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107CH8A23

Terms in this set (23)

What is a piece of legislation written and approved by a state or federal legislature and then signed into law by the state's governor or the president?

a. Municipal code
b. Statute
c. Regulation
d. Judicial decision
b. Statute
What is it called when accrediting bodies such as the Joint Commission or AOA can survey facilities for compliance with the Medicare Conditions of Participation for Hospitals instead of the government?

a. Deemed status
b. Judicial decision
c. Subpoena
d. Credentialing
a. Deemed status
What is a rule established by an administrative agency of government called?

a. Regulation
b. Statute
c. Judicial decision
d. Regulation
a. Regulation
What is a mandatory process whereby state governments grant individual facilities permission to operate within a specific geopolitical area and provide a specific range of healthcare services?

a. Municipal code
b. Local Authority
c. Deemed status
d. Licensure
d. Licensure
General written guidelines that dictate behavior and/or direct and constrain decision making within the organization are known as what?

a. Procedures
b. Policies
c. Standards
d. Rules
b. Policies
Which of the following would be an acceptable medium for reporting an individual's positive HIV test results to a state department of health?

a. Certified e-mail
b. Certified courier
c. Telephone
d. Facsimile
b. Certified courier
Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients?

a. Priority focus review
b. Periodic performance review
c. Tracer methodology
d. Performance improvement
c. Tracer methodology
What is a systematic quality review process that evaluates the healthcare facility's performance against preestablished, written criteria, or standards?

a. Regulation
b. Credentialing
c. Privacy
d. Accreditation
d. Accreditation
The Joint Commission has accreditation decision categories. What is not one of them?

a. Secondary Accreditation
b. Denial of Accreditation
c. Preliminary Accreditation
d. Conditional Accreditation
a. Secondary Accreditation
When is the timeframe for an unannounced survey after a full survey?

a. 1-3 months
b. 1-12 months
c. 12-18 months
d. 18-36 months
d. 18-36 months
What does PHI stand for?

a. Protected health informatics
b. Privileged health information
c. Private health information
d. Protected health information
c. Private health information
Which Joint Commission accreditation activity focuses survey activities on the organization-specific issues that are most relevant to safety and quality of care?

a. Periodic performance review
b. Presurvey review
c. Tracer process
d. Priority focus process
d. Priority focus process
Which of the following accreditation categories would the Joint Commission assign to a hospital that is not in substantial compliance with applicable standards and must remedy identified problem areas through preparation and submission of ESC and subsequently undergo on on-site, follow-up survey

a. Provisional accreditation
b. Preliminary accreditation
c. Accredited
d. Conditional accreditation
a. Provisional accreditation
What does the Joint Commission call unexpected occurrences that result in death or serious physical or psychological injury or the risk of death or serious injury?

a. Priority focus areas
b. Practice guidelines
c. Sentinel events
d. Medical errors
c. Sentinel events
What type of organization works under contract with the CMS to conduct Medicare/Medicaid certification surveys for hospitals?

a. Accreditation organizations
b. Certification organizations
c. State licensure agencies
d. Conditions of participation agencies
c. State licensure agencies
Written instructions that describe how functions and processes must be carried out are:

a. Procedures
b. Policies
c. Standards
d. Rules
a. Procedures
7. What does the Joint Commission call its accreditation and survey process?

a. Periodic Performance Review
b. Joint Commission Hospital Accreditation Program
c. Patient Tracer Methodology
d. Priority Focus Assessment
b. Joint Commission Hospital Accreditation Program
This purpose of this program is to reduce improper Medicare payments and prevent future improper payments made of claims of healthcare services?

a. Diagnostic-related groups
b. Recovery audit contractors
c. Medicare Conditions of Participation
d. HIPAA
b. Recovery audit contractors
What is the difference between monitoring and auditing?

a. Monitoring is more formal and auditing is more informal
b. Both are formal
c. Monitoring is less formal and auditing is more formal
d. Both are informal
c. Monitoring is less formal and auditing is more formal
Which is not a CMS quality measure that is reported by hospitals?

a. Heart Attack
b. Heart Failure
c. Kidney Failure
d. Pneumonia
c. Kidney Failure
The goal of _____ is to improve the quality of patient care while simultaneously decreasing healthcare costs?

a. Recovery Audit Contractors
b. Code of Federal Regulations
c. Privacy and Security Act
d. HITECH Act
d. HITECH Act
True or false? A hospital is required to use and disclose PHI without an individual's authorization?

a. True
b. False
b. False
According to the Joint Commission, how should the unanticipated death of a full-term infant be reported?

a. As a sentinel event
b. As a violation of a clinical practice guideline
c. As an unfortunate accident
d. As a medical complication
a. As a sentinel event
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