NAHQ CPHQ - Certified Professional in Healthcare Quality Examination

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

=========

The NAHQ CPHQ exam blueprint defines surveillance as the ongoing, systematic collection, analysis, and interpretation of health-related data to identify trends, patterns, and outbreaks.

Option D is correct because identifying disease outbreaks using population-level and laboratory data exemplifies surveillance in action.

Option A is reporting, not surveillance. Option B is clinical assessment. Option C is program evaluation.

The CPHQ framework highlights surveillance as a proactive public health and patient safety function, making Option D the correct answer.

Per the NAHQ CPHQ exam blueprint, clinical pathways are clinician-driven tools based on evidence-based practice. The role of the quality specialist is to support, not direct, clinical decision-making.

Option A is correct because quality specialists contribute data analysis, evidence synthesis, and performance information to inform pathway development. Clinicians use this information to design pathways aligned with best practice.

Option B is typically a clinical leadership role. Option C is inappropriate because pathway development requires clinical expertise. Option D occurs after implementation.

The CPHQ framework stresses collaboration, with quality professionals acting as facilitators and data experts, making Option A correct.

 One of the first steps in preparing for an organizational accreditation survey is to conduct a gap analysis of the identified standards against current practices123. This involves understanding the accreditation standards and reviewing adherence to these standards before applying for accreditation1. A gap analysis helps identify areas of weakness or nonconformance to the standards2. This process is crucial in setting up the organization for success in the accreditation survey1.

Detailed Explanation:

Case managers coordinating post-discharge care directly support smooth transitions by managing follow-up care needs, especially important in avoiding readmissions.

Option B: Using a case manager to coordinate post-discharge care needs with patients and families

This method ensures continuity of care and communication across settings.

The question implies that the readmission data for the 2nd quarter has been reviewed, and specific units (e.g., 2 South and 3 North) likely show higher readmission rates, prompting the need to identify improvement opportunities. Health data analytics involves using data to identify trends, prioritize areas of concern, and drive targeted interventions. Further analysis of specific units with elevated readmissions is a logical next step to uncover root causes.

Option A (Take no further action because the data is not definitive): This option is inappropriate, as quality professionals are expected to act on data trends, even if preliminary, to drive improvement. Waiting for “definitive” data risks delaying interventions and contradicts CPHQ principles of proactive quality management.

Option B (Use a scattergram to look for an association between readmissions and unit): A scattergram (or scatter plot) is useful for exploring correlations between two variables (e.g., readmissions vs. staffing levels). However, the question suggests the data already highlights specific units (2 South and 3 North), so a scattergram is less relevant than analyzing those units directly.

Option C (Further analyze 2 South and 3 North to determine possible causes): This is the most appropriate action, as it focuses on the units with likely higher readmission rates. According to NAHQ study materials, quality professionals should use data to drill down into specific areas of concern, applying tools like root cause analysis or process mapping to identify underlying causes. This aligns with the CPHQ domain of Health Data Analytics, which emphasizes targeted data analysis to drive improvement.

Option D (Meet with the Quality Council to share the results for 4 North and 4 South): The question does not indicate that 4 North and 4 South are the units with high readmissions. Focusing on these units without evidence is premature, and meeting with the Quality Council is a later step after causes are identified.

Anonymous surveys are one of the most effective tools for evaluating the current culture of safety in a healthcare organization123. These surveys, such as the Hospital Survey on Patient Safety Culture123, are designed to measure the attitudes and perceptions of staff towards patient safety. They provide a confidential and non-punitive way for staff to express their views and experiences related to patient safety123.

Anonymous surveys can reach a large number of staff members, providing a broad view of the safety culture across the organization123. They can identify areas of strength and areas that need improvement, which can inform safety improvement strategies123.

Therefore, the answer is option A: anonymous surveys. This tool allows for a comprehensive and honest assessment of the safety culture, which is crucial for improving patient safety123.

Secondary prevention in healthcare is primarily intended to focus on the early detection and treatment of disease12. This level of prevention is about detecting and treating disease early, often before symptoms are present, thus minimizing serious consequences2. It includes measures taken during an interaction between an individual patient and a clinician1. Examples of secondary prevention include screening programs, such as mammography to detect breast cancer and dual x-ray absorptiometry (DXA) to detect osteoporosis2. Therefore, the answer is option C: focus on early detection and treatment of disease.

 The annual evaluation of a quality improvement process should be based on organizational objectives. This is because the quality improvement process is designed to enhance the effectiveness and efficiency of an organization’s operations and align them with the organization’s strategic goals12. The AAAHC (Accreditation Association for Ambulatory Health Care) requires that documentation demonstrates at least an annual governing body review of the Quality Improvement (QI) program to evaluate effectiveness anddetermine if the purposes and objectives continue to be met3. Therefore, the annual evaluation of a quality improvement process must be based on organizational objectives to ensure that the process is effectively contributing to the achievement of these objectives.

A safety culture emphasizes systems thinking, non-punitive responses, and learning from incidents to improve processes, rather than blaming individuals.

Option A (Acknowledge the injuries as systems errors): This is the correct answer. The NAHQ CPHQ study guide states, “A safety culture acknowledges incidents like falls as systems errors, focusing on process improvements rather than individual blame” (Domain 1). This approach encourages reporting and systemic fixes, such as better lighting or protocols.

Option B (Hold the unit manager responsible for the increase): Blaming the manager is punitive and undermines a safety culture.

Option C (Require training of involved staff): Training may be part of a solution but assumes individual failure, not addressing system issues first.

Option D (Place involved staff on a corrective action plan): Corrective action is punitive, discouraging reporting and contrary to safety culture principles.

CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.2, “Promote a culture of safety,” emphasizes systems-based responses. The NAHQ study guide notes, “Recognizing falls as systems errors fosters a non-punitive safety culture” (Domain 1).

Rationale: Acknowledging falls as systems errors promotes learning and improvement, aligning with CPHQ’s safety culture principles.

 When planning an initiative to reduce barriers to healthcare in the community, it’s important to understand the demographic makeup of the area. This includes information about occupations and housing types, which can provide insights into socioeconomic status, access to transportation, and other factors that may affect healthcare access.

Community planning maps showing transportation routes (Option A) could be useful in later stages of planning, particularly when considering the location of healthcare facilities or services. However, this information is not as fundamental as demographic data for initial planning.

Reports from the public health department showing pediatric obesity rates (Option C) could be relevant if the initiative specifically targets pediatric health or obesity. However, for a general initiative to redu

Detailed Explanation:

The CNO as project sponsor provides high-level support, while the staff nurse in the ED as champion ensures buy-in from frontline staff.

Option C: Staff nurse ED as champion and CNO as project sponsor

This combination provides both leadership support and frontline engagement, which are essential for successful implementation.

Human factors design is the discipline concerned with the understanding and improvement of the interactions among humans and other elements of a system, such as technology, processes, workflows, teams, and environments12.

Human factors design aims to optimize human well-being and overall system performance, which includes patient safety12.

One of the domains of human factors design is physical ergonomics, which deals with the design of workplaces, equipment, and tasks to fit the physical capabilities and limitations of humans23.

A common problem in healthcare settings is the risk of occupational injuries and patient harm due to unsafe patient handling, such as lifting, transferring, or repositioning patients34.

A human factors design solution for this problem would be to provide new lift equipment that is accessible at the point of care, so that nursing staff can use it whenever they need to handle patients safely and comfortably34.

This solution would reduce the physical strain and fatigue on the nursing staff, as well as the potential for patient falls, pressure ulcers, or other adverse events34.

This solution would also improve the efficiency and quality of care, as nursing staff would spend less time and effort on patient handling and more time on other aspects of care34.

Therefore, option B is the best example of a human factors design solution for this scenario, as it addresses the physical ergonomics of the system and improves both human well-being and system performance.

Option A, development of an organizational minimal lift policy, is not a human factors design solution, but a policy intervention that may or may not be effective depending on the availability and usability of the lift equipment3.

Option C, a daily email with safe patient handling reminders, is not a human factors design solution, but a communication intervention that may or may not be followed by the nursing staff depending on their workload and motivation3.

Option D, an education module on safe patient handling, is not a human factors design solution, but a training intervention that may or may not be sufficient to change the behavior and skills of the nursing staff depending on the quality and frequency of the training3. References: 1: Human factors and ergonomics as a patient safety practice 2: Module 2: Human Factors Design: Applications for Healthcare 3: Human factors engineering can improve patient safety 4: Human factors engineering in patient safety

All of the options listed can be used to assess a population’s health status123.

County birth rate (A): This is ademographic indicator that can provide insights into the health status of a population. It can indicate trends in fertility, which can be linked to various health or social factors.

Retrospective chart audits (B): These can provide valuable data on patient outcomes, care processes, and adherence to clinical guidelines. They are often used in healthcare quality improvement to identify areas where care could be improved.

Clinical disease registries ©: These registries collect data on patients with specific diseases. This data can be used to track the health status of a population, identify trends in disease prevalence or outcomes, and evaluate the effectiveness of treatment strategies.

Core measure performance (D): Core measures are standardized indicators that allow for comparisons across different healthcare providers or systems. They can provide insights into the quality of care provided and the health outcomes achieved by a population.

Therefore, all of these data sources can be used to assess a population’s health status. It’s important to note that the choice of data source may depend on the specific health indicators of interest and the resources available for data collection and analysis123.

Establishing a Quality Council involves defining its purpose and focus to guide quality improvement efforts effectively.

Option A (Educate members on regulatory processes): Education is important but follows setting priorities to ensure relevance.

Option B (Identify quality priorities): This is the correct answer. The NAHQ CPHQ study guide states, “After forming a Quality Council, the next step is to identify quality priorities based on data and organizational needs to focus improvement efforts” (Domain 3). For a behavioral health center, priorities might include suicide prevention or medication safety.

Option C (Charter project improvement teams): Chartering teams follows priority identification.

Option D (Develop quality indicators): Indicators are developed after priorities are set to measure progress.

CPHQ Objective Reference: Domain 3: Organizational Leadership, Objective 3.1, “Establish Quality Council priorities,” emphasizes setting priorities. The NAHQ study guide notes, “Identifying priorities guides the council’s work” (Domain 3).

Rationale: Identifying priorities ensures the council’s focus, aligning with CPHQ’s leadership principles.