CHA Quality Improvement and Performance Management 3

Question 1

Which of the following is an 'outcome measure' in hospice quality reporting?

Accepted Answer

Family-reported satisfaction with end-of-life care on the CAHPS survey

Answer

The percentage of patients with a documented care plan

Answer

The rate of pain assessments completed at each nursing visit

Answer

The proportion of patients receiving a nursing visit within 48 hours of admission

Question 2

Which accreditation organization offers hospice-specific accreditation that can fulfill Medicare deemed-status requirements?

Accepted Answer

The Joint Commission (TJC)

Answer

URAC

Answer

CARF International

Answer

National Committee for Quality Assurance (NCQA)

Question 3

A hospice QAPI committee identifies that 40% of patients are not receiving a bereavement follow-up call within 13 months of death. The BEST next step is to:

Accepted Answer

Conduct a root cause analysis to identify barriers to timely bereavement follow-up

Answer

Retrain all clinical staff immediately without further analysis

Answer

Eliminate the bereavement program to reduce administrative costs

Answer

Report the finding to CMS without taking any internal corrective action

Question 4

The 'Triple Aim' framework in healthcare quality improvement focuses on improving:

Accepted Answer

Patient experience, population health, and per capita cost reduction

Answer

Cost reduction, staff satisfaction, and regulatory compliance

Answer

Clinical outcomes, documentation accuracy, and billing efficiency

Answer

Safety, effectiveness, and patient-centered care

Question 5

When a hospice organization's quality data is reported publicly through CMS's Care Compare website, this is an example of:

Accepted Answer

Public transparency and consumer accountability

Answer

Internal benchmarking activity

Answer

A regulatory enforcement action

Answer

Voluntary accreditation reporting

Question 6

Which method is used in quality improvement to distinguish between 'common cause' variation and 'special cause' variation in a process?

Accepted Answer

Statistical Process Control (SPC)

Answer

Standard deviation calculation only

Answer

Regression analysis

Answer

Confidence interval testing

Question 7

A hospice administrator reviews data showing a sudden spike in live discharge rates. According to CMS, an unusually high live discharge rate may trigger:

Accepted Answer

A medical review to assess whether admitted patients were appropriately certified as terminally ill

Answer

Automatic suspension of the Medicare hospice benefit

Answer

A mandatory merger with a competing hospice organization

Answer

Immediate revocation of the hospice operating license