CPCS Peer Review & Performance Improvement 3 — Questions and Answers
Question 1: Ongoing Professional Practice Evaluation (OPPE) data should be reviewed at minimum how frequently according to The Joint Commission standards?
- Monthly
- Every 6 months (Correct answer)
- Annually
- Every 2 years
Correct answer: Every 6 months
TJC requires OPPE data to be reviewed at least every six months as part of the reappointment cycle.
Question 2: Which of the six general competencies established by ACGME/ABMS is most directly measured by peer review of clinical decision-making?
- Interpersonal and Communication Skills
- Medical Knowledge
- Patient Care (Correct answer)
- Systems-Based Practice
Correct answer: Patient Care
Patient Care competency encompasses clinical decision-making, procedures, and treatment appropriateness—the core focus of most peer review.
Question 3: A performance improvement team uses a fishbone (Ishikawa) diagram. What is its primary function?
- Display trend data over time
- Identify root causes of a problem by category (Correct answer)
- Rank improvement priorities by frequency
- Map patient flow through a clinical process
Correct answer: Identify root causes of a problem by category
A fishbone diagram organizes potential root causes into categories (people, process, equipment, etc.) to facilitate systematic problem analysis.
Question 4: What distinguishes a sentinel event from a near-miss in quality management?
- A sentinel event involves a financial loss; a near-miss does not
- A sentinel event results in death or serious harm; a near-miss is caught before patient impact (Correct answer)
- A sentinel event requires OPPE review; a near-miss requires FPPE
- A sentinel event is reportable to NPDB; a near-miss is not
Correct answer: A sentinel event results in death or serious harm; a near-miss is caught before patient impact
A sentinel event is an unexpected occurrence resulting in death or serious physical or psychological harm, while a near-miss is an event that could have caused harm but did not reach the patient.
Question 5: Which tool is best suited for identifying the most frequent causes of a quality problem to prioritize improvement efforts?
- Run chart
- Pareto chart (Correct answer)
- Scatter diagram
- Control chart
Correct answer: Pareto chart
A Pareto chart ranks causes by frequency or impact, reflecting the 80/20 rule to help teams focus on the vital few issues causing most problems.
Question 6: Under HCQIA, which action by a peer review body would DISQUALIFY it from receiving immunity protections?
- Reviewing a physician's hospital-specific outcomes data
- Acting with a reasonable belief that the action furthers quality care
- Failing to provide the physician with adequate notice of the hearing (Correct answer)
- Querying the NPDB before reappointment
Correct answer: Failing to provide the physician with adequate notice of the hearing
HCQIA immunity requires that practitioners receive adequate notice and hearing opportunity; failure to provide due process can strip immunity protection.
Question 7: A credentialing specialist is assembling the peer review file for a physician's reappointment. Which document is LEAST relevant to include?
- OPPE summary from the past 24 months
- Patient satisfaction scores linked to the physician
- The physician's personal tax returns (Correct answer)
- Case-specific peer review outcomes
Correct answer: The physician's personal tax returns
Personal tax returns have no bearing on clinical competence or professional performance and are not part of a credentialing or peer review file.
CPCS Peer Review & Performance Improvement 3
Ongoing Professional Practice Evaluation (OPPE) data should be reviewed at minimum how frequently according to The Joint Commission standards?