CPHQ - Certified Professional in Healthcare Quality Quality Review and Accountability Questions and Answers

Question 1

A hospital's governing body (Board of Directors) holds the ultimate accountability for the quality and safety of patient care.
Which of the following activities best demonstrates the Board's fulfillment of this oversight responsibility?

Accepted Answer

Reviewing and approving the organization-wide Quality Assessment and Performance Improvement (QAPI) plan.

Answer

Directly investigating individual adverse patient events.

Answer

Establishing the annual operating budget for the quality department.

Answer

Managing the day-to-day schedule and activities of the peer review committees.

Question 2

A hospital peer review committee is reviewing a case. To encourage candid and honest evaluation of clinical performance, the proceedings and records of the committee are generally protected from discovery in a lawsuit. This protection is primarily established by which of the following?

Accepted Answer

The Health Care Quality Improvement Act (HCQIA) and state statutes.

Answer

The Health Insurance Portability and Accountability Act (HIPAA)

Answer

The Emergency Medical Treatment and Labor Act (EMTALA)

Answer

The Patient Safety and Quality Improvement Act (PSQIA)

Question 3

A surgeon, who has been on staff for several years with no performance issues, requests privileges to perform a new, complex laparoscopic procedure she learned at a recent conference. According to Joint Commission standards, this request would most appropriately trigger which of the following processes?

Accepted Answer

A Focused Professional Practice Evaluation (FPPE).

Answer

An immediate report to the National Practitioner Data Bank (NPDB).

Answer

A standard Ongoing Professional Practice Evaluation (OPPE).

Answer

A mandatory leave of absence pending a full credentials review.

Question 4

Which of the following is the primary role of the Medical Executive Committee (MEC) in the quality review and accountability structure of a hospital?

Accepted Answer

To make recommendations to the governing body regarding medical staff credentialing, privileging, and disciplinary actions.

Answer

To act as the final authority on all financial decisions for the organization.

Answer

To develop and publish consumer-facing reports on hospital quality.

Answer

To directly hire and manage all nursing and ancillary staff.

Question 5

A hospital takes a professional review action that restricts a physician's clinical privileges for more than 30 days due to concerns about clinical competence. The hospital is legally required to report this action to which of the following entities?

Accepted Answer

The National Practitioner Data Bank (NPDB).

Answer

The American Medical Association (AMA).

Answer

The local news media.

Answer

The Centers for Disease Control and Prevention (CDC).

Question 6

Which of the following issues is the MOST appropriate for evaluation through a formal clinical peer review process?

Accepted Answer

A pattern of unexpectedly high complication rates for a specific surgical procedure performed by a physician.

Answer

A physician's repeated failure to sign verbal orders in the required timeframe.

Answer

A conflict between a physician and a nurse over care coordination.

Answer

A physician's low patient satisfaction scores related to communication style.