CPHQ Questions Bank

The NAHQ CPHQ exam blueprint emphasizes that patient safety committees should prioritize issues that present the greatest risk of patient harm. In infection prevention and control, an increase in infection rates represents an immediate safety concern requiring timely review, investigation, and intervention.

Option A is correct because rising infection rates may indicate outbreaks, process failures, or lapses in adherence to evidence-based practices. Addressing these trends promptly supports harm prevention and regulatory expectations.

Options B, C, and D are routine administrative or operational items that can be addressed after urgent safety risks. The CPHQ framework stresses risk-based prioritization, making increased infection rates the appropriate agenda priority.

Incident reporting systems are tools to collect and analyze data onpatient safety incidents, such as medication errors, falls, infections, and adverse events12.

Incident reporting systems can help identify patterns, trends, and areas of improvement for patient safety and quality of care123.

The graph shows the incident rates for one facility compared to similar facilities in four categories: medication, falls, infection, and adverse events. The graph indicates that the facility has a higher incident rate for falls than the average of similar facilities, while the other categories are comparable or lower4.

Therefore, the first step after reviewing the graph should be to perform additional analysis on falls data, such as the types, causes, consequences, and contributing factors of falls incidents, and compare them with the best practices and standards for falls prevention and management567.

This will help the facility to understand the root causes of the high falls incident rate, and to develop and implement appropriate interventions to reduce the risk and harm of falls for patients567.

Reviewing medication processes, researching best practices, and sharing data with the governing body are also important steps, but they should be done after the additional analysis on falls data, as they are more general and less specific to the problem identified by the graph4. References: 1: Patient Safety Incident Reporting and Learning Systems | WHO 2: Incident Reporting: Key to Successful Healthcare Organizations | SafeQual 3: Report a patient safety incident | NHS England 4: Data from an Incident reporting system compares Incident rates for one facility to similar facilities | User-uploaded image 5: Falls Prevention and Management | NAHQ 6: Preventing Falls in Hospitals | Agency for Healthcare Research and Quality 7: Falls Prevention and Management | Institute for Healthcare Improvement

NAHQ guidance emphasizes prioritizing training based on weighted impact, not percentage compliance alone. While both progress notes and external communication show lower compliance, care plan documentation carries a higher weight (1.5) and has suboptimal performance at 80% compliance.

Weighted scoring reflects the relative importance of each category to quality and patient outcomes. Deficiencies in high-weight areas represent greater risk and therefore should be prioritized for improvement and training.

Assessment has high compliance, and external communication has lower weight. Progress notes have moderate weight. Therefore, the care plan represents the most significant opportunity for improvement, making Option C the correct answer.

In the Performance and Process Improvement domain, NAHQ emphasizes analyzing patterns across multiple performance indicators before selecting interventions. All three clinics exceed targets for complaints and wait times, and two clinics fail to meet compliment targets—indicating a system-wide customer service issue, not an isolated performance gap.

Implementing customer service strategies addresses complaints, compliments, and wait-time perception collectively. Continuing to track data (Option A) delays action. Complaint training (Option B) is too narrow. Wait-time training alone (Option C) does not address broader service experience concerns. Therefore, Option D is the most appropriate response.