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CPHQ Certified Professional in Healthcare Quality Examination Questions and Answers

Questions 4

A newpediatric psychiatric unit will open in one year. The utilization coordinator is responsible for developing the utilization management program. The program's success will depend on which of the following factors?

Options:

A.

Involving the team members in the development of the program

B.

developing the program and presenting it to the appropriate staff members

C.

obtaining approval from the chief psychiatrist at each stage of development

D.

providing educational in-services to all team members involved

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Questions 5

Which of the following is the best example of population health management?

Options:

A.

ensuring timely access to eye examinations for people with diabetes

B.

reducing medication errors in a pharmacy

C.

reducing turn-around times in the emergency department

D.

ensuring accurate medication reconciliation for people in hospice care

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Questions 6

An interdisciplinary learn met to review readmission rates at a health system. Issues were identified withcommunication across care providers. The team is interested in improving the coordination of care process and is now reviewing four candidates to serve in the role of process champion:

Of the four candidates, which represents the most effective choice to serve as a process champion?

Options:

A.

Candidate A

B.

Candidate B

C.

Candidate C

D.

Candidate D

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Questions 7

A facility Is reviewing their quality program for compliance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. Which of the following Is the most Important factor in program compliance?

Options:

A.

12 months of data for each project

B.

Integration into each department and service of the facility

C.

poor improvement outcomes monitored for an additional 12 months

D.

coordination by a full-time healthcare quality professional

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Questions 8

An increased number of outpatient surgery patients present to the emergency department with complaints of pain. Which would be the best strategy to address these occurrences?

Options:

A.

Standardize post-operative pain management protocols.

B.

Ensure patients have their home pain medications prior to discharge.

C.

Evaluate pain reassessment data in the post-anesthesia unit.

D.

Re-educate emergency room nurses on pain assessment.

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Questions 9

A director at a large health system is tasked with building a new population health program. What is the director’s first step?

Options:

A.

Implement artificial intelligence programs to stratify patients into categories of risk.

B.

Identify strategies to incorporate social determinants of health screenings.

C.

Design a complex care management programfocused on chronic health conditions.

D.

Analyze the data infrastructure capabilities and sources of information.

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Questions 10

Organizations with a positive safety culture are best characterized by

Options:

A.

mutual trust.

B.

self-directed teams.

C.

anonymous reporting.

D.

efficient staff.

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Questions 11

Evaluating data to determine high utilizers ofemergency departments and their related characteristics is a strategy that can best help with

Options:

A.

hospital throughput.

B.

culture of safety.

C.

population health management.

D.

high reliability.

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Questions 12

Toassess compliance with quality standards, a healthcare organization needs

Options:

A.

standardized data collection methods.

B.

approval by the governing body.

C.

a dedicated standards assessment team.

D.

an electronic data analysis program.

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Questions 13

A healthcare system has multiple medical clinics across a large geographic area. What is the best way to deliver education to assure continuous survey readiness?

Options:

A.

train the trainer sessions with clinic managers

B.

mandatory modules on accreditation standards

C.

one-on-one sessions with noncompliant employees

D.

just-in-time training to the highest risk clinics

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Questions 14

An effective method to increase an organization’s board of directors engagement in patient safety is to

Options:

A.

foster teamwork and good communication at all levels of the organization and conduct training for both of these skill sets.

B.

structure the board agenda so that quality and safety are given the same amount of attention as financial issues.

C.

focus on improvement projects that are important to the medical staff in the organization.

D.

guide them through a recent failure mode and effects analysis (FMEA) that was conducted prior to the launch of a new technology.

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Questions 15

Which of the following is the appropriate group to review care delivered by an individual physician to a patient who suffered a serious adverse event?

Options:

A.

peer review committee

B.

quality council

C.

governing body

D.

bioethics committee

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Questions 16

The healthcare quality professional is tasked with monitoring the monthly fall rates. The fall rate that requires the most immediate investigation is

Options:

A.

2 standard deviations above the fall rate average.

B.

a rate with a z-score of 1.5.

C.

2 standard deviations below the fall rate average.

D.

a rate with a z-score of -1.5.

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Questions 17

Which initiative should a quality professional promote in an organization seeking to optimize value-based reimbursement?

Options:

A.

Standardize Joint replacement care pathways.

B.

Implement computerized provider order entry (CPOE).

C.

Reduce use ofinpatient restraints.

D.

Improve hand hygiene compliance.

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Questions 18

Which of the following is the most effective method to identify adverse events that cause harm to patients?

Options:

A.

benchmarking

B.

conducting a failure mode and effect analysis

C.

using patient satisfaction surveys

D.

employing tiiyu.fi tools

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Questions 19

A recent Journal article has Identified three new patient safety Initiatives. When reviewing these Initiatives, the first action of a healthcare quality professional Is to

Options:

A.

collect data on the three Initiatives.

B.

Incorporate the initiatives into the organization's patient safety plan.

C.

assign owners to the identified initiatives.

D.

determine the applicability of the Initiatives to an organization.

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Questions 20

The quality manager needs to identify a set of process measures to improve wound care outcomes. The first step should be to

Options:

A.

review prior three years on wound outcome best practices.

B.

perform literature search for clinical trials relating to wound care.

C.

conduct clinical record review of wound care sentinel events.

D.

search for evidence-based guidelines for wound care.

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Questions 21

Prior to implementing a new patient service, the healthcare quality professional should recommend

Options:

A.

developing a safety monitoring checklist.

B.

conducting a root cause analysis (RCA).

C.

initiating a failure modes and effects analysis (FMEA).

D.

performing just-in-time staff safety training.

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Questions 22

When reporting infection control indicators to a governing body, a healthcare quality professional should demonstrate improvement with which of the following tools?

Options:

A.

run chart

B.

frequency plot

C.

pie chart

D.

scatter plot

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Questions 23

Which of the following should a healthcare plan use to collect satisfaction data from its health plan members?

Options:

A.

data collected through questionnaires or surveys

B.

claims data obtained from healthcare payors

C.

disease data obtained from disease registries

D.

data collected from the electronic health record

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Questions 24

A multidisciplinary team has been convened to review delays in laboratory turnaround time between the medicine clinic and the laboratory. The team’s first step in evaluating the issue is to

Options:

A.

create a flow chart to study the process.

B.

conduct a failure mode and effects analysis (FMEA).

C.

see if the surgery clinic is also experiencing delays.

D.

observe how the medical assistants prepare the specimens.

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Questions 25

Which of the following data sources can be used to assess a population's health status?

Options:

A.

county birth rate

B.

retrospective chart audits

C.

clinical disease registries

D.

core measure performance

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Questions 26

A healthcare organization had three medication incidents associated with narcotics. None of the events led to permanent loss of function or death, but could be considered near misses. Which of the following would be the best tool to use to identify influencing factors?

Options:

A.

report from electronic health record (EHR)

B.

root cause analysis (RCA)

C.

proactive risk assessment

D.

nominal group technique

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Questions 27

A Pareto chart can be used to

Options:

A.

graphically display a process.

B.

display variation.

C.

establish priorities for Improvement.

D.

establish a relationship among variables

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Questions 28

The quality manager needs to identify a set of process measures to improve wound cate outcomes. The firststep should be to

Options:

A.

search for evidence-based guidelines for wound care.

B.

conduct clinical record review of wound care sentinel events.

C.

perform literature search for clinical trials relating to wound care

D.

review prior three years on wound outcome best practices.

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Questions 29

In preparation for a provider organization accreditation survey, the most effective method for identifying training needs for staff is

Options:

A.

conducting a gap analysis with an interdisciplinary team.

B.

benchmarking with other organizations.

C.

engaging a consultant to identify areas needing improvement.

D.

comparing competency requirements with other facilities.

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Questions 30

A team has identified that labeled cutting boards are needed in a kitchen to decrease cross-contamination. After a new process has been implemented, it is discovered that the labeled cutting boards are not being used. Which of the following is the next action the team should take?

Options:

A.

Initiate progressive discipline.

B.

Conduct a root cause analysis.

C.

Increase monitoring.

D.

Determine barriers to compliance.

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Questions 31

An organization with a focus on population health may use data to

Options:

A.

identify high-risk patients.

B.

determine the voice of the customer.

C.

identify high-risk low-volume processes.

D.

determine high-cost procedures.

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Questions 32

Secondary prevention Is Primarily Intended to

Options:

A.

eliminate risk factors for a disease.

B.

prevent disease or disease process.

C.

focus on early detection and treatment of disease.

D.

reduce moderate disability associated with advanced disease.

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Questions 33

A goal of measurement is to collect valid and reliable data that reflects

Options:

A.

actual performance.

B.

desired performance.

C.

potential performance

D.

targeted performance.

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Questions 34

Ahospital has been experiencing a significant Increase in the number of medication errors. The hospital's governing board has adopted barcoding technology with electronic documentation at the point of care. Which of the following medication errors will most likely be reduced by the Implementation of this technology?

Options:

A.

prescribing errors

B.

transcription errors

C.

administration errors

D.

dispensing errors

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Questions 35

Which of the following is the key responsibility of a healthcare quality professional in all types of facilities and organizations?

Options:

A.

Resolve the management problems of the organization.

B.

Coordinate Internal support for quality improvement activities.

C.

Identify safety issues of the facility.

D.

Correct clinical qualityproblems.

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Questions 36

A healthcare quality professional's initial step in the creation of a patient safety program is to

Options:

A.

define key processes that contribute to patient complaints.

B.

assess the organization's current culture of safety.

C.

recommend software purchases to enhance the program.

D.

identify the applicable patient safety standards.

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Questions 37

A performanceimprovement specialist at an ambulatory surgery center is facilitating a Plan-Do-Study-Act Cycle (PDSA) process to improve the rate of hand hygiene amongst surgical post-recovery staff to 90% or above. Data from the past 12 months are as follows:

Baseline: 60% compliance

Q1: 87% compliance

Q2: 79% compliance

Q3: 91% compliance

Q4: 72% compliance

The specialist is preparing to discuss aggregate results with the Quality Committee. To most accurately convey the results, the specialist highlights the

Options:

A.

lack of overall change over the past 12 months indicates the process was unsuccessful.

B.

contributing factors to the variation in results over the past 12 months.

C.

sharp and consistent decline in results over the past 12 months.

D.

overall improvement over the past 12 months.

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Questions 38

Physician quality data reports for all credentialed physicians disseminated at regular Intervals, as generally mandated by accreditation standards, are called

Options:

A.

focused professional practice evaluation (FPPE).

B.

CMS star ratings.

C.

quality spot checks.

D.

ongoing professional practice evaluation (OPPE).

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Questions 39

For which incident would a process improvement manager be required to perform a root cause analysis (RCA)?

Options:

A.

Incorrect critical care patient transported to radiology.

B.

Admitting a visitor who fell on hospital grounds.

C.

Wrong prescription given to a discharged patient with diabetes.

D.

Procedure performed on the wrong knee.

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Questions 40

To effectively communicate performance indicator results, information should be disseminated to the

Options:

A.

Medical Executive Committee.

B.

entire staff.

C.

Quality Council.

D.

department heads.

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Questions 41

The median is defined as the

Options:

A.

difference between a data item and the mean of a data set.

B.

most frequently occurring value in a data set.

C.

arithmetic average of a data set.

D.

number thatdivides an ordered data set into two equal parts.

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Questions 42

Which of the following is an example of a social determinant of health used to monitor a quality improvement initiative?

Options:

A.

diabetes status

B.

race

C.

age

D.

neighborhood

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Questions 43

A new pediatric psychiatric unit will open in one year. The utilization coordinator is responsible for developing the utilization management program. The program's success will depend on which of the following factors?

Options:

A.

obtaining approval from the chief psychiatrist at each stage of development

B.

developing the program and presenting it to the appropriate staff members

C.

involving the team members in the development of the program

D.

providing educational in-services to all team members involved

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Questions 44

Which of the following regulatory agencies oversee development of electronic clinical quality measures (eCQMs)?

Options:

A.

Centers for Medicare and Medicaid Services (CMS)

B.

DNV GLHealthcare

C.

Occupational Safety and Health Association (OSHA)

D.

The Joint Commission (TJC)

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Questions 45

A hospital is considering changing the process of admissions from the emergency department. To support patient safety when this new process is deployed, the healthcare quality professional should suggest which of the following actions during the design stage of the process?

Options:

A.

examining the new process for stability and variation using a control chart

B.

completing a failure mode and effects analysis (FMEA) of the new process

C.

conducting a root cause analysis to predict errors in the new process

D.

analyzing incident reports from the last year using a Pareto chart

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Questions 46

Members of a performance improvement team voice complaints about not having as much decision-making authority as they expected. Which of the following should be developed to decrease the likelihood of such complaints?

Options:

A.

project checklist

B.

affinity diagram

C.

interrelationship diagram

D.

team charter

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Questions 47

Which Is a source of data tor analyzing staff flu vaccination trends for an accountable care organization?

Options:

A.

electronic health records

B.

vaccine manufacturer statistics

C.

insurance claims data

D.

pharmacy procurement records

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Questions 48

To promote staff engagement In a new Initiative, educators should focus on staff

Options:

A.

perceptions of the benefits of change.

B.

attitudes of business as usual.

C.

who appear resistant to change.

D.

who want to advance In the organization.

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Questions 49

A quality professional needs to select a new project from a list of requests. An organization has determined that new projects should focus on patient safety and cost-reduction. Which tool would help Identify the project that best meets these criteria?

Options:

A.

value-stream map

B.

prioritization matrix

C.

process decision program chart

D.

lotus diagram

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Questions 50

Which tool Is used to Identify resources needed to complete a project?

Options:

A.

control chart

B.

cause-and-effect diagram

C.

SIPOC diagram

D.

value stream man

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Questions 51

Ongoing practitioner practice evaluation (OPPE) Is used for which of the following?

Options:

A.

monitoring a provider with an Identified Practice Issue

B.

removal of privileges that a provider is no longer using

C.

approval by the governing board for new provider privileges

D.

identification of providers with potential competency issues

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Questions 52

When working with a new qualityImprovement team, the quality professional should stress the importance of

Options:

A.

making small changes in each cycle of change.

B.

involving the entire department on the first cycle of change.

C.

creating large goals to have a system-wide Impact.

D.

getting the desired result on the first cycle of change.

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Questions 53

A healthcare quality professional Is doing a study in the emergency room. Every other patient admitted to the department Is Included in the sample. This sampling technique Is best described as

Options:

A.

quota.

B.

systematic.

C.

cluster.

D.

stratified.

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Questions 54

A hospital received 50 Incident reports describing falls that occurred within aone-month period. Which of the following actions should be taken?

Options:

A.

Compare details from the Incident reports against the current fall prevention procedures.

B.

Ensure that each Incident report is correctly linked to the appropriate patient health record.

C.

Separate incident reports based on injury status.

D.

Review the Incident reports to Identify contributing factors.

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Questions 55

An emergency department's quality Improvement report for the first quarter showed the following data:

What was the approximate overall problem rate for March?

Options:

A.

1%

B.

2%

C.

15%

D.

18%

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Questions 56

A performance Improvement team has been meeting to examine delays in getting admissions from theemergency room to the nursing units. After six months of collecting data, the upper control limit was ISO minutes, and the lower control limit was 60 minutes. The next month's data shows a time of 155 minutes. The team should understand that this represents what type of variation?

Options:

A.

standard

B.

random

C.

common cause

D.

special cause

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Questions 57

Data from an Incident reporting system compares Incident rates for one facility to similar facilities:

After reviewing the graph, which of the following should be done first?

Options:

A.

Review medication processes.

B.

Research best practices.

C.

Share data with the governing body.

D.

perform additional analysis on falls data.

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Questions 58

A patient safety manager provided training on hand hygiene guidelines. The clinical manager Is confident that staff are following the guidelines. Which of the following Is the best method to evaluate the current compliance with the guidelines?

Options:

A.

collection of bacterial hand cultures

B.

direct observation of staff

C.

calculation of Infection rates compared to a baseline

D.

a test with a passing score of 98%

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Questions 59

The healthcare quality professional has been asked to participate in the organizations population health program related to cost and utilization.

Based on this Information, what Is the next action the quality professional should take?

Options:

A.

Request Information on the cost per patient for those discharged to skilled nursing facilities.

B.

Request Information on total number of patients discharged to each location for both quarters.

C.

Analyze the appropriateness of discharges to Inpatient rehabilitation centers.

D.

Analyze the cost differences between patients discharged to home and skilled nursing facilities.

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Questions 60

A physician's profile shows a 4% readmission rate following outpatient gallbladder surgery, which Is significantly higher than the rate for their peers.

What action should the quality professional take next?

Options:

A.

Report the surgeon to the medical board.

B.

Review the physician's privileges against the procedures performed.

C.

Compare the physician's readmission rate with peer physicians.

D.

Review a sample of recent individual cases of the physician's readmissions.

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Questions 61

Which of the following Is true of a clinical pathway?

Options:

A.

depicted using a value stream map

B.

limited to one patient care setting

C.

used to reduce variations in care

D.

required for accountable care organizations

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Questions 62

Which of the following actions best demonstrates that an organization has begun the work necessary to achieve the Malcolm Baldrige award?

Options:

A.

creating a team to revise operations to conform to the Malcolm Baldrige requirements

B.

develop a crosswalk between Malcolm Baldrige and Joint Commission requirements

C.

determine effects on Centers for Medicare and Medicaid Services (CMS) Conditions of Participation.

D.

reviewing the Malcolm Baldrige standards to determine organization alignment

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Questions 63

A department director has been asked to compare the productivity of the department with the productivity of similar departments at other facilities. Which of the following Is the first step of this project?

Options:

A.

Review department Job descriptions with another facility of similar size.

B.

Monitor the work flow in the department for at least six months.

C.

Conduct a search on the Internet for guidelines.

D.

Determine which processes will be evaluated,

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Questions 64

One of the first steps in preparing for an organizational accreditation survey Is to have a quality professional

Options:

A.

Identify the root causes of the most recent adverse events that have occurred.

B.

submit an electronic application to the organization Identifying a date for survey.

C.

conduct a gap analysis of the identified standards against current practices.

D.

complete a competency examination on the process of writing action plans.

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Questions 65

In a healthcare organization Implementing ongoing performance Improvement (PI), which of the following will most likely benefit the PI goals of the organization?

Options:

A.

a system selected by middle and senior management resulting from proposals by consultants

B.

a comprehensive process developed. Implemented, and monitored by the quality management department

C.

cross-functional processes evaluated by multidisciplinary teams with the support of management

D.

discrete systems relevant to, and monitored by. individual departments

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Questions 66

Infection control risk assessments are performed to

Options:

A.

prioritize organizational infection prevention and control goals.

B.

Identify types of personal protection needed by the organization.

C.

develop the organization's Infection prevention and control program.

D.

determine decontamination practices for the organization.

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Questions 67

Which of the following would best facilitate the development of priorities?

Options:

A.

comparing target versus actual performance

B.

creating a plan to evaluate performance

C.

surveying staff for potential priorities

D.

selecting valid and reliable metrics for the balanced scorecard

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Questions 68

The main purpose of conducting tracers as a part ofcontinuous readiness is to

Options:

A.

identify current gaps in processes of quality and patient safety that need correcting.

B.

prepare staff to be able to speak to the surveyors in a comfortable and easy manner.

C.

teach quality Improvement professionals how to prepare for accreditation surveys.

D.

minimize the number of recommendations for Improvement during an actual survey.

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Questions 69

The clinic has a goal to reduce the Healthcare Effectiveness Data and Information Set (HEDIS) measure of ' the percent of diabetic patients with a HgA1c greater than 9.0% for accreditation. Who should be Included on the quality Improvement team?

Options:

A.

clinic manager, provider champion. HEDIS chart abstractor

B.

clinic manager, quality Improvement specialist, provider champion

C.

HEDIS chart abstractor, coder, primary care provider

D.

primary care provider, quality improvement specialist, coder

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Questions 70

While the use of technology may result in fewer medical errors. In order for this strategy to be most effective. It should be supported by

Options:

A.

effectiveness of staff.

B.

anorganizational structure.

C.

a culture of safety.

D.

leadership training.

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Questions 71

In aligning an organization's performance Improvement plan with strategic goals, a healthcare quality professional should consider

Options:

A.

staff satisfaction data, risk management data, and utilization review data.

B.

customer expectations, occurrence reports, and utilization review data.

C.

staff satisfaction data, benchmarking data, and occurrence reports.

D.

customer expectations, benchmarking data, and patient outcome data.

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Questions 72

Which of the following is an effective method to motivate employees to participate in performance Improvement?

Options:

A.

Host regular town hall meetings.

B.

Display a success storyboard in the employee break room.

C.

Highlight successes real time in huddles.

D.

Provide mandatory training on an annual basis.

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Questions 73

The preferred culture in promoting patient safety

Options:

A.

auditsstandards and promotes learning from mistakes.

B.

uses anonymous reporting and audits standards.

C.

promotes learning from mistakes and fosters collaboration.

D.

fosters collaboration and uses anonymous reporting.

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Questions 74

Which of the following Is the best example of effective learning in a learning organization?

Options:

A.

management team taking a posttest after reading a bulletin on a regulatory standard

B.

management team auditing staff performance after a training program

C.

staff watching a video on how to complete a patient admission assessment

D.

staff using the results of a root cause analysis to change processes and improve patient safety

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Questions 75

Multi-voting Is frequently used in which of the following steps of the quality Improvement process?

Options:

A.

identifying root causes

B.

speculating on problem causes

C.

prioritizing Improvement opportunities

D.

Implementing solutions and controls

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Questions 76

A quality improvement professional believes that their MRSA facility rates are high. What should the quality improvement professional do first?

Options:

A.

Contact the infection control practitioner to obtainbenchmark data.

B.

Report the concerns to senior management and the Quality Council.

C.

Form a quality improvement team.

D.

Repeat the data collection process to Justify the new rate.

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Questions 77

Following evaluation of the compounding process used by a pharmacy, the batch compounding consistently yields 12% more drug than Is needed. The excess Is stored until used or expired. Which of the following types of waste should be recorded when reporting this finding?

Options:

A.

inventory

B.

overproduction

C.

extra processing

D.

overuse

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Questions 78

A healthcare quality professional has identified a gap In practice from regulatoryrequirements. The quality professional should

Options:

A.

meet with staff to determine the barriers to compliance.

B.

provide educational training to the manager on the regulatory requirements.

C.

inform the staff that the current practice Is not compliant with regulatory requirements.

D.

Initiate an audit collection tool to determine the rate of noncompliance.

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Questions 79

A study was performed to compare quality outcomes between case/care managed groups and non-case/care managed groups tor elective coronary artery bypass. The results are as follows:

What is the median length of stay (or non-case/care managed patients?

Options:

A.

10

B.

9

C.

8

D.

7

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Questions 80

An organization has compiled the scatter plots below:

Based on these plots, which of the following conclusions can be made by the quality professional?

Options:

A.

Setting 2 has a significant correlation between complication rate and time to positive outcome.

B.

Complication rates are not causing longer time to positive outcome at setting 2.

C.

Setting 1 has a strong positive correlation between complication rate and time to positive outcome.

D.

Complication rates are causing longer time to positive outcome at settling 1.

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Questions 81

A quality Improvement team has Identified specific changes to Implement for a quality Improvement Initiative. As the next step, the team would like to establish a concrete timeline for implementation. Which of the following is the best tool to use for this step?

Options:

A.

process map

B.

Gantt chart

C.

Ishikawa diagram

D.

bar graph

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Questions 82

A hand surgeon is referred for peer review for a case of a wrong-site surgery. Which of the following professionals would be the best choice as a member of the peer review committee?

Options:

A.

plastic surgeon with comparable training

B.

chief of surgery with general surgery experience

C.

quality Improvement coordinator with peer review experience

D.

physician assistant who routinely assists In hand surgeries

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Questions 83

The best means of reducing sentinel events In a care delivery system Is

Options:

A.

layering methods of mistake-proofing.

B.

removing the human variables.

C.

incorporating the perspectives of patients.

D.

using computerized decision-making tools.

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Questions 84

Which of the following Is the best approach to prepare care team members tor Interacting with accreditation surveyors?

Options:

A.

Review patient records proactively.

B.

Summarize and discuss past survey findings.

C.

Brief them on survey activities and what questions to expect.

D.

Provide techniques to defer surveyor questions to leaders.

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Questions 85

Annual evaluation of a quality Improvement process must

Options:

A.

be based on organizational objectives.

B.

survey all departments and teams.

C.

be accomplished by a healthcare quality professional.

D.

document all problems identified In care/service.

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Questions 86

When developing objectives for an educational program, the quality professional should recommend

Options:

A.

using thePlan-Do-Study-Act cycle of continuous improvement.

B.

stating the end result or desired outcome.

C.

keeping the objectives specific to the short term.

D.

tying the objectives to the organization's financial performance.

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Questions 87

A continuous survey readiness program requires which of the following?

Options:

A.

the use of checklists by department managers to prioritize accreditation tasks

B.

targeted training for staff in the months leading up to the accreditation survey

C.

a commitment from leadership to Improvement and compliance

D.

work plans to Identify key activities needed for accreditation compliance

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Questions 88

Which of the following Is an example of a population health strategy?

Options:

A.

scheduling discharged Inpatients for follow up appointments

B.

reviewing outpatient prescribing patterns for pain management patients

C.

Implementing an employee wellness program

D.

auditingInpatient admission medications for duplicates

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Questions 89

Accountability for quality ultimately rests with the

Options:

A.

governing body.

B.

quality manager.

C.

CEO.

D.

department leader.

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Questions 90

Leadership at a facility reviewed andrevised business process activities following staff layoffs. The activities were carefully planned, communicated, and implemented according to the plan. One year later, the business is stable but staff morale is very low. Based on the concepts of change theory, this is most likely due to:

Options:

A.

Leadership who were not immersed in the change process

B.

The revision of business processes

C.

Late adopters who are resistant to change

D.

A failure to address the needs of the staff who were retained

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Questions 91

Choosing a small number of items to represent characteristics of the whole is an example of

Options:

A.

sampling methodology.

B.

outlier identification.

C.

statistical significance.

D.

benchmarking.

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Questions 92

Which of the following actions will best promote organizational efficiency in managing quality improvement projects?

Options:

A.

Create a team whenever there is an improvement project

B.

Identify project managers for all improvement projects

C.

Assign some projects to individuals and others to teams

D.

Only approve projects that have a high return on investment

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Questions 93

Continued evaluation of a quality improvement initiative occurs within which of the following phases of the DMAIC process?

Options:

A.

Measure

B.

Analyze

C.

Improve

D.

Control

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Questions 94

Anemergency department's quality improvement report for the first quarter showed the following data:

What was the approximate overall problem rate for March?

Options:

A.

1%

B.

2%

C.

15%

D.

18%

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Questions 95

Which of the following is an example of collaboration for optimal care transitions?

Options:

A.

Involving a multidisciplinary team in the patient's daily inpatient care meeting

B.

Using a case manager to coordinate post-discharge care needs with patients and families

C.

Conducting regular support groups for patients with multiple chronic conditions

D.

Discharging patients with printed lists of all of their medications

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Questions 96

When an identified solution requires significant change, the best tool to increase the likelihood of success is a:

Options:

A.

Force field analysis

B.

Fishbone diagram

C.

Pareto chart

D.

Decision matrix

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Questions 97

After much planning and preparation, a healthcare quality professional believes the organization is ready to move forward with the process of achieving recognition through a program that highlights their achievements in nursing excellence. Which of the following distinctions is most appropriate for the organization to pursue?

Options:

A.

Baldrige

B.

Magnet

C.

CMS Stars

D.

Leapfrog Safety Grade

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Questions 98

An organization identified the need to improve the flow of admitted patients from the emergency department (ED) to the inpatient unit. The following individuals have been selected to be a part of the team:

Options:

A.

Housekeeping supervisor as process owner and quality professional as team leader

B.

Inpatient unit manager as team facilitator and ED manager as project sponsor

C.

Staff nurse ED as champion and CNO as project sponsor

D.

Staff nurse inpatient unit as facilitator and quality professional as champion

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Questions 99

Medical staff monitoring indicators are best developed through a collaborative effort between the hospital's quality management professionals and the:

Options:

A.

Quality Council

B.

Chief Medical Officer

C.

Director of Utilization Management

D.

Hospital's Administrative Leadership

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Questions 100

Ahealthcare quality professional has the following data on a hospital's surgical site infection rates:

Procedure

Hospital Infection Rate

95% Confidence Interval

State Mean Infection Rate

Total Hip Replacement

0.4%

0.2%-0.6%

0.9%

Total Knee Replacement

1.1%

0.8%-1.2%

1.0%

ACL Reconstruction

1.5%

1.4%-1.6%

1.5%

Total Shoulder Replacement

1.3%

1.0%-1.6%

0.9%

Which procedure is the best area for focused quality improvement?

Options:

A.

Total Hip Replacement

B.

Total Knee Replacement

C.

ACLReconstruction

D.

Total Shoulder Replacement

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Questions 101

In an improvement project to improve clinic flow, a spaghetti chart is best used to:

Options:

A.

Analyze the suppliers, inputs, processes, outputs, and customers.

B.

Identifyredundancies and wasted movement.

C.

Determine the strengths, weaknesses, opportunities, and threats of a process.

D.

Display the hierarchy of subtasks required to achieve an objective.

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Questions 102

Which of the following conclusions might be drawn from failure mode and effects analysis (FMEA)?

Options:

A.

Key factors were identified, and corrective action plans were created.

B.

Actions were taken to address baseline performance and monitored for sustainment.

C.

Risks were identified and prioritized, and action plans were developed.

D.

Special causes were identified, and variation was reduced.

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Questions 103

Which of the following is the best way to evaluate the success of a performance improvement team?

Options:

A.

Incorporation of team recommendations into policies

B.

Adherence to team deadlines

C.

Periodic measurement of outcomes

D.

Identification of improvement opportunities

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Questions 104

To determine the success of a transfusion quality improvement project, a healthcare quality professional should:

Options:

A.

Present the results to the staff.

B.

Monitor patient outcomes.

C.

Provide the report to the state department of health.

D.

Share results with the governing board.

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Questions 105

Based on this matrix, which of the following ideas should the team address first?

Options:

A.

1 and 7

B.

3 and 4

C.

2 and 5

D.

6 and 8

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Questions 106

Which of the following characteristics are most appropriate for a physician champion of healthcare quality?

Options:

A.

Credible member of medical staff and autocratic leadership style

B.

Popular member of medical staff and transactional leadership style

C.

Senior member of medical staff and democratic leadership style

D.

Respected member of medical staff and participatory leadership style

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Questions 107

A team adopted a solution to a recentproblem of not having the correct supplies at the start of a procedure. A new workflow has been in place for two weeks. This morning, a physician complained that the setup is still missing key supplies, despite the new workflow. Which phase of the Plan-Do-Study-Act (PDSA) model should the team revisit?

Options:

A.

Plan

B.

Do

C.

Study

D.

Act

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Questions 108

The trend of a variable over time is best illustrated by a:

Options:

A.

Pie chart

B.

Pictogram

C.

Line graph

D.

Frequency distribution

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Questions 109

Which of the following best describes how a quality professional should conduct an organizational assessment to ensure safe transitions of care?

Options:

A.

Evaluate processes for discharges and transfers.

B.

Audit documentation of patient discharge summaries.

C.

Review patient feedback about transfers to skilled nursing facilities.

D.

Assess case management discharge and transfer records.

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Questions 110

Which initiative should a quality professional promote in an organization seeking to optimize value-based reimbursement?

Options:

A.

Standardize joint replacement care pathways.

B.

Improve hand hygiene compliance.

C.

Reduce use of inpatient restraints.

D.

Implement computerized provider order entry (CPOE).

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Questions 111

Which of the following recommendations best supports effective transitions of care from hospital to home for patients?

Options:

A.

Collaborate with patients and their families to identify ongoing care needs.

B.

Prioritize discharging patients to home over going to skilled nursing facilities.

C.

Round on patients daily with a multidisciplinary care team.

D.

Monitor compliance with nursing-led discharge education.

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Questions 112

Where could a quality professional find data on causes ofinfant mortality?

Options:

A.

American Community Survey (ACS)

B.

Centers for Disease Control and Prevention (CDC) National Center for Health Statistics

C.

Centers for Medicare & Medicaid Services (CMS) Core Measures

D.

United States Preventive Services Taskforce (USPSTF)

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Questions 113

Leadership at an outpatient multi-specialty clinic is working toward becoming a high-reliability organization. In the past week, there have been three medication errors with high-risk medications in the procedure area. Which of thefollowing responses by leadership is consistent with high-reliability principles?

Options:

A.

Create an additional constraint on availability of high-risk medications.

B.

Require medications be double-checked before administration.

C.

Meet with staffinvolved in the errors to gain additional insight.

D.

Ensure risk management staff coordinate disclosure to the patients.

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Questions 114

An extended carefacility measures the percent of time a comprehensive exam is completed within 96 hours of admission. This is an example of which of the following types of measure?

Options:

A.

structure

B.

outcome

C.

process

D.

system

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Questions 115

Which of the following is the most effective way to promote a safe transition of care to home for patients leaving a hospital?

Options:

A.

Use the teach-back method for instructions and establish the first follow-up appointment.

B.

Provide written information and a reminder card to make a follow-up appointment.

C.

Send information to the patient’s physician and advise the patient to return to the emergency department for any concerns.

D.

Complete the discharge checklist and assign a transitions navigator to follow-up in 10 days.

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Questions 116

Prior to discharge, which of the following provides patient information to improve education for heart failure patients?

Options:

A.

Insurance claims data

B.

Patient satisfaction surveys

C.

Electronic health records

D.

Heart failure registry

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Questions 117

The control chart above indicates which of the following?

Options:

A.

Common cause variation

B.

Special causevariation

C.

Unique cause variation

D.

No variation

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Questions 118

Which of the following is an example of using human factors engineering to improve patient safety?

Options:

A.

performing a root cause analysis on events of harm

B.

providing simulation training for high-risk patient care tasks

C.

having a second person check medication calculations

D.

using checklists to complete complicated tasks

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Questions 119

Education sessions were held to improve bar code medication administration (BCMA) performance. Six months after completion of education, an analysis showed continued BCMA improvement. What is the key to sustaining this improvement?

Options:

A.

Revise the policy and procedures

B.

Request patient input on the process

C.

Monitor for continuous compliance

D.

Provide ongoing feedback to staff

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Questions 120

A pulmonologist is gathering social determinants of health data from their patients. Which of the following best explains the purpose of collecting this data?

Options:

A.

This information facilitates the patient's application for state resources.

B.

This is a result of an update to the electronic medical record system.

C.

This evaluates connections between the disease and the living conditions.

D.

This information is needed to meet a new quality metric.

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Questions 121

The quality improvement (QI) specialist recognizes that any documents related to medical peer review are:

Options:

A.

Classified as confidential documents.

B.

Used to determine privileges.

C.

Reviewed during accreditation surveys.

D.

Included in QI research.

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Questions 122

Which of the following should be used to show beginning and ending times for an activity along a timeline?

Options:

A.

Control chart

B.

Fishbone diagram

C.

Pareto chart

D.

Gantt chart

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Questions 123

An ambulatory care practice has reviewed data to identify patients with multiple visits to the emergency room within the last six months. The population health management technique for this type of data review is called

Options:

A.

public health surveillance.

B.

hot-spotting.

C.

syndromic surveillance.

D.

cold-spotting.

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Questions 124

The ability to safely manage complex tasks in the face of time pressures, quickly identify and contain errors, and bounce back after stressful situations relates to organizational:

Options:

A.

Lean capacity

B.

Resilience

C.

Disaster readiness

D.

Safety rules

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Questions 125

A clinic is implementing a new medication dispensing system. The vendors of three products are on site with staff interacting with the products prior to purchase. Which of the following best describes this type of safety intervention?

Options:

A.

Forcing function

B.

Standardization

C.

Usability testing

D.

Independent backup

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Questions 126

To evaluate outcomes, an ambulatory/outpatient care unit should analyze:

Options:

A.

Canceled surgeries

B.

Time of surgeries

C.

Admissions to the hospital

D.

Delays in obtaining laboratory results

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Questions 127

Which of the following stages may cause continuous quality improvement teams to dissolve prematurely?

Options:

A.

Performing

B.

Storming

C.

Norming

D.

Forming

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Exam Code: CPHQ
Exam Name: Certified Professional in Healthcare Quality Examination
Last Update: May 8, 2025
Questions: 424
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