CPHQ Exam Dumps - Certified Professional in Healthcare Quality Examination

Continuous readiness for unannounced accreditation surveys requires a culture of ongoing compliance, engaging all staff to maintain standards.

Option A (Placing "accreditation survey items" on meeting agendas immediately before the survey occurs): This is reactive, not continuous, as unannounced surveys require year-round readiness.

Option B (Encouraging all staff to take ownership): This is the correct answer. The NAHQ CPHQ study guide states, “Continuous readiness programs should encourage all staff to take ownership of compliance with accreditation standards, fostering a culture of preparedness” (Domain 4). This ensures sustained engagement.

Option C (Creating policies that mimic the accreditation organization’s policies, even when at odds with the institution’s culture): Policies should align with standards but adapt to the organization’s culture for sustainability.

Option D (Identifying a few champions to be available for surveys): Champions support readiness but relying on a few limits broad staff engagement.

CPHQ Objective Reference: Domain 4: Performance and Process Improvement, Objective 4.7, “Develop continuous readiness programs,” emphasizes staff ownership. The NAHQ study guide notes, “Engaging all staff ensures ongoing survey preparedness” (Domain 4).

Rationale: Staff ownership fosters a culture of readiness, aligning with CPHQ’s accreditation principles.

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

=========

Directing staff to the help desk for technical issues exemplifies deference to expertise (D), relying on specialized knowledge. Resilience (A), operations sensitivity (B), and failure preoccupation (C) are less relevant. NAHQ highlights expertise deference in HROs.

NAHQ CPHQ Study Guide, Patient Safety Section, “High-Reliability Organization Principles”; NAHQ CPHQ Practice Exam, Safety Culture and Expertise.

Changing organizational culture for a process improvement initiative requires leadership presence, engagement, and role modeling to build trust and commitment.

Option A (Establish training for managers and supervisors): Training is important but focuses on skills, not cultural change, which requires broader engagement.

Option B (Communicate that the costs are justified by the benefits): Cost-benefit communication may support buy-in but does not directly drive cultural change.

Option C (Maintain visibility and engage throughout the process): This is the correct answer. The NAHQ CPHQ study guide states, “Cultural change requires visible leadership engagement to model behaviors, build trust, and sustain momentum for improvement initiatives” (Domain 3). The quality director’s active involvement fosters a culture of quality.

Option D (Require regular quarterly reporting on progress): Reporting monitors progress but does not directly influence culture, which relies on leadership presence.

CPHQ Objective Reference: Domain 3: Organizational Leadership, Objective 3.3, “Foster a culture of quality through leadership engagement,” emphasizes visibility and engagement. The NAHQ study guide notes, “Leaders must be actively involved to drive cultural change for quality” (Domain 3).

Rationale: Visible engagement by the quality director ensures cultural alignment, as per CPHQ’s leadership principles for quality improvement.

Unreported incidents leading to claims indicate a weak reporting culture, requiring a focus on encouraging reporting to identify and mitigate risks.

Option A (Conduct retrospective medical record reviews to identify elements of risk): Reviews may identify risks but do not address the root issue of unreported incidents.

Option B (Implement a back-up paper process to the electronic reporting system): A paper process is unlikely to improve reporting culture and may complicate systems.

Option C (Identify options for a new electronic reporting system): A new system may help but is premature without addressing cultural barriers to reporting.

Option D (Create an organization-wide program that promotes reporting): This is the correct answer. The NAHQ CPHQ study guide states, “A non-punitive reporting culture, promoted through organization-wide programs, is essential to ensure incidents are reported and risks are identified” (Domain 1). Programs include training and incentives to encourage reporting.

CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.2, “Promote a culture of safety,” emphasizes fostering reporting. The NAHQ study guide notes, “Programs to promote reporting are critical when incidents are underreported” (Domain 1).

Rationale: Promoting reporting addresses the cultural barrier causing unreported claims, aligning with CPHQ’s safety culture principles.

A flowchart is a graphical representation that maps out the sequence of steps in a process, using standardized symbols to denote different types of actions or decisions. It provides a clear visualization of how a process functions, identifying each step from start to finish. Flowcharts are valuable tools for analyzing processes, identifying potential bottlenecks or inefficiencies, and facilitating understanding among team members.

DetailedExplanation:

Increased use of healthcare services can result from payer-driven quality initiatives as providers may increase testing or services to meet quality metrics.

Option A: Increased use of healthcare services

This unintended consequence may occur as providers aim to meet certain quality standards.