Test Review Report

Printed on: 8/27/2023

Test Name: CPHQ Practice Exam: Form A

Learner: Rawan ibrahim

Your Score 69.23%

Status Failed
Initial Score* 69.23%

* Initial Score is based on the first attempt of each question

Question 1 of 65
Which of the following team members is responsible for keeping meetings focused?

A. time keeper
B. facilitator
C. recorder
D. leader

Note: correct answer is displayed in bold

Result:
Incorrect
Option D is not correct

Feedback
DOMAIN: Performance and Process Improvement

EXPLANATION:
A. A time keeper monitors time and does not focus on team performance.
B. The facilitator facilitates and is responsible for team focus.
C. A recorder records minutes.
D. A leader guides the team towards outcomes.

Question 2 of 65
The utilization management committee is reviewing length-of-stay data for a particular procedure. In
comparing data by physician, which of the following statistics will be most useful?

A. correlation

B. range
C. mode
D. mean
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Note: correct answer is displayed in bold

Result:
Incorrect
Option A is not correct

Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. Correlation is used to describe the degree of relationship between two variables.
B. The range for a data set is the difference between the largest and smallest value. The range shows
the spread of the data, but alone is not as helpful in comparing the length of stay for physicians.
C. The mode is a measure of central tendency. It is the data element that occurs most often in the data
set. This is less robust than the mean as there can be more than one mode.
D. The mean is the statistical average in a data set. It is often used to describe average length of stay for
comparison and is used with the standard deviation to understand the variability around the mean.

Question 3 of 65
A medication error occurred and resulted in a severe adverse outcome. In addition to informing the
patient and/or family, a healthcare quality professional should

A. perform a regression analysis.

B. implement new technology.
C. reassign the employees involved.
D. conduct a root cause analysis.

Note: correct answer is displayed in bold

Result:
Correct
Answer 3 is D

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. Incorrect; a regression analysis identifies how a change in an independent variable affects the
dependent variable.
B. Incorrect; this intervention would not identify the root cause of an adverse outcome.
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C. Incorrect; this would be a disciplinary action and would not identify the root cause of an adverse
outcome.
D. Correct; exploration of system and process issues should be the primary function of a root cause
analysis.

Question 4 of 65
The primary purpose of an organization's quality improvement (QI) strategic plan is to

A. determine accountability for outcomes.

B. assess improvement opportunities.
C. define the future direction for quality.

D. explain the purpose of performance teams.

Note: correct answer is displayed in bold

Result:
Correct
Answer 4 is C

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. This item is done as a result of a plan, but is not the purpose of the plan.
B. Assessment and reassessment should be done before developing the plan.
C. This is a function of having a QI strategic plan.
D. Performance improvement teams are a part of executing on the plan.

Question 5 of 65
A policy for "time-outs" in an operating room was initiated in the first quarter. The second quarter data
demonstrated only 40% compliance with all elements of the process. The first step the Quality Council
should take is to

A. examine if the policy is clear and user-friendly.

B. ask the nurses to identify non-compliant surgeons.

C. continue to audit to confirm that a problem exists.
D. create a letter for the CEO to send to all surgeons.
Note: correct answer is displayed in bold
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Result:
Correct
Answer 5 is A

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. Since process has changed, it is important to make sure it is clear and all understand.
B. This is part of obtaining buy-in to encourage compliance.
C. This is a patient safety procedure. 40% compliance is a problem.
D. Although this may be a later step required to address individual performance, it is not documented
now.

Question 6 of 65
A new quality director has reviewed the information related to the Quality Council minutes, and notes the
following: - The council meets quarterly. Meetings last approximately 2 hours. - The council roster
includes all clinical department managers and the quality director. Attendance ranges from 45-60%. - The
primary role of the council is to receive department quality reports, which are then forwarded to the
organization's governing body. Based on the information above, which of the following actions is most
appropriate?

A. Require departments to forward reports for review prior to the meetings.

B. Redefine the council's role to coordinate and prioritize quality activities.

C. Switch to a monthly meeting with a new agenda format.

D. Eliminate the council and directly report quality data to the governing body.
Note: correct answer is displayed in bold

Result:
Correct
Answer 6 is B

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. This action may be helpful in facilitating the meeting, but is not the best answer available.
B. This is the best answer available.
C. Based on the information available, this may or may not be a factor.
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D. This action is not appropriate.

Question 7 of 65
The primary purpose of risk management trend analysis is to

A. meet regulatory requirements.

B. provide required reports to liability carriers.
C. identify opportunities for improvements.
D. eliminate financial loss for organizations.

Note: correct answer is displayed in bold

Result:
Incorrect
Option D is not correct

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. Reduction in risk may help to meet regulatory requirements, but is not the primary purpose of risk
management.
B. Provision of report to liability carriers is a component risk management, but is not the purpose of risk
management.
C. Risk management focuses on identification, assessment, and reduction of risk. The goal is to protect
the organization from losses, the key component of which is proactive improvement to avoid and reduce
risk.
D. Risk management does focus attempts to reduce financial loss due to risk issues, but does not
eliminate financial loss to the organization which may result from many other factors.

Question 8 of 65
A hospital-wide medical record audit on documentation has been completed. The following table shows
the compliance rate of documentation: Compliance Rate (%) Documentation: 1st Qtr 2nd Qtr Surgical
"time-outs" performed 90 95 Communication of critical results 91 95 Pain score used 50 60 Initial patient
assessment performed 52 45 Which of the following is the next step?

A. Benchmark the compliance rates against another facility.

B. Conduct training regarding pain score.
C. Give data feedback on physician signature to the units.
D. Conduct a focused review on the patient assessment process.
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Note: correct answer is displayed in bold

Result:
Correct
Answer 8 is D

Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. Although benchmarking is helpful for comparison to external organizations, it is not critical to initiating
internal improvement when opportunities are identified.
B. Although pain score compliance is low, there has been improvement from Q1 to Q2, so a focused
review of patient assessments should be permitted first (See D).
C. None of the data provided is related to physician signature.
D. A focused review of the patient assessment process should be prioritized because of low performance
and decreased performance from Q1 to Q2.

Question 9 of 65
Which of the following actions has the greatest impact in reducing harm?

A. revising the patient safety evaluation tool

B. improving interdisciplinary communication

C. forming a performance improvement team
D. increasing data collection frequency
Note: correct answer is displayed in bold

Result:
Incorrect
Option A is not correct

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. A safety tool may not be utilized constantly and accurately.
B. Improved communication has been proven to be a key factor in reducing harm.
C. Performance improvement items are not always focused on reducing harm. Other focus areas may be
efficiency, financial, etc.
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D. Data collection does not reduce harm independently.

Question 10 of 65
In lean thinking, a process step is defined as "value added" if the

A. customer recognizes the value.

B. customer corrects a mistake to add value.
C. process owner recognizes the value.
D. process owner changes the value of the product.

Note: correct answer is displayed in bold

Result:
Incorrect
Option D is not correct

Feedback
DOMAIN: Performance and Process Improvement

EXPLANATION:
A. Customer value is the key concept of lean thinking and improvement efforts.
B. Correcting mistakes does not add value in a lean improvement effort.
C. Customers are the main focus in lean, not the process owners.
D. Customers determine value, not the process owners.

Question 11 of 65
According to continuous quality improvement principles, which of the following concepts is most
important?

A. financial impact
B. constancy of purpose

C. resistance to change
D. performance of individuals
Note: correct answer is displayed in bold

Result:
Correct
Answer 11 is B
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Printed on: 8/27/2023

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. This is a factor, but not the most important.
B. This is the best answer.
C. This has to be addressed as part of improving performance, and can be a factor in successful
implementation or execution of improvement work, but not the best answer.
D. This is a factor, but not the most important concept for continuous quality improvement principles.

Question 12 of 65
Team cohesion is established during which of the following stages of team growth?

A. forming

B. storming
C. norming
D. performing
Note: correct answer is displayed in bold

Result:
Incorrect
Option A is not correct

Feedback
DOMAIN: Performance and Process Improvement

EXPLANATION:
A. Forming is the stage during which team members get to know each other.
B. During storming, team members deal with conflict.
C. The team moves towards cohesion and collaboration during the norming stage.
D. Purpose of the performing stage is meeting the expectations and outcomes.

Question 13 of 65
One difference between continuous quality improvement and traditional quality assurance is that quality
improvement always

A. requires the application of statistical process control.

B. excludes monitoring and evaluation of care provided.
C. focuses on systems or processes.
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D. addresses potential problems.

Note: correct answer is displayed in bold

Result:
Correct
Answer 13 is C

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
Quality improvement is focused on systems, processes, and groups to improve. Quality assurance is
focused on monitoring problem areas or individuals. Statistical process control may be employed a tool to
facilitate quality improvement, but is not a required component of quality improvement.

Question 14 of 65
When considering the use of an external subject matter expert (SME), which of the following is most
critical?

A. leadership's personal preference

B. geographic location of the SME
C. cost of the SME's services
D. references of the SME

Note: correct answer is displayed in bold

Result:
Correct
Answer 14 is D

Feedback
DOMAIN: Performance and Process Improvement

EXPLANATION:
A. Consideration must be based on an overall, not personal, preference.
B. While geography is important, it's not most critical.
C. While cost is important, it's not most critical.
D. The positive clinical reputation provides credibility support to the project.
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Question 15 of 65
Leadership can best integrate performance improvement within an organization through

A. multidisciplinary teams.

B. newsletters.
C. focus groups.
D. seminars.
Note: correct answer is displayed in bold

Result:
Correct
Answer 15 is A

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. Multidisciplinary teams best integrate performance improvement by promoting an interdisciplinary
approach to the process and including multiple subject matter experts.
B. Newsletters do not promote collaboration and engagement.
C. Focus groups do not promote integrated performance improvement.
D. Seminars help educate, but do not integrate performance improvement.

Question 16 of 65
An operating room circulating nurse reported that the instrument count indicated a missing clamp. X-ray
findings were negative, and the patient showed no adverse effects. This occurrence is an example of
which of the following?

A. claims management
B. malpractice
C. clinical incompetency
D. potentially compensable event

Note: correct answer is displayed in bold

Result:
Correct
Answer 16 is D
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Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. There has been no claim at this point.
B. No evidence of malpractice was identified.
C. No evidence of clinical incompetence was identified.
D. Although the clamp was not found, this has potential to become a compensable event. A potentially
compensable event is an event for which there is risk of future claim or settlement.

Question 17 of 65
Minimizing the chances for an adverse event to reoccur includes determining the primary contributing
factor by using

A. root cause analysis.

B. force field analysis.

C. clinical pathways.
D. failure mode and effects analysis (FMEA).
Note: correct answer is displayed in bold

Result:
Correct
Answer 17 is A

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. Correct, as exploration of system and process issues should be primary in identifying root causes of
error.
B. Incorrect, as force field analysis identifies forces that influence success or failure of improvement of a
process and not the identification of the root cause of an incident.
C. Incorrect, as clinical pathways are guidelines developed to assist in clinical management decisions.
D. Incorrect, as FMEA is a tool to design or redesign a process.

Question 18 of 65
When errors are discovered, staff and supervisors best demonstrate a culture of safety by

A. developing a plan for just-in-time training.

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B. studying the process to understand the error.

C. planning which details of the error to disclose to senior leadership.
D. performing a root cause analysis to determine which individuals were involved.
Note: correct answer is displayed in bold

Result:
Incorrect
Option A is not correct

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. This action is premature without knowing what training is needed.
B. Foundational statement
C. Transparency and trust is a key component to culture of safety and what gets disclosed to senior
leadership should have been predetermined.
D. Root cause analysis needs to be done to look at system issues and not at the people.

Question 19 of 65
In the process of strategic planning, an organization makes decisions about the future. A basic
component of the planning process is to

A. develop contractual relationships to enhance market share.

B. contract with a consulting firm to assist with the planning process.
C. determine organizational profitability during the most recent fiscal year.
D. examine both internal and external environments.

Note: correct answer is displayed in bold

Result:
Correct
Answer 19 is D

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. This may be a result of strategic planning, but not part of the process.
B. Some organizations may do this, but not a basic component of planning.
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C. This data might be reviewed.

D. Includes an examination of internal strength and weaknesses, and external opportunities and threats.

Question 20 of 65
After a significant unexpected event, an intense analysis is performed to

A. understand the cause.

B. collect risk management data.

C. prepare the facility for a lawsuit.
D. identify who made the error.
Note: correct answer is displayed in bold

Result:
Correct
Answer 20 is A

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. The root cause analysis is performed after an event with the goal to identify causes and contributing
factors.
B. This is not the purpose of the intense analysis.
C. See B.
D. See B.

Question 21 of 65
A federally certified electronic health record (EHR) with the capacity for e-prescribing, electronic
exchange of health information, and submission of healthcare quality measures meets

A. bar-code technology specifications.

B. computer-based monitoring specifications.
C. meaningful use requirements.

D. health privacy requirements.

Note: correct answer is displayed in bold

Result:
Correct
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Answer 21 is C

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. See explanation for C.
B. See explanation for C.
C. Meaningful use has several elements including those that are listed in the stem.
D. See explanation for C.

Question 22 of 65
A root cause analysis team examined a serious medication error and recommended changes. Which of
the following should be done next?

A. Random checks for compliance should be made by patient safety staff.

B. The Quality Council should review medication errors quarterly.
C. The process owner should implement and assess effectiveness.

D. Monthly reports should be sent to the regulatory body.

Note: correct answer is displayed in bold

Result:
Correct
Answer 22 is C

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. Incorrect; random checks would not be the next step.
B. Incorrect; this is not the function of implementing changes, but a continued monitoring function.
C. Correct; the recommended changes need to be assigned ownership.
D. Incorrect; this may be a regulatory requirement, but not the next step of implementing change.

Question 23 of 65
The following table shows the percentage of hospital-acquired pressure ulcers: Which of the following
should the healthcare quality professional do next?

A. Implement a new pressure ulcer protocol.

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B. Re-educate staff.
C. Continue to track and trend the data.
D. Conduct a focused analysis of pressure ulcer cases.

Note: correct answer is displayed in bold

Result:
Correct
Answer 23 is D

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. and B. Until further analysis of the problem is completed, it is not known whether additional
modifications to the protocol or education are needed.
C. Advanced-stage, hospital-acquired pressure ulcers are considered never-events. Because this is a
significant patient safety issue, you will continue to track and trend, but it is important to not delay
analysis.
D. Advanced-stage, hospital-acquired pressure ulcers are considered never-events. Because this is a
significant patient safety issue, it is important to not delay analysis so that trends and opportunities for
improvement can be determined.

Question 24 of 65
Which of the following should a Quality Council provide to best ensure success of performance
improvement teams?

A. facilitator and recorder

B. empowerment and training

C. indicators and a data analyst

D. standards and procedures
Note: correct answer is displayed in bold

Result:
Correct
Answer 24 is B

Feedback
DOMAIN: Organizational Leadership
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EXPLANATION:
A. These are important roles to have, but not the best answer.
B. This is the best answer. These are two key elements for ensuring success for the teams.
C. May be a function or work of the team with the data analyst; there are no guarantees that these items
will directly contribute to the success of the teams.
D. The presence of these items are important, but not factors that will guarantee success.

Question 25 of 65
A healthcare provider recently conducted a customer satisfaction survey that focused on the five key
quality characteristics in the graph below: By analyzing the information, the provider can identify that
customers were most dissatisfied with

A. cost and most satisfied with caring.

B. communication and most satisfied with comfort.

C. cost and most satisfied with communication.
D. caring and most satisfied with cost.
Note: correct answer is displayed in bold

Result:
Correct
Answer 25 is A

Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. From the graph above, cost has the largest percent of customers reporting they are disappointed.
Caring has the largest percent of customer reporting they are delighted.
B. See explanation for A.
C. See explanation for A.
D. See explanation for A.

Question 26 of 65
One aspect of a quality process that integrates with risk management is the review and evaluation of

A. adverse drug events.

B. encounter data.
C. case-mix analysis reports.
D. accreditation survey reports.
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Note: correct answer is displayed in bold

Result:
Correct
Answer 26 is A

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. Risk management has a role related to incident reporting.
B. Not a primary component of risk management.
C. Not a primary component of risk management.
D. Not a primary component of risk management.

Question 27 of 65
During quality management data analysis activities, Pareto charts are most appropriately used for

A. displaying parts of a whole.

B. displaying trends over time.
C. determining cause and effect relationships.
D. determining priorities among contributing factors.

Note: correct answer is displayed in bold

Result:
Correct
Answer 27 is D

Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. Pareto charts are more dynamic than just display of parts of a whole project.
B. Pareto charts do not show trends.
C. Pareto charts do not show cause and effect.
D. Pareto charts most appropriately assist to determine priority using represented values.

Question 28 of 65
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Training is being determined based on treatment record review results. The following weighted results
are available: Based on these results, which of the following areas should take priority for training?

A. assessment
B. external communication
C. care plan
D. progress notes

Note: correct answer is displayed in bold

Result:
Incorrect
Option D is not correct

Feedback
DOMAIN: Performance and Process Improvement

EXPLANATION: When ranked by weight and non-compliance (weight*(100-%compliance)), care plan

results in the highest weighted rank.

Question 29 of 65
Which of the following is an example of information that should be included in an incident report, but
should NOT be recorded in a patient's medical record?

A. the patient found on the floor next to the bed with the patient's right leg appearing to be rotated
B. the date, time, dose, and name of a medication administered to a patient in error
C. details concerning a medication preparation error discovered and corrected prior to administration
D. the patient's right knee replaced after consenting to replacement of the left knee

Note: correct answer is displayed in bold

Result:
Incorrect
Option D is not correct

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. Incorrect, as this information is clinical information and appropriate for the medical record.
B. Incorrect. See A.
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C. Correct, as this information is a part of identifying the root cause of the incident and not appropriate for
the clinical medical record.
D. Incorrect. See A.

Question 30 of 65
A healthcare entity initiating re-structuring must consider the impact on staff to ensure the greatest
opportunity for success by

A. defining the concepts of re-structuring to the staff and the community.

B. planning carefully, communicating openly, and leading effectively.

C. developing policies to assist in the change process so that fear will be minimized.
D. selecting a consultant, conducting a needs assessment, and analyzing results.
Note: correct answer is displayed in bold

Result:
Correct
Answer 30 is B

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. Not the best answer.
B. Best answer, these actions promote transparency and trust through communication and leadership.
C. Policies will not help at this point.
D. Not the best answer. The organization would have already completed the needs assessment and
analyzed the result prior to the restructuring.

Question 31 of 65
Which of the following elements must be present in order to evaluate the effectiveness of a healthcare
organization's quality improvement program?

A. quantifiable objectives
B. support from the medical staff
C. well-defined organizational structure
D. integrated data collection

Note: correct answer is displayed in bold

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Result:
Incorrect
Option D is not correct

Feedback
DOMAIN: Performance and Process Improvement

EXPLANATION:
A. To evaluate effectiveness, an organization must have quantifiable objectives in order to measure
progress toward meeting goals.
B. Support from the medical staff is helpful in the success of a quality improvement problem, but it does
not evaluate effectiveness.
C. A well-defined organization is helpful in the success of a quality improvement program, but it does not
evaluate effectiveness.
D. Integrated data collection would make it easier to evaluate effectiveness, but is not critical.

Question 32 of 65
A serious event has occurred related to the timely notification of critical test results. The root cause was
traced to nursing difficulty with following the organizational policy. To prevent a similar event from
reoccurring, which of the following should be done next?

A. Refer the involved nurse to nursing peer review.

B. Educate nursing staff on the importance of timely notification of critical test results.
C. Review the policy with nursing representatives to identify ambiguities.

D. Continue to collect data as one event is insufficient to take action.

Note: correct answer is displayed in bold

Result:
Correct
Answer 32 is C

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. Incorrect; this is a function of disciplinary action, not improvement.
B. Incorrect; this is not addressing the root cause.
C. Correct; this step addresses the result of the root cause.
D. Incorrect; this step does not address the root cause.
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Question 33 of 65
Deemed status refers to

A. a healthcare organization that passes a Centers for Medicare and Medicaid Services (CMS) survey.

B. surveyors who work for both an accrediting body and a healthcare organization.
C. physicians who have been reported to the National Practitioner Database.
D. accreditation equivalency with a Centers for Medicare and Medicaid Services (CMS) survey.
Note: correct answer is displayed in bold

Result:
Incorrect
Option A is not correct

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. This is not necessary to pass a CMS survey to obtain deemed status.
B. Deemed status has no relation with a surveyor's employment status.
C. Deemed status is not related to physicians.
D. CMS allows deemed status with meeting all conditions of participation requirements through Joint
Commission Accreditation.

Question 34 of 65
To avoid misinterpreting variances, which of the following statistical tools should be used?

A. control chart

B. fishbone diagram
C. force field analysis
D. Pareto chart analysis
Note: correct answer is displayed in bold

Result:
Correct
Answer 34 is A

Feedback
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DOMAIN: Health Data Analytics

EXPLANATION:
A. Control charts exhibit points between control limits, therefore displaying the variation.
B. Fishbone diagrams identify cause and effect of a problem.
C. Force field analysis helps look at the project and analyzes all the reasons impacting a change.
D. Pareto charts display and help determine priority.

Question 35 of 65
An organization can best measure its effectiveness in meeting customer expectations by

A. analyzing satisfaction data.

B. benchmarking occupancy rates.

C. creating a run chart of complaints.
D. tracking length of stay.
Note: correct answer is displayed in bold

Result:
Correct
Answer 35 is A

Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. Satisfaction data evaluates customer satisfaction.
B. Using benchmark data on occupancy rates does not evaluate customer expectations.
C. Reviewing complaints and trending over time does not measure customer expectations.
D. Length of stay tracking does not reveal information on customer expectations.

Question 36 of 65
A t-test may be used to

A. display the size of a sampling variation.

B. evaluate the effects of two different treatments.

C. evaluate differences among three or more treatments.

D. display a listing of the number of occurrences of a variable.
Note: correct answer is displayed in bold
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Result:
Correct
Answer 36 is B

Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. See explanation for B.
B. A t-test is used to examine if the mean of two treatments are statistically different from one another.
C. See explanation for B.
D. See explanation for B.

Question 37 of 65
The primary purpose of integrating financial and quality management information is to

A. identify problems in resource management.

B. develop physician profiles.

C. identify potential cash flow problems.
D. determine medical necessity of treatment.
Note: correct answer is displayed in bold

Result:
Correct
Answer 37 is A

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. This ties financial impact to quality management.
B. This is not related to physician profiles.
C. This is more financially-related, not quality-related.
D. Information is determined through resource management and evidence-based practice.

Question 38 of 65
Based on the principles from the Institute for Healthcare Improvement (IHI), who has the ultimate
responsibility for the effectiveness of quality improvement and patient safety within an organization?
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A. quality improvement director

B. medical director
C. CEO

D. governing body
Note: correct answer is displayed in bold

Result:
Incorrect
Option C is not correct

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. The quality improvement director has a key role in facilitation and operations of the QIPS program, but
is generally not the ultimate responsible individual.
B. Same as A; provides input and facilitates interactions between medical staff and operations.
C. Same as A; provides input and facilitates interactions throughout the organization.
D. This is the expectation of TJC and Centers for Medicare and Medicaid Services (CMS).

Question 39 of 65
The quality improvement director is responsible for coordination of accreditation survey activities.
Responsibilities will most likely include

A. facilitating self-assessments of compliance with standards, communicating new requirements to pertinent

parties, and distributing the agenda for the survey.
B. educating staff to all standards, writing the survey report, and completing the survey application.
C. developing a protocol for a mock survey, conducting unannounced surveys, and challenging the survey report.
D. preparing for unannounced surveys, disseminating the survey report, and developing new standards.
Note: correct answer is displayed in bold

Result:
Correct
Answer 39 is A

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
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A. These are essential functions for overseeing accreditation process.

B. Writing survey reports is not in scope of the work, but the role of a surveyor. The other items could be
part of their responsibility.
C. Conducting unannounced surveys is not in scope of the work; that is a surveyor function. The other
items could be part of their responsibilities.
D. Developing standards is not a function of their work, but of the accreditation organization. The other
items could be part of their responsibilities.

Question 40 of 65
Which of the following charts will most likely be used first in a root cause analysis?

A. Gantt
B. Pareto
C. flow

D. control
Note: correct answer is displayed in bold

Result:
Correct
Answer 40 is C

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. A Gantt chart is a project management chart.
B. A Pareto chart is a prioritization tool.
C. A flow chart is the best chart to use first for a root cause analysis.
D. A control chart is a tool to evaluate process.

Question 41 of 65
The best way to evaluate the effectiveness of performance improvement training is through

A. observed behavioral changes.

B. self-assessments.
C. participants' feedback.
D. post-test results.
Note: correct answer is displayed in bold
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Result:
Correct
Answer 41 is A

Feedback
DOMAIN: Organizational Leadership

EXPLANATION: All of these are methods to evaluate effectiveness of performance improvement training.
However, observed behavioral change is the best method as it demonstrates transfer of knowledge into
practice.

Question 42 of 65
An annual evaluation of a laboratory's quality program identified no opportunities for improvement. Which
of the following elements of the program should be reviewed?

A. performance indicators

B. format of data display

C. committee meeting attendance
D. frequency of data collection
Note: correct answer is displayed in bold

Result:
Correct
Answer 42 is A

Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. Performance indicators need to be reviewed for need for revision.
B. Format is not related.
C. Attendance does not tie back to indicators.
D. Frequency is one of the concepts related to data collection, but not related to elements.

Question 43 of 65
Which of the following is the best example of an outcome measure?

A. availability of computers
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B. pathway compliance
C. mortality rate

D. laboratory turnaround
Note: correct answer is displayed in bold

Result:
Correct
Answer 43 is C

Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. This is a structure measure.
B. This is a process measure.
C. An outcome measure is used to determine how the system or improvement project impacts the
patient.
D. This is a process measure.

Question 44 of 65
Balanced scorecards are useful because they

A. focus on the most significant strategic initiative.

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

C. put strategy and vision at the center of an organization's effort.
D. concentrate on the performance of individual units.
Note: correct answer is displayed in bold

Result:
Incorrect
Option A is not correct

Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. There may be some sort of visual display to highlight most significant strategic initiative, but the intent
of the scorecard is to highlight multiple objectives of the organization.
B. Not in scope of a balanced scorecard.
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C. The balanced scorecard is a management framework that translates an organization's strategic

objectives into a set of performance measures that are measured, monitored, and changed, if necessary,
to ensure that organization’s strategic goals are met.
D. The intent is to have a visual display of the entire organization's progress, not individual units.

Question 45 of 65
Which of the following is most appropriate in preparation for an external survey of a healthcare facility?

A. Assign key staff to answer all questions.

B. Ask department heads to prepare a presentation for the survey team.
C. Educate staff about the types of questions they may be asked.

D. Set up teams to make a good showing for the survey.

Note: correct answer is displayed in bold

Result:
Correct
Answer 45 is C

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. Survey process may involve all staff, so to assign certain staff might not be the best strategy.
B. May be an element for survey preparation, but not the best answer.
C. Best answer; survey process will involve all staff.
D. May be an element for survey preparation, but not the best answer.

Question 46 of 65
Healthcare leaders are confronted with the challenge of increasing quality while reducing costs. Which of
the following approaches best advances improvement efforts?

A. Support activities that improve outcomes and reduce variation.

B. Incorporate customer satisfaction results into quality initiatives.

C. Increase charges and decrease costs.
D. Develop new services to increase revenues.
Note: correct answer is displayed in bold

Result:
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Correct
Answer 46 is A

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. Best action since this will effect multiple domains within quality, including safety, effectiveness, and
efficiencies.
B. Impacts one domain of quality, but not all.
C. Not impactful for quality.
D. Not impactful for quality.

Question 47 of 65
Generic screening is an example of risk

A. evaluation.
B. reduction.
C. prevention.

D. identification.
Note: correct answer is displayed in bold

Result:
Incorrect
Option C is not correct

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. Evaluation follows all the processes.
B. Reduction follows prevention.
C. Prevention follows identification.
D. Identification is the first step in disease management/risk management.

Question 48 of 65
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
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A. the length of time the team has been together.

B. how well the team met the intended outcome.

C. the effectiveness of the team leader and facilitator.

D. the amount of data the team has collected.
Note: correct answer is displayed in bold

Result:
Correct
Answer 48 is B

Feedback
DOMAIN: Performance and Process Improvement

EXPLANATION:
A. The length of time the team has been together does not indicate that the team has met its goals and
intended outcomes.
B. The decision to disband should be based upon how well the team has met the intended outcomes.
C. The effectiveness of the team leader and facilitator may impact team performance, but is not a reason
to disband the team.
D. The amount of data the team collected is not an indicator of whether the goals or intended outcomes
of the team have been met.

Question 49 of 65
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

A. 10% of all discharge records for the past quarter.

B. all active records on one day of the past month.
C. 30% of records based on preliminary compliance review.

D. the number of records needed using a statistical method.

Note: correct answer is displayed in bold

Result:
Incorrect
Option C is not correct
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Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. This may not provide a relative sampling.
B. Sampling is not correct.
C. There is not enough data to determine if sampling is relative.
D. Correct; the confidence level and interval would be determined through calculation.

Question 50 of 65
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?

A. Evaluate compliance with the pathway.

B. Correlate the pathway with staffing levels.

C. Re-educate the staff on the purpose of the pathway.
D. Continue to monitor, and collect additional data.
Note: correct answer is displayed in bold

Result:
Correct
Answer 50 is A

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. Evaluation of compliance with the proven (pathway) should be conducted first to see if that may be
influencing the lack of change in the outcome.
B. Looking at staffing levels may be helpful in identifying challenge with pathway compliance, but
pathway compliance should be evaluated first.
C. Compliance with the pathway should be evaluated first before re-education to see if pathway
compliance is the issue and to narrow the focus of the education.
D. Given the lack of outcomes after 6 months, additional monitoring without action will not help this team
improve performance.

Question 51 of 65
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Which of the following is the most effective way to integrate performance improvement concepts
throughout an organization?

A. quarterly newsletters
B. monthly lectures
C. quality teams

D. continuous monitoring
Note: correct answer is displayed in bold

Result:
Correct
Answer 51 is C

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A., B. Quarterly newsletters and monthly lectures are a mechanism to communicate information, but may
not be read/heard by all and do not guarantee integration.
C. Quality teams include participation by front-line staff, which allows direct integration of performance
improvement into practice.
D. Monitoring does not include a communication component and does not address integration.

Question 52 of 65
Which of the following action plans is the first step in correcting inappropriate blood usage in an
emergency department?

A. in-service on ordering blood usage for the physicians

B. elimination of wasted blood
C. improvements in documentation
D. development of a new procurement procedure

Note: correct answer is displayed in bold

Result:
Incorrect
Option D is not correct

Feedback
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DOMAIN: Performance and Process Improvement

EXPLANATION:
A. Educating the physicians on the critical use of blood products will assist to better utilize blood supply.
B. Blood elimination is not a factor in blood use.
C. While documentation is important, it does not apply to blood usage.
D. Procurement of blood relates to donation, not usage.

Question 53 of 65
Satisfaction surveys, focus groups, and complaint tracking are tools used to

A. benchmark satisfaction.

B. develop clinical pathways/guidelines.

C. understand customers' expectations.
D. measure professional practice patterns.
Note: correct answer is displayed in bold

Result:
Incorrect
Option A is not correct

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. Benchmarks establish best practices and targets.
B. Clinical pathways are the steps in care used by caregivers.
C. Surveys, focus groups, and complaints with or from customers can provide information directly from
the customers regarding a variety of topics including customer expectations.
D. Measurements of professional practice patterns provide information about internal performance, not
customer expectations.

Question 54 of 65
Medication reconciliation is a process intended to

A. identify and resolve discrepancies.

B. investigate formulary discrepancies.

C. increase use of electronic medication administration.
D. improve efficiency of medication administration.
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Note: correct answer is displayed in bold

Result:
Correct
Answer 54 is A

Feedback
DOMAIN: Patient Safety

EXPLANATION:
A. Correct; the definition of medication reconciliation is a process of identifying the most accurate list of
all medications by comparing the medical record to an external list of medications.
B. Incorrect; formularies define the universal list of medications available to hospital patients or payor
benefits.
C. Incorrect; this is a function of medication administration.
D. Incorrect; this is referring medication administration processes and not an individual's medication list.

Question 55 of 65
When choosing an outside consultant to lead employee focus groups, which of the following priority
areas of expertise should a healthcare quality professional look for?

A. team development and management

B. organization assessment and change management
C. group dynamics and facilitation

D. organization design and re-engineering

Note: correct answer is displayed in bold

Result:
Correct
Answer 55 is C

Feedback
DOMAIN: Performance and Process Improvement

EXPLANATION:
A. This is the responsibility of the team leader, not an outside consultant.
B. A consultant is not tasked with changing culture, but with gathering information.
C. The primary role of a consultant who is leading focus groups is to facilitate interaction in the group
dynamic.
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D. Focus groups are not about design and re-engineering, but information gathering.

Question 56 of 65
When a team evaluating the use of restraints starts to discuss a liability claim related to a patient, the
facilitator should

A. redirect the team.

B. consult the risk manager.

C. request the medical record.
D. review team ground rules.
Note: correct answer is displayed in bold

Result:
Correct
Answer 56 is A

Feedback
DOMAIN: Performance and Process Improvement

EXPLANATION:
A. Redirection is needed to move team back on topic and towards performance improvement effort.
B. This would be done following meeting.
C. This is not an applicable action.
D. This should be done at the start of the meeting.

Question 57 of 65
A group of pediatric patients diagnosed with cystic fibrosis is being studied. Their attitudes toward the
disease have been measured each year for the past 4 years. The methodology used is an example of a

A. cohort study.

B. regression analysis.
C. case-mix study.
D. cross-sectional analysis.
Note: correct answer is displayed in bold

Result:
Correct
Answer 57 is A
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Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. Cohort study analyzes a group with a specific characteristic, such as cystic fibrosis.
B. Regression analysis looks at the relationship among variables. This study is looking at a single
variable: attitudes toward disease.
C. Case-mix study is more definitive and would require more analysis of each case within the study. This
study is looking at a qualitative measure and does not require a quantitative analysis.
D. A cross-sectional analysis measures data at a specific point in time.

Question 58 of 65
Quality improvement team development stages include all of the following EXCEPT

A. norming.
B. forming.
C. performing.
D. conforming.

Note: correct answer is displayed in bold

Result:
Correct
Answer 58 is D

Feedback
DOMAIN: Performance and Process Improvement

EXPLANATION:
A. 3rd stage
B. 1st stage
C. 4th stage
D. This is not one of the stages outlined by Tuckman's Stages of Group Development.

Question 59 of 65
Which of the following actions should a facilitator make the highest priority during the customer focus
group process?

A. selecting a homogeneous group

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B. establishing rapport with the group

C. providing written ground rules to the group
D. generalizing the findings to the population

Note: correct answer is displayed in bold

Result:
Incorrect
Option D is not correct

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. A facilitator is not responsible for selecting the group.
B. A facilitator must establish rapport in order facilitate the group towards outcomes.
C. This would be done by the leader.
D. This is done by the leader or reporter.

Question 60 of 65
Facility A is investigating its medication administration time for a specific diagnosis. Evidence-based
guidelines indicate that administration of a particular drug within 30 minutes significantly improves patient
outcomes. The national average is 32 minutes. The average for Facility B is 28 minutes. If the average
for Facility A is 35 minutes, Facility A should

A. determine whether its rate is within one standard deviation of the national average.
B. decrease its rate to meet the national average.
C. contact Facility B to determine its practices.

D. identify the average time of its competitors.

Note: correct answer is displayed in bold

Result:
Correct
Answer 60 is C

Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. Facility A is aware their average is low. There is no reason for additional calculations.
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B. Decreasing rates is the result.

C. Sharing best practices is encouraged for process improvement.
D. Progress is not gained from focusing on competitors' rates.

Question 61 of 65
In the quality improvement process, performing a cost-benefit analysis is most useful in

A. checking performance.
B. analyzing process problems.
C. designing solutions and controls.
D. implementing solutions and controls.

Note: correct answer is displayed in bold

Result:
Incorrect
Option D is not correct

Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. Cost-benefit analysis is not used for checking performance alone.
B. Cost-benefit analysis is more financial in nature.
C. Cost-benefit analysis allows for financial controls to be considered towards outcome achievement.
D. Implementation would follow the cost-benefit analysis.

Question 62 of 65
Refer to the following control chart: In assessing the timeliness for the administration of antibiotics for
pneumonia, this control chart demonstrates

A. process improvement.

B. no process improvement.
C. evidence of a trend.
D. evidence of an outlier.
Note: correct answer is displayed in bold

Result:
Correct
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Answer 62 is A

Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. Eight points below the control limit indicate a positive shift in the problem (special cause variation).
B. See explanation for A.
C. Based on statistical process control rules, this is a shift, not a trend.
D. An outlier would either be above or below the control limits.

Question 63 of 65
A physician who has a high inpatient mortality rate compared to others in a facility should first be

A. counseled by the department chairperson.

B. reviewed by the credentialing committee.

C. suspended in the interest of patient safety.
D. evaluated via a more in-depth review of cases.
Note: correct answer is displayed in bold

Result:
Incorrect
Option A is not correct

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A., B., and C. These steps cannot be done until the physician is subjected to a more in-depth review.
D. Required to make a determination based on quantity of cases and quality

Question 64 of 65
Which of the following graphs provides the best information for re-appointment/re-evaluation of an
individual physician? (Use the scroll bar to the right to scroll down as needed.)

A.
B.
C.
D.
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Note: correct answer is displayed in bold

Result:
Correct
Answer 64 is D

Feedback
DOMAIN: Health Data Analytics

EXPLANATION:
A. This chart doesn't compare the physician.
B. This chart doesn't compare the physician.
C. This chart doesn't show data over time.
D. This chart includes the best information to compare using time.

Question 65 of 65
Which of the following are the first steps when preparing for an initial accreditation or certification survey
of an organization?

A. Review the standards and determine readiness.

B. Appoint a survey coordinator and prepare a survey agenda.

C. Hire a consultant and conduct a mock survey.
D. Assess staff knowledge and plan staff training.
Note: correct answer is displayed in bold

Result:
Correct
Answer 65 is A

Feedback
DOMAIN: Organizational Leadership

EXPLANATION:
A. These actions are part of the gap analysis, which establishes a good baseline to determine where to
focus and how to prioritize efforts.
B. May be a good action, but not the first step.
C. See B.
D. See B.
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