A surgeon's elevated surgical site infection (SSI) rate (6.7% vs. 3.3% average) indicates a performance gap requiring targeted investigation.
Option A (Suspension of the surgeon): Suspension is punitive and premature without understanding the cause of the high rate.
Option B (A performance improvement project): A project may address systemic SSI issues but is too broad for an individual surgeon's performance.
Option C (A focused review): This is the correct answer. The NAHQ CPHQ study guide states, "A focused review investigates an individual provider's performance when data indicates a significant deviation, such as an elevated SSI rate" (Domain 4). It examines factors like technique or compliance.
Option D (A root cause analysis): RCA is used for specific incidents, not ongoing performance trends.
CPHQ Objective Reference: Domain 4: Performance and Process Improvement, Objective 4.6, "Evaluate provider performance," emphasizes focused reviews for outliers. The NAHQ study guide notes, "Focused reviews target individual performance issues" (Domain 4).
Rationale: A focused review investigates the surgeon's specific practices, aligning with CPHQ's improvement principles.
Reference: NAHQ CPHQ Study Guide, Domain 4: Performance and Process Improvement, Objective 4.6.

A strategic plan is a tool that helps organizations prioritize their goals, anticipate potential roadblocks, and quickly adapt to seize new opportunities12. It involves looking at the organization's internal and external environments using established strategic tools2. This ensures the organization is moving towards its long-term goals and objectives, even when making short-term decisions2. Sharing the strategic plan with everyone in the organization is crucial as it ensures alignment across different levels and functions, fosters a sense of ownership and commitment among employees, and facilitates effective execution of the plan12.
Reference: https://www.cascade.app/blog/strategic-planning-in-healthcare

Candidate B is the most effective choice to serve as a process champion. This candidate has a high level of interest, is respected as an opinion leader, and has some involvement with the current process. Although their authority to mobilize resources is low, their influence and interest in the project make them well-suited to champion the process. A process champion needs to have respect and credibility within the organization, which Candidate B has, along with sufficient involvement to understand the challenges and drive change.
* Candidate A (A): While Candidate A has high involvement and interest, they lack authority and are not a respected opinion leader, which are critical qualities for a process champion.
* Candidate C (C): Although Candidate C has high authority, their low involvement, interest, and moderate respectability make them less effective as a champion.
* Candidate D (D): Candidate D has some involvement and respectability but lacks interest and authority, making them less suitable for the role.
References
* NAHQ Body of Knowledge: Selecting Process Champions for Quality Improvement
* NAHQ CPHQ Exam Preparation Materials: Characteristics of Effective Process Champions
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Before patient outcome data can be used for benchmarking, the data should be adjusted for severity of illness.
Severity adjustment ensures that comparisons are fair and meaningful by accounting for differences in patient populations. Without this adjustment, outcomes could appear worse or better simply because one organization is treating sicker patients than another, rather than due to differences in quality of care.
* Organized by patient age (A): While age might be a factor in some cases, severity of illness is more critical for ensuring fair comparisons.
* Adjusted for length of stay (B): Length of stay adjustments might be necessary in some cases, but severity of illness is more fundamental for outcome comparisons.
* Organized by patient gender (D): Gender is less relevant compared to the need for severity adjustment in outcome benchmarking.
References
* NAHQ Body of Knowledge: Data Standardization and Benchmarking
* NAHQ CPHQ Exam Preparation Materials: Adjusting Data for Benchmarking
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Before making recommendations to leadership, the quality professional should prepare a comparative analysis based on the information gathered. This analysis should compare the capabilities, limitations, costs, and benefits of the existing system and the alternative products identified. A thorough comparative analysis will provide leadership with a clear understanding of the options available, enabling them to make an informed decision on whether to upgrade the current system or switch to a new one.
Conduct a focus group with participants from other sites within the organization (B): This might provide additional insights but should be part of the comparative analysis process rather than a standalone action.
Interview current users of the other identified products (C): This can inform the comparative analysis but is not a replacement for a comprehensive comparison.
Create a potential implementation plan for the preferred product (D): This should follow the decision- making process, not precede it.
Reference
NAHQ Body of Knowledge: Evaluation and Selection of Quality Improvement Tools NAHQ CPHQ Exam Preparation Materials: Decision-Making in Quality Management