The CAHIMS Exam Preparation Course and the CAHIMS exam are the result of collaboration between the Life Science Informatics Center at Bellevue College and the Healthcare Information and Management Systems Society (HIMSS). Significant content found in the CAHIMS Exam Preparation Course stems from the Office of the National Coordinator for Health Information Technology. Creation of the CAHIMS Exam Preparation Course and the CAHIMS exam was made possible through support from the National Science Foundation (NSF).
1. Providers are more likely to view healthcare quality as __________.
*a. use of computerized decision support to facilitate evidence-based practice
b. implementation of a web-based patient satisfaction survey
c. computerized flow sheets that enable documentation required by regulatory standards
d. centralized appointment scheduling system that decreases patient wait time
Answer: a. While providers may view each of the choices as having some effect on health care quality, they are more likely to view quality as the application of evidence-based professional knowledge. Computerized decision support can be designed to present evidence in a way to support application of best practices. Payers place more emphasis on patient satisfaction, so they are more likely to select choice b. Professional and regulatory bodies place more importance on regulatory standards, so they are more likely to select choice c. Patients and families would be more likely to view choice d, since they place more importance on how long they have to wait for services.
2. Patients and families are more likely to view quality as __________.
a. the application of evidence-based professional knowledge
b. adherence to standards
*c. how well the provider communicates
d. use of preventive services
Answer: c. Patients and families place more importance on how well the provider communicates with them or how long they are kept waiting, than they do on the use of evidence-based knowledge, adherence to standards or the use preventive services.
3. An example of a structure used to evaluate quality of health care information technology is __________.
*a. a policy describing the prescriber’s role and responsibilities with respect to provider order entry
b. data on medication errors noted in the on-line event reporting system
c. data on how well physicians and nurses document problems on the electronic problem list
d. patient satisfaction with the electronic portal
Answer: a. Structures refer to having the right things, process refers to doing things right, and outcomes refer to having the right things happen. A policy is a structure that ensures that the right things are in place to ensure quality, so choice “a” is the most appropriate selection. Choice “b” and “d” are outcome measures, and choice “c” is a process measure.
4. According to the Institute of Medicine Crossing the Quality Chasm, which of the following is NOT a quality improvement aim?
b. patient centeredness
Answer: d. The Institute of Medicine identified that to close the quality gap, health care should be safe, effective, patient-centered, timely, efficient, and equitable. While innovation is likely required to make these changes, it is not one of the six aims noted.
5. Which of the following is not one of the four basic tenants to quality improvement?
a. setting an aim
c. learning the system
Answer: Setting an aim, measurement, change and learning the system are the four basic tenants of quality improvement. These elements are cyclic in nature.
6. What quality improvement measures must eligible providers report in 2011 to qualify for meaningful use incentive payments?
*a. blood pressure, tobacco status, and adult weight screening as well as three additional measures from a list of metrics
b. a single quality improvement measure of their own choosing
c. substance abuse, exercise tolerance, and nutritional status
d. advance directives in patients aged 65 and older
Answer: a. Starting in 2011, eligible providers must report on six quality measures to qualify for meaningful use incentive payments—three core measures and three from lists of metrics ready for incorporation into electronic health records (EHRs). Blood pressure, tobacco status, and adult weight screening are core measures.
7. Which of the following are the goals of meaningful use of electronic health records? Select all that apply.
*a. Improve quality, safety, & efficiency
*b. Engage patients & their families
*c. Improve care coordination
*d. Improve population & public health; reduce disparities
*e. Ensure privacy & security protections
Answer: a, b, c, d & e. The five goals of meaningful use of electronic health records are: to use health records in a way that improves quality, safety, and efficiency of care, engages patients and families in their care, improves coordination of care, improves population and public health and reduces disparities; and ensure privacy and security protections for all.
8. One example of how HIT can enhance patient-centeredness is __________.
a. reduce drug errors through computerized provider order entry
b. increase efficiency through automated vital sign capture
*c. tailor care plan to individual needs through clinical decision support
d. remind providers of best practices through prompts and flags
Answer: c. Clinical decision support can tailor information according to patient characteristics; and customized health education and disease management messaging can enable patient self-management. Computerized provider order entry supports patient safety. Automated vital sign supports efficiency, and best practice prompts support effectiveness of care.
9. An example of a workaround that can result in unintended consequences is __________.
a. reporting patient fall via an on-line event reporting system
*b. having nurses enter prescriber orders because the prescriber is too busy
c. use of a patient locator board to track patients
d. use of paper-based report sheets to communicate changes in patient condition
Answer: b. Work-arounds are alternative processes that help workers avoid demands placed on them that they perceive to be unrealistic or harmful. These unanticipated behaviors can be directly or indirectly caused by the EHR when the system impedes the provider’s work. For example, a nurse may take a verbal orders rather than the prescriber entering the order into POE due to workflow timing of the event, such as the surgeon being scrubbed on a case in the OR. The other choices are examples of artifacts.
10. Man-made tools that aid or enhance the user’s thinking abilities are called:
Answer: c. Artifacts are man-made tools that help the worker to think. They are developed to meet the demands of a particular activity. Keeping references at the bedside so that the nurse can refer to them during the course of care is an example of an artifact.
Lectures 5 & 6
11. Which of the following is a basic principle of the science of safety?
*a. The system is perfectly designed to deliver the results it gets.
b. Workers are largely to blame when mistakes happen.
c. The principles of safe design only refer to technical work.
d. Providers should assume things will go right rather than wrong.
Answer: a. Every system is perfectly designed to achieve the results it gets. Common misunderstandings related to the science of safety are that workers are to blame, that safe design pertains only to the technical work, and that we can’t plan for the things that might go wrong.
12. Which of the following is the premise behind the Swiss Cheese Model?
a. The Swiss Cheese Model states there is always someone at fault for an error.
*b. There are “holes,” vulnerabilities, or hazards in the health care environment that have an impact on medical error.
c. Problems are usually the result of people who don’t know what they are doing
d. Hazards are fairly static; one need only look hard to find them.
Answer: b. In James Reason’s Swiss Cheese Model, the holes represent vulnerabilities or hazards in our work environment. The hazards are dynamic and can change location over time. When all the holes align, errors can occur.
13. One of the following is not a system factor that has an impact on patient safety?
a. patient characteristics
*b. time factors
c. team factors
d. provider skill
Answer: b. The patient characteristics, the skill of the provider, team factors, and work environmental are system factors that can have an impact of safety. Although time can create pressure in the execution of a task, systems’ thinking is about viewing the inter-relatedness of the parts and how they work together to prevent failures or errors.
14. Which of the following is not a principle of safe design?
b. create independent checks
*c. add steps
d. learn from mistakes
Answer: c. Principles of safe design include standardizing processes and creating independent checks. These principles enhance safety by simplifying and eliminating unnecessary steps and reducing the potential for hazards or errors.
15. An example of an independent check is __________.
*a. car alarm sounds when passenger fails to put on seatbelt
d. checking battery life
Answer: a. A car alarm that signals when a passenger fails to put on his seatbelt is an example of an independent check. It is an active alarm that reminds the user to complete a planned task when the user fails to remember to do so on his own.
16. Standardization is important because __________.
a. when patterns of care are widely divergent clinical outcomes suffer
b. standardization reduces errors and improves safety
c. it can be attempted both in the technical aspects of care and team aspects
*d. all of the above
Answer: d. Standardization is one of the important principles of safe design. It attempts to reduce divergence. It can be used in different setting such as technical and team settings.
17. An example of an independent check is __________.
a. playing “man-down”
b. limiting the number of choices of drugs in a drop-down list
*c. requiring two signatures on high alert medications
d. developing protocols on how to document in electronic records
Answer: c. An independent check is a back-up procedure that is designed to ensure safety. Requiring two nurses to independently check right drug, right dose, right route, right time, and right patient before high alert medications are administered provides an extra measure of safety.
18. An example of standardization is __________.
a. verbal read-backs
b. requiring two signatures on high alert medications
*c. using a checklist before doing a procedure
d. eliminating extraneous steps
Answer: c. Standardizing care whenever possible is a key principle of safe design. An effective tool to promoting standardization is a checklist that lists all required best practices as a reminder to ensure that optimal conditions are present before doing potentially risky interventions. Verbal read backs and two signature requirements are examples of independent double checks. Eliminating extra steps is the third key principle of safe design.
19. Which of the following indicate system factors that have an impact on patient safety?
a. patient and provider characteristics
b. task characteristics and the work environment
c. institutional factors
*d. all of the above
Answer: d. There is a wide variety of system factors that have an impact on patient safety. These include: patient characteristics, task factors, individual provider characteristics, team factors, the work environment, departmental, hospital, and institutional factors.
20. HIT teams make wise decisions when __________.
a. there is a strong, knowledgeable leader who can make decisions for them
*b. there is diverse and independent input
c. all members of the team think alike
d. there is no opposition to the prevailing viewpoint
Answer: b. Teams make wise decisions with diverse and independent input. Diversity increases the number of lenses through which the team can view a problem. The more input you get from consumers, from patients, from parents, from colleagues, the wiser a decision you’re going to make when designing and implementing HIT.
21. Regarding reliability measurement, which statement is false?
a. The characteristics of systems that perform at 10-1 are different from those that perform at 10-3.
b. To measure reliability, you divide the number of actions that achieved the intended result by the total number of actions taken.
*c. Reliability is expressed as an order of magnitude.
d. A system that performs at 10-3 is less reliable than a system that performs at 10-1.
Answer: c. Reliability science involves continually evaluating care, calculating the overall reliability of the care, and improving the structures, processes, and outcomes.
It improves the ability of a process to perform as intended under commonly occurring conditions.
Lecture/Slides: 7/3, 5
22. The IHI reliability framework __________.
a. employs a three-tiered strategy
*b. suggests prevention of failure is the first step to redesigning a reliable system
c. scheduling tasks is a tool to identify and mitigate
d. a and c
e. all of the above
Answer: b. Preventing failure to compensate for human limitations, the IHI framework employs a three-tiered strategy. The first line of defense is to prevent failure from occurring in the first place.
Lecture/Slides: 7/3, 7
23. Regarding prevention of failure, __________.
a. the strategies to prevent failure are using intent and standardization and segmentation
b. the intent and standardization phase is aimed at changing the human factors and introducing a degree of redundancy
*c. the intent and standardization phase attempts to prevent the effects of clinician distraction and interruption
d. a and c
e. all of the above
Answer: c. Complete reliance on the team is the hallmark of a high reliability organization. Decisions are made by the person or persons with the most direct experience, not necessarily the team leader.
Lecture/Slides: 7/3, 9
24. Which one of the following attributes is characteristic of a highly reliable organization?
a. Understand where the failure in the system is occurring and determine the remedy.
*b. Have highly skilled workers in the field of reliability.
c. Acknowledge mistakes when they happen.
d. Have a comprehensive QI department.
Answer: b. Oversimplifying explanations for how things work risks developing unworkable solutions and failing to understand the ways a system may fail, placing a patient at risk. Reliable organizations improve the consistent and standard delivery of high quality, safe healthcare. They continually evaluate care, calculating overall reliability of that care, and improving structures, processes, and outcomes
Lecture/Slides: 7/3, 5-7
25. Which of these statements is false?
a. A "bundle" is a group of interventions related to a disease process that, when executed together, result in better outcomes than when implemented individually.
b. Providing each element of care within a bundle leads to more reliable care for patients.
*d. All diabetic bundles must contain at least three measures
Answer: d. There are no determined number of elements that need to be part of a bundle.
Lecture/Slides: 7/3, 8
26. Which of these statements is false?
a. Designing a reliable system is a stepwise process that requires the incorporation of prevention of failure, identification and mitigation of failure, and system redesign from failure.
b. A highly reliable organization aims to have all processes perform at 10-6.
*c. Different processes require different levels of reliability.
d. Reliability principles, used to design systems that compensate for the limits of human ability, can improve safety and the rate at which a system consistently produces desired outcomes.
Answer: c. High reliability organizations survive in complex environments that depend on multi-team systems that must coordinate their respective activities for safety. High reliability organizations are also tightly coupled. That is, team members depend on tasks across the entire team. Roles are very clearly defined and differentiated in high reliability organizations. Intense coordination is required for the team to work cohesively. Complete reliance on the team is the hallmark of high reliability organization. There are multiple decision makers in high reliability organizations, and, processes must be in place to allow these decision-makers to communication with each other. Therefore, choice c is correct.
Lecture/Slides: 7/3, 5
Lectures 8 & 9
27. Which one of the following is not an example of clinical decision support?
a. Computer screen displays the hospital fall prevention policy.
b. Electronic flow sheet displays evidence-based fall prevention strategies
*c. The computer system times out after a period of inactivity.
d. The EHR sends an automated message to the physical therapy department when patients screen as high fall risk.
Answer: c. General decision support functions promote use of best practices and facilitate evidence-based population management. For example, rules-based logic can scan available patient information and flag patients who are not in compliance with wellness or disease management regimens and alert the provider or the patient that interventions are due. Formulas and algorithms can present relevant patient data and perform complex calculations that the providers used to have to perform by hand. Important patient information can be tracked in disease registries. Summary screens display patient problems, medications, recent laboratory test results, and other pertinent clinical information in a “patient at a glance” display. These serve as reminders for the patient’s care team about chronic issues to factor into decisions as well as for covering providers who may have gaps in knowledge about the patient. System time-outs are designed to protect patient confidentiality and are not a form of decision support.
28. A clinician has been using a system that has a reminder system. When the clinician performs an action even when not prompted by the reminder system, this response is called __________.
Answer: a. Spillover occurs when there is a spread of responses merely due to increased awareness of the need for an action, even when the clinician is not prompted by the reminder system.
29. Which one of the following is not a right of clinical decision support?
a. right information
b. right person
*c. right dose
d. right channel
Answer: c. Osheroff suggests the five rights of clinical decision support are that it should be designed to provide the right information to the right person in the right format through the right channel at the right time.
30. Which of the following statements is a myth regarding clinical decision support?
*a. Clinicians will use stand-alone decision-support tools.
b. Use of decision support is affected by patient characteristics and risk-benefit for patients.
c. Decision support needs to be integrated into the context of routine clinical workflow.
d. Decision support can reduce medication-related expenditures.
Answer: a. A myth of clinical decision supports is that clinicians will use stand-alone decision support tools. We know now that we need to integrate decision support into the context of routine clinical workflow and that patient-related factors can have an impact on use of CDSS.
31. Which of the following is NOT a recommendation of the consensus panel for effective use of clinical decision support?
a. seamless integration of CPOE with CDSS into workflow
b. access to Internet-based and other online support material
c. designing systems specifically for the clinical area
*d. maximizing the use of active data capture
Answer: d. Recommendations for clinical decision support systems success note that systems should maximize the use automated systems and provide for passive, not active, data capture. Passive data capture, such as use of bar code scanning, promotes efficiency and decreases error.
32. Clinical decision support is most appropriate for __________.
*d. all of the above
Answer: d. The merits of clinical decision support are not limited to any particular environment. Skilled IT professionals can guide clinicians through the considerations that can promote successful implementation in any health care setting.
33. Which of the following is a decision support rule that can enhance efficiency?
*a. rules that trigger alerts for high cost drugs and suggest lower cost alternatives
b. drug-drug alert
c. drug-allergy warnings
d. drug-disease contraindications
Answer: a. Clinical decision support rules for efficiency are rules that trigger alerts for high cost drugs and suggest lower cost alternatives, duplicate testing alerts, rules that help the provider to document information that supports appropriate medical coding, and rules that calculate risks and generate preventive recommendations. The other three choices trigger alerts to enhance patient safety by avoiding common sources of error.
34. All of the following statements are correct EXCEPT __________
a. Alerts and reminders have the potential to enhance patient safety.
b. Alerts and reminders have the potential to enhance medical error.
*c. Alerts should never be overridden.
d. Alert fatigue can cause medical error.
Answer: c. Alerts have the potential to enhance safety as well as errors. Alerts should be specific, sensitive, clear, and concise in order to prevent fatigue. Alerts should be designed to avoid the need be overridden and when this occurs the reasons should be explored to improve use
35. Basic medication order guidance is __________.
a. generated when the mode of action of one drug is known to be affected by simultaneously prescribing a second drug
*b. an alert that provides dosing information with default dosing being the most appropriate initial dosing.
c. generated when the patient is already receiving the medication just ordered or a different drug in the same therapeutic category
d. an alert that fires when a drug is ordered to which a patient has a documented allergy
Answer: b. Basic medication order guidance, a type of basic drug alert, is an alert that provides dosing information with default dosing being the most appropriate initial dosing.
36. In the absence of a valid and transparent measurement system, most people are __________.
*a. over-confident in their performance
b. highly critical of their performance
c. fairly accurate about their performance
d. unclear about their performance
Answer: a. Studies have shown that, in the absence of valid and transparent measures, health care workers tend to be over-confident in their performance. People go into health care to help people and that desire causes bias when trying to measure their own performance.
Lecture/Slide: 11/10, 18
37. When you analyze variation to understand its cause __________.
a. variation provides a basis for action on the process
b. Variation is based on what the process actually delivers
c. You use run chart as a method to understand the variation
*d. all of the above
Answer: d. When you analyze variation to understand its cause: variation provides a basis for action on the process, it is based on what the process actually delivers and uses run chart as a method to understand the variation. When you analyze variation to assess performance: evaluation classifies outcomes as acceptable or not, it is based on what the customer wants and uses a variety of methods including specifications, budgets, forecasts and numeric goals among others.
Lecture/Slide: 11/5, 6
38. Which characteristic typifies common cause variation?
*c. variation happens within historical parameters
d. evidence of some change in the system or our knowledge of the system
Answer: c. Variation happens within historical parameters
The characteristics of common cause variation are: variation happens on a regular basis, variation is predictable, variation happens within historical parameters and no change in the system or our knowledge of the system
Lecture/Slide: 11/5, 6
39. Which statistical rules to identify non-random signals in run charts are subjective?
*c. astronomical points
Answer: c. Shifts, runs and trends are three probability-based rules used to objectively analyze a run chart for evidence of nonrandom patterns in the data based on an α error of p<0.05 while astronomical points are a subjective rule that recognizes the importance of the visual display of the data in a run chart.
Lecture/Slide: 11/7, 11
40. A valid model for reporting and measuring quality and safety in health care includes attention to process, outcome, and balance measures. An example of a balance measure in health care is the __________.
a. number of patient falls
b. cost of the implementation of a fall reduction strategy
*c. percentage of time providers spend with patients.
d. number of times fall prevention measures are documented
Answer: c. A balance measure is used to determine if we are causing new problems in other parts of the system. Cost is a typical balance measure.
41. An example of an outcome measure is __________.
a. whether we have a policy to manage patients with heart valve repair on our unit
*b. the percentage of patients with central lines who develop a blood stream infection
c. how often we place patients in restraints to manage aggressive behavior
d. the number of new patient visits
Answer: b. The only outcome measure in this list is the percentage of patients with central line associated blood stream infections. This measure reflects the results of our care. The presence of an organizational policy is a structural measure since it reflects how we organize care. How often patients are placed in restraints and number of new patient visits both reflect process measures, since they look at what we do.
42. To calculate a fall rate, you need to have __________.
*a. a clear definition of the population that is at risk for falls
b. a calculator
c. an on-line reporting system
d. a fall risk assessment scale
Answer: a. For a rate-based measure to be valid, we need a clear definition of both the numerator (who fell) and the denominator (who was at risk to fall). While the other three choices are nice to have, they are not required for calculation of a valid fall rate.
43. Which of the following is not a means to enhance data validity?
*a. free text data
b. clarify who what when where and how
c. train and evaluate competency
d. evaluate data quality (look at data)
e. missing data, outliers, repeat values
Answer: a. One important aspect of data collection enhancement is to structure data entry or data collection forms whenever possible, to ensure those who are entering data are crystal clear about who, what, where, when and how, to formally train and evaluate the competency of those entering the data (ideally formal training that includes evaluation of performance and the provision of feedback), to evaluate data quality check for missing data and correct it if possible, look at your outliers and repeat values, especially for denominators.
Lecture/Slide: 11/7, 18
Lectures 12 & 13
44. Quality is defined as:
a. In many ways depending on the context
b. the suitability of procedures, processes and systems in relation to the strategic objectives
c. the ongoing process of building and sustaining relationships by assessing, anticipating, and fulfilling stated and implied needs
*d. All of the above
Answer: d. All of the above
45. Quality Assurance is:
*a. a set of activities designed to ensure that the development and/or maintenance process is adequate to ensure a system will meet its objectives
b. a set of activities designed to evaluate a developed a work product
c. a and b
d. None of the Above
Answer: a. a set of activities designed to ensure that the development and/or maintenance process is adequate to ensure a system will meet its objectives
46. Quality Control is:
a. a set of activities designed to ensure that the development and/or maintenance process is adequate to ensure a system will meet its objectives
*b. a set of activities designed to evaluate a developed a work product
c. a and b
d. None of the Above
Answer: b. a set of activities designed to evaluate a developed a work product
47. The Deming Cycle Consist of Which Elements:
b. Plan, Do, Check
*c. Act, Plan, Do, Check
d. None of the above
Answer: c. Act, Plan, Do, Check
48. The Pareto Principal is:
a. The 80/20 Rule
b. the idea that by doing 20% of work, 80% of the advantage of doing the entire job can be generated
c. a large majority of problems (80%) are produced by a few key causes (20%)
*d. All of the above
Answer: D - All of the above
49. The Key Components of Organizational Culture are:
a. Business Environment
b. Organizational Values
c. Cultural Role Models
d. Organizational rites, rituals, and customs
e. Cultural Transmitters
*f. All of the above
Answer: f. All of the above