CPHQ Reviews Questions

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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The key element in aim development that appears to have been lost after the training is "time-bound." The first aim statement includes a specific timeframe ("within 12 months"), but the second and third aim statements lack a clear deadline for achieving their goals. A SMART aim statement should include a specific time frame to create urgency and allow for timely assessment of progress.

Achievable (B): The goals seem realistic, so achievability is not the issue.

Measurable (C): The goals are quantifiable, indicating they are measurable.

Specific (D): The aims are clearly defined, making them specific.

References

NAHQ Body of Knowledge: SMART Goals and Aim Statements

NAHQ CPHQ Exam Preparation Materials: Developing Effective Aim Statements

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Sentinel events usually result from process failures—breakdowns or variations in how care is delivered, such as communication failures, procedural lapses, or system errors (The Joint Commission, Sentinel Event Policy, 2024; AHRQ, Patient Safety and Quality, 2023).

While staffing and competence impact care, process issues are more commonly root causes.

Structure refers to physical or organizational infrastructure, less commonly the direct cause.

The HEDIS measure of the percent of diabetic patients with a HgA1c greater than 9.0% is an indicator of poor glycemiccontrol and a risk factor for complications12. Reducing this measure is a quality improvement goal that requires a multidisciplinary approach and data-driven strategies34.

A quality improvement team is a group of individuals with different roles and responsibilities who work together to achieve a common aim56. The team should include representatives from various areas of the clinic, such as management, clinical staff, and data analysts78.

The clinic manager is responsible for providing effective and consistent leadership, communicating the vision and the steps for improvement, engaging the team in planning and monitoring, allocating resources and training, and fostering a culture of open communication and continuous learning78.

The quality improvement specialist is responsible for analyzing and reviewing the clinical and business data, suggesting and selecting the key priority areas, implementing and evaluating the improvement interventions, and reporting the results and outcomes78.

The provider champion is responsible for modeling enthusiasm and support for quality improvement, leading the clinical discussions and decisions, influencing and educating other providers and staff, and ensuring adherence to evidence-based guidelines and best practices78.

The HEDIS chart abstractor, the coder, and the primary care provider are also important members of the quality improvement process, but they are not sufficient to form a comprehensive and effective team. The HEDIS chart abstractor and the coder are mainly involved in collecting and coding the data, while the primary care provider is mainly involved in delivering the care. They need the guidance and coordination of the clinic manager, the quality improvement specialist, and the provider champion to align their efforts and achieve the desired outcomes78. References: 1: Hemoglobin A1c Control for Patients with Diabetes (HBD) 2: Glycemic Status Assessment for Patients with Diabetes 3: Quality Improvement Team Roles and Responsibilities - PracticeAssist 4: The Roles & Responsibilities of A Quality Management Team 5: QUALITY IMPROVEMENT TEAMS COMPOSITION 6: Comprehensive Diabetes Care - NCQA 7: HEDIS 2022 Manual - Johns Hopkins Medicine 8: HEDIS® Hemoglobin A1c Control for Patients with Diabetes (HBD) 9: GSD - Glycemic Status Assessment for Patients With Diabetes