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Chapter 21
Question 1
Which of the following organizations cannot perform accreditation and establish standards
for health care delivery in the United States?
1. The Joint Commission
2. Commission for Accreditation of Rehabilitation Facilities (CARF)
3. Nursing Administrative Quarterly (NAQ)
4. The National Committee for Quality Assurance (NCQA)
Correct Answer: 3
Rationale 1:
The Joint Commission performs accreditation and establishes standards for health care
delivery in the United States.
Rationale 2:
The Commission for Accreditation of Rehabilitation Facilities (CARF) performs
accreditation and establishes standards for health care delivery in the United States.
Rationale 3:
Nursing Administrative Quarterly (NAQ) is a peer-reviewed periodical aimed at nurse
executives.
Rationale 4:
The National Committee for Quality Assurance (NCQA) performs accreditation and
establishes standards for health care delivery in the United States.
Question 2
_____________determines whether providers receive funding. It also serves to enhance
provider image, instills confidence in the quality of services rendered, and attracts qualified
professionals. This process has direct implications for how documentation and information
systems are structured.
Correct Answer: Accreditation

Rationale:
Accreditation determines whether providers receive funding. It also serves to enhance
provider image, instills confidence in the quality of services rendered, and attracts qualified
professionals. This process has direct implications for how documentation and information
systems are structured. Several accrediting bodies exist.
Question 3
The typical participants involved in the preparations for accreditation and for the
accreditation process itself are which of the following?
1. Medical records personnel
2. Privacy and security officers
3. Quality assurance staff
4. Clinicians
5. Compliance officers
Correct Answer: 1,2,3,4,5
Rationale 1:
Medical records personnel play a crucial role in accreditation preparations and the
accreditation process. They ensure that medical records are complete, accurate, and compliant
with accreditation standards. They may also assist in organizing documentation and preparing
for site visits or audits.
Rationale 2:
Privacy and security officers are essential participants in accreditation preparations,
particularly regarding compliance with regulations such as HIPAA (Health Insurance
Portability and Accountability Act) and other privacy laws. They help ensure that patient
information is protected and that the organization's policies and procedures align with
accreditation standards related to privacy and security.
Rationale 3:
Quality assurance staff are directly involved in accreditation preparations and the
accreditation process. They monitor and assess the quality of care and services provided by

the organization, identify areas for improvement, and implement quality improvement
initiatives to meet accreditation standards and requirements.
Rationale 4:
Clinicians, including physicians, nurses, and other healthcare providers, are integral
participants in accreditation preparations and the accreditation process. They contribute
expertise in patient care delivery, clinical practices, and adherence to clinical guidelines and
standards. Their input is essential for demonstrating compliance with accreditation standards
related to clinical care and patient outcomes.
Rationale 5:
Compliance officers are responsible for ensuring that the organization adheres to relevant
laws, regulations, and accreditation standards. They play a key role in accreditation
preparations by overseeing compliance efforts, conducting audits or assessments, and
implementing corrective actions to address areas of non-compliance. Compliance officers
help ensure that the organization meets accreditation requirements related to regulatory
compliance and ethical standards.
Question 4
Which of the following best describes the role of the Joint Commission and information
system design?
1. The Joint Commission standards and goals shape organization practice and documentation,
thereby affecting information system documentation design.
2. The Joint Commission penalizes organizations when information standards are
substandard.
3. The Joint Commission designs the information systems.
4. The Joint Commission expects all entities comply with the standards of information
technology.
Correct Answer: 1
Rationale 1:
The role of the Joint Commission in information system design is primarily to shape
organizational practice and documentation through its standards and goals. The Joint

Commission establishes standards and requirements for healthcare organizations to ensure
quality and safety in patient care. These standards influence how organizations design and
implement their information systems, including documentation practices. Healthcare
organizations often align their information system documentation design with the
requirements and expectations set forth by the Joint Commission to demonstrate compliance
with accreditation standards.
Rationale 2:
While the Joint Commission does assess organizations' compliance with its standards,
including those related to information systems, it does not typically penalize organizations
solely based on substandard information standards. Penalties may result from broader noncompliance with accreditation standards, which could include deficiencies in information
systems, but the focus is on overall quality and safety in patient care rather than solely on
information standards.
Rationale 3:
The Joint Commission does not design information systems for healthcare organizations.
Instead, it sets standards and requirements that organizations must meet to demonstrate
compliance with accreditation standards. The design and implementation of information
systems are the responsibility of the healthcare organization itself, often guided by industry
best practices and regulatory requirements.
Rationale 4:
While the Joint Commission expects healthcare entities to comply with its standards,
including those related to information technology, its role is not solely focused on enforcing
compliance with information technology standards. The Joint Commission's standards cover
a wide range of areas related to patient care, safety, and quality improvement, and
information technology is just one component of overall organizational compliance.
Question 5
The Joint Commission standards and goals shape organization practice and documentation,
thereby affecting information system documentation design. The Joint Commission assesses
organizations for compliance with set standards. Which of the following statements are
considered standards?

1. Measures to protect information confidentiality, security, and integrity
2. Uniform definitions and methods for data capture as a means to facilitate data comparison
within and among health care institutions
3. Education on the principles of information management and training for system use. This
may include education about the transformation of data into information for subsequent use
in decision support and statistical analysis.
4. Accurate, timely transmission of information
5. Integration of clinical systems (i.e., pharmacy, nursing, laboratory, and radiology systems)
and nonclinical systems for ready availability of information
Correct Answer: 1,2,3,4,5
Rationale 1:
Measures to protect information confidentiality, security, and integrity are considered
standards set forth by the Joint Commission. These standards ensure that healthcare
organizations implement appropriate safeguards to protect patient information from
unauthorized access, disclosure, or alteration, thereby safeguarding patient privacy and
confidentiality.
Rationale 2:
Uniform definitions and methods for data capture to facilitate data comparison within and
among healthcare institutions are established standards by the Joint Commission.
Standardized data capture methods help ensure consistency and accuracy in the collection and
reporting of healthcare data, which is essential for quality improvement, research, and
benchmarking purposes.
Rationale 3:
Education on the principles of information management and training for system use,
including the transformation of data into information for decision support and statistical
analysis, is considered a standard by the Joint Commission. Ensuring that healthcare
personnel receive appropriate education and training on information management principles
and system use helps promote effective and efficient use of information technology in support
of patient care and organizational goals.

Rationale 4:
The accurate, timely transmission of information is a standard established by the Joint
Commission. This standard ensures that healthcare organizations implement processes and
systems to facilitate the timely exchange of information between healthcare providers,
departments, and external entities, supporting continuity of care and effective communication
among stakeholders.
Rationale 5:
The integration of clinical systems (e.g., pharmacy, nursing, laboratory, radiology) and
nonclinical systems to ensure the ready availability of information is a standard set forth by
the Joint Commission. Integrated systems allow for seamless sharing of information across
different healthcare domains, promoting efficiency, accuracy, and accessibility of data for
clinical decision-making and patient care coordination.
Question 6
Which of the following statements accurately states the impact that accreditation agencies
have on automated documentation in health care organizations?
1. The goal of information systems is to remain in compliance with accrediting bodies.
2. Standards mandate the use of information systems in all settings.
3. Quality and standards are synonymous.
4. Accrediting bodies offer assistance in choosing system functionality.
Correct Answer: 1
Rationale 1:
Accreditation agencies have a significant impact on automated documentation in healthcare
organizations by influencing the goal of information systems to remain in compliance with
accrediting bodies. Healthcare organizations often align their information systems and
documentation practices with the standards and requirements set forth by accreditation
agencies, such as The Joint Commission or the Centers for Medicare and Medicaid Services
(CMS). Compliance with accreditation standards is a key consideration in the design,
implementation, and maintenance of automated documentation systems to ensure that
organizations meet regulatory and quality requirements.

Rationale 2:
While accreditation standards may encourage or recommend the use of information systems
in healthcare settings, they do not necessarily mandate their use in all settings. The adoption
and implementation of information systems may be influenced by accreditation requirements,
but organizations have some flexibility in choosing the systems and technologies that best
meet their needs and goals.
Rationale 3:
Quality and standards are related concepts, but they are not synonymous. Accreditation
standards set by agencies like The Joint Commission or CMS define the criteria for quality
healthcare delivery and patient safety within healthcare organizations. Compliance with these
standards contributes to achieving and maintaining high-quality care, but quality
encompasses broader aspects beyond mere adherence to standards, including patient
outcomes, patient experience, and organizational performance.
Rationale 4:
Accrediting bodies may provide guidance or recommendations regarding system
functionality as part of their accreditation standards or guidance documents, but they do not
typically offer direct assistance in choosing system functionality to individual healthcare
organizations. The selection of system functionality is typically based on organizational
needs, requirements, and resources, often with input from stakeholders, including clinicians,
administrators, and IT professionals.
Question 7
The Magnet Recognition Program has teamed with another organization calling for a need for
transformational leadership that will change the way health care organizations function in the
future. The organization that has partnered with Magnet Recognition Program is which of the
following?
1. American Nurses Associations National Database of Nursing Quality Indicators (NDNQI)
2. TIGER Initiative
3. National Committee for Quality Assurance (NCQA)
4. The Joint Commission

Correct Answer: 2
Rationale 1:
The American Nurses Association's National Database of Nursing Quality Indicators
(NDNQI) focuses on measuring nursing-sensitive indicators to improve patient outcomes and
nursing practice. While NDNQI is an important initiative in nursing quality improvement, it
is not the organization that has partnered with the Magnet Recognition Program in calling for
transformational leadership.
Rationale 2:
The Technology Informatics Guiding Education Reform (TIGER) Initiative is the
organization that has partnered with the Magnet Recognition Program in calling for
transformational leadership to change the way healthcare organizations function in the future.
The TIGER Initiative aims to advance the integration of information technology into nursing
practice and education to improve patient care and outcomes. Its partnership with the Magnet
Recognition Program underscores the importance of leadership in driving technological
innovation and transformation in healthcare delivery.
Rationale 3:
The National Committee for Quality Assurance (NCQA) is a nonprofit organization that
focuses on improving healthcare quality through accreditation, certification, and
measurement. While the NCQA plays a significant role in healthcare quality improvement, it
is not the organization that has partnered with the Magnet Recognition Program in calling for
transformational leadership.
Rationale 4:
The Joint Commission is a widely recognized accrediting body that sets standards for
healthcare organizations to promote quality and safety in patient care. While the Joint
Commission collaborates with various stakeholders to advance healthcare quality, it is not the
organization that has partnered with the Magnet Recognition Program in calling for
transformational leadership specifically related to information technology integration and
organizational change.
Question 8

The Magnet Recognition Program, while not an accrediting body, is very much like an
accrediting body because it provides an assurance of quality and recognizes the essential role
that information systems play in supporting that process. Which of the following databases is
used to measure quality?
1. American Nurses Associations National Database of Nursing Quality Indicators (NDNQI)
2. Joint Commission Standards of Information Technology
3. National American Nurses standardized databases
4. American Medical Association Taxonomy
Correct Answer: 1
Rationale 1:
The American Nurses Association's National Database of Nursing Quality Indicators
(NDNQI) is a widely used database that measures nursing-sensitive indicators to assess and
improve the quality of nursing care and patient outcomes. It provides benchmarking data and
enables healthcare organizations to track their performance over time, identify areas for
improvement, and compare their outcomes with national averages and best practices. The
NDNQI is a valuable tool for promoting evidence-based practice and enhancing the quality of
nursing care.
Rationale 2:
The Joint Commission Standards of Information Technology are a set of guidelines and
requirements established by the Joint Commission to ensure the safe and effective use of
information technology in healthcare settings. While these standards address information
technology, they are not specifically used as a database to measure quality.
Rationale 3:
There is no specific entity known as the "National American Nurses standardized databases."
While there may be various databases and repositories used by nursing organizations to
collect and analyze data related to nursing practice and quality, there is no single standardized
database with this name.
Rationale 4:

The American Medical Association Taxonomy is a classification system used to categorize
and organize medical information and terminology. While it serves an important role in
medical coding and documentation, it is not a database used to measure quality in nursing
care.
Question 9
According to ANCC (2011), the Magnet Recognition Program recognizes health care
organizations that provide nursing excellence and provide a means for disseminating
successful nursing practices and strategies. How is information technology tied into this
process?
1. Informatics and information systems support the process by providing aggregate data
related to quality improvement.
2. Informatics and information systems support the process by providing individualized data
related to quality improvement.
3. Informatics and information systems support the process by providing aggregate data
related to combating Joint Commission sanctions.
4. Informatics and information systems support the process by providing encrypted data to
prevent breaches in security.
Correct Answer: 1
Rationale 1:
Informatics and information systems support the Magnet Recognition Program process by
providing aggregate data related to quality improvement. These systems collect, analyze, and
present data on nursing-sensitive indicators, patient outcomes, and nursing practice metrics.
By leveraging informatics and information technology, healthcare organizations can track
their performance, identify areas for improvement, and implement evidence-based practices
to achieve nursing excellence. Aggregate data allows organizations to benchmark their
performance against national standards and best practices, facilitating continuous quality
improvement efforts.
Rationale 2:

While informatics and information systems may provide individualized data for various
purposes within healthcare organizations, such as personalized patient care or clinical
decision support, the primary focus in the context of the Magnet Recognition Program is on
aggregate data related to quality improvement across the organization as a whole.
Rationale 3:
Informatics and information systems may play a role in addressing issues related to
compliance with regulatory standards, including those set forth by accrediting bodies like the
Joint Commission. However, combating Joint Commission sanctions is not the primary
purpose of informatics and information systems within the context of the Magnet Recognition
Program and nursing excellence.
Rationale 4:
While security measures, including encryption, are essential components of healthcare
informatics and information systems, their primary role in the context of the Magnet
Recognition Program is not specifically focused on preventing breaches in security. Instead,
informatics and information systems are utilized to support quality improvement initiatives
and the dissemination of successful nursing practices and strategies.

Test Bank for Handbook of Informatics for Nurses and Healthcare Professionals
Toni Lee Hebda, Patricia Czar, Theresa Calderone
9780132574952, 9780132959544, 9780134711010, 9780131512627, 9780130311023, 9780805373264, 9780135205433, 9780135043943

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