Quality Assurance & Compliance Flashcards

Which metric is used by CMS as a hospital inpatient quality reporting measure for obstetric care related to elective deliveries?

Answer: PC-01: Elective delivery prior to 39 weeks gestation

CMS Perinatal Care measure PC-01 tracks the rate of non-medically indicated deliveries before 39 weeks, which was a key driver of the '39-week rule' initiative.

During a quality review, a hospital finds its episiotomy rate is 25%. According to current ACOG guidance, what does this suggest?

Answer: The rate is likely too high; restrictive use is recommended

ACOG recommends restrictive (not routine) episiotomy use; most quality benchmarks target rates below 5–12%, so 25% suggests overuse.

A quality officer reviews documentation of informed consent for a cesarean delivery performed emergently for fetal bradycardia. What is the most defensible approach when time does not permit full informed consent?

Answer: Document the emergent nature, the information provided, and the patient's response as completely as possible

In true emergencies, implied consent allows treatment, but thorough documentation of the clinical urgency and any communication with the patient is essential for compliance and liability.

What is the primary goal of the Alliance for Innovation on Maternal Health (AIM) program?

Answer: Reduce preventable maternal mortality and morbidity through evidence-based safety bundles

AIM, supported by ACOG and HRSA, develops and promotes safety bundles targeting the leading causes of maternal mortality, including hemorrhage and hypertension.

Which HIPAA provision most directly governs how obstetric records may be shared with a patient's family members who are present at delivery?

Answer: The Privacy Rule's allowance to share information with individuals involved in the patient's care if not objected to by the patient

HIPAA's Privacy Rule permits sharing relevant information with family members involved in care unless the patient has objected or it is inconsistent with their wishes.

A postpartum patient develops a surgical site infection after cesarean delivery. To comply with quality reporting, which surveillance definition is used to classify this infection?

Answer: CDC/NHSN surgical site infection (SSI) criteria

The CDC's National Healthcare Safety Network (NHSN) provides standardized definitions for surgical site infections used in mandatory quality reporting programs.

Which of the following best describes the function of a hospital's Peer Review Committee in obstetrics?

Answer: Confidentially evaluate clinical care to identify educational opportunities and improve quality

Peer review committees conduct protected, confidential case reviews to identify opportunities for improvement in individual and system-level clinical performance.