Quality Review and Accountability Flashcards
7 cards from real CPHQ practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Quality Review and Accountability flashcards as text
A hospital's peer review committee finds that a physician's complication rate is twice the expected benchmark. What is the most appropriate next step?
Answer: Conduct a focused professional practice evaluation (FPPE)
FPPE is the structured process used to evaluate a specific concern about a practitioner's competency before any privilege action is taken.
Which data source is MOST useful for identifying patterns of healthcare-associated infections across an entire hospital system?
Answer: The National Healthcare Safety Network (NHSN)
NHSN is the CDC's surveillance system specifically designed to track and benchmark healthcare-associated infections nationally.
A quality manager discovers that a root cause analysis (RCA) was completed after a sentinel event but no action plan was created. Which standard is MOST likely being violated?
Answer: The Joint Commission's sentinel event policy
The Joint Commission requires that an RCA result in an actionable improvement plan to address identified system vulnerabilities.
When using a run chart to monitor a quality metric over time, what feature indicates a statistically significant process change?
Answer: Six or more consecutive points above or below the median
A run of six or more consecutive points on one side of the median is a standard rule signaling a non-random shift in a run chart.
A quality team wants to prioritize which of five patient safety issues to address first. Which tool is BEST suited for this decision?
Answer: Failure Prioritization Matrix (risk matrix)
A risk matrix (prioritization matrix) ranks issues by severity and likelihood to help teams allocate improvement resources effectively.
Under the concept of Just Culture, a nurse who made a medication error due to a confusing look-alike label should PRIMARILY be addressed through:
Answer: System redesign to eliminate the labeling hazard
Just Culture distinguishes human error from reckless behavior and addresses look-alike labeling errors through system redesign rather than individual punishment.
A quality professional is reviewing credentialing files and finds a practitioner's license expired two months ago. What action is required FIRST?
Answer: Immediately suspend clinical privileges until licensure is restored
Active, unencumbered licensure is a fundamental prerequisite for clinical privileges, requiring immediate suspension when a license lapses.