NAHQ CPHQ Exam Questions

Continuous survey readiness ensures that healthcare organizations are consistently prepared for accreditation surveys (e.g., Joint Commission, CMS) by maintaining compliance with standards. Tracers, which involve following a patient's care journey to assess compliance with standards, are a key tool for identifying gaps and ensuring ongoing readiness.

Option A (Facilitate a failure mode and effects analysis (FMEA) on patient consent): FMEA is a proactive risk assessment tool for specific processes, not a broad strategy for survey readiness. It may be used for targeted improvements but does not address overall compliance monitoring.

Option B (Conduct time studies for patient registration processes): Time studies are useful for process improvement (e.g., reducing wait times) but are not directly tied to survey readiness, which focuses on compliance with accreditation standards across multiple areas.

Option C (Map the value stream for elective surgery patients): Value stream mapping is a Lean tool for process optimization, not a method for ensuring survey readiness. It is too narrow in scope to address comprehensive compliance needs.

Option D (Perform tracers on patients in restraints): Tracers are a cornerstone of survey readiness, as they simulate the survey process by tracking patient care across departments to verify compliance with standards (e.g., restraint use, documentation, safety protocols). NAHQ CPHQ study materials recommend tracers as a best practice for continuous readiness, particularly for high-risk areas like restraint use, which is heavily scrutinized by accrediting bodies.

Detailed Explanation:

Before implementing new initiatives, a healthcare quality professional should assess their relevance to the organization's needs and context:

Option A: Determine the applicability of the initiatives to an organization

This is the most logical first step, as not all initiatives will be suitable or necessary for every organization. Evaluating applicability ensures that resources are focused on relevant initiatives.

Option B: Incorporate the initiatives into the organization's patient safety plan

This step follows once the initiatives have been deemed applicable andfit the organization's goals.

Option C: Collect data on the three initiatives

Data collection is essential for evaluating impact but should only be performed on initiatives relevant to the organization.

Option D: Assign owners to the identified initiatives

Assigning responsibility comes after determining which initiatives will be implemented.

CPHQ guidelines suggest evaluating the applicability of quality or safety initiatives to ensure that resources align with organizational priorities.

A quality improvement team is a group of people who work together to identify and solve problems in healthcare, improve service provision, and provide better outcomes for patients1.

One of the most widely used tools for the continuous improvement model is the plan-do-check-act (PDCA) cycle, which is a four-step quality assurance method2.

The PDCA cycle involves planning an improvement, testing it on a small scale, checking the results, and acting on the findings to either implement the change on a wider scale or start the cycle again with a different plan2.

The quality professional should stress the importance of making small changes in each cycle of change because this allows theteam to learn from each test, adapt to the local context, and avoid wasting resources on ineffective or harmful interventions3.

Making small changes also reduces the risk of resistance or backlash from stakeholders who may be affected by the change, as they can be involved in the testing and feedback process4.

Additionally, making small changes enables the team to measure the impact of each change and compare it with the baseline data, which helps to determine whether the improvement is achieving the desired outcomes5.

Therefore, the correct answer is A. making small changes in each cycle of change, as this is consistent with the principles and methods of quality improvement.Reference:

1: Quality improvement into practice | The BMJ

2: Continuous Improvement Model - Continual Improvement Tools | ASQ

3: PDSA Quality Improvement: A Scientific Method of Change

4: Different approaches to making and testing change in healthcare | The BMJ

5: Utilization of Improvement Methodologies by Healthcare Quality Professionals During the COVID-19 Pandemic | Journal for Healthcare Quality

The median is a measure of central tendency in statistics that represents the middle value of an ordered data set.

Data Set Ordering: To find the median, the data set must first be arranged in ascending or descending order.

Middle Value Identification: The median is the value that divides the data set into two equal parts, with 50% of the data points lying below it and 50% above it. If the number of observations is odd, the median is the middle number; if even, it is the average of the two middle numbers.

Robustness: Unlike the mean, the median is not affected by extreme values (outliers), making it a more robust measure of central tendency in skewed distributions.

NAHQ Study Guide on Statistical Methods in Quality Improvement.

Quality Management in Health Care, Chapter on Measures of Central Tendency.

The assessment reveals that while team member satisfaction and growth scores are high (96% and 95% respectively), team productivity is slightly lower at 90%. Since the desired patient outcome has not been achieved, it is important to identify and address any barriers that may be hindering the team's productivity. By evaluating these barriers, the team can better understand the factors impacting their ability to meet their goals, such as workflow inefficiencies, resource limitations, or external factors affecting performance.

The other options are less relevant in this context:

Developing interventions to maintain team member satisfaction (B) is unnecessary at this point, as satisfaction is already high.

Continuing to monitor as the team is performing within acceptable limits (C) does not address the fact that the desired outcomes have not been achieved.

Creating a reward system based on team member growth (D) is unrelated to the immediate issue of productivity and patient outcomes.

National Association for Healthcare Quality (NAHQ) - Certified Professional in Healthcare Quality (CPHQ) Study Materials.

Team Effectiveness and Productivity Barriers, NAHQ Documentation.