Download Full Version CPHQ NAHQ Exam

Unreported incidents leading to claims indicate a weak reporting culture, requiring a focus on encouraging reporting to identify and mitigate risks.

Option A (Conduct retrospective medical record reviews to identify elements of risk): Reviews may identify risks but do not address the root issue of unreported incidents.

Option B (Implement a back-up paper process to the electronic reporting system): A paper process is unlikely to improve reporting culture and may complicate systems.

Option C (Identify options for a new electronic reporting system): A new system may help but is premature without addressing cultural barriers to reporting.

Option D (Create an organization-wide program that promotes reporting): This is the correct answer. The NAHQ CPHQ study guide states, “A non-punitive reporting culture, promoted through organization-wide programs, is essential to ensure incidents are reported and risks are identified” (Domain 1). Programs include training and incentives to encourage reporting.

CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.2, “Promote a culture of safety,” emphasizes fostering reporting. The NAHQ study guide notes, “Programs to promote reporting are critical when incidents are underreported” (Domain 1).

Rationale: Promoting reporting addresses the cultural barrier causing unreported claims, aligning with CPHQ’s safety culture principles.

Sustaining performance improvement initiatives requires mechanisms to ensure changes are maintained over time.

Option A (Conducting annual staff surveys): Surveys assess perceptions but do not directly sustain improvements.

Option B (Establishing ongoing monitoring systems): This is the correct answer. The NAHQ CPHQ study guide states, “Ongoing monitoring systems, such as dashboards or control charts, are key to sustaining performance improvements by tracking metrics and detecting deviations” (Domain 4).

Option C (Limiting team meetings to quarterly): Infrequent meetings may hinder sustained engagement.

Option D (Assigning new project leaders periodically): Changing leaders disrupts continuity, not sustaining improvements.

CPHQ Objective Reference: Domain 4: Performance and Process Improvement, Objective 4.5, “Sustain improvement initiatives,” emphasizes monitoring systems. The NAHQ study guide notes, “Monitoring ensures improvements are maintained” (Domain 4).

Rationale: Ongoing monitoring sustains improvements, aligning with CPHQ’s improvement principles.

Peer review committee minutes are confidential and protected under laws and accreditation standards to encourage candid discussion and quality improvement. These documents typically are not distributed broadly or to non-members. The appropriate procedure is to refer the request to the committee chair, who can assess the legitimacy and decide if sharing is appropriate based on privacy, confidentiality, and organizational policy (The Joint Commission, Peer Review Confidentiality, 2024; NAHQ, Ethics in Quality, 2024). Directly providing minutes (Option B or D) without proper authorization violates confidentiality. Refusing outright (Option C) may be necessary if policies prohibit disclosure but is better managed through official channels first. Referral ensures appropriate governance and protects the integrity of the peer review process. This approach aligns with regulatory requirements under state peer review protection laws and accreditation standards that emphasize privacy and quality assurance processes.

Ongoing Professional Practice Evaluation (OPPE) is part of the credentialing process for medical staff aimed at evaluating a provider’s clinical competence and professional behavior on an ongoing basis, rather than at the time of reappointment only. OPPE is typically used to monitor providers with identified practice issues. It involves collecting data about a provider’s performance over time, reviewing the information regularly, and using it to ensure that the provider meets professional standards. This proactive monitoring can lead to early identification and resolution of potential issues.