CPMSM: STUDY
QUESTIONS/DEFINITIONS WITH
CORRECT SOLUTIONS
The medical staff is actively involved in measuring, assessing, and improving what? -
ANSWER-Patient Safety Data
An independent review committee consisting of physicians external to NCQA is called
what? - ANSWER-ROC (regulatory oversight committee)
If a hospital loses accreditation for providing falsified information to TJC, it may not
participate in the accreditation process again for a period of how long? - ANSWER-1
year
What does the NCQA use for public reporting of survey results? - ANSWER-Health Plan
Report Card
Areas of an organization's system, structure and process that are most relevant to the
organization's patient safety & quality of care, AND most at risk for negative outcomes
are referred to as what according to the Joint Commission? - ANSWER-Critical focus
areas
If a hospital changes ownership/control/change in capacity, it must notify TJC in writing
not less than how many days after the change? - ANSWER-30 days
According to TJC what report details the actions an organization took to bring itself into
compliance with a standard or that clarifies why an organization believes it was in
compliance with the standard for which it received a recommendation? - ANSWER-ESC
(evidence of standards compliance)
Evidence of Standards Compliance (ESC's) - ANSWER-All partially compliant or
insufficiently compliant EP's must be addressed via the ESC submission process:
Elements of Performance that have a direct impact on patient, individual served or
resident care require submission within 60 days (previously 45 days - changed in 2017)
Elements of Performance that have an indirect impact on patient, individual served or
resident care require an ESC within 60 days
QUESTIONS/DEFINITIONS WITH
CORRECT SOLUTIONS
The medical staff is actively involved in measuring, assessing, and improving what? -
ANSWER-Patient Safety Data
An independent review committee consisting of physicians external to NCQA is called
what? - ANSWER-ROC (regulatory oversight committee)
If a hospital loses accreditation for providing falsified information to TJC, it may not
participate in the accreditation process again for a period of how long? - ANSWER-1
year
What does the NCQA use for public reporting of survey results? - ANSWER-Health Plan
Report Card
Areas of an organization's system, structure and process that are most relevant to the
organization's patient safety & quality of care, AND most at risk for negative outcomes
are referred to as what according to the Joint Commission? - ANSWER-Critical focus
areas
If a hospital changes ownership/control/change in capacity, it must notify TJC in writing
not less than how many days after the change? - ANSWER-30 days
According to TJC what report details the actions an organization took to bring itself into
compliance with a standard or that clarifies why an organization believes it was in
compliance with the standard for which it received a recommendation? - ANSWER-ESC
(evidence of standards compliance)
Evidence of Standards Compliance (ESC's) - ANSWER-All partially compliant or
insufficiently compliant EP's must be addressed via the ESC submission process:
Elements of Performance that have a direct impact on patient, individual served or
resident care require submission within 60 days (previously 45 days - changed in 2017)
Elements of Performance that have an indirect impact on patient, individual served or
resident care require an ESC within 60 days
