Regulatory
Care Excellence
Infection Prevention
Public Reporting
Patient Safety
100

Any manipulation of a sterile or nonsterile product intended to produce a sterile final product.

What is sterile compounding?

100

A proven, research-based approach using selected pre, intra, and post-operative interventions in concert to optimize outcomes and patient experience.

What is ESR?

100

Which organization does not provide HLD instructional guidance for processing medical equipment, devices and supplies?

SGNA

AORN

CDC

AAMI

TJC

TJC

100

This program encourages hospitals to improve the quality, efficiency, patient experience and safety of care that Medicare beneficiaries receive during acute care inpatient stays by:

  • Eliminating or reducing adverse events 
  • Adopting evidence-based care standards and protocols 
  • Incentivizing hospitals to improve patient experience.
  • Increasing the transparency of care quality for consumers, clinicians, and others.
  • Recognizing hospitals that provide high-quality care at a lower cost 

What is Hospital Value-Based Purchasing?

100

A patient safety event that results in death, permanent harm, or severe temporary harm.

What is a sentinel event?

200

Standardized, color coded, pediatric emergency measuring tape. This tape provides you with a rapid estimate of a child's weight based on their recumbent length.

What is a Broselow tape?

200

This program requires hospitals report their compliance with a multicomponent 3- and 6-hour treatment and resuscitation bundle for patients.

What is SEP-1?

200

What is the incubation period of B. pertussis?

2-3 days

3-5 days

7-10 days

>14 days

7-10 days

200

Most sophisticated and highly regarded overall measures of quality in health care, rating the benchmarked outcomes of cardiothoracic surgery programs in the U.S.

What is STS star rating?

200

The Facility Chief Executive Officer (CEO) or Administrator, in consultation with the Chief of the Medical Staff or Chief Medical Officer, has the primary responsibility to ensure that the patient/patient’s representative/family and/or support person is informed about the serious safety event.


What is disclosure?

300

Size of this unit cannot exceed 22,500 square feet maximum. This unit component includes rooms and corridors, and creates areas that may be accessed horizontally, which is the preferable method to rapidly move patients.

What is a smoke compartment?

300

Goal is to achieve 25% for this metric so as to improve maternal or newborn health outcomes.

What is NTSV C-section?

300

This negative outcome follows antimicrobial use, surely as night follows day.

What is antimicrobial resistance?

300

Assigned twice a year it uses more than 30 national performance measures.

What is the Leapfrog Hospital Safety Grade?

300

A member of nursing administration/management (e.g., nursing supervisor/manager, charge nurse, manager/director, CNO, etc.) will review the need for restraint or seclusion with the RN who has determined that the patient requires restraint or seclusion.

What is second tier review?

400

Has clearance for under the bottom of a door of 3/4” and clearance between door and frame is 1/8".

What is a fire door?

400

These goals are Specific, Measurable, Achievable, Realistic and anchored within a Time Frame.

What are SMART goals?

400

How often should propofol bottle and tubing be changed on patients who require this medication?

  • Every 12 hours
  • Every 24 hours
  • Every 48 hours
  • Every 96 hours

Every 12 hours.

400

This program measures PSI-90, CLABSI, CAUTI, C.Diff, MRSA, SSI-Colo and SSI-Hyst for value based purchasing. 

What is the HAC reduction program?

400

Occurs immediately prior to incision and/or start of procedure and initiated by the surgeon.

What is a time-out?

500

Is able to be activated hands-free (arms are ok) and remain flowing without requiring the use of the hand.

What are the requirements for an an eye wash station?

500

Monthly review of progress towards the goals with Facility and Division leadership.

What is CEMOR?

500

Can grow either aerobically or in the absence of oxygen (anaerobic conditions), but they generally do better with oxygen.

  • Aerobe
  • Obligate anaerobe
  • Facultative anaerobe
  • Microaerophilic aerobe

What is an Obligate anaerobe?

500

Designed for consumers to use along with their healthcare provider to make decisions on where to receive care.

What is Overall Hospital Quality Star Rating?

500

A written or verbal complaint by a patient, or the patient’s representative, regarding the patient’s care, abuse or neglect.

What is a grievance?