Exactprep CPHQ Questions

When dealing with a significant increase in the time it takes for insurance claims to be submitted, which results in the hospital not being paid in a timely manner, the best course of action for a healthcare quality professional is to assemble a work group and facilitate the development of a fishbone diagram12.

A fishbone diagram, also known as a cause-and-effect diagram or Ishikawa diagram, is a visual tool used to systematically identify and present all the possible causes of a particular problem in order to find its root causes1. This approach is particularly useful in this scenario because it allows the team to visualize the many potential factors contributing to the increase in submission time for insurance claims.

Here are the steps that the healthcare quality professional would take:

Assemble a Work Group: Gather a team of individuals who are familiar with the process and can contribute to identifying potential causes of the problem1.

Define the Problem: Clearly articulate the problem of increased time for insurance claims submission. This is typically written at the head or mouth of the fish in the fishbone diagram1.

Identify Major Cause Categories: Common categories include methods, machines (equipment), people (manpower), materials, measurement, and environment. These are drawn as the “bones” of the fish1.

Identify Possible Causes: Brainstorm all the possible causes of the problem that fall into each category. These are written on the smaller “bones” off of the major cause categories1.

Analyze and Prioritize Causes: Discuss and analyze the identified causes, and prioritize them based on their impact on the problem1.

Identify Solutions: For each high-priority cause, develop strategies or changes to address the cause1.

Implement and Monitor Solutions: Implement the identified solutions, monitor their effectiveness, and make adjustments as necessary1.

By following these steps, the healthcare quality professional can systematically address the problem of increased insurance claim submission time, ultimately improving the hospital’s revenue cycle2.

Developing a patient safety program requires a comprehensive understanding of the organization’s risks, priorities, and strategic direction to ensure the plan is aligned and effective.

Option A (Infection control data and accreditation results): While infection control data is relevant to safety, it is already partially covered by incident reports and performance indicators. Accreditation results provide compliance insights but are not foundational for planning.

Option B (Staff satisfaction and root cause analysis (RCA) data): Staff satisfaction is indirectly related to safety culture, and RCA data may be included in incident reports. Neither is the most critical missing piece for planning a broad safety program.

Option C (The facility risk assessment and strategic goals): This is the correct answer. NAHQ CPHQ study materials emphasize that a facility risk assessment (e.g., identifying high-risk processes like medication errors) and strategic goals (e.g., reducing harm events) are essential for developing a patient safety plan, as they provide context for prioritizing interventions and aligning with organizational objectives.

Option D (Physician satisfaction and financial goals): Physician satisfaction and financial goals are not directly tied to patient safety planning, which focuses on clinical and operational risks rather than provider morale or finances.

The data shows variable compliance rates for pain assessment across different staff groups, with physicians having the lowest rates (20–50%), nurses the highest (75–83%), and physical therapists in between (50–60%). To improve performance, the next step should address the identified gaps through a structured intervention, leveraging data to drive action.

Option A (Disseminate the results to nursing staff): Disseminating results to nursing staff alone is insufficient, as their compliance rates are already high (75–83%). The focus should be on lower-performing groups (physicians and physical therapists), and dissemination without a plan does not ensure improvement.

Option B (Hire a pain management specialist): Hiring a specialist may be premature without first analyzing the root causes of low compliance. This option assumes a lack of expertise is the issue, which is not supported by the data alone.

Option C (Continue monitoring for another quarter): Continuing to monitor without intervention delays action on clear performance gaps, particularly for physicians (20% in March). CPHQ principles emphasize acting on data to drive improvement rather than passive monitoring.

Option D (Create an action plan with the department leaders): This is the most appropriate next step, as it involves collaboration with leaders from all relevant departments (physicians, nurses, physical therapists) to address specific compliance gaps. NAHQ study materials advocate for data-driven action plans that engage stakeholders to identify causes (e.g., training needs, workflow issues) and implement targeted interventions, aligning with performance improvement methodologies like Plan-Do-Study-Act (PDSA).

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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