Quality Assurance & Standards Flashcards

Under HIPAA's Privacy Rule, a 'minimum necessary' standard requires covered entities to:

Answer: Limit PHI disclosure to the least amount needed for the intended purpose

The minimum necessary standard mandates that only the PHI required for the specific purpose be accessed, used, or disclosed.

A Pareto chart in quality improvement is used to identify:

Answer: The vital few causes responsible for the majority of problems

A Pareto chart applies the 80/20 rule to show which categories account for most of the defects or problems.

The CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey is primarily designed to measure:

Answer: Patient-reported experience of care

CAHPS surveys collect standardized patient reports about their experiences with healthcare providers and systems.

In process improvement, 'waste' in the Lean methodology includes which of the following categories?

Answer: Waiting, overproduction, and defects

Lean identifies eight wastes (including waiting, overproduction, and defects) that do not add value to the patient care process.

Which CMS program penalizes hospitals with excess readmissions for conditions such as heart failure and pneumonia?

Answer: Hospital Readmissions Reduction Program (HRRP)

The HRRP reduces Medicare payments to hospitals with higher-than-expected 30-day readmission rates for specified conditions.

A healthcare analyst wants to compare their hospital's surgical site infection rate to a national benchmark. The most appropriate source for this comparison is:

Answer: CDC's National Healthcare Safety Network (NHSN)

NHSN is the nation's most widely used HAI tracking system and provides standardized benchmarks for surgical site infections.

In quality measurement, 'face validity' means:

Answer: A measure appears logically relevant to the concept being measured

Face validity is the degree to which a measure appears on its surface to capture the intended concept, as judged by experts or stakeholders.