CPHQ Practice Questions Part 1

CPHQ
Review Questions
CPHQ Practice Questions – Part 1

Question 1
❑ The scientific method in quality improvement is
represented by
A. Failure Mode and Effects Analysis.

B. Statistical process control.
C. Sequential problem solving.
D. The PDCA cycle.
❑ Answer: D
The Plan-Do-Check-Act (PDCA) Cycle exemplifies the
scientific method in quality improvement: planning a
change, doing it, checking to see its effect, and then
acting on what we have learned by either rejecting the
change or making it a standard part of the process.
❑ Content Category: Management and Leadership
Cognitive level required for a response: Recall
❑ Tasks on the CPHQ exam content outline to which the
question is linked: Determine applicability of
performance improvement models (e.g. PDCA, Six
Sigma, Lean)
Question 2
❑ Clinical practice guidelines reduce
A. Random variation.
B. Anticipated variation.
C. Assignable variation.
D. All types of variation.
Answer: C
❑ Clinical practice guidelines reduce assignable variation.
The latter arises from identifiable causes that can be
tracked and eliminated. In the context of clinical
practice guidelines, assignable variation represents
inappropriate variation.
❑ Content Category: Performance Measurement and
Improvement Cognitive level required for a response:
Recall
question is linked: Facilitate evaluation/selection of
evidence-based practice guidelines (e.g. for standing
orders or as guidelines for physician ordering practice)
Question 3
❑ How should a team leader manage a disruptive
member?
A. Discuss general group-process concerns

without pointing out individuals.
B. Confront the offending team member in the
presence of the team.
C. Talk privately with the disruptive team
member.
D. Dismiss the offending team member.
Answer: C
❑ The best approach to disruptive behavior is to talk
privately to the offending team member, pointing out
that disruptive behavior seems inconsistent with a
commitment to help the team succeed.
Application
question is linked: Participate on performance/quality
improvement teams (i.e. as a coordinator or team
member/leader/facilitator)
Question 4
❑ Benchmarking is a tool that compares current
performance with
A. Performance of industry leaders.

B. Performance in similar organizations.
C. Performance goals.
D. All of the above.
Answer: A
❑ In general, benchmarking means "measuring an
organization's performance against that of best-in-class
companies, determining how the best in class achieve
those performance levels and using the information as a
basis for one's own company targets, strategies and
implementation.
question is linked: Integrate the results of
performance/quality improvement process into
strategic planning for the organization
Question 5
❑ When using quality measures, for which purpose are the
requirements for validity and reliability the highest?
A. Accountability
B. Quality improvement
C. Research
D. The requirements for validity and reliability
are the same when using measures for
accountability, quality improvement, or
research.
Answer: A
❑ In general, the requirements for validity and reliability
are highest when using quality measures for
accountability. According to the AHRQ, "uses of quality
measures for the purpose of accountability include
purchaser and/or consumer decision making, variation
in payment in relation to the level of performance
and/or certification of professionals or organizations.
question is linked: Identify performance measures/key
performance/quality indicators (e.g. balanced
scorecards, dashboards)
Question 6
❑ What information will be considered a caution flag in
credentialing activities?
A. A missing peer recommendation.

B. Missing dates or gaps in practice.
C. Licensure in more than one state.
D. All of the above.
Answer: D
❑ Caution flags are those pieces of data or information
that should send up warning signals to the credentialing
staff and the reviewers. Missing peer information, missing
dates or gaps in practice, and licensure in more than
one state are all caution flags.
Recall
question is linked: Facilitate or participate in the
credentialing and privileging process (e.g. Focused
Professional Practitioner Evaluation (FPPE), Ongoing
Professional Practitioner Evaluation (OPPE))
Question 7
❑ Primary source verification may include
A. A faxed copy.
B. A copy from the practitioner.
C. A copy forwarded by another hospital.
D. None of the above.
Answer: D
❑ Primary source verification may be accomplished by
“mail, secure electronic communication (including
secure websites), or by telephone if the details of the
verification are documented.” The practitioner or
another hospital is not a primary source of information
Recall
Question 8
❑ How does clinical peer review differ from quality
improvement?
A. Clinical peer review monitors activities of
physicians while quality improvement is focused on
organizational activity.
B. Clinical peer review is focused on individual
practitioners while quality improvement focuses on
process.
C. Peer review identifies outliers to standard practice
while quality improvement is concerned with the
process in which outliers will be addressed.
D. There is no difference between the two activities.
Answer: B
❑ Clinical peer review may be considered part of an
organization's quality improvement activities. Its focus is not
confined to physicians only (answer option A) but also nurses,
pharmacists, and other health care professionals. Peer
review does not only aim to identify outliers to standard
practice (answer option C), e.g. it may include evaluation of
evidence-based practice.
Improvement Cognitive level required for a response: Recall
Question 9
❑ Reappointment or recredentialing in a hospital
accredited by The Joint Commission should be
conducted
A. Annually or more frequently.
B. Every two years or more frequently.
C. Every three years or more frequently.
D. On an ongoing basis.
Answer: D
❑ In the past, recredentialing and reappointment in TJC-
accredited hospitals were expected to be done every 2
years or more frequently. However, since 2007, TJC
standards require that practitioners’ performance be
evaluated on an ongoing basis.
Recall
Question 10
❑ The completeness of credentialing activities can be
assessed by
A. File audits.
B. A practitioner satisfaction survey.
C. Productivity reports.
D. Review of quality improvement information.
Answer: A
❑ The completeness of credentialing activities can be
assessed by file audits. Credentialing files may be
selected randomly or according to some criteria, e.g.
initial appointments, current temporary privileges,
practitioners who perform invasive procedures.
Recall
Professional Practitioner Evaluation (OPPE).
Question 11
❑ A multidisciplinary team is tasked to implement a
picture archiving and communication system (PACS) in
a large acute care facility. Staffs in the outpatient
department are resisting the necessary changes. Who
should the team leader approach about this issue in the
first instance?
A. Team sponsor
B. Team facilitator
C. Chief Operating Officer
D. Chief Executive Officer .
Answer: A
❑ One of the key roles of the team sponsor is to represent
team interests to the organization. This includes obtaining
the support of executive managers and the staff with whom
they work.
❑ In this case, it would be inappropriate for the team leader to
immediately approach the medical staff, COO, or CEO.
Application
Question 12
❑ A medical staff peer review committee has concluded
that the care provided in the case reviewed had a
marginal deviation from the standard of care. What is
the “standard of care”?
❑ A. Care that is consistent with best practice

❑ B. Care that is minimally accepted practice
❑ C. Care that a reasonable physician in similar
circumstances would provide
❑ D. Care that can generally be expected by
patients in similar circumstances
Answer: C
❑ The term of “standard of care” is generally accepted to
mean “the caution that a reasonable person in similar
circumstances would exercise in providing care to a
patient.”
Application
credentialing and privileging process (e.g., Focused
Question 13
❑ Which of the following organizations does NOT have
authority by the Centers for Medicare & Medicaid
Services (CMS) to grant “deemed status” to hospitals?
❑ A. The Joint Commission
❑ B. American Osteopathic Association
❑ C. Det Norske Veritas
❑ D. All three organizations listed above are
authorized to grant “deemed status” to
hospitals .
Answer: D
❑ Three organizations have the authority to grant “deemed status”
to hospitals:
❑ The Joint Commission;
❑ American Osteopathic Association (through its Healthcare
Facilities Accreditation Program (HFAP)); and
❑ Det Norske Veritas.
❑ Content Category: Management and Leadership Cognitive level
required for a response: Recall
❑ Tasks on the CPHQ exam content outline to which the question is
linked: Facilitate evaluation and/or selection of appropriate
accreditation or recognition program(s) (e.g. The Joint
Commission (TJC), Magnet, Baldrige, Det Norske Veritas (DNV),
American Osteopathic Association (AOA), Healthcare Facility
Accreditation Program (HFAP))
Question 14
❑ Which of the following is a possible benefit of hospital
accreditation by The Joint Commission (TJC)?
❑ A. Discount on insurance
❑ B. Reduced frequency of state hospital licensing
surveys
❑ C. "Deemed status" by the Centers for Medicare
& Medicaid Services
❑ D. All of the above are benefits of accreditation
by TJC
Answer: D
❑ A number of liability insurers offer a discount to organizations that
are accredited by TJC.
❑ TJC accreditation reduces or eliminates the need for hospitals
accredited by TJC to undergo surveys to assess compliance with
state hospital licensing regulations.
❑ "Deemed status" is a recognized benefit of accreditation by TJC.
linked: Facilitate evaluation and/or selection of appropriate
accreditation or recognition program(s) (e.g. The Joint
Commission (TJC), Magnet, Baldrige, Det Norske Veritas (DNV),
American Osteopathic Association (AOA), Healthcare Facility
Accreditation Program (HFAP)).
Question 15
❑ Which of the following methods is MOST appropriate for
the structured assessment of nontechnical skills in a
ward-based hospital environment at a team level?
❑ A. Administering a computer-based
standardized test
❑ B. Using a behavioral marker tool
❑ C. Implementing a staff satisfaction survey
❑ D. Implementing a patient satisfaction survey
Answer: B
❑ Behavioral marker tools define observable behaviors
exhibited by individuals or teams. By comparing
performance against a set of required skills, these tools
facilitate the structured assessment of nontechnical skills
in the clinical environment.
Recall
question is linked: Evaluate team performance
Question 16
An acute care facility decided to improve the reliability of evidence-based care
for acute myocardial infarction (AMI). "Perfect care" is defined as delivery of all six
indicated evidence-based interventions for AMI patients. The facility's
performance on AMI perfect care is shown in the graph below. CPHQ Practice
Questions Selected & Prepared by Alaa M. Abu Al Rub, RN, CPHQ, FISQua, CPKPI,
CRM 9
In January 2013 (red arrow in the graph), the facility introduced education,
communication, data feedback to medical staff, and training for nurses and other
professionals to improve its performance. What should be the next course of
action?
A. Continue to monitor perfect care but make no further changes.
B. Abandon the initiative to improve the reliability of evidence-based care
for AMI.
C. Stop the changes that were introduced in January 2013 and try new
ones.
D. Continue the changes that were introduced in January 2013 and take
additional actions.
Question 16
Answer: D
❑ The graph indicates that baseline performance on AMI perfect
care from January 2012 through December 2012 was about 80%.
In the same month the changes were introduced (January 2013),
perfect care rose to above 95%. But this improvement in
performance lasted only 3 months, and then returned to the
baseline level. This is suggestive of a "Hawthorne effect." The
actions that had been taken in the early part of 2013 are fairly
standard, and there is no reason to stop doing them (answer
option C). To improve performance, additional actions need to
be taken.
❑ Content Category: Information Management Cognitive level
required for a response: Analysis
linked: Interpret data to support decision making (e.g.
benchmarking, outcome data)
Question 17
❑ Secular variation of a time series is represented
graphically by
❑ A. Cyclic movements.
❑ B. Sporadic motions.
❑ C. A trend line.
❑ D. Staying within control limits.
Answer: C
❑ Secular movements, or secular variation, refer to the
general direction in which the graph of a time series
appear to be going over a long interval of time. Secular
movements are indicated by a trend line.
❑ Content Category: Information Management Cognitive
level required for a response: Recall
question is linked: Facilitate the use of process analysis
tools to display data (e.g. fishbone, Pareto chart, run
chart, scattergram, and control chart)
Question 18
❑ An acute care facility aims to reduce postsurgical
infection rates by implementing a list of evidence-
based practices. Which of the following goals is most
likely to gain commitment and buy-in if reinforced?
❑ A. Improved patient care

❑ B. Reduced cost of care
❑ C. Compliance with insurance carrier's rules
❑ D. Compliance with accreditation standards .
Answer: A
❑ All four answer options give commonly cited goals for
conducting quality improvement initiatives. However,
reinforcing goals that are linked to improved patient
care is most likely to result in staff becoming more
amenable to changes.
Cognitive level required for a response: Application
question is linked: Facilitate assessment, development,
and design of the organization's quality culture
Question 19
❑ There were 260 sharps injuries at an acute care facility in
the past 3 years. The number of worked full-time-
equivalent employees (WFTE) during this period was
1050. The WFTE in the next 12 months is expected to
increase to 1200. Other things being equal, how many
sharps injuries can the facility expect in the next 12
months? You may wish to use a calculator.
❑ A. 87
❑ B. 99
❑ C. 275
❑ D. 297
Answer: B
❑ This is a relatively straightforward math-based question. This task (of anticipating the
impact of a particular problem) is sometimes asked of quality professionals. Further, some
candidates report being stumped by such math-based questions on the CPHQ exam.
❑ The average annual number of sharps injuries is 260/3. We need not calculate this figure
immediately.
❑ The historical annual rate of sharps injuries is, therefore, 260/3 ÷ 1050. The unit of
measurement here is "sharps injuries/WFTE". Again, we need not calculate this figure.
❑ We are told that everything other than the WFTE has remained constant. Therefore, we
can assume that the rate of sharps injuries will be the same in the next 12 months.
❑ To calculate the number of sharps injuries in the next 12 months, we simply multiply the
historical rate of sharps injuries with the WFTE: 260/3 ÷ 1050 × 1200 = 99
❑ Content Category: Information Management Cognitive level required for a response:
Application
❑ Tasks on the CPHQ exam content outline to which the question is linked: Interpret data to
support decision making (e.g. benchmarking, outcome data)
Question 20
❑ Which of the following statements about capability
analysis of a process is TRUE?
❑ A. Capability analysis requires the presence of a

special cause of variation.
❑ B. Capability analysis requires that the process is
in statistical control.
❑ C. Capability analysis compares current process
performance with past performance.
❑ D. Capability analysis is used to identify the limits
of the current process.
Answer: B
❑ Capability analysis of a process is used to determine
whether a process is able to meet its specifications or
requirements. In order to perform a capability analysis,
the process needs to be in statistical control. Process
capability compares process performance with process
requirements.
chart, scattergram, control chart)
Question 21
❑ You are the Director of Quality Management at an
acute care facility that will soon open. The Chief
Executive Officer has asked you to select the
organization's key performance indicators. What
information will you request first?
❑ A. The human resource available for data
collection
❑ B. The organization's strategy and goals
❑ C. Management's commitment to act on
performance reports
❑ D. The timeline for preparing the list of
performance indicators .
Answer: B
❑ As suggested in this article on performance indicators, in
this situation, it is probably best to first gain a clear
understanding of the organization's strategy and goals.
scorecards, dashboards).
Question 22
❑ The degree to which the average temperature in
refrigerators in a hospital falls outside specification on
any given day may be displayed in a
❑ A. Bar chart.
❑ B. Pareto chart.
❑ C. Control chart.
❑ D. Histogram.
Answer: D
❑ A histogram is appropriate in this case because it can show the shape of
distribution of the temperature readings on any given day. It can also
help one to determine whether the spread of the readings falls within
specification, and, if not, how much falls outside of specifications.
❑ A bar chart or Pareto chart is more appropriate for attribute data. In our
case above, the data have not been categorized. Hence, a bar chart
or Pareto chart cannot be used to examine the degree of variability.
❑ The example above deals with cross-sectional data (average
temperature on any given day), and not time-series data. Therefore, a
control chart is not appropriate.
❑ Content Category: Information Management Cognitive level required
for a response: Application
❑ Tasks on the CPHQ exam content outline to which the question is linked:
Facilitate the use of process analysis tools to display data (e.g. fishbone,
Pareto chart, run chart, scattergram, and control chart)
Question 23
❑ Falls per 1,000 patient-days in an acute care facility has
remained stable in the last 14 months. Management
concluded that the falls rate in the facility is satisfactory.
What other analysis, if any, is useful to support the
management's conclusion?
❑ A. Review of the actual number of falls per month during
the 14 months.
❑ B. Comparison of the falls rate to other similar
organizations.
❑ C. Breakdown of the falls rate according to patient care
unit.
❑ D. Breakdown of the falls rate according to patient age.
Answer: B
❑ Monitoring only trend reports is not sufficient. Even if performance
remains stable, i.e. a flat slope, comparison to other organizations
is still important to gauge whether the bar has risen. The overall
group of facilities may raise the bar or benchmark. Even if
individual performance is stable, relative performance may
decline because the rest of the group in the data set improved.
❑ Selected & Prepared by Alaa M. Abu Al Rub, RN, CPHQ, FISQua,
CPKPI, CRM 14
❑ Content Category: Performance Measurement and Improvement
linked: Coordinate or participate in quality improvement projects
Question 24
❑ A hospital system is participating in a regional nursing quality
measurement database. Data are collected for a variety of nurse-
sensitive quality indicators in the following categories: nurse
staffing, RN education level, certification, patient falls, pressure
ulcers, use of restraints, central line-associated bloodstream
infections, and medication administration. For which indicators
should graphs be used to summarize comparative hospital
performance?
❑ A. All indicators in the database.
❑ B. Only indicators in the database prioritized for
performance improvement.
❑ C. Only indicators in the database for which the data
suggest underperformance.
❑ D. Only indicators in the database for which the data
suggest outperformance.
Answer: B
❑ Graphs should not be used to summarize all data—
although commonly done, creating many pages of
graphs often leads to people missing key analyses.
❑ Graphs should only be used for those indicators
prioritized for performance improvement. Displaying
data that do not demonstrate underperformance or
outperformance may still be valuable.
Application
question is linked: Organize information for committee
meetings (e.g. agendas, reports, minutes)
Question 25
❑ The senior management team of an acute care facility
is setting a breakthrough goal for efficiency.
❑ Which measure is the most appropriate?

❑ A. Length of stay
❑ B. Hospital costs
❑ C. Cost per capita
❑ D. Cost per case
Answer: C
❑ Selected & Prepared by Alaa M. Abu Al Rub, RN, CPHQ,
FISQua, CPKPI, CRM 15 Cost per capita assumes
responsibility for the total cost of care, rather than a specific
aspect of care (e.g. hospital costs, length of hospital stay,
cost per case. It would be the most appropriate measure for
a breakthrough goal because of its level of ambition and
scope—setting aims for total cost of care requires design
concepts that relate to the whole system.
❑ Content Category: Management and Leadership Cognitive
level required for a response: Application
question is linked: Link performance/quality improvement
activities with strategic goals
Question 26
The upper limit of a control chart should be
A. 2 standard deviations above the center line.
B. 3 standard deviations above the center line.
C. 4 standard deviations above the center line.
D. None of the above.
Answer: D
❑ The upper (and lower) limit of a control chart is usually 3
standard deviations from the mean, but this does not
necessarily have to be the case. Depending on the
process being studied, the control limits may be more or
less than 3 standard deviations from the mean.
Question 27
❑ What is the most frequent cause of failure in any
improvement effort?
❑ A. Inadequate or improper training

❑ B. Lack of senior and middle management
involvement
❑ C. Poor communication across the organization
❑ D. Unrealistic expectations .
Answer: B
❑ The most frequent cause of failure in any improvement
effort is indifferent or uninvolved senior and middle
management.
question is linked: Facilitate development of leadership
values and commitment to quality
Question 28
❑ A team is developing a check sheet to record the
reasons patients are readmitted within 48 hours of
discharge.
❑ What is the best way of ensuring the check sheet is
effective?
❑ A. Carefully plan the form to make it as complete as
possible before using it full-scale.
❑ B. Review forms used in other organizations and adopt
them for implementation in the present organization.
❑ C. Test the form on dummy patients before using it full-
scale.
❑ D. Try out the form on a small sample of patients before
using it full-scale.
Answer: D
❑ In general, when developing a data collection tool, it is
best to test it on a small sample of actual patients (not
dummy ones) and make any necessary changes before
full implementation. Some teams spend a lot of time
trying to develop the “perfect” tool/form (either on their
own or adopting one from elsewhere) and then
attempt to implement it (full-scale)—this is usually not
the best approach.
question is linked: Perform or coordinate data
collection methodology (e.g. qualitative, quantitative)
Question 29
❑ The Centers for Medicare & Medicaid Services (CMS)
Five-Star Quality Rating System for nursing homes
consists of an overall 5-star rating and a separate rating
for each of the following sources of information EXCEPT
❑ A. Consumer surveys.
❑ B. Staffing.
❑ C. Quality measures.
❑ D. Inspection results.
Answer: A
❑ Selected & Prepared by Alaa M. Abu Al Rub, RN, CPHQ,
FISQua, CPKPI, CRM 17
❑ The Error! Hyperlink reference not valid. for nursing
homes consists of three domains: nursing home
inspection results, staffing, and quality measures. In
addition there is an overall rating calculated from the
three domains.
question is linked: Participate in public reporting
activities (e.g. organizational transparency, website
content, ensuring accuracy)
Question 30
❑ Which of the following is LEAST likely to be a patient
perspective of quality?
❑ A. Following the standard of care
❑ B. Responsiveness and empathy
❑ C. Safety and freedom from injury
❑ D. Provision of clear information
Answer: A
❑ Patient perspectives of quality include safety and
freedom of injury, access to care, responsiveness and
empathy, good communication, clear information
provision, appropriate treatment, relief of symptoms,
and improvement of health status. Patients are less likely
to focus on whether providers follow a set standard of
care.
❑ Content Category: Patient Safety Cognitive level
question is linked: Facilitate the ongoing development
and enhancement of a patient safety program
Question 31
❑ Consider a four-step treatment process with yields for each step:
Step 1 — Yield 99% Step 2 — Yield 95% Step 3 — Yield 95% Step 4 —
Yield 94% . On average, what percentage of the organization's
effort in this process requires rework?
❑ A. 5%
❑ B. 6%
❑ C. 15%
❑ D. 16%
Answer: D
❑ Yield is defined as the ratio of desired outcomes to all outcomes.
❑ In this process, only 84%, i.e. 0.99 × 0.95 × 0.95 × 0.94, of patients
are getting their treatment right the first time all the way through.
Therefore, 16% of patients, on average, are being held up for
additional treatment or to fix paperwork or something else
unplanned. On first approximation, 16% of the organization's effort
is going toward rework.
required for a response: Application
benchmarking, outcome data).
Question 32
❑ Failure modes and effects analysis can be done
❑ A. From causes forward to effects.

❑ B. From effects back to causes.
❑ C. From causes forward to effects or from
effects back to causes.
❑ D. By none of the above approaches.
Answer: C
❑ Failure modes and effects can be done from effects back to causes or from causes
forward to effects.
❑ For example, consider this effect: a wheel comes off the mail cart. What can cause this?
The wheel itself could break, the cart leg could break, the axle could break, the cotter
pin could come out of the axle, or the shank of the leg down where the axle goes
through it could get bent so that the axle could pop out. We could then go further back
to ask, what would cause the axle to break? Well, the answer may be poor lubrication,
material defect, destructive handling during assembly, abrasion against the strut,
chemical attack by disinfectant used to wash the cart, and so on. Similar lists could be
developed for each of the other causes of the wheel coming off.
❑ Alternatively, we could go in the other direction and ask, what happens if the wheel
comes off? Well, the cart might tip, mail could be dumped on the floor, mail would be
held up, some mail might get lost, the aisle could be blocked by the wreckage, the cart
user might be injured by the spill, another cart going might be tipped in turn, the floor
might get gouged, or a passerby might get a pocketful of mail.
❑ Content Category: Patient Safety Cognitive level required for a response: Recall
❑ Tasks on the CPHQ exam content outline to which the question is linked: Perform or
coordinate risk management: failure mode and effects analysis
Question 33
❑ An acute care facility has found that the incidence rate of pressure ulcer cases,
although low, is not as low as the incidence rate reported by comparable
organizations. Because the incidence of pressure ulcers may detract from the
organization's reputation for giving good care, management decides to take
this matter seriously and assigns a project manager and analyst.
❑ On review of the records, the project team decides that the existing policy is
the right one and something is going wrong in the implementation.
❑ Which of the following options is most appropriate?
❑ A. Develop a new policy.

❑ B. Failure modes and effects analysis.
❑ C. Root cause analysis.
❑ D. Review the data on pressure ulcers.
Answer: B
❑ Because the existing policy is deemed to be the right one,
developing a new policy is not the best option at this stage.
❑ FMEA is appropriate because it will help to identify ways that the
current process may fail and therefore help plan improvement.
❑ Root cause analysis is not appropriate because there is no
evidence of special-cause variation, i.e. evidence to indicate
that the process is out of control.
❑ Reviewing the data is not appropriate because a conclusion has
already been made about the incidence rate.
linked: Facilitate program development, evaluation, planning,
projects, and activities
Question 34
❑ Which of the following statements about queuing and
the bottleneck of a workflow is TRUE?
❑ A. Queuing at the bottleneck is desirable.

❑ B. Queuing at the bottleneck should be
eliminated.
❑ C. Queuing at the bottle should be minimized.
❑ D. Queuing at the bottleneck is unavoidable.
Answer: A
❑ Queuing is waiting for service. Queuing is appropriate
and even necessary at the bottleneck because it is
important to the organization that the bottleneck never
runs out of work.
Recall .
member/leader/facilitator).
Question 35
❑ From a study of a sample of patient records for the prior
20 months, the medication error rate was found to be 1
per 1000, with a 90% confidence interval between zero
and 3.4 errors per 1000.
❑ What is the chance that the true value is NOT covered
by the interval?
❑ A. 0%
❑ B. 3.4%
❑ C. 10%
❑ D. 90%
Answer: C
❑ A 90% confidence interval means that the likelihood
that the true value lies within this interval is 90%.
Therefore, there is a 10% chance that the true value is
not covered by the interval.
question is linked: Interpret data to support decision
making (e.g. benchmarking, outcome data) .
Question 36
❑ At the office of a family dentist, he was the sole
practitioner with an established practice. From a quality
improvement perspective, what is the expected effect
of another dentist joining the practice?
❑ A. Increase in capacity with no effect on the
bottleneck.
❑ B. Expansion of the bottleneck with no effect on
capacity.
❑ C. Increase in capacity and tightening of the
bottleneck.
❑ D. Increase in capacity and expansion of the
bottleneck.
Answer: D
❑ Addition of another dentist will increase capacity.
❑ When the first dentist was working by himself, the workflow had a
bottleneck (as with any workflow). For the purpose of answering
this question, we need not concern ourselves about the nature of
this bottleneck. When the second dentist joins the practice,
he/she will expand the bottleneck.
❑ Therefore, the overall effect of a second dentist joining the
practice is an increase in capacity and expansion of the
bottleneck.
linked: Integrate the results of the performance/quality
improvement process into strategic planning for the organization
Question 37
❑ The primary goal of a program to assist with appropriate
antibiotic selection and dosing is to
❑ A. Minimize adverse events.

❑ B. Reduce cost.
❑ C. Prevent the misuse and overuse of
antibiotics.
❑ D. Reduce the average length of stay.
Answer: A
❑ The goal of an antibiotic stewardship program is to minimize the
risk of adverse events, such as Clostridium difficile infection and
antibiotic toxicity. The program will also probably result in cost
reduction and a decrease in the average length of stay. The
program will lead to the prevention of misuse and overuse of
antibiotics but this is not the goal; it may be viewed as a means to
achieve the desired result.
linked: Participate in the process of organizational reviews or
audits for: infection prevention and control processes .
Question 38
❑ In an acute care facility, the delivery times of x-ray
results were higher on Saturday and Sunday, compared
with the other days of the week. What should the
management do next to improve weekend
performance?
❑ A. Increase the number of staff in the Radiology
Department.
❑ B. Provide more training for staff in the Radiology
Department.
❑ C. Use a process flow chart to better understand the
process.
❑ D. Review the productivity of each staff member involved in
the process.
Answer: C
❑ The problem is probably due to a mismatch between workload and staff or
staff skills. However, more work is required to gain a better understanding of the
problem.
❑ A process flow chart helps management as well as participants from diverse
departments to understand what is going on in the process. The chart may
even help the knowledgeable participants to understand more fully what is
going on because they may never have thought about things in just the way
they were presented in the chart. This type of analysis is often the first step in
trying to improve a process.
❑ At this stage in the improvement effort, it is best to assume that staff are working
as productively as they can in the current process.
❑ Content Category: Performance Measurement and Improvement Cognitive
Coordinate or participate in quality improvement projects
Question 39
❑ The upper and lower control limits of a process control
chart are three standard deviations from the mean. A
data point that falls outside these limits
❑ A. Will be found 5% of the time even if the

process is in statistical control.
❑ B. Will be found 5% of the time if the process is
out of statistical control.
❑ C. Indicates the presence of a sentinel event.
❑ D. Is a signal for further investigation.
Answer: D
❑ This question tests your understanding of (process) control charts and control
limits.
❑ In general, 99.7% of the data points will fall within the control limits if the latter
are three standard deviations above and below the mean because a normal
distribution is assumed (cf. central limit theorem). Therefore, there is only a 0.3%
chance that data points may show up outside these limits even if the process in
“in control.” In other words, it is possible for a data point to fall outside the
control limits even if there is no “sentinel event” but it will be extremely rare, and
therefore warrants further investigation. If the data points stay within these limits,
everything can be considered to be working the way it is expected to work
given the system as it currently exists.
❑ Content Category: Information Management Cognitive level required for a
response: Application
Facilitate the use of process analysis tools to display data (e.g. fishbone, Pareto
chart, run chart, scattergram, control chart)
Question 40
❑ The current error rate is one per 1000 pharmacy orders.
The hospital has 200 acute beds plus an outpatient
service. The number of pharmacy orders is 2000 orders
per month (4 weeks). A trial of a handheld device is
planned. An analyst recommends a sample of 3000
pharmacy orders for the trial. The two patient care units
being tested generate about one-third of the total
pharmacy orders each. How long will the trial take?
❑ A. 6 weeks
❑ B. 9 weeks
❑ C. 10 weeks
❑ D. 12 weeks
Answer: B
❑ This is clearly a practical math question—such questions appear on the
CPHQ examination.
❑ To answer this question, we merely have to pick out the relevant
information.
❑ 3000 pharmacy orders are required for the trial. Only two patient care
units are being tested and together, they generate two-thirds of the
total pharmacy orders, i.e. (1/3 + 1/3) × 2000 = 2/3 * 2000 = 1333 orders
every 4 weeks, or 333 orders per week. Therefore, the total number of
weeks to obtain a sample of 3000 orders is 3000/333 = 9 weeks.
Perform or coordinate data collection methodology (e.g. qualitative,
quantitative)
Question 41
❑ Which of the following statements about Six Sigma is
TRUE?
❑ A. Six Sigma is based on the premise that getting
the process right will eventually lead to the
desired outcomes.
❑ B. Six Sigma aims to achieve 6 errors per million
opportunities or less.
❑ C. Six Sigma focuses on achieving the desired
outcomes from the outset.
❑ D. Six Sigma projects are suitable for redesigning
processes only.
Answer: C
❑ Unlike Total Quality Management, Six Sigma focuses on
getting the outcomes (output) right immediately, i.e. 3.4
errors per million opportunities or less.
❑ Six Sigma may be used for redesigning processes,
solving problems, instituting a change, or monitoring key
processes.
question is linked: Determine applicability of
performance improvement models (e.g. PDCA, Six
Sigma, Lean)
Question 42
❑ The medication administration process at an acute care facility
was deemed to be unacceptable due to frequent errors
associated with patient harm. A subsequent trial of a handheld
device, conducted at the same facility, showed that use of the
device in two patient care units significantly reduced the rate of
medication administration errors.
❑ How should the facility conduct a cost-benefit analysis to the
change from the old process to the new process?
❑ A. The facility should compare the benefits and costs of the old and
new processes based on the results of the trial only.
❑ B. The facility should perform a cost-benefit analysis only after the
use of the handheld device is extended to the whole facility.
❑ C. The facility should take into account other improvements besides
the handheld device when comparing the benefits and costs of the
old and new processes.
❑ D. The facility should not perform a cost-benefit analysis.
Answer: D
❑ A cost-benefit analysis in this case will not be
meaningful because the old process was
unacceptable, no matter how favorable its costs. Cost-
benefit analysis is appropriate only when comparing
sufficient solutions.
question is linked: Demonstrate financial benefits of a
quality program
Question 43
❑ In which of the following scenarios is rule-based
sampling most appropriate?
❑ A. Obtaining customer feedback.

❑ B. Assessing compliance to the time-out
procedure.
❑ C. Measuring patient falls.
❑ D. Functional testing of laboratory machines.
Answer: D
❑ Rule-based sampling focuses attention on key times and key events,
which are times when random sampling or periodic sampling would not
provide sufficient insight.
❑ When a machine is turned on, the obvious thing to do is to check it and
its setup immediately to see if it is operable. Electronics are known to fail
most often just when the machine is turned on, so the fact that the
machine ran yesterday is not sufficient to know that it will run today.
Indeed, most computerized machines check themselves upon boot-up
for this very reason.
❑ A functional test, which involves running the equipment against a known
standard, is good practice every time any machine is turned on.
Perform or coordinate data collection methodology
Question 44
❑ The accounting system of an organization has an error rate of 25
errors per million transactions, and there are 200 accounting
transactions in the typical patient record. The treatment stage
has an error rate of seven per million opportunities, and there are
an average of 500 opportunities for error in the average patient's
treatment. What is the process yield, considering both
accounting and treatment? (You may wish to use a calculator.)
❑ A. 99.9%
❑ B. 99.2%
❑ C. 98.3%
❑ D. 91.5%
Answer: B
❑ This question tests your understanding of cumulative process
performance, which is called the first-time-through yield when
expressed quantitatively.
❑ The error rate is the error count divided by the total number of
opportunities for error. Yield is then defined as the complement of
the error rate (the error rate subtracted from one); an error rate of
0.1% means a yield of 99.9%.
❑ For low error rates (as in this question), the error rates for several
stages can be added together without appreciable loss of
precision in the result.
❑ For the accounting system, the error rate is 25/1,000,000, and there
are 200 opportunities for error. Therefore, the expected number of
accounting errors per patient is: 25/1,000,000 × 200 = 0.005.
❑ For the treatment stage, the error rate is 7/1,000,000, and there are 500
opportunities for error. Therefore, the expected number of treatment errors per
patient is 7/1,000,000 × 500 = 0.0035.
❑ The composite error rate is calculated by finding the sum of the two error results
from above, i.e. 0.005 + 0.0035 = 0.0085.
❑ The process yield is the complement of the error rate, i.e. 1 − 0.0085 = 0.9915 or
99.2%.
❑ This question could have been answered without the use of a calculator.
However, using a calculator reduces the chance of making an error, e.g.
misplacement of a decimal point. A simple calculator may be brought into the
test center and used during the CPHQ exam—you should declare it to the
proctor when you enter the center. I recommend that candidates bring a
simple electronic calculator to the exam with them—most people have one
lying around the office or at home, and it may save you from making a silly
calculation error.
❑ Content Category: Information Management Cognitive level required for a
response: Application Tasks on the CPHQ exam content outline to which the
question is linked: Interpret data to support decision making (e.g.
Question 45
❑ When dealing with data sets with fewer than 20
samples, which statistical method is applied for
confidence intervals for the population standard
deviation?
❑ A. Binomial method and distribution

❑ B. Chi-square method and distribution
❑ C. Student's t method and distribution
❑ D. Z method and distribution
Answer: B
❑ For small samples (e.g. fewer than 20), the confidence
interval for the population average value is calculated
using the Student's t method and distribution. On the
other hand, for confidence intervals for the population
standard deviation, the chi-square method and
distribution are applied.
question is linked: Use epidemiological principles in
data collection and analysis
Question 46
❑ Where in a process is the ideal placement of the
bottleneck?
❑ A. First step in the process.

❑ B. Middle of the process.
❑ C. Final step in the process.
❑ D. The bottleneck should be eliminated.
Answer: A
❑ In almost any process, there will be a bottleneck. However, placement
of the bottleneck may be beyond the control of management.
❑ Nevertheless, the ideal place to have a bottleneck is at the first step in
the process. For example, some theme parks throttle the number of
patrons allowed into the park so that the patrons will not have to wait
interminably in queue to ride the popular rides. They put the bottleneck
at the first step of their service process; this is the best place to have it.
❑ The best place for the bottleneck is not at the end of the process.
Everyone who shops at a grocery store is infuriated by the grocery store
bottleneck: the checkout counters.
Participate on performance/quality improvement teams (i.e. as a
coordinator or team member/leader/facilitator) .
Question 47
❑ The intentional grouping of patients so that one setup
can be used several times
❑ A. Increases variability in the overall service

performance time.
❑ B. Increases the overall service performance
time.
❑ C. Decreases variability in the overall service
performance time.
❑ D. Decreases the overall service performance
time.
Answer: A
❑ Batching is the intentional grouping of patients or other work so that one
setup can be used several times. Batching the work of the bottleneck is
appropriate if some setup time is required at the bottleneck because
that setup time is non-productive. Using the same setup several times in
a row by batching the work minimizes the nonproductive portion of the
day and maximizes production. Therefore, the overall service
performance time may increase or decrease with batching, depending
on where the latter is placed.
❑ Batching increases variability in the overall service performance time.
Patients at the head of the batch are processed in less overall time than
patients at the end of the batch.
Cognitive level required for a response: Recall Tasks on the CPHQ exam
content outline to which the question is linked: Participate on
performance/quality improvement teams (i.e. as a coordinator or team
Question 48
❑ In project management, achieving the proper balance
of cost, schedule, and quality is under the control of
❑ A. The project sponsor alone.

❑ B. The project manager alone.
❑ C. The customers alone.
❑ D. All stakeholders.
Answer: D
❑ At the start of any project, three things need to be agreed upon:
what should be built/designed, the cost or price of the
product/service, and when it must be delivered. This cost-
schedule-quality equilibrium is also known as the triple constraint.
These three variables define the overall goals of a project. After a
balance between these variables is struck, a change to one will
affect the other two.
❑ All stakeholders, especially those involved in project selection,
influence the choices and trade-offs that make up the triple
constraint.
linked: Facilitate or participate in organization-wide strategic
planning
Question 49
❑ What is the most likely effect of tampering when dealing
with control charts?
❑ A. Reducing variation when the process is stable

❑ B. Increasing variation when the process is
stable
❑ C. Failing to recognize special cause variation
when it is present
❑ D. Falsely identifying special cause variation
when none exists
Answer: B
❑ Tampering refers to over-responding to individual
common cause data points as if they signified special
causes—asking for explanations or making changes
based on the individual data points. When a process is
stable and well targeted, tampering is likely to increase
variation.
question is linked: Interpret data to support decision
making (e.g. benchmarking, outcome data)
Question 50
❑ Diverting traffic away from wet floors until dry in a
hospital is an example of
❑ A. Risk transfer.
❑ B. Risk reduction.
❑ C. Risk avoidance.
❑ D. Risk adjustment.
Answer: C
❑ Because wet floors are usually slippery, accidents can occur. By
diverting traffic away from wet floors, the chance of an accident
occurring as a result of the floor being wet is eliminated, i.e. risk
avoidance.
❑ Risk transfer refers to transferring the risk to another party, e.g. an
insurance company.
❑ Risk reduction is a risk management strategy that attempts to optimize or
mitigate the risk.
❑ Risk adjustment, in the context of healthcare risk management, is a
“statistical process that takes into account the underlying health status
and health spending of the enrollees in an insurance plan when looking
at their health care outcomes or health care costs.”
❑ Content Category: Patient Safety Cognitive level required for a
response: Application Tasks on the CPHQ exam content outline to which
the question is linked: Facilitate the ongoing development and
enhancement of a patient safety program
Question 51
❑ In what situation may a control chart lack a stair-
shaped look in its upper and lower control limit lines?
❑ A. The number of cases in the numerator is
basically the same from one time period to
another.
❑ B. The number of cases in the numerator is
different from one time period to another.
❑ C. The number of cases in the denominator is
basically the same from one time period to
another.
❑ D. The number of cases in the denominator is
different from one time period to another.
Answer: C
❑ A control chart may lack a stair-shaped look in its upper
and lower control limit lines if the number of cases in the
denominator is basically the same from one time period
to another.
Question 52
❑ A frequency plot may be used to examine
❑ A. The shape of data.

❑ B. The spread of data.
❑ C. The center of data.
❑ D. All of the above.
Answer: D
❑ A frequency plot, or histogram, is used to examine the
center, spread (range), and shape of data.
question is linked: Use basic statistical techniques to
present data (e.g. mean, standard deviation)
Question 53
❑ Successful implementation of a standardized process
requires
❑ A. Local customization.
❑ B. A carefully written policy.
❑ C. All persons involved in the process to be
owners of the process.
❑ D. Planning so that the design is close to perfect
from the outset.
Answer: A
❑Standardization of clinical processes is possible but the
methodology of development and implementation is often
flawed. Local customization will be required—making an attempt
to compromise and account for all possible objections and
contingencies will usually lead to failure.
❑Development of a written policy while trying to implement a
standardized process is often inappropriate. The process should be
assigned one owner, not more. The ability to sustain a protocol is
dependent on an owner. The owner of a process/protocol has
several responsibilities, including being aware of any new literature
that would impact the protocol, having available the compliance
data regarding the use of the protocol, and having basic data
regarding the reasons why the protocol is not being used, if
applicable. No changes can be made to the protocol without
consent and delegation of those changes from the process
owner.
❑Initial standardization of a care process will never be
perfect, and the designers should expect failures. If an
attempt is made in the initial design to deal with any and
all probabilities that engage the clinical process, the
initial protocol will become far too complicated. A
complicated design is much more difficult to understand
by the frontline staff that need to implement the
protocol.
❑Content Category: Performance Measurement and
Recall Tasks on the CPHQ exam content outline to which
the question is linked: Participate on
performance/quality improvement teams (i.e. as a
coordinator or team member/leader/facilitator)
Question 54
❑ A team plans to improve the reliability of the “time-out”
procedure in the Operating Room. What should it do
first?
❑ A. Engage leaders around transparency and

continuous learning.
❑ B. Reliably design processes.
❑ C. Provide targeted team training.
❑ D. Systematically survey the culture and identify
risk areas.
Answer: A
❑ Many teams find it difficult to know where to begin their
improvement work. Based on research and tested theories
of the Institute of Healthcare Improvement, the first step in
the "sequencing for action" is engaging leaders, both senior
and physician, around transparency and continuous
learning. This will involve creating an accountability system
and a systematic flow of information.
❑ Content Category: Performance/Quality Measurement and
Application
question is linked: Coordinate or participate in quality
improvement projects
Question 55
❑ Which of the following is the LEAST appropriate trigger to
identify a possible adverse event in the Operating
Room?
❑ A. Unplanned return to surgery

❑ B. Transfusion or use of blood products
❑ C. Transfer to higher level of care
❑ D. Change in surgery
Answer: C
❑ Among the four answer options, the one least likely to
be associated with a potential adverse event in the
Operating Room is "transfer to higher level of care." In
other words, unplanned return to surgery, transfusion or
use of blood products, and a change in surgery are all
more likely to be associated with an adverse event that
occurred in the Operating Room.
❑ Content Category: Performance/Quality Measurement
and Improvement Cognitive level required for a
response: Application Tasks on the CPHQ exam content
outline to which the question is linked: Facilitate or
participate in the process of departmental reviews (e.g.
pathology, radiology, pharmacy, nursing)
Question 56
❑ In improving safety and reliability in the operating room,
the organization has designated a clinical leadership
group to own and drive the work. What should the next
step be?
❑ A. Develop performance measures for the
operating room.
❑ B. Implement structured communication
techniques in the operating room.
❑ C. Review the cultural assessment information
about the operating room.
❑ D. Provide teamwork training for operating
room staff.
Answer: C
According to the collective opinions, research, and tested theories
of a panel of experts1, the following sequence is recommended for
improving safety and reliability:
Step 1. Engage leaders, both senior and physician.
Step 2. Systematically survey the culture and identify risk areas.
Step 3. Provide targeted team training that combines specific tools
and behaviors, which are embedded within clinical domain-specific
processes of care.
Step 4. Reliably design processes.
Step 5. Apply direct observation and feedback to observe
teamwork behaviors and monitor the success of initiatives.
Step 6. Define, implement, monitor, and establish a feedback
mechanism for process, outcome, and organizational measures to
show success and drive improvement.
Step 7. Use performance improvement strategies to
structure continuous improvement.
Content Category: Patient Safety Cognitive level required
for a response: Application Tasks on the CPHQ exam
content outline to which the question is linked: Integrate
patient safety concepts within the organization
Reference
1. Leonard M, Frankel A, Federico F, Frush K, Haraden C,
eds.
2. The Essential Guide for Patient Safety Officers.
Oakbrook Terrace, IL: Joint Commission Resources,
Institute for Healthcare Improvement; 2013. ISBN:
9781599407036.
Question 57
❑ For the purpose of improvement, assessment of safety
culture in a hospital is best conducted at the level of
the
❑ A. Individual.
❑ B. Unit.
❑ C. Hospital.
❑ D. System.
Answer: B
❑ Assessment of safety culture within a hospital should be
at the unit level. There is more variability between units
in a typical hospital than there is between hospitals.
Because interventions to improve safety are
implemented at the clinical area level, it is critical to
understand culture at that level.
question is linked: Facilitate assessment and
development of the organization’s patient safety
culture
Question 58
❑ Within a hospital, which units are the preferred locations
to target improvement work in patient safety?
❑ A. Units with high rates of adverse events and

less positive patient safety culture.
❑ B. Units with high rates of adverse events and
more positive patient safety culture.
❑ C. Units with low rates of adverse events and
less positive patient safety culture.
❑ D. Units with low rates of adverse events and
more positive patient safety culture.
Answer: A
❑ The areas with high rates of adverse events and low
patient safety culture scores, i.e. less positive patient
safety culture, are the preferred locations to conduct
improvement work in patient safety. This is because the
opportunity for improvement is greatest in these areas.
question is linked: Facilitate the ongoing development
and enhancement of a patient safety program.
Question 59
❑ The entire surgical staff of an organization has been working of its teamwork
and communication skills. One day during a procedure, a surgeon lost his
temper with the circulating nurse because he thought the nurse was not
moving fast enough and was slowing him down by asking him to clarify the
situation. As she continued to ask for clarification, he flung a bloody sponge at
her and yelled for her to stop talking for one minute so he could think.
❑ As the patient safety officer of the organization, what would you recommend
be done immediately?
❑ A. The surgeon is monitored for similar behavior over the next few months.
❑ B. The surgeon is asked by the organization's leadership to apologize to the
nurse.
❑ C. The surgeon is required to undergo further training in teamwork and
communication skills.
❑ D. A thorough review of the teamwork and communication skills training
provided to the surgical staff.
Answer: B
❑ Following such disrespectful behavior, the leadership
has to intervene immediately by asking the surgeon to
apologize to the nurse instantly. This would strongly
reinforce the desired behaviors and send a powerful
message to the rest of the organization.
question is linked: Facilitate assessment and
development of the organization’s patient safety
culture
Question 60
❑ For which of the following situations is closed-loop
communication most beneficial?
❑ A. When administering intravenous medications

and fluids.
❑ B. During a handoff from operating room to the
Intensive Care Unit.
❑ C. When trying to get the physician's attention
during an intense patient care period.
❑ D. While obtaining informed consent from a
patient.
Answer: B
❑ Closed loop communication helps improve the reliability of
communication by having the person receiving the
communication restate what the sender has said to confirm
understanding. One specific type of closed loop
communication is repeat back. The tool involves four distinct
actions:
❑ The "sender" concisely states information to the
"receiver."
❑ The receiver then repeats back what he or she heard.
❑ The sender then acknowledges the repeat back was
correct or makes a correction.
❑ The process continues until a shared understanding is
verified.
❑ Organizations requiring this type of closed-loop communication
during times in which communication must be reliable and
effective can help smooth the communication process and
ensure no critical information is lost. Closed-loop communication
can be particularly helpful in situations such as during surgery to
confirm sponge count, during high-risk patient handoffs to ensure
comprehensive information exchange (e.g. handoffs from
operating room to the Intensive Care Unit), and during medication
ordering to ensure that the right medication, right dose, and right
route are communicated.
linked: Integrate patient safety concepts within the organization
Question 61
❑ In improving safety and reliability in the operating room,
the organization has designated a clinical leadership
group to own and drive the work. What should the next
step be?
❑ A. Develop performance measures for the
operating room.
❑ B. Implement structured communication
techniques in the operating room.
❑ C. Review the cultural assessment information
about the operating room.
Answer: C
According to the collective opinions, research, and tested theories
of a panel of experts1, the following sequence is recommended for
improving safety and reliability:
Step 1. Engage leaders, both senior and physician.
Step 2. Systematically survey the culture and identify risk areas.
Step 3. Provide targeted team training that combines specific tools
and behaviors, which are embedded within clinical domain-specific
processes of care.
Step 4. Reliably design processes.
Step 5. Apply direct observation and feedback to observe
teamwork behaviors and monitor the success of initiatives.
Step 6. Define, implement, monitor, and establish a feedback
mechanism for process, outcome, and organizational measures to
show success and drive improvement.
Step 7. Use performance improvement strategies to
structure continuous improvement. Content Category:
Patient Safety Cognitive level required for a response:
Application
Tasks on the CPHQ exam content outline to which the
question is linked: Integrate patient safety concepts within
the organization
Reference
1. Leonard M, Frankel A, Federico F, Frush K, Haraden C,
eds. The Essential Guide for Patient Safety Officers.
Oakbrook Terrace, IL: Joint Commission Resources, Institute
for Healthcare Improvement; 2013. ISBN: 9781599407036.
Question 62
❑ An acute care facility is tracking the monthly rate of
ventilator-associated pneumonia in the adult ICU. What
is the most sensitive tool for identifying special cause
variation?
❑ A. Line chart
❑ B. Run chart
❑ C. Control chart
❑ D. Pareto chart
Answer: C
❑ Time series data, such as the monthly rate of ventilator-
associated pneumonia, may be plotted on a line chart,
run chart, or control chart (but not a Pareto chart,
which displays categorical data). Among these options,
a control chart is the most sensitive for identifying
special cause variation.
Question 63
❑ What is the most common reason for a team to struggle
to develop a data collection plan?
❑ A. Lack of leadership support.

❑ B. Lack of motivation and enthusiasm among
team members.
❑ C. Inadequate expertise in the methods and
tools of data collection.
❑ D. The team's goals are too ambitious.
Answer: C
❑ Teams often encounter difficulty in developing a data
collection plan because team members are not well
versed in the methods and tools of data collection.
Recall
question is linked: Design organizational
performance/quality improvement training (e.g. quality,
patient safety)
Question 64
❑ How can the Chief Executive Officer best contribute to
the success of a key improvement project in her
organization?
❑ A. Assign a quality professional to assist in the

project.
❑ B. Conduct regular, in-person reviews of the
project.
❑ C. Offer financial incentives.
❑ D. Personally select members of the
improvement team.
Answer: B
❑ A key ingredient to the success of any improvement
effort is executive review. A Chief Executive Officer's
active, in-person, real-time engagement in key quality
projects in their organization has a larger effect on their
success, scale, and spread than other tactics.
Question 65
❑ Which of the following is an organizational measure?
❑ A. Prophylactic antibiotic received within one
hour prior to surgical incision
❑ B. Unplanned return to theatre
❑ C. Percent of clean surgery patients with
surgical infection
❑ D. Percent of surgical cases that were started
on time
Answer: D
❑ Organizational measures, as opposed to process and
outcome measures, reflect system issues. An example is how
often surgical cases were started on time. "Prophylactic
antibiotic received within one hour prior to surgical incision" is
an example of process measures (which show whether the
processes of care were followed). "Unplanned return to
theatre" and "percent of clean surgery patients with surgical
infection" are examples of outcome measures.
❑ Content Category: Management and Leadership Cognitive
performance/quality indicators (e.g. balanced scorecards,
dashboards)
Question 66
❑ Progress of an improvement project has stalled. One of
the main issues identified was that a few loud naysayers
were blocking implementation of ideas by the rest of
the team, which suggests
❑ A. Absence of strong enough ideas for

improvement.
❑ B. Failure to execute changes.
❑ C. A lack of organizational will.
❑ D. Too many physicians on the team.
Answer: C
❑ If a project is not achieving the intended results, it is probably due to
one (or more) of only three problems:
❑ Lack of organization will Selected & Prepared by Alaa M. Abu Al Rub,
RN, CPHQ, FISQua, CPKPI, CRM 40
❑ Absence of strong enough ideas for improvement
❑ Failure to execute changes
❑ Inability or unwillingness to effectively manage a few loud naysayers
who are blocking implementation of ideas by the rest of the team
suggests lack of organizational will.
Facilitate program/project development and evaluation (e.g. enterprise
risk management, patient safety, infection prevention and control, new
service lines)
Question 67
❑ In failure mode and effects analysis, what does the Risk
Priority Number refer to?
❑ A. Each failure mode and the process

❑ B. Each failure mode and its effects
❑ C. The potential causes of each failure mode
only
❑ D. None of the above.
Answer: A
❑ A Risk Priority Number (RPN), or Criticality Index, should
be assigned to each failure mode. In addition, the
overall RPN for the process is the sum of the RPNs for the
failure modes.
question is linked: Perform or coordinate risk
management: failure mode and effects analysis.
Question 68
❑ Which of the following is NOT an appropriate red rule?
❑ A. When a midwife is concerned at the bedside
and asks the obstetrician to come to the bedside,
he or she should come in a timely manner.
❑ B. Elective induction of labor prior to 39 weeks for
nonmedical reasons is not permitted.
❑ C. If there is a discrepancy in the sponge count
during surgery, the patient should have an X-ray
before leaving the operating room.
❑ D. Nurses should observe the “5 Rights” of
medication administration when administering any
drug.
Answer: D
❑ Red rules are rules that cannot be broken. Therefore, if a red rule is
violated, the organization should be prepared to stop further
patient care associated with the red rule, no matter how
inconvenient or costly, in order to protect the patient or employee
from harm.
❑ Among the four answer options, the “5 Rights” of medication
administration, though almost universally adopted, frequently do
not prevent medication errors, partly because the “5 Rights” do
not offer adequate procedural guidance. Therefore, they are the
least appropriate candidate for a red rule.
Question 69
❑ As part of its initiative to improve prophylactic
perioperative antibiotic utilization, an acute care facility
aimed to administer perioperative antibiotics within 1
hour of surgical incision in 100% of cases. To whom
should the responsibility of timely perioperative
antibiotic administration be assigned?
❑ 1. Anesthesiologist
❑ 2. Surgeon
❑ 3. Scrub nurse
❑ 4. Circulating nurse
Answer: A
❑ Adherence to the clinical protocol can be enhanced
by making the performance measure of interest (timely
perioperative antibiotic administration, in this case) part
of the everyday work of caregivers. The anesthesiologist
would be the most appropriate person to ensure
satisfactory performance in the timing of antibiotic
administration, as he/she may administer the
antibiotic(s) with induction of anesthesia.
question is linked: Integrate patient safety concepts
within the organization
Question 70
❑ An acute care facility performed failure mode and effects (FMEA) analysis of
the medication administration process. For the final step of the process, an
identified possible failure mode was the availability of discontinued medications
for use. Its likelihood of occurrence, likelihood on detection, and severity of
impact were given a rating on a scale of 1 to 10:
❑ Occurrence 4
❑ Detection 8
❑ Severity 6
❑ What action should the FMEA team recommend to reduce the occurrence of
failure?
❑ A. Introduce dedicated medication nurses.
❑ B. Implement an automated medication dispensing system.
❑ C. Train staff to recognize early signs of drug toxicity.
❑ D. Implement pharmacy rounds to remove discontinued medications
from patient care units within 1 hour of discontinuation.
Answer: D
❑ In this case, detection of the failure mode is, in relative
terms, the biggest problem (the higher the rating, the
lower the likelihood the failure will be detected). In
general, if the failure mode is unlikely to be detected,
strategies that should be considered include:
❑ Identifying other events that may occur prior to the
failure mode and can serve as "flags" that the failure
mode might happen;
❑ Adding a step to the process that intervenes at the
earlier event to prevent the failure mode (removing
discontinued medications soon after discontinuation is
an example of this); and
❑ Technological alerts.
❑ Dedicated medication nurses and an automated
dispensing system may reduce the occurrence of the
failure mode.
❑ Training staff to detect an event soon after its
occurrence, and therefore provide opportunity for early
mitigating intervention, is most appropriate if the failure
is likely to cause severe harm.
question is linked: Perform or coordinate risk
management: failure mode and effects analysis
Question 71
❑ The system level measures of a hospital include overall mortality
rate and emergency room (ER) waiting time. The projects that are
being implemented include:
❑ Use of evidence-based bundles in ICU care
❑ ER flow management
❑ Surgical wound infection reduction
❑ After 12 months, the weekly average percentage of under-4-hour
waits has increased significantly. However, the mortality rate has
not shown any change. What should the hospital do next?
❑ A. Abandon one or more projects
❑ B. Add one or more projects
❑ C. Modify the existing projects
❑ D. Continue to monitor the mortality rate
Answer: C
❑ After 12 months, the hospital should have witnessed a change in
the mortality rate if the projects selected were linked to mortality
(e.g. improving flow would reduce mortality in this hospital) and
the projects were properly implemented, as evidenced by their
process measures. It would be reasonable to assume that the
three projects listed above would impact the mortality rate.
Therefore, the most appropriate next step would be to review
and modify the current projects.
linked: Participate on performance/quality improvement teams
(i.e. as a coordinator or team member/leader/facilitator)
Question 72
❑ The number of pressure ulcers, number of admissions, and annual mean length
of stay at a hospital are shown below.
❑ What is your conclusion about the annual incidence of pressure ulcers in this
hospital from 2010 through 2012?
❑ A. The incidence of pressure ulcers was unchanged.

❑ B. The incidence of pressure ulcers increased.
❑ C. The incidence of pressure ulcers decreased.
❑ D. The incidence of pressure ulcers demonstrated common cause
variation.
Answer: A
❑ Incidence is the number of new cases over the period of interest
(each year in this example). To calculate the incidence, the
number of cases is the numerator and the number of admissions
is the denominator. For example, in 2010, there were 1,200 cases
and 24,000 admissions. Therefore, the incidence of pressure ulcers
was 5% (1,200/24,000) in 2010. The incidence of pressure ulcers in
the next two years is also 5%. Therefore, the annual incidence did
not change between 2010 and 2012.
❑ The length of stay would only have been relevant if the question
required us to calculate the incidence rate.
Question 73
❑ What element(s) of care should patients be asked to
teach back?
❑ A. Contact information for getting help

❑ B. The importance of keeping the follow-up visit
❑ C. Self-care on return home
❑ D. All of the above
Answer: D
❑ Some of the critical elements of care that patients
should be asked to teach back are:
❑ The importance of keeping the follow-up visit
❑ Self-care on return home
❑ Contact information for getting help, if needed
❑ Use and doses of prescribed medications
question is linked: Integrate patient safety initiatives into
organizational activities
Question 74
❑ The office layout at an acute care facility was restricting
the work flow and was not customer friendly. The
management decided that a redesign of both the
layout and the process in which patients are registered
and receive care was required.
What is the greatest barrier to success?
❑ A. Lack of knowledge and skills in quality
improvement
❑ B. Misallocation of staff time
❑ C. Suboptimal team composition
❑ D. Mind-set about the work
Answer: D
❑ The most challenging aspect of redesign—as opposed
to incremental improvements—is changing the mind-set
about the work and establishing new ways of doing the
work. Redesign requires more time, more effort, and a
new mind-set. It includes changing the culture and
engaging in a new dialogue.
Application
Question 75
❑ “Workdays lost per 100 employees per year” is a
measure of
❑ A. Timeliness.
❑ B. Safety.
❑ C. Effectiveness.
❑ D. Efficiency.
Answer: B
❑ “Workdays lost per 100 employees per year” is a
measure of safety, in particular staff safety.
scorecards, dashboards)
Question 76
❑ Tacrolimus is an immunosuppresive drug used in transplant
patients. The drug has a narrow therapeutic range: administering
too little of the drug may result in the transplanted organ being
rejected; administering too much of the drug risks damaging the
patient's kidneys or weakening his or her defenses against
infection.
❑ Among the following methods of administering tacrolimus, which is the safest?
❑ A. Start on a dose based on a guideline, measure blood levels of tacrolimus on a regular
basis, and adjust the dose according to the blood level.
❑ B. Measure the patient's renal function before treatment to determine the initial dose,
measure renal function on a regular basis, and modify the dose according to renal
function.
❑ C. Start on a dose based on a guideline, measure blood levels of tacrolimus on a regular
basis, create run charts for each patient and establish statistical rules for adjusting the
dose.
❑ D. Start on a dose based on a guideline and adjust the dose according to clinical
response.
Answer: C
❑ The usual method of administering tacrolimus involves starting on a dose
based on a guideline, measuring blood levels of tacrolimus at regular
intervals, and adjusting the dose according to the blood level. However,
this standard method is associated with a relatively low frequency of
tacrolimus levels being in the desired therapeutic range.
❑ Applying statistical process control (SPC) to the problem will more likely
yield better results. Healthcare providers can create run charts for each
patient and establish statistical rules for adjusting dosage. These rules,
based on SPC, determine whether any given blood level is just “noise”
(common cause variation) or is a “signal” (special cause variation).
Facilitate the use of process analysis tools to display data (e.g. fishbone,
Pareto chart, run chart, scattergram, and control chart)
Question 77
❑ In a risk register, risks are ranked by the
❑ A. Probability of occurrence.
❑ B. Impact if the event occurred.
❑ C. Risk score.
❑ D. Delectability of the risk.
Answer: C
❑ In a risk register, risks are usually ranked by the Risk
Score, which is the product of the probability of
occurrence and the impact should the event occur.
question is linked: Contribute to development and
revision of a written plan for a patient safety program
(e.g. risk register)
Question 78
❑ A data inventory and a data dictionary will
❑ A. Increase the need for new data elements.

❑ B. Increase the efficiency of the data collection
process.
❑ C. Increase the cost of the data collection
process.
❑ D. Result in all of the above.
Answer: B
❑ A data inventory lists all data currently being collected by the
organization.
❑ A data dictionary, on the other hand, is a catalog of the data,
listing all the data elements collected, each element's definition,
storage, ownership, who is responsible for obtaining the data,
users, etc.
❑ Both a data inventory and a data dictionary will likely increase the
efficiency and reduce the cost of the data collection process.
They may or may not increase the need for new data elements.
linked: Perform or coordinate data inventory listing activities
Question 79
❑ An acute care facility recently revised its clinical protocol for
the prevention of ventilator-associated pneumonia. It has
since experienced greater variation in monthly staff
performance. The number of ventilated patients per month
has remained approximately the same. When sampling
medical records for the monthly review, how should the
organization adjust the sample size?
❑ A. Reduce the sample size.
❑ B. Increase the sample size.
❑ C. Keep the sample size the same.
❑ D. Review the medical record of each
ventilated patient until variation is reduced.
Answer: B
❑ In general, the more variation that exists within the
population, the larger the sample size needed to make
correct inference about the population.
question is linked: Use epidemiological principles in
data collection and analysis .
Question 80
❑ What is the maximum time interval between data points
on a run chart?
❑ A. One week
❑ B. One month
❑ C. One quarter
❑ D. None of the above .
Answer: D
❑ On a run chart, data may be gathered weekly,
monthly, bimonthly, quarterly, semiannually, or annually.
Question 81
❑ What is the minimum number of cases in each data
point on a run chart?
❑ A. 1
❑ B. 10
❑ C. 25
❑ D. None of the above
Answer: B
❑ On a run chart, a minimum of 10 cases in each data
point are required.
chart, scattergram, and control chart).
Question 82
❑ A 700-bed acute care facility receives 40% of its
admissions from the emergency department(ED).
Quality problems, especially wait time, were expressed
by patients, family members, and physicians.
❑ Which tool should the ED team use first in the
investigational phase of the improvement process?
❑ A. Histogram
❑ B. Control chart
❑ C. Flow chart
❑ D. Pareto chart
Answer: C
❑ A flow chart is the most appropriate tool to better
understand the situation and to identify points in the
process where patients might experience a wait.
Question 83
❑ A multidisciplinary team investigated laboratory
turnaround times in an Emergency Department that
were longer than external benchmarks. Root causes
identified included manual transport of specimens to
the laboratory and insufficient number of clinical ED
staff to perform order processing. What should the team
do next?
❑ A. Recommend an increase in the number of clinical ED staff.
❑ B. Recommend a mechanical tube system for transporting
specimens.
❑ C. Show the report of the root cause analysis to ED staff.
❑ D. Pilot test an increase in clinical ED staff and monitor the
laboratory turnaround times.
Answer: C
❑ It is important that the team checks their conclusions
about the root causes with people most
knowledgeable about the process, i.e. the ED staff,
before making/testing any changes.
Question 84
❑ Manually abstracted data are most commonly
validated by
❑ A. Periodic reabstraction by a person other than

the usual data collector.
❑ B. Cross-reference checking of results between
similar or complementary measures.
❑ C. Data collection software with built-in editing
functions.
Answer: A
❑ Manually abstracted data are most commonly validated by
periodic reabstraction by a person other than the usual data
collector for a sample group of patient records. This method
is referred to as "interrator or interobserver reliability."
Although they are recognized techniques of data validation,
cross-reference checking of results between similar
complementary measures and use of data collection
software are not common ways of validating manually
abstracted data.
question is linked: Perform or coordinate data collection
methodology (e.g. qualitative, quantitative).
Question 85
❑ The dimension of care on which complete discharge
summaries by the time of follow-up have the greatest
impact is
❑ A. Timeliness.
❑ B. Respect and caring.
❑ C. Continuity of care.
❑ D. Safety.
Answer: C
❑ The dimension of care that is impacted the most by
complete discharge summaries by the time of follow-up
is continuity of care. Safety is also impacted by
discharge summaries; safety events can occur as a
result of poor transfer of information at discharge, i.e.
lack of continuity of care.
Question 86
❑ One member of an improvement team has been
exhibiting disruptive behavior since work on the project
began 6 weeks ago. What should the team leader do in
the first instance?
❑ A. Do nothing.
❑ B. Talk privately to the disruptive member.
❑ C. Deal with the offending behavior in the
presence of the team.
❑ D. Dismiss the member from the team.
Answer: B
❑ In this situation, the best strategy usually involves the
team leader talking privately with the offending team
member, pointing out that disruptive behavior seems
inconsistent with a commitment to help the team
succeed.
Question 87
❑ Which of the following is a signal to end a project?
❑ A. The purpose of the project has been

accomplished.
❑ B. Some progress has been made and further
progress would require a new breakthrough
effort.
❑ C. Analysis of the problem has revealed that the
real problem is different from the team's charter.
❑ D. All of the above are signals to end a project.
Answer: D
❑ Options A, B, and C are examples of situations in which
it is appropriate to end a project.
Question 88
❑ In comparing the percentage of falls with injuries in
calendar year 2012 between facilities that use restraints
and those that do not, which chart should be used?
❑ A. Line chart
❑ B. Bar chart
❑ C. Pie chart
❑ D. Scatter plot
Answer: B
❑ A bar chart is the best option in this case. A line chart is
more appropriate for time series data.
❑ A pie chart is used to display proportions. A pie chart can be
used in this case but a bar chart displays the data more
clearly if you are doing a comparison.
❑ A scatter plot displays the relationship between two
variables.
question is linked: Facilitate the use of process analysis tools
to display data (e.g. fishbone, Pareto chart, run chart,
scattergram, control chart)
Question 89
❑ In prioritizing opportunities for improvement, a team first
used Multivoting to achieve consensus on a list of the
most important items. It then brainstormed all the
potential criteria that can be used to evaluate
performance issues. Appropriate criteria include
❑ A. Probability of success.
❑ B. Physician satisfaction.
❑ C. Leadership interest.
Answer: D
❑ Evaluation criteria commonly used by healthcare
organizations include:
❑ Impact on the customer
❑ Need to improve
❑ Urgency of the improvement need
❑ Relationship to the organization's strategic plan
❑ Frequency of occurrence
❑ Probability of success
❑ Financial impact
❑ Leadership interest
❑ Effect on patient outcomes
❑ physician satisfaction
❑ Support of the organization's mission
❑ Regulatory requirements

question is linked: Facilitate establishment of priorities for
performance/quality improvement activities
Question 90
❑ What is the main purpose of the team charter?
❑ A. Help team members understand the

purpose and function of the team.
❑ B. Help others in the organization to
understand the purpose and function of the
team.
❑ C. Facilitate accountability among team
members.
❑ D. Inform leaders about the resources
required.
Answer: A
❑ The main purpose of the team charter, also known as
the "terms of reference," is to help team members
understand the purpose and function of the team.
response: Recall
question is linked: Facilitate development of
performance/quality improvement action plans and
projects
Question 91
❑ Which of the following display formats is best used to
evaluate the number of ear infections, urinary tract
infections, and conjunctivitis experienced by individuals
served in a group home?
❑ A. Line graph
❑ B. Bar chart
❑ C. Histogram
❑ D. Control chart
Answer: B
❑ Categorical data, such as the frequency of various
types of infections, are best displayed using a bar chart.
❑ On the other hand, time-ordered data is better
displayed with a line chart, run chart, or control chart.
❑ Histograms are used to display continuous data.
question is linked: Contribute to development and
revision of a written plan for a patient safety program
(e.g. risk register)
Question 92
❑ A line graph may be transformed into a run chart by
❑ A. Determining the range of the data.

❑ B. Drawing in the median measurement.
❑ C. Changing the vertical scale.
❑ D. Modifying the time scale.
Answer: B
❑ A line graph can be easily transformed into a run chart
by drawing in the median measurement value as the
center line.
Question 93
❑ The primary purpose of baseline data is to
❑ A. Make a comparison to demonstrate

successful performance improvement
initiatives.
❑ B. Determine whether there is an important
issue to address.
❑ C. Determine organizational priorities.
❑ D. Meet hospital accreditation standards and
regulatory compliance.
Answer: B
❑ Each answer option gives a valid reason for collecting
baseline data. However, the main use of baseline data
is to determine whether there is an important issue to
address.
question is linked: Integrate the results of the
performance/quality improvement process into
strategic planning for the organization.
Question 94
❑ Ultimate responsibility for ensuring that data collected in
the operating room are transformed into information lies
with
❑ A. The director of the operating room.

❑ B. The operating room staff.
❑ C. The surgeons.
❑ D. The board of directors.
Answer: D
❑ Ultimate responsibility for ensuring that data are
measured effectively and transformed into information
lies with the leaders of the organization.
Question 95
❑ The use of restraints on nursing home residents
❑ A. Reduces the risk of residents from harming

themselves.
❑ B. Is unavoidable.
❑ C. Includes the use of bedside rails.
Answer: C
❑ Traditionally, nursing home staff have believed that restraining
residents was necessary to prevent the residents from harming
themselves. However, the literature indicates that inactivity—as a
result of restraint use—decreases muscle mass and bone density.
So, inactive residents who fall are more likely to incur an injury such
as a hip fracture.
❑ The use of restraints can not only be reduced but also eliminated,
i.e. restraint-free care.
❑ Restraints include bedside rails, chest poseys, soft wrist restraints,
and gerichairs with tables latched in place.
Question 96
❑ An improvement team plans to collect data on the rate
of falls with injury on a monthly basis.The numerator of
the performance measure is: "All resident falls that
resulted in injuries (requiring physician
intervention/treatment and resulting in a temporary or
permanent change in the resident's activities of daily
living)."
❑ What is the most appropriate denominator?
❑ A. All residents
❑ B. All resident falls
❑ C. All residents who suffered at least one fall
❑ D. All resident falls that resulted in injury
Answer: B
❑ The most appropriate denominator for the performance
measure in this case is "all resident falls." The numerator tells
us that "all resident falls" are being considered.
❑ Use of the other options, i.e. "all residents," "all residents who
suffered at least one fall," and "all resident falls that resulted
in injury" will likely give very different results. The last answer
option (D) is identical to the numerator, and will therefore
not be useful, i.e. the performance measure will be
meaningless.
question is linked: Perform or coordinate data definition
activities
Question 97
❑ The monthly rate of resident falls in the past 12 months
was plotted on a control chart. All data points are within
the control limits but the last data point falls exactly on
the upper control limit. The improvement team should
conclude that
❑ A. The process is in statistical control.
❑ B. The process is out of statistical control.
❑ C. More data points are needed to determine
whether the process is in statistical control.
❑ D. Other statistical techniques should be used to
determine whether the process is in statistical
control.
Answer: A
❑ A data point falling exactly on the upper or lower
control limit is not considered to be out of statistical
control.
Question 98
❑ Which of the following issues should be measured
through a performance improvement program?
❑ A. Business plan
❑ B. Potential impact of operations in the
community
❑ C. Employee satisfaction
❑ D. All of the above
Answer: D
❑ Important nonclinical issues that should be measured through a
performance improvement program, including:
❑ Organization Stability and Growth
❑ Operational Issues
❑ Reputation/Community Standing
❑ Employee Satisfaction
❑ Financial Issues
❑ Compliance with External Standards and Regulations
Improvement Cognitive level required for a response: Application
linked: Facilitate development of performance/quality
improvement action plans and projects
Question 99
❑ When an organization's leadership uses an advanced
prioritization matrix to select the improvement projects
for the next 12–24 months,
❑ A. The criteria used will be equally important.

❑ B. All options should be rank ordered even if
some are unanimously considered unworkable
initially.
❑ C. The solutions should be based on the
different rankings under each criterion only.
❑ D. Differences in rankings by the leaders for the
various criteria should be discussed.
Answer: D
❑ When using an advanced prioritization matrix, some criteria will be
considered more important than others, and the team will need to
weight the criteria. The criteria will not carry equal weight.
❑ The team should review the list of options being considered and
eliminate items that everyone agrees are unworkable.
❑ The selection of the best options should not be based on the math
alone, i.e. taking the average of the different rankings by the
team members only. Differences should be explored to arrive at
the best decision.
linked: Facilitate establishment of priorities for
performance/quality improvement activities
Question 100
❑ Work-flow diagrams are used to illustrate the
movements of
❑ A. People.
❑ B. Documents.
❑ C. Materials.
Answer: D
❑ A work-flow diagram is a pictorial representation of the
movements of people, materials, documents, or
information in a process.
Question 101
❑ When creating a fishbone diagram, why is it important
to refine the definition of the problem before trying to
explore its causes?
❑ A. The effort to create the diagram will be

more manageable.
❑ B. It is easier to identify possible causes to
take action on.
❑ C. Verifying the causes will be more
manageable.
Answer: D
❑ It's important that the team refines the definition of the problem
before trying to explore its causes because:
❑ The effort to create the diagram will be more manageable.
❑ It will be easier to come up with possible causes to take action on.
❑ The effort to verify the causes will be more manageable.
❑ Time and resources are used more effectively.
linked: Facilitate the use of process analysis tools to display data
(e.g. fishbone, Pareto chart, run chart, scattergram, control chart)
Question 102
❑ When gathering data on adverse events in an acute
care facility over time, why is it necessary to measure
the number of patients admitted and their length of
stay?
❑ A. To make the data more valid.

❑ B. To make the data more reliable.
❑ C. To make the data more comparable.
❑ D. It is not necessary to measure the number of
patients and/or their length of stay.
Answer: C
❑ When gathering data over time, the data need to be standardized
to compare the data collected at different points. In this case, the
rate of adverse events is compared over time—the numerator is
the number of adverse events and the denominator is the number
of patient-days. The latter is usually calculated from the number of
patient admissions and the average length of stay for the period of
interest.
❑ Measuring the number of patients admitted and/or their length of
stay does not improve validity or reliability.
linked: Use epidemiological principles in data collection and
analysis
Question 103
❑ What is the benefit of studying a process?
❑ A. To highlight obvious problems.

❑ B. To arrive at a common understanding
among team members.
❑ C. To eliminate inconsistencies.
❑ D. All or the above.
Answer: D
❑ Benefits of studying a process include:
❑ Highlighting obvious problems.
❑ Eliminating inconsistencies.
❑ Arriving at a common understanding.
response: Recall
improvement teams (i.e. as a coordinator
Question 104
❑ In a project to improve the safety of surgical care in an acute
care facility, which of the following is a responsibility of the
healthcare quality professional?
❑ A. Teaches the collection and analysis techniques,
showing the team what conclusions may or may not be
drawn from the data.
❑ B. Carry out assignments between meetings, interview
customers, observe processes, gather and chart data,
and write and present reports
❑ C. Calls meetings, and handles or assigns administrative
details.
❑ D. Ensures that changes made by the team are
monitored, and implements any changes the team is
not authorized to make.
Answer: A
❑ On an improvement team, the role of the healthcare quality professional is
usually as the Team Facilitator/coach.
❑ The other responsibilities listed above belong should belong to other
persons:
❑ Carry out assignments between meetings, interview customers, observe
processes, gather and chart data, and write and present reports: Team
Members
❑ Calls meetings, and handles or assigns administrative details: Team Leader
❑ Ensures that changes made by the team are monitored, and implements
any changes the team is not authorized to make: Team Sponsor
❑ Content Category: Performance Measurement and Improvement Cognitive
Participate on performance/quality improvement teams (i.e. as a
coordinator, or team member/leader/facilitator)
Question 105
❑ IHI Global Trigger Tool record reviewers found an
unreported case of a radiologist inadvertently causing a
small pneumothorax (collapsed lung) by incorrectly
positioning a percutaneous small-bowel feeding tube.
❑ To whom should the reviewers report this

finding?
❑ A. Chief Medical Officer
❑ B. Chief of Radiology
❑ C. Risk Manager
❑ D. Director of Quality
Answer: B
❑ Such a case should be reported to the Chief of
Radiology because he is in the best position to evaluate
whether further action is appropriate.
question is linked: Interact with staff regarding quality
issues (e.g. patient issues, service delivery, human
resources)
Question 106
❑ Which of the following statements about unannounced
surveys by The Joint Commission is TRUE?
❑ A. A primary goal of unannounced surveys is to
detect evidence of non-compliance.
❑ B. Unannounced surveys include initial surveys.
❑ C. Unannounced surveys reduce the
unnecessary costs associated with survey
preparation.
❑ D. An organization may undergo an
unannounced survey between 12 and 24
months after its previous survey.
Answer: C
❑ For the CPHQ exam, you should be aware of the basic
facts of The Joint Commission's unannounced surveys.
response: Recall
question is linked: Facilitate program development,
evaluation, planning, projects, and activities.
Question 107
❑ The purpose of quality outcome measurement is
❑ A. Quality improvement.
❑ B. Marketing.
❑ C. Staff performance appraisal.
Answer: A
❑ The measurement of outcomes should be done for the
purpose of internal quality improvement, not marketing
or staff performance appraisal.
Question 108
❑ Consensus requires
❑ A. Active participation of all team members.

❑ B. Communication skills.
❑ C. Creative thinking.
Answer: D
❑ Consensus requires
❑ Time
❑ Active participation of all team members
❑ Skills in communication, listening, conflict resolution, and
facilitation
❑ Creative thinking and open-mindedness
Question 109
❑ Implementation of an influenza vaccination program
for staff across multiple sites should ideally be
❑ A. Customized to be suitable to each site.

❑ B. Overseen by a single site champion.
❑ C. Carried out simultaneously.
❑ D. Standardized to unify evaluation metrics.
Answer: A
❑ Customization of the implementation may be necessary to fit the unique
characteristics of the individual site/facility. This might entail editing, dropping, or
creating one or more items. Customization will facilitate multi-site implementation.
❑ According to the Rogers Diffusion of Innovation theory, ideally, there should be a
champion for each site, i.e. the implementation spanning multiple sites should not
be overseen by only one champion.
❑ Implementation of any program or change across multiple sites does not need to
be done simultaneously. This would make the implementation more complex and
possibly increase the chance of failure.
❑ Many organizations attempt to standardize implementation of a program at
multiple sites for the sole purpose of maintaining the same measures. The latter is
unnecessary if the aim is to implement the program across multiple sites, and not
compare performance between sites.
❑ Content Category: Performance/Quality Measurement and Improvement Cognitive
level required for a response: Application Tasks on the CPHQ exam content outline
to which the question is linked: Facilitate program development, evaluation,
planning, projects, and activities
Question 110
❑ The first step in collecting meaningful data is
❑A. Establishing the goals of data collection.

❑B. Developing operational definitions.
❑C. Planning for data consistency.
❑D. Evaluating the resources available.
Answer: A
❑ The first step in collecting meaningful data is clarifying
the data collection goals.
question is linked: Perform or coordinate data
collection methodology (e.g. qualitative, quantitative)
Question 111
❑ As an external consultant, you have completed a gap
analysis of an acute care facility that is preparing for
TJC accreditation. Which of the following charts will you
use to summarize your findings in six of the chapters of
standards for the Hospital Accreditation Program?
❑ A. Line chart
❑ B. Radar chart
❑ C. Bar chart
❑ D. Pareto chart
Answer: B
❑ A radar chart is ideal in this situation. It can be used to
display the performance gaps, i.e. both current and
target performance, in multiple areas of interest.
Performance in 5–10 areas is usually graphically
represented on a radar chart.
question is linked: Compile and write
performance/quality improvement reports
Question 112
❑ A shared accountability model in which every
employee has the opportunity to make decisions about
care processes will likely result in
❑ A. Increased conflict among staff.

❑ B. Lower staff satisfaction scores.
❑ C. Greater staff innovation.
❑ D. Increased staff workload.
Answer: C
❑ Shared accountability is a feature of participatory
management. Shared accountability has been shown
to improve staff motivation and innovation, and lead to
greater staff satisfaction.
question is linked: Lead and facilitate change within
the organization
Question 113
❑ For which aspect of care is patient-reported measures
most credible?
❑ A. Communication between providers

❑ B. Patient-provider interactions
❑ C. Adherence to clinical practice guidelines
❑ D. Appropriateness of therapy .
Answer: B
❑ The aspect of care for which patient-reported measures
are most credible is patient-provider interactions.
question is linked: Assess customer needs/expectations
(e.g. surveys, focus groups, teams) to ensure the voice
of the customer is heard.
Question 114
❑ The Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) Survey is administered
❑ A. Within 48 hours post-discharge.

❑ B. Between 48 hours and 21 days post-
discharge.
❑ C. Between 48 hours and 42 days post-
discharge.
❑ D. After 28 days post-discharge.
Answer: C
❑ The HCAHPS is administered between 48 hours and six
weeks post-discharge.
question is linked: Assess customer needs/expectations
(e.g. surveys, focus groups, teams) to ensure the voice
of the customer is heard .
Question 115
❑ Antibiotics for a coronary artery bypass graft (CABG)
surgery patient should be discontinued within
❑ A. 24 hours after surgery end time.

❑ B. 48 hours after surgery end time.
❑ C. 72 hours after surgery end time.
❑ D. 1 week after surgery end time.
Answer: B
❑ Current literature suggests that, in most surgical cases,
antibiotics should be discontinued within 24 hours after
surgery end time. However, for cardiac procedures,
antibiotics should be discontinued within 48 hours. Duration
of prophylactic perioperative antibiotics is a performance
measure in the Surgical Care Improvement Project (SCIP).
question is linked: Participate in the process of
organizational reviews for audits for infection prevention and
control processes
Question 116
❑ In healthcare quality improvement, common causes, in
comparison to special causes, are
❑ A. Easily identified.
❑ B. Infrequent.
❑ C. Extrinsic to the normal process.
❑ D. Difficult to solve.
Answer: D
❑ "Common causes," as opposed to special causes, are
more difficult to identify, are pervasive and less
infrequent than "special causes." Unlike special causes,
common causes are intrinsic to the process. Common
causes are considered more difficult to resolve.
question is linked: Use or coordinate the use of statistical
process control components (e.g. common and special
cause variation, random variation, trend analysis)
Question 117
❑ The criticality index in failure mode and effect analysis is
❑ A. A measure of the effectiveness of control

measures.
❑ B. A product of the estimated likelihood of
occurrence of the failure mode and the
severity of effect.
❑ C. A measure of anticipated severity of the
effect of the failure mode.
❑ D. Reflected in the risk priority number.
Answer: D
❑ The Risk Priority Number (RPN) is calculated by multiplying
three items:
❑ Occurrence rating;
❑ Severity rating; and
❑ Detection rating.
❑ The RPN is an indication of the criticality index. The failure
modes with the highest RPNs are usually selected for
corrective action.
❑ Content Category: Patient Safety Cognitive level required for
a response: Recall
question is linked: Perform or coordinate risk management:
failure mode and effect analysis.
Question 118
❑ Which of the following may be a trigger for intensive
analysis?
❑ A. Management literature
❑ B. Staff feedback
❑ C. Sentinel event
❑ D. All of the above .
Answer: D
❑ Triggers for intensive analysis may be based on
quantitative or qualitative data. Management
literature, staff feedback, and sentinel events may all
trigger intensive analysis.
response: Recall
question is linked: Facilitate program development,
evaluation, planning, projects, and activities
Question 119
❑ A team used a cause-and-effect diagram in their root
cause analysis of a retained surgical instrument. They
should next
❑ A. Develop corrective action for each cause

identified on the diagram.
❑ B. Use a pareto chart to determine which
causes to tackle first.
❑ C. Develop solutions to the deepest causes
identified on the diagram.
❑ D. Verify the causes.
Answer: D
❑ The cause-and-effect diagram only identifies potential
causes. Before taking action, the team needs to verify
which potential causes are actual causes.
Question 120
❑ You have been asked to observe a team meeting to
better understand how the team is interacting. Which of
the following actions will you perform?
❑ A. Ignore the discussion of topics

❑ B. Guide the team through the meeting
process
❑ C. Record your interpretations of comments
and behaviors
❑ D. Share observations with the team during
the meeting
Answer: A
❑ The healthcare quality professional may be asked to observe a
team meeting to assess how well the team is interacting. The
observer does not participate in the meeting content. He / She
merely pays attention to the discussion methods and interactions
among members.
❑ The observer notices behaviors and verbatim comments but does
not interpret or judge them.
❑ The observer does not share observations with the team during
the meeting, but does so only at the scheduled meeting
evaluation time.
linked: Evaluate team performance.

CPHQ Practice Questions Part 1

Uploaded by

Copyright:

Available Formats

You might also like

CPHQ Practice Questions Part 1

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Read this document in other languages

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

CPHQ Practice Questions Part 1

Uploaded by

Copyright:

Available Formats

CPHQ

CPHQ Practice Questions – Part 1

A. Failure Mode and Effects Analysis.

A. Discuss general group-process concerns

A. Performance of industry leaders.

A. A missing peer recommendation.

❑ A. Care that is consistent with best practice

❑ A. Improved patient care

❑ A. Capability analysis requires the presence of a

❑ Which measure is the most appropriate?

❑ A. Inadequate or improper training

❑ A. From causes forward to effects.

❑ A. Develop a new policy.

❑ A. Queuing at the bottleneck is desirable.

❑ A. Minimize adverse events.

❑ A. Will be found 5% of the time even if the

❑ A. Obtaining customer feedback.

❑ A. Binomial method and distribution

❑ A. First step in the process.

❑ A. Increases variability in the overall service

❑ A. The project sponsor alone.

❑ A. Reducing variation when the process is stable

❑ A. The shape of data.

❑ A. Engage leaders around transparency and

❑ A. Unplanned return to surgery

❑ A. Units with high rates of adverse events and

❑ A. When administering intravenous medications

❑ A. Lack of leadership support.

❑ A. Assign a quality professional to assist in the

❑ A. Absence of strong enough ideas for

❑ A. Each failure mode and the process

❑ A. The incidence of pressure ulcers was unchanged.

❑ A. Contact information for getting help

❑ A. Increase the need for new data elements.

❑ A. Periodic reabstraction by a person other than

❑ A. The purpose of the project has been

❑ Content Category: Performance/Quality Measurement

❑ A. Help team members understand the

❑ A. Determining the range of the data.

❑ A. Make a comparison to demonstrate

❑ A. The director of the operating room.

❑ A. Reduces the risk of residents from harming

❑ A. The criteria used will be equally important.

❑ A. The effort to create the diagram will be

❑ A. To make the data more valid.

❑ A. To highlight obvious problems.

❑ To whom should the reviewers report this

❑ A. Active participation of all team members.

❑ A. Customized to be suitable to each site.

❑A. Establishing the goals of data collection.

❑ A. Increased conflict among staff.

❑ A. Communication between providers

❑ A. Within 48 hours post-discharge.

❑ A. 24 hours after surgery end time.

❑ A. A measure of the effectiveness of control

❑ A. Develop corrective action for each cause

❑ A. Ignore the discussion of topics