CMSM Quality Improvement and Performance Metrics Flashcards

Which statistical tool used in quality improvement displays process variation over time and helps distinguish between common-cause and special-cause variation?

Answer: Control chart (Shewhart chart)

A control chart plots process data over time with upper and lower control limits, allowing managers to identify whether variation is random (common cause) or due to a specific identifiable factor (special cause).

Under the Hospital Value-Based Purchasing (VBP) Program, Medicare payment adjustments are based on a hospital's performance in which domains?

Answer: Clinical outcomes, safety, efficiency, and patient experience

The VBP Program evaluates hospitals on clinical outcomes, patient safety, efficiency/cost reduction, and patient experience (HCAHPS) to adjust Medicare payments up or down.

A healthcare manager implements a new hand hygiene protocol and tracks compliance weekly. The compliance rate increases steadily over 8 weeks. Which quality improvement tool best displays this trend?

Answer: Run chart

A run chart displays data points plotted over time in sequence, making it ideal for tracking whether a quality improvement intervention is producing a sustained trend.

What is the primary goal of Failure Mode and Effects Analysis (FMEA) in healthcare quality management?

Answer: To prospectively identify potential failure points in a process before harm occurs

FMEA is a proactive risk assessment tool that identifies potential failure modes in a process, evaluates their likelihood and impact, and prioritizes preventive actions before harm reaches a patient.

Which term describes the unintended harm caused to a patient by a medical intervention rather than by the underlying disease?

Answer: Iatrogenic injury

An iatrogenic injury is harm that results from medical treatment or the actions of healthcare providers rather than from the patient's underlying condition.

A CMSM is tasked with improving the facility's performance on the CMS Core Measures for surgical care. These measures are best described as:

Answer: Standardized evidence-based process and outcome measures used to assess quality of care for specific clinical conditions

CMS Core Measures are nationally standardized, evidence-based clinical quality measures that assess how consistently hospitals provide recommended care for specific conditions.