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CPHQ ACTUAL EXAM COMPLETE
ACCURATE EXAM 400 QUESTIONS WITH
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"The administration of a hospital has discovered that a lack of communication among different hospital departments has led to overspending and unnecessary errors in patient care. The administration has asked the healthcare quality management professional to assemble a team that can improve department communication and address the problems. What type of team would be most useful for this task?
- cross functional
- work group
- quality circle
4) self-directed - CORRECT ANSWER=> 1) cross functional
The key here is the need for a team that can find ways to improve communication among the different departments. This type of team would need to be cross functional, because it would be composed of people from the different departments who would then be delegated to communicate with one another and pass on the communication to others in their respective departments. The other types of teams - work group, quality circle, and self-directed - all have their place in professional improvement, but a cross-functional team would be best in this situation." "A clinic is looking into adding a new computer software program to update an outdated program. The new computer system will keep better track of patient records and will enable the clinic to streamline the care that patients receive. What is the healthcare quality management professional's role in this?
- Research the history of the software to see how it has impacted other clinics
- Create a simulation for the software to allow the clinic to see how it operates day to day
- Assist the clinic in evaluating the pros and cons of the software
4) Advise the clinic to implement the software because of its value in improving patient care - CORRECT
ANSWER=> 3) Assist the clinic in evaluating the pros and cons of the software
Advising the clinic to adopt the software would come after the necessary evaluation process
Researching the software and creating a simulation would be part of the evaluation process, but each item is limited in itself. The larger goal for the healthcare quality management professional is one of evaluation to assist the facility in making the best decision." "All of the following represent federally-mandated patient rights in the United States EXCEPT:
- Right to receive healthcare services
- Right to informed consent for medical treatment
- Rights to obtain a copy of medical records
4) Right to maintain the privacy of medical records - CORRECT ANSWER=> 1) Right to receive
healthcare services There is no federally mandated right to healthcare services for people in the United States. There are other statutes - such as the law that forbids emergency rooms from turning away people without insurance - but the federal government does not guarantee to people that they have the right to receive healthcare services. The other rights listed (right to informed consent, right to privacy, right to a copy of medical records) are all protected at the federal level." "One of the largest departments within a hospital has been running over budget for some time. The increasing expenditure has become problematic, and therefore the department has been asked to maintain a budget. What is the healthcare quality management professional's role in this?
- Provide the department with the software tools to enable it to set a manageable budget
- Follow the hospital administration's guidelines in setting a budget for the department
- Assist the department in developing a manageable budget and reviewing it for compliance
4) Appoint a financial advisor to support the department in developing a compliant budget - CORRECT
ANSWER=> 3) Assist the department in developing a manageable budget and reviewing it for
compliance He or she is not necessarily responsible for setting the budget; that would require the assistance of the financial department. Providing software tools to help with developing a budget would be part of the process, but the process is not limited to this. Additionally, the healthcare quality management professional might appoint a financial advisor, but this again is part of the process but not the only part."
standards for the clinic's operation. What is the healthcare quality management professional's role in this?
- Develop educational programs to assist the consultants and ensure that the standards are met
- Create simulated activities to test the consultants and see if they are meeting the standards
- Supply the consultants with the information about state standards and ensure full compliance
4) Review the activities of the consultants and report the results to the clinic administration - CORRECT
ANSWER=> 4) Review the activities of the consultants and report the results to the clinic administration
The healthcare quality management professional is not responsible for overseeing consultants in general, but in the case of a failure in consultant activities, he or she is expected to review the activities of consultants and report on results. The other answer choices all contain details that might be part of the review process for the healthcare quality management professional, but they lack the larger role of reviewing and reporting." "Which of the following performance improvement models would be the best recommendation for a clinic that wants to discover the source of problems in patient care, eliminate these problems, and achieve consistently high quality results in patient care?
- FOCUS
- LEAN
- PDCA
4) Six Sigma - CORRECT ANSWER=> 4) Six Sigma
Six Sigma is recommended as a performance improvement model that enables an organization to reduce problems and, more importantly, achieve consistency in results. The other performance improvement models - FOCUS, PDCA, and LEAN - offer variations of problem identification and reduction, but only Six Sigma specifically focuses on generating consistently good results." "What is the best explanation for the relatively slow introduction of lean practices into medical laboratories?
- The variability and complexity of the samples in a laboratory is much higher than in a manufacturing environment
- Medical research is mostly funded by the government
- Scientists are less receptive to the core principles of lean
4) Medical laboratories function differently than factories - CORRECT ANSWER=> 1) The variability and
complexity of the samples in a laboratory is much higher than in a manufacturing environment" "A delay in discharging patients is likely to cause recurrent bottlenecks in...
- All of the above
- Admissions from the emergency room
- The filling of prescriptions
4) Admissions from surgical wards - CORRECT ANSWER=> 1) All of the above"
"Which of the following conditions should a quality assessment program NOT examine?
- A rare condition that has a small effect on mortality or morbidity
- A condition that is thought to be treatable
- A condition for which the treatment is susceptible to significant influence by health care providers
4) A condition that has cost-effective treatments - CORRECT ANSWER=> 1) A rare condition that has a
small effect on mortality or morbidity" "A doctor fails to administer an indicated test, and the patient's condition deteriorates to the point that he must be admitted to an inpatient facility. This is an example of...
- Communication error
- Preventive error
- Treatment error
4) Diagnostic error - CORRECT ANSWER=> 1) Communication error"
"When is the best time for chairing during a meeting?
- At the beginning
- One hour beforehand
- In the middle
4) At the end - CORRECT ANSWER=> 1) At the beginning"
"The primary benefit of adopting a countrywide or global uniform set of discharge data is to
- Facilitate collection of comparable health information
- Facilitate computerization of data 3)Validate data being collected from other sources.
- medical staff
- governing body
- ancillary department
4) organizations systems - CORRECT ANSWER=> 4) organizations systems"
"The best way to evaluate the effectiveness of performance improvement training is through
- observed behavioral changes
- self-assessments
- participants feedback
4) post-test results - CORRECT ANSWER=> 1) observed behavioral changes"
"The primary objective of the operational linkage between risk management and quality/performance improvement is to
- meet regulatory requirements
- develop a plan of action
- develop comprehensive plan to prevent future occurrences
4) alert the hospital attorney of a potentially compensable event - CORRECT ANSWER=> 3) develop
comprehensive plan to prevent future occurrences" "The primary reason to analyze customer satisfaction surveys is to
- provide data for the quality improvement program
- meet pay for performance requirements
- identify how perceptions relate to the services provided
4) assist with evaluating employee performance - CORRECT ANSWER=> 3) identify how perceptions
relate to the services provided" "Which of the following should a Quality Council provide to best ensure success of performance improvement teams?
- facilitator and recorder
- empowerment and training
- indicators with a data analyst
4) standards and procedures - CORRECT ANSWER=> 2) empowerment and training"
"Which of the following is the most effective way to integrate performance improvement concepts throughout an organization?
- quarterly newsletters
- monthly lectures
- quality teams
4) continuous monitoring - CORRECT ANSWER=> 3) quality teams"
"A critical difference between quality assurance (QA) and quality improvement is a shift in focus from
- retrospective review to concurrent review
- nonclinical aspects to customer satisfaction
- identifying poor performers to improving group performance
4)QA coordinators to teams - CORRECT ANSWER=> 3) identifying poor performers to improving group
performance" "A clinical pathway on the management of hip fractures has been developed by a multi-disciplinary team and implemented in a large teaching hospital. After monitoring for 6 months, the length of stay continues to exceed the guidelines. Which of the following should be the next step?
- evaluate compliance with the pathway
- correlate the pathway with staffing levels
- re-educate the staff on the purpose of the pathway
4) continue to monitor and collect data - CORRECT ANSWER=> 1) evaluate compliance with the
pathway" "One difference between continuous quality improvement and traditional quality assurance is that quality improvement always
- requires the application of statistical process control
- excludes monitoring and evaluation of care provided
- focuses on systems or processes
4) addresses potential problems - CORRECT ANSWER=> 3) focuses on systems or processes"
"Which of the following sampling techniques selects participants based on their availability in a certain place during a specific time frame?
- quota
- random
- volunteer
4) convenience - CORRECT ANSWER=> 4) convenience"
"The quality improvement director is responsible for coordination of accreditation survey activities. Responsibilities will most likely include
- facilitating self assessments of compliance with standards, communicating new requirements to pertinent parties, and distributing the agenda of the survey
- educating staff to all standards, writing the survey report and completing the survey application
4) admissions, discharges, and transfers over the last 30 days - CORRECT ANSWER=> 3) discharge
placement problems over the last year" "Problem-solving, cross-functional understanding, expanded areas of expertise, and increased span of knowledge are examples of
- strategic alliance
- customer expectations
- resource requirements
4) a benefit of teams - CORRECT ANSWER=> 4) a benefit of teams"
"A health plan is required to have a mechanism for members to submit complaints. Which of the following actions must be included in the complaint analysis to ensure the plan makes full use of this type of information?
- total each complaint category at least on an annual basis
- calculate the average number of complaints per office site
- review complaints to find system problems that can be improved
4) determine the date/time the complaint occurred and the person responsible - CORRECT ANSWER=>
- review complaints to find system problems that can be improved" "A healthcare quality professional wants to measure the success of a corrective action plan with a 95% confidence level. The average daily census at the quality professional's organization is 1,000 patients. The best sampling technique for this study is to review
- 10% of all discharge records for the past quarter
- all active records on one day of the past month
- 30% of all records based on preliminary compliance review
4) the number of records needed for using a statistical method - CORRECT ANSWER=> 4) the number
of records needed for using a statistical method" "Quality improvement teams go through stages of development. These team development stages include all of the following EXCEPT
- norming
- forming
- performing
4) conforming - CORRECT ANSWER=> 4) conforming"
"Timeliness and compliance of documentation were discussed at a multidisciplinary team meeting. To evaluate the effectiveness of the team's action plan, which of the following will provide the most useful information?
- physician attendance
- number of complaints
- frequency of meetings
4) medical record review - CORRECT ANSWER=> 4) medical record review"
"A strategy used in brainstorming is that ideas are
- prioritized as they occur
- discussed when they are mentioned
- progressively eliminated
4) all recorded - CORRECT ANSWER=> 4) all recorded"
"The leader of a pain management performance improvement team has asked the Quality Council to disband the team. The most important factor for the Quality Council to assess is
- the length of time the team has been together
- how well the team met the intended outcome
- the effectiveness of the team leader and facilitator
4) the amount of data the team has collected - CORRECT ANSWER=> 2) how well the team met the
intended outcome" "Which of the following elements must be present in order to evaluate the effectiveness of a healthcare organization's quality improvement program?
- quantifiable objects
- support from the medical staff
- well defined organizational structure
4) integrated data collection - CORRECT ANSWER=> 1) quantifiable objects"
"A healthcare quality professional is attempting to refine the differences between an organization's objectives and the stakeholder needs. Which of the following tools is most appropriate?
- gap analysis
- ishikawa diagram
- gantt chart
4) kanban method - CORRECT ANSWER=> 1) gap analysis"
"A performance improvement team reviewing timeliness of outpatient clinic appointments identified the following issues: multiple patient moves, redundant paperwork, and long waiting times to be triaged. In lean terminology, these issues are
- waste
- variation
- poor performance
4) poka-yoke - CORRECT ANSWER=> 1) waste"
- personal accountability is removed from the organization
- near miss reporting of safety issues decline
- staff members serve as safety advocates
4) a root cause analysis is performed regularly - CORRECT ANSWER=> 3) staff members serve as safety
advocates" "One aspect of a quality process that integrates with risk management is the review and evaluation of
- adverse drug events
- encounter data
- case mix analysis reports
4) accreditation survey reports - CORRECT ANSWER=> 1) adverse drug events"
"Failure modes can be prioritized by calculating the criticality index. Which of the following three categories are normally used to calculate a criticality index?
- probability, likelihood and criticality
- frequency, severity and ease of detection
- effectiveness, risk and priority
4) response, evidence and outcome - CORRECT ANSWER=> 2) frequency, severity and ease of
detection" "Staff has been trained and oriented on a new electronic incident reporting system. In the past, staff could report anonymously. The new system requires staff to sign in with an individualized username and password. Three months after implementation, there is a sharp reduction in the number of reported incidents. Which of the following reasons for underreporting of incidents is of greatest concern?
- staff fear of negative consequences of reporting
- lack of knowledge about how to use the system
- time required to complete an incident report
4) incomplete understanding about required reporting - CORRECT ANSWER=> 1) staff fear of negative
consequences of reporting" "A healthcare quality professional has been asked to examine a new method of reviewing adverse events in an organization. It has been decided that a system of triggers will be established to alert the Quality Council of a potential problem. The best example of a trigger that should be set with a threshold of zero is a
- medical record not completed by a physician
- staff member not using proper handwashing technique
- near miss from failure to perform a "time out"
4) patient complaint regarding wait times - CORRECT ANSWER=> 3) near miss from failure to perform a
"time out""
"T/F: Examples of data for physician profiles include data representing major service lines, patient safety
issues and outpatient information. - CORRECT ANSWER=> True"
"T/F: data for physician profiles is useful if kept in a number of different information systems. - CORRECT
ANSWER=> False - Data should be easily accessed and used"
"T/F: Physician profiles are the same for all physicians - CORRECT ANSWER=> False"
"T/F: The best information for physician profiles use national targets and benchmarks. - CORRECT
ANSWER=> True"
"T/F: Data for physician profiles should be meaningful to physicians - CORRECT ANSWER=> True"
"Which program best describes the following: Recognizes national role model with presidential award -
CORRECT ANSWER=> Baldridge Program"
"Which program best describes the following: Dedicated to improving healthcare quality and driving
improvement throughout the healthcare system - CORRECT ANSWER=> NCQA"
"Which program best describes the following: Accreditation program CMS approved to accredit hospitals
and critical access hospitals and require ISO 9001 certification by the 4th year - CORRECT ANSWER=>
DNV GL"
"Which program best describes the following: Primary focus is on rehab facilities - CORRECT
ANSWER=> CARF"
"Which program best describes the following: Survey hospitals on compliance with Medicare Conditions
of Participation and Coverage - CORRECT ANSWER=> HFAP"
"Which program best describes the following: Primarily covers nursing excellence and innovation -
CORRECT ANSWER=> MAGNET"
"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.
- believe the costs are justified by the benefits.
- be a visible participant in the process.
- receive quarterly reports.
4) limit training to managers and supervisors - CORRECT ANSWER=> 2) be a visible participant in the
process" "when a healthcare organization is contracting with an outside provider for services, the subcontractor must:
- provide a representative to the quality council
"a performance improvement training program has been conducted. The healthcare quality professionals has determined that improvement has NOT occurred. the most likely cause for the lack of improvement would be that:
- organizational systems are inhibiting change
- employee practice what they are trained to do
- staff members thought the program was too long
4) the facilitator did not prepare agenda materials - CORRECT ANSWER=> 1) organizational systems are
inhibiting change" "a healthcare organizations strategic plan objectives include a customer satisfaction rating of 85%. The following data are available for three units:- customer satisfaction Rate: Unit A = 88%, Unit B = 80%, Unit C = 62%.Which of the following should a healthcare quality professional recommend.
- change the target to 90% satisfaction
- provide incentives for the staff of Units B & C
- Review the performance improvement plan
4) share Unit A's practices with other units - CORRECT ANSWER=> Share Unit A's practices with the
other units"
"when a team is in the norming phase, what actions should be taken - CORRECT ANSWER=> 1. assign a
devils advocate
- assign small groups to work on a portion of the project" "In evaluating "long waiting times," a healthcare quality professional best demonstrates components related to staffing, methods, measures, materials, and equipment utilizing:
- run chart.
- histogram.
- pie chart.
4) an Ishikawa diagram. - CORRECT ANSWER=> 4) an ishikawa (cause and effect) diagram helps to
analyze potential causes" "the relationship between patient satisfaction and hours per patient per day on a medical unit was found to be (r = 0.60, p <0.05). what is the correlation between these two values?
4) 0.60 - CORRECT ANSWER=> D - 0.60. "r" is used to signify the correlation coefficient"
"the most effective way for a healthcare quality professional to communicate quality improvement activities to the medical staff is by:
- Developing professional relationships
- Evaluating physician participation on quality teams
- Providing outcome data at medical staff meetings
4) Inviting medical staff to an in-service on quality tools - CORRECT ANSWER=> C - Providing outcome
data because it communicates feedback to medical staff" "An interdisciplinary team is looking at a better process for checking in patients. At the last meeting, everyone suggested ideas but there was criticism of almost every solution. one person tended to dominate the conversation. What stage in team development are they in?
- forming
- storming
- norming
4) performing - CORRECT ANSWER=> 2) storming"
"an ongoing quality council has just had 6 out of 18 members rotate off and replaced by 6 new members. There is pressure on the council to quickly establish strategic direction for the coming year. You are worried that some of the newer members may feel intimidated and reluctant to share. what stage in team development are they in?
- forming
- storming
- norming
4) performing - CORRECT ANSWER=> 1) Forming"
"By and large the pediatric group is a tight knit group that works well together. they like to work on every problem as a large team, but this is slowing down planning for the upcoming TJC visit. you also notice that there is some reluctance to disagree once a solution is proposed. everyone tends to jump on board and move forward. what stage in team development are they in?
- forming
- storming
- norming
4) performing - CORRECT ANSWER=> 3) Norming"
"the following is an example of what kind of analysis: Driving Force: Families provide comfort and reassurance to patients during ICU stays. Restraining Force: Nursing staff find the open visiting policy disruptive to nursing routines and getting
their work done - CORRECT ANSWER=> Force Field Analysis"
- conduct a retrospective review
- compare outcomes with pre-established goals
4) survey patients and customers. - CORRECT ANSWER=> 3) compare outcomes with pre-established
goals" "team building goals for a first meeting should include all of the following EXCEPT:
- learning to work as a team
- setting meeting ground rules
- evaluating the project
4) getting to know one another - CORRECT ANSWER=> 3) evaluating the project"
"an organizations data demonstrates an increase in the number of patient falls. a healthcare quality professional should recommend:
- revising the fall risk assessment tool
- convening a focus group of medical staff to discuss fall risks
- increasing staff on the weekends and nights
4) sharing the data with the staff to provide feedback - CORRECT ANSWER=> sharing the data with the
staff to provide feedback" "the best way to facilitate change in a healthcare organization is to:
- communicate through group meetings
- involve individuals directly affected by the change
- arrange presentations by senior leaders
4) communicate through group email - CORRECT ANSWER=> 2) involve individuals directly affected by
the change" "how many patients had surgery this month is an example of _________ data
- categorical
- continuous
3) ongoing - CORRECT ANSWER=> 1) categorical"
"You want to know what the average daily census was for each month in the first six months of the year. This is an example of _______ data
- categorical
- continuous
3) ongoing - CORRECT ANSWER=> 2) continuous"
"What is the appropriate chart for the following situation? urinary tract infections over one year
- scatter diagram
- histogram
- control chart
4) pareto chart - CORRECT ANSWER=> control chart"
"What is the appropriate chart for the following situation? medication admin errors for ordering, dispensing or administering medications
- scatter diagram
- pareto chart
- control chart
4) histogram - CORRECT ANSWER=> "
"What is the appropriate chart for the following situation? The amount of calories and weight
- scatter diagram
- control chart
- histogram
4) pareto chart - CORRECT ANSWER=> 1) scatter diagram"
"What is the appropriate chart for the following situation? where to begin looking at over one hour delays in recover room leading to back log
- scatter diagram
- control chart
- histogram
4) pareto chart - CORRECT ANSWER=> 4) pareto chart"
"What is the appropriate chart for the following situation? statistically significant patient fall rate identified
- scatter diagram
- pareto chart
- control chart
4) histogram - CORRECT ANSWER=> control chart"
"What is the appropriate chart for the following situation? where problem areas in a particular process are located
- scatter diagram
- control chart
- histogram
4) flow chart - CORRECT ANSWER=> 4) flow chart"
"the following is an example of what kind of test? 15 of 30 men (50%) fail to keep appointments
