Question 1

Excluding laboratories,how often must a health care organization undergo an on-site survey in order to maintain accreditation with The Joint Commission?

Accepted Answer

Health care organizations must undergo an on-site survey by The Joint Commission every 3 years to maintain accreditation, excluding laboratories which have a different schedule.

Question 2

Which of the following original CMS value-based programs determines whether or not an acute care hospital should be paid a reduced amount based on performance across health-acquired infections and unacceptable adverse events?

Accepted Answer

The Hospital-Acquired Conditions (HAC) Reduction Program is the CMS value-based purchasing program that reduces payments to hospitals with high rates of health-acquired infections and other adverse events.

Question 3

Who oversees the licensure of health care facilities?

Accepted Answer

State governments are primarily responsible for the licensure of healthcare facilities, ensuring they meet certain standards and regulations.

Question 4

Which initiative encourages individual eligible professionals and group practices to assess and report the quality of care provided to their patients and risk negative payment adjustments if they do not do so?

Accepted Answer

The Physician Quality Reporting System (PQRS) was a program under Medicare that encouraged eligible professionals and group practices to report information on the quality of care to Medicare. Providers who did not participate or failed to meet the reporting requirements were subject to negative payment adjustments.

Question 5

Which organization developed a widely used group of patient experience surveys in the public arena under the Consumer Assessment of Healthcare Providers and Systems program?

Accepted Answer

The Agency for Healthcare Research and Quality (AHRQ) developed the Consumer Assessment of Healthcare Providers and Systems (CAHPS) program, which includes a widely used group of patient experience surveys in the public arena.

Question 6

Which of the following is not a "lever" that helps align organizations with the NQS?

Accepted Answer

Incident reporting is more directly related to quality improvement and safety monitoring rather than a mechanism for aligning organizations with the National Quality Strategy (NQS). The NQS focuses on broader strategies such as payment incentives, regulatory frameworks, and workforce development to drive systemic improvements in healthcare quality.

Question 7

Which is one of the oldest and widely used sets of health care performance measures in the US with more than 90 percent of health plans in the US collecting and reporting this data?

Accepted Answer

HEDIS (Healthcare Effectiveness Data and Information Set) is one of the oldest and most widely used sets of health care performance measures in the United States, with more than 90 percent of health plans collecting and reporting this data.

Question 8

Which new program streamlines three existing quality programs and rewards eligible professionals for meeting and surpassing established thresholds?

Accepted Answer

MIPS, or the Merit-based Incentive Payment System, streamlines three existing quality programs (PQRS, VM, and MU) into one, rewarding eligible professionals for meeting and surpassing established quality thresholds.

Question 9

How often are CQMs (clinical quality measures) updated?

Accepted Answer

CQMs are updated annually to ensure they remain relevant and reflect current clinical guidelines and practices.

Question 10

__________ is the process that gives a facility legal approval to operate.

Accepted Answer

Licensure is the process by which an agency of government grants permission to individuals or organizations to engage in a given occupation or activity that would otherwise be illegal. It is a form of legal approval to operate.

Question 11

Which of the following is defined as a patient safety event that did not reach the patient?

Accepted Answer

Near misses are events that could have harmed a patient but did not either by chance or through timely intervention.

Question 12

__________ is the process of comparing one or more performance measures against a standard.

Accepted Answer

Benchmarking is the process where performance measures are compared against a standard to evaluate or improve performance.

Question 13

Which of the following is NOT one of the six aims for establishing quality health care as outlined by Crossing the Quality Chasm?

Accepted Answer

"Crossing the Quality Chasm: A New Health System for the 21st Century," a report by the Institute of Medicine (IOM), outlines six aims for improving health care, which are to make it safe, effective, patient-centered, timely, efficient, and equitable. "Ethical" is not listed among these specific aims, making it the correct answer.

Question 14

__________ gives a health care organization the authority to participate in the federal Medicare and Medicaid programs.

Accepted Answer

Certification is the process that gives a healthcare organization the authority to participate in the federal Medicare and Medicaid programs. It ensures that the organization meets certain federal standards.

Question 15

All of the following are online tools that allow organizations to compare data sets except:

Accepted Answer

All the options listed (Dartmouth Atlas, Quality Check, and Hospital Compare) are indeed online tools that organizations can use to compare various data sets, particularly in the context of healthcare quality and performance.

Question 16

Which of the following is NOT one of the four major categories of quality measures?

Accepted Answer

All of the above are categories of quality measures in healthcare, including Structure, Process, and Outcome.

Question 17

Which of the following is NOT an accrediting agency?

Accepted Answer

CMS (Centers for Medicare & Medicaid Services) is a federal agency that administers the nation's major healthcare programs, but it is not an accrediting agency.

Question 18

Which of the following organizations is the leading accrediting body for health plans?

Accepted Answer

The National Committee for Quality Assurance (NCQA) is the leading accrediting body for health plans, focusing on improving healthcare quality.

Question 19

Which of the following is NOT one of the three broad aims of the National Quality Strategy?

Accepted Answer

The three broad aims of the National Quality Strategy are better care, healthy people/healthy communities, and affordable care. Innovative care, while important, is not listed as one of the three broad aims.

Question 20

Which is a nonprofit organization with board members from both private and public sectors that maintains a large,searchable database of performance measures?

Accepted Answer

The National Quality Forum (NQF) is a nonprofit organization with board members from both the private and public sectors. It maintains a large, searchable database of performance measures to improve the quality of healthcare.

Quiz 10: Performance Standards and Measures