MHA Quality and Performance Improvement 2 — Questions and Answers
Question 1: Which statistical tool displays the frequency distribution of defects or problems in descending order to prioritize improvement efforts?
- Control chart
- Pareto chart (Correct answer)
- Scatter diagram
- Histogram
Correct answer: Pareto chart
A Pareto chart ranks defects from most to least frequent, helping teams focus on the 20% of causes responsible for 80% of problems.
Question 2: The Donabedian model evaluates healthcare quality across three dimensions. Which combination is correct?
- Input, Process, Output
- Structure, Process, Outcome (Correct answer)
- Plan, Do, Study, Act
- Efficiency, Effectiveness, Equity
Correct answer: Structure, Process, Outcome
Avedis Donabedian's model assesses quality through structure (resources/settings), process (care delivery), and outcomes (patient results).
Question 3: A hospital notices its central line-associated bloodstream infection (CLABSI) rate has been consistently above the national benchmark for six months. Which improvement methodology is most appropriate for a structured, data-driven intervention?
- Nominal group technique
- Root cause analysis followed by PDSA cycles (Correct answer)
- Benchmarking alone
- Sentinel event review only
Correct answer: Root cause analysis followed by PDSA cycles
Root cause analysis identifies underlying causes of the persistent issue, and PDSA cycles allow iterative, evidence-based improvement interventions.
Question 4: Which accreditation body requires hospitals to conduct proactive risk assessments using Failure Mode and Effects Analysis (FMEA)?
- NCQA
- The Joint Commission (Correct answer)
- URAC
- CMS
Correct answer: The Joint Commission
The Joint Commission's National Patient Safety Goals include requirements for proactive risk assessment using FMEA to identify and prevent potential failures.
Question 5: In Lean methodology applied to healthcare, 'muda' refers to:
- Standardized work procedures
- Any waste or non-value-added activity (Correct answer)
- Patient flow mapping
- Error-proofing techniques
Correct answer: Any waste or non-value-added activity
Muda is the Japanese term for waste, encompassing non-value-added activities like unnecessary motion, waiting, overproduction, and defects.
Question 6: Which measure is a key component of the Triple Aim framework introduced by the Institute for Healthcare Improvement (IHI)?
- Reducing administrative overhead
- Improving population health, enhancing patient experience, and reducing per capita cost (Correct answer)
- Eliminating all medical errors
- Maximizing hospital revenue
Correct answer: Improving population health, enhancing patient experience, and reducing per capita cost
IHI's Triple Aim simultaneously pursues better health for populations, better care for individuals, and lower per capita costs.
Question 7: A run chart showing a process metric has eight consecutive data points all above the median. This pattern indicates:
- Random variation within normal limits
- A non-random signal suggesting a special cause (Correct answer)
- The process is in statistical control
- Measurement error in data collection
Correct answer: A non-random signal suggesting a special cause
Eight or more consecutive points on the same side of the median is a standard run chart rule indicating non-random (special cause) variation.
