CHSA CHSA Quality Improvement & Regulatory Compliance

Question 1

Which accrediting body evaluates US hospitals and healthcare organizations for quality and patient safety standards, granting 'deemed status' for Medicare participation?

Accepted Answer

The Joint Commission (TJC)

Answer

OSHA

Answer

CMS Office of Inspector General

Answer

American Hospital Association (AHA)

Question 2

In quality improvement, a 'root cause analysis' (RCA) is performed primarily to:

Accepted Answer

Identify the underlying system and process failures that led to an adverse event

Answer

Discipline the staff member involved in an adverse event

Answer

Calculate the financial liability of a medical error

Answer

Satisfy state licensing renewal requirements

Question 3

The Plan-Do-Study-Act (PDSA) cycle is a widely used healthcare quality improvement model. What happens in the 'Study' phase?

Accepted Answer

The results of the change are analyzed to see if improvement occurred

Answer

A small-scale change is implemented

Answer

A new improvement goal is set

Answer

Staff are trained on the new process

Question 4

Which CMS program adjusts Medicare payments to hospitals based on performance on quality measures, including patient experience and outcomes?

Accepted Answer

Hospital Value-Based Purchasing (VBP) Program

Answer

Meaningful Use incentive program

Answer

Prospective Payment System adjustment

Answer

Merit-based Incentive Payment System (MIPS)

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?

Accepted Answer

Institute for Healthcare Improvement (IHI) Central Line Bundle

Answer

SBAR communication tool

Answer

FMEA risk assessment matrix

Answer

HCAHPS patient survey

Question 6

Under CMS Conditions of Participation, hospitals must report which type of adverse events to their state health department?

Accepted Answer

Serious reportable events (SREs), also called 'never events'

Answer

Near-miss events with no patient harm

Answer

Sentinel events defined by the Joint Commission

Answer

All medication administration errors regardless of outcome