CBN Quality Assurance & Compliance 3 — Questions and Answers
Question 1: A bariatric center wants to compare its leak rate after sleeve gastrectomy with risk-adjusted national data. Which resource provides this benchmarking?
- State immunization registry
- CDC's BRFSS survey
- Hospital Consumer Assessment (HCAHPS) scores
- MBSAQIP semiannual report (Correct answer)
Correct answer: MBSAQIP semiannual report
MBSAQIP provides participating centers with risk-adjusted semiannual reports for benchmarking outcomes against national data.
Question 2: Which quality improvement model uses the sequence Plan-Do-Study-Act to test changes on a small scale?
- PDSA cycle (Correct answer)
- Failure Mode and Effects Analysis
- Root cause analysis
- SWOT analysis
Correct answer: PDSA cycle
The PDSA cycle is an iterative rapid-cycle improvement method for testing changes before broad implementation.
Question 3: A patient develops a wrong-site surgical error during a bariatric procedure. How is this event classified for reporting purposes?
- Near miss
- Sentinel event (Correct answer)
- Adverse drug event
- Benchmark deviation
Correct answer: Sentinel event
Wrong-site surgery is a sentinel event, a serious occurrence requiring immediate investigation and response.
Question 4: Which proactive tool should a bariatric team use to identify potential failure points in a new enhanced recovery (ERAS) protocol before implementing it?
- Root cause analysis
- Retrospective chart audit
- Failure Mode and Effects Analysis (FMEA) (Correct answer)
- Morbidity and mortality conference
Correct answer: Failure Mode and Effects Analysis (FMEA)
FMEA prospectively identifies where a process could fail and prioritizes risks before harm occurs.
Question 5: A bariatric nurse notices a colleague documenting vital signs that were never taken. What is the nurse's primary obligation?
- Correct the record quietly and say nothing
- Warn the colleague privately and take no further action
- Post about the concern on a professional forum
- Report the falsification through the facility's chain of command or incident reporting system (Correct answer)
Correct answer: Report the falsification through the facility's chain of command or incident reporting system
Falsification of records is fraud and a patient safety risk that must be reported through official channels.
Question 6: Which requirement must a hospital meet under CMS Conditions of Participation regarding quality for bariatric and all inpatient programs?
- Maintain an ongoing, data-driven Quality Assessment and Performance Improvement (QAPI) program (Correct answer)
- Publish surgeon-specific outcomes on its website
- Employ a full-time bariatrician
- Achieve zero readmissions annually
Correct answer: Maintain an ongoing, data-driven Quality Assessment and Performance Improvement (QAPI) program
CMS Conditions of Participation require hospitals to operate an effective, ongoing, hospital-wide QAPI program.
Question 7: In evaluating compliance with VTE prophylaxis orders on the bariatric unit, the nurse audits 30 charts and finds 24 compliant. What is the compliance rate?
- 70%
- 80% (Correct answer)
- 85%
- 90%
Correct answer: 80%
24 compliant charts divided by 30 audited charts equals 80%.
CBN Quality Assurance & Compliance 3
A bariatric center wants to compare its leak rate after sleeve gastrectomy with risk-adjusted national data.
Which resource provides this benchmarking?