Improving compliance with a corrective action plan requires identifying why the plan is not being followed, which involves analyzing root causes of non-compliance.
Option A (Determine areas of non-compliance through a root cause analysis): This is the correct answer. The NAHQ CPHQ study guide states, “Root cause analysis (RCA) is used to identify underlying reasons for non-compliance with action plans, enabling targeted interventions to improve adherence” (Domain 1). RCA helps pinpoint barriers like training gaps or process issues.
Option B (Determine if the action plan is in compliance with the national standards): Verifying standards is important but does not address current non-compliance issues.
Option C (Provide an analysis for the Patient Safety Committee): Analysis for a committee is a later step after identifying causes of non-compliance.
Option D (Provide disciplinary action to non-compliant departments): Disciplinary action is punitive and undermines a safety culture, not a QI approach.
CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.5, “Use root cause analysis to address compliance issues,” emphasizes RCA for non-compliance. The NAHQ study guide notes, “RCA is a key tool for improving adherence to corrective action plans” (Domain 1).
Rationale: RCA identifies barriers to compliance, enabling effective solutions, as per CPHQ’s patient safety principles.
[Reference: NAHQ CPHQ Study Guide, Domain 1: Patient Safety, Objective 1.5., , , ]
