types of review?

a. Proactive
b. Retrospective
c. Concurrent
d. Recurrent
25-Positive correlation is seen in the scatter diagram when:
There is a scattering of points in circular pattern
There is a scattering of points in triangular pattern
Increase in X-axis related to increase in Y-axis
Increase in X-axis related to decrease in Y-axi

26-After significant unexpected event, an intensive analysis is performed to:

A. Understand the cause
B. Correct risk management data
C. Prevent the facility from law suit
D. Identify who made the error

27-Data gathering method includes all of the following except:

Measurement
Observation
Correlation
Interviewing

28-The best effective way to evaluate training is:

(Answer :C)

29-Which of the following could the quality professional BEST deal with?
30-A balanced scorecard for an organization

(Answer :C)

(Answer :D)

(Answer :A)

(Answer :C)

31-A hospice agency conducted a satisfaction survey of all 200 patients currently
receiving pain management service. When asked if they were satisfied with their
pain management, 170 said "Yes" and 30 said "No". In this case, the healthcare
quality professional should:
[Link] all dissatisfied persons for similarities
[Link] more data to ensure statistical significance
[Link] monitoring because 85% satisfaction rate is excellent
[Link] monitoring because 15% dissatisfaction rate is acceptab

32-The operating room circulating nurse reported that the instrument cannot indicate
a missing clamp. X-ray finding was negative and the patient showed no adverse
effect. This occurrence is an example of which of the following?
[Link] management
[Link]
[Link] incompetency
[Link] compensable event
33-Multivoting

(Answer :C)
34-The paradigm shift is:

35-Surgeon do a colonoscopy done perforation to colon in surgery :

(Answer :A)

36-Which of the following is the primary benefit of using external quality consultants
[Link] knowledge gaps.
[Link] mission and vision of the organization
[Link] effective communication.
[Link] performance standards for the organization
37-When using cost-benefit analysis in decision making it is important to remember
that
38-Which of the following is the primary goal of risk management?
a-patient safety
b-Identify the high risk areas of the organization.
c-maintain an effective incident reporting system.

(Answer :1-D / 2-A / 3-A)

39-Which of the followings NOT example for sentinel event?

PT is threating to suicide within 24 after admit
hemolytic TRANSFUSION reaction
death of patient due to medication error
surgery on wrong part of the body
70-What is the best way to deal with conflict in a group

(Answer :B)

41-Team cohesion .. in which stage :

(Answer :C)

42-Number of discharges.......................142
Number of procedures.......................100
Arthroscopies.....................................20
Hip replacement.................................40
Surgical wound infections..................32
Incomplete medical records...............40
The rate of overall delinquent medical record:(delinquent )
a.40%.
b.28%.>>>>B 40/142*100=28%
c.30%.

43-Obstetric outcome for morbidity:

a-Normal delivery
b- Ceserian
c- Neonatal death
d-Postoperative septicemia

44-the pt discharged without any counseling of his care, this problem, concerned
with
a-medical coverage
b-case management
c-transition care
d-reconciliation
45-Aim of 6-sigma is

(Answer :D)

46-Performance improvement program for supervisors should include :

A. Rapid cycle process
B. Results of FMEA
C. Budget variance reporting
D. Review of patient falls

47-CEO decides to have accreditation to the hospital after 18 months, what should
he do:
A. Communicate accreditation process to all staff
B. Hire external quality expert to give lectures
C. Make monthly newspaper

48-External survey ,the role of HQP to

A- Make Team to make good show for the survey
B- Ask key staff for answer the questions
C- Ask department directors to make presentation for survey
D- Educate all staff about questions they may asked

49- Which is best to do during the accreditation survey:

A. To assign a team to answer the questions asked by surveyors
B. To have a departmental director who know 3 standards about their concerned
departments
C. To educate all staff members the expected survey questions
‫مع تغيير صيغه الكالم‬

‫ عن‬.. ‫(في بوست جميل لألسمراني الحليوه د معتصم‬

Accreditation
)‫ وشاكلته‬14 ‫ و‬14 ‫نفس السؤال‬
50- Physician and nurse director compensation for busy Emergency room due to
aggression door-to-disposition. Staff workarounds save times but increase the
potential errors. This situation may consider:
A. forcing function.
B. Unintended consequences.
C. Lean, Six sigma, Poka YOKA

51-First task of a newly established quality council for implementation of safety

A provide protocol for rapid response teams
B assess preparedness and disaster plan
C prepare job description for quality council
D scan the environment for risk

52- which of the following is the first step in implementing lean management
effectively in a hospital?
A. Create an organizational culture that is receptive to lean thinking.
B. Distinguish between value-added steps from non-value-added steps in any given
process.
C. waste elimination
D. Identify key processes for kaizen projects
‫نفس فكره السؤال بس الصيغه مختلفه‬

53-Quality teams can be an important component in an organization’s

quality/performance improvement program by providing an avenue for:
a. Reporting to the governing body
b. Credentialing and re-appointment
c. Staff involvement
d. Administrative support

54- A health plan decide to use flu vaccine for the total population at their services
area. What is the intangible benefit from this decision
A- savings from treatment of non infected people
B- savings from decreased rate of infection in non immunized people
C-piece of mind as a result of lowest incidence of flu infection
D- reduced hospitalization rate

55-Red rules are used for

A. Tool for Monitoring safety.
B. Root cause analysis
c. a patient safety goal
56-Which of the following is NOT an appropriate red rule?
A- When a midwife is concerned at the bedside and asks the obstetrician to come to
the bedside, he or she should come in a timely manner.
B- Elective induction of labor prior to 39 weeks for nonmedical reasons is not
permitted.
C- If there is a discrepancy in the sponge count during surgery, the patient should
have an X-ray before leaving the operating room.
D- Nurses should observe the “5 Rights” of medication administration when
administering any drug

57-In a culture of patient safety error is considered:

[Link].
[Link]
[Link]

58- A target study on pediatric patients of cystic fibrosis was conducted for 4 years.
Which is this type of study?
A. case control
B. cohort study
C. Randomized control trial
D. Case mix group

59- A 75 y patient done side hip replacement climbed upstairs and had been fallen ,
risk manager go to pt family and discuss that issue ,the risk manager's action is
considered example of potential:
A-risk assessment
B- Compensable event
C- Loss transfer
D- Loss reduction

60-Which of the following tools is most appropriate for investigating the relationship
between two characteristics?
A. Scatter plot
B. Cause-and-effect diagram
C. Failure modes and effects analysis
D. Pareto chart
61- Nurse in the post-operative found missed clamp, x-ray has done to the patient
was negative & the patient has no symptoms this occurrence is type of
a. Claim management
b. Potentially compensable event
c. Malpractice from the nurse
d. Incompetent surgeon
62-The average daily census at the organization is 1000 patients. The most
accurate & efficient sampling technique for this study would be:
A. review 100% of all active records on one day of past month
B. review 10% of all discharge records for the past quarter
C. estimate the percentage of records to be reviewed using an accepted statistical
formula appropriate for the population
‫ كان فيه اختيار كمان مش فكراه غير ان االختيار‬c ‫مكنش كده كان بصيغه تانيه تحمل نفس المعني‬

63-When developing a strategic plan with integration of patient safety, what is

considered to be crucial:
A. Culture of the performance improvement
B. Resources of new technology
C. Cost benefit analysis of pt. safety program
D. Patient to staff ratio

64-For CQI to be successful who must be included in staff

A. Administrator
B. Person performing process ‫ تقريا كانت‬owner
C. Quality management representative
D. Department supervisor

65- The CEO has directed the quality improvement council to develop objectives to
meet an identified goal. When developing the objectives, the council should
remember to:
A. State the end result of that outcome
B. Keep the objective specific to the short term
C. Use the plan do check act (PDCA) for continuous improvement
D. Tie the objective to financial performance
‫بصيغه مختلفه تقريبا‬

66-The consensus building group of diverse stakeholders who reviews and

endorses measures for public reporting in the U.S is known as the :
A. Institute is medicine (IOM)
B. Agency for health care quality and research(AHRQ)
C. Center for Medicare and Medicaid services(CMS)
D. National quality forum(NQF)

67-One of the AHRQ main components?

A. Accreditation
B. Clearinghouse for evidence based guidelines
68-To collect (qualitative) data :
A- Focus group
B- score questionnaire
C- Survey
69-organization made focus group to performance evaluate who should participate :
- patient
-leader
‫مش فاكره الباقى‬

70-In medical gp. Of 70physcians;there were 10000 pts. In the 4th quarter of last
year with 100 complints. The 4th quarter of this year there were 60000 pts. With 360
complaints. The quality improvement team target was 5 complints /1000 pt. By
analyzing these coordinates;what will be found
A. Rate decreased;goal is not reached
B. Rate increased;goal is reached
C. Rate decreased;goal is already reached
D. Rate increased; goal is not reached
‫السؤال ده جه بنفس الصيغه ونفس االرقام‬

71-Review of hospital staff, it's found that most of Staff complain of back pain which
can be solved by
A. Physiotherapy
B. Change beds
C. Involvement of occupational nurse
D form multidisciplinary team
‫ السؤال ده جه االختيلرال كانت بصيغ مختلفه اجابته‬D ‫وكانت من ضمن االختيارات فعال‬

72- The result of the customer survey the mean score was calculated with each
item. Weight was applied to range each item in order to importance to the customer
which of the following the highest weighted mean score :
a. Mean 3 and weight 0.9 3X0.9=2.7
b. Mean 4 and weight 0.8 4X0.8=3.2
c. Mean 5 and weight 0.7 5X0.7=3.5
d. Mean 6 and weight 0.6 6X0.6=3.6
73-Frequency distribution can be best display through:
A. Pareto
B. Histogram
C. Control
D. Bar graph

74- An outbreak of measles in a school district resulted in 58 cases over a period of

5 months. Which of the following data displays best illustrate the monthly occurrence
of measles
a. Gantt chart
b. Scatter diagram
c. Histogram
d. Pie chart

75- ‫ سؤال عن‬shewhart ‫ بيسأل ايه الجراف اللي بنستخدمه في تقييم‬viration ‫ ومكنش فيه‬control chart ‫في‬
‫االجابه فاخترته‬

Answer: C

Answer: B

76-Which of the following is used to summarize characteristic in a population

a- Regression analysis
b- Frequency distribution
c- Control chart

77-Which is best example of population heath management

A-decrease in turn around time in er
B-examination of increased admission
C- ensure of periodic eye examination of diabetic patient
78-Severe event occurs and want to prevent reoccurring it:
1-FMEA
2-RCA

79-pareto cart ‫ سؤال مباشر عن‬prioritization

Answer: A

Answer: D

80-which is most effective for harm prevention

a-interdisciplinary communication
b -quality teams

81-According to Deming the continuous quality improvement applied in (HR)

a. story board outcome of quality improvement
b. Abandonment traditional annual performance appraisal
c. Practicing in community improvement project
d. Automatic annual wages pay increase

82-A in safety culture medication error is regarded as:

A. Malpractice
B. Purposeful
C. Negligence
D. Normal

83-Strategy of brainstorming:
A. Discussion of issues
B. Prioritization of issues
C. Recording of issues
84-The governing body hired an independent quality firm to assess quality in your
organization. As a quality manager, what is the first thing you should do:
1- Point out the quality problems in your organization.
2- Prepare a schedule for their visits.
3- Determine the goals and outcomes expected from them.
4- (forgot the last choice)

85-Consulting firm to evaluate performance improvement program, as a quality

professional what u should do first:
A- Schedule the program for the consulting firm.
B- Allow the consultant to establish the necessary goals for the project.
C- Ask the consultant for job description that s/he will follow.
D- Defer to the consultant regarding time frames and deadlines.

86-When using mortality data in benchmarking, it should be :

A- DRG
b- severity adjusted
C- LOS adjusted

87-promoting teamwork by
[Link] support
[Link] project objectives

control chart ‫ كان فيه رسمه‬-88

ucl and lcl ‫اللى بيكون فيها ال‬
‫مش خط مستقيم وكنت فاكره ان النوع ده المفروض مش علينا بس جالى‬
mean =7.06‫المهم االختيارات كانت سهله كان خط ال‬
-mode =7.06
-no outlier event
-lcl is the same

staff ‫ سؤال عن اداره مستشفى قررت تفتح حاجه جديده فدربوا ال‬-88
‫وخلوهم يروحوا زيارات ل مؤسسات تانيه عندهم نفس الحاجه‬
blanced scor card ‫قرروا انهم حيعملوا‬
‫عشان يراقبوا االداء‬
‫اللى عملوه ده اسمه ايه‬
-importance of training
-importance of competency
- high level of strategic planning
-commitment to quality
 ‫‪ -89‬كان فى سؤال سهل انهم عملوا ‪survey‬‬
‫للموظفين عن الحاجات اللى بتضايقهم وكانتت النتيجه‬
‫‪operation is so complicated why i have to wait for pharmacy to prepare medicine it‬‬
‫‪should be in the floor there is too many non value added steps‬‬
‫‪what is the best solution‬‬
‫‪lean-‬‬
‫‪-‬اختياراات تانيه ملهاش عالقه اوى‬

‫‪ -83‬كان فيه جدول مقارنه بين تالت دكاتره بمعدل حدوث العدوى وبين المستشفى‬
‫الجدول كان خاناته عدد حاالت ال ‪infection‬‬
‫و عدد الحاالت اللى شافها الطبيب‬
‫المفروض بتحسب لكل طبيب نسبه االصابه بتقسم الرقمين على بعض وتقارنهم بمعدل المستشفى وواحد منهم حيتعمله‬
‫‪reappointment‬‬
‫او حيتحول ل ‪ focus review‬مش فاكره بالظبط بس كان سهل‬

‫‪ -89‬كان فى سؤالين نفس الفكره‬

‫‪RPN= O X S X D‬‬ ‫جايبن جدول ‪FMEA‬‬
‫وفيه ارقام ال ‪occurrence , detectablity, severity‬‬
‫وبيسال حتختار ايه االول عشان تحسنه‬

‫‪-81‬كان فيه سؤال عن مشكله عملنا فى حلها خطوات ويسأل الخطوه الجايه ايه فى ال ‪rapid cycle‬‬
‫فراجعوا خطوات ال ‪rapid cycle‬‬
‫اعتقد انى عملته غلط‬

‫الجدول بيتكلم عن ‪organization‬‬

‫فيها ‪facilities 1‬‬
‫بيقارن بين عدد الشكاوى وعدد المجامالت وزمن ال ‪turn over time‬‬

‫‪Facility A‬‬ ‫‪Facility B‬‬ ‫‪Facility C‬‬

‫‪Complain‬‬ ‫‪60‬‬ ‫‪50‬‬ ‫‪70‬‬
‫***‬ ‫‪80‬‬ ‫‪95‬‬ ‫‪85‬‬
‫‪Time of turnover‬‬ ‫‪200‬‬ ‫‪195‬‬ ‫‪210‬‬
‫‪A. Enforce customer Service training‬‬
‫‪B. Define good Strategies‬‬
‫??? ‪C. Make break through in time of turnover‬‬
 ‫‪ -81‬نفس سؤال د مروه بس فى خيار زياده‬
‫كان فى رسمه جراف مقارنه بين كذا مشكله فى المستشفى عندنا والمستشفيات التانيه‬
‫كنت المستشفى عندنا كويسه فى حاجات‬
‫بس كان فيه ‪ 1‬حاجات المستشفى معدل االخطاء عندها اعلى من المستشفيات التانيه‬
‫منها ال ‪patient fall‬‬
‫االختيارات كانت‬
‫‪-recommend new protocol for patient fall‬‬
‫‪-collect more data‬‬
‫‪-Share data with governing body‬‬
95-Based on data from the next graph what should QM do:

A. Arrange staff for education class of hand hygiene

B. Try to found solutions with the staff to solve the hand full

96-

97-
‫‪98-‬‬

‫عبارة عن ‪ bar chart‬مقسمة إلى ‪bars 4‬‬

‫‪Risk5 & Risk4 & Risk3 & Risk2 & Risk1‬‬
‫وتقريباً كان فيهم بعض المشاكل وتم عمل ليهم‬
‫‪Action plan for improvement‬‬
‫وكان واضح من الجراف إنه كلهم حصل فيهم تحسن باستثناء ‪ Risk3‬ساءت اكتر من األول‬
‫وبالنسبة ل ‪ risk 5‬حصل فيها تحسن كبير وملحوظ جدا مقارنة باآلخرين‬
‫السؤال بقى هنا عن‬
‫‪?What should CPHQ do‬‬
‫‪a) Review the action/pilot for Risk3‬‬
‫‪b) take Risk5 as a benchmark‬‬
‫‪C- decrease cutoff line level‬‬
99- Which chart of those could be used for physician reappointment
Answer : Graph B

‫كل الشكر لـ‬

Maha Batisha
Dr-n Algendy
Mahmoud Alserafy
‫براديم شيفت‬
Abdel Aziz Elbadry
‫ وجزاهم اهلل خير‬.. ‫على تجميعهم األسئلة‬

‫ وال تنسونا من دعائكم‬.. ‫بالتوفيق للجميع‬