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 holds individuals accountable for reckless choices while recognizing that most errors stem from system design flaws, not individual malice.

Question 2

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

Accepted Answer

The Joint Commission

Answer

The Joint Commission requires accredited hospitals to complete a thorough and credible root cause analysis following a sentinel event.

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

When a complication falls within accepted norms for a given procedure's complexity, peer reviewers classify it as an expected or acceptable outcome.

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

A control chart displays process data over time with upper and lower control limits to distinguish common-cause variation from special-cause variation.

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

NPDB reporting is mandatory for clinical privilege actions lasting more than 30 days or surrendered while under investigation, per federal regulation.

(CPCS) Certified Professional Credentialing Specialist Practice Test

(CPCS) Certified Professional Credentialing Specialist Practice Test

CPCS Peer Review & Performance Improvement 4