HCQM CORRECT FINAL EXAMS QUESTIONS AND
ANSWERS SURE A+
✔✔Just Culture - ✔✔Developed by David Marx in 2007 to create a hierarchy of levels of
accountability for different behaviors: 1. Human error - inadvertent mistakes which
should managed by consoling the individual and making changes to processes,
procedures, training, and design 2. At risk behavior includes choices involving risk that
is not recognized or justified and should be managed by coaching the individual and
rewarding healthy behavior. 3. Reckless behavior includes conscious disregard of
unreasonable risk which should result in remedial and punitive actions. Is considered a
more appropriate evolution from the blame free environment first supported with the
advent of error transparency.
✔✔High Reliability Organizations - ✔✔Companies that work in complex, hazardous
industries and exemplify practices that demonstrate deep understanding of safety
✔✔High Reliability Organizations have a preoccupation with - ✔✔Failure
✔✔High Reliability Organizations consider errors to be - ✔✔Everyday occurrences,
inherent in systems and part of being human.
✔✔2005's Institute for Safe Medication Practices' 7 themes that contribute to high
reliability - ✔✔1. Sincere commitment to safety as a strategic priority in practical,
tangible actions and goals 2. Visible effective leadership from middle managers to
frontline workers 3. Cross departmental sharing of information, data, discussion, and
stories that provide knowledge, trust, and inspiration 4. Reporting systems that allow all
workers to share and learn from close calls and adverse events without fear or
retribution 5. Teams of individuals who support each other with technical expertise and
a shared commitment to clear communication and respect 6. Systems designed with
human factors in mind making it easier to do the right thing than the wrong thing 7.
Transparency of information shared within the organization and the community including
public officials, citizens, patients and families.
, ✔✔Pennsylvania's Act 52 of 2007 - ✔✔Institutions must report hospital acquired
infections to the Department of Health.
✔✔The Health Care Quality Improvement Act of 1986 - ✔✔Established National
Practitioner Data Bank to collect detrimental information so other state's PRO
organizations would have access to background knowledge in order to make an
informed decision regarding credentialing and privileges.
✔✔Health Care Quality Improvement Act of 1986's 4 pronged immunity test asks
whether the action was taken - ✔✔1. In the furtherance of quality health care 2. After
reasonable effort to obtain facts 3. After due process to the affected physician 4. Was
the action warranted by the facts known. If HCQIA immunity is found to exist, the
information cannot be used in a lawsuit.
✔✔Deficit Reduction Act of 2005 - ✔✔Requires the Secretary to identify conditions that
are 1. High cost or high volume 2. Result in the assignment of a case to a DRG that has
a higher payment when present as a secondary diagnosis 3. Could reasonably have
been prevented through the application of evidence based guidelines - resulted in Never
Events List
✔✔2008 Inpatient Prospective Payment System (IPPS) Fiscal Year 2009 Final Rule -
✔✔CMS published a list of 10 Never Events/Hospital Acquired Conditions that as of
October 1, 2008 had payment implications based on present on admission status.
✔✔2013 Inpatient Prospective Payment System - ✔✔Hospital Acquired Conditions list
was increased from 10 to 14
✔✔Patient Safety and Quality Improvement Act of 2005 - ✔✔Established to increase
reporting of adverse events and medical errors for data analysis and trending via a
voluntary reporting system. Defined patient safety as "work product" and provided
federal protections to providers. Went into effect in 2009.
✔✔2005's Patient Safety and Quality Improvement Act's provisions for confidentiality
protections and enforcement are handled by - ✔✔The Department of Health and
Human Services Office of Civil Rights
✔✔2005's Patient Safety and Quality Improvement Act's provisions for listing and
delisting of patient safety organizations are handled by - ✔✔Agency for Health Care
Research and Quality
✔✔2010 the Patient Protection and Affordable Care Act - ✔✔Enacted to increase the
quality and affordability of health insurance, lower the uninsured rate by expanding
public and private insurance coverage and reduce the costs of health care for
individuals and the government. Introduced mechanisms like mandates, subsidies and
ANSWERS SURE A+
✔✔Just Culture - ✔✔Developed by David Marx in 2007 to create a hierarchy of levels of
accountability for different behaviors: 1. Human error - inadvertent mistakes which
should managed by consoling the individual and making changes to processes,
procedures, training, and design 2. At risk behavior includes choices involving risk that
is not recognized or justified and should be managed by coaching the individual and
rewarding healthy behavior. 3. Reckless behavior includes conscious disregard of
unreasonable risk which should result in remedial and punitive actions. Is considered a
more appropriate evolution from the blame free environment first supported with the
advent of error transparency.
✔✔High Reliability Organizations - ✔✔Companies that work in complex, hazardous
industries and exemplify practices that demonstrate deep understanding of safety
✔✔High Reliability Organizations have a preoccupation with - ✔✔Failure
✔✔High Reliability Organizations consider errors to be - ✔✔Everyday occurrences,
inherent in systems and part of being human.
✔✔2005's Institute for Safe Medication Practices' 7 themes that contribute to high
reliability - ✔✔1. Sincere commitment to safety as a strategic priority in practical,
tangible actions and goals 2. Visible effective leadership from middle managers to
frontline workers 3. Cross departmental sharing of information, data, discussion, and
stories that provide knowledge, trust, and inspiration 4. Reporting systems that allow all
workers to share and learn from close calls and adverse events without fear or
retribution 5. Teams of individuals who support each other with technical expertise and
a shared commitment to clear communication and respect 6. Systems designed with
human factors in mind making it easier to do the right thing than the wrong thing 7.
Transparency of information shared within the organization and the community including
public officials, citizens, patients and families.
, ✔✔Pennsylvania's Act 52 of 2007 - ✔✔Institutions must report hospital acquired
infections to the Department of Health.
✔✔The Health Care Quality Improvement Act of 1986 - ✔✔Established National
Practitioner Data Bank to collect detrimental information so other state's PRO
organizations would have access to background knowledge in order to make an
informed decision regarding credentialing and privileges.
✔✔Health Care Quality Improvement Act of 1986's 4 pronged immunity test asks
whether the action was taken - ✔✔1. In the furtherance of quality health care 2. After
reasonable effort to obtain facts 3. After due process to the affected physician 4. Was
the action warranted by the facts known. If HCQIA immunity is found to exist, the
information cannot be used in a lawsuit.
✔✔Deficit Reduction Act of 2005 - ✔✔Requires the Secretary to identify conditions that
are 1. High cost or high volume 2. Result in the assignment of a case to a DRG that has
a higher payment when present as a secondary diagnosis 3. Could reasonably have
been prevented through the application of evidence based guidelines - resulted in Never
Events List
✔✔2008 Inpatient Prospective Payment System (IPPS) Fiscal Year 2009 Final Rule -
✔✔CMS published a list of 10 Never Events/Hospital Acquired Conditions that as of
October 1, 2008 had payment implications based on present on admission status.
✔✔2013 Inpatient Prospective Payment System - ✔✔Hospital Acquired Conditions list
was increased from 10 to 14
✔✔Patient Safety and Quality Improvement Act of 2005 - ✔✔Established to increase
reporting of adverse events and medical errors for data analysis and trending via a
voluntary reporting system. Defined patient safety as "work product" and provided
federal protections to providers. Went into effect in 2009.
✔✔2005's Patient Safety and Quality Improvement Act's provisions for confidentiality
protections and enforcement are handled by - ✔✔The Department of Health and
Human Services Office of Civil Rights
✔✔2005's Patient Safety and Quality Improvement Act's provisions for listing and
delisting of patient safety organizations are handled by - ✔✔Agency for Health Care
Research and Quality
✔✔2010 the Patient Protection and Affordable Care Act - ✔✔Enacted to increase the
quality and affordability of health insurance, lower the uninsured rate by expanding
public and private insurance coverage and reduce the costs of health care for
individuals and the government. Introduced mechanisms like mandates, subsidies and
