CPHQ Quality Review and Accountability 3

Question 1

Which methodology uses Define, Measure, Analyze, Improve, and Control (DMAIC) phases to reduce process variation?

Accepted Answer

Six Sigma

Answer

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?

Accepted Answer

Process measure

Answer

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:

Accepted Answer

A hospital initially grants or renews a practitioner's clinical privileges

Answer

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:

Accepted Answer

Balancing measure

Answer

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?

Accepted Answer

CMS Conditions of Participation

Answer

CMS Conditions of Participation require Medicare/Medicaid-participating hospitals to inform patients of their rights and have a written policy.

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