Quality Assurance & Improvement Flashcards
7 cards from real CMC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Quality Assurance & Improvement flashcards as text
A hospital's cardiac surgery program is a significant outlier on risk-adjusted mortality in the STS database. What is the most appropriate first step?
Answer: Conduct a detailed case review and internal audit to identify patterns contributing to excess mortality
When a significant outlier signal appears, the first step is a rigorous internal case review and audit to determine whether the variation reflects true quality gaps or data/coding issues.
Which quality framework uses 'Aim, Measures, Changes' as its three foundational questions?
Answer: The Model for Improvement (Institute for Healthcare Improvement)
The IHI Model for Improvement asks: What are we trying to accomplish? How will we know a change is an improvement? What changes can we make that will result in improvement?
In Six Sigma applied to cardiac care, what does a defect represent?
Answer: Any instance where a patient does not receive a specified evidence-based care element
In Six Sigma, a defect is defined as any failure to meet a customer (patient) requirement or specified standard of care, allowing mathematical quantification of process performance.
A cardiac ICU implements a checklist for daily goal-setting during rounds. This intervention targets which domain of the IOM's six aims for quality health care?
Answer: Equitable and Patient-Centered
Daily goal checklists during ICU rounds improve team communication about the patient's care plan, addressing patient-centered care and effectiveness of care delivery.
Which of the following is the primary purpose of a Failure Mode and Effects Analysis (FMEA) in cardiac quality management?
Answer: To prospectively identify potential process failures and their impact before they cause patient harm
FMEA is a proactive risk assessment tool that systematically identifies how a process might fail and prioritizes preventive actions based on severity, occurrence, and detectability.
According to ACC/AHA performance measures, which of the following is a Class I recommended discharge medication for patients hospitalized with reduced ejection fraction heart failure?
Answer: ACE inhibitor or ARB plus beta-blocker plus aldosterone antagonist (if appropriate)
Guideline-directed medical therapy for HFrEF at discharge includes ACE inhibitor/ARB (or ARNI), evidence-based beta-blocker, and aldosterone antagonist when tolerated and appropriate.
A QI coordinator notices that physician documentation of left ventricular ejection fraction is missing in 40% of heart failure discharges. Which QI tool would best display which physicians account for the majority of this gap?
Answer: Pareto chart
A Pareto chart ranks contributors by frequency, visually showing that roughly 80% of a problem often comes from 20% of causes — ideal for identifying the physicians responsible for most documentation gaps.