accreditation
What is the minimum number of patient identifiers (such as full name and medical record number) required by CBAHI standards whenever taking blood samples, administering medications, or performing procedures?
A) One identifier (The patient's name)
B) Two identifiers (e.g., Full name and Medical Record Number)
C) Three identifiers (Name, MRN, and Bed Number)
D) No specific number, as long as the staff knows the patient
Correct Answer: B
What does RCA stand for?
A) Risk Control Analysis
B) Root Cause Analysis
C) Risk Classification Assessment
D) Rapid Corrective Action
B) Root Cause Analysis
What is the primary purpose of the Quality Management Committee in a hospital?
A) To manage hospital finances and budgets
B) To oversee and coordinate quality improvement activities throughout the hospital
C) To handle staff recruitment and performance reviews
D) To approve medication purchases
B) To oversee and coordinate quality improvement activities throughout the hospital
Your department has 5 quality problems to solve but limited time and resources. How do you decide which problem to work on first?
A) Start with the easiest problem
B) Start with the most expensive problem
C) Use a Pareto Chart to identify which problem causes the most impact
D) Ask the hospital director to decide
C) Use a Pareto Chart to identify which problem causes the most impact
To ensure effective oversight of the hospital’s strategic plan, quality, and safety, how often is the Executive Management body (Hospital, Medical, Nursing, and Quality Directors) required to meet?
A) At least four times per year (Quarterly)
B) Once every two months
C) At least ten times per year
D) Weekly without fail
Correct Answer: C
What are the 4 steps of the risk management cycle?
A) Plan, Do, Check, Act
B) Define, Measure, Analyze, Improve
C) Identify, Assess, Treat, Monitor
D) Report, Investigate, Escalate, Close
C) Identify, Assess, Treat, Monitor
Which committee in the hospital is responsible for reviewing and approving all medication-related policies, formulary changes, and adverse drug reactions?
A) Quality Management Committee
B) Infection Control Committee
C) Pharmacy and Therapeutics Committee
D) Medical Executive Committee
C) Pharmacy and Therapeutics Committee
Which improvement tool follows the steps: Define, Measure, Analyze, Improve, and Control?
A) PDCA
B) Lean
C) Six Sigma DMAIC
D) RCA
Question: The Laboratory department is held to a specific quota for Quality Improvement (QI) projects. During a current accreditation cycle, what is the minimum number of QI projects the lab must be engaged in, and how must they be distributed?
A) At least two general laboratory projects only
B) At least four projects: Two general laboratory, one blood bank, and one transfusion services project
C) At least three projects: One for every shift (Morning, Evening, Night)
D) At least one project for every section of the laboratory (Hematology, Chemistry, etc.)
Correct Answer: B
A risk was identified, assessed as high likelihood and high impact, and added to the risk register. Six months later it was never acted on. Who holds the primary accountability for this failure?
A) The quality department for not following up
B) The risk owner assigned to that specific risk
C) The frontline staff who reported it
D) The accreditation committee
B) The risk owner assigned to that specific risk
A hospital's Medical Executive Committee receives a CPR code report showing a 40% failure rate in a specific ward. The committee reviews it, documents it in the minutes, but takes no action. Three months later another failure occurs in the same ward. What governance principle did the committee violate?
A) Quorum requirements
B) Committee reporting structure
C) Accountability and closing the loop on committee decisions
D) Conflict of interest policy
C) Accountability and closing the loop on committee decisions
A hospital has been running a quality improvement project for 6 months. Data shows the process improved in month 3 but then returned to its previous performance level by month 6. What does this indicate and what tool should be used to prevent it?
A) The project failed; restart with a new team
B) The improvement was not sustained; a Control Chart should be used to monitor and hold the gains
C) The data is unreliable; validate the KPIs first
D) The project succeeded; variation is normal and acceptable
B) The improvement was not sustained; a Control Chart should be used to monitor and hold the gains