CPHQ Exam Dumps - NAHQ CPHQ Certification Questions and Answers

A strategy to address social determinants of health involves creating patient education materials that are culturally competent. Culturally competent materials consider the cultural, linguistic, and literacy needs of the patient population, making the information accessible and relevant. This approach helps to bridge gaps in understanding and engagement, which are often influenced by social determinants such as education, income, and cultural background.

Launch a community campaign to promote influenza vaccines (A): While important for public health, this is not directly focused on social determinants of health.

Identify high-risk patients with high-cost medications (B): This is more related to cost management and clinical care than addressing social determinants.

Implement a standard questionnaire for pediatric lead screening (D): This addresses a specific health issue but does not broadly address social determinants of health.

References

NAHQ Body of Knowledge: Addressing Social Determinants of Health in Healthcare

NAHQ CPHQ Exam Preparation Materials: Culturally Competent Care and Education

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The development of priorities in any organization, including healthcare, is best facilitated by comparing target versus actual performance12. This approach allows organizations to identify areas where performance is not meeting expectations and prioritize efforts to address these gaps12. This process involves setting clear goals, establishing benchmarks for performance, and regularly reviewing progress3. When actual performance falls short of the target, this indicates a priority area for improvement12.

The other options, while important in the overall management and improvement of performance, do not directly facilitate the development of priorities12. Creating a plan to evaluate performance (Option B) is a part of the performance management process, but it does not in itself help to establish priorities12. Surveying staff for potential priorities (Option C) can provide valuable insights, but it is the comparison of actual performance against targets that will objectively identify priority areas12. Selecting valid and reliable metrics for the balanced scorecard (Option D) is crucial for measuring performance, but again, it is the comparison of these metrics against targets that will highlight the areas that need to be prioritized12.

To properly assess the cost and utilization patterns in the population health program, it is essential to understand the volume of patients being discharged to various post-acute care settings. By requesting the total number of patients discharged to each location, the healthcare quality professional can calculate the average cost per patient, which is crucial for assessing efficiency and for comparing costs across different discharge locations. This data will also allow for an evaluation of utilization patterns and help identify if certain locations are being used more frequently and if the associated costs are justified based on patient outcomes.

References:The response aligns with healthcare quality improvement practices that prioritize a comprehensive understanding of patient flow and associated costs, as recommended by the NAHQ. This includes analysis of patient discharge patterns and post-discharge care utilization as foundational data for assessing quality and cost in healthcare delivery.

An organization's culture is best assessed by examining the behavioral alignment with its core values. Culture is reflected in how closely the actions, decisions, and behaviors of employees at all levels align with the organization’s stated values. When there is strong alignment, it indicates a cohesive culture that reinforces the organization's mission and vision. Conversely, a disconnect between behaviors and core values can signal cultural issues that need to be addressed.

Collaboration of medical staff and administration (B): Collaboration is important but is just one aspect of culture.

Number of performance improvement activities (C): The quantity of activities doesn’t necessarily reflect cultural values or behaviors.

Involvement of each patient care department in strategic planning (D): While important, involvement in planning is more related to governance and strategy than to overall culture.

References

NAHQ Body of Knowledge: Organizational Culture and Core Values

NAHQ CPHQ Exam Preparation Materials: Assessing and Aligning Organizational Culture

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The first step for a quality improvement professional who believes that their MRSA facility rates are high is to contact the infection control practitioner to obtain benchmark data. Benchmark data are comparative data that can help identify gaps in performance and set realistic and achievable goals for improvement 1. Benchmark data can be obtained from various sources, such as national or regional databases, professional organizations, peer-reviewed literature, or other similar facilities 2.

By contacting the infection control practitioner, the quality improvement professional can access reliable and valid data on MRSA rates in their facility and compare them with other facilities or standards. This can help them determine the magnitude and significance of the problem, and whether it warrants further investigation and action. The infection control practitioner can also provide guidance on the best practices and protocols for preventing and controlling MRSA infections, and the potential risk factors and causes of high MRSA rates 3.

The other options are not the best first steps for the quality improvement professional. Reporting the concerns to senior management and the Quality Council (option B) may be premature and unnecessary without having sufficient evidence and analysis of the problem. Forming a quality improvement team (option C) may be helpful later in the process, but not before defining and measuring the problem. Repeating the data collection process to justify the new rate (option D) may be wasteful and inaccurate, as it may not account for the variability and trends in the data, and it may not address the underlying causes of the problem . References:

1: NAHQ Healthcare Quality Competency Framework, Domain 5: Data Analytics, Skill 5.1.1

2: Benchmarking in Healthcare: A Practical Approach | NAHQ

3: Success and failures in MRSA infection control during the COVID-19 pandemic | Antimicrobial Resistance & Infection Control | Full Text 2

: NAHQ Healthcare Quality Competency Framework, Domain 3: Performance and Process Improvement, Skill 3.1.1

A performance improvement plan (PIP) is a set of focused activities designed to monitor, analyze, and improve the quality of processes and outcomes in a healthcare organization12.

A PIP should be aligned with the strategic goals of the organization, which are the long-term objectives that reflect the vision, mission, and values of the organization3.

To align a PIP with strategic goals, a healthcare quality professional should consider the following factors45:

Customer expectations: These are the needs, preferences, and perceptions of the patients, families, and other stakeholders who receive or are affected by the healthcare services. Customer expectations are a key driver of quality improvement, as they reflect the degree of satisfaction and loyalty of the customers. Customer expectations can be measured by surveys, feedback, complaints, and compliments6 .

Benchmarking data: These are the comparative data that show how the organization performs relative to other similar or best-in-class organizations in terms of quality, efficiency, and effectiveness. Benchmarking data can help identify gaps, opportunities, and best practices for improvement. Benchmarking data can be obtained from external sources, such as national databases, accreditation agencies, or professional associations, or from internal sources, such as historical data, peer groups, or departments .

Patient outcome data: These are the data that show the results or impacts of the healthcare services on the health status, quality of life, and satisfaction of the patients. Patient outcome data are the ultimate indicators of quality improvement, as they reflect the effectiveness and value of the healthcare services. Patient outcome data can be measured by clinical indicators, such as mortality, morbidity, complications, or readmissions, or by patient-reported indicators, such as functional status, symptom relief, or experience of care .

By considering these factors, a healthcare quality professional can align a PIP with strategic goals in the following ways45:

Identify the strategic goals and priorities of the organization and ensure that they are clear, specific, measurable, achievable, relevant, and time-bound (SMART).

Assess the current performance of the organization in relation to the strategic goals and priorities, using customer expectations, benchmarking data, and patient outcome data as sources of information and evidence.

Identify the gaps and opportunities for improvement based on the assessment of the current performance and the comparison with the strategic goals and priorities.

Develop and implement improvement actions that address the gaps and opportunities for improvement, using evidence-based methods and tools, such as the Plan-Do-Study-Act (PDSA) cycle, root cause analysis, or process mapping.

Monitor and evaluate the improvement actions and their effects on the performance of the organization, using customer expectations, benchmarking data, and patient outcome data as measures of success and feedback.

Communicate and disseminate the improvement results and the lessons learned to the relevant stakeholders, such as the leadership, staff, customers, and partners, and celebrate the achievements and recognize the contributions.

Review and revise the improvement actions and the PIP as needed, based on the monitoring and evaluation results and the changing needs and expectations of the customers and the organization.

References:

1: Health Care Quality Improvement (QI) Action Plan Template 2: Quality Improvement (QI) Toolkit with Templates, Instructions, and … 3: The Top 4 Examples of Quality Improvement in Healthcare 4: Model Quality & Performance Improvement Plan 5: 8 Examples Of Quality Improvement Initiatives In Healthcare 6: [Shaping the Future of the Healthcare Quality Profession] : [The Role of the Healthcare Quality Professional in Population Health Management] : [Healthcare Quality Solutions: Ready Your Workforce for Quality] : [HQ Principles] : [The Financial Case for Quality as a Business Strategy] : [Utilization of Improvement Methodologies by Healthcare Quality Professionals During the COVID-19 Pandemic]

When a hospital receives incident reports describing falls, it is crucial to review these reports to identify contributing factors1. This process is part of ‘Incident Reporting in Healthcare,’ which aims to highlight an emerging problem in a non-blaming way to root out the cause of the error or the contributing factors1. By identifying these factors, the hospital can take appropriate measures to prevent future incidents and improve patient safety1.

While options A, B, and C are also important steps in managing incident reports, option D is the most immediate and crucial action. Comparing details from the incident reports against current fall prevention procedures (option A) and ensuring each report is correctly linked to the appropriate patient health record (option B) are steps that can be taken after the initial review. Separating incident reports based on injury status (option C) can be part of the analysis process after identifying contributing factors.

References: 

https://www.quasrapp.com/blog/incident-reporting-in-healthcare/

Before making recommendations to leadership, the quality professional should prepare a comparative analysis based on the information gathered. This analysis should compare the capabilities, limitations, costs, and benefits of the existing system and the alternative products identified. A thorough comparative analysis will provide leadership with a clear understanding of the options available, enabling them to make an informed decision on whether to upgrade the current system or switch to a new one.

Conduct a focus group with participants from other sites within the organization (B): This might provide additional insights but should be part of the comparative analysis process rather than a standalone action.

Interview current users of the other identified products (C): This can inform the comparative analysis but is not a replacement for a comprehensive comparison.

Create a potential implementation plan for the preferred product (D): This should follow the decision-making process, not precede it.

References

NAHQ Body of Knowledge: Evaluation and Selection of Quality Improvement Tools

NAHQ CPHQ Exam Preparation Materials: Decision-Making in Quality Management

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