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
Which methodology uses Define, Measure, Analyze, Improve, and Control (DMAIC) phases to reduce process variation?
Answer: Six Sigma
Six Sigma's DMAIC framework is a data-driven methodology specifically designed to reduce defects and process variation.
A hospital wants to reduce door-to-balloon time for STEMI patients. Which type of measure would track whether the process change is working?
Answer: Process measure
Door-to-balloon time is a process measure because it tracks whether the specific care steps (process) are being performed correctly and timely.
The National Practitioner Data Bank (NPDB) must be queried when:
Answer: A hospital initially grants or renews a practitioner's clinical privileges
Federal law requires hospitals to query the NPDB when initially granting privileges and at least every two years at re-credentialing.
A quality improvement team notices their intervention reduced falls but increased call-light response times. The call-light data represents a:
Answer: Balancing measure
Balancing measures monitor unintended consequences of an improvement to ensure the change doesn't create new problems elsewhere in the system.
Which accreditation standard specifically addresses the requirement for hospitals to have a written patient rights policy?
Answer: CMS Conditions of Participation
CMS Conditions of Participation require Medicare/Medicaid-participating hospitals to inform patients of their rights and have a written policy.
During an accreditation survey, a surveyor finds that staff cannot locate the organization's infection control policies. This finding MOST likely reflects a gap in:
Answer: Document control and policy management
Inability to locate current policies indicates a failure in document control systems, which are required by accreditation standards.
A hospital's quality dashboard shows a sudden spike in patient fall rates. The FIRST step in responding to this data is to:
Answer: Validate the data to ensure accuracy and completeness
Before acting on a data anomaly, quality professionals must validate the data to rule out measurement errors, coding changes, or data collection issues.