CHSA CHSA Quality Improvement & Regulatory Compliance 1 — Questions and Answers
Question 1: Which accrediting body evaluates US hospitals and healthcare organizations for quality and patient safety standards, granting 'deemed status' for Medicare participation?
- OSHA
- The Joint Commission (TJC) (Correct answer)
- CMS Office of Inspector General
- American Hospital Association (AHA)
Correct answer: The Joint Commission (TJC)
The Joint Commission accredits healthcare organizations and its accreditation grants CMS deemed status, satisfying Medicare Conditions of Participation.
Question 2: In quality improvement, a 'root cause analysis' (RCA) is performed primarily to:
- Discipline the staff member involved in an adverse event
- Identify the underlying system and process failures that led to an adverse event (Correct answer)
- Calculate the financial liability of a medical error
- Satisfy state licensing renewal requirements
Correct answer: Identify the underlying system and process failures that led to an adverse event
RCA is a structured retrospective process that looks beyond individual errors to identify systemic causes and prevent recurrence.
Question 3: The Plan-Do-Study-Act (PDSA) cycle is a widely used healthcare quality improvement model. What happens in the 'Study' phase?
- A small-scale change is implemented
- The results of the change are analyzed to see if improvement occurred (Correct answer)
- A new improvement goal is set
- Staff are trained on the new process
Correct answer: The results of the change are analyzed to see if improvement occurred
In the Study phase, data collected during the Do phase is analyzed to determine whether the tested change produced the intended improvement.
Question 4: Which CMS program adjusts Medicare payments to hospitals based on performance on quality measures, including patient experience and outcomes?
- Meaningful Use incentive program
- Hospital Value-Based Purchasing (VBP) Program (Correct answer)
- Prospective Payment System adjustment
- Merit-based Incentive Payment System (MIPS)
Correct answer: Hospital Value-Based Purchasing (VBP) Program
The Hospital VBP Program withholds a portion of base DRG payments and redistributes them based on hospitals' performance scores on safety, clinical care, efficiency, and patient experience.
Question 5: A healthcare administrator wants to reduce central line-associated bloodstream infections (CLABSIs). Which evidence-based tool provides a standardized checklist for central line insertion?
- SBAR communication tool
- Institute for Healthcare Improvement (IHI) Central Line Bundle (Correct answer)
- FMEA risk assessment matrix
- HCAHPS patient survey
Correct answer: Institute for Healthcare Improvement (IHI) Central Line Bundle
The IHI Central Line Bundle is a set of evidence-based practices—including hand hygiene, chlorhexidine skin antisepsis, and full-barrier precautions—that when implemented together significantly reduce CLABSI rates.
Question 6: Under CMS Conditions of Participation, hospitals must report which type of adverse events to their state health department?
- Near-miss events with no patient harm
- Sentinel events defined by the Joint Commission
- Serious reportable events (SREs), also called 'never events' (Correct answer)
- All medication administration errors regardless of outcome
Correct answer: Serious reportable events (SREs), also called 'never events'
Most states require mandatory reporting of serious reportable events (never events), such as wrong-site surgery or foreign object retained after surgery, to the state health department.
CHSA CHSA Quality Improvement & Regulatory Compliance 1
Which accrediting body evaluates US hospitals and healthcare organizations for quality and patient safety standards, granting 'deemed status' for Medicare participation?