The data shows variable compliance rates for pain assessment across different staff groups, with physicians having the lowest rates (20–50%), nurses the highest (75–83%), and physical therapists in between (50–60%). To improve performance, the next step should address the identified gaps through a structured intervention, leveraging data to drive action.
Option A (Disseminate the results to nursing staff): Disseminating results to nursing staff alone is insufficient, as their compliance rates are already high (75–83%). The focus should be on lower-performing groups (physicians and physical therapists), and dissemination without a plan does not ensure improvement.
Option B (Hire a pain management specialist): Hiring a specialist may be premature without first analyzing the root causes of low compliance. This option assumes a lack of expertise is the issue, which is not supported by the data alone.
Option C (Continue monitoring for another quarter): Continuing to monitor without intervention delays action on clear performance gaps, particularly for physicians (20% in March). CPHQ principles emphasize acting on data to drive improvement rather than passive monitoring.
Option D (Create an action plan with the department leaders): This is the most appropriate next step, as it involves collaboration with leaders from all relevant departments (physicians, nurses, physical therapists) to address specific compliance gaps. NAHQ study materials advocate for data-driven action plans that engage stakeholders to identify causes (e.g., training needs, workflow issues) and implement targeted interventions, aligning with performance improvement methodologies like Plan-Do-Study-Act (PDSA).
[Reference: NAHQ CPHQ Study Guide, Domain 2: Health Data Analytics, emphasizes using performance data to develop action plans with stakeholders to address identified gaps in quality metrics., , , ]
