Chapter 20: Managing Quality and Risk Nursing School Test Banks

Chapter 20: Managing Quality and Risk
Yoder-Wise: Leading and Managing in Nursing, 6th Edition

MULTIPLE CHOICE

1. A new graduate is asked to serve on the hospitals quality improvement (QI) committee. The nurse understands that the first step in quality improvement is to:
a. Collect data to determine whether standards are being met.
b. Implement a plan to correct the problem.
c. Identify the standard.
d. Determine whether the findings warrant correction.
ANS: C
Before further action (data collection, decision making related to correction, and implementation of a plan) can occur, it is necessary to identify the standards against which data collection and decision making will occur. Institutions may or may not adopt standards that are already established by organizations such as the ANA.

REF: Page 369 TOP: AONE competency: Knowledge of the Health Care Environment

2. The chief executive officer asks the nurse manager of the telemetry unit to justify the disproportionately high number of registered nurses on the telemetry unit. The nurse manager explains that nursing research has validated which statement about a low nurse-to-patient ratio? It:
a. Promotes teamwork among healthcare providers.
b. Increases adverse events.
c. Improves outcomes.
d. Contributes to duplication of services.
ANS: C
Studies related to staffing and patient outcomes suggest that patient outcomes are improved with a low nurse-to-patient ratio and especially with a low registered nurse-to-patient ratio.

REF: Page 376 TOP: AONE competency: Knowledge of the Health Care Environment

3. A nurse manager wants to decrease the number of medication errors that occur in her department. The manager arranges a meeting with the staff to discuss the issue. The manager conveys a total quality management philosophy by:
a. Explaining to the staff that disciplinary action will be taken in cases of additional errors.
b. Recommending that a multidisciplinary team should assess the root cause of errors in medication.
c. Suggesting that the pharmacy department should explore its role in the problem.
d. Changing the unit policy to allow a certain number of medication errors per year without penalty.
ANS: B
Quality management stresses improving the system, and the detection of staff errors is not stressed. If errors occur, reeducation of staff is emphasized rather than imposition of punitive measures such as disciplinary action or blaming.

REF: Page 365 | Page 366
TOP: AONE competency: Knowledge of the Health Care Environment

4. The nurse educator of the pediatric unit determines that vital signs are frequently not being documented when children return from surgery. According to quality improvement (QI), to correct the problem, the educator, in consultation with the patient care manager, would initially do which of the following?
a. Talk to the staff individually to determine why this is occurring.
b. Call a meeting of all staff to discuss this issue.
c. Have a group of staff nurses review the established standards of care for postoperative patients.
d. Document which staff members are not recording vital signs, and write them up.
ANS: B
Leadership must identify safety shortcomings and must locate resources at patient care levels to identify and reduce risks. One method of doing this is to invite all staff into a discussion related to solutions to an identified concern. This approach encourages teamwork.

REF: Page 364 TOP: AONE competency: Knowledge of the Health Care Environment

5. A nurse is explaining the pediatric units quality improvement (QI) program to a newly employed nurse. Which of the following would the nurse include as the primary purpose of QI programs?
a. Evaluation of staff members performances
b. Determination of the appropriateness of standards
c. Improvement in patient outcomes
d. Preparation for accreditation of the organization by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
ANS: C
The primary purpose of QI is improvement of patient outcomes, which relates to prevention of error, quality patient care, and patient satisfaction.

REF: Page 362 | Page 367
TOP: AONE competency: Knowledge of the Health Care Environment

6. Before beginning a continuous quality improvement project, a nurse should determine the minimal safety level of care by referring to the:
a. Procedure manual.
b. Nursing care standards.
c. Litigation rate of unsafe practice.
d. Job descriptions of the organization.
ANS: B
Standards establish the minimal safety level of care. Procedure manuals provide information about how standards are to be achieved.

REF: Page 367 TOP: AONE competency: Knowledge of the Health Care Environment

7. The nurse gives an inaccurate dose of medication to a patient. After assessment of the patient, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication understands that:
a. The error will result in suspension.
b. An incident report is optional for an event that does not result in injury.
c. The error will be documented in her personnel file.
d. Risk management programs are not designed to assign blame.
ANS: D
QM stresses improving the system, and the detection of staff errors is not stressed. If errors occur, reeducation of staff is emphasized rather than imposition of punitive measures such as disciplinary action or blaming.

REF: Page 365 | Page 366
TOP: AONE competency: Knowledge of the Health Care Environment

8. The nurse manager is concerned about the negative ratings her unit has received on patient satisfaction surveys. The first step in addressing this issue from the point of view of quality improvement is to:
a. Assemble a team.
b. Establish a benchmark.
c. Identify a clinical activity for review.
d. Establish outcomes.
ANS: C
In theory, any and all aspects of clinical activity could be improved through the QI process. However, QI efforts should be concentrated on changes to patient care that will have the greatest effect.

REF: Page 364 | Page 366 | Page 380
TOP: AONE competency: Knowledge of the Health Care Environment

9. With the rise of violence in the psychiatric department, the nurse manager decides that she should work with the risk manager in violence prevention. The nurse manager should:
a. Request all staff to accept new risk management practices.
b. Hold staff accountable for safe practices.
c. Document inappropriate behavior.
d. Hire more police security.
ANS: B
Active involvement of staff in risk management activities is key to prevention of adverse events. Nursing has a primary role in leadership in optimizing patient outcomes, preventing patient care issues, and mitigating adverse events. Accountability for safety can be one aspect of performance evaluations.

REF: Page 362 TOP: AONE competency: Knowledge of the Health Care Environment

10. A new RN staff member asks you about the difference between QA and QI. You explain the difference by giving an example of QI.
a. Last year, the management team established new outcomes that addressed issues such as medication errors.
b. At a staff meeting last year, two of our staff commented on the number of recent falls and asked, What can we do about it?
c. A process audit was done recently to determine how much time was being spent on patient documentation.
d. Errors are reported on our new computerized forms, and I follow up with staff to make sure that they understand the seriousness of their error.
ANS: B
In QI, followers invest in the process by continually asking What makes this indicator important to measure? What has been done to improve it? What can I do to improve it?

REF: Page 365 TOP: AONE competency: Knowledge of the Health Care Environment

11. Healthcare organization X is committed to improving patient outcomes and, as part of the QI process, examines its executive structure and organizational design. This approach recognizes:
a. The importance of decentralized structure in QA.
b. That structure influences nurse burnout and participation in quality improvement initiatives.
c. The need to ensure sufficient supervisory staff to respond in a corrective manner when mistakes occur.
d. That a narrow hierarchy ensures accountability for errors and outcomes.
ANS: B
Common organizational characteristics of Magnet hospitals include structure factors (e.g., decentralized organizational structure, participative management style, and influential nurse executives) and process factors (e.g., professional autonomy and decision making, ongoing professional development/education, active quality improvement initiatives). ANCC Magnet designated hospitals and other high-reliability organizations in the United States and Europe generally have lower burnout rates, higher levels of job satisfaction, and provide higher levels of quality care resulting in greater levels of patient satisfaction (Aiken et al., 2012; Kelly, McHugh, & Aiken, 2011).

REF: Page 362 TOP: AONE competency: Knowledge of the Health Care Environment

12. Hospital ABCD is a Magnet hospital. This designation has been applied to Hospital ABCD because it:
a. Facilitates active staff participation in decision making related to quality nursing care.
b. Has implemented a graduate nurse orientation program.
c. Espouses commitment to excellence in patient care.
d. Is establishing career ladders for nurses.
ANS: A
Magnet hospitals are particularly successful in implementing excellence in patient care through use of standards, evidence, and participatory decision making in quality improvement. Organizations that cannot pursue Magnet status can implement strategies such as career ladders.

REF: Page 362 TOP: AONE competency: Knowledge of the Health Care Environment

13. A nursing-led classification system that has led to greater reliability and standardization in data utilized for QI processes is:
a. NANDA.
b. AHRQ.
c. NIOSH.
d. Nursing process.
ANS: A
NANDA has been developed by nurses and uses standardized terminology that enables study of health problems across populations, settings, and caregivers.

REF: Page 373 TOP: AONE competency: Knowledge of the Health Care Environment

14. In determining the relationship between injury-producing falls and proposed preventive measures as part of the QI process, a QI team might turn to which of the following for confirmatory evidence?
a. NDNQI
b. NANDA
c. NIOSH
d. AHRQ
ANS: A
The National Database of Nursing Quality Indicators is a national, nursing quality measurement program from the American Nurses Association that provides hospitals with unit-level performance reports with comparisons to national averages and rankings.

REF: Page 372 | Page 373
TOP: AONE competency: Knowledge of the Health Care Environment

15. A method commonly used in Quality Assurance to monitor adherence to established standards is:
a. A Pareto chart.
b. Brainstorming.
c. Patient interviews.
d. Chart audit.
ANS: D
Chart audits are a common method of addressing process standards. Chart audits over time yield trend charts.

REF: Page 375 TOP: AONE competency: Knowledge of the Health Care Environment

16. Hospital Magnet decides against creating a separate department to lead and monitor quality activities because:
a. Total organizational involvement is critical to QI.
b. Data generated by a single, separate department are generally flawed.
c. Monitoring and commitment to QI can come only from senior-level managers.
d. Staff resent suggestions for improvement that originate outside of their unit.
ANS: A
Decentralized approaches are effective in developing unit-level solutions, as well as commitment to strategies and implementation of changes.

REF: Page 362 TOP: AONE competency: Knowledge of the Health Care Environment

17. As a nurse manager, you know that the satisfaction of patients is critical in making QI decisions. You propose to circulate a questionnaire to discharged patients, asking about their experiences on your unit. Your supervisor cautions you to also consider other sources of data for decisions because:
a. The return rate on patient questionnaires is frequently low.
b. Patients are rarely reliable sources about their own hospital experiences.
c. Hospital experiences are frequently obscured by pain, analgesics, and other factors affecting awareness.
d. Patients are reliable sources about their own experiences but are limited in their ability to gauge clinical competence of staff.
ANS: D
Patients are reliable and motivated sources of their own experience but often do not have sufficient knowledge of clinical procedures to provide feedback about clinical competence.

REF: Page 366 TOP: AONE competency: Knowledge of the Health Care Environment

18. An example of an effective patient outcome statement is:
a. Eighty percent of all patients admitted to the Emergency Department will be seen by a nurse practitioner within 3 hours of presentation in the Emergency Department.
b. Patients with cardiac diagnoses will be referred to cardiac rehabilitation programs.
c. The hospital will reduce costs by 3% through the annual budget process.
d. Quality is a desired element in patient transactions.
ANS: A
Patient outcomes must be measurable, specific, and patient-centered.

REF: Page 367 TOP: AONE competency: Knowledge of the Health Care Environment

19. Patient perceptions are useful in:
a. Determining disciplinary actions in QI.
b. Establishing the competitive advantage of QI decisions.
c. Providing one source of data for QI initiatives.
d. Establishing blame for poor-quality care.
ANS: C
Customers define quality and patient dissatisfaction as useful indicators of which areas are of greatest concern to patients and of what matters then to nurses and organizations. Patient perceptions guide areas of inquiry; however, they do not establish what disciplinary decisions will be made.

REF: Page 366 | Page 367
TOP: AONE competency: Knowledge of the Health Care Environment

20. Through the QI process, the need to transform and change the admissions process across administrative and patient care units is identified. In this particular situation, what method of data organization will be most effective?
a. Flowchart
b. Histogram
c. Narrative
d. Line graphs
ANS: A
Flowcharts are useful in identifying and visualizing sequential steps, such as the admissions process.

REF: Page 369 TOP: AONE competency: Business Skills

21. A nursing unit is interested in refining its self-medication processes. In beginning this process, the team is interested in how frequently errors occur with different patients. To assist with visualizing this question, which organizational tool is most appropriate?
a. Histogram
b. Flowchart
c. Fishbone diagram
d. Pareto chart
ANS: A
Histograms are bar graphs that are useful in outlining and identifying frequency.

REF: Page 369 TOP: AONE competency: Knowledge of the Health Care Environment

22. The outcome statement Patients will experience a ten percent reduction in urinary tract infections as a result of enhanced staff training related to catheterization and prompted voiding is:
a. Physician-sensitive and nonmeasurable.
b. Measurable and nursing-sensitive.
c. Precise, measurable, and physician-sensitive.
d. Patient carecentered and nonmeasurable.
ANS: B
Nursing-sensitive outcomes refer to outcomes that are affected by nursing activity and are precise, measurable, and patient-centered.

REF: Page 367 | Page 368
TOP: AONE competency: Knowledge of the Health Care Environment

23. Your institution has identified a recent rise in postsurgical infection rates. As part of your QI analysis, you are interested in determining how your infection rates compare with those of institutions of similar size and patient demographics. This is known as:
a. Quality assurance.
b. Sentinel data.
c. Benchmarking.
d. Statistical analysis.
ANS: C
Benchmarking is a widespread search to identify the best performance against which to measure practices and processes.

REF: Page 371 TOP: AONE competency: Knowledge of the Health Care Environment

24. At Hospital Ajax, there has been a 20% increase in instruments and sponges being left in patients during surgery and surgeries on the wrong limbs. These are known as:
a. Sentinel events.
b. Medically sensitive events.
c. Nurse-sensitive events.
d. Never events.
ANS: D
The NQF and CMS define never events as errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients and that indicate a real problem in the safety and credibility of a healthcare facility. Examples of never events include surgery on the wrong body part, foreign body left in a patient after surgery, mismatched blood transfusion, major medication error, severe pressure ulcer acquired in the hospital, and preventable postoperative deaths.

REF: Page 377 TOP: AONE competency: Knowledge of the Health Care Environment

MULTIPLE RESPONSE

1. Examples of sentinel events include (select all that apply):
a. Forceps left in an abdominal cavity.
b. Patient fall, with injury.
c. Short staffing.
d. Administration of morphine overdose.
e. Death of patient related to postpartum hemorrhage.
ANS: A, B, D, E
Sentinel events are serious, unexpected occurrences involving death or physical or psychological harm.

REF: Page 376 | Page 377
TOP: AONE competency: Knowledge of the Health Care Environment

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