CHSA Quality Improvement & Regulatory Compliance Flashcards
6 cards from real CHSA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CHSA Quality Improvement & Regulatory Compliance flashcards as text
Which CMS program penalizes hospitals with excess readmissions within 30 days for conditions such as heart failure, pneumonia, and hip/knee replacement?
Answer: Hospital Readmissions Reduction Program (HRRP)
The HRRP reduces Medicare payments to hospitals whose risk-adjusted 30-day readmission rates exceed the national average for targeted conditions.
The Hospital-Acquired Condition Reduction Program (HACRP) penalizes hospitals that rank in which quartile for hospital-acquired infections and patient safety indicators?
Answer: Bottom-performing 25% (highest HAC rates)
HACRP reduces Medicare payments by 1% for hospitals whose Total HAC Score places them in the worst-performing 25% nationally.
Under HIPAA's Security Rule, a covered entity must conduct which foundational activity to protect electronic protected health information (ePHI)?
Answer: An accurate and thorough risk analysis of potential vulnerabilities to ePHI
The HIPAA Security Rule requires covered entities to conduct an ongoing, organization-wide risk analysis to identify and mitigate threats to the confidentiality, integrity, and availability of ePHI.
A healthcare quality manager wants to determine if a process is statistically stable over time. Which tool is most appropriate?
Answer: Statistical Process Control (SPC) / run chart
SPC charts plot performance data over time against statistically derived control limits to distinguish common cause variation from special cause signals requiring investigation.
The Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) is used by hospitals primarily to:
Answer: Track and benchmark healthcare-associated infection (HAI) rates
NHSN is the nation's most widely used HAI tracking system; hospitals submit infection data that CMS uses for quality reporting and VBP program calculations.
Which accreditation standard requires hospitals to maintain a formal Utilization Management (UM) program to review the appropriateness of admissions and lengths of stay?
Answer: CMS Conditions of Participation (CoPs) for hospitals
CMS CoPs require hospitals to have a UM committee and program that reviews admissions, continued stays, and professional services to ensure medical necessity and appropriate resource use.