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CPHQ Practice Test 2025 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS)
|ALREADY
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 - CORRECT ANSWERS ANSWER
A. in-service on ordering blood usage for the physicians
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. - CORRECT ANSWERS ANSWER
C. Educate staff about the types of questions they may be asked.
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.
B. Re-educate staff.
C. Continue to track and trend the data.
D. Conduct a focused analysis of pressure ulcer cases - CORRECT ANSWERS ANSWER
D. Conduct a focused analysis of pressure ulcer cases
Leadership can best integrate performance improvement within an organization through:
A. multidisciplinary teams.
B. newsletters.
C. focus groups.
D. seminars. - CORRECT ANSWERS ANSWER
A. multidisciplinary teams
(best integrate performance improvement by promoting an interdisciplinary approach to the process and including multiple subject matter experts.)
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. - CORRECT ANSWERS ANSWER
D. conduct a root cause analysis.
(exploration of system and process issues should be the primary function of a root cause analysis)
D. eliminate financial loss for organizations - CORRECT ANSWERS ANSWER
C. identify opportunities for improvements.
(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.)
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 - CORRECT ANSWERS ANSWER
A. quantifiable objectives
(To evaluate effectiveness, an organization must have quantifiable objectives in order to measure progress toward meeting goals)
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. - CORRECT ANSWERS ANSWER
C. put strategy and vision at the center of an organization's effort.
(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.)
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 - CORRECT ANSWERS ANSWER
B. evaluate the effects of two different treatments.
(A t-test is used to examine if the mean of two treatments are statistically different from one another)
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 - CORRECT ANSWERS ANSWER
B. empowerment and training
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 - CORRECT ANSWERS ANSWER
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. - CORRECT ANSWERS ANSWER
C. The process owner should implement and assess effectiveness.
(the recommended changes need to be assigned ownership.)
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 - CORRECT ANSWERS ANSWER
C. details concerning a medication preparation error discovered and corrected prior to administration
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?
A. quality improvement director
B. medical director
C. CEO
D. governing body - CORRECT ANSWERS D. governing body
(This is the expectation of TJC and Centers for Medicare and Medicaid Services (CMS))
Which of the following charts will most likely be used first in a root cause analysis?
A. Gantt
B. Pareto
C. flow
D. control - CORRECT ANSWERS D. control
(a tool to evaluate process)
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 - CORRECT ANSWERS C. meaningful use requirements.
Team cohesion is established during which of the following stages of team growth?
A. forming
B. storming
C. norming
D. performing - CORRECT ANSWERS C. norming
(The team moves towards cohesion and collaboration during the norming stage.)
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?
B. reduction.
C. prevention.
D. identification. - CORRECT ANSWERS D. identification
Identification is the first step in disease management/risk management.
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.
D. addresses potential problems. - CORRECT ANSWERS C. focuses on systems or processes.
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.
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. - CORRECT ANSWERS D. examine both internal and external environments.
Includes an examination of internal strength and weaknesses, and external opportunities and threats.
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. - CORRECT ANSWERS B. planning carefully, communicating openly, and leading effectively.
these actions promote transparency and trust through communication and leadership.
A hospital-wide medical record audit on documentation has been completed. The following table shows the compliance rate of documentation: 1st Qtr (Q1) & 2nd Qtr (Q2)
Surgical "time-outs" performed: Q1 = 90% Q2 = 95%
Communication of critical results: Q1= 91% Q2= 95%
Pain score used: Q1= 50% Q2= 60%
Initial patient assessment performed: Q1= 52% Q2= 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. improve efficiency of medication administration. - CORRECT ANSWERS A. identify and resolve discrepancies.
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.
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 - CORRECT ANSWERS A. adverse drug events.
Risk management has a role related to incident reporting.
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. - CORRECT ANSWERS B. Redefine the council's role to coordinate and prioritize quality activities.
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. - CORRECT ANSWERS D. determining priorities among contributing factors.
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. - CORRECT ANSWERS A. Support activities that improve outcomes and reduce variation.
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 - CORRECT ANSWERS C. group dynamics and facilitation
The primary role of a consultant who is leading focus groups is to facilitate interaction in the group dynamic.
An outcome measure is used to determine how the system or improvement project impacts the patient.
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:
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. - CORRECT ANSWERS B. how well the team met the intended outcome.
The decision to disband should be based upon how well the team has met the intended outcomes.
Quality improvement team development stages include all of the following EXCEPT
A. norming.
B. forming.
C. performing.
D. conforming. - CORRECT ANSWERS D. conforming
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 - CORRECT ANSWERS B. improving interdisciplinary communication
Improved communication has been proven to be a key factor in reducing harm.
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 - CORRECT ANSWERS D. potentially compensable event
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.
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 - CORRECT ANSWERS A. control chart
Control charts exhibit points between control limits, therefore displaying the variation.
Which of the following team members is responsible for keeping meetings focused?
A. time keeper
B. facilitator
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. - CORRECT ANSWERS C. contact Facility B to determine its practices.
Sharing best practices is encouraged for process improvement.
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. - CORRECT ANSWERS A. analyzing satisfaction data.
Satisfaction data evaluates customer satisfaction.
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. - CORRECT ANSWERS D. the number of records needed using a statistical method.
the confidence level and interval would be determined through calculation.
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.
- CORRECT ANSWERS A. facilitating self-assessments of compliance with standards, communicating new requirements to pertinent
parties, and distributing the agenda for the survey.
These are essential functions for overseeing accreditation process.
Minimizing the chances for an adverse event to reoccur includes determining the primary contributing factor by using:
