Quality Improvement and Performance Management Flashcards
7 cards from real CHA 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 Performance Management flashcards as text
Which of the following is an 'outcome measure' in hospice quality reporting?
Answer: Family-reported satisfaction with end-of-life care on the CAHPS survey
Family-reported satisfaction scores represent an outcome measure because they reflect the overall result and perceived quality of the care experience, rather than whether a specific process step occurred.
Which accreditation organization offers hospice-specific accreditation that can fulfill Medicare deemed-status requirements?
Answer: The Joint Commission (TJC)
The Joint Commission offers hospice accreditation with deemed status, meaning accredited organizations are considered to have met Medicare Conditions of Participation.
A hospice QAPI committee identifies that 40% of patients are not receiving a bereavement follow-up call within 13 months of death. The BEST next step is to:
Answer: Conduct a root cause analysis to identify barriers to timely bereavement follow-up
A root cause analysis helps identify the specific barriers causing the gap, ensuring that corrective action addresses the actual problem rather than a symptom.
The 'Triple Aim' framework in healthcare quality improvement focuses on improving:
Answer: Patient experience, population health, and per capita cost reduction
The Triple Aim, developed by the Institute for Healthcare Improvement (IHI), focuses on improving patient experience, improving the health of populations, and reducing per capita healthcare costs.
When a hospice organization's quality data is reported publicly through CMS's Care Compare website, this is an example of:
Answer: Public transparency and consumer accountability
Public reporting on Care Compare promotes transparency and consumer accountability by allowing patients and families to compare hospice quality performance before selecting a provider.
Which method is used in quality improvement to distinguish between 'common cause' variation and 'special cause' variation in a process?
Answer: Statistical Process Control (SPC)
Statistical Process Control (SPC) uses control charts to differentiate between normal variation inherent to a process (common cause) and unusual variation that signals an assignable problem (special cause).
A hospice administrator reviews data showing a sudden spike in live discharge rates. According to CMS, an unusually high live discharge rate may trigger:
Answer: A medical review to assess whether admitted patients were appropriately certified as terminally ill
CMS may initiate a medical review of a hospice with an unusually high live discharge rate to determine whether patients were appropriately certified as having a prognosis of six months or less.