Pass the NAHQ CPHQ Certification CPHQ Questions and answers with CertsForce

According to the National Association for Healthcare Quality (NAHQ), one of the core competencies of healthcare quality professionals is patient safety, which includes ensuring effective transitions of care and reducing preventable readmissions12.

One of the strategies to achieve this goal is to improve patient compliance with follow-up visits, which can help monitor patient outcomes, prevent complications, and provide continuity of care34.

Among the four options given, the best way to improve patient compliance is to initiate a process where the discharge planners call patients prior to the follow-up visit. This is because:

A phone call can serve as a reminder for the patient to keepthe appointment, as well as an opportunity to address any barriers or concerns that the patient may have34.

A phone call can also help establish rapport and trust between the patient and the discharge planner, which can increase patient satisfaction and adherence4.

A phone call can also allow the discharge planner to confirm the patient’s understanding of the discharge instructions, medication regimen, and follow-up plan, and to provide any additional education or support that the patient may need34.

Theother options are less effective because:

Benchmarking with other facilities in the area to determine the rate of patient compliance may provide some insight into the current performance and best practices, but it does not directly address the specific needs and preferences of the individual patient5.

Including handouts in the discharge documents on the importance of keeping follow-up appointments may increase the patient’s awareness and knowledge, but it may not be sufficient to motivate the patient to act on the information, especially if the patient has low health literacy, cognitive impairment, or mental health issues.

Communicating to noncompliant patients that appointments should be kept may sound authoritative and judgmental, which may alienate the patient and reduce their willingness to cooperate. Instead, a patient-centered and empathetic approach that acknowledges the patient’s challenges and preferences may be more effective. References: 1: [NAHQ Code of Ethics] 2: [NAHQ HQ Principles] 3: The Importance of Patient Follow-Up | MagMutual 4: The Importance of Patient Follow-Up and Service Recovery 5: [The Financial Case for Quality as a Business Strategy] : [Utilization of Improvement Methodologies by Healthcare Quality Professionals During the COVID-19 Pandemic] : [Understanding the Evolving Landscape of Healthcare Quality] : https://nahq.org/about-nahq/code-of-ethics/ : https://nahq.org/products/hq-principles/ : https://nahq.org/resources/the-financial-case-for-quality-as-a-business-strategy-2/ : https://nahq.org/resources/jour nal-for-healthcare-quality/utilization-of-improvement-methodologies-by-healthcare-quality-professionals-during-the-covid-19-pandemic/ : https://nahq.org/news-media/news/understanding-the-evolving-landscape-of-healthcare-quality/

A control chart, also known as a Shewhart chart or process-behavior chart, is a statistical tool used to monitor how a process changes over time. It helps distinguish between common causevariations (natural fluctuations inherent to the process) and special cause variations (unexpected fluctuations due to specific factors). By plotting data points in time order and establishing upper and lower control limits, control charts enable quality professionals to identify when a process is operating outside of its expected parameters, signaling the need for further investigation.

In contrast, a bar chart is a graphical representation of categorical data with rectangular bars, a Pareto chart is a type of bar chart that identifies the most significant factors in a dataset, and a run chart displays data points over time without control limits. While these tools are useful for various purposes, they do not provide the same level of insight into process stability and variation as control charts.

Detailed Explanation:

Verifying data for accuracy ensures that the results and recommendations are reliable, which is essential before presenting to leadership or proceeding further.

Option B: Verify data for accuracy

Accurate data provides a credible basis for making informed decisions.

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.

Social determinants of health (SDOH) are non-medical factors that influence health outcomes, such as education, income, and social support, distinct from clinical or biological factors.

Option A (High body mass index): BMI is a clinical health outcome, not an SDOH.

Option B (Advanced age): Age is a demographic factor, not a primary SDOH, though it may interact with social factors.

Option C (Low literacy level): This is the correct answer. The NAHQ CPHQ study guide states, “Low literacy level is a social determinant of health, impacting health behaviors and access to care” (Domain 5). It affects understanding of medical instructions and health navigation.

Option D (Poorly managed chronic condition): This is a health outcome, not an SDOH.

CPHQ Objective Reference: Domain 5: Population Health and Care Transitions, Objective 5.4, “Incorporate SDOH into health strategies,” includes literacy as an SDOH. The NAHQ study guide notes, “Literacy significantly influences health literacy and outcomes” (Domain 5).

Rationale: Low literacy is a key SDOH, impacting health management, as per CPHQ’s population health principles.

A criterion is considered valid if it measures what it is intended to measure. Validityrefers to the accuracy of a measure, meaning the criterion accurately reflects the concept or outcome it is supposed to assess. For example, if a criterion is designed to measure patient satisfaction, it should accurately capture patients' perceptions of their care.

Consistently yields the same results (A): This describes reliability, not validity.

Does not change with changes in technology (B): This is not related to validity.

Is applicable to many groups and settings (C): This refers to generalizability, not validity.

References

NAHQ Body of Knowledge: Measurement Principles in Quality Improvement

NAHQ CPHQ Exam Preparation Materials: Validity and Reliability in Quality Measures

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The concept of care quality that remains consistent across diverse patient characteristics is rooted in the Institute of Medicine’s (IOM) six aims for healthcare improvement, as outlined in Crossing the Quality Chasm (2001).

Option A (Efficient): Efficient care minimizes waste, not addressing variation across demographics.

Option B (Effective): Effective care delivers evidence-based results, not specifically ensuring consistency across groups.

Option C (Equitable): This is the correct answer. The NAHQ CPHQ study guide states, “Equitable care, as defined by the IOM, ensures quality does not vary due to gender, ethnicity, geographic location, or socioeconomic status” (Domain 4). Equity is one of the six IOM aims, focusing on fairness in care delivery.

Option D (Evidence-based): Evidence-based care relies on scientific evidence, not directly addressing demographic disparities.

CPHQ Objective Reference: Domain 4: Performance and Process Improvement, Objective 4.1, “Apply quality principles to care delivery,” includes the IOM’s equitable care aim. The NAHQ study guide notes, “Equitable care ensures fairness across all patient populations” (Domain 4).

Rationale: Equitable care directly addresses consistent quality across diverse groups, aligning with CPHQ’s improvement principles and IOM standards.

Comprehensive and Detailed Explanation From Exact Extract:

Within the Patient Safety domain, sentinel events are typically traced to process failures — breakdowns in how care is delivered, coordinated, or monitored.

Root cause analyses of sentinel events frequently reveal that system-level process design, not individual error or competence, is the main contributing factor.

Examples include communication failures, inadequate handoffs, or lack of standardized procedures.

Structural issues or staffing shortages may contribute indirectly, but process variation remains the predominant source of sentinel events in healthcare.

In the Define phase of the DMAIC (Define, Measure, Analyze, Improve, Control) process, the quality manager identifies and prioritizes the problems to be addressed. This phase involves defining the project goals, scope, and customer requirements, which sets the direction for the subsequent phases.

In a data set, thedifference between the highest and lowest observed values is known as the range. The range is a measure of dispersion that indicates the spread of the data. It is calculated by subtracting the smallest value in the data set from the largest value. The range gives a quick sense of the variability in the data but does not provide information about the distribution of values between the extremes.

Percentile (A): A percentile indicates the value below which a given percentage of observations in a data set falls.

Standard deviation (B): Standard deviation measures the average amount by which each data point differs from the mean, indicating the spread of the data around the mean.

Quartile deviation (D): Quartile deviation, or semi-interquartile range, measures the spread of the middle 50% of data, providing an understanding of variability around the median.

References

NAHQ Body of Knowledge: Data Measurement and Analysis

NAHQ CPHQ Exam Preparation Materials: Understanding Measures of Dispersion

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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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Assigning the team leader to document overall project progress is a strategy that promotes timely completion of a quality improvement project. The team leader is responsible for overseeing the project, tracking progress, and ensuring that milestones are met. By documenting progress, the team leader can identify potential delays or issues early, coordinate efforts to address them, and keep the project on schedule.

Allowing the project sponsor to direct the project team's work (A): The sponsor provides support and resources but should not be involved in day-to-day project management.

Requiring team members to devote a majority of their time to project work (C): While important, this may not be feasible and does not ensure timely completion if not managed properly.

Focusing routine senior leader updates on project successes (D): While recognizing successes is important, it should not be the sole focus, as it might overlook areas needing attention.

References

NAHQ Body of Knowledge: Project Management and Leadership in Quality Improvement

NAHQ CPHQ Exam Preparation Materials: Strategies forTimely Project Completion

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The governing body holds the ultimate accountability for patient safety within a healthcare organization. They are responsible for setting policies, ensuring compliance with regulations, and fostering a culture of safety throughout the organization.

Reviewing priorities, regulatory requirements, and goals is key to developing a quality improvement plan (D), guiding quality efforts. Competency checklists (A), survey teams (B), and bonus plans (C) are unrelated. NAHQ emphasizes these components for quality planning.

NAHQ CPHQ Study Guide, Organizational Leadership Section, “Quality Improvement Planning”; NAHQ CPHQ Practice Questions, Strategic Quality Management.

A quality improvement initiative is a systematic and data-driven approach to enhance the quality and safety of healthcare services and outcomes12.

One of the first steps in starting a new quality improvement initiative is to define the problem and measure the current performance123. This involves collecting and analyzing baseline data to understand the magnitude, frequency, and variation of the problem, as well as the potential causes and contributing factors123.

Evaluating baseline data to determine the cause of falls (option B) is therefore a crucial step in designing and implementing a quality improvement initiative to reduce patient falls. This will help to identify the gaps between the current and desired states, prioritize the areas of improvement, and set measurable and realistic goals and objectives123.

Training the staff on the proper falls screening protocol (option A) is an important intervention to prevent falls, but it is not the first step in starting a quality improvement initiative. Training should be based on the evidence and best practices, and tailored to the specific needs and characteristics of the staff and the patients124. Training should also be evaluated for its effectiveness and impact on the outcomes124.

Researching evidence-based guidelines (option C) is another essential component of a quality improvement initiative, but it is not the first step either. Evidence-based guidelines provide recommendations for the prevention and management of falls, based on the best available scientific evidence and expert consensus45 . Researching evidence-based guidelines should be done after defining the problem and measuring the current performance, and before developing and testing the interventions123.

Implementing post-fall huddles on all units (option D) is a valuable strategy to improve the communication and learning from falls, and to prevent future falls . However, it is not the first step in starting a quality improvement initiative. Post-fall huddles should be part of the implementation and evaluation phases of the quality improvement cycle, and should be aligned with the goals and objectives of the initiative123 . References: 1: [Quality Improvement Essentials Toolkit] 2: [Quality Improvement MadeSimple] 3: [The Model for Improvement] 4: The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities 5: Preventing Falls in Hospitals : Clinical Practice Guidelines : [Post-Fall Huddles: A Quality Improvement Project] : [Post-Fall Huddles: A Strategy to Reduce Falls and Improve Patient Safety] : 1 : 2 : 3 : 4 : 5