CPHQ Exam Dumps - Certified Professional in Healthcare Quality Examination

Nonprofit hospitals are federally required under the Affordable Care Act to conduct a community health needs assessment (CHNA) at least every three years to maintain tax-exempt status (IRS, CHNA Requirements, 2024; The Joint Commission, Community Health, 2024).

Sending surveys and reporting events are best practices but not regulatory requirements specific to nonprofits.

Following QIP is essential but not a regulatory mandate.

The Institute for Healthcare Improvement (IHI) promotes collaborative approaches to quality improvement, emphasizing rapid-cycle testing to achieve measurable results. The model at the core of IHI’s methodology is well-documented in quality improvement frameworks.

Option A (DMAIC): DMAIC (Define, Measure, Analyze, Improve, Control) is a Six Sigma methodology focused on reducing variation, not the core of IHI’s approach, which emphasizes rapid testing.

Option B (PDSA): This is the correct answer. The NAHQ CPHQ study guide states, “The Plan-Do-Study-Act (PDSA) cycle is the core performance improvement model used by the Institute for Healthcare Improvement for its collaborative approach, enabling rapid-cycle testing and iterative improvements” (Domain 4). PDSA involves planning a change, testing it, studying results, and acting on findings, aligning with IHI’s Breakthrough Series model.

Option C (Lean): Lean focuses on eliminating waste, which IHI may incorporate, but it is not the primary model for IHI collaboratives.

Option D (Six Sigma): Six Sigma uses data-driven methods like DMAIC, not IHI’s rapid-cycle focus.

CPHQ Objective Reference: Domain 4: Performance and Process Improvement, Objective 4.3, “Apply performance improvement models,” emphasizes PDSA as IHI’s core methodology. The NAHQ study guide notes, “IHI’s collaborative approach relies on PDSA cycles to test and scale improvements across organizations” (Domain 4).

Rationale: PDSA’s rapid-cycle testing is central to IHI’s collaborative framework, enabling iterative improvements, as per CPHQ’s improvement principles.

The Balanced Scorecard is a strategic planning and management system that organizations use to align business activities with thevision and strategy of the organization, improve internal and external communications, and monitor organization performance against strategic goals12. It translates an organization’s mission and strategy into a set of performance measures that provide the framework for a strategic measurement and management system1. The Balanced Scorecard approach provides a clear prescription as to what companies should measure in order to ‘balance’ the financial perspective2.

Theimprovement project successfully increased the utilization of primary care services from a baseline of 5% to 22% by the fourth month, surpassing the initial goal of 20%. At this point, the quality professional should focus on ensuring that this improvement is sustained over time. Monitoring for sustainment involves tracking the ongoing performance to confirm that the increased utilization is maintained and identifying any potential declines or issues early. Continuous monitoring helps to determine if the implemented changes have become fully integrated into routine practices and are producing the desired outcomes consistently.

Implement another improvement cycle (A): This is unnecessary at this stage, as the goal has been met and even exceeded. Further improvement cycles should only be considered if the current gains are not sustained or if new goals are established.

Assess patient satisfaction with providers (C): While assessing patient satisfaction is important, it is not the immediate priority after meeting the primary utilization goal. Satisfaction assessments could be part of a broader quality strategy but do not address the current need for ensuring the sustainability of improvements.

Disband the improvement team (D): Disbanding the team could be premature, as their role in monitoring sustainment is crucial. The team may still be needed to support ongoing improvements or address any emerging issues.

References

NAHQ Body of Knowledge: Quality Improvement Processes

NAHQ CPHQ Exam Preparation Materials: Sustaining Improvements

NAHQ Guide to Measuring Healthcare Outcomes

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The primary purpose of a sentinel event review, particularly in the context of never events, is to identify and implement sustainable systems-based improvements. Here’s why:

Focus on Systemic Issues:

Sentinel event reviews aim to uncover underlying system flaws that contributed to the event. By focusing on systems-based improvements, the organization can preventrecurrence and enhance overall safety.

Long-term Impact:

Sustainable improvements ensure that changes made as a result of the review have a lasting impact on patient safety, rather than just addressing the immediate issue.

Holistic Approach:

Addressing system-wide issues, rather than just individual performance gaps, promotes a culture of safety and continuous improvement across the organization.

Compliance and Accreditation:

Regulatory bodies and accreditation organizations emphasize the importance of systems-based improvements following sentinel event reviews, aligning with best practices in patient safety.

While engaging leadership, identifying performance gaps, and monitoring involvement are important aspects of a sentinel event review, the ultimate goal is to implement changes that improve the safety of the system as a whole.

In rapid cycle improvement methodologies such as Plan-Do-Study-Act (PDSA), after pilot testing and confirming effectiveness, the next critical step is spreading change—implementing successful changes broadly across the organization or relevant units to maximize impact (Institute for Healthcare Improvement, Rapid Cycle Improvement, 2023; The Joint Commission, Performance Improvement, 2024). Defining scope and setting aims are earlier steps to establish the project framework. Benchmarking is typically used for comparative analysis rather than the spread phase. The spread phase involves standardizing improvements, educating staff, and embedding changes into daily operations to ensure sustainability.

A root cause analysis (RCA) is required when a serious incident occurs, such as a "never event" or a sentinel event, which includes a procedure performed on the wrong knee. This type of incident isconsidered a significant error that could cause severe harm to the patient and is a clear indicator of a breakdown in the system that requires thorough investigation through an RCA to prevent recurrence.

Incorrect critical care patient transported to radiology (A): While concerning, this may not reach the threshold for a required RCA unless it led to significant harm.

Admitting a visitor who fell on hospital grounds (B): This incident may require investigation but typically would not trigger an RCA unless the fall resulted in severe injury.

Wrong prescription given to a discharged patient with diabetes (C): This is serious but does not usually require an RCA unless it led to severe consequences.

References

NAHQ Body of Knowledge: Incident Reporting andRoot Cause Analysis

NAHQ CPHQ Exam Preparation Materials: Conducting Root Cause Analysis

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