ABQAURP FINAL PAPER 2025/2026 QUESTIONS AND
SOLUTIONS GRADED A+
✔✔QA - Quality Assurance vs PI - Performance Improvement - ✔✔QA is reactive and
retrospective effort to examine why a facility failed to meet certain standards. QA
activities often end once the standard is met
PI is also called QI and is pro-active continuous study of processes with the intent of
preventing problems by identifying areas of opportunity and testing new approaches to
fix underlying causes of persistent problems. PI can make good quality even better
✔✔Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule
Hospital Acquired Conditions (HAC): - ✔✔· Foreign Object Retained After Surgery
· Air Embolism
· Blood Incompatibility
· Stage III and IV Pressure Ulcers
· Falls and Trauma
o Fractures
o Dislocations
o Intracranial Injuries
o Crushing Injuries
o Burn
o Other Injuries
· Manifestations of Poor Glycemic Control
o Diabetic Ketoacidosis
o Nonketotic Hyperosmolar Coma
o Hypoglycemic Coma
o Secondary Diabetes with Ketoacidosis
o Secondary Diabetes with Hyperosmolarity
· Catheter-Associated Urinary Tract Infection (UTI)
· Vascular Catheter-Associated Infection
· Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG):
· Surgical Site Infection Following Bariatric Surgery for Obesity
o Laparoscopic Gastric Bypass
o Gastroenterostomy
o Laparoscopic Gastric Restrictive Surgery
· Surgical Site Infection Following Certain Orthopedic Procedures
o Spine
o Neck
o Shoulder
o Elbow
· Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)
· Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic
Procedures:
o Total Knee Replacement
o Hip Replacement
, · Iatrogenic Pneumothorax with Venous Catheterization
✔✔When did congress authorize Inpatient Hospital VBP? - ✔✔Section 3001(a) of the
Affordable Care Act
✔✔What does the Inpatient Hospital VBP use to determine VBP? - ✔✔Data from
Hospital Inpatient Quality Reporting (IQR) which was authorized by Section 501(b) of
the Medicare Prescription Drug, Improvement, and Modernization Act of 2003
✔✔What are Hospital "never events"? - ✔✔Proposed by Ken Kizer in 2001 when CEO
of National Quality Forum: last updated 2011. 29 events in 6 categories. The 14 HACs
are sometimes called CMS "never events"
✔✔Who puts out the National Patient Safety Goals (NPSG)? - ✔✔Joint Commission for
the Accreditation of Healthcare Organizations (JCAHO)
✔✔2018 Hospital NPSGs: - ✔✔-Identify patients correctly
-Improve staff communication
-Use medicines safely
-Prevent Infection
-Identify patient safety risks
-Prevent mistakes in surgery
✔✔What accounts for nearly a quarter of Joint Commission Sentinel Event Alerts? -
✔✔Medication management/administration errors
✔✔The 5 Rights of Medication Safety - ✔✔Right: Drug, Patient, Dosage, Route,
Time/Frequency
✔✔Additional Rights for medications: - ✔✔Right Reason, Right Documentation, Right
Response
✔✔Three JCAHO documents to help analysis of sentinel events: - ✔✔-Patient safety
systems chapter
-Sentinel Event Policy
-RCA2
✔✔How does Failure Modes Effects Analysis (FMEA) differ from RCA? - ✔✔FMEA is
proactive not reactive and includes identify low hanging fruit and a process to identify
those variables that are far less likely (latent) but could possibly have the greatest
negative effect on outcomes.
✔✔TJCs Comprehensive Accreditation Manila for Hospitals (CAMH): - ✔✔Provides
policy and guidance regarding sentinel and reviewable events between hospitals and
TJC
SOLUTIONS GRADED A+
✔✔QA - Quality Assurance vs PI - Performance Improvement - ✔✔QA is reactive and
retrospective effort to examine why a facility failed to meet certain standards. QA
activities often end once the standard is met
PI is also called QI and is pro-active continuous study of processes with the intent of
preventing problems by identifying areas of opportunity and testing new approaches to
fix underlying causes of persistent problems. PI can make good quality even better
✔✔Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule
Hospital Acquired Conditions (HAC): - ✔✔· Foreign Object Retained After Surgery
· Air Embolism
· Blood Incompatibility
· Stage III and IV Pressure Ulcers
· Falls and Trauma
o Fractures
o Dislocations
o Intracranial Injuries
o Crushing Injuries
o Burn
o Other Injuries
· Manifestations of Poor Glycemic Control
o Diabetic Ketoacidosis
o Nonketotic Hyperosmolar Coma
o Hypoglycemic Coma
o Secondary Diabetes with Ketoacidosis
o Secondary Diabetes with Hyperosmolarity
· Catheter-Associated Urinary Tract Infection (UTI)
· Vascular Catheter-Associated Infection
· Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG):
· Surgical Site Infection Following Bariatric Surgery for Obesity
o Laparoscopic Gastric Bypass
o Gastroenterostomy
o Laparoscopic Gastric Restrictive Surgery
· Surgical Site Infection Following Certain Orthopedic Procedures
o Spine
o Neck
o Shoulder
o Elbow
· Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)
· Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic
Procedures:
o Total Knee Replacement
o Hip Replacement
, · Iatrogenic Pneumothorax with Venous Catheterization
✔✔When did congress authorize Inpatient Hospital VBP? - ✔✔Section 3001(a) of the
Affordable Care Act
✔✔What does the Inpatient Hospital VBP use to determine VBP? - ✔✔Data from
Hospital Inpatient Quality Reporting (IQR) which was authorized by Section 501(b) of
the Medicare Prescription Drug, Improvement, and Modernization Act of 2003
✔✔What are Hospital "never events"? - ✔✔Proposed by Ken Kizer in 2001 when CEO
of National Quality Forum: last updated 2011. 29 events in 6 categories. The 14 HACs
are sometimes called CMS "never events"
✔✔Who puts out the National Patient Safety Goals (NPSG)? - ✔✔Joint Commission for
the Accreditation of Healthcare Organizations (JCAHO)
✔✔2018 Hospital NPSGs: - ✔✔-Identify patients correctly
-Improve staff communication
-Use medicines safely
-Prevent Infection
-Identify patient safety risks
-Prevent mistakes in surgery
✔✔What accounts for nearly a quarter of Joint Commission Sentinel Event Alerts? -
✔✔Medication management/administration errors
✔✔The 5 Rights of Medication Safety - ✔✔Right: Drug, Patient, Dosage, Route,
Time/Frequency
✔✔Additional Rights for medications: - ✔✔Right Reason, Right Documentation, Right
Response
✔✔Three JCAHO documents to help analysis of sentinel events: - ✔✔-Patient safety
systems chapter
-Sentinel Event Policy
-RCA2
✔✔How does Failure Modes Effects Analysis (FMEA) differ from RCA? - ✔✔FMEA is
proactive not reactive and includes identify low hanging fruit and a process to identify
those variables that are far less likely (latent) but could possibly have the greatest
negative effect on outcomes.
✔✔TJCs Comprehensive Accreditation Manila for Hospitals (CAMH): - ✔✔Provides
policy and guidance regarding sentinel and reviewable events between hospitals and
TJC
