This analysis helps a healthcare organization to determine the types of disasters that they may face:
Hazard Vulnerability
Material Vulnerability
Material Safety data sheets
Hazards safety data sheets
Hazards Vulnerability

List three examples of workplace violence that must be addressed in the facilities’ security management plan.
Threatening behavior
Verbal/Written threats
Harassment
Verbal Abuse
Physical attacks
Employee to Employee Domestic Violence

List 6 critical areas that need to be addressed in a healthcare organization’s Emergency Operation Plan (EOP):
Communication
Resources/Assets
Safety/Security
Staff Responsibilities
Utilities Management
Patient Clinical/Support Activities

What are the four components in a fishbone diagram?
Manpower
Material
Methods
Machinery

What are the seven steps in a cycle of a PI team process?
Identify an improvement
Research/Define performance expectations
Design & redesign process/education
Implement process/education
Measure performance
Document/communicate findings
Analyze & compare internal/external data

Identify the steps in the process of change management?
Identify the losses
Acknowledge the losses
Provide information & ask for feedback
Mark the endings
Manage the transition
Clarify & reinforce the beginning
Celebrate the successes

Identify the five essential steps in Robust Process Improvement as defined by the Joint Commission.
Specify the improvement
Measure the size of the problem
Identify the specific cause(s)
Target interventions
Embedding interventions

What does the acronym RACE stand for?
Rescue
Activate
Confine
Extinguish

What is a QIO?
Private or Public agency contracted by the CMS to undertake examination & evaluation of the quality of healthcare rendered to beneficiaries of federal healthcare programs.

List the five possible categories JCAHO uses to report its decisions on accreditation.
Accredited
Accreditation with follow-up survey
Contingent accreditation
Preliminary denial of accreditation
Denial of accreditation

.) _____________ are performed to fulfill legal or licensure requirements.
Compulsory Review

This organization accredits managed care organizations, managed behavioral health organizations, and credentials verification for physician organizations.
National Committee for Quality Assurance

the stage of project team development in which team members work together easily is called:
Collaborative teamwork

Every Organization that provides services to Medicare and Medicaid beneficiaries must demonstrate its compliance with this set of standards:
Conditions of Participation

What is the process of meeting a prescribed set of standards or regulations to maintain active accreditation licensure, or certification called?
Compliance

Events that occur in a healthcare a organization that do not necessarily affect an outcome, but if were to recur, carry significant change of being a serious adverse event are called:
Near Misses

This program provides safe and RELIABLE equipment to patients, trains care providers in the safe and effective use of the equipment, and ensures that the equipment is maintained by qualified individuals.
Medical Equipment Management

This program is designed to manage the PHYSICAL and personal safeguard of the patients served, staff, and individuals coming to the organization:
Security Management

The stage of project team development in which conflicts emerge is called:
Competitiveness

The investigational technique that facilitates the identification of the various factors that contribute to a problem known as a fishbone diagram is also called a (n):
Cause-and-Effect Diagram

An unexpected occurrence involving death or serious physical or psychological injury, or the risk there of is a (n):
Sentinel Event

The forming stage of project team development in which team members tend to be very polite as they get to know one another is also called:
Cautious Affiliation

_____________ are conducted at the request of the healthcare facility seeking accreditation or certification.
Voluntary Review

.) How often should the Emergency Operation Plan be practiced?
2 times a year

A process surveyor’s use during the on site survey to analyze an organization’s systems is called:
Tracer Methodology

The act of granting a healthcare organization or an individual healthcare practitioner permission to provide services of a defined scope in a limited geographical area is called:
Licensure

This plan demonstrates the master planning and outlines the design of the safety functions for the organization:
Safety Management Plan

What is a Force-Field Analysis?
The analysis of the 3 phases of change:
Unfreezing, Changing, and Refreezing

Risk Management only involves the process of working through a malpractice suite. True or False?
False

The act of granting approval for a healthcare organization to provide services to a specific group of beneficiaries is called:
Certification

Analysis of a sentinel event from all aspects to identify how each contributed to the occurrence of the event and to develop new systems that will prevent recurrence is called:
Root-Cause-Analysis

In risk management terminology, and exposure to the chance of injury or financial loss and their associated liability is:
Risk

The investigational technique that facilitates the identification of the various factors that contribute to a problem known as a fishbone diagram IS ALSO called a (n):
Case-and-Effect Diagram

The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards is called:
Accreditation

This type of healthcare organization review is performed to fulfill legal or licensure requirements:
Compulsory Review

This phase in the project life cycle includes clear objectives, importance of the project and the expected outcome on the organization:
Planning

This type of healthcare organization review is conducted at the request of the healthcare facility seeking accreditation.
Voluntary Review

The change phase that is characterized by CONFUSION & CREATIVITY is called:
Transition

The change phase that is characterized by GRIEF and letting go is called:
Ending

The Risk managers principal tool for capturing the facts about potentially compensable events is the __________________.
Occurrence Report

The person who represents the rights and interests of another individual as though they were the persons own is referred to as a (n):
Patient Advocate

An opportunity to improve patient safety-related practices based on a condition or incident with potential for more serious consequence is a:
Near Miss

What does the acronym PASS stand for?
Pass
Aim
Squeeze
Spray

Occurrences involving liability for injury or property loss are called:
Potentially Compensable Events

This phase in the project life cycle is where the project shifts to become an Integrated part of organizational operations:
Closure

How often are healthcare facilities required to practice their emergency preparedness plan?
Twice

This acronym is used to train healthcare staff on the proper steps to USE a Fire Extinguisher:
PASS

This acronym is used to train healthcare staff the proper METHODS for Fire Responses
RACE

These documents give detailed information about a material, including any hazards associated with the material.
Material Safety Data Sheets

This private, not-for-profit organization is committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation progress.
Commission on Accreditation of Rehabilitation Facilities
[CARF]

This program is designed to ensure that electricity, water, sewer, and natural gas systems throughout the environment of care are planned and maintained safely and comfortably, that they are delivered without interruption, and mechanical systems operate safely.
Utilities Management

The risk manager’s principle tool for capturing the fact about potentially compensable events is the:
Occurrence Report

This phase in the project life cycle begins with determination that there is a gap between organization performance and expected outcomes:
Initiation

The change phase that is characterized by Acceptance & Hope for the Future is called:
Beginning

This organization has been responsible for accrediting healthcare organizations since the middle 1950’s and determines whether the organization is continually monitoring and improving the equality of care they provide.
Joint commission on Accreditation of Healthcare Organizations

This phase in the project life cycle is where installation of equipment or construction begins, and any policy or procedure manuals should be prepared for distribution.
Execution

An effective tool for PLANNING & TRACKING the implementation of a project is the:
Gnatt Chart

This planning technique provides a structure that requires the project team to IDENTIFY the Order & projected duration of activities Needed to COMPLETE a project
PERT Chart

Name two chapters from a typical Joint Commission Accreditation standards
Medical Staff
Nursing
Organization Leadership
Environment of care
Information management

EOP stand for?
Emergency Operation Plan

What does NIMS stand for?
National Incident Management System

What is the MSDS?
Documents that give Detailed Information about a Material, and any associated hazards. Must be available for employees at locations where hazardous materials are used.

The use of infection prevention and control measures to protect against possible exposure to infectious agents is called standard precautions Proper handwashing has been identified by the CDC as one of the single most important methods for preventing the spread …

Recent developments in the healthcare provision have necessitated the change of approach to health care provision. A shift has been in the quality management. In place of quality assurance, a new criterion has been set by the Joint Commission on …

Agency for Healthcare Research and Quality (AHRQ) The primary federal agency devoted to improving quality, safety, efficiency, and effectiveness of health care -authored the “Five Steps to Safer Healthcare” -facilitator of TeamStepps -recently issued “Making Health Care Safer 2”; identified …

Health Care organizations goal is to provide excellent care to all patients. Every day patients, members, and their families trust Health Care organizations to give them the very best medical care and services. These organizations are committed to honoring their …

The JCAHO’s Sentinel Event Policy requests a hospital voluntarily reporting a sentinel event to transmit it along with a root cause analysis, action plan and any other sentinel event-related information via an online form. Causal factors in an RCA should …

The Joint Commission on Accreditation of Healthcare Organizations is a private, not for profit organization established in 1951 to evaluate health care organizations that voluntarily seek accreditation. The Joint Commission evaluates and accredits more than 16,000 health care organizations in …

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