Question 1 (2 points)

Your internship preceptor asks, “I want to know if we have everything we need in our knowledge management system. Do you think you could start a review? You reply:

Question 1 options:

1) “Sure. Did you have any specific concerns?”

2) “Sure, I’d start with the Poudre Valley summary in my textbook from class.”

3) “Sure, that would be easy.”

4) “Gee, that would be tough, but I could try.”

Question 2 (1 point)

A young patient care assistant, Sally Jones, tells her nurse manager, “Dr. Baker asked me to meet him for a drink in his office after work. When I said no, he said, “I can make life a lot better for you.” The nurse manager should reply:

Question 2 options:

1) “He probably won’t ask you again, but let me know if he does.”

2) “I’ll speak to him about it if you want.”

3) “I’ll call Human Resources for you. They will want you to meet with a counselor. What you say will be confidential, and it won’t be used against you.”

4) “He does that, but he’s harmless. Tell him no, your boyfriend would be upset.”

Question 3 (1 point)

On rounds with the nursing supervisor, a nurse manager says, “We’ve had a lot of problems with laundry. Deliveries are coming too late for our bed changing, and it’s complicating our day.” What’s your best response?

Question 3 options:

1) Let the nursing supervisor take the lead, but be ready to jump in.

2) “Tell me more about that. Is this a recent problem? What time does the linen arrive, and what time do you need it?”

3) “Let’s form a PIT to look at that problem.”

4) “I’ll talk with the supply service and see that it’s fixed.”

Question 4 (2 points)

A new board member asks, “How do we know that the board is doing a good job?” You reply, “Good question! The answer isn’t easy, but there are several important indicators…”

Question 4 options:

1)“Strategic scorecard measures (exhibit 4.3) are good and improving.”

2) “The board works at its own self-evaluation.”

3) “Board members themselves are comfortable with process and results.”

4) “Conflicts of interest are in the record but also announced for relevant issues.”

5) All of the above

Question 5 (2 points)

Serena Smart, a leader of the African American community, accepts nomination to your governing board. Of course, senior leadership briefs her on how the board works. “Tell me more about the governance committee,” she says. “It’s a concept I haven’t encountered before.” Your reply begins:

Question 5 options:

1) “It’s worked well for us. It systematically monitors board activity, identifies OFIs, and applies continuous improvement to board activities.”

2) “It makes sure the board is scrupulous about conflict of interest.”

3) “It doesn’t really do much. It’s just a routine auditing function.”

4) “It surveys all the board members and solicits comments on both the quality of board decisions and the way the meetings are run.”

Question 6 (2 points)

As you start your internship at North Mississippi Health Services (NMHS), you know that they emphasize “service excellence” (see exhibit 2.2). Your preceptor asks, “Do you know why this is important?” Your best reply is, “It’s because…”

Question 6 options:

1) “…NMHS wants to delight every patient.”

2) “…it shows that, if all the parts of NMHS support each other, we will thrive.”

3) “…it’s ‘best practice.’ It’s what all the leaders are doing.”

4) “…it’s what NMHS’s competitors are doing.”

Question 7 (2 points)

In your internship, one of the younger people on the senior leadership team reflects, “You know that, when you’re a leader, any associate or patient comment should get a constructive response. When I started, I had a lot of trouble understanding what ‘constructive response’ means. What do you think that term means?” You reply, “I think it means…”

Question 7 options:

1) “…solving the problem raised if you can and promising to work on it if you can’t.”

2) “…explaining how the HCO has many problems, so it can only work on important ones.”

3) “…trying to make the asker happy.”

4) “…solving the problem raised if you can and accepting it as an OFI if you can’t.”

Question 8 (2 points)

At your interview to get employed as a manager at Atlanticare, the interviewer presses you. “You’ve said you admire Atlanticare’s worker empowerment. What do our leaders need to do to make sure worker enthusiasm actually improves mission achievement?” You answer: “Leaders need to make sure…”

Question 8 options:

1) “…there are clear goals, and support to achieve them.”

2) “…the workers are trained and equipped for what they do.”

3) “…we are servant leaders—we respond quickly and effectively to associate needs.”

4) All of the above

Question 9 (2 points)

In midyear, a first-line manager says to a rounding senior manager, “We’re not making a couple of our goals for this year.” What is the best response?

Question 9 options:

1) “We can bring in a team to help you out and make a 90-day plan for recovery. Can you and I meet with your manager, to plan what to do?”

2) “Well, you should push for benchmark anyway.”

3) “I’m sorry. Can you and I meet with your manager, to plan what to do?”

4) “Which one was it? If it’s not too far off, we can let it go.”

Question 10 (2 points)

All of the following statements about empowerment are true. Select the one most important to convey to associates.

Question 10 options:

1) Empowerment is a basic statement emphasizing equality between associates and deemphasizing rank.

2) Empowerment gives an associate the right to refuse an unclear or dangerous order.

3) Empowerment gives an associate the right to seek redress of unreasonable working conditions.

4) Empowerment gives an associate the ability to control his or her work situation in ways consistent with the mission and values.

Question 11 (1 point)

A trustee says, “You have said that the right diagnosis is critical. How does the HCO help its clinicians make good diagnoses?” You reply, “Our HCO does several things to support reaching the right diagnosis quickly on every patient, including…”

Question 11 options:

1) “…reliable clinical support services—lab, imaging, pharmacy, etc.”

2) “…reliable consultation from other specialists.”

3) “…IPOCs and a team approach.”

4) “…renewal of privileges based on clinical results.”


All of the above

Question 12 (2 points)

You are orienting a group of newly appointed first-line managers. The takeaway you want them to remember most is that the HCO’s not-for-profit governing board…

Question 12 options:

1) …holds the ultimate responsibility but believes the quality of care is a matter best left to the clinical practitioners.

2) …if necessary, will remove clinicians who cannot meet quality standards or who fail to uphold the HCO’s values.

3) …is legally responsible for ensuring the quality of care and must monitor quality of care to maintain accreditation.

4) …must also monitor and maintain financial performance.

Question 13 (2 points)

You are meeting a group of new associates joining your well-managed HCO. You show them the mission on the HCO’s website and say, “Our mission is very real to us. It’s…”

Question 13 options:

1) “…what we say we are to patients.”

2) “…a public declaration of intentions—why we’re here.”

3) “…a summary of shared objectives among competing stakeholders.”

4) “…a way to focus everybody’s best effort.”

Question 14 (2 points)

The board is reviewing the recommendations of the Clinical Staff Executive Committee, which has advised that a certain internist not be reappointed. Ms. Jones, a trustee, says, “Gee, he’s my physician!” A physician trustee says, “We have followed procedures in the bylaws related to impairment (substance abuse), and we have an obligation to protect our patients.” The CEO looks at the chair, who looks stunned. The CEO says:

Question 14 options:

1) Nothing. It’s the chair’s job, not hers.

2) “Gee, that’s unfortunate. We all need to remember that these discussions are strictly confidential.”

3) “Gee, that’s unfortunate. Ms. Jones may need to recuse herself from the discussion and vote. We all need to remember that these discussions are strictly confidential.”

4) “I think the board should accept the committee’s recommendation. The HCO has assistance programs that might help the doctor.”

Question 15 (2 points)

A few days after the systemwide planning retreat (May–Aug., #4, in exhibit 3.7), a first-line manager says to a rounding senior manager, “The PIC did not fund any of our OFIs. I don’t think we can improve any scorecard goals next year.” What is the best response?

Question 15 options:

1) “Gee, that’s disappointing,”

2) “Really? Let’s go over your OFIs.”

3) “Well, you should push for benchmark anyway.”

4) “I’m sorry. Can you and I meet with your manager, to plan what to do?”

Question 16 (1 point)

Pursuing the nurse’s complaint in the previous question, you look up the lab’s patient waiting time results and goals on its scorecard. It’s not there, but patient satisfaction is lower than nursing or most other CSS. You talk to the lab manager, who says that delays happen sometimes, and they’re not avoidable. He adds that the EHR records arrival and service times by patient.

Question 16 options:

1) You tell the lab manager that it is important, and that you will enter an OFI to improve lab scheduling.

2) You get a sample of patients from Knowledge Management and, with their help, find that the median wait is near 30 minutes. About one patient in five waits 45 minutes or longer. You report the data to the lab manager and the chief pathologist, who agree it’s an OFI.

3) You complete the actions described in option b and thank the nurse manager for identifying an OFI.

4) You complete the actions described in option b, except for reporting to the chief pathologist. The lab manager says again that it’s unimportant, that “all labs work that way.” You thank him and drop the matter.

Question 17 (2 points)

Why is a values statement important? Like the mission, many associates will assume that it’s window dressing. What does leadership need to say? “We’re serious about our values, and they are important because…”

Question 17 options:

1) “…they are a foundation for working together.”

2) “…they establish basic expectations about conduct.”

3) “…they create a more comfortable workplace.”

4) All of the above

Question 18 (2 points)

The board is reviewing the strategic scorecard, which is modeled on exhibit 3.4. A member asks, “There are three yellows—weren’t they there last month?” The COO, who is a guest at the meeting, gets a nod from the chair. He says.

Question 18 options:

1) “Yes, we’re working on them.”

2) “Yes, we’ve instituted 90-day plans for all three.”

3) “Yes, we’ve instituted 90-day plans for all three.” He then briefly summarizes progress and identifies any difficulty that might lead to year end failure.

4) “Yes, we’ve instituted 90-day plans for all three.” He then starts a lengthy explanation of what went wrong and why.

Question 19 (1 point)

A registered nurse on the HCO’s staff says, “The patient care assistant, Mary Smith, doesn’t seem to know what she’s doing. She takes forever. Yesterday, she took 30 minutes to change an empty bed.” The nurse’s immediate supervisor should reply:

Question 19 options:

1) “Nobody else has complained about her.”

2) “We have to put up with whoever the staffing office sends us.”

3) “I’ll observe her, and if you are right, I’ll report her and have her terminated.

4) “I will observe her and see if we can get some better results. Keep me posted.”

Question 20 (1 point)

Orienting a group of new patient care assistants, you explain that functional protocols or “standard work”…

Question 20 options:

1) “…help the HCO plan the equipment and supplies for each procedure.”

2) “…help us guard against errors and omissions. You can always access the protocol, and sometimes a video, on our computers.”

3) “…cut the cost of clinical procedures.”

4) “…must always be followed exactly.”

Question 21 (2 points)

A promising young associate, just promoted to first-line leadership, asks you, “Can you list a few skills I should think about and work on to become a really good transformational leader?” You begin your reply, “I think these are what you should emphasize.” Which skills do you include in your list?

Question 21 options:

1) Listening, responding, and reassuring

2) Explaining, encouraging, and rewarding

3) Creating a “blame-free” culture

4) Identifying paths to resolve issues

5) All of the above

Question 22 (2 points)

Responsive or “servant” leadership emphasizes listening. Explain to your BFF or your mom why listening by managers at all levels is important.

Question 22 options:

1) “It searches for team members’ concerns.”

2) “It shows team members that the HCO is serious about its mission.”

3) “It brings out OFIs that can be fixed.”

4) All of the above

Question 23 (2 points)

You are interviewing for an HCO CEO position, and a search committee member asks, “What kinds of reports should the board receive?” You reply, “The board should receive several items at every meeting.” Which of the following should be your list?

Question 23 options:

1) A “state of the HCO” report by the CEO; the strategic scorecard; any new accreditation, regulations, and legal actions

2) The strategic scorecard; any new accreditation, regulations, and legal actions; any changes in clinical staff appointments or bylaws

3) A “state of the HCO” report by the CEO; the strategic scorecard; any new accreditation actions; any changes in clinical staff appointments or bylaws

4) A “state of the HCO” report by the CEO; the strategic scorecard; any new accreditation, regulations, or legal actions; any changes in clinical staff appointments or bylaws

Question 24 (1 point)

There’s an undercurrent of dissatisfaction with the nursing scheduling system. Senior leadership decides it’s an OFI. You will staff a PIT. What’s your plan?

Question 24 options:

1) Use the senior management meeting minutes to describe the charge.

2) Ask the CNO how the charge should be worded.

3) Identify by unit the number of shifts where staffing was below standard, at standard, and above standard, and recover comments about scheduling in nursing personnel satisfaction surveys. Review this with the PIT’s chair before the first meeting.

4) Identify by unit the number of shifts where staffing was below standard, at standard, and above standard, and recover comments about scheduling in nursing personnel satisfaction surveys. Present this at the PIT’s first meeting.

Question 25 (1 point)

The local chapter of the Human Rights Campaign has asked for a speaker to describe how the HCO meets the association’s members’ needs. The HRC website rates HCOs according to its “Core Four” criteria: Patient Non-Discrimination, Equal Visitation, Employment Non-Discrimination, and Training in LGBT Patient-Centered Care. Your HCO, like many, is not rated, but the description says, “We did not find an LGBTQ-inclusive patient nondiscrimination policy.” The cause seems to be that your patient information addresses only “sexual orientation,” without adding “gender identity.” You start an amendment process, but it will require committee reviews lasting at least six months. What else do you do to prepare?

Question 25 options:

1) Check your clinical staff for clinicians who explicitly encourage LGBT patients in their practice and nondiscrimination in their policies and on their website. Ask them for advice on possible issues, and strong points in the HCO’s services.

2) Be prepared to state that the HCO agrees with the “Core Four” standards and will monitor progress toward these goals.

3) Consider how you will respond to specific complaints from the floor on discriminatory practices, end-of-life problems, parents’ rights, employment discrimination, and unjustifiable remarks.

4) All of the above

Question 26 (2 points)

A trustee says, “We’re asked to invest big sums of money based on forecasts of demand. How do we know those forecasts are accurate?” You reply, “That’s a great question. We use a sophisticated planning model that…” What’s your strongest point?

Question 26 options:

1) “…uses national incidence and prevalence data to tailor forecasts for specific diseases to our local population.”

2) “…has a good track record, not just here but among other clients.”

3) “…is implemented with a PIT that can consider our unique needs.”

4) “…is a critical component in sizing all parts of any HCO.”

Question 27 (2 points)

You’ve been working for two years at an HCO that works hard at maintaining an environment where all associates are empowered and motivated to meet their customers’ needs. A woman you knew in college moves to town. She’s now an experienced baccalaureate-prepared nurse, and she asks if she should apply to your HCO or a competitor. You say:

Question 27 options:

1) “I’ll check to see if we have any openings in your specialty.”

2) “Come here. It’s a great place to give care. I can introduce you to several nurses I know you’ll like.”

3) “Come here. I really like it.”

4) “It doesn’t matter much. All the HCOs in this city are good.”

Question 28 (1 point)

Your HCO has several clinical services, and a record of improvement on quality, patient satisfaction, and associate satisfaction in most of them. One service is lagging. Guidelines are not routinely used, and the clinicians argue over guidelines. Outcomes quality and patient satisfaction are the lowest in the HCO, although still better than national medians. Senior leadership debates, and decides…

Question 28 options:

1) …to form a PIT of clinicians in the service.

2) …to form a PIT of clinicians in the service, chaired by the chief of a similar service with top or near top scores on all the unit scorecard dimensions.

3) …to replace the service chief.

4) …to have the chief medical officer meet with the service chief and tell him that next year’s goals must move toward benchmark on all dimensions.

Question 29 (2 points)

Newcomers are often impressed at the complexity of the measurement system for individual work teams (see exhibits 3.3, 3.4, and 3.5). Explaining the measures to them, which of the following statements is least useful?

Question 29 options:

1) “Teams use the measures successfully. They set goals, achieve them, and often earn bonuses.”

2) “The measures are all carefully designed to be reliable and valid, and most of them are used by a large number of HCOs.”

3) “The measures used for a unit reflect things that the unit can actually control.”

4) “Many of the measures are reported by Medicare.”

Question 30 (2 points)

You want to describe evidence-based management (EBM) to a group of civic leaders. Which of the following would you start with?

Question 30 options:

1) “EBM has led us to formal process specification.”

2) “EBM relies heavily on performance measurement.”

3) “EBM replaces authority and opinion with fact.”

4) “EBM is the cheapest way to get the job done.”

Question 31 (2 points)

Orienting a group of new associates on the HCO’s values, you want them to take away all of the following points. Which one should you start with?

Question 31 options:

1) The values provide an ethical core for teamwork.

2) The values are consistent with many associates’ personal belief systems.

3) The values make the HCO a great place to give care.

4) Violating the values is unacceptable.

Question 32 (2 points)

Excellence is defined as “safe, effective, patient-centered, timely, efficient, and equitable.” A new associate asks you why “safe” is first. You reply:

Question 32 options:

1) “Because it has a long tradition. Hippocrates said ‘First, do no harm.’ 2,000 years ago. It’s also consistent with ‘Do unto others.’”

2) “Because people come to healthcare with troubles and limitations, and they trust us to help, not harm.”

3) “Because accrediting and regulatory stakeholders expect safety.”

4) All of the above

Question 33 (2 points)

Your HCO is part of a large not-for-profit system. You are recruiting a prominent local citizen to join the local governing board. “Let’s be candid,” the citizen says. “This is just an honorific post. All the real decisions are made by your corporate office.” “I’m glad you brought that up,” you reply. “Our system wants strong local input. The central office expects its local boards to initiate all local actions.” You continue:

Question 33 options:

1) “The central office is seeking understanding, and support by local community leaders is essential to our success.”

2) “The central office reviews local decisions but almost never interferes.”

3) “Our system wants local board members who will help us achieve our mission here in this community. It’s a working board, about a day a month of your time.”

4) “It’s almost the same as being a free-standing HCO.”

Question 34 (2 points)

You’re on a PIT that’s charged to improve your HCO’s strategic scorecard (exhibits 3.3 and 3.5), and a number of additions and deletions have been suggested. It’s clear that the PIT will need some criteria for deciding what to include. What will you emphasize when you explain the charge to them?

Question 34 options:

1) “Strategic measures should be HCO-wide. Measures that affect only one service line or one unit should generally be handled at those levels.”

2) “The underlying criterion is the sense of importance to mission.”

3) “We should have at least four HCO-wide measures for each of the five major categories in exhibit 3.5.”

4) “We might check what measures the Baldrige recipients are using.”

5) “We should use nationally standardized measures whenever possible.”

Question 35 (2 points)

You’re an intern at a high-performing HCO with a community health mission. Your preceptor says, “We’re about to start our annual review process. We need to put together the book for the board retreat. Here’s last year’s. Look it over. It was organized into ‘Customers/Market,’ ‘Med Staff and Associates,’ ‘Insurance Trends,’ and ‘Financials.’ I wonder if we can organize it better?” You think about it and look back at exhibit 3.2. It’s clear this isn’t an amateur effort, so you’ll start with something like, “Last year’s arrangement was certainly strong. Do you think we should add a section about…”

Question 35 options:

1) “…regulatory issues?”

2) “…community health needs?”

3) “…competitors’ plans?”

4) None of the above. Recommend leaving the sections the same.

Question 36 (2 points)

You’re on a team of senior managers preparing the annual planning data for the board retreat, step 1 of exhibit 3.7. One of the team members says, “Our quality and satisfaction will look good, but our costs don’t. I think we should say that the cost benchmarks are not realistic for places like us.” Pick the single best reply.

Question 36 options:

1) “Maybe, but we need to make clear what it is about our situation that might make the benchmarks unrealistic.”

2) “I think we’re obligated to report all the facts, maybe especially the unpleasant ones.”

3) “That’s just a rationalization, unless you can prove it. The board’s too smart to fall for it.”

4) Say nothing, and think about looking for a better job somewhere else.

Question 37 (2 points)

At many excellent HCOs, the CEO reviews the mission with all new hires. When you’re hired as a young manager, you attend with all the other hires. At the coffee break, you hear one new hire say, “The boss really put emphasis on the mission and stuff. I wonder if he really means it.” What is your best comment?

Question 37 options:

1) “He probably wouldn’t take time to talk with us if he didn’t think it was important.”

2) “Yeah. A lot places, it’s just window dressing.”

3) “I’m pretty sure he does. You could ask coworkers on your team.”

4) Say nothing. It’s not your concern.

Question 38 (1 point)

You’re explaining your HCO’s approach to a new attending physician. You want to be sure she understands that…

Question 38 options:

1) …the HCO web has evidence-based guidelines for most common causes of admission.

2) …the attending physician leads the care team that applies evidence-based guidelines to each patient’s needs.

3) …the number of times she departs from the guideline is reported to the service line’s quality committee.

4) …her notes and the other caregivers’ notes are integrated into the IPOC, which keeps everybody on track.

Question 39 (1 point)

You staff your HCO’s credentialing committee. At a meeting, you hear one older member grumble to another, “Credentialing these nurse practitioners is stupid. They are not as good as doctors, and they cut into our income.” What is your response?

Question 39 options:

1) Discuss the comment with the chair, encouraging the chair to take a few minutes to reinforce why the HCO needs and credentials nurse practitioners and other nonphysician LIPs.

2) Point out to the member that the board has approved LIP credentialing, and the HCO documents that they provide safe care.

3) At the next LIP vote, remind the committee of its obligation to evidence and fairness.

4) Suggest to the chair that the member be replaced.

5) Don’t do anything.

Question 40 (1 point)

A registered nurse on the HCO’s staff says, “These checklists are nothing but a pain. It takes time to enter them into the record, and they almost never help the patient.” His nursing manager should reply:

Question 40 options:

1) “Yes, they do take a few minutes, but they prevent really serious problems.”

2) “No, they save lives, and they take almost no time to complete.”

3) “Well, I don’t know. Last week I caught a drug allergy that could have been fatal.”

4) “You’re right, but accreditation requires them.”

Question 41 (2 points)

As fellow, you take your regular rotation on call for senior leadership. One evening, a trustee calls, very upset. He’s in your emergency department. His elderly mother has been in the ED for two hours, and nothing seems to be happening. He’d like your help to get her admitted. You go to ED, where the physician managing her case reports that she’s been examined and diagnosed, and will be admitted. She’s waiting for an appropriate inpatient bed. You thank the emergency physician, and together you explain to the trustee. You call the CEO to alert her. What else should you do?

Question 41 options:

1) Nothing.

2) Ask the trustee if there is anything that would make the family more comfortable.

3) Go to the floor where the patient will be admitted. Ask the floor charge nurse what the plan is and when a room will be available. Report that back to the trustee.

4) Go to the floor where the patient will be admitted. Ask the charge nurse to move as quickly as possible, explaining that the patient is a trustee’s mother.

Question 42 (2 points)

As an administrative resident at a Baldrige-winning healthcare system, you report to the COO. She says, “Let’s improve improvement. Where do we look for OFIs in our goal-setting and continuous improvement programs?” You reply, “Well, we could…”

Question 42 options:

1) “…check the strategic scorecard (exhibit 3.5). We are almost always green or blue, but we could see where the most yellows occur.”

2) “…ask each senior leader to nominate OFIs.”

3) “…review the record of 90-day plans. Where are they most likely to occur?”

4) “…check out the data from service recovery, unexpected event, and communication and resolution to see if there are indicators.”

5) All of the above

Question 43 (2 points)

You’re recruiting a physician to join your HCO. She says, “The story you tell, of what you call empowerment and continuous improvement, sounds good, and I contacted some people I know on your clinical staff. They say very complimentary things, that your HCO delivers, and they like practicing there. My concern is this: I’m making basically a lifetime commitment. How do I know the HCO will continue to be cutting-edge?” You begin, “Well, nobody can foresee the future, but…” What’s the best way to complete the sentence?

Question 43 options:

1) “…the HCO works hard to keep up with changing needs in our marketplace. We have an annual review to make sure we’re on track.”

2) “…our record is our best argument. We’ve got growing market share, delighted patients, and enthusiastic associates.”

3) “…all of us have a stake in keeping the HCO a leader. If we work together, we can win.”

4) “…we do everything the textbook says to stay current.”

Question 44 (1 point)

Your aunt Sarah, who lives in another city, is selecting a care provider. She says, “I’ve looked up two cardiologists in my insurance panel. Each is privileged at a different hospital. Does the hospital make any difference?” You reply: “It might make a difference. I’ll look up the record of each on…”

Question 44 options:

1) “If both hospitals are accredited, you could go to the closest one.”

2) “If you go to one that takes quality seriously, you’ll know not only that your cardiologist is competent but also that other specialists you might need are competent.”

3) “You really should go to a general internist; you might not need a cardiologist.”

4) “I can’t help you much more. I’ve never dealt with any of the hospitals in your city.”

Question 45 (2 points)

A curious associate asks, “Who owns our HCO?” It’s a nonreligious not-for-profit that is a subsidiary of a larger system with many HCOs (like Sharp, Henry Ford, or Sutter Health). You respond, “The individual HCOs are owned by…”

Question 45 options:

1)“…the communities they serve.”

2) “… our overall corporate system.”

3) “…the trustees of our overall corporate system.”

4) “…the trustees of each local HCO.”

Question 46 (1 point)

As fellow at an HCO like Charleston Area Medical Center, you spend a month with the chief medical officer. She says, “There’s a big rhubarb in anesthesia. The anesthesiologists limited the nurse anesthetists (CRNAs) from certain procedures, and now the CRNAs are threatening to strike. I think there are attitude problems, too; some of the older anesthesiologists are quick with the put-downs. What do you think I should do?” You respond, “Let’s form a PIT.” You go on:

Question 46 options:

1) “We need to point out that the HCO’s policy is to follow published guidelines.”

2) “The charge should be addressing expressed concerns of the CRNAs.”

3) “The charge should be resolving the argument over privileges.”

4) “We should collect some data on CRNA safety. Is their record as good as the anesthesiologists?”

Question 47 (2 points)

Interviewing for a position at Sharp Healthcare, you are asked, “Are you familiar with our 12 Behavior Standards? We want all our managers, even our beginners, to exemplify them. Do you think you can do that?” Which is the best response?

Question 47 options:

1) “Yes, of course.”

2) “Yes, of course. How did you generate the list?”

3) “Yes, of course. I don’t remember them in detail, but I know they’ve been important at Sharp.”

4) “Yes, of course. I studied them with my class at __________. I especially like ‘All For One, One For All’” (or any other one that you remember).

Question 48 (2 points)

Your preceptor says, “When I started out, it was ‘command and control.’ Somebody, usually a doctor, gave an order, and everybody was supposed to jump. Now it’s ‘encourage, reward, and celebrate.’ Does that work as well?” You respond:

Question 48 options:

1) “Yes, but it’s really hard to get it set up right.”

2) “It can, when it’s combined with measures, benchmarks, and continuous improvement.”

3) “No, sometimes you still need ‘command and control.’”

4) “Actually, when it’s combined with benchmarks and continuous improvement, it works better than command and control.”

Question 49 (1 point)

In several questions in this quiz, a nurse manager encounters realistic situations and can make some serious errors. How does an excellent HCO make sure he answers correctly?

Question 49 options:

1) It trains him.

2) It only hires experience managers.

3) It trains him and gives him a coach with more seniority.

4) It trains him, gives him a coach with more seniority, and rounds so that he and his staff can approach senior management directly.

Question 50 (2 points)

WMHO defines stakeholders as having “a direct interest in an organization’s success.” A PIT studying a not-for-profit HCO’s mission wants to know, “Are some stakeholders more important than others? Can we give priority to the interests of some group of stakeholders at the expense of others shown in exhibit 1.3?” You reply:

Question 50 options:

1) “Patients come first, but any unhappy stakeholder group will hamper the ability to deliver SEPTEE care.”

2) “If we meet our existing contracts, we can give priority to any stakeholder group.”

3) “They all have equal rights. If their ‘direct interests’ are not met, any stakeholder group can close us down.”

4) “Giving any group except patients a priority might be illegal.”

Question 51 (1 point)

A religious leader on your governing board suggests that low income is an important cause of disease and preventable use of HCO services. She proposes that the HCO lead the community by raising pay levels for its lowest earners by about 50 percent, and require its contractors to do the same. “Getting everybody in our community a living wage is a first step to health,” she says. Senior leadership is asked to report on the proposal.

Question 51 options:

1) “Slow walk” the response. Many businesses in town will resent the action, and there’s a lot to do implementing the population health mission.

2) Prepare a report documenting the impact on the HCO. The COO’s initial estimate is that, if revenue remains constant, the proposal would seriously erode funds for new and replacement capital. Present the findings without recommendation.

3) Prepare a report documenting the impact on the HCO. Note that, if implemented community-wide, increased labor costs would generate higher insurance premiums and lower total employment.

4) Prepare a report documenting the impact on the HCO. Recommend that the HCO promote a  community-wide program to increase income of low-wage workers, noting that the concept has promise, but also complexity and risk.

Question 52 (2 points)

A colleague at the HCO where you are a manager says, “Rounding takes a lot of time. I wonder why the senior leadership team wants us to spend five hours a week at it.” You think before you answer, and conclude that your strongest response is:

Question 52 options:

1) “Rounding helps managers understand what workers face.”

2) “Rounding encourages workers and first-line managers to raise questions and get answers.”

3) “Rounding opens opportunities to report problems with values (e.g., harassment, incivility, fraud, lying, theft) that might otherwise not be recognized.”

4) “Rounding supplements the quantitative data (turnover, absenteeism, surveys) with examples and detail.”

Question 53 (2 points)

In your HCO fellowship, you meet on a biweekly basis with the CEO. Today, she says, “I’m off to a meeting of the board nominating/governance committee. It will be a while before you get to go to one; they are very confidential. But tell me what I should be looking for at the meeting. How do I monitor the committee’s functioning?” You reply:

Question 53 options:

1) “Recruiting appropriate candidates is critical. If we get good candidates, that’s all we need.”

2) “The committee monitors itself, the strategic scorecard, and overall board effectiveness. That and good candidates should be enough.”

3) “I think I’d work off exhibit 4.3. Could we make a checklist of how well the board is doing on the ten items and use it as a survey?”

4) “The strategic scorecard is all that really matters. If we’re moving to benchmark, the board’s doing okay.”

Question 54 (1 point)

A clinical staff member says he thinks a guideline should be changed. The nurse manager should reply:

Question 54 options:

1) “You’ll have to take that up with the service chief.”

2) “Why? It seems to work pretty well.”

3) “Why? You’ll have to explain why to the service line chief, but maybe I can help.”

4) “Yeah, but the red tape is awful. It takes months to change anything.”

Question 55 (1 point)

On rounds, the OR supervisor motions you into her office and closes the door. “Yesterday, Dr. Smith showed up late for his afternoon case. I don’t know how to put it. The operation went okay, but he dropped some instruments on the floor, and the assistant did a lot of the work. But afterwards, the scrub nurse said she smelled alcohol on his breath.” You reply: “Thanks for bringing this up. I know it’s tough…”

Question 55 options:

1) “Did you file an unexpected event report?”

2) “Does Dr. Smith have any cases scheduled?”

3) “I think the chair of the Department of Surgery needs to be notified as soon as possible. Let’s call her right now.”

4) “What’s Dr. Smith’s record? Has this ever happened before?”

5) “We have an LIP impairment committee. I’ll ask the committee chair to talk to Dr. Smith.”

Question 56 (2 points)

You are addressing a group of newly hired associates. You will mention all of the following points to help them understand the HCO’s continuous improvement philosophy. What’s the most critical takeaway?

Question 56 options:

1) “We deliver on our promises—that is, we set realistic goals and meet them.”

2) “Leadership is here to help. Always speak up when you have concerns; always expect an honest answer.”

3) “We use PITs to improve our work processes. You may be asked to serve on one.”

4) “We rely on measures whenever we can. Your unit scorecard is important.”

Question 57 (1 point)

Meeting with a small group of newly hired therapists, you tell them the HCO is committed to excellence and gets there through continuous improvement, with measures, benchmarks, OFIs, PITs, and goals. One of the therapists asks, “What does that mean for therapists?” You reply:

Question 57 options:

1) “It means doing your best job with every patient, helping meet your team’s scorecard goals, following protocols, and speaking up when you see an OFI.”

2) “It means being prompt, doing what the doctor ordered, and being considerate of your teammates.”

3) “It means helping meet your team’s scorecard goals, following protocols, and doing what your team leader asks.”

4) “It means the HCO wants on-time, 100% correct response to every patient’s orders.”

Question 58 (2 points)

You’re part of the strategy team at a small NFP HCO with a strong patient-care mission. The question of joining are large system comes up. One of the senior managers asks you, “Just in general, why might we do that?” You reply, “I think the most important reason might be…”

Question 58 options:

1) “The system will help us do a better job of supporting patient care.”

2) “The system will help us lower costs.”

3) “The system will allow us to get higher prices from insurance companies.”

4) “Managers in the system earn bigger bonuses than we do.”

Question 59 (2 points)

As a fellow in a high-performing HCO, you often take time for coffee with the house officers and younger nurses. One of them comments, “Our electronic health record (EHR) is a pain. It’s too slow, too complicated.” When you reply, “Really?,” she says, “It’s hard to find critical parts of the history. I was looking for patient advocate and advance directives yesterday, and it took forever.” Which of the following should start your reply?

Question 59 options:

1) “This is a problem everywhere. The EHR just isn’t as easy as everybody thought.”

2) “That’s discouraging! Were you able to find it and work out a plan for the patient?”

3) “That sounds like an OFI. I’ll see what Info Services says and get back to you.”

4) “Do you have problems with other parts of the history?”

Question 60 (1 point)

The board is considering changing from an excellence-in-care mission to a population health mission. One member says, “Why should we do this? We will be jack of all trades, master of none.” The CEO should say: “Our scorecard shows we are masters of acute care…”

Question 60 options:

1) “Population health will help control health insurance costs. We think we can move toward it without endangering our care.”

2) “Our excellence in care is not threatened by population health. They are two different things.”

3) “That’s right. Population health is a hopeless job.”

4) “Population health will help control health insurance costs, and Medicare is pushing us that way.”

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