NEA-BC care delivery, models, ethics, technology

After a publicized medication error that seriously harmed a patient, the hospital is preparing a public statement. The family has not authorized release of any clinical information. Which content is MOST appropriate?

1. Acknowledge the event and describe system improvements without identifiers
   Acknowledging the event and describing the system improvements, without identifiers, is honest and still respects the family's privacy.
2. Describe the clinical timeline so the public understands exactly what occurred
   A detailed clinical timeline discloses the patient's health information without authorization.
3. State that privacy law prevents the hospital from commenting on the event
   Privacy law does not bar a hospital from acknowledging an event in general terms, so claiming it does reads as evasion.
4. Name the unit and shift involved to demonstrate accountability for the error
   Naming the unit and shift points the public toward identifiable staff and the patient, and accountability does not require it.

A CNO decides to fund the program that will produce the greatest total health benefit for the most patients, even though a small group will lose a specialized service. Which ethical approach guides this decision?

1. Respect for autonomy
   Respect for autonomy concerns individual self-determination, not distributing resources by aggregate benefit.
2. Virtue ethics
   Virtue ethics asks what a person of good character would do, not which option yields the greatest total benefit.
3. Rawlsian justice
   Rawlsian justice favors arrangements that help the worst-off, which argues against cutting a small group's service.
4. Utilitarianism
   Choosing the program with the greatest total benefit for the most people, even at a cost to a few, is utilitarian reasoning.

A Medicare patient develops a Stage 4 pressure injury during a hospital stay; it was not present on admission. How does this affect the hospital's Medicare inpatient payment for the stay?

1. The hospital receives a 1% cut on all Medicare payments
   The 1% cut comes from the separate HAC Reduction Program for worst-quartile hospitals, not from a single patient's stay.
2. The HAC cannot raise the DRG payment for the stay
   Under the present-on-admission rule, a hospital-acquired Stage 4 pressure injury cannot be used to raise the DRG payment for that stay.
3. Payment is unaffected unless the patient is readmitted
   Payment is affected for the stay itself, whether or not the patient is readmitted.
4. Medicare denies payment for the entire admission
   Medicare does not deny the whole admission; it only ignores the condition when assigning the DRG.

A five-hospital system's agency RN spending has tripled in two years. Which strategy most directly reduces premium labor cost while preserving staffing flexibility?

1. Freeze agency use and close beds when staffing is short
   Freezing agency use and closing beds cuts cost by cutting access and revenue, not by replacing premium labor.
2. Negotiate a lower bill rate with a single agency vendor
   A lower rate from one agency trims the price but keeps the system dependent on premium labor.
3. Require mandatory overtime before any agency request
   Mandatory overtime before any agency request burns out staff and drives more turnover, which feeds the agency need.
4. Build a cross-site internal float pool with differential pay
   Building a cross-site internal float pool with differential pay replaces agency premiums with the system's own flexible staff.

Incident reports show nurses floated to unfamiliar units are involved in a growing share of medication events, and floating is the top complaint in exit interviews. Which design change should the CNO make to the float system?

1. Rotate every nurse through every unit on an equal basis
   Rotating every nurse through every unit spreads unfamiliarity further and increases the risk.
2. Give floats tasks only, never a full patient assignment
   Restricting floats to tasks only wastes RN capacity and still leaves the competency mismatch unaddressed.
3. Cluster units into float groups with shared competencies
   Clustering units into float groups with shared competencies sends floats only where their skills transfer, cutting both errors and complaints.
4. Add a float pay differential and keep current float rules
   A float differential pays nurses more but leaves them in unfamiliar units where the medication events are happening.

A hospital pilots a virtual nursing model: experienced RNs working remotely handle admission histories, discharge education, and mentoring for bedside nurses on several units. What is the primary workforce aim of this model?

1. Remove the need for bedside RNs on the night shift
   Removing bedside RNs at night is unsafe, and virtual nursing is designed to support bedside nurses, not replace them.
2. Keep expert RNs while easing bedside RN workload
   Virtual nursing keeps experienced nurses in practice remotely while taking admission, discharge, and mentoring work off bedside RNs.
3. Replace unit LPNs with remote registered nurses
   Replacing LPNs with remote RNs is not the model's aim; the remote nurse supports the bedside team rather than taking over roles.
4. Lower the RN share of care hours on pilot units
   Lowering the RN share of care hours misreads virtual nursing as a substitution model rather than added RN support.

Presenting a proposal to reduce medical-surgical patient loads from six to five patients per RN, the CNO cites the landmark study by Aiken and colleagues (2002) on nurse staffing and surgical outcomes. What did that research find?

1. Each added patient per nurse raised mortality odds about 7%
   Aiken and colleagues found that each added patient per nurse raised the odds of 30-day mortality by about 7%.
2. Staffing ratios had no measurable effect on patient mortality
   Aiken's study found the opposite: patient-to-nurse ratios had a measurable effect on surgical mortality.
3. Mortality rose only when loads exceeded 10 patients per nurse
   There was no 10-patient threshold; risk rose with each added patient across the range studied.
4. Each added patient per nurse raised mortality odds about 1%
   1% understates the published finding, which was about 7% higher odds of death per added patient.

An AI telehealth triage tool flags 30% of patients as high-risk, and chart review shows that 40% of those flags are false positives. The vendor promises staffing savings from automated escalation. Which condition should the CNO require before expanding beyond the pilot?

1. Retained clinician override and set targets for false and missed flags
   Keeping clinician override and setting targets for both false and missed flags guards against automation bias and proves accuracy before expansion.
2. Projected staffing savings exceeding the tool's annual license cost
   Savings beating the license cost is a financial test that says nothing about whether the tool triages safely.
3. Vendor confirmation that the model was retrained to cut false positives
   A vendor's word that the model was retrained to cut false positives is not evidence that it performs well on this system's patients.
4. Mandatory escalation of all flags to reduce the risk of missed cases
   Escalating every flag would multiply the 40% false positives and deepen alert fatigue.

To protect the go-live date and budget of an EHR upgrade, the nurse executive defers several analytics features that clinicians had requested. The steering committee wants a measure that will show early whether the deferral is eroding the value the upgrade was meant to deliver. Which measure is most appropriate?

1. Percentage of project milestones completed on schedule after go-live
   Milestones completed on schedule track project delivery, not whether the deferred features are costing value.
2. Rate of clinician workarounds in workflows the deferred features support
   Workarounds in the workflows the deferred features would support show early, directly, whether clinicians are losing value.
3. Number of feature requests submitted by department leaders each quarter
   Counting feature requests measures demand, not lost value in the affected workflows.
4. Hospital-wide average length of stay versus the prior year
   Hospital-wide length of stay is a distant outcome with many causes and would not show the deferral's effect early.

CMS notifies the hospital that it is out of compliance with the Hospital Price Transparency rule. What must the hospital publicly post to comply?

1. An exact out-of-pocket bill for every service offered
   An exact out-of-pocket bill for every service is not what the rule requires the hospital to post.
2. Average cost per case for each DRG it treats
   The rule does not ask for average cost per DRG; it requires prices, including payer-specific negotiated rates.
3. List prices, provided only on patient request
   Prices must be public online, not given only when a patient asks for them.
4. A machine-readable file of charges and negotiated rates
   The Hospital Price Transparency rule requires a machine-readable file of standard charges, including payer-specific negotiated rates.

A hospital has only four transitional care nurses to reduce 30-day readmissions across 1,500 discharges a month. Which approach makes the best use of this limited resource?

1. Give every discharge the same follow-up call schedule
   Giving every discharge the same follow-up spreads four nurses too thin to help the patients most likely to return.
2. Focus on Medicare patients because of HRRP penalties
   Limiting the program to Medicare patients follows the penalty rather than the risk, and misses high-risk patients with other payers.
3. Target high-risk patients using a tool like LACE
   Using a risk tool such as LACE to target high-risk patients puts scarce transitional care where it prevents the most readmissions.
4. Focus only on patients with the longest stays
   Length of stay alone is a weak proxy for readmission risk compared with a validated multi-factor tool.

Skilled nursing facilities report that hospital discharge information often arrives days after their new residents do, leading to medication errors. Which approach best improves this care transition?

1. A structured electronic record sent to the SNF at discharge
   A structured electronic record sent to the SNF at discharge gets medications and plans to the receiving nurses before or with the patient.
2. A printed discharge summary carried by the patient as the only copy
   A printed discharge summary carried by the patient can be lost, and as the only copy it leaves the facility without a reliable record.
3. Read access for SNF staff to the hospital's entire EHR
   Opening the whole hospital EHR to SNF staff violates minimum-necessary access and still does not deliver a usable summary.
4. A nurse-to-nurse call to the SNF the next day
   A next-day call arrives after the first medication passes, the very gap that produces the errors.

The hospital's own count of 30-day heart failure readmissions does not match the rate in its CMS Hospital Readmissions Reduction Program report. What is the MOST likely reason?

1. CMS uses a 60-day window rather than a 30-day window
   HRRP uses a 30-day window, not a 60-day window.
2. CMS includes patients of every payer, not just Medicare
   HRRP measures Medicare fee-for-service patients, not patients of every payer.
3. CMS risk-standardizes and counts readmissions anywhere
   CMS risk-standardizes its rates and counts readmissions to any acute care hospital, which the hospital's own count usually misses.
4. CMS counts only planned readmissions to the same hospital
   CMS excludes planned readmissions and counts readmissions to any hospital, the reverse of this option.

A health system joins an accountable care organization in the Medicare Shared Savings Program. The board asks the CNO how the system will earn revenue under this arrangement beyond its usual fee-for-service payments. Which explanation is accurate?

1. It receives a fixed payment per member each month covering all of their care
   A fixed per-member monthly payment covering all care is capitation, not the shared-savings model.
2. It keeps a share of spending below its benchmark if quality standards are met
   The ACO keeps a share of the spending it holds below its benchmark, but only if it also meets the quality performance standard.
3. It earns a bonus for each added service billed above last year's volume
   Bonuses for added billed services reward volume, which is the opposite of an ACO's incentive.
4. It is paid one target price per surgical episode through 90 days after discharge
   One target price per episode through 90 days describes bundled payment, not an ACO.

A ransomware attack takes the EHR, medication dispensing, and lab interfaces offline at all five of a system's hospitals, and IT expects several days of recovery. What should the nurse executive do first?

1. Have IT restore the most recent backups before declaring an incident
   Restoring backups before declaring an incident skips containment, can reload infected systems, and leaves units without safe workflows in the meantime.
2. Wait for IT's recovery estimate before changing workflows
   Waiting for a recovery estimate leaves units improvising without downtime procedures during the most dangerous hours.
3. Authorize paying the ransom so the systems return quickly
   Paying a ransom is a legal and executive decision that federal agencies discourage, and it does nothing to keep care safe while systems are down.
4. Activate downtime procedures under the incident command structure
   Activating downtime procedures through incident command keeps care running safely on paper workflows and coordinates the response across all five hospitals.

A health system plans to expand virtual sitting, in which one technician watches several high-risk patients by video, to cut in-person sitter costs. Which safeguard matters most before the program expands?

1. A patient-to-technician ratio set as high as the software allows
   Pushing the patient-to-technician ratio to the software's limit trades safety for savings, because one technician can respond to only so many alerts at once.
2. Removal of bed alarms on units covered by video monitoring
   Removing bed alarms strips away a layer of protection; video monitoring adds to fall prevention rather than replacing it.
3. Criteria defining which patients still need an in-person sitter
   Clear criteria for who still needs an in-person sitter, based on whether a voice prompt and a called-in staff member would reach the patient in time, keep video monitoring for patients it can safely protect.
4. Replacement of in-person sitters on every unit at the same time
   Replacing every in-person sitter at once skips the patient selection and testing that make the model safe.