Quality Improvement and Compliance Flashcards
7 cards from real TRIVIUM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Quality Improvement and Compliance flashcards as text
A 'sentinel event' as defined by The Joint Commission is BEST described as:
Answer: An unexpected event involving death or serious physical or psychological injury
The Joint Commission defines a sentinel event as an unexpected occurrence involving death or serious injury, signaling the need for immediate investigation.
The primary purpose of benchmarking in healthcare quality improvement is to:
Answer: Compare an organization's performance to best practices or peer organizations
Benchmarking compares an organization's performance metrics against industry standards or top performers to identify improvement opportunities.
Which of the following BEST describes the concept of 'harm reduction' in healthcare compliance?
Answer: Implementing strategies that minimize the negative impact of unavoidable risks
Harm reduction focuses on practical strategies to minimize the negative consequences of risks that cannot be completely eliminated.
Under CMS Conditions of Participation, hospitals are required to have a functioning quality assessment and performance improvement (QAPI) program that:
Answer: Tracks and improves indicators related to care, safety, and services across the organization
CMS CoPs require hospitals to have a QAPI program that tracks, analyzes, and improves performance across all care, safety, and operational domains.
A Pareto chart in quality improvement is based on the principle that:
Answer: Roughly 80% of problems stem from 20% of causes
The Pareto principle (80/20 rule) holds that a small number of causes are responsible for the majority of problems, helping teams prioritize interventions.
An 'advance directive' serves which function in healthcare compliance and patient rights?
Answer: It documents a patient's wishes regarding future medical treatment if they become unable to decide
An advance directive (e.g., living will, healthcare proxy) legally documents a patient's treatment preferences for situations when they cannot speak for themselves.
Which of the following represents a 'leading indicator' in healthcare quality measurement?
Answer: Hand hygiene compliance rates among staff
Leading indicators measure actions or processes (like hand hygiene compliance) that predict future outcomes, unlike lagging indicators that report past results.