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Welcome to the CPHQ practice test. The test includes 35 multiple choice questions
designed to assess your interest and readiness for the CPHQ certification exam. It
aligns with the current exam outline and provides you immediate results including
correct and incorrect answers. Let’s get started!

The evolution of quality improvement in healthcare has shifted the primary focus from
performance of individuals to the performance of the

medical staff.

governing
body.

ancillary
departments.

organization's
systems.
 The best way to evaluate the effectiveness of performance improvement training is
through

observed behavioral changes.

self-assessments.

participants'
feedback.

post-test results.

The primary objective of the operational linkage between risk management and
quality/performance improvement is to

meet regulatory
requirements.

develop a plan of action for individual

cases.

develop a comprehensive plan to prevent future

occurrences.

alert the hospital attorney of a potentially compensable

event.

The primary reason to analyze customer satisfaction surveys is to

provide data for the quality improvement
program.

meet pay-for-performance
requirements.

identify how perceptions relate to the services

provided.

assist with evaluating employee

performance.

Which of the following should a Quality Council provide to best ensure success of
performance improvement teams?

facilitator and recorder

empowerment and
training

indicators and a data

analyst

standards and procedures

Which of the following is the most effective way to integrate performance

improvement concepts throughout an organization?

quarterly newsletters

monthly lectures
quality teams

continuous monitoring

A critical difference between quality assurance (QA) and quality improvement is a

shift in focus from

retrospective review to concurrent

screening.

nonclinical aspects to customer

satisfaction.

identifying poor performers to improving group

performance.

QA coordinators to
teams.

A clinical pathway on the management of hip fractures has been developed by a

multi-disciplinary team and implemented in a large teaching hospital. After
monitoring for 6 months, the length of stay continues to exceed the guidelines.
Which of the following should be the next step?

evaluate compliance with the

pathway.

correlate the pathway with staffing

levels.
re-educate the staff on the purpose of the
pathway.

continue to monitor and collect additional

data.

One difference between continuous quality improvement and traditional quality

assurance is that quality improvement always

requires the application of statistical process

control.

excludes monitoring and evaluation of care

provided.

focuses on systems or
processes.

addresses potential
problems.

Which of the following sampling techniques selects participants based on their

availability in a certain place during a specific time frame?

quota

random

volunteer

convenience
 The quality improvement director is responsible for coordination of accreditation
survey activities. Responsibilities will most likely include

facilitating self-assessments of compliance with standards, communicating new

requirements to pertinent parties, and distributing the agenda for the survey.

educating staff to all standards, writing the survey report, and completing the survey
application.

developing a protocol for a mock survey, conducting unannounced surveys, and

challenging the survey report.

preparing for unannounced surveys, disseminating the survey report, and developing new
standards.

Frequency distribution can best be displayed through use of

a histogram.

a flow
chart.

a force field
analysis.

an interrelationship
diagram.
 An outpatient clinic is attempting to measure the quality of a newly developed
diabetes disease management program. To accomplish this, laboratory results will
be measured over time. The best way to display the data is to use a

Gantt chart.

control chart.

Pareto chart.

flow chart.

A valid data collection tool should incorporate

a minimum of 20 data
elements.

a reliable graphic
presentation.

the definition of data

elements.

allowance for variance of

interpretation.

Balanced scorecards are useful because they

focus on the most significant strategic

initiative.
evaluate the pros and cons of the governing body's
priorities.

put strategy and vision at the center of an organization's

effort.

concentrate on the performance of individual

units.

Hospital administration is considering designating 20 beds for long-term, chronically

ill patients. Which of the following information best supports this?

premature discharges over the last 6

months

readmissions within 30 days over the last

year

discharge placement problems over the last

year

admissions, discharges, and transfers over the last 30

days

Problem-solving, cross-functional understanding, expanded areas of expertise, and

increased span of knowledge are examples of

strategic alliances.

customer
expectations.
resource requirements.

the benefits of
teams.

A health plan is required to have a mechanism for members to submit complaints.

Which of the following actions must be included in the complaint analysis to ensure
the plan makes full use of this type of information?

Total each complaint category at least on an annual

basis.

Calculate the average number of complaints per office

site.

Review complaints to find system problems that can be

improved.

Determine the date/time the complaint occurred and the person

responsible.

A healthcare quality professional wants to measure the success of a corrective action

plan with a 95% confidence level. The average daily census at the quality
professional's organization is 1,000 patients. The best sampling technique for this
study is to review

10% of all discharge records for the past

quarter.

all active records on one day of the past

month.

30% of records based on preliminary compliance

review.

the number of records needed using a statistical

method.

Quality improvement teams go through stages of development. These team

development stages include all of the following EXCEPT

norming.

forming.

performing.

conforming.

Timeliness and compliance of documentation were discussed at a multidisciplinary

team meeting. To evaluate the effectiveness of the team's action plan, which of the
following will provide the most useful information?

physician
attendance

number of
complaints

frequency of
meetings

medical record
review
 A strategy used in brainstorming is that ideas are

prioritized as they
occur.

discussed when they are

mentioned.

progressively
eliminated.

all recorded.

The leader of a pain management performance improvement team has asked the
Quality Council to disband the team. The most important factor for the Quality
Council to assess is

the length of time the team has been

together.

how well the team met the intended

outcome.

the effectiveness of the team leader and

facilitator.

the amount of data the team has

collected.
 Which of the following elements must be present in order to evaluate the
effectiveness of a healthcare organization's quality improvement program?

quantifiable
objectives

support from the medical

staff

well-defined organizational
structure

integrated data
collection

A healthcare quality professional is attempting to refine the differences between an

organization's objectives and the stakeholder needs. Which of the following tools is
most appropriate?

gap analysis

Ishikawa diagram

Gantt chart

Kanban
method

A performance improvement team reviewing timeliness of outpatient clinic

 appointments identified the following issues: multiple patient moves, redundant
paperwork, and long waiting times to be triaged. In lean terminology, these issues
are

waste.

variation.

poor
performance.

Poka-Yoke.

Which of the following should be included in an annual performance improvement

report to a governing body?

meeting minutes

team achievements

physician peer
reviews

incident/occurrence reports

A physician complains to a healthcare quality professional that the nursing staff did
not strictly follow orders for a patient. The physician requests that the quality
professional speak with the nurse manager. To facilitate improved communication,
the quality professional should
arrange a meeting with the physician and nurse
manager.

speak with the nurse manager on behalf of the

physician.

evaluate the patient outcome to determine organizational

risk.

review the patient record to determine legibility of the physician's

orders.

A summary of antibiotic usage for the fourth quarter showed that an internal medicine
department did not meet pre-established criteria in 82% of the patients reviewed.
Following review, the Pharmacy and Therapeutics Committee should recommend
that the results be shared first with the

Quality Council.

governing
body.

utilization
committee.

chief of the
department.

A pharmacy has been dispensing a higher than acceptable rate of antibiotics to

patients with documented allergies to the antibiotics. Which forcing function should
the performance improvement coordinator recommend to decrease the rate of
inappropriately dispensed antibiotics?
require the pharmacist to call the physician to confirm the appropriateness of each
antibiotic ordered.

provide mandatory education for pharmacy staff on medication profile documentation

requirements.

revise policy to require nursing documentation of allergies before medication

administration.

modify pharmacy software to require review of allergic profile before dispensing

antibiotics.

A culture of patient safety in an organization will have been successfully created

when

personal accountability is removed from the

organization.

near miss reporting of safety issues

declines.

staff members serve as safety

advocates.

a root cause analysis is performed regularly.

One aspect of a quality process that integrates with risk management is the review
and evaluation of

adverse drug events.

encounter data.
case-mix analysis
reports.

accreditation survey
reports.

Failure modes can be prioritized by calculating the criticality index. Which of the
following three categories are normally used to calculate a criticality index?

probability, likelihood, and

criticality

frequency, severity, and ease of

detection

effectiveness, risk, and

priority

response, evidence, and

outcome

Staff has been trained and oriented on a new electronic incident reporting system. In
the past, staff could report anonymously. The new system requires staff to sign in
with an individualized username and password. Three months after implementation,
there is a sharp reduction in the number of reported incidents. Which of the following
reasons for underreporting of incidents is of greatest concern?

staff fear of negative consequences of

reporting

lack of knowledge about how to use the

system
time required to complete an incident
report

incomplete understanding about required

reporting

A healthcare quality professional has been asked to examine a new method of

reviewing adverse events in an organization. It has been decided that a system of
triggers will be established to alert the Quality Council of a potential problem. The
best example of a trigger that should be set with a threshold of zero is a

medical record not completed by a

physician.

staff member not using proper handwashing

technique.

near miss from failure to perform a "time-

out."

patient complaint regarding wait

times.

Thank you for completing the Free CPHQ Practice Exam. You answered 16 out of 35
questions correctly. If you answered any questions incorrectly, the question along
with your answer will be listed below.

To learn more about the CPHQ Practice Exam and the CPHQ certification, please
visit our Certification page on our website.
The evolution of quality improvement in healthcare has shifted the primary focus from
performance of individuals to the performance of the governing body.

The best way to evaluate the effectiveness of performance improvement training is

through post-test results.

Which of the following should a Quality Council provide to best ensure success of
performance improvement teams? standards and procedures

Which of the following is the most effective way to integrate performance

improvement concepts throughout an organization? quarterly newsletters

A critical difference between quality assurance (QA) and quality improvement is a

shift in focus from retrospective review to concurrent screening.

One difference between continuous quality improvement and traditional quality

assurance is that quality improvement always addresses potential problems.
Which of the following sampling techniques selects participants based on their
availability in a certain place during a specific time frame? quota

The quality improvement director is responsible for coordination of accreditation

survey activities. Responsibilities will most likely include educating staff to all
standards, writing the survey report, and completing the survey application.

An outpatient clinic is attempting to measure the quality of a newly developed

diabetes disease management program. To accomplish this, laboratory results will
be measured over time. The best way to display the data is to use a Pareto chart.

Balanced scorecards are useful because they evaluate the pros and cons of the
governing body's priorities.

Hospital administration is considering designating 20 beds for long-term, chronically

ill patients. Which of the following information best supports this? premature
discharges over the last 6 months

Problem-solving, cross-functional understanding, expanded areas of expertise, and

increased span of knowledge are examples of resource requirements.

A healthcare quality professional wants to measure the success of a corrective action

plan with a 95% confidence level. The average daily census at the quality
professional's organization is 1,000 patients. The best sampling technique for this
study is to review all active records on one day of the past month.

A healthcare quality professional is attempting to refine the differences between an

organization's objectives and the stakeholder needs. Which of the following tools is
most appropriate? Kanban method

A physician complains to a healthcare quality professional that the nursing staff did
not strictly follow orders for a patient. The physician requests that the quality
professional speak with the nurse manager. To facilitate improved communication,
the quality professional should speak with the nurse manager on behalf of the
physician.

A pharmacy has been dispensing a higher than acceptable rate of antibiotics to

patients with documented allergies to the antibiotics. Which forcing function should
the performance improvement coordinator recommend to decrease the rate of
inappropriately dispensed antibiotics? revise policy to require nursing documentation
of allergies before medication administration.
 One aspect of a quality process that integrates with risk management is the review
and evaluation of case-mix analysis reports.

Failure modes can be prioritized by calculating the criticality index. Which of the
following three categories are normally used to calculate a criticality index?
probability, likelihood, and criticality

A healthcare quality professional has been asked to examine a new method of

reviewing adverse events in an organization. It has been decided that a system of
triggers will be established to alert the Quality Council of a potential problem. The
best example of a trigger that should be set with a threshold of zero is a medical
record not completed by a physician.

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