Free NAHQ CPHQ Practice Exam with Questions & Answers | Set: 4

Social determinants of health (SDOH) refer to non-medical factors that influence health outcomes, such as socioeconomic status, food security, and access to resources (WHO, Social Determinants of Health, 2023). Working with local food pantries to improve access to healthy foods directly addresses food insecurity, a critical SDOH affecting diabetes management. This approach tackles root causes beyond clinical care and supports better glycemic control and overall health outcomes. Educating patients (A) and addressing clinical risks (B) are important clinical interventions but do not address social determinants. Targeting age groups (C) addresses epidemiologic risk factors but not underlying social needs. Integrating community resources exemplifies holistic, population health management endorsed by the CDC and AHRQ.

A physician champion in healthcare quality should be a respected member of the medical staff who employs a participatory leadership style. This approach fosters collaboration, encourages input from team members, and promotes shared decision-making, all of which are essential for successful quality improvement initiatives.

Autocratic (Option A) and transactional (Option B) leadership styles may hinder team engagement. While seniority (Option C) can be beneficial, respect and participatory leadership are more critical for driving quality improvements.

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.

Alternative Payment Models (APMs) are payment approaches developed by the Centers for Medicare & Medicaid Services (CMS) and other payers that provide added incentives to clinicians to deliver high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.

Option A: Patient-Centered Medical Home (PCMH)

PCMH is a care delivery model where patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it. While it focuses on care coordination and communication, it is not primarily a payment model.

Option B: Shared Savings Program

The Shared Savings Program is an APM that encourages providers to reduce healthcare costs for a defined patient population by offering them a percentage of any net savings realized as a result of their efforts. This model aligns financial incentives with the goal of improving patient outcomes and reducing unnecessary spending.

Option C: Hospital at Home Program

This program provides hospital-level care to patients in their homes. While it represents an innovative care delivery model, it is not primarily structured as a payment model.

Option D: Collaborative Care Model

This model integrates mental health services into primary care settings. It focuses on care delivery and is not primarily a payment model.

Therefore, among the options provided, the Shared Savings Program (Option B) is the example of an Alternative Payment Model (APM).

The scenario described in the question is a classic example of sampling bias, also known as selection bias123. This type of bias occurs when the sample chosen for a study or survey is not representative of the entire population thestudy intends to investigate123.

In this case, the healthcare quality professional wants to assess the satisfaction of the community served by the organization, which includes patients living within a 10-mile radius. However, the professional only sends surveys to households within a 3-mile radius. This means that the sample (households within 3 miles) does not accurately represent the entire population (patients within a 10-mile radius). As a result, the findings from this survey may not accurately reflect the satisfaction levels of the entire community served by the organization123.

To avoid this type of bias, it’s important to ensure that the sample chosen for a study or survey is as representative as possible of the population being studied123. This might involve using different sampling techniques or adjusting the scope of the survey to ensure a more diverse and representative sample is obtained123.

The support of organizational leaders is widely recognized as the most critical factor in the success of any performance improvement program. According to the Joint Commission’s Comprehensive Accreditation Manual for Hospitals (CAMH) and the National Association for Healthcare Quality (NAHQ) standards, leadership commitment provides the vision, resources, and culture necessary to drive and sustain improvement efforts. Leadership engagement ensures alignment of performance goals with organizational strategy, facilitates resource allocation, and fosters accountability across all levels of staff.

The Institute for Healthcare Improvement (IHI) also emphasizes leadership’s role in establishing a culture of safety and continuous improvement, which is foundational for effective performance improvement activities. Without leadership support, performance improvement teams may lack authority, resources, and motivation, and data collection efforts may not translate into meaningful organizational change.

Establishing performance improvement teams (A), while important, is secondary and depends on leadership endorsement.

Integrating data collection capabilities (C) is essential for measurement but without leadership backing, data use may be ineffective.

Dedicating resources (D) is necessary but again contingent on leadership priorities and support.

An affinity diagram (C) organizes brainstorming ideas into thematic categories, aiding analysis of infection rate causes. Decision matrices (A), Pareto charts (B), and force field analysis (D) are less suited for sorting ideas. NAHQ emphasizes affinity diagrams for idea organization.

NAHQ CPHQ Study Guide, Performance and Process Improvement Section, “Affinity Diagrams and Idea Organization”; NAHQ CPHQ Practice Questions, Quality Improvement Tools.

A successful patient safety program must be aligned with the organization’s core values, which reflect its mission, vision, and culture. This alignment ensures that safety initiatives are integrated into everyday operations, supported by leadership, and embraced by staff at all levels (The Joint Commission, Patient Safety Culture, 2024; Institute for Healthcare Improvement, Leading for Safety, 2023). Core values provide a foundation for establishing safety priorities, fostering accountability, and sustaining improvements. While public reporting (A), payors (B), and patient satisfaction (D) influence healthcare, they are external or outcome-focused measures, not foundational drivers. Embedding safety within organizational values promotes a culture where safety is a shared responsibility and a strategic priority.

The ability to moderate a work group (C) is the most important facilitator characteristic, ensuring effective collaboration and progress. Selecting members (A) and knowledge of mental health (B) or levels of care (D) are secondary. NAHQ prioritizes moderation skills.

NAHQ CPHQ Study Guide, Performance and Process Improvement Section, “Team Facilitation Skills”; NAHQ CPHQ Practice Questions, Quality Team Dynamics.

The ultimate goal of training is application in practice, not just knowledge acquisition or favorable evaluations. Therefore, evidence that staff have initiated performance improvement processes demonstrates real-world transfer of learning and impact on organizational quality (The Joint Commission, Education and Training Standards, 2024; NAHQ, CPHQ Study Guide, 2024). Favorable evaluations or test results (Options A, C, D) assess immediate understanding or satisfaction but do not confirm behavior change or quality improvement implementation. Measuring initiation of PI processes post-training is a more robust indicator of training effectiveness and supports continuous improvement culture.

To support patient safety when deploying a new admissions process from the emergency department, the healthcare quality professional should suggest completing a Failure Mode and Effects Analysis (FMEA) during the design stage. FMEA is a proactive tool used to identify potential failure points in a process and assess their impact on patient safety. By analyzing the process before it is implemented, the organization can anticipate and mitigate risks, ensuring a safer rollout of the new process.

Examining the new process for stability and variation using a control chart (A): This is typically done after implementation to monitor ongoing performance, not during the design stage.

Conducting a root cause analysis (C): Root cause analysis is reactive and used after an error has occurred, making it unsuitable for proactive safety planning.

Analyzing incident reports using a Pareto chart (D): This is useful for identifying common causes of past issues but does not directly contribute to the safety design of a new process.

References

NAHQ Body of Knowledge: Risk Management and FMEA

NAHQ CPHQ Exam Preparation Materials:Proactive Safety Design and FMEA

A "time-out" takes place immediately before surgery. This pause is a critical safety step designed to ensure that the surgical team is about to perform the correct procedure on the correct patient and at the correct site. During the time-out, the surgical team reviews and confirms key details such as patient identity, surgical site, and procedure, thereby preventing errors and enhancing patient safety.

Just before leaving the unit (A): This step may involve confirming patient information, but the formal time-out occurs just before surgery.

Just before entering the operating room (C): Final checks may be conducted, but thetime-out is conducted after the patient is in the operating room and before the procedure begins.

Immediately upon arrival in the recovery room (D): This is after the surgery is completed, so it is not the appropriate time for a time-out.

References

NAHQ Body of Knowledge: Surgical Safety and Time-Out Procedures

NAHQ CPHQ Exam Preparation Materials: Ensuring Correct Surgery Protocols

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Psychological safety refers to an environment where team members feel safe to express concerns, admit mistakes, and offer ideas without fear of punishment or ridicule (Edmondson, Psychological Safety, 2019). Conducting collaborative debriefs after incidents such as medication errors promotes openness, shared learning, and trust. This approach encourages reporting and teamwork essential for patient safety and continuous improvement (The Joint Commission, Patient Safety Culture, 2024). Options A, C, and D are more top-down, offering limited opportunity for team engagement or shared ownership. A collaborative debrief embodies principles of inclusiveness and respect, critical components of psychological safety.

The most logical sequence for the phases of shifting from top-down leadership to participatory management is to start with making the commitment, then gathering baseline data, implementing the program, and evaluating effectiveness and improvement.

Making the commitment is the first step because it involves creating a shared vision, setting goals and objectives, and securing support and resources for the change process12. Without a clear and strong commitment, the other steps may not be feasible or successful.

Gathering baseline data is the second step because it helps to assess the current situation, identify the gaps and needs, and establish a baseline for comparison and measurement13. Data can be collected from various sources, such as surveys, interviews, observations, and records, and can cover aspects such as organizational culture, performance, quality, satisfaction, and costs13.

Implementing the program is the third step because it involves putting the plan into action, engaging and empowering the staff and stakeholders, and monitoring and adjusting the process as needed14. Implementation can be done in phases, pilots, or trials, depending on the scope and complexity of the program14.

Evaluating effectiveness and improvement is the fourth step because it helps to measure the outcomes, impacts, and benefits of the program, compare them with the baseline data and the goals and objectives, and identify the strengths, weaknesses, and areas for improvement15. Evaluation can be done using quantitative and qualitative methods, such as indicators, metrics, feedback, and stories, and can be conducted at different levels, such as individual, team, and organizational15.

This question is identical to Question 95, indicating a potential duplication in the document. The analysis remains the same: a significant medication error causing harm requires a reactive investigation to identify causes and prevent recurrence.

Option A (Multiple regression analysis): Inappropriate for analyzing specific incidents, as it is a statistical tool for relationships.

Option B (Variation analysis): Not suitable for investigating a single harmful event, as it focuses on process variability.

Option C (Root cause analysis): Correct answer. The NAHQ CPHQ study guide reiterates, “RCA is the standard approach for analyzing serious safety events like medication errors with harm, using a multidisciplinary team to identify root causes” (Domain 1).

Option D (Failure mode and effects analysis (FMEA)): FMEA is proactive, not for post-incident analysis.

CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.5, “Conduct root cause analysis for significant safety events.” The NAHQ study guide emphasizes, “RCA ensures thorough investigation of harmful errors to improve safety” (Domain 1).

Rationale: RCA is the correct tool for a harmful medication error, consistent with CPHQ’s safety investigation principles.