A surgeon’s elevated surgical site infection (SSI) rate (6.7% vs. 3.3% average) indicates a performance gap requiring targeted investigation.
Option A (Suspension of the surgeon): Suspension is punitive and premature without understanding the cause of the high rate.
Option B (A performance improvement project): A project may address systemic SSI issues but is too broad for an individual surgeon’s performance.
Option C (A focused review): This is the correct answer. The NAHQ CPHQ study guide states, “A focused review investigates an individual provider’s performance when data indicates a significant deviation, such as an elevated SSI rate” (Domain 4). It examines factors like technique or compliance.
Option D (A root cause analysis): RCA is used for specific incidents, not ongoing performance trends.
CPHQ Objective Reference: Domain 4: Performance and Process Improvement, Objective 4.6, “Evaluate provider performance,” emphasizes focused reviews for outliers. The NAHQ study guide notes, “Focused reviews target individual performance issues” (Domain 4).
Rationale: A focused review investigates the surgeon’s specific practices, aligning with CPHQ’s improvement principles.
[Reference: NAHQ CPHQ Study Guide, Domain 4: Performance and Process Improvement, Objective 4.6., , , ]
