CPHQ Quality Review and Accountability 2 — Questions and Answers
Question 1: 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?
- Immediately revoke the physician's privileges
- Conduct a focused professional practice evaluation (FPPE) (Correct answer)
- Report the physician to the state medical board
- Notify the patient and family of the findings
Correct 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.
Question 2: Which data source is MOST useful for identifying patterns of healthcare-associated infections across an entire hospital system?
- Patient satisfaction surveys
- The National Healthcare Safety Network (NHSN) (Correct answer)
- Voluntary incident reports submitted by staff
- Billing and claims data only
Correct answer: The National Healthcare Safety Network (NHSN)
NHSN is the CDC's surveillance system specifically designed to track and benchmark healthcare-associated infections nationally.
Question 3: 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?
- HIPAA Privacy Rule
- The Joint Commission's sentinel event policy (Correct answer)
- CMS Conditions of Participation for staffing
- OSHA bloodborne pathogen standards
Correct 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.
Question 4: When using a run chart to monitor a quality metric over time, what feature indicates a statistically significant process change?
- A single data point far above the mean
- Six or more consecutive points above or below the median (Correct answer)
- Any point that exceeds the upper control limit
- Two consecutive data points trending upward
Correct 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.
Question 5: A quality team wants to prioritize which of five patient safety issues to address first. Which tool is BEST suited for this decision?
- Fishbone diagram
- Failure Mode and Effects Analysis (FMEA)
- Failure Prioritization Matrix (risk matrix) (Correct answer)
- Scatter diagram
Correct answer: Failure Prioritization Matrix (risk matrix)
A risk matrix (prioritization matrix) ranks issues by severity and likelihood to help teams allocate improvement resources effectively.
Question 6: 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:
- Immediate termination to set an example
- System redesign to eliminate the labeling hazard (Correct answer)
- Mandatory retraining as punitive consequence
- Anonymous reporting with no follow-up
Correct 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.
Question 7: A quality professional is reviewing credentialing files and finds a practitioner's license expired two months ago. What action is required FIRST?
- Wait for the practitioner to self-report the renewal
- Immediately suspend clinical privileges until licensure is restored (Correct answer)
- Issue a formal written warning and allow practice to continue
- File a complaint with the National Practitioner Data Bank
Correct 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.
CPHQ Quality Review and Accountability 2
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?