NAHQ Updated CPHQ Exam Questions and Answers by aadam

Physician quality data reports for all credentialed physicians disseminated at regular intervals, as generally mandated by accreditation standards, are referred to as ongoing professional practice evaluation (OPPE).

Ongoing Professional Practice Evaluation (OPPE): OPPE is a continuous evaluation of a provider’s performance at a frequency greater than every 12 months1. It involves a peer review process, where practitioners are reviewed by other practitioners of the same discipline and have personal knowledge of the applicant2. The purpose of OPPE is to ensure that the hospital, through the activities of its medical staff, assesses a practitioner’s clinical competence and professional behavior on an ongoing basis3.

Focused Professional Practice Evaluation (FPPE): FPPE is a process whereby the medical staff evaluates the privilege-specific competence of the practitioner that lacks documented evidence ofcompetently performing the requested privilege(s) at the organization4. It is not a regular, ongoing process, but rather is implemented whenever a question arises regarding a practitioner’s ability to provide safe, high-quality patient care5.

CMS Star Ratings: The CMS Star Ratings system is a consumer-oriented system developed by the Centers for Medicare & Medicaid Services (CMS) to help consumers compare the quality of health and drug plans67. It is not a regular report disseminated for all credentialed physicians.

Quality Spot Checks: Quality spot checks refer to a random inspection or review of a specific aspect or area within a company’s operations8. They are often used to monitor quality control, identify fraud, or ensure adherence to regulations. However, they are not specifically related to physician quality data reports910.

Therefore, the correct answer is D. ongoing professional practice evaluation (OPPE), as it best fits the description of physician quality data reports for all credentialed physicians disseminated at regular intervals, as generally mandated by accreditation standards.

A scatter diagram is a graphical tool that displays the relationship between two variables by plotting pairs of data points on a coordinate plane. It can help identify possible correlations, trends, outliers, and patterns in the data.

A Pareto chart is a type of bar chart that shows the frequency or impact of different factors or causes in descending order, along with a cumulative line that indicates the percentage of the total. It can help prioritize the most significant issues or opportunities for improvement.

A fishbone diagram is a visual tool that helps identify the root causes of a problem or effect by organizing possible factors into categories, such as people, process, environment, etc. It can help facilitate brainstorming and root cause analysis.

A histogram is a type of bar chart that shows the distribution of a continuous variable by grouping the data into bins of equal width and displaying the frequency or count of each bin. It can help describe the shape, center, spread, and outliers of the data.

In this case, the long-term care facility wants to analyze the relationship between two variables: the number of medications and the number of falls. Therefore, a scatter diagram is the most appropriate tool to help them understand the data. A scatter diagram can show if there is a positive, negative, or no correlation between the two variables, and how strong or weak the correlation is. It can also reveal any outliers or clusters of data points that may indicate other factors affecting the relationship.

A Pareto chart, a fishbone diagram, and a histogram are not suitable tools for this purpose, as they do not show the relationship between two variables. A Pareto chart can show the relative importance of different factors or causes, but not how they are related to each other. A fishbone diagram can help identify the possible causes of a problem or effect, but not how they are quantitatively related to each other. A histogram can show the distribution of a single variable, but not how it is influenced by another variable.

A statistical process control (SPC) chart, such as a control chart, is used to monitor process performance over time, distinguishing between common-cause variation (inherent to the process) and special-cause variation (due to specific factors). In this scenario, the SPC chart tracks compliance with a revised medication reconciliation process over 21 months. According to NAHQ CPHQ study materials, interpreting an SPC chart involves analyzing trends, shifts, and patterns within the data points relative to the control limits and centerline (mean).

Since the chart is not provided, I’ll consider a typical scenario for a performance improvement context. The question implies the performance improvement coordinator is evaluating long-term performance, and the options suggest looking for trends or changes in compliance. Option D, “There is an increasing trend toward compliance in recent months,” aligns with a common SPC chart interpretation where a trend is identified by a consistent direction in data points over time. In SPC terms, an increasing trend is often defined as six or more consecutive points moving upward, indicating a positive shift in the process (e.g., improved compliance). This interpretation is reasonable for a 21-month period where recent months show improvement, suggesting the revised process is gaining traction.

Option A, “The data indicate compliance has decreased,” would require a downward trend or a shift below the centerline with special-cause variation, which is less likely if the process has been in place for 21 months and improvements are expected. Option B, “The data are inconclusive, and additional monitoring is required,” would apply if the chart shows random variation within control limits with no clear trend or shift, but this is less actionable for a performance improvement coordinator evaluating a mature process. Option C, “The number of compliant clinicians has increased,” is too specific, as the chart likely measures overall compliance rates (e.g., percentage of compliant reconciliations), not individual clinician counts. NAHQ emphasizes identifying trends in SPC charts to guide improvement actions, making option D the most likely conclusion if recent months show an upward trend.

A fishbone diagram, also known as an Ishikawa or cause-and-effect diagram, helps teams systematically identify potential causes of a problem. It visually organizes possible contributing factors to facilitate root cause analysis.