CPHQ Quality Review and Accountability 3 — Questions and Answers
Question 1: Which methodology uses Define, Measure, Analyze, Improve, and Control (DMAIC) phases to reduce process variation?
- Lean manufacturing
- Six Sigma (Correct answer)
- Plan-Do-Study-Act (PDSA)
- Total Quality Management (TQM)
Correct answer: Six Sigma
Six Sigma's DMAIC framework is a data-driven methodology specifically designed to reduce defects and process variation.
Question 2: A hospital wants to reduce door-to-balloon time for STEMI patients. Which type of measure would track whether the process change is working?
- Outcome measure
- Process measure (Correct answer)
- Balancing measure
- Structure measure
Correct 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.
Question 3: The National Practitioner Data Bank (NPDB) must be queried when:
- A patient files a grievance against a physician
- A hospital initially grants or renews a practitioner's clinical privileges (Correct answer)
- An employee receives a performance improvement plan
- A physician requests a leave of absence
Correct 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.
Question 4: A quality improvement team notices their intervention reduced falls but increased call-light response times. The call-light data represents a:
- Process measure
- Outcome measure
- Balancing measure (Correct answer)
- Structural measure
Correct answer: Balancing measure
Balancing measures monitor unintended consequences of an improvement to ensure the change doesn't create new problems elsewhere in the system.
Question 5: Which accreditation standard specifically addresses the requirement for hospitals to have a written patient rights policy?
- OSHA General Duty Clause
- CMS Conditions of Participation (Correct answer)
- EPA hospital waste regulations
- DEA controlled substance protocols
Correct 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.
Question 6: 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:
- Outcome performance
- Staff competency assessment
- Document control and policy management (Correct answer)
- Financial accountability reporting
Correct answer: Document control and policy management
Inability to locate current policies indicates a failure in document control systems, which are required by accreditation standards.
Question 7: A hospital's quality dashboard shows a sudden spike in patient fall rates. The FIRST step in responding to this data is to:
- Immediately implement a new fall prevention protocol
- Validate the data to ensure accuracy and completeness (Correct answer)
- Report the spike to the state department of health
- Convene a root cause analysis team
Correct 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.
CPHQ Quality Review and Accountability 3
Which methodology uses Define, Measure, Analyze, Improve, and Control (DMAIC) phases to reduce process variation?