NAHQ CPHQ EVALUATION 2026 TEST QUESTIONS
AND ANSWERS SURE A+
✔✔Evidence based quality mgmt is based on 2 types of research - ✔✔Clinical research
- evaluate impact of interventions on patient outcomes. Outcome measures may include
clinical outcomes, functional outcomes and patient satisfaction. Assists HCP in
determining clinical evidence based best practice
Health Services research - evaluates the health system at micro and macro levels.
Guide HCP in improving work processes and systems of care
✔✔clinical guidelines - ✔✔Consensus statements developed to assist in clinical
management decisions
✔✔clinical pathways - ✔✔Tools to manage quality outcomes and cost of care based on
clinical guidelines and current evidence
✔✔The use of clinical pathways and guidelines reduces variation of clinical practice to
optimize patient outcomes - ✔✔True or False
✔✔Steps for development of a Clinical Pathway - ✔✔1. Select the topic.
2. Select a mutlidisciplinary team including representatives from all groups affected
3. Evaluate and map the current process of care for the condition or procedure to
identify current variation and create an idealized process
4. Evaluate current evidence in the literature
5. Determine the pathway form.
6. Educate all users on how to use the tool and implement it. Critical to define roles.
7. Document and analyze variances that do not meet expectations of the pathway. Key
to process improvement.
✔✔Baldrige National HC Criteris for Performance Excellence Framework - ✔✔A model
that displays the QPI principles and shows the relationships between the structural,
process and outcome factors
,✔✔QPI Teams - ✔✔An important structural element for QPI
Have many different types depending on purpose/mission, tine, degree of autonomy,
authority structure, physical presence
Teams gave leaders, facilitators and coaches
✔✔core members - ✔✔the members of a team who bear primary responsibility for the
success of a project and who stay with a project from inception to completion. Often
have complementary skills needed for the desired work output
✔✔Resource members - ✔✔Critical only for a specific phases of the project and may
move in and out of the team
✔✔Natural Work Teams - ✔✔Involve the people in a given work setting who share
responsibilities for a process, workflow or type of work
✔✔self-directed work team - ✔✔A type of natural work team that shares management
responsibilities
✔✔Process Management Team - ✔✔Focuses on sharing responsibility for monitoring
and controlling a work process, such as new product development.
✔✔virtual teams - ✔✔Typically use technology supported communications rather than
face to face interactions to accomplish tasks
✔✔Steering Committee - ✔✔Permanent QPI teams consisting of cross functional
members. Self managed teams that provide direction and focus by identifying and
prioritizing improvement opportunities in the organization.
✔✔Role of the steering committee - ✔✔To sustain, facilitate and expand QP initiative
based on the strategic plan
✔✔Main responsibilities of quality council or steering committee - ✔✔Lending legitimacy
go QPI efforts, maintaining organization focus on identified goals and priorities, fostering
teamwork for improvement, providing necessary resources and formulating QPI policies
regarding quality and safety priorities, participation, annual self assessments, and
reward and recognition systems
✔✔2 teams of great importance in QPI - ✔✔1. QPI Teams
2. Steering committees (quality councils)
✔✔How managers determine when to use a team - ✔✔Task complexity,
interdependence and objectives (clear and time bound)
, ✔✔Team charter - ✔✔An approach to make task objectives clear
Contains the following info:
Description of the process, why it needs improvement and who is affected
Development of criteria to demonstrate that the process has improved
Timeline for meetings
Resources available
Structure of leadership (self managed or leader directed)
Expected communication of progress and results
✔✔How do teams develop and grow? 4 stages of development - ✔✔Stage 1 - Forming -
little accomplished
Stage 2 - Storming - most difficult, conflict typically arises. Leaders need to manage the
conflict by using it to energize the team. Leader delegates tasks.
Stage 3 - Norming - shift from I to WE. Develop harmony. Leaders need to challenge
team members to continue to grow and guard against too much conformity.
Stage 4 - Performing - optimize goal orientation, highly task oriented and productive.
Leader needs to develop mechanisms for sharing leadership responsibilities.
✔✔Characteristics of effective teams - ✔✔Competent members with technical, problem
solving, interpersonal and organizational skills; commitment to clear, common goals;
standards of excellence; contributions from every member; collaborative environment;
leadership support; nonhierarchical structure and external support and recognition
✔✔4 key traits that predict a team's success (4cs) - ✔✔Cohesiveness
Communication
Clear roles
Clear goals
✔✔Facilitator - ✔✔Guides group process in an unbiased manner ensuring that the
meeting agenda is carried out and decisions are responsibly reached with independent
contributions from all team members
✔✔2 special team types that have patient safety as main focus and error reduction -
✔✔TeamSTEPPS
CRM
✔✔Team Strategies and Tools to Enhance Performance and Patient Safety
(TeamSTEPPS) - ✔✔A teamwork system designed for HCPs that is evidence-based
and improved communication and teamwork skills. Team members learn 4 primary
teamwork skills: leadership, communication, situation monitoring and mutual support. 3
types of team outcomes desired: performance, knowledge and attitudes.
✔✔Crew Resource Management (CRM) - ✔✔Although team focused on patient safety,
the effectiveness of team functioning is a first critical component. Additional elements
include a focus on the patient safety mindset and high reliability functioning. Team
AND ANSWERS SURE A+
✔✔Evidence based quality mgmt is based on 2 types of research - ✔✔Clinical research
- evaluate impact of interventions on patient outcomes. Outcome measures may include
clinical outcomes, functional outcomes and patient satisfaction. Assists HCP in
determining clinical evidence based best practice
Health Services research - evaluates the health system at micro and macro levels.
Guide HCP in improving work processes and systems of care
✔✔clinical guidelines - ✔✔Consensus statements developed to assist in clinical
management decisions
✔✔clinical pathways - ✔✔Tools to manage quality outcomes and cost of care based on
clinical guidelines and current evidence
✔✔The use of clinical pathways and guidelines reduces variation of clinical practice to
optimize patient outcomes - ✔✔True or False
✔✔Steps for development of a Clinical Pathway - ✔✔1. Select the topic.
2. Select a mutlidisciplinary team including representatives from all groups affected
3. Evaluate and map the current process of care for the condition or procedure to
identify current variation and create an idealized process
4. Evaluate current evidence in the literature
5. Determine the pathway form.
6. Educate all users on how to use the tool and implement it. Critical to define roles.
7. Document and analyze variances that do not meet expectations of the pathway. Key
to process improvement.
✔✔Baldrige National HC Criteris for Performance Excellence Framework - ✔✔A model
that displays the QPI principles and shows the relationships between the structural,
process and outcome factors
,✔✔QPI Teams - ✔✔An important structural element for QPI
Have many different types depending on purpose/mission, tine, degree of autonomy,
authority structure, physical presence
Teams gave leaders, facilitators and coaches
✔✔core members - ✔✔the members of a team who bear primary responsibility for the
success of a project and who stay with a project from inception to completion. Often
have complementary skills needed for the desired work output
✔✔Resource members - ✔✔Critical only for a specific phases of the project and may
move in and out of the team
✔✔Natural Work Teams - ✔✔Involve the people in a given work setting who share
responsibilities for a process, workflow or type of work
✔✔self-directed work team - ✔✔A type of natural work team that shares management
responsibilities
✔✔Process Management Team - ✔✔Focuses on sharing responsibility for monitoring
and controlling a work process, such as new product development.
✔✔virtual teams - ✔✔Typically use technology supported communications rather than
face to face interactions to accomplish tasks
✔✔Steering Committee - ✔✔Permanent QPI teams consisting of cross functional
members. Self managed teams that provide direction and focus by identifying and
prioritizing improvement opportunities in the organization.
✔✔Role of the steering committee - ✔✔To sustain, facilitate and expand QP initiative
based on the strategic plan
✔✔Main responsibilities of quality council or steering committee - ✔✔Lending legitimacy
go QPI efforts, maintaining organization focus on identified goals and priorities, fostering
teamwork for improvement, providing necessary resources and formulating QPI policies
regarding quality and safety priorities, participation, annual self assessments, and
reward and recognition systems
✔✔2 teams of great importance in QPI - ✔✔1. QPI Teams
2. Steering committees (quality councils)
✔✔How managers determine when to use a team - ✔✔Task complexity,
interdependence and objectives (clear and time bound)
, ✔✔Team charter - ✔✔An approach to make task objectives clear
Contains the following info:
Description of the process, why it needs improvement and who is affected
Development of criteria to demonstrate that the process has improved
Timeline for meetings
Resources available
Structure of leadership (self managed or leader directed)
Expected communication of progress and results
✔✔How do teams develop and grow? 4 stages of development - ✔✔Stage 1 - Forming -
little accomplished
Stage 2 - Storming - most difficult, conflict typically arises. Leaders need to manage the
conflict by using it to energize the team. Leader delegates tasks.
Stage 3 - Norming - shift from I to WE. Develop harmony. Leaders need to challenge
team members to continue to grow and guard against too much conformity.
Stage 4 - Performing - optimize goal orientation, highly task oriented and productive.
Leader needs to develop mechanisms for sharing leadership responsibilities.
✔✔Characteristics of effective teams - ✔✔Competent members with technical, problem
solving, interpersonal and organizational skills; commitment to clear, common goals;
standards of excellence; contributions from every member; collaborative environment;
leadership support; nonhierarchical structure and external support and recognition
✔✔4 key traits that predict a team's success (4cs) - ✔✔Cohesiveness
Communication
Clear roles
Clear goals
✔✔Facilitator - ✔✔Guides group process in an unbiased manner ensuring that the
meeting agenda is carried out and decisions are responsibly reached with independent
contributions from all team members
✔✔2 special team types that have patient safety as main focus and error reduction -
✔✔TeamSTEPPS
CRM
✔✔Team Strategies and Tools to Enhance Performance and Patient Safety
(TeamSTEPPS) - ✔✔A teamwork system designed for HCPs that is evidence-based
and improved communication and teamwork skills. Team members learn 4 primary
teamwork skills: leadership, communication, situation monitoring and mutual support. 3
types of team outcomes desired: performance, knowledge and attitudes.
✔✔Crew Resource Management (CRM) - ✔✔Although team focused on patient safety,
the effectiveness of team functioning is a first critical component. Additional elements
include a focus on the patient safety mindset and high reliability functioning. Team
