CPHQ Exam Practice 3

CPHQ Exam Practice Quiz (February 2013)
Congratulations—you have completed CPHQ Exam Practice Quiz (February

2013).
All the questions in the quiz along with their Answers are shown below.
Question 1 of 22
In a risk register, risks are ranked by the
A. probability of occurrence.
B. impact if the event occurred.
C. Risk Score.
D. detectability of the risk.
Answer: C
In a risk register, risks are usually ranked by the Risk Score, which is the
product of the probability of occurrence and the impact should the event
occur.
Content Category: Patient Safety

Cognitive level required for a response: Recall
Tasks on the CPHQ exam content outline to which the Question is
linked: Contribute to development and revision of a written plan for a patient
safety program (e.g. risk register)
Question 2 of 22
A data inventory and a data dictionary will
A. increase the need for new data elements.

B. increase the efficiency of the data collection process.
C. increase the cost of the data collection process.
D. result in all of the above.
Answer: B
A data inventory lists all data currently being collected by the organization.
A data dictionary, on the other hand, is a catalog of the data, listing all the
data elements collected, each element's definition, storage, ownership, who is
responsible for obtaining the data, users, etc.
Both a data inventory and a data dictionary will likely increase the efficiency
and reduce the cost of the data collection process. They may or may not
increase the need for new data elements.
Content Category: Information Management

linked: Perform or coordinate data inventory listing activities
Question 3 of 22
An acute care facility recently revised its clinical protocol for the prevention of
ventilator-associated pneumonia. It has since experienced greater variation in
monthly staff performance. The number of ventilated patients per month has
remained approximately the same. When sampling medical records for the
monthly review, how should the organization adjust the sample size?
A. Reduce the sample size.

B. Increase the sample size.
C. Keep the sample size the same.
D. Review the medical record of each ventilated patient until variation is
reduced.
Answer: B
In general, the more variation that exists within the population, the larger the
sample size needed to make correct inference about the population.

Cognitive level required for a response: Application
linked: Use epidemiological principles in data collection and analysis
Question 4 of 22
What is the maximum time interval between data points on a run chart?
A. One week
B. One month
C. One quarter
D. None of the above
Answer: D
On a run chart, data may be gathered weekly, monthly, bimonthly, quarterly,
semiannually, or annually.

linked: Facilitate the use of process analysis tools to display data (e.g.
fishbone, Pareto chart, run chart, scattergram, control chart)
Question 5 of 22
What is the minimum number of cases in each data point on a run chart?
A. 1
B. 10
C. 25
D. None of the above
Answer: B
On a run chart, a minimum of 10 cases in each data point are required.

Question 6 of 22
A 700-bed acute care facility receives 40% of its admissions from the
emergency department(ED). Quality problems, especially wait time, were
expressed by patients, family members, and physicians.
Which tool should the ED team use first in the investigational phase of the
improvement process?
A. Histogram
B. Control chart
C. Flow chart
D. Pareto chart
Answer: C
A flow chart is the most appropriate tool to better understand the situation
and to identify points in the process where patients might experience a wait.

Question 7 of 22
A multidisciplinary team investigated laboratory turnaround times in an
Emergency Department that were longer than external benchmarks. Root
causes identified included manual transport of specimens to the laboratory
and insufficient number of clinical ED staff to perform order processing.
What should the team do next?
A. Recommend an increase in the number of clinical ED staff.

B. Recommend a mechanical tube system for transporting specimens.
C. Show the report of the root cause analysis to ED staff.
D. Pilot test an increase in clinical ED staff and monitor the laboratory
turnaround times.
Answer: C
It is important that the team checks their conclusions about the root causes
with people most knowledgeable about the process, i.e. the ED staff, before
making/testing any changes.
Content Category: Performance/Quality Measurement and Improvement

linked: Coordinate or participate in quality improvement projects
Question 8 of 22
Manually abstracted data are most commonly validated by
A. periodic reabstraction by a person other than the usual data collector.

B. cross-reference checking of results between similar or complementary
measures.
C. data collection software with built-in editing functions.
D. all of the above.
Answer: A
Manually abstracted data are most commonly validated by periodic
reabstraction by a person other than the usual data collector for a sample
group of patient records. This method is referred to as "interrator or
interobserver reliability." Although they are recognized techniques of data
validation, cross-reference checking of results between similar
complementary measures and use of data collection software are not common
ways of validating manually abstracted data.

linked: Perform or coordinate data collection methodology (e.g. qualitative,
quantitative)
Question 9 of 22
The dimension of care on which complete discharge summaries by the time of
follow-up have the greatest impact is
A. timeliness.
B. respect and caring.
C. continuity of care.
D. safety.
Answer: C
The dimension of care that is impacted the most by complete discharge
summaries by the time of follow-up is continuity of care. Safety is also
impacted by discharge summaries; safety events can occur as a result of poor
transfer of information at discharge, i.e. lack of continuity of care.

linked: Coordinate or participate in quality improvement projects
Question 10 of 22
One member of an improvement team has been exhibiting disruptive
behavior since work on the project began 6 weeks ago. What should the team
leader do in the first instance?
A. Do nothing.
B. Talk privately to the disruptive member.
C. Deal with the offending behavior in the presence of the team.
D. Dismiss the member from the team.
Answer: B
In this situation, the best strategy usually involves the team leader talking
privately with the offending team member, pointing out that disruptive
behavior seems inconsistent with a commitment to help the team succeed.

linked: Participate on performance/quality improvement teams (i.e. as a
coordinator or team member/leader/facilitator)
Question 11 of 22
Which of the following is a signal to end a project?
A. The purpose of the project has been accomplished.

B. Some progress has been made and further progress would require a new
breakthrough effort.
C. Analysis of the problem has revealed that the real problem is different
from the team's charter.
D. All of the above are signals to end a project.
Answer: D
Options A, B, and C are examples of situations in which it is appropriate to
end a project.

linked: Participate on performance/quality improvement teams (i.e. as a
coordinator or team member/leader/facilitator)
Question 12 of 22
In comparing the percentage of falls with injuries in calendar year 2012
between facilities that use restraints and those that do not, which chart should
be used?
A. Line chart
B. Bar chart
C. Pie chart
D. Scatter plot
Answer: B
A bar chart is the best option in this case. A line chart is more appropriate for
time series data.
A pie chart is used to display proportions. A pie chart can be used in this case
but a bar chart displays the data more clearly if you are doing a comparison.
A scatter plot displays the relationship between two variables.

Question 13 of 22
In prioritizing opportunities for improvement, a team first used multivoting
to achieve consensus on a list of the most important items. It then
brainstormed all the potential criteria that can be used to evaluate
performance issues. Appropriate criteria include
A. probability of success.
B. physician satisfaction.
C. leadership interest.
Answer: D
Evaluation criteria commonly used by healthcare organizations include:
 Impact on the customer
 Need to improve
 Urgency of the improvement need
 Relationship to the organization's strategic plan
 Frequency of occurrence
 Probability of success
 Financial impact
 Leadership interest
 Effect on patient outcomes
 Physician satisfaction
 Support of the organization's mission
 Regulatory requirements
linked: Facilitate establishment of priorities for performance/quality
improvement activities
Question 14 of 22
What is the main purpose of the team charter?
A. Help team members understand the purpose and function of the team.
B. Help others in the organization to understand the purpose and function
of the team.
C. Facilitate accountability among team members.
D. Inform leaders about the resources required.
Answer: A
The main purpose of the team charter, also known as the "terms of reference,"
is to help team members understand the purpose and function of the team.

linked: Facilitate development of performance/quality improvement action
plans and projects
Question 15 of 22
Which of the following display formats is best used to evaluate the number of
ear infections, urinary tract infections, and conjunctivitis experienced by
individuals served in a group home?
A. Line graph
B. Bar chart
C. Histogram
D. Control chart
Answer: B
Categorical data, such as the frequency of various types of infections, are best
displayed using a bar chart.
On the other hand, time-ordered data is better displayed with a line chart, run
chart, or control chart.
Histograms are used to display continuous data.

linked: Contribute to development and revision of a written plan for a patient
safety program (e.g. risk register)
Question 16 of 22
A line graph may be transformed into a run chart by
A. determining the range of the data.

B. drawing in the median measurement.
C. changing the vertical scale.
D. modifying the time scale.
Answer: B
A line graph can be easily transformed into a run chart by drawing in the
median measurement value as the center line.
Question 17 of 22
The primary purpose of baseline data is to
A. make a comparison to demonstrate successful performance

improvement initiatives.
B. determine whether there is an important issue to address.
C. determine organizational priorities.
D. meet hospital accreditation standards and regulatory compliance.
Answer: B
Each Answer option gives a valid reason for collecting baseline data.
However, the main use of baseline data is to determine whether there is an
important issue to address.
Content Category: Management and Leadership

linked: Integrate the results of the performance/quality improvement process
into strategic planning for the organization.
Question 18 of 22
Ultimate responsibility for ensuring that data collected in the operating room
are transformed into information lies with
A. the director of the operating room.

B. the operating room staff.
C. the surgeons.
D. the Board of Directors.
Answer: D
Ultimate responsibility for ensuring that data are measured effectively and
transformed into information lies with the leaders of the organization.
Content Category: Management and Leadership
linked: Facilitate development of leadership values and commitment to
quality
Question 19 of 22
The use of restraints on nursing home residents
A. reduces the risk of residents from harming themselves.

B. is unavoidable.
C. includes the use of bedside rails.
Answer: C
Traditionally, nursing home staff have believed that restraining residents was
necessary to prevent the residents from harming themselves. However, the
literature indicates that inactivity—as a result of restraint use—decreases
muscle mass and bone density. So, inactive residents who fall are more likely
to incur an injury such as a hip fracture.
The use of restraints can not only be reduced but also eliminated, i.e.
restraint-free care.
Restraints include bedside rails, chest poseys, soft wrist restraints, and
gerichairs with tables latched in place.
Content Category: Patient Safety

linked: Integrate patient safety concepts within the organization
Question 20 of 22
An improvement team plans to collect data on the rate of falls with injury on a
monthly basis.
The numerator of the performance measure is: "All resident falls that resulted
in injuries (requiring physician intervention/treatment and resulting in a
temporary or permanent change in the resident's activities of daily living)."
What is the most appropriate denominator?
A. All residents
B. All resident falls
C. All residents who suffered at least one fall
D. All resident falls that resulted in injury
Answer: B
The most appropriate denominator for the performance measure in this case
is "all resident falls." The numerator tells us that "all resident falls" are being
considered.
Use of the other options, i.e. "all residents," "all residents who suffered at
least one fall," and "all resident falls that resulted in injury" will likely give
very different results. The last Answer option (D) is identical to the
numerator, and will therefore not be useful, i.e. the performance measure will
be meaningless.

linked: Perform or coordinate data definition activities
Question 21 of 22
The monthly rate of resident falls in the past 12 months was plotted on a
control chart. All data points are within the control limits but the last data
point falls exactly on the upper control limit. The improvement team should
conclude that
A. the process is in statistical control.

B. the process is out of statistical control.
C. more data points are needed to determine whether the process is in
statistical control.
D. other statistical techniques should be used to determine whether the
process is in statistical control.
Answer: A
A data point falling exactly on the upper or lower control limit
is not considered to be out of statistical control.
Question 22 of 22
Which of the following issues should be measured through a performance
improvement program?
A. Business plan
B. Potential impact of operations in the community
C. Employee satisfaction
D. All of the above
Answer: D
Important nonclinical issues that should be measured through a performance
improvement program, including:
 Organization Stability and Growth

 Operational Issues
 Reputation/Community Standing
 Employee Satisfaction
 Financial Issues
 Compliance with External Standards and Regulations
linked: Facilitate development of performance/quality improvement action
plans and projects

CPHQ Exam Practice 3

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CPHQ Exam Practice Quiz (February 2013)

Congratulations—you have completed CPHQ Exam Practice Quiz (February

Content Category: Patient Safety

A. increase the need for new data elements.

Content Category: Information Management

A. Reduce the sample size.

Content Category: Information Management

Content Category: Information Management

Content Category: Information Management

Content Category: Information Management

What should the team do next?

A. Recommend an increase in the number of clinical ED staff.

Content Category: Performance/Quality Measurement and Improvement

A. periodic reabstraction by a person other than the usual data collector.

Content Category: Information Management

Content Category: Performance/Quality Measurement and Improvement

Content Category: Performance/Quality Measurement and Improvement

A. The purpose of the project has been accomplished.

Content Category: Performance/Quality Measurement and Improvement

A scatter plot displays the relationship between two variables.

Content Category: Information Management

Content Category: Performance/Quality Measurement and Improvement

Histograms are used to display continuous data.

Content Category: Information Management

A. determining the range of the data.

A. make a comparison to demonstrate successful performance

Content Category: Management and Leadership

A. the director of the operating room.

A. reduces the risk of residents from harming themselves.

Content Category: Patient Safety

Content Category: Information Management

A. the process is in statistical control.

 Organization Stability and Growth

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