CPCS Peer Review & Performance Improvement 4

Question 1

What is the key difference between a punitive peer review culture and a non-punitive (just culture) approach?

Accepted Answer

Just culture distinguishes between system failures and reckless individual behavior

Answer

Just culture ignores individual accountability entirely

Answer

Punitive culture results in better quality outcomes

Answer

Just culture eliminates the need for FPPE

Question 2

Which accreditation standard requires hospitals to conduct a root cause analysis (RCA) after a sentinel event?

Accepted Answer

The Joint Commission

Answer

CMS Conditions of Participation

Answer

URAC

Answer

NCQA

Question 3

A peer review committee is evaluating a case where a surgeon's complication was determined to be within the expected range for the procedure complexity. How should this case be classified?

Accepted Answer

No issue identified / expected outcome

Answer

Opportunity for improvement

Answer

Substandard care requiring FPPE

Answer

Mandatory NPDB report

Question 4

In performance improvement, what does a 'control chart' help an organization identify?

Accepted Answer

Whether process variation is within acceptable statistical limits

Answer

The most common causes of adverse events

Answer

Which staff members are underperforming

Answer

The cost-benefit ratio of a proposed change

Question 5

When must a hospital report an adverse peer review action to the NPDB?

Accepted Answer

When a clinical privilege is revoked, suspended for more than 30 days, or surrendered under investigation

Answer

Any time peer review results in additional training requirements

Answer

After every sentinel event investigation

Answer

Whenever an OPPE score falls below the institutional benchmark

Question 6

Which of the following BEST describes the role of a credentials verification organization (CVO) in peer review?

Accepted Answer

CVOs verify primary source credentials that inform peer review decisions

Answer

CVOs conduct the actual peer review of clinical cases

Answer

CVOs issue immunity protections to peer reviewers

Answer

CVOs replace the medical staff office for OPPE reporting

Question 7

What is 'benchmarking' in the context of performance improvement for credentialing?

Accepted Answer

Measuring an organization's performance metrics against best-practice standards or peer institutions

Answer

Comparing a practitioner's malpractice history to national averages

Answer

Setting individual practitioner quotas for case volume

Answer

Ranking credentialing staff by processing speed