NAHQ Updated CPHQ Exam Questions and Answers by arjun

Incident reporting systems are tools to collect and analyze data onpatient safety incidents, such as medication errors, falls, infections, and adverse events12.

Incident reporting systems can help identify patterns, trends, and areas of improvement for patient safety and quality of care123.

The graph shows the incident rates for one facility compared to similar facilities in four categories: medication, falls, infection, and adverse events. The graph indicates that the facility has a higher incident rate for falls than the average of similar facilities, while the other categories are comparable or lower4.

Therefore, the first step after reviewing the graph should be to perform additional analysis on falls data, such as the types, causes, consequences, and contributing factors of falls incidents, and compare them with the best practices and standards for falls prevention and management567.

This will help the facility to understand the root causes of the high falls incident rate, and to develop and implement appropriate interventions to reduce the risk and harm of falls for patients567.

Reviewing medication processes, researching best practices, and sharing data with the governing body are also important steps, but they should be done after the additional analysis on falls data, as they are more general and less specific to the problem identified by the graph4. References: 1: Patient Safety Incident Reporting and Learning Systems | WHO 2: Incident Reporting: Key to Successful Healthcare Organizations | SafeQual 3: Report a patient safety incident | NHS England 4: Data from an Incident reporting system compares Incident rates for one facility to similar facilities | User-uploaded image 5: Falls Prevention and Management | NAHQ 6: Preventing Falls in Hospitals | Agency for Healthcare Research and Quality 7: Falls Prevention and Management | Institute for Healthcare Improvement

Detailed Explanation:

Reviewing resources, capabilities, and core competencies is essential for assessing project feasibility by determining if the organization has the necessary resources and skills.

Option C: Reviewing resources, capabilities, and core competencies

This action assesses the internal factors that impact an organization’s ability to undertake projects.

The Quality Council oversees quality improvement initiatives and must prioritize requests to allocate resources effectively, given multiple competing demands.

Option A (Review patient satisfaction to verify problem areas): Patient satisfaction data may inform some requests (e.g., meal delivery, room turnaround), but not all (e.g., overtime, equipment) are directly patient-facing, and verification is a secondary step.

Option B (Obtain CFO approval): CFO approval may be needed for funding but is not the first step, as prioritization determines which initiatives to pursue.

Option C (Determine team leaders): Assigning leaders follows prioritization, as teams are formed for selected initiatives.

Option D (Prioritize the requests): This is the correct answer. The NAHQ CPHQ study guide states, “When faced with multiple improvement requests, a Quality Council should first prioritize based on impact, risk, and alignment with organizational goals” (Domain 4). For example, meal delivery and room turnaround may directly affect patient experience, while equipment issues pose safety risks, requiring a prioritization framework like a scoring matrix.

CPHQ Objective Reference: Domain 4: Performance and Process Improvement, Objective 4.2, “Prioritize performance improvement activities,” emphasizes prioritizing based on impact and goals. The NAHQ study guide notes, “Quality Councils use prioritization to manage competing demands effectively” (Domain 4).

Rationale: Prioritizing requests ensures resources are allocated to high-impact initiatives, aligning with CPHQ’s improvement principles.

The data shows variable compliance rates for pain assessment across different staff groups, with physicians having the lowest rates (20–50%), nurses the highest (75–83%), and physical therapists in between (50–60%). To improve performance, the next step should address the identified gaps through a structured intervention, leveraging data to drive action.

Option A (Disseminate the results to nursing staff): Disseminating results to nursing staff alone is insufficient, as their compliance rates are already high (75–83%). The focus should be on lower-performing groups (physicians and physical therapists), and dissemination without a plan does not ensure improvement.

Option B (Hire a pain management specialist): Hiring a specialist may be premature without first analyzing the root causes of low compliance. This option assumes a lack of expertise is the issue, which is not supported by the data alone.

Option C (Continue monitoring for another quarter): Continuing to monitor without intervention delays action on clear performance gaps, particularly for physicians (20% in March). CPHQ principles emphasize acting on data to drive improvement rather than passive monitoring.

Option D (Create an action plan with the department leaders): This is the most appropriate next step, as it involves collaboration with leaders from all relevant departments (physicians, nurses, physical therapists) to address specific compliance gaps. NAHQ study materials advocate for data-driven action plans that engage stakeholders to identify causes (e.g., training needs, workflow issues) and implement targeted interventions, aligning with performance improvement methodologies like Plan-Do-Study-Act (PDSA).