CPCS Peer Review & Performance Improvement 3

Question 1

Ongoing Professional Practice Evaluation (OPPE) data should be reviewed at minimum how frequently according to The Joint Commission standards?

Accepted Answer

Every 6 months

Answer

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?

Accepted Answer

Patient Care

Answer

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?

Accepted Answer

Identify root causes of a problem by category

Answer

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?

Accepted Answer

A sentinel event results in death or serious harm; a near-miss is caught before patient impact

Answer

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?

Accepted Answer

Pareto chart

Answer

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.

(CPCS) Certified Professional Credentialing Specialist Practice Test

(CPCS) Certified Professional Credentialing Specialist Practice Test

CPCS Peer Review & Performance Improvement 3