CPHRM cheat sheet

Four elements the plaintiff must prove in a malpractice claim, each by a preponderance of the evidence: duty, breach of the standard of care, causation (actual and proximate), and damages.

Statute of limitations is set by state law and runs from the date of injury; the discovery rule tolls accrual until the patient knew or reasonably should have known of the injury and its negligent cause.

Res ipsa loquitur permits an inference of negligence when the injury would not ordinarily occur absent negligence and the instrumentality was in the defendant's exclusive control.

Informed consent claims proceed as battery when no consent was obtained at all, and as negligence when consent was obtained but material risks were not disclosed.

Claims-made professional liability policies respond to claims first made and reported during the policy period, subject to the retroactive date; occurrence policies respond to the date of the act regardless of when reported.

Extended reporting period (tail) endorsements must be purchased within a defined window after a claims-made policy expires; verify tail cost at contract signing, not at expiration.

The National Practitioner Data Bank collects malpractice payments and adverse licensure or privileging actions; hospitals must query it at initial appointment and reappointment.

Common pre-suit procedural hurdles that shorten or bar a claim: notice-of-intent letters, expert certificate of merit or affidavit requirements, and state caps on noneconomic damages.

Destruction or alteration of records after litigation is reasonably anticipated supports spoliation sanctions, including an adverse inference instruction or a separate tort claim.

Joint Commission sentinel event definition: unexpected occurrence involving death, permanent harm, or severe temporary harm requiring intervention to sustain life; a root cause analysis and action plan are due within 45 calendar days.

Just Culture decision rule: human error → console and redesign systems; at-risk behavior → coach and remove incentives; reckless behavior → punitive or disciplinary response.

FMEA is prospective and scores risk priority number (RPN) = severity × occurrence × detection; RCA is retrospective and focuses on systems causes rather than individual blame.

Universal Protocol has three components: pre-procedure verification, site marking for laterality/involvement, and a time-out immediately before the procedure with the full team present.

High-alert medications (insulin, heparin, concentrated electrolytes, opioids, neuromuscular blockers) require standardized concentrations, independent double checks, and differentiated storage.

Additional harm-prevention bundles with proven effect: CLABSI (hand hygiene, maximal barrier, chlorhexidine, optimal site, daily line-necessity review) and CAUTI (appropriate indication, early removal).

Medication reconciliation is required at admission, transfer, and discharge; most reconciliation failures originate at transitions where the receiving clinician lacks an accurate prior list.

Communication failure is the most frequently cited root cause category in sentinel events; standardized handoff tools (SBAR, I-PASS) reduce omission of critical information.

IHI Global Trigger Tool methodology: retrospective random chart review that screens for predefined triggers (e.g., naloxone administration) and counts confirmed adverse events per 1,000 patient days.

EMTALA applies to any hospital with an emergency department that participates in Medicare: it requires a medical screening examination, stabilizing treatment, and restriction of transfer to medical-benefit or patient-request situations.

Credentialing requires primary source verification of licensure, education, training, and board status, plus OIG exclusion screening and an NPDB query; reappointment occurs at least every two years.

CMS Conditions of Participation deficiencies yield a plan of correction stating the corrective action, responsible party, and completion date; failure can escalate to termination from Medicare.

CMS emergency preparedness requires a risk-based all-hazards plan, an annual full-scale exercise, and a second exercise each year that may be a tabletop.

HCAHPS scores and the three Medicare value-based purchasing domains (clinical outcomes, safety, patient experience) directly adjust inpatient payment.

Never events (wrong-site surgery, retained foreign body, transfusion with wrong blood type) are reportable to state agencies and generally non-reimbursable under CMS payment policy.

Life Safety Code compliance requires documented fire drills once per shift per quarter, plus annual inspection and testing of fire detection and suppression systems.

Revenue cycle risk points: charge capture accuracy, ICD-10-CM/PCS coding specificity, medical necessity documentation, and recovery audit contractor targets such as one-day stays.

HIPAA breach notification timeline: notify affected individuals without unreasonable delay and no later than 60 days after discovery; notify HHS at the same time if 500 or more individuals are affected, and notify media if 500 or more reside in one state or jurisdiction.

The minimum necessary standard governs routine uses, disclosures, and requests of protected health information but does not apply to treatment disclosures or to disclosures to the patient.

Anti-Kickback Statute: criminal, intent-based, and covers remuneration intended to induce referrals of items or services payable by federal health care programs; safe harbors provide protection only if all conditions are met.

Stark Law: civil and strict liability, applying to physician referrals of designated health services to an entity with which the physician or an immediate family member has a financial relationship, absent an exception.

False Claims Act liability: treble damages plus per-claim penalties for knowingly false claims; qui tam relators may receive 15–30 percent of the recovery.

Medicare overpayments must be reported and returned within 60 days of identification; a retained identified overpayment creates potential reverse False Claims Act exposure.

PSQIA protects patient safety work product from discovery and disclosure; original medical records, billing information, and information required by law to be reported remain discoverable.

HCQIA grants limited antitrust immunity for professional review actions only when notice, hearing rights, and reasonable belief standards are satisfied.

Patient Self-Determination Act requires Medicare-participating hospitals to inform patients of advance directive rights and to document directives in the record, without requiring a directive as a condition of care.

Cost of risk = insurance premiums + retained losses (paid and reserved) + administrative and claims handling expense + risk control and loss prevention spending.

Expected loss for an exposure unit = loss frequency × average severity; funding decisions compare expected loss plus risk margin against the market premium.

Self-insured retention differs from a deductible in that the insured typically funds defense costs inside the retention and the carrier has no duty to defend until the SIR is exhausted.

Claims-made coverage requires two conditions: the act occurred on or after the retroactive date, and the claim was reported during the policy period or an extended reporting period.

IBNR reserves are actuarially estimated for losses incurred but not yet reported; reserve adequacy is tested with development factors and case reserve adequacy reviews.

The law of large numbers supports greater retention: as the number of independent, homogeneous exposure units grows, actual losses converge toward expected losses, reducing volatility.

Captive forms include single-parent, group, association, and risk retention groups; feasibility depends on capitalization, fronting arrangements, reinsurance, and premium volume sufficient to absorb fixed costs.

Risk retention groups formed under the Liability Risk Retention Act are regulated by their domiciliary state but must register and comply with certain non-domiciliary state requirements.

Renewal underwriting relies on loss runs showing paid and outstanding amounts by policy year; missing or incomplete loss runs should trigger a reservation of rights in the submission.