Selected CPHQ CPHQ Certification Questions Answers

A retained surgical sponge is a serious safety event (never event), requiring a thorough investigation to prevent recurrence. Changing procedures without understanding the cause risks ineffective solutions.

Option A (Enforce "time-outs"): Time-outs prevent wrong-site surgery but are not directly related to sponge retention, which involves counts.

Option B (Identify the root cause of the error): This is the correct answer. The NAHQ CPHQ study guide states, “Before changing procedures after a serious safety event, organizations should conduct a root cause analysis (RCA) to identify underlying causes and ensure effective solutions” (Domain 1). For example, RCA might reveal issues with sponge counting protocols.

Option C (Evaluate radiation exposure levels): Radiation evaluation is relevant for the new x-ray procedure but should follow RCA to ensure the change addresses the root cause.

Option D (Conduct a cost benefit analysis): Cost analysis is secondary to understanding the cause and ensuring patient safety.

CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.5, “Conduct root cause analysis for safety events,” emphasizes RCA before process changes. The NAHQ study guide notes, “RCA ensures changes target the true causes of errors” (Domain 1).

Rationale: Identifying the root cause via RCA ensures effective, targeted changes, as per CPHQ’s safety principles.

Under the Health Data Analytics domain, NAHQ emphasizes optimizing performance by focusing on high-weight measures that have not yet met targets. Measures that already meet or exceed targets do not yield additional incentive gains.

Breast Cancer Screening and Controlling High Blood Pressure have already met or exceeded targets. Colorectal Cancer Screening is below target but has a low weight (10%). Childhood Immunization Status has a moderate weight (20%) and is below target, representing the greatest opportunity to increase incentive earnings.

NAHQ guidance stresses prioritizing efforts where improvement will have the largest financial and quality impact, making Childhood Immunization Status the correct focus.

Control limits on a control chart are calculated using statistical methods based on the process data. They represent the expected range of variation in a process and help identify when a process is going out of control.

NAHQ emphasizes that continuous readiness is the most effective strategy for sustained regulatory compliance. Continuous readiness programs integrate standards into daily operations, promote shared accountability, and reduce reliance on reactive, inspection-driven behavior.

Just-in-time training and audits are important tools but are episodic and reactive. Benchmarking informs improvement but does not ensure compliance. Leaders who foster a culture of accountability and readiness ensure that compliance is embedded in routine practice. Therefore, Option A is the best strategy.