CHSA CHSA Quality Improvement & Regulatory Compliance 2 — Questions and Answers
Question 1: OSHA's Bloodborne Pathogens Standard (29 CFR 1910.1030) requires healthcare employers to provide hepatitis B vaccination to:
- All patients admitted for surgery
- Employees with occupational exposure to blood or other potentially infectious materials at no cost to the employee (Correct answer)
- Volunteers and contracted staff only
- Employees who request it and pay a co-pay
Correct answer: Employees with occupational exposure to blood or other potentially infectious materials at no cost to the employee
OSHA requires that hepatitis B vaccination be offered free of charge to all employees who have reasonably anticipated occupational exposure to bloodborne pathogens.
Question 2: The Leapfrog Group's hospital safety grade assesses performance in which key area?
- Hospital financial solvency
- Preventable medical errors, accidents, injuries, and infections (Correct answer)
- Physician board certification rates
- Patient appointment wait times
Correct answer: Preventable medical errors, accidents, injuries, and infections
The Leapfrog Group assigns A–F safety grades based on hospitals' performance in preventing medical errors and hospital-acquired conditions.
Question 3: Which quality framework categorizes healthcare quality into six domains: safe, effective, patient-centered, timely, efficient, and equitable?
- IOM Crossing the Quality Chasm framework (Correct answer)
- Malcolm Baldrige National Quality Award criteria
- Donabedian structure-process-outcome model
- Six Sigma DMAIC methodology
Correct answer: IOM Crossing the Quality Chasm framework
The IOM's 2001 'Crossing the Quality Chasm' report defined these six aims for improvement as the foundation for healthcare quality reform in the United States.
Question 4: In failure mode and effects analysis (FMEA), the Risk Priority Number (RPN) is calculated by multiplying:
- Frequency × Severity × Detectability (Correct answer)
- Cost × Duration × Staff count
- Probability × Impact × Urgency
- Occurrence × Harm × Reportability
Correct answer: Frequency × Severity × Detectability
RPN = Severity × Occurrence × Detectability; a higher RPN signals a failure mode that warrants priority corrective action.
Question 5: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores are publicly reported and affect hospital reimbursement under:
- The Hospital Readmissions Reduction Program
- The Hospital Value-Based Purchasing Program (Correct answer)
- The Inpatient Quality Reporting Program
- The Medicare Shared Savings Program
Correct answer: The Hospital Value-Based Purchasing Program
HCAHPS patient experience scores account for 25% of a hospital's Total Performance Score under the VBP Program, directly affecting Medicare payment adjustments.
Question 6: A healthcare organization's compliance program must include which element as specified in the OIG Compliance Program Guidance?
- An annual external financial audit by a Big-4 firm
- A mechanism for employees to report compliance concerns confidentially without fear of retaliation (Correct answer)
- A board-approved investment policy statement
- Mandatory arbitration agreements with all patients
Correct answer: A mechanism for employees to report compliance concerns confidentially without fear of retaliation
OIG guidance identifies a confidential reporting mechanism (hotline or similar) as one of the seven essential elements of an effective compliance program.
CHSA CHSA Quality Improvement & Regulatory Compliance 2
OSHA's Bloodborne Pathogens Standard (29 CFR 1910.1030) requires healthcare employers to provide hepatitis B vaccination to: