Quality Review and Accountability Flashcards

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.