Peer Review & Performance Improvement Flashcards
7 cards from real CPCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Peer Review & Performance Improvement flashcards as text
What is the key difference between a punitive peer review culture and a non-punitive (just culture) approach?
Answer: Just culture distinguishes between system failures and reckless individual behavior
Just culture holds individuals accountable for reckless choices while recognizing that most errors stem from system design flaws, not individual malice.
Which accreditation standard requires hospitals to conduct a root cause analysis (RCA) after a sentinel event?
Answer: The Joint Commission
The Joint Commission requires accredited hospitals to complete a thorough and credible root cause analysis following a sentinel event.
A peer review committee is evaluating a case where a surgeon's complication was determined to be within the expected range for the procedure complexity. How should this case be classified?
Answer: No issue identified / expected outcome
When a complication falls within accepted norms for a given procedure's complexity, peer reviewers classify it as an expected or acceptable outcome.
In performance improvement, what does a 'control chart' help an organization identify?
Answer: Whether process variation is within acceptable statistical limits
A control chart displays process data over time with upper and lower control limits to distinguish common-cause variation from special-cause variation.
When must a hospital report an adverse peer review action to the NPDB?
Answer: When a clinical privilege is revoked, suspended for more than 30 days, or surrendered under investigation
NPDB reporting is mandatory for clinical privilege actions lasting more than 30 days or surrendered while under investigation, per federal regulation.
Which of the following BEST describes the role of a credentials verification organization (CVO) in peer review?
Answer: CVOs verify primary source credentials that inform peer review decisions
A CVO performs primary source verification of credentials, which provides the foundation of factual data used in credentialing and peer review processes.
What is 'benchmarking' in the context of performance improvement for credentialing?
Answer: Measuring an organization's performance metrics against best-practice standards or peer institutions
Benchmarking compares an organization's performance indicators to external best-practice standards or comparable organizations to identify improvement gaps.