When the chairperson of the governing body requests an annual report on improvements in patient care, the report should provide an overview of the quality program, with a specific focus on how these activities have impacted patient care. This approach gives the governing body a comprehensive understanding of the effectiveness of the quality initiatives and their direct influence on patient outcomes, safety, and satisfaction.
It helps the leadership to assess the overall performance and supports informed decision-making for future improvements.
* The names of physicians who fall below the threshold of standards of care (A): This information could lead to a punitive focus and might not be suitable for a high-level annual report.
* A detailed description of all quality activities (B): While detailed information is valuable, an annual report should focus on the impact rather than every activity.
* The results of peer review (D): Peer review results are typically confidential and might not be included in a high-level report to the governing body.
References
* NAHQ Body of Knowledge: Quality Program Reporting and Governance
* NAHQ CPHQ Exam Preparation Materials: Reporting to the Governing Body
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In the context of a Failure Modes and Effects Analysis (FMEA) for a new patient safety event reporting system, the team should use the risk priority number (RPN) to determine which failure mode to address first. Here's why:
* Comprehensive Assessment: The RPN is calculated by multiplying the values assigned to the severity, frequency of occurrence, and detectability of a failure mode. This number provides a comprehensive assessment of the risk associated with each potential failure.
* Prioritization: By using the RPN, the team can prioritize which failure modes to address first based on the overall risk they pose. The higher the RPN, the more critical it is to address that failure mode.
* Efficient Resource Allocation: Addressing the highest RPN first ensures that resources are allocated to the areas that have the greatest potential impact on patient safety, making the risk mitigation process more efficient.
* Balanced Decision-Making: The RPN allows the team to consider not just how often a failure might occur, but also how severe the consequences would be and how easy it is to detect before it causes harm. This balanced approach ensures that all relevant factors are considered in decision-making.
References: (Based on Healthcare Quality NAHQ documents and resources)
* NAHQ Modules on Risk Management and FMEA.
* Quality Management in Health Care, Chapter on Using Risk Priority Number in FMEA.
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According to the National Association for Healthcare Quality (NAHQ), one of the core competencies of healthcare quality professionals is patient safety, which includes ensuring effective transitions of care and reducing preventable readmissions12.
One of the strategies to achieve this goal is to improve patient compliance with follow-up visits, which can help monitor patient outcomes, prevent complications, and provide continuity of care34.
Among the four options given, the best way to improve patient compliance is to initiate a process where the discharge planners call patients prior to the follow-up visit. This is because:
A phone call can serve as a reminder for the patient to keepthe appointment, as well as an opportunity to address any barriers or concerns that the patient may have34.
A phone call can also help establish rapport and trust between the patient and the discharge planner, which can increase patient satisfaction and adherence4.
A phone call can also allow the discharge planner to confirm the patient's understanding of the discharge instructions, medication regimen, and follow-up plan, and to provide any additional education or support that the patient may need34.
Theother options are less effective because:
Benchmarking with other facilities in the area to determine the rate of patient compliance may provide some insight into the current performance and best practices, but it does not directly address the specific needs and preferences of the individual patient5.
Including handouts in the discharge documents on the importance of keeping follow-up appointments may increase the patient's awareness and knowledge, but it may not be sufficient to motivate the patient to act on the information, especially if the patient has low health literacy, cognitive impairment, or mental health issues.
Communicating to noncompliant patients that appointments should be kept may sound authoritative and judgmental, which may alienate the patient and reduce their willingness to cooperate. Instead, a patient- centered and empathetic approach that acknowledges the patient's challenges and preferences may be more effective. References: 1: [NAHQ Code of Ethics] 2: [NAHQ HQ Principles] 3: The Importance of Patient Follow-Up | MagMutual 4: The Importance of Patient Follow-Up and Service Recovery 5: [The Financial Case for Quality as a Business Strategy] : [Utilization of Improvement Methodologies by Healthcare Quality Professionals During the COVID-19 Pandemic] : [Understanding the Evolving Landscape of Healthcare Quality] : https://nahq.org/about-nahq/code-of-ethics/ : https://nahq.org/products/hq-principles/ : https://nahq.
org/resources/the-financial-case-for-quality-as-a-business-strategy-2/ : https://nahq.org/resources/journal-for- healthcare-quality/utilization-of-improvement-methodologies-by-healthcare-quality-professionals-during-the- covid-19-pandemic/ : https://nahq.org/news-media/news/understanding-the-evolving-landscape-of-healthcare- quality/

Root cause analysis (RCA) is a structured process to identify underlying causes of significant safety events to prevent recurrence. It is typically reserved for serious incidents with high potential for harm.
Option A (Patient death): Not all patient deaths require RCA unless they meet sentinel event criteria (e.g., unexpected death due to error).
Option B (Medication error): Medication errors may warrant RCA if severe, but not all errors meet this threshold.
Option C (Sentinel event): This is the correct answer. The NAHQ CPHQ study guide states, "A root cause analysis is required for sentinel events, defined as unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof" (Domain 1). The Joint Commission mandates RCA for sentinel events like wrong-site surgery.
Option D (Near miss): Near misses are analyzed to improve systems but typically do not require formal RCA unless they indicate significant risk.
CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.5, "Conduct root cause analysis for significant safety events," specifies RCA for sentinel events. The NAHQ study guide notes, "RCA is a critical tool for analyzing sentinel events to prevent future harm" (Domain 1).
Rationale: Sentinel events, due to their severity, mandate RCA to identify and address root causes, aligning with CPHQ's patient safety principles.
Reference: NAHQ CPHQ Study Guide, Domain 1: Patient Safety, Objective 1.5.