Achieving 100% compliance with patient safety goals (hand hygiene, time-out) requires addressing gaps in current performance (80% and 90%). The most effective approach is to understand why compliance is not met.
Option A (Projecting the number of preventable adverse events): Projections estimate impact but do not address how to improve compliance.
Option B (Prioritizing implementation of strategies): Strategies are premature without understanding barriers to compliance.
Option C (Determining barriers to compliance): This is the correct answer. The NAHQ CPHQ study guide states, "To improve compliance with safety goals, quality professionals should firstidentify barriers (e.g., workflow issues, lack of training) through methods like root cause analysis or staff interviews" (Domain 1).
This informs targeted interventions.
Option D (Benchmarking with a similar facility): Benchmarking provides context but does not directly address internal barriers to compliance.
CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.3, "Identify barriers to safety goal achievement," emphasizes analyzing compliance gaps. The NAHQ study guide notes, "Understanding barriers is the first step to improving safety compliance" (Domain 1).
Rationale: Determining barriers identifies root causes of non-compliance, enabling effective interventions, as per CPHQ's patient safety principles.
Reference: NAHQ CPHQ Study Guide, Domain 1: Patient Safety, Objective 1.3.

The question "Did anything happen last night that could lead to a central line infection?" demonstrates a culture of safety because it proactively addresses potential patient safety issues. It encourages staff to reflect on recent events, identify possible risks, and take preventive actions to avoid harm. This focus on identifying and mitigating risks before they result in adverse events is a key component of a safety-oriented culture.
* "Do we have available beds in the ICU?" (A): This question is operational and does not directly address safety concerns.
* "Who is the last person that committed a medication error?" (C): This question could foster a blame culture rather than a culture of safety, which emphasizes systemic improvements over individual blame.
* "What was the patient's intake and output?" (D): This is a clinical question focused on patient care details, not on safety culture.
References
* NAHQ Body of Knowledge: Building a Culture of Safety
* NAHQ CPHQ Exam Preparation Materials: Safety Culture and Communication
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The data in the table shows that Department C has the lowest compliance rate in pain management at 65%, which is well below the organization's goal of a 90% mean compliance rate. This indicates that pain management presents the greatest opportunity for improvement. Focusing on pain management in Department C could yield significant gains in overall patient care and satisfaction, as managing pain effectively is a critical component of quality care.
* Patient flow (A): Although Department C also has low compliance in patient flow, pain management has the lowest compliance rate, making it a higher priority.
* Environment of care (B): Compliance rates are higher in this focus area, especially in Department B.
* Infection prevention (D): Compliance rates are generally higher across all departments in this area, so it is not the most pressing issue.
References
* NAHQ Body of Knowledge: Quality Improvement Prioritization
* NAHQ CPHQ Exam Preparation Materials: Analyzing Performance Data for Improvement

The scatter diagram shows that as the decrease in staffing targets becomes more significant (moving right on the horizontal axis), the incidence of infection goes up (moving up on the vertical axis). This indicates a negative relationship because as one variable increases, the other one decreases. The relationship appears to be strong because the points lie closely to an imaginary line that slopes upwards from left to right, which suggests a consistent trend across the data points.
References:In healthcare quality improvement, it is critical to use data to inform decision-making. Scatter diagrams are a common tool used for this purpose. The NAHQ Healthcare Quality Competency Framework emphasizes the importance of analyzing and utilizing data in decision-making, as indicated in the Performance and Process Improvement domain. A strong negative relationship in this context could indicate that decreased staffing levels are associated with higher infection rates, which is a significant finding for a nursing director assessing outcomes and considering quality improvement initiatives.