CPHQ Exam Dumps - NAHQ CPHQ Certification Questions and Answers

Handling customer complaints requires a prompt, appropriate response to address the issue and maintain trust, with escalation as needed.

Option A (Create a quality improvement team to address the concern): A QI team is appropriate for systemic issues, not an individual complaint, which requires immediate resolution.

Option B (Refer the issue to the appropriate department): This is the correct answer. The NAHQ CPHQ study guide states, “The first step in addressing a customer complaint is to refer it to the department best equipped to resolve it, ensuring timely action” (Domain 1). For example, a billing complaint goes to finance, or a care issue to clinical staff.

Option C (Direct the customer to put the complaint in writing): Requiring written complaints may delay resolution and frustrate the customer, not aligning with patient-centered care.

Option D (Review patient experience data for the department): Reviewing data is useful for trends but not the first step for an individual complaint, which needs direct action.

CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.6, “Address patient and family concerns,” emphasizes prompt referral for complaints. The NAHQ study guide notes, “Referring complaints to the appropriate department ensures efficient resolution” (Domain 1).

Rationale: Referring the complaint to the relevant department ensures timely resolution, aligning with CPHQ’s patient safety and service principles.

Understanding the Control Chart ComponentsThis control chart shows the median delay over time (by week), with control limits (UCL - Upper Control Limit, LCL - Lower Control Limit) and a center line (CL) indicating the process average before the intervention. Control charts like this one are used to determine whether an intervention has led to a significant change in process performance.

Analyzing the Data Before and After the Intervention

From weeks 1 to 19, before theintervention, the process appears to fluctuate around the control limits, with several points near the upper control limit, indicating higher variation and a generally stable process around a higher median delay.

After week 20, following the intervention, the data points show a clear shift downward, consistently staying below the previous control line (CL). The process median delay has notably reduced, and all data points fall within a new, lower range.

Conclusion Based on the Control Chart

The consistent reduction in median delay and the clustering of data points below the previous center line indicate a shift in performance rather than mere random variation. This type of change, sustained over multiple weeks, strongly suggests that the intervention had a substantial impact on reducing the delay.

While there may also be a decrease in variation, the primary visible effect is a shift in performance toward lower median delay values.

Rationale for Selecting Answer BThe correct answer is B. The intervention resulted in a shift in performance, as the chart shows a distinct change in the process level post-intervention, indicating an improvement.

A clinical pathway, also known as a care pathway, is a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course12. It details the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol, or other 'inventory of actions’1. The main purpose of a clinical pathway is to reduce variation and improve the quality of care13245. It is not necessarily depicted using a value stream map (option A), not limitedto one patient care setting (option B), and not required for accountable care organizations (option D).

Multi-voting is a technique that helps a group narrow down a large list of options to a smaller list of the most important or preferred ones. It is also known as NGT voting or nominal prioritization 1.

Multi-voting is frequently used in the quality improvement process when there are many potential problems or solutions to choose from, and the group needs to focus on the most critical or feasible ones. It can help the group reach a consensus and avoid bias or domination by a few members 1.

According to the NAHQ Healthcare Quality Competency Framework, one of the skills required for healthcare quality professionals is to “use multi-voting to prioritize improvement opportunities” 2. This skill belongs to the domain of performance and process improvement, which involves identifying, analyzing, and implementing changes to improve outcomes and efficiency 3.

The steps of multi-voting are as follows 1:

Generate a list of options or ideas using brainstorming, affinity diagram, or other methods.

Display thelist on a flip chart, whiteboard, or computer screen so that everyone can see it.

Ask each group member to select a certain number of options (usually 3 to 5) that they think are the most important or relevant. They can use stickers, dots, or marks to indicate their choices.

Count the number of votes for each option and rank them from the highest to the lowest.

Eliminate the options that received the least votes (usually less than half of the highest vote) and repeat the voting process with the remaining options until the desired number of options is reached (usually 3 to 5).

Discuss the final list of options and agree on the priority order or the final selection. References:

2: NAHQ Healthcare Quality Competency Framework, Domain 3: Performance and Process Improvement, Skill 3.1.4

3: NAHQ Healthcare Quality Competency Framework Overview 4

1: What is Multivoting? NGT Voting, Nominal Prioritization | ASQ 1

Developing a patient safety program requires a comprehensive understanding of the organization’s risks, priorities, and strategic direction to ensure the plan is aligned and effective.

Option A (Infection control data and accreditation results): While infection control data is relevant to safety, it is already partially covered by incident reports and performance indicators. Accreditation results provide compliance insights but are not foundational for planning.

Option B (Staff satisfaction and root cause analysis (RCA) data): Staff satisfaction is indirectly related to safety culture, and RCA data may be included in incident reports. Neither is the most critical missing piece for planning a broad safety program.

Option C (The facility risk assessment and strategic goals): This is the correct answer. NAHQ CPHQ study materials emphasize that a facility risk assessment (e.g., identifying high-risk processes like medication errors) and strategic goals (e.g., reducing harm events) are essential for developing a patient safety plan, as they provide context for prioritizing interventions and aligning with organizational objectives.

Option D (Physician satisfaction and financial goals): Physician satisfaction and financial goals are not directly tied to patient safety planning, which focuses on clinical and operational risks rather than provider morale or finances.

Before implementing a new patient service, the healthcare quality professional should recommend conducting a Failure Modes and Effects Analysis (FMEA). FMEA is a proactive tool used to identify potential failure points in a new process or service before they occur. This analysis helps to prioritize risks based on their severity, occurrence, and detectability, and to implement corrective actions to mitigate these risks. By using FMEA, the organization can enhance patient safety by addressing potential problems before they affect patients.

Developing a safety monitoring checklist (A): While useful, this step comes after identifying potential risks and failure modes through FMEA.

Conducting a root cause analysis (RCA) (B): RCA is a reactive tool used after anadverse event occurs, making it unsuitable for proactive risk assessment before implementing a new service.

Performing just-in-time staff safety training (D): While important, this should follow the identification of risks and implementation of safety measures based on the FMEA findings.

References

NAHQ Body of Knowledge: Risk Management and Patient Safety

NAHQ CPHQ Exam Preparation Materials: FMEA Process and Application

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Involving frontline staff in quality and safety committees ensures that those directly involved in patient care have a voice in quality initiatives. Their insights can lead to more practical and effective improvements, fostering a culture of continuous quality enhancement.

To properly assess the cost and utilization patterns in the population health program, it is essential tounderstand the volume of patients being discharged to various post-acute care settings. By requesting the total number of patients discharged to each location, the healthcare quality professional can calculate the average cost per patient, which is crucial for assessing efficiency and for comparing costs across different discharge locations. This data will also allow for an evaluation of utilization patterns and help identify if certain locations are being used more frequently and if the associated costs are justified based on patient outcomes.

Implementing a new electronic health record (EHR) system in an outpatient clinic often introduces challenges that impact patient safety and workflow. NAHQ CPHQ study materials emphasize that post-implementation evaluation should focus on identifying barriers to effective use, as these can undermine the system’s benefits, such as improved medication safety and care coordination. Common metrics in such evaluations include system-related medication errors, help desk calls, downtime events, overrides, workarounds, and staff complaints, which reflect user experience and system performance.

Since the chart is not provided, I’ll base the answer on typical CPHQ scenarios for EHR implementation. The options suggest the chart includes data on e-prescribing stability, system-related medication errors, help desk calls, downtime events, overrides, workarounds, and complaints. Option D, “Overrides, workarounds, and complaints indicate there are underlying barriers to use,” aligns with a common finding in EHR post-implementation reviews. Overrides (e.g., bypassing alerts), workarounds (e.g., using paper notes instead of the EHR), and complaints typically signal usability issues, such as a poorly designed interface, inadequate training, or system inefficiencies. These barriers can lead to errors, staff frustration, and reduced patient safety, requiring targeted interventions like workflow redesign or additional support.

Option A, “While e-prescribing processes are now stable, additional training is needed to improve staff competency,” assumes e-prescribing stability, which may not be supported without specific chart data showing consistent performance (e.g., no recent errors). It also assumes training is the primary issue, which isn’t directly indicated without evidence of competency gaps. Option B, “There is a strong positive correlation between system-related med errors and help desk calls,” requires specific data showing a statistical correlation (e.g., both metrics trending together), which cannot be confirmed without the chart. Option C, “Minimal IT-related med errors and downtime events indicate that the system has improved patient safety,” assumes low error and downtime rates, but the presence of overrides, workarounds, and complaints (implied by option D) suggests ongoing safety risks, contradicting this conclusion. NAHQ emphasizes identifying and addressing barriers to EHR adoption to ensure patient safety, making option D the most likely conclusion based on typical post-implementation challenges.

Detailed Explanation:

The storming stage involves conflict and differing opinions, which can lead to premature dissolution if not managed effectively.

Option B: Storming

During this stage, teams often experience disagreements, which can lead to dissolution if members cannot resolve conflicts.

A strategy to address social determinants of healthinvolves creating patient education materials that are culturally competent. Culturally competent materials consider the cultural, linguistic, and literacy needs of the patient population, making the information accessible and relevant. This approach helps to bridge gaps in understanding and engagement, which are often influenced by social determinants such as education, income, and cultural background.

Launch a community campaign to promote influenza vaccines (A): While important for public health, this is not directly focused on social determinants of health.

Identify high-risk patients with high-cost medications (B): This is more related to cost management and clinical care than addressing social determinants.

Implement a standard questionnaire for pediatric lead screening (D): This addresses a specific health issue but does not broadly address social determinants of health.

References

NAHQ Body of Knowledge: Addressing Social Determinants of Health in Healthcare

NAHQ CPHQ Exam Preparation Materials: Culturally Competent Care and Education

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Explanation: A Pareto chart (B) ranks causes from most to least significant using a vertical bar graph, applying the 80/20 rule. Gantt charts (A), run charts (C), and histograms (D) serve different purposes. NAHQ emphasizes Pareto charts for cause prioritization.

The board’s actions reflect a deliberate focus on ensuring the palliative care unit’s success through evidence-based practices, staff preparation, and performance monitoring.

Option A (High-level strategic planning): While strategic, the actions are specific to quality implementation, not broad strategic planning.

Option B (A board’s need to manage patient care): Boards oversee governance, not direct patient care management.

Option C (A commitment to quality): This is the correct answer. The NAHQ CPHQ study guide states, “Authorizing best practice reviews, staff training, and performance monitoring demonstrates a board’s commitment to quality in new initiatives” (Domain 3). These actions ensure high-quality palliative care delivery.

Option D (The importance of competence and training): Training is one component, but the broader commitment includes best practices and monitoring, not just competence.

CPHQ Objective Reference: Domain 3: Organizational Leadership, Objective 3.1, “Support quality through governance,” emphasizes board actions for quality. The NAHQ study guide notes, “Boards demonstrate quality commitment through resource allocation and oversight” (Domain 3).

Rationale: The board’s actions prioritize quality through best practices, training, and monitoring, aligning with CPHQ’s leadership principles.

An accountable care organization (ACO) is a network of health care providers that agrees to be accountable for the quality, cost, and overall care of a defined population of patients1.

ACOs aim to improve population health outcomes by coordinating care across different settings and providers, and by implementing quality improvement initiatives1.

One of the quality improvement initiatives that ACOs may adopt is to increase the influenza vaccination rate among their staff, especially those who have direct contact with patients2.

Influenza vaccination canprevent flu-related morbidity and mortality, reduce absenteeism and presenteeism, and protect vulnerable patients from infection3.

To analyze staff flu vaccination trends for an ACO, a source of data that can be used is electronic health records (EHRs)4.

EHRs are digital versions of patients’ medical histories, diagnoses, treatments, medications, immunizations, and other health information that are maintained by health care providers5.

EHRs can provide data on staff flu vaccination trends for an ACO by:

Identifying the staff members who belong to the ACO and their roles, locations, and contact information6.

Tracking the dates and types of flu vaccines that staff members received, as well as any adverse reactions or contraindications7.

Comparing thevaccination rates of staff members across different departments, facilities, and time periods8.

Evaluating the impact of flu vaccination on staff health outcomes, such as flu-like illness, hospitalization, and mortality.

Generating reports and feedback for staff members and managers on their flu vaccination status and performance.

Therefore, the correct answer is A. electronic health records, as this is a source of data that can be used to analyze staff flu vaccination trends for an ACO. References:

1: Accountable Care Organizations (ACOs): General Information | CMS

2: Increasing Health and Social Care Worker Flu Vaccinations: Five Components

3: P141 FluCare: Improving flu vaccination rates in care home staff: A cluster randomised controlled trial | Journal of Epidemiology & Community Health

4: Frontiers | Influenza vaccination rates among healthcare workers: a systematic review and meta-analysis | Public Health

5: What is an electronic health record (EHR)? | HealthIT.gov

6: The National Association for Healthcare Quality

7: Flu vaccination guidance for social care workers and carers

8: CDC: COVID-19, flu vaccination rates for health care workers low last season

Utilization of Improvement Methodologies by Healthcare Quality Professionals During the COVID-19 Pandemic | Journal for Healthcare Quality

Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development