CPHQ Quality Review and Accountability 4 — Questions and Answers
Question 1: Which of the following BEST describes the purpose of a Failure Mode and Effects Analysis (FMEA)?
- Investigating the cause of an adverse event that already occurred
- Prospectively identifying potential process failures before they cause harm (Correct answer)
- Analyzing staff compliance with existing policies
- Benchmarking performance against national databases
Correct answer: Prospectively identifying potential process failures before they cause harm
FMEA is a proactive risk assessment tool used to identify and prioritize potential failure points in a process before patient harm occurs.
Question 2: A quality coordinator is preparing a report for the board of directors on patient safety culture. Which validated tool is MOST appropriate to measure safety culture?
- HCAHPS patient satisfaction survey
- AHRQ Hospital Survey on Patient Safety Culture (HSOPS) (Correct answer)
- OSHA 300 Log injury records
- CMS Star Rating comparison tool
Correct answer: AHRQ Hospital Survey on Patient Safety Culture (HSOPS)
The AHRQ HSOPS is the validated, widely-used instrument for measuring staff perceptions of patient safety culture in hospitals.
Question 3: The Ongoing Professional Practice Evaluation (OPPE) process differs from FPPE in that OPPE is:
- Triggered only by a sentinel event
- A continuous, periodic review of all practitioners' performance (Correct answer)
- Limited to physicians on probationary status
- Required only during initial credentialing
Correct answer: A continuous, periodic review of all practitioners' performance
OPPE is a routine, continuous monitoring process for all credentialed practitioners, while FPPE is triggered by specific concerns.
Question 4: A patient grievance is defined by CMS as a formal written complaint or a complaint that is NOT resolved at the time it is submitted. Who is responsible for reviewing and responding to patient grievances?
- The bedside nurse who received the complaint
- The Patient Grievance Committee or its designee (Correct answer)
- The hospital's legal department
- The attending physician named in the complaint
Correct answer: The Patient Grievance Committee or its designee
CMS requires hospitals to have a grievance process with a designated committee or individual responsible for reviewing and responding to formal grievances.
Question 5: Which statistical concept describes the degree to which a measurement tool consistently produces the same results under the same conditions?
- Validity
- Reliability (Correct answer)
- Sensitivity
- Specificity
Correct answer: Reliability
Reliability refers to the consistency and reproducibility of a measurement instrument across repeated applications.
Question 6: A quality professional notices that surgical site infection rates dropped after a new preoperative checklist was introduced. To confirm causation rather than correlation, the BEST next step is:
- Announce the results as a confirmed improvement
- Conduct a controlled study with a comparison group (Correct answer)
- Submit the results to a peer-reviewed journal immediately
- Stop the intervention since the goal was achieved
Correct answer: Conduct a controlled study with a comparison group
Establishing causation requires a controlled comparison — a study with a control group or time-series analysis can rule out confounding factors.
Question 7: Which federal law requires hospitals to report adverse events related to medical devices to the FDA?
- The Patient Safety and Quality Improvement Act (PSQIA)
- The Safe Medical Devices Act (SMDA) (Correct answer)
- The Health Insurance Portability and Accountability Act (HIPAA)
- The Emergency Medical Treatment and Labor Act (EMTALA)
Correct answer: The Safe Medical Devices Act (SMDA)
The Safe Medical Devices Act requires hospitals to report serious device-related injuries and deaths to the FDA and the device manufacturer.
CPHQ Quality Review and Accountability 4
Which of the following BEST describes the purpose of a Failure Mode and Effects Analysis (FMEA)?