Free Practice Questions for NAHQ CPHQ Exam

To find the problem rate, divide the totalnumber of problems by the total number of patients treated in March:

Total problems in March: 8+4+19=318 + 4 + 19 = 318+4+19=31

Total patients treated in March: 1,3501,3501,350

Problem rate: (31/1,350)×100=2.3%(31 / 1,350) \times 100 = 2.3\%(31/1,350)×100=2.3%, approximately 2%.

The governing body holds the ultimate accountability for patient safety within a healthcare organization. They are responsible for setting policies, ensuring compliance with regulations, and fostering a culture of safety throughout the organization.

A fishbone diagram, also known as an Ishikawa or cause-and-effect diagram, helps teams systematically identify potential causes of a problem. It visually organizes possible contributing factors to facilitate root cause analysis.

The table shows the compliance data by three different abstractors across four clinics. There is a noticeable variation in the data collected by different abstractors for the same clinic.

According to NAHQ’s resources, ensuring data accuracy and reliability is crucial in healthcare quality. One of the ways to achieve this is through an interrater reliability process, which assesses the degree of agreement among raters or evaluators.

Implementing an interrater reliability process will help in evaluating if the variations are due to errors or actual differences in compliance levels. It ensures that the data collected is consistent and reliable across all abstractors.

Educating Abstractor 1 and 3 or developing a corrective action plan for Clinic B might be necessary steps later on, but without first establishing the reliability of the data through an interrater reliability process, it would be premature to take these steps.

Studying best practices in Clinic D could be beneficial but does not directly address the issue of data accuracy and consistency among different abstractors.

Peer review committee minutes are confidential and protected under laws and accreditation standards to encourage candid discussion and quality improvement. These documents typically are not distributed broadly or to non-members. The appropriate procedure is to refer the request to the committee chair, who can assess the legitimacy and decide if sharing is appropriate based on privacy, confidentiality, and organizational policy (The Joint Commission, Peer Review Confidentiality, 2024; NAHQ, Ethics in Quality, 2024). Directly providing minutes (Option B or D) without proper authorization violates confidentiality. Refusing outright (Option C) may be necessary if policies prohibit disclosure but is better managed through official channels first. Referral ensures appropriate governance and protects the integrity of the peer review process. This approach aligns with regulatory requirements under state peer review protection laws and accreditation standards that emphasize privacy and quality assurance processes.

Comprehensive and Detailed Explanation From Exact Extract:

In the Population Health and Care Transitions domain, an effective disease management strategy focuses on ongoing monitoring and self-management to prevent complications and hospital readmissions.

Providing home blood pressure monitors empowers patients to manage their condition daily and improves adherence to treatment plans.

Tracking data or routine screening are useful for surveillance or prevention but not for managing existing hypertension. Education alone does not ensure ongoing control without actionable monitoring.

According to the NAHQ CPHQ exam blueprint, patient safety is the highest priority in quality improvement planning. Before considering analytics, benchmarking, or data visualization, organizations must identify potential safety risks associated with new services.

Option A is correct because determining patient safety risk priorities ensures that the improvement plan addresses high-risk processes, regulatory expectations, and harm prevention. This step aligns with proactive risk management and high-reliability principles.

Options B, C, and D are important technical considerations but should follow risk identification. The CPHQ framework consistently emphasizes that safety-first planning underpins all quality initiatives.

 A flowchart is a type of diagram that represents a workflow or process, showing the steps as boxes of various kinds, and their order by connecting them with arrows. This diagrammatic representation illustrates a solution model to a given problem. Flowcharts are used in analyzing, designing, documenting, or managing a process or program in various fields12. In the context of a wrong site surgery, a flowchart can help visualize the entire process, identify potential points of failure, and understand how different steps in the process are interrelated. This makes it an effective tool for developing a shared understanding of the current process.

A culture of safety in healthcare is the extent to which an organization’s culture supports and promotes patient safety1. It refers to the values, beliefs, and norms that are shared byhealthcare practitioners and other staff throughout the organization that influence their actions and behaviors2.

A culture of safety requires a collaborative and data-driven approach that involves multiple stakeholders, such as clinicians, managers, patients, and quality professionals3. It also requires a commitment to continuous improvement, learning from errors, and addressing system-level factors that contribute to patient harm.

According to the National Association for Healthcare Quality (NAHQ), one of the core competencies for healthcare quality professionals is to lead and facilitate change initiatives that align with the organization’s strategic goals and priorities. NAHQ also states that healthcare quality professionals should advocate for a culture of safety and quality across the organization.

Therefore, the option that best reflects the first step in establishing a culture of safety is C. leadership. Leadership is essential for creating a vision, setting expectations, providing resources, and empowering staff to participate in safety improvement efforts. Leadership also influences the organizational climate, which affects the attitudes and behaviors of staff towards patient safety.

The other options are less likely to be the first step in establishing a culture of safety, as they are either too specific, too vague, or too dependent on other factors. For example, recruitment strategies, plan, and educational programs are important components of a culture of safety, but they are not sufficient or effective without strong and supportive leadership . References:

1: Safety Culture in Healthcare: A 7-Step Framework

2: What Is Patient Safety Culture?

3: 9 Effective Performance Management Strategies for Healthcare

A Guide to Performance Improvement in Healthcare

Healthcare Quality Solutions: Ready Your Workforce for Quality

Code of Ethics

Safety Culture in Healthcare Settings

Understanding the Evolving Landscape of Healthcare Quality

A rapid process improvement event (e.g., Kaizen) focuses on quick, targeted interventions to improve a specific process, such as reducing central line-associated bloodstream infections (CLABSIs).

Option A (Design indicators for hospital-wide data collection plan): Designing indicators is a long-term strategy, not suited for a rapid event, which focuses on immediate process changes.

Option B (Search the United States Preventive Services Taskforce for recommendations): USPSTF provides preventive care guidelines, not specific hospital infection control strategies like CLABSIs.

Option C (Review the Agency for Healthcare Research and Quality for relevant resources): This is the correct answer. The NAHQ CPHQ study guide states, “AHRQ provides evidence-based resources, such as toolkits for reducing CLABSIs, that are practical for rapid improvement events” (Domain 4). AHRQ’s CLABSI toolkit offers actionable protocols for rapid implementation.

Option D (Conduct a systematic review of studies in intensive care units): Systematic reviews are time-intensive and not feasible for a rapid event, which prioritizes quick action over exhaustive research.

CPHQ Objective Reference: Domain 4: Performance and Process Improvement, Objective 4.4, “Use evidence-based resources for improvement initiatives,” highlights AHRQ as a key source for practical tools. The NAHQ study guide notes, “AHRQ toolkits are ideal for rapid process improvement events due to their evidence-based, ready-to-use protocols” (Domain 4).

Rationale: AHRQ’s CLABSI resources provide immediate, evidence-based strategies for a rapid improvement event, aligning with CPHQ’s focus on actionable interventions.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results provide insights intopatients’ experiences with healthcare services12. In this case, the survey results indicate that there may be issues with how well doctors communicate and the ease of getting necessary care. These are areas where practitioners can directly influence patient experience. Therefore, initiating a practitioner communication initiative on access to care standards (option B) would be an appropriate next step. This initiative could involve training or workshops to improve communication skills and strategies to enhance access to care3. It’s also important to continuously monitor CAHPS survey results to track progress and identify new areas for improvement4.

The CAHPS survey results indicate that the health plan's score on how well doctors communicate is lower than the Quality Compass Mean. Since communication with healthcare providers is a key aspect of patient experience and can greatly affect patient satisfaction and outcomes, focusing on improving practitioners' communication skills is essential. A practitioner communication initiative could address the gap in communication scores by providing training and resources to enhance how doctors interact with patients. This initiative would likely involve coaching for practitioners on how to effectively listen, explain, and engage with patients to ensure they understand their health conditions and the care provided.

To ensure safe transitions of care, a quality professional should focus on evaluating the processes for discharges and transfers (Answer A). This approach involves examining theprotocols and procedures that are in place for discharging patients from one level of care to another, such as from a hospital to a skilled nursing facility or home. Evaluating these processes helps identify potential gaps, inconsistencies, or risks that could compromise patient safety during transitions. It also ensures that all necessary information, including medication lists, follow-up care instructions, and patient education, is communicated effectively between care providers.

The other options are important aspects but do not encompass the entire scope of ensuring safe transitions:

Auditing documentation of patient discharge summaries (B) focuses only on the documentation aspect, not the overall process.

Reviewing patient feedback abouttransfers to skilled nursing facilities (C) is valuable but limited to patient perceptions rather than assessing the entire transition process.

Assessing case management discharge and transfer records (D) looks at specific records but may miss broader process issues.

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In the Performance and Process Improvement domain, NAHQ emphasizes selecting initiatives that impact clinical outcomes, patient safety, and reimbursement. Inpatient urinary catheter utilization is directly linked to catheter-associated urinary tract infections (CAUTIs), which are publicly reported and tied to CMS value-based purchasing and hospital-acquired condition (HAC) penalties.

Reducing catheter utilization lowers infection risk, improves patient outcomes, and protects reimbursement. While the other options may improve operational efficiency or staff satisfaction, they are not as directly connected to nationally reported quality metrics and financial incentives. This makes Option D the highest-priority project from both quality and reimbursement perspectives.

A sentinel event is a patient safety event that reaches a patient and results in any of the following:

Death

Severe temporary harm

Permanent harm

An intervention required to sustain life

Option D, "An intervention to sustain life," aligns with the definition of a sentinel event. Such interventions may include actions like cardiopulmonary resuscitation (CPR), defibrillation, or other emergency procedures necessary to keep the patient alive following a significant adverse event.