NAHQ CPHQ Certified Professional in Healthcare Quality Exam Practice Test

Answer : A

Tracers are a method of assessing the quality and safety of care, treatment, or services by following the experience of a patient or a process through the entire health care delivery system1.

Tracers are used by The Joint Commission and other accreditation bodies to evaluate the compliance of health care organizations with the standards and requirements for accreditation1.

Tracers can help identify the strengths and weaknesses of an organization's processes and practices, as well as the risks and opportunities for improvement23.

Tracers can also help engage staff and stakeholders in continuous improvement activities and foster a culture of quality and safety24.

Therefore, the main purpose of conducting tracers as a part of continuous readiness is to identify current gaps in processes of quality and patient safety that need correcting, as this will help the organization achieve better outcomes and meet the expectations of accreditation1234.Reference:1:Tracer Methodology Fact Sheet | The Joint Commission2:How tracer rounds can support effective continuous improvement in healthcare3:Unlocking QTRACER's secret to ensure continuous improvement in healthcare4:Continuous Service Readiness | Joint Commission Resources

Answer : D

The first step in identifying a set of process measures to improve wound care outcomes should be to search for evidence-based guidelines for wound care. Evidence-based guidelines are developed based on a thorough review of the latest research and clinical best practices, providing a reliable foundation for selecting process measures that have been proven to improve outcomes. These guidelines ensure that the measures implemented are aligned with current standards of care and can effectively contribute to better patient outcomes.

Review prior three years on wound outcome best practices (A): This might provide valuable insights but does not ensure the latest evidence-based practices are being considered.

Perform literature search for clinical trials relating to wound care (B): This could provide useful data but is more time-consuming and less focused on immediate application compared to established guidelines.

Conduct clinical record review of wound care sentinel events (C): This is more reactive, focusing on past failures rather than proactive improvement based on best practices.

Reference

NAHQ Body of Knowledge: Evidence-Based Practice and Process Improvement

NAHQ CPHQ Exam Preparation Materials: Identifying and Implementing Process Measures

Answer : D

A medically underserved population is a population of individuals with either a large elderly population, high infant mortality rate, high level of poverty or lack of providers1. This definition aligns with option D, which refers to patients living below the income poverty line.These individuals often lack access to primary care health services2, which is a key characteristic of medically underserved populations. Therefore, the answer is D. patients living below the Income poverty line.

Answer : C

The measurement of the percent of time a comprehensive exam is completed within 96 hours of admission is an example of a process measure. Process measures evaluate the methods or steps taken to deliver healthcare. They focus on the actions performed to achieve desired outcomes and are a way to assess whether specific processes are being followed correctly to ensure quality care.

Understanding Process Measures: Process measures indicate what the healthcare providers do to maintain or improve health, such as the rate of compliance with a clinical guideline or the frequency of performing a certain procedure within a specific timeframe.

Relevance to the Scenario: In this case, measuring the completion of a comprehensive exam within 96 hours of admission assesses whether a critical step in the patient care process is being consistently executed, reflecting adherence to best practices.

Comparison to Other Measure Types:

A . Structure measures refer to the attributes of the settings in which care is provided, such as facilities, equipment, and staff.

B . Outcome measures assess the results of healthcare services, such as improvement in patient health status.

D . System measures could encompass broader aspects of healthcare delivery but are not specifically focused on individual care processes.

Answer : B

The Joint Commission (TJC) adopted a formal Sentinel Event Policy in 1996 to help health care organizations that experience serious adverse events improve safety and learn from those sentinel events1.The Sentinel Event Policy explains how The Joint Commission partners with health care organizations that have experienced a serious patient safety event to protect the patient, improve systems, and prevent further harm1.Each accredited organization is strongly encouraged, but not required, to report sentinel events to The Joint Commission1.Organizations benefit from self-reporting in the following ways: The Joint Commission can provide support and expertise during the review of a sentinel event1. Therefore, the answer is B. The Joint Commission (TJC).

Answer : A

Continuous readiness for an accreditation survey is a crucial aspect of healthcare quality management. It involves a series of actions to ensure that the healthcare organization meets the standards set by the accrediting body. Among the options provided, identifying variation between policy and practice is a key management accountability action. This involves comparing the organization's current practices with its established policies and procedures. Any discrepancies or variations are identified and addressed, ensuring that the organization is adhering to its own standards and those set by the accrediting body. This process helps to maintain a state of continuous readiness for an accreditation survey.

Tips for Continuous Joint Commission Readiness1

Tips to achieve continuous compliance readiness2

8 strategies for bringing greater accountability to your workplace3

Answer : B

The Ishikawa diagram, also known as a fishbone diagram or cause-and-effect diagram, is the best tool to determine the root cause of variations in a process. This diagram helps teams visually map out all potential causes of a problem, categorizing them into major factors such as methods, machinery, materials, and people. By exploring these potential causes systematically, teams can identify the root causes of variations and focus their improvement efforts accordingly.

Histogram (A): A histogram is used to display the distribution of data points but does not help in identifying root causes.

Shewhart chart (C): Also known as a control chart, it monitors process stability over time but is not specifically for root cause analysis.

Scatter plot (D): A scatter plot shows relationships between two variables but does not identify root causes of variations.

Reference

NAHQ Body of Knowledge: Root Cause Analysis Tools in Quality Improvement

NAHQ CPHQ Exam Preparation Materials: Using Ishikawa Diagrams for Root Cause Analysis