CPHQ Quality Review and Accountability 5 — Questions and Answers
Question 1: A hospital implements a new hand hygiene protocol but compliance rates remain low six months later. According to the Model for Improvement, what should the quality team do?
- Accept the current compliance rate as the new baseline
- Run additional PDSA cycles to test modified change strategies (Correct answer)
- Escalate to administration for mandatory disciplinary action
- Abandon the project and select a new improvement topic
Correct answer: Run additional PDSA cycles to test modified change strategies
The Model for Improvement uses iterative PDSA cycles to test, learn from, and refine changes until the desired improvement is achieved.
Question 2: Which of the following BEST describes the primary purpose of the Patient Safety and Quality Improvement Act (PSQIA) of 2005?
- Mandating public reporting of all adverse events
- Providing federal privilege and confidentiality protections for patient safety work product reported to PSOs (Correct answer)
- Establishing minimum staffing ratios for acute care hospitals
- Creating a national database of hospital infection rates
Correct answer: Providing federal privilege and confidentiality protections for patient safety work product reported to PSOs
PSQIA established federal privilege protections for information reported to Patient Safety Organizations (PSOs) to encourage voluntary reporting of safety events.
Question 3: A Pareto chart is used in quality improvement to illustrate that:
- All causes of a problem contribute equally to outcomes
- A small number of causes account for the majority of problems (Correct answer)
- Process variation is within acceptable statistical limits
- Two variables have a linear correlation
Correct answer: A small number of causes account for the majority of problems
The Pareto principle (80/20 rule) states that roughly 80% of problems stem from 20% of causes, visualized by a Pareto chart to prioritize improvement efforts.
Question 4: When a hospital reports a quality measure to CMS for public reporting, this is an example of:
- Internal benchmarking
- External accountability and transparency (Correct answer)
- Voluntary quality improvement activity
- Peer review under legal privilege
Correct answer: External accountability and transparency
Reporting to CMS for public display (e.g., Hospital Compare) represents external accountability because results are disclosed to regulators and the public.
Question 5: A quality team discovers that medication reconciliation is performed inconsistently at discharge. Which Lean tool would BEST help visualize where in the process the inconsistency occurs?
- Control chart
- Value stream map (Correct answer)
- Scatter diagram
- Histogram
Correct answer: Value stream map
A value stream map is a Lean tool that visually maps all steps in a care process to identify waste, delays, and inconsistencies.
Question 6: Which of the following is an example of a structural measure of quality in healthcare?
- The percentage of diabetic patients with HbA1c < 8%
- The presence of a board-certified intensivist covering the ICU 24/7 (Correct answer)
- The rate of central line-associated bloodstream infections
- Patient satisfaction scores for pain management
Correct answer: The presence of a board-certified intensivist covering the ICU 24/7
Structural measures reflect the capacity and organization of care delivery, such as whether qualified staff or resources are in place.
Question 7: A quality professional is asked to calculate the positive predictive value (PPV) of a screening test. PPV answers which question?
- What proportion of people without the disease test negative?
- What proportion of positive test results truly have the disease? (Correct answer)
- What proportion of people with the disease test positive?
- What proportion of negative test results truly do not have the disease?
Correct answer: What proportion of positive test results truly have the disease?
Positive predictive value (PPV) is the proportion of individuals with a positive test result who truly have the condition being tested.
CPHQ Quality Review and Accountability 5
A hospital implements a new hand hygiene protocol but compliance rates remain low six months later.
According to the Model for Improvement, what should the quality team do?