‫من ال يشكر هللا ‪...

‬ال يشكر العبد‬

‫شكر واجب للدكتور مصطفي القاضي‬
‫علي مجهوداتة في تجميع‬
‫مذكرات النجاح‪4 ،3،2،1‬‬
‫واستمرارا لمسيرتة ومجهودة ان شاء هللا‬
‫تم تجميع مذكرة النجاح ‪5‬‬
‫وشكر واجب لكل من ساهم ف‬
‫تجميع المادة العلمية‬
‫كل التوفيق للجميع ‪........‬‬
‫فريق عمل ديسمبر ‪2018‬‬
‫اللهم اجعل هذا العمل خالصا لوجه هللا‬
 ‫(‪)1‬‬
‫جدول فيه عدة اشياء وعمود مقابل كل شي للتارجت ‪.‬‬
‫جميع النقاط متعلقه ب ‪ .Patient safety‬السؤال كان‬
‫اية المفروض نبدأ نحسن حتى نصل ل ‪target‬‬

‫اإلجابة ‪:‬‬
‫‪Improve just culture‬‬
 ‫)‪(3‬‬
‫مؤسسه ترغب بعمل برنامج لتطوير موضوع عدد االخطاء‬
‫الطبيه بسبب االدويه‬

‫من ضمن الخيارات‬

‫‪BCMA‬‬
 (4)
Malcolm Baldrige A ward
Know the standard of Malcolm Baldrige
 (5)
Team has assigned to do a job, their productivity
was good and composition was good also
‫السؤال انهم كانو مستوفين كل الشروط والحاجه الناقصه هي‬
Satisfaction
 (6)
Leader of a project did a brain storming then he
put the ideas into thermic group. What is the tool
used after this?

1- Affinity Diagram
2- Ishikawa
(7)
 (8)
Which tool used to check process stability?

1- Run chart
2- Control Chart
 (9)
The best random sample to review doctors coding
file in a hospital is :
1- every Friday
2- The best one writing the file.
3 sample for one month
4- files from operating room
 ‫)‪(10‬‬
‫عامل بروسيس معينه بطريقة ‪ DMAIC‬ايه من االختيارات‬
‫التاليه يعتبر خطوة ‪Analysis‬‬
‫من ضمن الخيارات‬
‫‪Compare data‬‬
 (11)
Quality metrics characteristics?
1- Reliable, valid, feasible.
2- Reactive, repeatable, reliable
 (12)
Schedule (high, medium, low) and choose from
the schedule the best doctor champion to
improve communication in your organization:
1- interested in quality project
2- role model
3- working in same area
4- lovable
 (13)
Who is responsible for clinical quality measure?
1- CMS quality measure
2- Medicare and Medicaid
3- JCI
4- NQF
5- AHRQ
 )14(
6 Sigma looks for
1-perfection of 100%
2- not exceed 3.4 defect per million
3- less than 3.4 defect per million
4- perfection of 80%
 (15)
To review accreditation standard, should be done
:
1- every week
2- every month
3- quarterly
4- annually
 (16)
Quality management process assess effectiveness
of:

Intervention taken
 (17)
There is a problem , meeting done, after finishing
the initial steps of Schwert cycle what is next:

1- Analysis
2- Collect Data
 (18)
In root cause variation use :
1- control chart
2- Ishikawa Digram
(19)
To know the root cause of variance
1- Ishikawa Diagram
2- Schwerte Diagram
 (20)
External customer in managed care
‫كل الخيارات كانت لناس شغاله جوا التأمين االختيار‬
‫حيكون‬
‫المكان اللي بتتعاقد‬
1-Insurance commissioner ‫معاه‬
2-G.B
3-Departmental manager
4-Clinician
 ))21
Who make assignments between meeting?

Team member
 ‫)‪(22‬‬
‫فيه جراف واضح انه فيه شفت للداتا نعمل ايه‬

‫‪Analysis‬‬
 (23)
Which of the following reflect patient centered
care
1- survey
2- active involvement
 ‫)‪(24‬‬
‫معطي ‪ Pareto chart‬ومرتب االختيارات من االكبر الى‬
‫االصغر والسؤال أي وحده راح اشتغل عليها االول‬
‫الجواب اول وحده النها االهم‬
 )25(
In which stage the team put its goal?
Forming
(26)
Evaluation of team
Production, satisfaction, growth
 ‫(‪)27‬‬
‫سؤال عن ‪ survey‬فكرته انه لما نعمل السيرفي يجب ان‬
‫نشمل مين؟‬

‫‪Staff and physician‬‬

 )28(
PDCA done , after plan what we will do

DO ‫ندور على حاجه معناه‬

Answer: stimulate of hand washing
 )29(
Why one variance and SD are the most popular
measure of variability?
1- they are most stable and are found for more
advanced statistical analysis.
2- they are the most simple to calculate with large data
set.
3- they provide normally scaled data
4- non of the above
 )30(
Which of the following is true concerning definition
of SD?
1- difference between measured value and true value
2- difference between upper and lower control limit
3- standard distribution
4- lowest and highest value
 ‫(‪)31‬‬
‫ترتيب الخطوات للتحضير لالعتماد‬
‫‪1- leadership commitment‬‬
‫‪2- team readiness‬‬
‫‪3- Standard‬‬
‫ممكن يذكر بس رقم ‪ 3‬بدون‬
‫‪ 1‬و ‪ 2‬حنختارها عادي‬
‫مراحلة االعتماد تاخذ سنين وقبل بسنه على االقل نبدا نحضر لها واثناء‬
‫ذلك يتم تعليم الناس االستاندرد‬
 )32(
The team took an action and evaluate it to determine:

1- intervention taken
2- level of improvement
 (33)
Surgeon has 6.7% SSI in a specific procedure, while his
collgue has 3.3 %. The data reviewed by chair of the
department, the quality professional recommend:
1- Focus review
2- RCA
3- temporarily suspension the surgeon
4- stop the privilege of the doctor
 )34(
How to embedded the quality principles in daily
organization activity?

1- ad hoc team
2-Empower person to take decision
3-Appoint external consultant
 )35(
Annual review of QI program done to :

1- effectiveness of the program

2- identify mission statement.
3- review/ identify scope of service
 )36(
Resurgery for missed surgical gauze , in absence of
incident report, the only proof is:
1- Peer review.
2- Physician disclosure
3- patient complaint.
4- patient claim
‫دا سؤال اختلفو علي اجابتة‬
 (37)
. ‫انه فيه تيم اتعمل عشان يحسن‬PDCA ‫سؤال عن‬
Compliance with hand hygen.
Utilizing PDCA,the plan step has been
accomplished.They will use improvement using
shewhart cycle,what is the next step:
1-collect data
2-stimulate hand washing(proper hand hygen)
3-review the observation of staff in hand washing.
‫طبعا زميلتنا شاكه في االختيارات واختارت التاني‬
 (38)
:‫للحفظ‬‫معلومة‬
By empirical rule for normal distribution
68% of sample values are found in( +/- 1SD)
95% of sample values are found in( +/- 2SD)
99% of sample values are found in (+/- 3SD)
‫معلومة للحفظ‬
External customers are the people that pay
for and use the products or services in your
company offers.
 (39)
‫سؤال ان فيه جروب عايز يعمل‬
FMEA for improvement of patient discharge
Quality improvement team found many problems
related to patient and family.
: ‫وجمل كتيره وطويلة والسؤال‬
What is next step for quality improvement team?
1-consult family
2-observe patient discharge
3-calculate RPN
 (40)

What is the initial step in preparing of

accreditation of survey?
1-multidisceplinary standard education.
2-clinical improvement initiatives
 (41)
Surgeon almost always operates on the wrong body part, best act:
1-temporary suspension till the investigation end.
2-focused review of his cases.
‫السؤال دا بيتوقف‬
‫انة ف االخر عاوز يسال‬
‫عن اية الكوالتي مثال‬
Red rules for:
‫هتكون االجابة‬
1-patient safety
‫االولي ادق طبعا‬
2-safety of performance
‫سؤال ان اكتر من قسم قدموا افكار للكواليتي كاونسل للتحسين‬
:‫الكاونسل هتعمل ايه عشان تختار بينهم‬
prioritization
 (42)
‫سؤال فيه جدول فيه اكتر من منطقه للتحسن وحاطين تاثير كل وحده على‬
 Patient safety
‫االجابه هتكون اعلى وحده للتاثير على سالمة المرضى‬

A control chart has one point which is special

cause,other points are common cause.
‫االجابه‬
Need more monitor
 (43)
When health care organization is contracting with an outside provider for
service,the subcustomer must:
1-provide a representative to the quality council.
2-agree upon performance expectation.
3-have an active risk management program.
4-have copetitively priced service.
How to keep team focus during meeting:
1-send meeting agenda one day before.
2-keep facilitative objective.
‫انسب واحد‬
‫ه رغم ان‬
‫ ساعه‬48 ‫المفروض االجندة تتبعت قبلها ب‬
What action make team member focus on task during meeting:
1-review agenda &based on team input.
2-review original objective
 (44)
Question about prioritization matrix.
‫سؤال فيه جدول وفي االخر تجميعه للحاجات وفيه حاجتين لهم نفس الرقم‬
%90 ‫وكان‬
)‫(احنا طبعا بناخد الرقم االعلى‬
‫واالختيارات‬
:
1-wrong surgical site
2-central line infection
‫االولى اهم من التانبه اننا نشتغل عليها االول‬
 Nurse staff are complaining about time for patient transfer,histogram was
done on 59 days ,about 450 patient hours:
1-create fish bone
2-perform FMEA
3-prioritization matrix
4-using control chart ,listing statistical
 (45)
 Difference between research &CQI is that CQI differs in :
 1-analysis of data.
 2-designing of data.
 3-evaluation and communication of outcome.

 Difference between research&CQI:

 1-withdraw outcome
 2-data analysed&displayed
 3-identify RCA
 (46)
measure physician target direction
1 above
2 below
3 below
4 above
5 above
6 above

Organization is making physician profiling according to overall

results,and if there is no improvement in readmission
process,there will be financial penalities.
If>80% of measure above threshold (full met)
If 65-79% (met)
If 40-65 (partial)
 ‫الفكرة ان اربعه قيم من اصل ستة‬
‫‪Above‬‬
‫‪4/6 *100=67%‬‬
‫‪ANSWER:met crieteria‬‬
 (47)

Health plan is going to conduct study about HBA1C on

samples for behavioral patients.
But it is very difficult to access for these patients medical
records,?

1-to approach staff in behavioral health to tell them about

study &you will use medical record securely.
‫دا اللي فهمته زميلتنا اللي نقلت السؤال ولكن الجواب ماكانش حرفيا بس فيما معناه‬

2-develop a system to get specific information from related

individuals to be used in study for accessing in the file.
(48)
 49

After statistical control of process which

step should be done?

A-eliminate rework done.

B-increase monitoring with slow rate.
C-increase monitoring with high rate.
D-work on reducing variation.
 50
‫سؤال عن كنترول شارت ال‬patient fall
‫وكان فيه‬
2 special cause
One is above upper control limit and the
other is a shift more than 14 points.
A-process not stable and needs additional
monitoring.
B-patient fall complain decrease.
C-patient fall complaint increase.
D-the shift near to mean
 51
 The main responsibi lity of Q.I program is
to:
 A-establish target priorities
 B-obtain customer satisfaction data

 Annual review of Q.Iprogram is to :

 A-effectiveness of program
 B-identify mission statement
 C-review /identify scope of service
 52

Which of the following reflect medication

reconcilliation?
A-write the accurate medication list and compare
with other list"to identify dose ·name"
B-consult the medical physician to validate patient
medication list.
C-write the medication name,dose,frequency,route
in the medical record.
 53

CAHPS developed by CMS with help of

AHRQ
 54
Team evaluation

target score
Staff productivity 90% 85%
Team satisfaction 88% 90%
Team growth 85% 84%

Quality councel wants to evalute team improvement for

last year.
Which one you choose to improve?

‫حسب الجدول كانت اقل حاجه‬productivity

 55
‫سؤال طويل ان ال‬champion
‫كان حاطط درجات تتراوح بين‬none-low-high
Involved in process
Level of interest.
Ability to remobilize resources.
Commitment to leader insructionor to follow up
leader.
‫سؤال كان واضح وتقدر تحله بسهولةز‬
‫اختارت‬physician B
 56
Display data for last year monthly:
A-histogram.
B-Pareto

‫سؤال بيحكي عن دور منسق الجودة في تقليل االخطاء الدوائيه في المستشفى بعد ما‬
:‫جاءهم تقرير انها ارتفعت وكان من ضمن االختيارات‬
A-drill down data to identify a trend before making
recommendations.
B-conduct research to use BCMA.
C-assess staff competency for medication administration.
57
 58

‫كان فيه مريض بيعمل‬knee or hip replacement

‫وعاوزين يعملوا‬patient out come indicator;
A-clinical path way complications.
B-procedure complications
 59
target score
Time out 100% 100% above
Hand wash 80% 82% above
documentatio 90% 95% above
n
readmission 5% 3% below

‫دي داتا الطبيب هتتعرض على‬focused peer review

:‫االجابه هتكون‬
NO need because all within the target
 60

‫سؤال ان العمالء كانوا بيشتكوا من‬

Complicated medication process
‫واتكررت كلمات‬
Complicated process,over processing,long waiting time,waste in
dispensing.
‫السؤال ده كان طويل جدا وسيناريو طويل بس مضمونه ما سبق‬

Six sigma
Poke yoke
PDCA
lean
 61
‫كان فيه مشكله‬
‫ ان‬laboratory tecnechian
‫بيتعرضوا‬
‫كتير لشكات‬
‫ السرنجات في‬ER
‫وبعدما عملوا‬improvement
‫عاوزين يشوفوا‬
Results and initial data outcome.
‫هتروح لمين؟‬
A-all staff of hospital
B-staff of ER department
C-physician
D-customer
 62

Primary goal for benchmarking?

A-compare results and outcome with competitive
leaders.
B-assest the organization improving its out come.
63
 64

Which of the following needs cross functional

improvement or performance improvement team?
A-lab delayed results.
B-staff turn over
 65

‫سؤال ان كان فيه مشكله في احد االقسام‬

Medical error,the quality manager asked the physician to make
a list with all possiple intervention to solve this proplem,then
he collected interventions and classified them into groups.
How to display data?
A-histogram
B-affinity diagram
C-pic chart
D-control chart
 66
‫معلومة‬
If a question asks for proportion?
:‫ترتيب االجابة‬
Pie
Bar
Pareto
‫خلي بالك من نوع الداتا الن ممكن يلخبطك ويجيب االجابات دي كلها مع‬
‫بعض‬
If categorical data ………………..bar
If too much data…………….pareto
If continous data……………histogram
 67
Q:
Improvement project in radiology department ,they found no
opportunity for improvement :
A-review statisical methods .
B-review clinical process indicators
‫حلي بالك دي محتلفة عن ال‬KPI
‫بس هي االجابه الصح هنا‬
Q:
First task CQI process analysis to do :
A-identify proplem in the system.
B-evaluate the change effect on the system.

Organization do draft plan for New clinical service ,you should focus on :
A-assess evidence based protocol.
B-determine pt.safety and risk priorities.
68
 69
New accreditation,accreditation coordinator :
A-assess staff educational needs on standards
B-review standards

Org. is doing hand hygene program,

‫الحظوا ان مافيش التزام بيه وانه بيقل‬
A-random audit and onsite councelling &take feed back.
B-competency assessment.
70
 ‫‪71‬‬
‫‪factor‬‬ ‫‪benchmark‬‬ ‫‪year1‬‬ ‫‪year2‬‬ ‫‪year3‬‬
‫‪x‬‬ ‫‪50%‬‬ ‫‪20%‬‬ ‫‪30%‬‬ ‫‪40%‬‬

‫الفكرة‬
‫في السؤال ان كان فيه‬
‫‪3‬‬
‫فاكتور والبنش‬
‫مارك لهم‬
‫خالل‬
‫‪ 3‬سنوات هتالقي‬
‫ان االرقام‬
‫بتزيد‬
‫بس‬
‫ماوصلناش للبنش مارك‬
‫كان بيتكلم عن بينش مارك ف تالتة فاكتور وتالتة بتدي نجاتيف اوت كم‬

‫‪premature labor or death‬كانت عن‬

‫االرقام ف جدول تقريبية بس هتختار اقل فاكتور لية تاثير مقارنة من بينشن مارك‬