NAHQ Updated CPHQ Exam Questions and Answers by erica

Detailed Explanation:

To improve compliance with a corrective action plan, the QI professional should first identify the reasons for non-compliance. Conducting a root cause analysis (RCA) allows the QI professional to examine underlying factors and obstacles that may be hindering compliance. This information can then guide targeted interventions.

Option D: Determine areas of non-compliance through a root cause analysis

RCA is a structured approach to identifying underlying issues, which is critical in understanding why certain departments or individuals may not comply withcorrective actions. Once causes are identified, solutions can be tailored to address those specific barriers.

Option A: Provide disciplinary action to non-compliant departments

Disciplinary actions may not address the actual reasons behind non-compliance and can create resistance.

Option B: Provide an analysis for the Patient Safety Committee

This could be useful later but is not the first step to directly address compliance issues.

Option C: Determine if the action plan is in compliance with the national standards

Compliance with national standards is important but does not address specific compliance challenges within the organization.

A root cause analysis (RCA) is asystematic process of identifying the factors that contributed to an adverse event or near miss in order to prevent recurrence and improve patient safety1.

Alarm fatigue is a condition in which clinicians become desensitized to the numerous alerts and warnings generated by medical devices, leading to longer response times or missed alarms2.

Alarm fatigue can compromise patient safety by increasing the risk of adverse events, such as delayed treatment, missed diagnosis, or cardiac arrest3.

To reduce alarm fatigue, the Joint Commission recommends a four-step approach: establish alarm system management as a priority; identify the most important alarms to manage; establish policies and procedures for alarm system management; and educate staff and patients about alarm system management4.

The most appropriate first intervention for an event related to a delayed high-priority alarm response is to review alarm signals for clinical appropriateness. This means to evaluate the alarm settings, limits, and delays for each device and patient population, and adjust them according to evidence-based guidelines and best practices5. This can help reduce the number of false or clinically insignificant alarms, and improve the specificity and sensitivity of the alarm system.

Establishing a written policy for alarm escalation is also an important intervention, but it is not the first step. A policy for alarm escalation should define the roles and responsibilities of staff, the criteria and process for escalating alarms, and the expected response time and actions for each alarm level. However, before developing such a policy, it is necessary to review the alarm signals and ensure that they are clinically relevant and meaningful.

Implementing a guideline with clear criteria for initiation of cardiac monitoring is another intervention that can reduce alarm fatigue, but it is not the first step either. A guideline for cardiac monitoring should specify the indications, duration, and discontinuation of continuous electrocardiographic (ECG) monitoring for patients at risk of cardiac arrhythmias or ischemia. However, before implementing such a guideline, it is necessary to review the alarm signals and ensure that they are appropriate forthe patient population and clinical setting. References: 1: NAHQ Code of Ethics 2: Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue 3: Alarm fatigue: impacts on patient safety 4: The Joint Commission National Patient Safety Goal on clinical alarm safety 5: Alarm Management: Advancing From Failure Cause To Root Cause Analysis : [Utilization of Improvement Methodologies by Healthcare Quality Professionals During the COVID-19 Pandemic] : [The Financial Case for Quality as a Business Strategy] : [Shaping the Future of the Healthcare Quality Profession] : [PracticeStandards for Electrocardiographic Monitoring in Hospital Settings] : [Understanding the Evolving Landscape of Healthcare Quality]

A preventive care checklist is best suited to help identify health-determinant information in a patientpopulation. This type of data includes information on preventive health measures, such as screenings, vaccinations, and lifestyle interventions, which are crucial determinants of overall health. By analyzing this data, healthcare organizations can identify gaps in preventive care and address social determinants of health that may impact patient outcomes.

Payor claims (A): These primarily provide financial and utilization data, not health determinants.

Patient satisfaction (C): This measures perceptions of care quality but does not provide health determinant information.

Event reporting (D): This focuses on adverse events and safety issues, not on determinants of health.

References

NAHQ Body of Knowledge: Population Health Management and Social Determinants of Health

NAHQ CPHQ Exam Preparation Materials: Data Sources for Health Determinants

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A Pareto chart is ideal for identifying the most significant factors in a dataset. In this scenario, it can help highlight which individuals or roles are contributing most to incomplete documentation. By displaying the data in descending order of frequency, the Pareto chart allows for quick identification of the primary sources of documentation issues, enabling targeted quality improvement efforts.

Bar charts (Option B) display data but do not prioritize issues by frequency. Run charts (Option C) are used for data over time, and Gantt charts (Option D) are project management tools, not data analysis tools.