NAHQ CPHQ ACTUAL EXAM SCRIPT QUESTIONS
AND ANSWERS SURE A+
✔✔Rules for the 21st-Century Healthcare system (from IOM's report Crossing the
Quality Chasm) - ✔✔Preference is given to professional roles over the system
Care is customized according to patient needs and values
The patient is the source of control
Knowledge is shared and information flows freely
Decision making is evidence based
Safety is a system priority
Transparency is necessary
The system anticipated needs
Waste is continuously decreased
Cooperation among clinicians is a priority
✔✔What is necessary for high reliability performance? - ✔✔Strong leadership and
skilled management
✔✔Leadership - ✔✔Coping with change by developing a vision and aligning the
subsystems of the organization. Ability to influence an individual or group toward
achievement of goals. Determines the correct direction or path.
✔✔Management - ✔✔Coping with complexity through planning and budgeting; setting
goals; organizing, staffing and creating a structure to foster goal attainment; setting up
mechanisms for monitoring and controlling results. Doing the correct things to stay on
the path.
✔✔True or False
Change is not so much about overcoming resistance as it is about creating attraction. -
✔✔True
✔✔Different leadership styles - ✔✔Autocratic
Participative
,Empowering
Transactional
Transformational
✔✔autocratic leadership - ✔✔Directive and controlling. Employees have little
discretionary power in their work
✔✔Participative leadership - ✔✔Allows employees some degree of autonomy in
completing their work while maintaining some control of the group and the decision-
making process; seeks input from employees and serves as facilitator
✔✔Empowering leadership - ✔✔Shares power and decision making with employees;
enabling others by providing the necessary resources and support
✔✔Transactional leadership - ✔✔Views the leader-follower relationship as a process of
exchange where compliance or performance is achieved through the process of giving
rewards and punishment
✔✔Transformational leadership - ✔✔Able to inspire others to change expectations and
motivations to work toward common goals
✔✔5 important general principles of exemplary leaders - ✔✔1. Challenge the system
2. Inspire a shared vision
3. Enable others to act
4. Mode the way
5. Encourage the heart
✔✔Challenge the system - ✔✔Question status quo and lead the way as an early
adopter of innovation; recognize good ideas and demonstrate a willingness to stretch
and grow to improve quality of care; adoption of core values as a learning organization
Ask what should be instead of accepting what is!
✔✔Inspire a Shared Vision - ✔✔For change to be a success, provide and influence
others to share vision; develop a strong culture for QPI; requires more than just telling
others what needs to be done; communicates vision in a manner that causes others to
embrace it
✔✔Enable others to act - ✔✔Share decision making and power in a way that enables
others to move toward the direction of the vision. Share power and enable by having
appropriate structural design and the appropriate resources to support quality
management initiatives
✔✔Model the Way - ✔✔Model desired behaviors as a role model. Actions speak louder
than words. "On-stage behavior"
,✔✔Encourage the Heart - ✔✔A critical component. Recognize the contributions that
employees make and celebrate the core values and victories. Reward desired
behaviors.
✔✔Framework for Leadership for Improvement (5 steps - IHI) - ✔✔1. Set direction:
mission, vision and strategy.
2. Establish the foundation.
3. Build will.
4. Generate ideas.
5. Execute change.
✔✔NQF endorsed safe practice of Leadership Structures and Systems (4 elements) -
✔✔1. Awareness structures and systems
2. Accountability structures and systems
3. Structures and systems
4. Action structures and systems
✔✔Accountability structures and systems - ✔✔- enable leaders to establish
accountability to governing body, senior mgmt, mid-level mgmt, physician leaders and
frontline staff
Patient safety program
Patient safety officer
Direct organization-wide leadership accountability
Interdisciplinary patient safety committee
External reporting activities
✔✔Structures and systems-driving ability - ✔✔- allows leaders to assess the capacity,
resources and competence necessary to implement change in culture and patient safety
performance
Patient safety budgets
People systems
Quality systems
Technical systems
✔✔Action structures and systems - ✔✔- enable leaders to take direct and appropriate
action
QPI programs
Regular actions of governance, including confirmation of values, basic teamwork
training and governance board competence in patient safety
, Regular actions of senior administrative leadership, including commitment of time to
patient safety; culture measurement, feedback and interventions; basic teamwork
training and team interventions; identification and mitigation of risks and hazards
Regular actions of unit, service line, departmental and mid-level mgmt leaders
Regular actions with respect to independent medical leaders
✔✔Awareness structures and systems - ✔✔- provide leaders with continuous
information about potential risks, hazards and performance gaps that may contribute to
patient safety issues
Identification of risks and hazards
Culture mgmt, feedback and intervention
Direct patient input
Governance board and senior mgmt briefings and meetings
✔✔Organization Structural elements of Infrastructure for Quality and Safety -
✔✔Governing body structures - ultimate responsibility for quality of care, either full
responsibility or delegates
Operational structures - manage the coordination of quality and improvement efforts
Teams - work on 1 or more targeted improvement opportunities
HCQP role is to evaluate the effectiveness of various structures, paying close attention
to alignment, coordination and communication
✔✔3 categories of team membership (IHI) - ✔✔1. Clinical leadership representation
2. Technical expertise
3. Day to day leadership
+ a project sponsor or champion with executive authorities and serve as a liaison to
other areas and senior mgmt
✔✔Who bears ultimate responsibility for the setting of policy, financial and strategic
direction and quality of care and service provided? - ✔✔Organization's governing body
or board of trustees
✔✔6 categories of responsibilities for governing body - ✔✔Organization
Public policy and external relationships
Strategic planning
Resource management
Human resource development
Education and research
✔✔5 core leadership activities to drive improvement (IHI Framework for leadership for
improvement) - ✔✔1. Establish the mission, vision and strategy
2. Establish the foundation
AND ANSWERS SURE A+
✔✔Rules for the 21st-Century Healthcare system (from IOM's report Crossing the
Quality Chasm) - ✔✔Preference is given to professional roles over the system
Care is customized according to patient needs and values
The patient is the source of control
Knowledge is shared and information flows freely
Decision making is evidence based
Safety is a system priority
Transparency is necessary
The system anticipated needs
Waste is continuously decreased
Cooperation among clinicians is a priority
✔✔What is necessary for high reliability performance? - ✔✔Strong leadership and
skilled management
✔✔Leadership - ✔✔Coping with change by developing a vision and aligning the
subsystems of the organization. Ability to influence an individual or group toward
achievement of goals. Determines the correct direction or path.
✔✔Management - ✔✔Coping with complexity through planning and budgeting; setting
goals; organizing, staffing and creating a structure to foster goal attainment; setting up
mechanisms for monitoring and controlling results. Doing the correct things to stay on
the path.
✔✔True or False
Change is not so much about overcoming resistance as it is about creating attraction. -
✔✔True
✔✔Different leadership styles - ✔✔Autocratic
Participative
,Empowering
Transactional
Transformational
✔✔autocratic leadership - ✔✔Directive and controlling. Employees have little
discretionary power in their work
✔✔Participative leadership - ✔✔Allows employees some degree of autonomy in
completing their work while maintaining some control of the group and the decision-
making process; seeks input from employees and serves as facilitator
✔✔Empowering leadership - ✔✔Shares power and decision making with employees;
enabling others by providing the necessary resources and support
✔✔Transactional leadership - ✔✔Views the leader-follower relationship as a process of
exchange where compliance or performance is achieved through the process of giving
rewards and punishment
✔✔Transformational leadership - ✔✔Able to inspire others to change expectations and
motivations to work toward common goals
✔✔5 important general principles of exemplary leaders - ✔✔1. Challenge the system
2. Inspire a shared vision
3. Enable others to act
4. Mode the way
5. Encourage the heart
✔✔Challenge the system - ✔✔Question status quo and lead the way as an early
adopter of innovation; recognize good ideas and demonstrate a willingness to stretch
and grow to improve quality of care; adoption of core values as a learning organization
Ask what should be instead of accepting what is!
✔✔Inspire a Shared Vision - ✔✔For change to be a success, provide and influence
others to share vision; develop a strong culture for QPI; requires more than just telling
others what needs to be done; communicates vision in a manner that causes others to
embrace it
✔✔Enable others to act - ✔✔Share decision making and power in a way that enables
others to move toward the direction of the vision. Share power and enable by having
appropriate structural design and the appropriate resources to support quality
management initiatives
✔✔Model the Way - ✔✔Model desired behaviors as a role model. Actions speak louder
than words. "On-stage behavior"
,✔✔Encourage the Heart - ✔✔A critical component. Recognize the contributions that
employees make and celebrate the core values and victories. Reward desired
behaviors.
✔✔Framework for Leadership for Improvement (5 steps - IHI) - ✔✔1. Set direction:
mission, vision and strategy.
2. Establish the foundation.
3. Build will.
4. Generate ideas.
5. Execute change.
✔✔NQF endorsed safe practice of Leadership Structures and Systems (4 elements) -
✔✔1. Awareness structures and systems
2. Accountability structures and systems
3. Structures and systems
4. Action structures and systems
✔✔Accountability structures and systems - ✔✔- enable leaders to establish
accountability to governing body, senior mgmt, mid-level mgmt, physician leaders and
frontline staff
Patient safety program
Patient safety officer
Direct organization-wide leadership accountability
Interdisciplinary patient safety committee
External reporting activities
✔✔Structures and systems-driving ability - ✔✔- allows leaders to assess the capacity,
resources and competence necessary to implement change in culture and patient safety
performance
Patient safety budgets
People systems
Quality systems
Technical systems
✔✔Action structures and systems - ✔✔- enable leaders to take direct and appropriate
action
QPI programs
Regular actions of governance, including confirmation of values, basic teamwork
training and governance board competence in patient safety
, Regular actions of senior administrative leadership, including commitment of time to
patient safety; culture measurement, feedback and interventions; basic teamwork
training and team interventions; identification and mitigation of risks and hazards
Regular actions of unit, service line, departmental and mid-level mgmt leaders
Regular actions with respect to independent medical leaders
✔✔Awareness structures and systems - ✔✔- provide leaders with continuous
information about potential risks, hazards and performance gaps that may contribute to
patient safety issues
Identification of risks and hazards
Culture mgmt, feedback and intervention
Direct patient input
Governance board and senior mgmt briefings and meetings
✔✔Organization Structural elements of Infrastructure for Quality and Safety -
✔✔Governing body structures - ultimate responsibility for quality of care, either full
responsibility or delegates
Operational structures - manage the coordination of quality and improvement efforts
Teams - work on 1 or more targeted improvement opportunities
HCQP role is to evaluate the effectiveness of various structures, paying close attention
to alignment, coordination and communication
✔✔3 categories of team membership (IHI) - ✔✔1. Clinical leadership representation
2. Technical expertise
3. Day to day leadership
+ a project sponsor or champion with executive authorities and serve as a liaison to
other areas and senior mgmt
✔✔Who bears ultimate responsibility for the setting of policy, financial and strategic
direction and quality of care and service provided? - ✔✔Organization's governing body
or board of trustees
✔✔6 categories of responsibilities for governing body - ✔✔Organization
Public policy and external relationships
Strategic planning
Resource management
Human resource development
Education and research
✔✔5 core leadership activities to drive improvement (IHI Framework for leadership for
improvement) - ✔✔1. Establish the mission, vision and strategy
2. Establish the foundation
