Ace Your CPHQ CPHQ Certification Exam

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

Detailed Explanation:

To improve compliance with a corrective action plan, the QI professional should first identify the reasons for non-compliance. Conducting a root cause analysis (RCA) allows the QI professional to examine underlying factors and obstacles that may be hindering compliance. This information can then guide targeted interventions.

Option D: Determine areas of non-compliance through a root cause analysis

RCA is a structured approach to identifying underlying issues, which is critical in understanding why certain departments or individuals may not comply withcorrective actions. Once causes are identified, solutions can be tailored to address those specific barriers.

Option A: Provide disciplinary action to non-compliant departments

Disciplinary actions may not address the actual reasons behind non-compliance and can create resistance.

Option B: Provide an analysis for the Patient Safety Committee

This could be useful later but is not the first step to directly address compliance issues.

Option C: Determine if the action plan is in compliance with the national standards

Compliance with national standards is important but does not address specific compliance challenges within the organization.

NAHQ references the tracer methodology as a key survey and assessment technique used in accreditation and internal quality reviews. A tracer follows the actual patient experience across departments, services, and transitions, assessing compliance with standards and identifying system-level gaps.

Reviewing records alone (Option A) does not capture workflow and communication. Asking about duties or workplace issues (Options C and D) reflects interviews or audits, not tracers. The tracer’s purpose is to evaluate care delivery end-to-end, making Option B correct.

The NAHQ CPHQ blueprint distinguishes clearly between structure, process, and outcome measures. Outcome measures evaluate the result of care on the patient’s health status.

A procedural complication rate directly reflects the clinical outcome of knee replacement surgery, such as infections, embolism, or readmission. Patient experience surveys (Option A) measure perception, not clinical outcomes. Pathway compliance (Option C) and time-outs (Option D) are process measures, assessing whether care was delivered as intended. Therefore, Option B is the most appropriate outcome measure.