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 accrediting body evaluates US hospitals and healthcare organizations for quality and patient safety standards, granting 'deemed status' for Medicare participation?
Answer: The Joint Commission (TJC)
The Joint Commission accredits healthcare organizations and its accreditation grants CMS deemed status, satisfying Medicare Conditions of Participation.
In quality improvement, a 'root cause analysis' (RCA) is performed primarily to:
Answer: Identify the underlying system and process failures that led to an adverse event
RCA is a structured retrospective process that looks beyond individual errors to identify systemic causes and prevent recurrence.
The Plan-Do-Study-Act (PDSA) cycle is a widely used healthcare quality improvement model. What happens in the 'Study' phase?
Answer: The results of the change are analyzed to see if improvement occurred
In the Study phase, data collected during the Do phase is analyzed to determine whether the tested change produced the intended improvement.
Which CMS program adjusts Medicare payments to hospitals based on performance on quality measures, including patient experience and outcomes?
Answer: Hospital Value-Based Purchasing (VBP) Program
The Hospital VBP Program withholds a portion of base DRG payments and redistributes them based on hospitals' performance scores on safety, clinical care, efficiency, and patient experience.
A healthcare administrator wants to reduce central line-associated bloodstream infections (CLABSIs). Which evidence-based tool provides a standardized checklist for central line insertion?
Answer: Institute for Healthcare Improvement (IHI) Central Line Bundle
The IHI Central Line Bundle is a set of evidence-based practices—including hand hygiene, chlorhexidine skin antisepsis, and full-barrier precautions—that when implemented together significantly reduce CLABSI rates.
Under CMS Conditions of Participation, hospitals must report which type of adverse events to their state health department?
Answer: Serious reportable events (SREs), also called 'never events'
Most states require mandatory reporting of serious reportable events (never events), such as wrong-site surgery or foreign object retained after surgery, to the state health department.