NAHQ CPHQ Practice Exam (Latest 2023/ 2024 Update) Questions and Verified Answers| 100% Correct| Grade A

NAHQ CPHQ Practice Exam (Latest 2023/ 2024 Update) Questions and Verified Answers| 100% Correct| Grade A

NAHQ CPHQ Practice Exam (Latest 2023/
2024 Update) Questions and Verified
Answers| 100% Correct| Grade A
Q: A healthcare quality professional is developing a policy regarding access to physician
quality files. In addition to the date and name of the person requesting the information, which of
the following should be included in the policy?
a. Purpose of the request
b. Permission from the applicable physician
c. Approval from the department chair
d. Approval from legal counsel
Answer:
a. Purpose of the request
Q: Physician profiles should be reviewed at the time of reappointment to:
a. Review the number of complaints
b. Assess practitioner competency
c. Compare the practitioner to their peers
d. Facilitate reappointment approval
Answer:
b. Assess practitioner competency
Q: Which of the following is the first step in the strategic planning process?
a. Setting goals and objectives
b. Defining organizational structure
c. Establishing and controlling a budget
d. Determining productivity indicators
Answer:
a. Setting goals and objectives

Q: If someone in your organization is resisting and not willing to make the change, what is the
best strategy to take?
a. Set goals, measure performance, provide coaching and feedback, reward and recognize
positive efforts
b. Communicate what, why, how, when and who of change process, present positive outlook,
have clear focus and goal for change and expectations
c. Provide education and training in new skills and use of various management techniques
Answer:
a. Set goals, measure performance, provide coaching and feedback, reward and recognize
positive efforts
Q: If someone in your organization is resisting and not able to perform change, what is the best
strategy to take?
a. Provide education and training in new skills and use of various management techniques
b. Communicate what, why, how, when and who of change process, present positive outlook,
have clear focus and goal for change and expectations
c. Provide education and training in new skills and use of various management techniques
Answer:
a. Provide education and training in new skills and use of various management techniques
Q: If someone in your organization is resisting change and lack knowledge about what is
required, what is the best strategy to take?
a. Provide education and training in new skills and use of various management techniques
b. Communicate what, why, how, when and who of change process, present positive outlook,
have clear focus and goal for change and expectations
c. Provide education and training in new skills and use of various management techniques
Answer:
b. Communicate what, why, how, when and who of change process, present positive outlook,
have clear focus and goal for change and expectations
Q: For a quality improvement team to deal effectively with conflict, it is important to appoint
which of the following to its membership?

a. Risk manager
b. HR representative
c. Facilitator
d. Senior leader
Answer:
c. Facilitator
Q: Which of the following is essential to effective Quality Councils?
a. Involvement of leadership
b. Consultation of legal advisor
c. Participation of the strategic planning committee
d. Direction from the organization’s quality department
Answer:
a. Involvement of leadership
Q: A Quality Council has chartered a performance improvement team to reduce medication
errors. The team has been meeting for several months and progress has been slow. Which of the
following is the most important factor for the Quality Council to assess with the team leader?
a. Composition of the team
b. Number of medication errors since team was chartered
c. Team members’ ability to interpret graphs
d. Length of team meetings
Answer:
a. Composition of the team
Q: Two surveys were completed in a healthcare facility that showed conflicting results
concerning patient satisfaction with food services. The two surveys were independently designed
and distributed by different departments within the facility. The healthcare quality professional
should first:
a. Set up a quality improvement team to improve food service
b. Redistribute the surveys to obtain a larger sample size.
c. Design, distribute, and analyze a new survey instrument
d. Meet with the departments to review the survey processes
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Each individual in the population has an equal chance to be chosen
A. Quota Sampling
B. Simple Random Sampling
C. Convenience Sampling
D. Systematic Sampling
B. Simple Random Sampling
Reason: provides a logical way of making statements about a larger group: sample

A chief quality officer has the responsibility for education and implementation of a quality improvement process. to affect cultural change, the chief quality officer must:
A. Believe the costs are justified by the benefits
B. Be a visible visible participant in process
C. Receive quarterly reports
D. Limit training to managers and supervisors
B. Be a visible visible participant in process
Rationale: Leadership must be part of the change

When a healthcare organization is contracting with an outside provider for services, the subcontractor must:
A. Provide a respective to the Quality Council
B. Meet all regulatory requirement
C. Have an active risk management program
D. Have a competitively priced service
B. Meet all regulatory requirement
Reason: reference is key element, promotes and design group function

A healthcare quality professional is developing a policy regarding access to physician quality files. In addition to the date and name of the person requesting the information, which of the following should be included in the policy?
A. Permission from the applicable physician
B. Purpose of the request
C. Approval from legal counsel
D. The department chair’s approval
B. Purpose of the request
Reason: Profile confidentiality key component; log/sign-out sheet date of request, reason for request, name of person reviewing, notes.

Physician profiles should be reviewed at the time of re-appointment to:
A. Assess practitioner competency
B. Compare the practitioner to their peers
C. Review the number of complaints
D. Facilitate reappointment approval
A. Assess practitioner competency
Reason: Key elements – based on performance, regular bases, use of project team, risk adj algorithms, medical staff & clinical leadership determines metrics, timely & accurate

Which of the following is the first step in the strategic planning process?
A. Setting goals and objective
B. Defining organizational structure
C. Determining productivity indicators
D. Establishing and controlling budget
A. Setting goals and objective
Reason: Key elements – Identify patient needs, goals for the future, internal & external customer satisfaction, prioritize, impact change, implementation, & communication
Goals: foster anticipation, innovation, & excellence

What is the ultimate responsibility of the board of directors?
Quality Improvement
Reason: Key elements – set policy, financial & strategic direction, quality care, & goals & objectives.

How do you define a successful leadership?
Key elements: define & inspire, shared vision, empower others to lead, & make quality everyone responsibility.

Quality person role in credentialing
Key elements: Consultative role, tracking of files kept separate from others, medical staff determines requirement, input on process, oversight, ensure completed,

There are several surveys and accreditation and recognition programs. Quality professional
self-assessment, education & training, assess readiness

Integration of environmental safety within quality program
patient safety and practitioners, prevent, and standardize

Organization that supports quality contains
involvement of leadership, allocate resources, rewards, focus on behaviors, & ongoing

Recognizes healthcare organizations for quality patient care, nursing excellence, and innovations in professional nursing practice
A. Magnet Recognition Program
B. Malcolm Baldbrige Award
C. Det Norske Veritas (DNV)
D. International Organization for Standardization – ISO
A. Magnet Recognition Program

Define Balanced Scorecard
based on strategic plan
focus on needs & priority of org and community
visual aid with objectives & goals
see if org is on track to meet goals
Benefits: gov. board involvement, visual aid, easy to read, identify neg trends, effective & efficiency of measures, informed decision

Define Dashboard
overview of org
KPI displayed
Graph or charts
updates daily/weekly/month

Utilization Management Definition
Example: LOS
Goal to facilitate delivery of high quality, low cost, efficient, & effective care to patients
change in org needs, innovations, ongoing quality care level, involvement of medical staff and gov. body

What report would you use to provide the gov. body on utilization management?
Dashboard is best model
Reason: Monitor process, reports incorporated into quality dashboards for gov. body.

What items are needed for HIPAA protection on EMR
Name & date
Phone/Fax # & email address
Medical Record, health plan, beneficiaries
Certificate/License, vehicle ID, biometric identifiers
CEO does not need to sign auth

Focus on elimination of errors in process
A. Rapid Cycle Improvement (RCI)
B. Six Sigma (DMAIC)
C. Lean
D. Culture
B. Six Sigma (DMAIC)
Reason: Improvement Model usedDefine, Measure, Analyze, Improve, Control (DMAIC) uses statistical analysis to measure & improve performance
six standard deviation from the mean

Focusing on activities that add value for the customers
A. Rapid Cycle Improvement (RCI)
B. Six Sigma (DMAIC)
C. Lean
D. Culture
C. Lean
Reason: uses cross-functional teams to emphasize reduction of waste & focus on customer value. Finds the root cause. look at the process.
Focus on activities and add value for the customers (cross-functional team)

Quality Structure Key elements
Focus on process
Recognition of internal customers
team-based org
leadership support
Reduction of hierarchy

Elements of Quality support
Involvement of leadership
allocation of resources
focus on process
recognize of internal customers
reduce hierarchy
Focus on system not individuals

Elements of Culture
language, slogans and brands convey culture meaning
Stores, legends, and meths are narrative examples of culture

Shared value and behavior norms
A. Rapid Cycle Improvement (RCI)
B. Six Sigma (DMAIC)
C. Lean
D. Culture
D. Culture
Reason: buy-in from org,

Quality Information Key elements
Evaluate effectiveness of programs
org resources, efficiency & effectiveness
assist the gov. body evaluate & improve performance

Quality Information Management Process
Analyze data
Aggregate & display data
Report data/information/knowledge/decision

Moving quality group across organization using evidence based
A. Rapid Cycle Improvement (RCI)
B. Six Sigma (DMAIC)
C. Lean
D. Culture
iA. Rapid Cycle Improvement (RCI)
Reason: dentifies & prioritizes
evidence-based practice
rapid change in process

Every element in the population has an equal or random chance of being selected
A. Quota Sampling
B. Probability Sampling
C. Convenience Sampling
D. Systematic Sampling
B. Probability Sampling

Every ___nth element from population is selected
A. Quota Sampling
B. Probability Sampling
C. Convenience Sampling
D. Systematic Sampling
D. Systematic Sampling

Divided groups has equal probability of being selected
A. Stratified Random Sampling
B. Simple Random Sampling
C. Convenience Sampling
D. Systematic Sampling
A. Stratified Random Sampling

Any available group of subjects is based: Chuck Sampling
A. Stratified Random Sampling
B. Simple Random Sampling
C. Convenience Sampling
D. Systematic Sampling
C. Convenience Sampling
Example: information about participants who took one instructor’s CPQH class but not all classes taught

A judgment is made about the most representative
A. Quota Sampling
B. Simple Random Sampling
C. Convenience Sampling
D. Systematic Sampling
A. Quota Sampling

How to prepare and pass CPHQ examination is example of what chart
A. Histogram
B. Pareto Diagram
C. Cause and Effect Diagram
D. Control Chart
C. Cause and Effect Diagram
Reason: Effect is the exam – the cause is what will happen; need at least 4 categories; determine the problem and analyze the data
Example: Fishbone or Ishikawa Diagram

Amount of calories and weight is example of
A. Control Chart
B. Run Chart
C. Scatter Diagram
D. Flow Chart
C. Scatter Diagram
Reason: tells you the relationship between 2 variables. use to determine positive and negative btw 2 variables. Example: wt and calories – wt gain based on calorie intake

Urinary Tract Infection rates over one year is example of
A. Control Chart
B. Run Chart
C. Scatter Diagram
D. Flow Chart
B. Run Chart
Reason: trend chart or time series – overtime. data plotted. Examples: UTI or Falls. Help understand variation. Tell if a change occurred.
Rules: 5 or more going up or down is a trend, 6 or more data points is a shift

Medication administration errors for ordering, dispensing, and administering medications
A. Histogram
B. Pareto Diagram
C. Cause and Effect Diagram
D. Control Chart
A. Histogram
Reason: group. frequency, patterns, subsets, process performance: freq overtime
for example: wait time after scheduled appt.
Bar & lines: bell curve; continuous data

Where to begin looking at over one-hour delays in recovery room leading to a backlog
A. Histogram
B. Pareto Diagram
C. Cause and Effect Diagram
D. Control Chart
B. Pareto Diagram
Reason: causes, prioritization of series of problems: highest risk, highest frequency, 80/20% rule, focus on improvement efforts, cause of problem,
Examples: Delays in care, Types of errors, wait time reasons, readmission causes, patient flow. single item

Review Charts: Which chart shows no signal of change
A. Call Abandonment Rate
B. Staff Turnover
C. Inpatient Falls
D. Hand hygiene Compliance
C. Inpatient Falls
Reason: No signal of non-random change are visible

Statistically significant patient fall rate identified
A. Histogram
B. Pareto Diagram
C. Cause and Effect Diagram
D. Control Chart
D. Control Chart
Reason: demonstrates process is stable, predictable, sustain improvement, statistical change.
Special cause & common cause
Shift = 8 or more data points above or below
Trend = 6 or more data points ascending or descending

Where problem areas in a particular process are located
A. Control Chart
B. Run Chart
C. Scatter Diagram
D. Flow Chart
D. Flow Chart
Reason: find the root cause in a process,
Tools: RCA or FMEA

In evaluating long waiting times, a healthcare quality professional can best demonstrate components related to staffing, methods, measures, materials, and equipment by using:
A. A Run Chart
B. A histogram
C. A pie chart
D. An Ishikawa Diagram
D. An Ishikawa Diagram
Rationale: cause and effect diagram. what is the cause for wait time. 4 or more categories that could cause

An emergency department trends wait times from patient arrival to physician assessment. Data are reported using a run chart. Which of the following demonstrates a true statistical increase in treatment delays
A. 6 consecutive ascending data points
B. 7 consecutive descending data points
C. A zigzag pattern of 10 data points
D. Data points close to the mean line
A. 6 consecutive ascending data points
Rationale follow the rules; Trend = 6 or more data points going up or down

The relationship between patient satisfaction and hours per patient day on a medical unit was found to be r=060, p<0.05. What is the correlation between these two values?
A. 0.05
B. 0.36
C. 0.55
D. 0.60
D. 0.60
Reason: T-test = < or = 0.05 is statistically significant
T-test used to analyze difference between two means scores

Regression analysis
based on statistical correlation, the higher the correlation, the more accurate the degree of prediction

The most effective way for a health care quality professional to communicate quality improvement activities to the medical staff is by:
A. Developing professional relationship
B. Inviting medical staff to an in-service on quality tools.
C. Evaluating physician participation on quality teams
D. Providing outcome data at medical staff meetings.
D. Providing outcome data at medical staff meetings.

The following chart describes two samples of five hospitals’ hysterectomy rates per 1,000 women 40-60 years of age. What can be concluded?
Rates Mean Standard Deviation
Sample A 3,5,7,8,5 5.6 1.8
Sample B 4,5,6,7,5 5.4 1.1
A. Sample A has more variability than Sample B
B. Sample A’s performance is superior to Sample B’s
C. There are more cases in Sample B
D. There is a data collection error in Sample B
A. Sample A has more variability than Sample B
Reason: Because the standard deviation is higher

Which of the following is essential component in a performance improvement report?
A. Governing body approval
B. Data Analysis and Display
C. Individual Performance Review
D. Team composition and attendance
B. Data Analysis and Display
Reason: Key component of quality improvement is data & analysis toward goals and aims

Recommend an approach to leadership development and oversee plans as they develop
A. Steering Committee/Quality Council
B. Quality Performance Improvement Team
C. Team Not Needed
D. All the above
A. Steering Committee/Quality Council
Reason: Process at highest level- Key element of the committee is oversight

Determine efficiencies with moving patients from the waiting room to see the doctor.
A. Steering Committee/Quality Council
B. Quality Performance Improvement Team
C. Team Not Needed
D. All the above
B. Quality Performance Improvement Team
Reason: Specific problem related to individual.

Identify cost reductions in lab supplies
A. Steering Committee/Quality Council
B. Quality Performance Improvement Team
C. Team Not Needed
D. All the above
B. Quality Performance Improvement Team
Reason: Specific problem related to individual.

Decide pay raises for staff
A. Steering Committee/Quality Council
B. Quality Performance Improvement Team
C. Team Not Needed
D. All the above
C. Team Not Needed
Reason: that is HR issues not quality team – based on leadership decision

Determine the policy for overall safety programs
A. Steering Committee/Quality Council
B. Quality Performance Improvement Team
C. Team Not Needed
D. All the above
A. Steering Committee/Quality Council
Reason: Quality committee is responsible to review, evaluate and recommend to gov. body for approval.
responsible for policy and integrated with risk management. key word oversight

Determine how to reward and recognize employees
A. Steering Committee/Quality Council
B. Quality Performance Improvement Team
C. Team Not Needed
D. All the above
A. Steering Committee/Quality Council
Reason: Quality Council is part of policy setting & overview of guidelines to recognize employees for quality care delivery.
Project team would develop the process on how to get there.

For a quality improvement team to deal effectively with conflict, it is important to appoint which of the following to its membership
A. Risk management
B. Human Resources representative
C. Facilitator
D. Senior Leader
C. Facilitator
Reason: Facilitator, Recorder, Team lead, & team members make up a project team

Which of the following is essential to effective Quality Councils?
A. Involvement of leadership
B. Consultation of the legal advisor
C. Participation of the strategic planning committee
D. Direction from the organization’s quality department
A. Involvement of leadership
Reason: Key component is active, visible, supportive of change

Leadership role with quality change management
establish the culture of change, role model flexibility, and behavior needed to adapt to change.
determine resilience of individuals

What is quality person role in promoting change?
advisor & facilitator; consulate

What is the culture to impact change?
Assess readiness
support creativity, innovation, & risk takeng
encouragement of ideas
involvement of all staff members: multidisciplinary
focus learning & improvement
empowerment
focus on systems/process not individuals
available resources

A number of specialty and primary care clinicians have participated in several meetings to develop clinical practice guidelines for management of diabetes. The team leader has moved the team through the actual guideline development. Which of the following sequences of steps should the team consider in developing the quality of care product evaluation phase?
A. identify medical review criteria, identify sampling methods to be use, pilot test
B. Identify populations covered by the guideline, identify the data sources, conduct the review
C. Define objectives of the performance review, develop data collection form, pilot test
D. Consider costs of the review, identify clinician and sites of care, define objectives of the performance review
C. Define objectives of the performance review, develop data collection form, pilot test
Reason: objective and goals are primary indicator in PDSA. Steps: identify and priorities, intervention, test, study results, and implement plan,

A Quality Council has chartered a performance improvement team to reduce medication errors. The team has been meeting for several months and progress has been slow. Which of the following is the most important factor for the Quality Council to assess with the team leader?
A. Composition of the team
B. Number of medication errors since team was chartered
C. Team members’ ability to interpret graphs
D. Length of team meetings
A. Composition of the team
Reason: most important and main reason for failure

Two surveys were completed in a healthcare facility that showed conflicting results concerning patient satisfaction with food services. The two surveys were independently designed and distributed by different departments within the facility. The healthcare quality professional should first:
A. Set up a quality improvement team to improve food services
B. Redistribute the surveys to obtain a larger sample size.
C. Design, distribute, and analyze a new survey instrument
D. Meet wit the departments to review the survey processes
D. Meet wit the departments to review the survey processes

Which of the following steps occurs first in facilitating change in an organization?
A. Identify problems to be addressed in the organization
B. Solicit feedback from management
C. Select Key people in the organization to serve on the team
D. Develop a performance improvement plan
A. Identify problems to be addressed in the organization
Reason: First step is identify the problem, empower employees, and address the change

The separate services of pharmacy and nursing are having difficulty developing an action plan for medication errors. Pharmacy services states that nursing services causes the majority of the problems related to errors, while nursing services states the opposite. What is the quality professional’s role in resolving this problem?
A. Provide them with directives on how to solve the problem.
B. Facilitate discussion between the groups to enable them to assume ownership of their portions of the problem.
C. Assign the task to an uninvolved manager.
D. Refer the problem to the facility-wide quality council.
B. Facilitate discussion between the groups to enable them to assume ownership of their portions of the problem.
Reason: the role of a quality person is to advise and facilitate. The group has the knowledge and the expertise to resolve the issue.

A root cause analysis revealed a patient in an acute psychiatric unit committed suicide by hanging himself with his shoelaces. To prevent this from occurring again, the most appropriate action is to institute:
A. Patient checks every 15 minutes
B. A policy allowing only non-laced shoes
C. A 24-hour video monitoring system
D. A buddy system for the patients
B. A policy allowing only non-laced shoes
Reason: eliminates object and promotes patient safety

The concept of “patient safety” applies most appropriately to:
A. Environmental safety measures
B. Serious patient injuries
C. A 24-hour video monitoring system
D. Risk Prevention
D. Risk Prevention
Reason: The Joint Commission safety is a degree of prevention and decrease environmental structure, and situation. All areas of safety

A Quality Council is preparing a patient safety plan. A key factor that needs to be considered for the long-term success of the patient safety program is to:
A. Determine which patient safety goals need to be monitored.
B. Involve the entire organization in the program
C. Review incident reports to identify what disciplinary action should occur
D. Research how technology can be used to prevent errors
B. Involve the entire organization in the program
Reason: Key to program success. patient safety is everyone responsability

To be useful in preventing future error, a root cause analysis (RCA) should be performed:
A. At least 45 days after the event.
B. Using practitioners who were not involved in the event.
C. Utilizing a multidisciplinary team
D. Documenting opinion as well as facts
C. Utilizing a multidisciplinary team
Reason: Root Cause Analysis team – timely investigation, factual, all disciplines involvement

A failure mode and effects analysis (FMEA) is performed:
A. To immediately investigate an incident that occurred
B. As a preventative measure before an incident occurs
C. If the severity of an incident led to a patient death
D. When there is a chance of an incident reoccurring
B. As a preventative measure before an incident occurs
Reason: FMEA is a systematic and proactive method of identifying and preventing failures before they occur

A Quality Council has created a Patient Safety Council. The council is concerned that staff may see this as another program that has been added to their busy schedules that will eventually go away. The best way for the organization to establish patient safety as an ongoing part of the organization to establish patient safety as an ongoing part of the organization’s culture is to:
A. Display the number of incident reports monthly with lessons learned.
B. Identify the patient safety goals and how they will be monitored
C. Integrate patient safety into all employees’ job expectations.
D. Include a presentation on patient safety in employee orientation.
C. Integrate patient safety into all employees’ job expectations.
Reason: holds everyone accountable for patient safety and quality improvement.
Integrate risk management