CPHQ Practice Questions

A strategy used in brainstorming is that ideas are a. prioritized as they occur b. discussed when they are mentioned c. progressively eliminated d. all recorded

d. all recorded

A patient safety program can best be enhanced by which of the following technologies? a. online evidence-based medicine guidelines b. computers on wheels at the patients' bedsides c. digital medication reference materials d. barcode system for medication administration

d. barcode system for medication administration

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 a. quality council b. governing body c. utilization committee d. chief of the department

d. chief of the department

Quality improvement teams go through stages of development. These team development stages include all of the following EXCEPT a. norming b. forming c. performing d. conforming

d. conforming

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 overtime. The best way to display the data is to use a a. Gantt chart. b. Pareto chart. c. flow chart. d. control chart.

d. control chart

Which of the following sampling techniques selects participants based on their availability in a certain plan during a specific time frame? a. quota b. random c. volunteer d. convenience

d. convenience

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

d. details concerning a medication preparation error discovered and corrected prior to administration

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? a. physician attendance b. number of complaints c. frequency of meetings d. medical record review

d. medical record review

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? a. require the pharmacist to call the physician to confirm the appropriateness of each antibiotic ordered b. provide mandatory education for pharmacy staff on medication profile documentation requirements c. revise policy to require nursing documentation of allergies before medication administration d. modify pharmacy software to require review of allergic profile before dispensing antibiotics

d. modify pharmacy software to require review of allergic profile before dispensing antibiotics

The evolution of quality improvement in healthcare has shifted the primary focus from performance of individuals to the performance of the a. medical staff b. governing body c. ancillary departments d. organization's systems

d. organization's systems

A physician who has a high inpatient mortality rate compared to others in a facility should first be a. suspended in the interest of patient safety. b. counseled by the department chairperson. c. evaluated by the credentialing committee. d. subjected to a more in-depth review of cases.

d. subjected to a more in-depth review of cases.

Random screening of newborns by the neonatology department has confirmed a high incidence of glucose insufficiency (G6PD) in the local population. Management believes that the cost of testing all newborns would be too high. Which of the following should the healthcare quality professional suggest? a. review literature to determine best practices b. continue to conduct random testing c. conduct an analysis to confirm management's beliefs d. test only newborns with a family history of G6PD

d. test only newborns with a family history of G6PD

Problem-solving, cross-functional understanding, expanded areas of expertise, and increased span of knowledge are examples of a. strategic alliances b. customer expectations c. resource requirements d. the benefits of teams

d. the benefits of teams

Which of the following charts would most likely be used first in a root cause analysis? a. Pareto b. control c. flow d. Gantt

c. flow

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 two 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. Redefine the council's role to coordinate and prioritize quality activities. B. Require departments to forward reports for review prior to the meetings. C. Eliminate the council and directly report quality data to the governing body. D. Switch to a monthly meeting with a new agenda format

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

The clinical competency of a physician is determined by A. a committee of peers. B. the hospital governing body. C. a quality management committee. D. the chief executive officer.

A. a committee of peers.

In lean thinking, a process step is defined as "value added" if the A. customer recognizes the value. B. process owner recognizes the value. C. process owner changes the value of the product. D. customer corrects a mistake to add value.

A. customer recognizes the value.

In the quality improvement process, performing a cost-benefit analysis would be most useful in A. designing solutions and controls. B. checking performance. C. analyzing process problems. D. implementing solutions and controls.

A. designing solutions and controls.

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? A. gap analysis B. Gantt chart C. Kanban method D. Ishikawa diagram

A. gap analysis

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. health privacy requirements. B. bar-code technology specifications. C. meaningful use requirements. D. computer-based monitoring specifications.

A. health privacy requirements.

The primary purpose of risk management trend analysis is to A. identify opportunities for improvements. B. meet regulatory requirements. C. provide required reports to liability carriers. D. eliminate financial loss for organizations.

A. identify opportunities for improvements.

Informed consent for hip surgery was obtained and documented for an elderly patient. In the recovery room, a nurse discovered the wrong hip had been replaced. A healthcare quality professional should A. perform a root cause analysis. B. review the practitioner's qualifications and licensure. C. initiate the disciplinary action process. D. conduct a failure mode and effects analysis (FMEA).

A. perform a root cause analysis.

Which of the following obstetrical outcomes would result in a morbidity review? A. post-delivery septicemia B. neonatal deaths C. cesarean sections D. normal deliveries

A. post-delivery septicemia

Which of the following is the most effective way to integrate performance improvement concepts throughout an organization? A. quality teams B. monthly lectures C. continuous monitoring D. quarterly newsletters

A. quality teams

Minimizing the chances of an adverse event reoccurring includes determining the primary contributing factor by using A. root cause analysis. B. clinical pathways. C. failure mode and effects analysis (FMEA). D. force field analysis.

A. root cause analysis.

A quality improvement manager must decide how to present data that demonstrates the relationship between two process characteristics. Which of the following data display techniques is most appropriate? A. scatter diagram B. Pareto chart C. line graph D. bar chart

A. scatter diagram

The phrase "reaching consensus" is often used in performance improvement. The term consensus refers to A. unanimous agreement B. everyone being totally satisfied. C. a majority vote of those present D. support by all members.

A. unanimous agreement

Satisfaction surveys, focus groups, and complaint tracking are tools used to A. understand customers' expectations. B. develop clinical pathways/guidelines. C. measure professional practice patterns. D. benchmark satisfaction.

A. understand customers' expectations.

In managed care, the most widely used performance measures are A. Agency for Healthcare Research and Quality (AHRQ). B. Healthcare Effectiveness Data and Information Set (HEDIS). C. National Quality Forum (NQF). D. Uniform Hospital Discharge Data Set (UHDDS).

B. Healthcare Effectiveness Data and Information Set (HEDIS).

When developing a strategic plan that integrates patient safety, which of the following factors is most critical? A. cost-benefit of patient safety programs B. culture of performance improvement C. patient-to-staff ratio D. resources for advanced technology

B. culture of performance improvement

The perception of how an organization operates, including how employees relate to internaland external customers, is the organizational A. mission. B. vision. C. structure. D. culture.

D. culture

Which of the following are attributes of a culture of safety? A. increased patient acuity level and error-proof environment B. empowered staff and transparency C. error-proof environment and empowered staff D. transparency and increased patient acuity level

B. empowered staff and transparency

A monitoring system is being designed in which data will be collected and compared to criteria. Which of the following will best enhance the validity and reliability of the data? A. providing a practice-based definition and specific instructions for each element B. establishing criteria that are based on the most recent changes in medical science and technology C. using a computerized system to substitute data for missing responses D. assigning one staff member to identify, collect, enter, and interpret all data

B. establishing criteria that are based on the most recent changes in medical science and technology

A hospital has recently moved to a paperless system. It is noted that some data is missing from the obstetrics delivery record. A healthcare quality professional should recommend A. providing a paper trail. B. evaluating the computerized data entry process. C. designating one data entry person per shift. D. assessing the need for additional education.

B. evaluating the computerized data entry process.

Which of the following is the best tool to begin an investigation into the causes of laboratory labeling errors? A. histogram B. flow chart C. affinity diagram D. prioritization matrix

B. flow chart

When conducting a sentinel event review, a root cause analysis A. proactively identifies causes and effects. B. identifies gaps in patient care processes. C. provides judgment of staff behaviors. D. requires team consensus.

B. identifies gaps in patient care processes.

Which of the following action plans is the first step in correcting inappropriate blood usage in an emergency department? A. development of a new procurement procedure B. improvements in documentation C. elimination of wasted blood D. in-service on blood usage for the physicians

B. improvements in documentation

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

B. potentially compensable event

Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization's quality improvement program? A. integrated data collection B. quantifiable objectives C. support from the medical staff D. well-defined organizational structure

B. quantifiable objectives

In profiling length-of-stay data for benchmarking, it is important that data be A. raw numbers. B. severity adjusted. C. equal numbers. D. reported monthly.

B. severity adjusted.

When errors are discovered, staff and supervisors best demonstrate a culture of safety by A. planning which details of the error to disclose to senior leadership. B. studying the process to understand the error. C. performing a root cause analysis to determine which individuals were involved. D. developing a plan for just-in-time training.

B. studying the process to understand the error.

A valid data collection tool should incorporate A. a reliable graphic presentation. B. the definition of data elements. C. allowance for variance of interpretation. D. a minimum of 20 data elements.

B. the definition of data elements.

Leaders enhance employee commitment to organizational values by fostering which of the following types of communication? A. clear, written, top-down B. timely, open, two-way C. formal, electronic, "need to know" D. face-to-face, oral, scheduled

B. timely, open, two-way

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. Continue to collect data as one event is insufficient to take action. B. Refer the involved nurse to nursing peer review. C. Review the policy with nursing representatives to identify ambiguities. D. Educate nursing staff on the importance of timely notification of critical test results.

C. Review the policy with nursing representatives to identify ambiguities.

A 69-year-old female admitted for hip replacement is taken to surgery. The patient is identified, the surgical site is marked incorrectly, and equipment/x-rays are present. A near miss was most likely identified as a result of A. a root cause analysis. B. informed consent documentation. C. a surgical team "time-out." D. an equipment check.

C. a surgical team "time-out."

A physician complains to the healthcare quality professional that the nursing staff did not strictly follow orders for a patient. The physician requests that the healthcare quality professional speak with the nurse manager. To facilitate improved communication, the healthcare quality professional should A. review the patient record to determine legibility of the physician's orders. B. speak with the nurse manager on behalf of the physician. C. arrange a meeting with the physician and nurse manager. D. evaluate the patient outcome to determine organizational risk.

C. arrange a meeting with the physician and nurse manager.

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. chief executive officer B. quality improvement director C. medical director D. governing body

D. governing body

Which of the following is the best example of an outcome measure? A. laboratory turnaround B. average length of stay C. medication dispensing error D. mortality rate

D. mortality rate

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

C. contact Facility B to determine its practices.

Balanced scorecards are useful because they A. concentrate on the performance of individual units. B. focus on the most significant strategic initiative. C. evaluate the pros and cons of the governing body's priorities. D. put strategy and vision at the center of an organization's effort

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

Medication reconciliation is a process intended to A. improve efficiency of medication administration. B. investigate formulary discrepancies. C. identify and resolve discrepancies. D. increase use of electronic medication administration.

C. identify and resolve discrepancies.

Which of the following actions would have the greatest impact in reducing harm? A. increasing data collection frequency B. forming a performance improvement team C. improving interdisciplinary communication D. revising the patient safety evaluation tool

C. improving interdisciplinary communication

Team cohesion is established during which of the following stages of team growth? A. storming B. performing C. norming D. forming

C. norming

When a team evaluating the use of restraints starts to discuss a liability claim related to a patient, the facilitator should A. consult the risk manager. B. redirect the team. C. review team ground rules. D. request the medical record.

C. review team ground rules.

After a significant unexpected event, an intense analysis is performed to A. collect risk management data. B. prepare the facility for a lawsuit. C. understand the cause. D. identify who made the error.

C. understand the cause.

Which of the following is the best example of use of human factors engineering? A. implementing a Kaizen process to reduce inventory B. eliminating waste through reduction in motion C. using PDCA to improve compliance with hand hygiene D. designing products to prevent tubing misconnections

C. using PDCA to improve compliance with hand hygiene

Which of the following is the major responsibility of senior management regarding continuous quality improvement? A. Communicate the organizational mission and values. B. Develop organization-wide training sessions. C. Participate in Quality Council activities. D. Conduct periodic reviews of the program.

D. Conduct periodic reviews of the program.

Which of the following is most appropriate in preparation for an external survey of a healthcare facility? A. Set up teams to make a good showing for the survey. B. Assign key staff to answer all questions. C. Ask department heads to prepare a presentation for the survey team. D. Educate staff about the types of questions they may be asked.

D. Educate staff about the types of questions they may be asked.

When using cost-benefit analysis in decision making, it is important to remember that A. qualitative and quantitative data should be used. B. implementation costs are more important than return on investment. C. return on investment should be at least 10 to 1. D. consideration of the benefit is more important than cost.

D. consideration of the benefit is more important than cost.

A healthcare quality professional wants to develop a continuous survey readiness model.The initial step should be A. selecting the standards to be taught. B. establishing leadership accountability. C. appointing a steering group. D. planning education for the entire team.

D. planning education for the entire team.

A performance improvement training program for supervisors should include A. review of patient falls. B. results of a failure mode and effects analysis (FMEA). C. budget-variance reporting. D. rapid-cycle process.

D. rapid-cycle process.

Human factors engineering is defined as the study of humans and their interaction with A. medical technology and the organizational systems. B. adverse events and latent errors. C. demographics and the organization. D. the tools they use and the environment.

D. the tools they use and the environment.

Frequency distribution can best be displayed through use of a. a histogram b. a flow chart c. a force field analysis d. an interrelationship diagram

a. a histogram

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

a. adverse drug events

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 a. arrange a meeting with the physician and nurse manager b. speak with the nurse manager on behalf of the physician c. evaluate the patient outcome to determine organizational risk d. review the patient record to determine legibility of the physician's orders

a. arrange a meeting with the physician and nurse manager

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 steps? 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

a. evaluate compliance with the pathway

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

a. facilitating self-assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda for the survey

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? a. gap analysis b. Ishikawa diagram c. Gantt chart d. Kanban method

a. gap analysis

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

a. observed behavioral changes

Comparing healthcare organizations by using medical error rates a. provides the best method for benchmarking patient safety. b. must include a minimum of 10 different facilities. c. may present bias due to differences in reporting practices. d. cannot be performed by facilities with less than 100 beds.

a. provides the best method for benchmarking patient safety.

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

a. quantifiable objectives

When considering the use of an external subject matter expert (SME), which of the following characteristics is most critical? a. references of the SME b. cost of the SME's services c. geographic location of the SME d. leadership's personal preference

a. references of the SME

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? a. staff fear of negative consequences of reporting b. lack of knowledge about how to use the system c. time required to complete an incident report d. incomplete understanding about required reporting

a. staff fear of negative consequences of reporting

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 a. waste b. variation c. poor performance d. Poka-Yoke

a. waste

A medication error occurred resulting in a severe adverse outcome. In addition to informing the patient and/or family, a healthcare quality professional should a. implement new technology. b. conduct a root cause analysis. c. reassign the employees involved. d. perform a regression analysis.

b. conduct a root cause analysis.

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 a. gantt chart b. control chart c. pareto chart d. flow chart

b. control chart

To avoid misinterpreting variances, which of the following statistical tools should be used? a. fishbone diagram b. control chart c. Pareto chart analysis d. force field analysis

b. control chart

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

b. empowerment and training

Failure modes can be prioritized by calculating the criticality index. Which of the following three categories are normally used to calculate a criticality index? a. probability, likelihood, and criticality b. frequency, severity, and ease of detection c. effectiveness, risk, and priority d. response, evidence, and outcome

b. frequency, severity, and ease of detection

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

b. how well the team met the intended outcome

For a continuous quality improvement team to be successful, who must be included on the team? a. department supervisor b. person performing the process c. quality management representative d. administrator

b. person performing the process

A failure mode and effects analysis (FMEA) provides which of the following types of review? a. retroactive b. proactive c. retrospective d. concurrent

b. proactive

Which of the following should be included in an annual performance improvement report to a governing body? a. meeting minutes b. team achievements c. physician peer reviews d. incident/occurrence reports

b. team achievements

Deemed status refers to: a. surveyors who work for both an accrediting body and a healthcare organization b. physicians who have been reported to the National Practitioner Database c. accreditation equivalency with a Census for Medicare & Medicaid Services (CMS) survey d. a healthcare organization that passes a Centers for Medicare & Medicaid services (CMS) survey

c. accreditation equivalency with a Census for Medicare & Medicaid Services (CMS) survey

The primary objective of the operational linkage between risk management and quality/performance improvement is to a. meet regulatory requirements b. develop a plan of action for individual cases c. develop a comprehensive plan to prevent future occurrences d. alert the hospital attorney of a potentially compensable event

c. develop a comprehensive plan to prevent future occurrences

Hospital administration is considering designating 20 beds for long-term, chronically ill patients. Which of the following information best supports this? a. premature discharges over the last 6 months b. readmissions within 30 days over the last year c. discharge placement problems over the last year d. admissions, discharges, and transfers over the last 30 days

c. discharge placement problems over the last year

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

c. focuses on systems or processes

The primary reason to analyze customer satisfaction surveys is to a. provide data for the quality improvement program b. meet pay-for-performance requirements c. identify how perceptions relate to the services provided d. assist with evaluating employee performance

c. identify how perceptions relate to the services provided

A critical difference between quality assurance (QA) and quality improvement is a shift in focus from a. retrospective review to concurrent screening b. nonclinical aspects to customer satisfaction c. identifying poor performers to improving group performance d. QA coordinators to teams

c. identifying poor performers to improving group performance

Which of the following should be included in an annual performance improvement report to a governing body? a. team achievements b. meeting minutes c. incident/occurrence reports d. physician peer reviews

c. incident/ occurrence reports

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 a. medical record not completed by a physician b. staff member not using proper handwashing technique c. near miss from failure to perform a "time-out" d. patient complaint regarding wait times

c. near miss from failure to perform a "time-out"

Balanced scorecards are useful because the 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

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

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

c. quality 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? a. total each complaint category at least on an annual basis b. calculate the average number of complaints per office site c. review complaints to find system problems that can be improved d. determine the date/time the complaint occurred and the person responsible

c. review complaints to find system problems that can be improved

A culture of patient safety in an organization will have been successfully created when a. personal accountability is removed from the organization b.near-miss reporting of safety issues declines c. staff members serve as safety advocates d. a root cause analysis is performed regularly

c. staff members serve as safety advocates

The target for performance improvement should be A. policies and procedures. B. employees. C. systems. D. standards and regulations.

c. systems

A valid data collection tool should incorporate a. a minimum of 20 data elements b. a reliable graphic presentation c. the definition of data elements d. allowance for variance of interpretation

c. the definition of data elements

Frequency distribution can best be displayed through use of a. an interrelationship diagram b. a force field analysis c. a flow chart d. a hisogram

d. a histogram

Which of the following is the first step in preparing for an initial accreditation or certification survey of an organization? a. Assess staff knowledge and plan staff training. b. Hire a consultant and conduct a mock survey. c. Appoint a survey coordinator and prepare a survey agenda. d. Review the standards and determine readiness.

d. Review the standards and determine readiness.

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

d. the number of records needed using a statistical method