To support patient safety when deploying a new admissions process from the emergency department, the healthcare quality professional should suggest completing a Failure Mode and Effects Analysis (FMEA) during the design stage. FMEA is a proactive tool used to identify potential failure points in a process and assess their impact on patient safety. By analyzing the process before it is implemented, the organization can anticipate and mitigate risks, ensuring a safer rollout of the new process.
* Examining the new process for stability and variation using a control chart (A): This is typically done after implementation to monitor ongoing performance, not during the design stage.
* Conducting a root cause analysis (C): Root cause analysis is reactive and used after an error has occurred, making it unsuitable for proactive safety planning.
* Analyzing incident reports using a Pareto chart (D): This is useful for identifying common causes of past issues but does not directly contribute to the safety design of a new process.
References
* NAHQ Body of Knowledge: Risk Management and FMEA
* NAHQ CPHQ Exam Preparation Materials: Proactive Safety Design and FMEA

Accountability for quality ultimately rests with the governing body of a health care organization, such as the board of directors or trustees. The governing body is responsible for setting the vision, mission, values, and strategic goals of the organization, as well as overseeing its performance, compliance, and risk management.
The governing body also appoints, evaluates, and supports the CEO, who is accountable to the governing body for implementing the organization's strategy and ensuring quality and safety throughout the organization.
The quality manager, the CEO, and the department leader are all important roles in ensuring quality within their respective scopes of authority and responsibility, but they are not the ultimate source of accountability for quality. The quality manager is responsible for designing, coordinating, and evaluating quality improvement initiatives, as well as providing education, training, and support to staff and leaders on quality methods and tools. The CEO is responsible for providing leadership, direction, andoversight to the organization's operations, finances, and culture, as well as ensuring alignment and integration of quality across all functions and levels. The department leader is responsible for managing the daily activities, resources, and performance of a specific unit or service, as well as ensuring compliance with quality standards and policies within their area of responsibility.
However, none of these roles can ensure quality without the support, guidance, and accountability of the governing body, which has the ultimate authority and responsibility for the organization's quality and safety.
The governing body sets the tone and expectations for quality at the top, and holds the CEO and other leaders accountable for delivering quality outcomes and improving quality processes. The governing body also monitors and evaluates the organization's quality performance and improvement efforts, and ensures that the organization has the necessary resources, structures, and systems to support quality. The governing body also ensuresthat the organization engages with external stakeholders, such as regulators, accreditors, payers, and patients, to demonstrate its commitment and accountability for quality.
References:
NAHQ Code of Ethics, Principle 1: The healthcare quality professional acts as a change agent and leader within the organization and community, promoting a culture of excellence in quality, safety, and performance outcomes.
NAHQ Learning Lab: The Role of the Healthcare Quality Professional in Population Health Management, Module 1: Introduction to Population Health Management, Slide 9: The Role of the Governing Body NAHQ Journal for Healthcare Quality, Volume 41, Issue 2, March/April 2019, Article: The Role of the Board in Quality and Safety Performance: Perceptions of Board Members and Quality Leaders, Page 72: Abstract and Page 77: Discussion

In an organization seeking to optimize value-based reimbursement, a healthcare quality professional should promote initiatives that directly impact clinical outcomes, patient satisfaction, and cost-efficiency.
Standardizing joint replacement care pathways (Answer A) is an initiative that aligns with these goals. By ensuring consistency in care, reducing variability, and following evidence-based practices, standardized pathways improve outcomes, decrease complications, and reduce costs, which are all critical components in value-based reimbursement models.
The other initiatives, while beneficial, are not as directly linked to optimizing value-based reimbursement:
* Improving hand hygiene compliance (B) is essential for infection control but has a more indirect impact on value-based reimbursement.
* Reducing the use of inpatient restraints (C) focuses on patient safety and ethical care, which is important but not directly related to reimbursement optimization.
* Implementing computerized provider order entry (CPOE) (D) can reduce errors and improve efficiency, but its impact on value-based reimbursement is broader and less direct compared to standardized care pathways.
References:
* National Association for Healthcare Quality (NAHQ) - Certified Professional in Healthcare Quality (CPHQ) Study Materials.
* Value-Based Reimbursement Strategies, NAHQ Documentation.
* Clinical Pathway Standardization and Its Impact on Value-Based Care, NAHQ Resources.
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