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Based on the data below, which shows the percentage of patients who acquired a hospital-associated infection (HAI) in each unit, the quality improvement coordinator should focus on Unit C, which has the highest rate of HAI among the four units.

A hospital-associated infection (HAI) is an infection that patients get during or after receiving health care in a hospital or other health care facility. HAIs can cause serious complications, increase morbidity and mortality, prolong hospital stays, and increase health care costs. Therefore, preventing and reducing HAIs is a key quality and safety goal for health care organizations.

A quality improvement coordinator is a professional who develops and implements quality improvement initiatives, monitors and evaluates quality performance, and provides education and support to staff and leaders on quality methods and tools. One of their responsibilities is to identify and prioritize areas for improvement based on data analysis and evidence-based practices.

To determine which unit should be the focus of quality improvement efforts, the quality improvement coordinator can use a data analysis tool such as a Pareto chart, which shows the frequency or impact of different factors or causes in descending order, along with a cumulative line that indicates the percentage of the total. A Pareto chart can help identify the most significant issues or opportunities for improvement, based on the 80/20 rule, which states that 80% of the effects come from 20% of the causes.

Using the data below, a Pareto chart can be created as follows:

Table

Unit

HAI Rate (%)

A

5

B

7

C

12

D

4

The Pareto chart shows that Unit C has the highest HAI rate (12%), followed by Unit B (7%), Unit A (5%), and Unit D (4%). Thecumulative line shows that Unit C alone accounts for 40% of the total HAI rate, and Units C and B together account for 63.3% of the total HAI rate. Therefore, according to the Pareto principle, the quality improvement coordinator should focus on Unit C, as it represents the most significant problem area and the greatest opportunity for improvement.

The quality improvement coordinator can then conduct a root cause analysis to identify the possible factors or causes that contribute to the high HAI rate in Unit C, such as staff compliance, infection control practices, patient characteristics, environmental factors, etc. A root cause analysis can be facilitated by using a visual tool such as a fishbone diagram, which organizes possible factors into categories, such as people, process, equipment, environment, etc. The quality improvement coordinator can also collect and compare data from other units or sources to identify gaps and best practices.

Based on the root cause analysis, the quality improvement coordinator can then develop and implement an action plan to address the identified causes and improve the HAI rate in Unit C. The action plan should include specific, measurable, achievable, relevant, and time-bound (SMART) goals, interventions, and indicators. The quality improvement coordinator can also involve the staff and leaders of Unit C in the planning and implementation process, to ensure their engagement and ownership of the improvement efforts.

The quality improvement coordinator should also monitor and evaluate the progress and outcomes of the action plan, using data collection and analysis tools such as run charts, control charts, or statistical process control (SPC), which can show the variation and trends in the HAI rate over time. The quality improvement coordinator should also provide feedback and recognition to the staff and leaders of Unit C, and make adjustments to the action plan as needed, based on the data and evidence.

The success of a utilization management program for a new pediatric psychiatric unit will largely depend on involving the team members in the development of the program. Engaging team members in the process ensures that the program is practical, addresses real-world challenges, and gains buy-in from those who will be implementing it. Team involvement fosters collaboration, allows for the inclusion of diverse perspectives, and enhances the likelihood of the program's success.

Obtaining approval from the chief psychiatrist at each stage of development (A): While important for ensuring alignment with clinical leadership, it does not replace the need for broader team involvement.

Developing the program and presenting it to the appropriate staff members (B): This approach is less effective as it does not involve the team in the development process, which is crucial for successful implementation.

Providing educational in-services to all team members involved (D): Education is important, but the success of the program relies more on the team’s involvement in its creation than on subsequent training alone.

References

NAHQ Body of Knowledge: Program Development and Team Involvement in Healthcare

NAHQ CPHQ Exam Preparation Materials: EffectiveUtilization Management Program Development

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Intangible benefits are non-quantifiable outcomes that cannot be easily measured in monetary or numerical terms, such as emotional or psychological benefits. In the context of a free flu vaccination program, the intangible benefit relates to subjective improvements in well-being rather than direct, measurable outcomes like cost savings or reduced hospitalizations.

Option A (Prevention of hospital admissions): This is a tangible benefit, as hospital admissions can be quantified (e.g., number of admissions avoided) and often translated into cost savings, making it measurable.

Option B (Peace of mind among vaccinated persons): Peace of mind is an intangible benefit, as it reflects an emotional or psychological outcome (e.g., reduced anxiety about contracting the flu) that cannot be directly quantified. NAHQ CPHQ study materials recognize intangible benefits in population health initiatives as those that enhance quality of life or perception of safety, making this the correct answer.

Option C (Savings resulting from lower morbidity among unvaccinated persons): This is a tangible benefit, as it involves measurable cost savings due to reduced illness (e.g., fewer outpatient visits or treatments), often calculated through herd immunity effects.

Option D (Savings associated with prevented illness among vaccinated persons): This is also a tangible benefit, as it can be quantified in terms of reduced healthcare costs (e.g., avoided treatments or hospitalizations) for vaccinated individuals.

A culture of safety encourages reporting and learning from incidents without fear of punishment, fostering proactive risk mitigation.

Option A (Promote a non-punitive response to needlesticks reported): This is the correct answer. The NAHQ CPHQ study guide states, “A non-punitive response to incident reporting, such as needlesticks, is a hallmark of a safety culture, encouraging staff to report without fear” (Domain 1). This applies across all units.

Option B (Evaluate the needle safety device for Unit B): Evaluating devices is reactive and unit-specific, not a broad safety culture action.

Option C (Congratulate Unit A for fewer needlestick injuries): Congratulating Unit A may discourage reporting in other units, undermining safety culture.

Option D (Review training records for needlestick prevention): Training review is useful but not the primary action to promote a safety culture.

CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.2, “Promote a culture of safety,” emphasizes non-punitive reporting. The NAHQ study guide notes, “Non-punitive responses enhance incident reporting” (Domain 1).

Rationale: A non-punitive response fosters a safety culture, aligning with CPHQ’s safety principles.