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CPHQ Certified Professional in Healthcare Quality Examination Questions and Answers

Questions 4

An organization is shifting paradigms from top-down leadership to participatory management. The process of moving forward includes the four identified phases below:

gathering baseline data

evaluating effectiveness and improvement

making the commitment

implementing the program

Which of the following is the most logical sequence for these phases?

Options:

A.

1, 2, 4, 3

B.

1, 3, 2, 4

C.

3, 1, 4, 2

D.

3, 4, 1, 2

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Questions 5

During a recent code blue situation at an organization, there was a delay in administering the defibrillator's shock, A root cause analysis found the delay was due to the fact that defibrillator pads available on the unit were not compatible with the unit's defibrillator Which of the following applications of human factors engineering could have prevented this delay?

Options:

A.

forcing functions

B.

checklists

C.

resiliency efforts

D.

usability testing

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Questions 6

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 7

Which of the following is a key component in establishing a comprehensive populationhealth management program?

Options:

A.

Partnership with an accountable care organization

B.

A business plan demonstrating expected cost savings

C.

Data infrastructure

D.

Patient satisfaction metrics

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Questions 8

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 9

The following data are known:

Which ofthe following accurately describes this chart?

Options:

A.

The lower control limits were the same in Report Time A and B.

B.

The mode was 0.7517 In Report Time B.

C.

There was one outlier in Report Time A.

D.

There were no special cause variations.

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Questions 10

A nursing unit has collected the following data:

50 medical records reviewed

Nurse A

Nurse B

Doctor A

Doctor B

Timely initial assessment

45

40

10

25

Incomplete documentation

0

12

26

20

Which of the following is the best method to display this data?

Options:

A.

Pareto chart

B.

Bar chart

C.

Run chart

D.

Gantt chart

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Questions 11

Which of the following is essential for effective functioning of a Quality Council?

Options:

A.

Standardized formats for reporting and minutes

B.

An annual meeting calendar with attendance expectations

C.

Written job descriptions for members of the group

D.

A defined quality improvement structure and plan

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Questions 12

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 13

A quality professional was asked to assist with strategic planning. Which ofthe following should have the primary impact on the quality and performance improvement goals?

Options:

A.

results of gap analysis

B.

findings from a staff needs assessment

C.

financial statement of the organization

D.

report of major competitors' performance

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Questions 14

The upper and lower limits on a control chart are:

Options:

A.

Used to display the distribution of data.

B.

The same as thresholds.

C.

Used to determine if the long-range average is changing.

D.

Statistically calculated from the related data.

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Questions 15

The performance improvement team developed a prioritization matrix based on the identified improvement opportunities. Based on the information below, what would be the first improvement effort implemented?

Options:

A.

Create a paper checklist

B.

Create a sign-in sheet

C.

Modify the check-in process for patients

D.

Send education to all possible patients

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Questions 16

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 17

A physician group with a patient population of 10,000 during the fourthquarter of a year reviewed 100 complaints regarding access to specialty care. During the fourth quarter of the next year, the patient population had grown to 60,000 with 360 complaints regarding access to specialty care. The group has a target goal of five complaints per 1,000 patients. Which of the following should a healthcare quality professional conclude based on the data?

Options:

A.

The rate of complaints has increased and has exceeded the target.

B.

The rate of complaints has decreased, and the target has been reached.

C.

The rate of complaints has increased, but remains within the target range.

D.

The rate of complaints has decreased, but the target has not been reached.

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Questions 18

An organization Is looking for a creative approach at Improving heart failure outcomes to reduce readmissions. Several clinician's express concerns that nothing can be done to Improve this. Two clinicians recommend a set of clinical practiceguidelines recently developed by a specialty organization. Which of the following would the two clinicians be considered?

Options:

A.

early adopters

B.

early majority

C.

facilitators

D.

sponsors

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Questions 19

An acute care facility has established an outpatient heart failure clinic. Which of the following will best define the success of the program?

Options:

A.

Decreased readmission rate

B.

Increased patient satisfaction

C.

Increased compliance with post-discharge plan

D.

Decreased serious adverse events

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Questions 20

Which of the following tools will best help a quality professional to exhibit project activities and results?

Options:

A.

Storyboard

B.

Value Stream Map

C.

Gantt Chart

D.

Prioritization Matrix

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Questions 21

Which of the following tools should be used to determine the root cause of variations in a process?

Options:

A.

histogram

B.

Ishikawa diagram

C.

Shewhart chart

D.

scatter plot

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Questions 22

A hospitalized patient received a medication that was contraindicated based on their home medications. This should have been prevented by

Options:

A.

Reaching out to the patient's family to discuss medications

B.

Obtaining a list of the patient's current prescribed medications

C.

Using the teach-back method on medication education

D.

Performing a medication reconciliation upon hospital admission

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Questions 23

The healthcare quality professional is engaged with a leadership team. Which of the following will best help to establish performance improvement opportunities?

Options:

A.

Reviewing the organization’s balanced scorecard

B.

Evaluating the organization’s mission, vision, and values statement

C.

Creating an organizational action plan

D.

Performing a failure mode and effects analysis (FMEA)

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Questions 24

Medication reconciliation Is described as

Options:

A.

documenting a complete list of medications into the medical record including name, dose, route and frequency.

B.

the process of Identifying an accurate list of medications and comparing to another list.

C.

providing a complete list of medications to the patient andpower of attorney at discharge.

D.

contacting the primary care provider and validating the medication list.

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Questions 25

Which of the following is best solved by a quality improvement team?

Options:

A.

Financial variance

B.

Systems issue

C.

Customer complaint

D.

Discipline problem

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Questions 26

In order to make effective long-term changes, performance Improvement emphasizes the need to study and understand

Options:

A.

outcomes.

B.

statistics.

C.

standards.

D.

processes.

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Questions 27

An organization IsImplementing a new electronic medical record and has employed a project manager. At the first meeting, the project manager observes the following:

• The team estimates It Is one-fourth finished with Identifying benchmark organizations.

• Team members have not yet begun to identify the current state.

- They are halfway through collecting public data, which puts them slightly behind schedule for that task.

Which of the following tools should the quality Improvement project manager recommend?

Options:

A.

Model for Improvement

B.

Design of Experiments

C.

Gantt chart

D.

Ishlkawa diagram

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Questions 28

How can a quality professional best engage stakeholders in the organization's quality efforts?

Options:

A.

Report key performance indicators to board members.

B.

Include frontline staff on quality and safety committees.

C.

Initiate physician-related quality projects.

D.

Share process indicator dashboard with midlevel leaders.

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Questions 29

Which of the following tools depicts a sequence of events in a process?

Options:

A.

Pareto diagram

B.

Flowchart

C.

Run chart

D.

Scatter diagram

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Questions 30

An internal customer of the admission process in a skilled nursing facility is the

Options:

A.

nurse completing the Initial assessment.

B.

insurance company.

C.

patient's spouse and family.

D.

patient being admitted.

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Questions 31

Which of the following is one purpose of clinical pathways?

Options:

A.

to increase efficiency by generation of automated care plans

B.

to minimize errors by guiding staff through the steps of a process

C.

to reduce variability by establishing a standardized process

D.

to improve diagnostic accuracy by making diagnostic recommendations

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Questions 32

What is the initial step an organization should take when the strategic goal of improving patient satisfaction has not been met?

Options:

A.

Implement benchmarking

B.

Review department-specific data

C.

Perform a needs assessment

D.

Conduct a root cause analysis

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Questions 33

Refer to the below medication administration audit:

Patient

Medication administered within 1 hour

Was the correct dosage of medication administered?

Were patient allergies confirmed prior to medication administration?

Was medication administration documented in the patient’s record?

Did the patient experience an adverse medication reaction?

A

Yes

Yes

Yes

Yes

Yes

B

Yes

Yes

No

Yes

Yes

C

No

Yes

Yes

Yes

No

D

Yes

Yes

Yes

No

No

Which patient’s record should the quality professional investigate first?

Options:

A.

Patient D

B.

Patient B

C.

Patient C

D.

Patient A

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Questions 34

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

Options:

A.

Ensure risk management staff coordinate disclosure to the patients.

B.

Meet with staff Involved In the errors to gain additional Insight.

C.

Require medications be double-checked before administration

D.

Create anadditional constraint on availability of high-risk medications.

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Questions 35

Through routine collection of incident reports, an increase in medication errors was noted over a period of 6 months on 2 nursing units. Which of the following is the best method of displaying the data to illustrate this finding?

Options:

A.

Scatter diagram

B.

Pie chart

C.

Histogram

D.

Run chart

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Questions 36

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 37

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 38

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

Which of the following additional information should be included in this report for each month?

Options:

A.

number of incomplete medical records

B.

turnaround time for laboratory results

C.

number of inappropriate admissions

D.

number of X-rays performed

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Questions 39

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.

Research best practices.

B.

Share data with the governing body.

C.

Perform additional analysis on falls data.

D.

Review medication processes.

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Questions 40

Ahospital is using the above chart to monitor the average length of stay (ALOS) for patients diagnosed with acute myocardial infarction (AMI). Which of the following conclusions should be made?

Options:

A.

Data collection should be continued for an additional quarter.

B.

The average length of stay is consistent with the national average.

C.

The average length of stay is highest during the fourth quarter.

D.

Standard deviation is needed to determine the degree of control.

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Questions 41

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 42

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 43

The primary purpose of practice guidelines is to

Options:

A.

decrease malpractice premiums.

B.

minimize variations.

C.

document outcomes.

D.

decrease the length of stay.

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Questions 44

Which of the following is the primary benefit of the initial phase brainstorming?

Options:

A.

Fosters discussion of ideas

B.

Defines problem-solving roles and responsibilities

C.

Allows input from all team members

D.

Focuses on identifying the best solutions

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Questions 45

A healthcare quality professional Is assisting an organization with evaluating patient safety actions that will prevent errors of omission. Which of the following systems will most likely be effective?

Options:

A.

a reminder system that Is in close proximity to the task and provides sufficient information about what needs to be done

B.

a warning system that Is contiguous to the task and cues that the Individual Is about to Initiate the wrong intervention

C.

a proactive risk assessment system that Integrates with the task and automatically notifies the risk manager

D.

a detection system that notifies the team when an error has occurred and provides a checklist for mitigation measures

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Questions 46

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 47

A team has identified five opportunities for improvement related to patient wait times. Which of the following is the best tool for selecting the opportunity with the highest impact?

Options:

A.

Pareto chart

B.

Ishikawa diagram

C.

Control chart

D.

Check sheet

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Questions 48

To best achieve a low rate of harm in spite of inherent risks in healthcare, an organization must:

Options:

A.

Meet at least 95% of accreditation standards.

B.

Employ effective physician leaders.

C.

Apply principles of high reliability.

D.

Adopt a zero-tolerance for defect policy.

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Questions 49

In addition to being a good communicator, an essentialcharacteristic of a quality champion is:

Options:

A.

Serving as a department head or chief.

B.

Being highly respected by peers.

C.

Being a quality improvement expert.

D.

Having excellent technological skills.

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Questions 50

Each department in a hospital self-monitors and reports hand hygiene data each quarter. Results typically fall within the 58-72% range, with the exception of Respiratory Therapy, whichconsistently reports 100% compliance. Which of the following steps should a healthcare quality professional take next?

Options:

A.

Require departments not achieving at least 95% compliance to develop corrective action plans.

B.

Validate that the Respiratory Therapy results are accurate.

C.

Recognize theRespiratory Therapy department for its outstanding compliance.

D.

Provide remedial hand hygiene training for the lowest scoring departments.

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Questions 51

Performance Improvement plans are most successful when linked first with

Options:

A.

strategic goals.

B.

organizational structure.

C.

core values.

D.

bylaws.

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Questions 52

During a risk assessment, It Is noted that a unit manager and start feel there Is a high risk of aggressive patient behavior toward unit start Which of the following steps should a healthcare quality professional take first?

Options:

A.

Organize a staff focus group to explore perceptions.

B.

Discuss with administration the need for increased staff.

C.

Continue to survey staff to assess perceptions of risk.

D.

Review the facility's restraint policy.

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Questions 53

A healthcare quality professional is preparing a presentation related to incomplete documentation. According to principles of adult learning, the first step in preparing is to

Options:

A.

Determine the audience's knowledge and expectations

B.

Develop an evaluation tool for the presentation

C.

Present an inservice for the staff

D.

Obtain administrative support for the presentation

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Questions 54

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 55

Which team role is responsible for maintaining improvements after the implementation of a quality initiative?

Options:

A.

Champion

B.

Process Owner

C.

Sponsor

D.

Facilitator

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Questions 56

When recommending a quality improvement project, the quality professional must first consider

Options:

A.

when and how the project outcomes will be measured.

B.

how the project aligns with the organization's strategic goals.

C.

who will provide the resources for the quality project.

D.

what departments and stakeholders need to be engaged.

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Questions 57

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 58

To integrate performance improvement with organization planning, there must be alignment between

Options:

A.

Performance improvement teams and human resources

B.

Measuring and monitoring performance results

C.

Quality control processes and systems

D.

Strategic and improvement objectives

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Questions 59

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 60

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 61

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 62

Following the formation of a team, the success of the project will be most highly influenced by:

Options:

A.

Monitoring key metrics for sustainment.

B.

Maintaining communication with process owners.

C.

Prioritizing actions for more complex problems.

D.

Documenting the successes of the activities.

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Questions 63

Organizational leadership asks the healthcare quality professional to review patient identification safety events and develop an action plan. Which of the following steps is most effective for defining the problem?

Options:

A.

Review relevant policies and procedures

B.

Trend data with a control chart

C.

Use a Pareto chart to identify key issues

D.

Create a value stream map

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Questions 64

Which of the following tools Is most effective in assisting an organization seeking to evaluate the current culture of safety?

Options:

A.

anonymous surveys

B.

brainstorming by a governing body

C.

face-to-face interviews

D.

focus groups facilitated by leaders

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Questions 65

An external audit of medical records was just completed. In order for the results to be shared with leadership, which of the following must be done?

Options:

A.

Acquire authorization from external auditors to share

B.

Remove patient identifiers

C.

Classify sections with protected health information as confidential

D.

Obtain specific patient consent

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Questions 66

A patient was found unresponsive on a medical-surgical floor. Upon review of the patient's medical record, it was found that the patient had accidentally been given two doses of a sedating agent that had not been ordered. Which of the following would have helped prevent this error?

Options:

A.

Automated dispensing machine (ADM)

B.

Radio frequency identification (RFID)

C.

Barcode medication administration (BCMA)

D.

Computerized provider order entry (CPOE)

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Questions 67

A healthcare organization has experienced a recent increase in the number of falls with injury. A response by leadership that best demonstrates a safety culture is in place within the organization is to

Options:

A.

Acknowledge the injuries as systems errors

B.

Hold the unit manager responsible for the increase

C.

Require training of involved staff

D.

Place involved staff on a corrective action plan

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Questions 68

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 69

A performance measure for Infection control such as the number of primary blood stream Infections per 1000 central line days Is an example of a

Options:

A.

variance.

B.

mean.

C.

proportion.

D.

rate.

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Questions 70

In reviewing information offered by the Agency for Healthcare Research and Quality (AHRQ), the quality improvement (QI) specialist recognizes that the three broad aims pursued by the National Quality Strategy are

Options:

A.

reduce medical waste, use Lean, and achieve equity and better access to care.

B.

reduce complications, reduce readmissions, and improve health outcomes.

C.

better care, healthy people/health communities, and affordable care.

D.

triple aim, reduce utilization, and affordable care.

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Questions 71

An organization that demonstrates a culture of safety

Options:

A.

has a balanced scorecard.

B.

penalizes reporting of errors.

C.

learns from errors.

D.

generates a low number of incident reports.

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Questions 72

A healthcare quality professional receives complaints from numerous patients that the registration process is inefficient. Which of the following should be used to best identify customer expectations, perceptions, and improvement opportunities?

Options:

A.

telephone survey of patients

B.

focus group with patients

C.

written survey of registration staff

D.

interviews with registration staff

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Questions 73

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 74

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 75

Which of the following is most effective to sustain knowledge gained from performance improvement training?

Options:

A.

Integrating key improvement teachings into daily work

B.

Rewarding demonstrations of performance improvement

C.

Using simulations to illustrate complex concepts

D.

Requiring repeat training and reassessments

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Questions 76

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 77

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 78

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 79

In a data set, the difference between the highest and lowest observed values is known as the

Options:

A.

percentile.

B.

standard deviation.

C.

range.

D.

quartile deviation.

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Questions 80

The collection, analysis, and Interpretation of data for planning, Implementing, and evaluating health programs is

Options:

A.

prevalence.

B.

surveillance.

C.

Incidence.

D.

sampling.

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Questions 81

The consensus-building group of diverse stakeholders who reviews and endorses measures for public reporting in the U.S. is known as the

Options:

A.

National Quality Forum (NQF)

B.

Center for Medicare and Medicaid Services (CMS)

C.

Institute of Medicine (IOM)

D.

Agency for Healthcare Quality and Research (AHRQ)

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Questions 82

A Lean improvement concept that represents rapid improvement is

Options:

A.

Kaizen

B.

Six Sigma

C.

Poka-yoke

D.

Kanban

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Questions 83

A performance improvement coordinator is having difficulty keeping a new team focused on its goal of decreasing patient waiting times. To understand why the team process is not working, the team leader shouldinitially assess the

Options:

A.

composition of the team.

B.

attendance at team meetings.

C.

amount of data collected.

D.

method of data collection.

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Questions 84

A local health center is launching a community health assessment. What data is recommended to identify the potential needs of the population?

Options:

A.

zip codes for patients frequently using the emergency department

B.

highest level of education of healthcare professionals

C.

top five diagnoses for patient visits

D.

number of fast food restaurants in the area

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Questions 85

A home health agency has purchased an automated phone notification system to alert nurses that a patient has been discharged from a healthcare facility. The healthcare quality professional should complete which process as a next step?

Options:

A.

Failure mode and effects analysis (FMEA)

B.

Supplier-inputs-process-outputs-customers (SIPOC)

C.

Coordination of benefits (COB)

D.

Root cause analysis (RCA)

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Questions 86

Which of the following is the most effective means of communicating commitment to patient safety?

Options:

A.

CEO presenting most recent medication error rates to the governing body

B.

articles by a CEO in the employee newsletter

C.

posters and bulletin boards on units displaying up-to-date patient falls data

D.

senior leaders having discussions on units with front-line staff

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Questions 87

A long-term care facility Is Interested in analyzing data to determine If there Is arelationship between the number of medications residents are prescribed and the number of falls the residents experience. Which of the following quality tools Is most appropriate to help the long-term care facility understand the data?

Options:

A.

Pareto chart

B.

fishbone diagram

C.

histogram

D.

chatter diagram

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Questions 88

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 89

A nursing home has established a quality indicator to accomplish a 5% reduction in falls. A guideline has been developed and implemented. After six months, the goal has not been reached. The next action steps should include

Options:

A.

revising annual evaluations to include compliance with fall prevention guidelines.

B.

providing feedback on a weekly basis rather than displaying data over time.

C.

measuring employee competency on understanding and use of the guideline.

D.

continuing to measure outcomes monthly and re-evaluate every threemonths.

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Questions 90

Based on the data below, which unit should the quality Improvement coordinator focus on?

Options:

A.

Unit A

B.

Unit B

C.

Unit C

D.

Unit D

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Questions 91

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 92

Using the Information below, which patient population Is at the highest risk tor tailing?

Options:

A.

has problems sleeping

B.

falls prior to admission

C.

needs help with toileting

D.

uses a cane

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Questions 93

Which of the following is the role a healthcare quality professional should play in strategic planning?

Options:

A.

Provide data on performance indicators.

B.

Review and redefine annual objectives.

C.

Develop the vision, mission, and goals.

D.

Identify causes of lost revenue.

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Questions 94

An organization is implementing a palliative care unit. As part of the planning and implementation processes, the board authorizes the following:

• Learning visits with existing programs to obtain information about best practices

• Formal training of all staff assigned to the unit in the principles of palliative care

• The development of a balanced scorecard to monitor program performance

The actions of the board best illustrate

Options:

A.

High-level strategic planning

B.

A board’s need to manage patient care

C.

A commitment to quality

D.

The importance of competence and training

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Questions 95

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 96

Several leaders in a healthcare facility have differing opinions regarding the pursuit of alternative certifications and recognitions. The Chief Quality Officer (CQO) has opted to retain an external quality consultant to determine relevance, appropriateness, and readiness for an alternative certification. The most appropriate role for an external consultant is to

Options:

A.

Uncover other opportunities for improvement within the facility

B.

Support the CQO’s choice for alternative certification

C.

Evaluate the facility’s needs, goals, and stakeholder input

D.

Determine the final certification selection

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Questions 97

The strategic plan for an organization calls for expansion of information technology. The following information is available:

If equal weight is given to each consideration, which of the following options should be the primary choice?

Options:

A.

Option A

B.

Option B

C.

Option C

D.

Option D

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Questions 98

A health system in an underserved area seeks to improve medication adherence in patients with hypertension. One of the barriers identified is patients with limited English proficiency. Which of the following solutions will best improve medication adherence?

Options:

A.

Use clinicians with shared language as interpreters.

B.

Use a telephonic interpreter service to communicate instructions.

C.

Provide written medication instructions in patients' preferred language.

D.

Implement an automatic refill program for hypertension medications.

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Questions 99

A nursing director for a unit in a cancer hospital Is reviewing and assessing outcomes data in the followingscatter diagram:

The relationship between the incidence of infection and the decrease in staffing targets is

Options:

A.

strong and positive.

B.

weak and negative.

C.

weak and positive.

D.

strong and negative.

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Questions 100

A surgeon has a surgical site infection rate of 6.7% for a particular procedure. The average infection rate for other surgeons performing the same procedure at this facility is 3.3%. After notifying the department chair of this situation, the quality professional should recommend

Options:

A.

Suspension of the surgeon

B.

A performance improvement project

C.

A focused review

D.

A root cause analysis

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Questions 101

According to the Institute of Medicine’s (IOM) report, Crossing the Quality Chasm, which of the following is identified as one of the six aims for improvement?

Options:

A.

Low costs

B.

Population-centered

C.

Effective

D.

Coordinated

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Questions 102

Integration of a quality culture within an organization Is best demonstrated by

Options:

A.

reduced adverse outcomes, culture of patient safety, and expansion of services.

B.

mission and vision statements, high patient census, and governing body involvement

C.

physician competence, staff longevity, and high patient satisfaction scores.

D.

leadership rounds. Increased staff satisfaction, and positive patient outcomes.

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Questions 103

Which of the following is an example of an alternative payment model (APM)?

Options:

A.

Patient-centered medical home

B.

Sharedsavings program

C.

Hospital at home program

D.

Collaborative care model

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Questions 104

Which of the following is required for the successful development of clinical pathways?

Options:

A.

Staff education

B.

Patient education materials

C.

Quality improvement tools

D.

Physician involvement

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Questions 105

Which action should be taken to support continuous survey readiness?

Options:

A.

Facilitate a failure mode and effects analysis (FMEA) on patient consent

B.

Conduct time studies for patient registration processes

C.

Map the value stream for elective surgery patients

D.

Perform tracers on patients in restraints

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Questions 106

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 107

An orthopedic surgery practice has been working on improving patient safety for the last 3 years. The following data table is available:

Which of the following is the most appropriate conclusion about patient safety outcomes?

Options:

A.

The patient safety culture has remained consistent.

B.

Patient safety outcomes have improved.

C.

The increase in "time-outs" has reduced patient harm.

D.

The safety event rate has remained stable.

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Questions 108

A pay-for-performance structure includes a payout based on achieving the NCQA Quality Compass® 50th Percentile, plus an additional bonus for achieving the NCQA Quality Compass® 75th Percentile. Individual performance on measures is as follows:

NCQA Measure

Physician A

Physician B

Nurse Practitioner C

Physician Assistant D

50th Percentile

75th Percentile

Diabetic Retinal Eye Exam

75%

80%

60%

63%

65%

70%

Nephropathy

53%

43%

50%

48%

50%

52%

HbA1c Testing

76%

80%

52%

70%

72%

76%

Which provider will not earn pay-for-performance based on reaching either the NCQA Quality Compass® 50th or 75th percentile?

Options:

A.

Physician A

B.

Physician B

C.

Nurse Practitioner C

D.

Physician Assistant D

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Questions 109

A quality professional was asked to assist with strategic planning. Which of the following should have the primary impact on the quality and performance improvement goals?

Options:

A.

report of major competitors ‘performance

B.

findings from a staff needs assessment

C.

financial statement of the organization

D.

results of gap analysis

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Questions 110

Data for an organization's annual Influenza vaccine administration yields the following results:

What is the median for the organization's annual vaccine count?

Options:

A.

10

B.

55

C.

63

D.

79

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Questions 111

A CEO has directed a quality improvement council to develop objectives to meet an identified goal. When developing objectives, the council must remember to

Options:

A.

keep the objectives specific to the short term.

B.

tie the objectives to theorganization’s financial performance.

C.

use the Plan-Do-Study-Act cycle of continuous improvement.

D.

state the end result or desired outcome.

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Questions 112

A provider’s Ongoing Professional Practice Evaluation (OPPE) profile is shown below. In this organization, if a provider partially meets or does not meet performance expectations, they are referred to peer review for a Focused Professional Practice Evaluation (FPPE).

Fully Meets: >80% of measures at threshold

Meets: 65% to 80% of measures at threshold

Partially Meets: 40% to 64% of measures threshold

Does Not Meet: <40% of measures at thresholdAfter reviewing this provider’s overall profile, what should the healthcare quality professional suggest?

Measure

Performance

Threshold

Direction

Timely Medical Record Documentation

95%

90%

Higher

Readmission Rate

13%

10%

Lower

Surgical Site Infection Rate

9%

5%

Lower

Use of Pre-procedure timeouts

100%

100%

Higher

Patient Experience Score (Top Box)

94%

80%

Higher

Clinical Pathway Adherence

81%

70%

Higher

Options:

A.

The provider does not meet expectations; refer to peer review

B.

The provider partially meets expectations; retain privileges

C.

The provider meets expectations; retain privileges

D.

The provider fully meets expectations; do nothing

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Questions 113

An electronic medical records system was implemented in a department. Which of the following is the next step?

Options:

A.

Proceed with risk identification and prevention

B.

Report the results to senior leadership

C.

Implement the system throughout the organization

D.

Evaluate the system's performance

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Questions 114

Practice guidelines should be based on

Options:

A.

cost-benefit analysis.

B.

scientific evidence.

C.

computer-generated data.

D.

utilization review criteria.

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Questions 115

A hospital's quality professional notices a high 30-day readmission rate for patients with chronic obstructive pulmonary disease (COPD) exacerbation. What is the quality professional's next best step?

Options:

A.

Evaluate the post-discharge instructions for patients with COPD.

B.

Use hot-spotting to identify COPD patients needing case management.

C.

Share readmission data with the hospitalist group.

D.

Conduct tracers on the discharge process of patients with COPD.

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Questions 116

An interdisciplinary team 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 117

A patient safety officer is developing a patient safety program. The following information has been reviewed:

Incident report data

Performance indicators

Customer complaintsWhich of the following additional information is needed prior to writing the patient safety plan?

Options:

A.

Infection control data and accreditation results

B.

Staff satisfaction and root cause analysis (RCA) data

C.

The facility risk assessment and strategic goals

D.

Physician satisfaction and financial goals

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Questions 118

Benchmark is a term used to describe

Options:

A.

Internal organizational performance

B.

Progressive attainment of improvement

C.

Achievement of outcomes

D.

Measurement against others

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Questions 119

A quality coordinator was asked to evaluate team effectiveness for a struggling quality improvement team. When interviewed about the team, members say they are frustrated because they do not know what the team is supposed to accomplish. Which of the following should be explored first?

Options:

A.

Effectiveness of the team leader

B.

Clarity of team goals

C.

Clarity of team roles

D.

Effectiveness of the facilitator

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Questions 120

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 121

The following information is available on a health system's performance dashboard:

Employee turnover decreased from 9% to 6%

Reporting of patient safety events and near misses increased 5%

Overall patient satisfaction increased from 58% to 61%Which of the following should the quality professional conclude as a result of this information?

Options:

A.

Safety culture remains unchanged; while patient satisfaction increased, the safety events also increased.

B.

Safety culture has improved; metrics are moving in the right direction.

C.

Safety culture remains unchanged; while turnover decreased, the safety events increased.

D.

Safety culture has declined; metrics are moving in the wrong direction.

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Questions 122

Which of the following actions best illustrates an organization has begun the work necessary to achieve the Malcolm Baldrige Award?

Options:

A.

evaluating current operations against the ISO standards

B.

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

C.

reviewing the Malcolm Baldrige criteria to determine organization alignment

D.

demonstrating wide-spread integration of Lean principles

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Questions 123

A risk manager comes to the quality improvement (QI) professional and requests help to improve compliance with a corrective action plan. How can the QI professional help?

Options:

A.

Determine areas of non-compliance through a root cause analysis

B.

Determine if the action plan is in compliance with the national standards

C.

Provide an analysis for the Patient Safety Committee

D.

Provide disciplinary action to non-compliant departments

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Questions 124

The quality professional has been asked to perform chart audits on a population to assess how often hypertension is being addressed by clinicians when hypertensive patients presented to theclinic in the last year. The clinic has over 8,000 patients diagnosed with hypertension. Which of the following would be most appropriate for the quality professional to consider when selecting a sampling methodology?

Options:

A.

Selection of patients who had a visit during the last month of the year

B.

Selection of 400 charts using a simple random sampling method

C.

Selection of 800 patients using a snowball sampling method

D.

Selection of the entire population as a sample to make sure the results are accurate

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Questions 125

A department analyzed Its process for distributing paychecks to employees. The analysis showed there were multiple checkpoints tor approval, delays In processing of the checks, and errors that caused extra work for staff. Which of the following types of waste were identified during the analysis?

Options:

A.

variation, overproduction, and over processing

B.

defects, waiting, and over processing

C.

waiting. Inventory, andtransportation

D.

Inventory, variation, and motion

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Questions 126

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 127

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 128

During development of a clinical pathway, a quality professional should

Options:

A.

evaluate peer review committee findings.

B.

implement best practice alerts.

C.

consult peer-reviewed evidence.

D.

gather patient outcome data.

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Questions 129

Which of the following could be used as an outcome measure during indicator development?

Options:

A.

laboratory compliance with policy and procedure for drawing peak and trough levels

B.

staff adherence to a standard of practice

C.

required diagnostic testing performed before medication was prescribed

D.

complication rate for a specific surgical procedure

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Questions 130

The health quality professional recognizes that which of the following events should be reported to regulatory or accreditation organizations?

Options:

A.

Medication error

B.

Wrong-site surgery

C.

Patient fall

D.

Patient grievance

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Questions 131

Which of the following is a social determinant of health?

Options:

A.

Medical care access

B.

Genetics

C.

Ethnicity

D.

Family size

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Questions 132

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 133

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 134

A focused professional practice evaluation (FPPE) Is Initiated

Options:

A.

annually for all providers on staff.

B.

during the survey corrective action period.

C.

at the discretion of the chief medical officer (CMO).

D.

when new privileges are granted.

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Questions 135

Which of the following tools aids decision-making through organizing tasks, issues, or actions based on agreed-upon criteria?

Options:

A.

Brainstorming

B.

Multi-voting

C.

Prioritization matrix

D.

Delphi method

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Questions 136

Which of the following best describes the goal of the Healthy People Initiative?

Options:

A.

Allocate funding to prevent disparities related to social determinants of health.

B.

Support health promotion and disease prevention across the lifespan.

C.

Provide each state with individualized plans for Improving vaccination rates.

D.

Reduce the spread of infectious disease and prevent pandemics.

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Questions 137

A quality improvement coordinator is asked to develop a training session on team facilitation based onadult learning principles. Which of the following would be the best approach to include?

Options:

A.

Ask participants to practice facilitation with the group during class.

B.

Ask participants to study facilitation techniques after class.

C.

Teach all the concepts and test participants at the end of class.

D.

Teach the basic concepts and handout printed slides for participants to refer to after class.

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Questions 138

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 139

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 140

An example of a clinical care process measure is:

Options:

A.

Patient experience

B.

Administration of beta blocker

C.

Case mix mortality

D.

30-day readmission rate

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Questions 141

Which of the following Is an essential step in the strategic planning process?

Options:

A.

determining productivity indicators

B.

establishing organizational goals

C.

establishing and controlling a budget

D.

defining organizational structure

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Questions 142

A quality improvement team has been trained on writing SMART aim statements. Below are the team’s aim statements:

Reduce adverse drug events in critical care by 10% within 12 months.

Reduce the time from 911 call to intervention for cardiac complaints by 15%.

Reduce30-day readmissions from 20% to 15%.Which of the following key elements in aim development appears to have been lost after the training?

Options:

A.

time-bound

B.

achievable

C.

measurable

D.

specific

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Questions 143

A healthcare organization has two years of data on infection rates by month. Which of the following process tools would be best to use for analyzing this data?

Options:

A.

Fishbone diagram

B.

Pareto chart

C.

Run chart

D.

Histogram

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Questions 144

The primary focus of Six Sigma methodology is

Options:

A.

reducing variation.

B.

complying with standards.

C.

eliminating waste.

D.

improving patient safety.

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Questions 145

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 146

A strategy to address social determinants of health would be to

Options:

A.

launch a community campaign to promote influenza vaccines.

B.

identify high-risk patients with high-cost medications.

C.

create patient education materials that are culturally competent.

D.

implement a standard questionnaire for pediatric lead screening.

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Questions 147

Which of the following is the best data source to assess an organization’s culture of safety?

Options:

A.

Adverse event reports

B.

Staff-completed survey results

C.

Workplace injury claims

D.

Patient complaints

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Questions 148

An organization conducts daily briefing sessions. Which of the following questions demonstrates a culture of safety?

Options:

A.

"Do we have available beds in the ICU?"

B.

"Did anything happen last night that could lead to a central line infection?"

C.

"Who is the last person that committed a medication error?"

D.

"What was the patient’s intake and output?"

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Questions 149

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 150

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 151

A continuous quality improvement team has proposed a major change in the billing process for home health service. Staff acceptance of the change is best facilitated by:

Options:

A.

Immediate implementation

B.

Medical staff education

C.

Long-range planning

D.

A pilot project

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Questions 152

Establishing a culture of safety begins with having the right

Options:

A.

recruitment strategies.

B.

plan.

C.

leadership.

D.

educational programs.

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Questions 153

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 154

Using the data below, which issue would be identified as a priority for further performance improvement?

Issue

High Risk

High Strategic Priority

Cost

Customer Satisfaction

Quality Concern

Pressure Injuries

4

4

1

4

5

Medication Errors

3

1

2

1

5

Transfer to Higher Level of Care Within One Hour of Admission

2

5

4

1

3

Miscommunication of Abnormal Findings

4

3

5

1

4

Options:

A.

Pressure Injuries

B.

Medication Errors

C.

Transfer to Higher Level of Care Within One Hour of Admission

D.

Miscommunication of Abnormal Findings

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Questions 155

A facility’s performance on a clinical outcome measure has deteriorated. The healthcare quality professional’s initial action should be to

Options:

A.

Analyze related process measure performance

B.

Re-educate staff on appropriate clinical outcomes

C.

Review current best practices on areas of deterioration

D.

Assess data entry errors in areas of deficiency

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Questions 156

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 157

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 158

In statistics, the p-value provides the data user with

Options:

A.

An index of data reliability

B.

A level of significance

C.

A measure of central tendency

D.

A degree of deviation

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Questions 159

Which tool would be best suited to sequence interventions within a project?

Options:

A.

Prioritization matrix

B.

Affinity diagram

C.

Pareto chart

D.

Histogram

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Questions 160

Within the strategic management process, which of the following actions is most relevant indetermining what projects are feasible for an organization?

Options:

A.

Performing a stakeholder analysis

B.

Identifying strategic opportunities and threats

C.

Reviewing resources, capabilities, and core competencies

D.

Completing a community health needs assessment

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Questions 161

An organization’s nursing units report the following needlestick injuries:

Unit

# Needlestick Injuries

# Admissions

A

2

1,000

B

12

800

C

5

752

Which response by leadership demonstrates a culture of safety?

Options:

A.

Promote a non-punitive response to needlesticks reported

B.

Evaluate the needle safety device for Unit B

C.

Congratulate Unit A for fewer needlestick injuries

D.

Review training records for needlestick prevention

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Questions 162

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

Options:

A.

Coordinate internal support for quality improvement activities.

B.

Identify safety issues of the facility.

C.

Resolve the management problems of the organization.

D.

Correct clinical quality problems.

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Questions 163

An organization has implemented a quality improvement project. The goal is a mean compliance rate of 90%. The results of observations are found in the table below:

Which focus area presents the greatest opportunity for the organization?

Options:

A.

patient flow

B.

environment of care

C.

pain management

D.

infection prevention

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Questions 164

A managed care peer review committee should obtain which of the following first?

Options:

A.

clinical practice guidelines

B.

confidentiality statement

C.

copies of themedical licenses

D.

statement of authenticity

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Questions 165

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 166

Priorities must be established for selecting processes for quality improvement because

Options:

A.

Some improvements are not meaningful

B.

Few processes require improvement

C.

Many organizations lack the resources to improve all processes

D.

There are difficulties in accurately measuring improvement

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Exam Code: CPHQ
Exam Name: Certified Professional in Healthcare Quality Examination
Last Update: May 17, 2025
Questions: 556
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