Control charts may lack stair-shaped look if numerator varies

Question 1
Question 1
In what situation may a control chart lack a stair-shaped
look in its upper and lower control limit lines?
The number of cases in the numerator is basically the same from one
A
time period to another.
The number of cases in the numerator is different from one time
B
period to another.
The number of cases in the denominator is basically the same from
C
one time period to another.
The number of cases in the denominator is different from one time
D
period to another.
Question 2
A frequency plot may be used to examine
A the shape of data.

B the spread of data.
C the center of data.
D all of the above
Question 3
Successful implementation of a standardized process
requires
A local customization.
B a carefully written policy.
C all persons involved in the process to be owners of the process.
D planning so that the design is close to perfect from the outset.
Question 4
A team plans to improve the reliability of the ―time-out‖
procedure in the Operating Room. What should it do first?
A Engage leaders around transparency and continuous learning.

B Reliably design processes.
C Provide targeted team training.
D Systematically survey the culture and identify risk areas.
Question 5
Which of the following is the LEAST appropriate trigger to
identify a possible adverse event in the Operating Room?
A Unplanned return to surgery

B Transfusion or use of blood products
C Transfer to higher level of care
D Change in surgery
Question 6
Which of the following is NOT one of the performance
measures in The Joint Commission's core measure set for
perinatal care?
Antenatal steroids for births between 24 and 32 weeks of

A
gestation.
B Exclusive breastfeeding at hospital discharge.
Deep venous thrombosis prophylaxis for women having a
C
Cesarean birth.
D Elective delivery prior to 39 weeks.
Question 7
For the purpose of improvement, assessment of safety
culture in a hospital is best conducted at the level of the
A individual.
B unit.
C hospital.
D system.
Question 8
Within a hospital, which units are the preferred locations to
target improvement work in patient safety?
Units with high rates of adverse events and less positive patient
A safety culture.
Units with high rates of adverse events and more positive patient
B safety culture.
Units with low rates of adverse events and less positive patient
C safety culture.
Units with low rates of adverse events and more positive patient
D safety culture.
Question 9
The entire surgical staff of an organization has been working
on its teamwork and communication skills. One day during a
procedure, a surgeon lost his temper with the circulating
nurse because he thought the nurse was not moving fast
enough and was slowing him down by asking him to clarify
the situation. As she continued to ask for clarification, he
flung a bloody sponge at her and yelled for her to stop talking
for one minute so he could think.
As the patient safety officer of the organization, what would

you recommend be done immediately?
The surgeon be monitored for similar behavior over the next few
A months.
The surgeon be asked by the organization's leadership to apologize
B to the nurse.
The surgeon be required to undergo further training in teamwork
C and communication skills.
A thorough review of the teamwork and communication skills
D training provided to the surgical staff.
Question 10
For which of the following situations is closed-loop
communication most beneficial?
A When administering intravenous medications and fluids.
B During a handoff from operating room to the Intensive Care Unit.

When trying to get the physician's attention during an intense
C patient care period.
D While obtaining informed consent from a patient.

Question 11
In improving safety and reliability in the operating room, the
organization has designated a clinical leadership group to
own and drive the work. What should the next step be?
A Develop performance measures for the operating room.

Implement structured communication techniques in the operating
B room.
Review the cultural assessment information about the operating
C room.
D Provide teamwork training for operating room staff.

Question 12
An acute care facility is tracking the monthly rate of
ventilator-associated pneumonia in the adult ICU. What is
the most sensitive tool for identifying special cause
variation?
A Line chart
B Run chart
C Control chart
D Pareto chart
Question 13
What is the most common reason for a team to struggle to
develop a data collection plan?
A Lack of leadership support.

B Lack of motivation and enthusiasm among team members.
C Inadequate expertise in the methods and tools of data collection.
D The team's goals are too ambitious.
Question 14
How can the Chief Executive Officer best contribute to the
success of a key improvement project in her organization?
A Assign a quality professional to assist in the project.

B Conduct regular, in-person reviews of the project.
C Offer financial incentives.
D Personally select members of the improvement team.
Question 15
Which of the following is an organizational measure?
Prophylactic antibiotic received within one hour prior to surgical

A incision
B Unplanned return to theatre
C Percent of clean surgery patients with surgical infection
D Percent of surgical cases that were started on time

Question 16
Progress of an improvement project has stalled. One of the
main issues identified was that a few loud naysayers were
blocking implementation of ideas by the rest of the team,
which suggests
A absence of strong enough ideas for improvement.

B failure to execute changes.
C a lack of organizational will.
D too many physicians on the team.
Question 17
In failure mode and effects analysis, what does the Risk
Priority Number refer to?
A Each failure mode and the process

B Each failure mode and its effects
C The potential causes of each failure mode only
D None of the above
Question 18
Which of the following is NOT an appropriate red rule?
When a midwife is concerned at the bedside and asks the

A obstetrician to come to the bedside, he or she should come in a
timely manner.
Elective induction of labor prior to 39 weeks for nonmedical
B reasons is not permitted.
If there is a discrepancy in the sponge count during surgery, the
C patient should have an X-ray before leaving the operating room.
Nurses should observe the ―5 Rights‖ of medication administration
D when administering any drug.
Question 19
As part of its initiative to improve prophylactic perioperative
antibiotic utilization, an acute care facility aimed to
administer perioperative antibiotics within 1 hour of surgical
incision in 100% of cases.
To whom should the responsibility of timely perioperative

antibiotic administration be assigned?
A Anesthesiologist
B Surgeon
C Scrub nurse
D Circulating nurse
Question 20
An acute care facility performed failure mode and effects
(FMEA) analysis of the medication administration process.
For the final step of the process, an identified possible failure

mode was the availability of discontinued medications for
use. Its likelihood of occurrence, likelihood on detection, and
severity of impact were given a rating on a scale of 1 to 10:
 Occurrence 4
 Detection 8
 Severity 6
What action should the FMEA team recommend to reduce

the occurrence of failure?
A Introduce dedicated medication nurses.
B Implement an automated medication dispensing system.
C Train staff to recognize early signs of drug toxicity.

Implement pharmacy rounds to remove discontinued medications
D from patient care units within 1 hour of discontinuation.
Question 21
The system level measures of a hospital include overall
mortality rate and emergency room (ER) waiting time. The
projects that are being implemented include:
 Use of evidence-based bundles in ICU care

 ER flow management
 Surgical wound infection reduction
After 12 months, the weekly average percentage of under-4-
hour waits has increased significantly. However, the
mortality rate has not shown any change. What should the
hospital do next?
A Abandon one or more projects

B Add one or more projects
C Modify the existing projects
D Continue to monitor the mortality rate
Question 22
The number of pressure ulcers, number of admissions, and
annual mean length of stay at a hospital are shown below.
What is your conclusion about the annual incidence of
pressure ulcers in this hospital from 2010 through 2012?
A The incidence of pressure ulcers was unchanged.
B The incidence of pressure ulcers increased.
C The incidence of pressure ulcers decreased.

The incidence of pressure ulcers demonstrated common cause
D variation.
Question 23
What element(s) of care should patients be asked to teach
back?
A Contact information for getting help

B The importance of keeping the follow-up visit
C Self-care on return home
D All of the above
Question 24
The office layout at an acute care facility was restricting the
work flow and was not customer friendly. The management
decided that a redesign of both the layout and the process in
which patients are registered and receive care was required.
What is the greatest barrier to success?

A Lack of knowledge and skills in quality improvement
B Misallocation of staff time
C Suboptimal team composition
D Mind-set about the work
Question 25
―Workdays lost per 100 employees per year‖ is a measure of
A timeliness.
B safety.
C effectiveness.
D efficiency.
Question 26
Tacrolimus is an immunosuppresive drug used in transplant
patients. The drug has a narrow therapeutic range:
administering too little of the drug may result in the
transplanted organ being rejected; administering too much
of the drug risks damaging the patient's kidneys or
weakening his or her defenses against infection.
Among the following methods of administering tacrolimus,

which is the safest?
Start on a dose based on a guideline, measure blood levels of

A tacrolimus on a regular basis, and adjust the dose according to the
blood level.
Measure the patient's renal function before treatment to determine
B the initial dose, measure renal function on a regular basis, and
modify the dose according to renal function.
C tacrolimus on a regular basis, create run charts for each patient and
establish statistical rules for adjusting the dose.
Start on a dose based on a guideline and adjust the dose according to
D clinical response.
t
Question 1
In what situation may a control chart lack a stair-shaped look in its
upper and lower control limit lines?
The number of cases in the numerator is basically the same from one
A
time period to another.
The number of cases in the numerator is different from one time
B
period to another.
The number of cases in the denominator is basically the same from
C
one time period to another.
The number of cases in the denominator is different from one time
D
period to another.
Question 1 Explanation:
Answer: C
A control chart may lack a stair-shaped look in its upper and lower
control limit lines if the number of cases in the denominator is
basically the same from one time period to another.
Content Category: Information Management

Cognitive level required for a response: Recall
Tasks on the CPHQ exam content outline to which the
question is linked:Facilitate the use of process analysis tools to
display data (e.g. fishbone, Pareto chart, run chart, scattergram,
control chart)
Results
Question 2
A frequency plot may be used to examine
A the shape of data.

B the spread of data.
C the center of data.
D all of the above.
Answer: D
A frequency plot, or histogram, is used to examine the center,
spread (range), and shape of data.

question is linked:Use basic statistical techniques to present
data (e.g. mean, standard deviation)
Question 3
Successful implementation of a standardized process requires
A local customization.
B a carefully written policy.
C all persons involved in the process to be owners of the process.
D planning so that the design is close to perfect from the outset.
Answer: A
Standardization of clinical processes is possible but the
methodology of development and implementation is often flawed.
Local customization will be required—making an attempt to
compromise and account for all possible objections and
contingencies will usually lead to failure.
Development of a written policy while trying to implement a

standardized process is often inappropriate.
The process should be assigned one owner, not more. The ability to
sustain a protocol is dependent on an owner. The owner of a
process/protocol has several responsibilities, including being aware
of any new literature that would impact the protocol, having
available the compliance data regarding the use of the protocol,
and having basic data regarding the reasons why the protocol is not
being used, if applicable. No changes can be made to the protocol
without consent and delegation of those changes from the process
owner.
Initial standardization of a care process will never be perfect, and

the designers should expect failures. If an attempt is made in the
initial design to deal with any and all probabilities that engage the
clinical process, the initial protocol will become far too
complicated. A complicated design is much more difficult to
understand by the frontline staff that need to implement the
protocol.
Content Category: Performance Measurement and

Improvement
question is linked:Participate on performance/quality
improvement teams (i.e. as a coordinator or team
member/leader/facilitator)
Question 4
A team plans to improve the reliability of the ―time-out‖ procedure in

the Operating Room. What should it do first?
A Engage leaders around transparency and continuous learning.
B Reliably design processes.
C Provide targeted team training.

D Systematically survey the culture and identify risk areas.
Answer: A
Many teams find it difficult to know where to begin their
improvement work. Based on research and tested theories of the
Institute of Healthcare Improvement, the first step in the
―sequencing for action‖ is engaging leaders, both senior and
physician, around transparency and continuous learning. This will
involve creating an accountability system and a systematic flow of
information.
Content Category: Performance/Quality Measurement and

Improvement
Cognitive level required for a response: Application
question is linked:Coordinate or participate in quality
improvement projects
Question 5
Which of the following is the LEAST appropriate trigger to identify
a possible adverse event in the Operating Room?
A Unplanned return to surgery
B Transfusion or use of blood products
C Transfer to higher level of care
D Change in surgery
Answer: C
Among the four answer options, the one least likely to be associated
with a potential adverse event in the Operating Room is ―transfer to
higher level of care.‖ In other words, unplanned return to surgery,
transfusion or use of blood products, and a change in surgery are
all more likely to be associated with an adverse event that occurred
in the Operating Room.

Improvement
question is linked:Facilitate or participate in the process of
departmental reviews (e.g. pathology, radiology, pharmacy,
nursing)
Question 6
Which of the following is NOT one of the performance measures in
The Joint Commission's core measure set for perinatal care?
A Antenatal steroids for births between 24 and 32 weeks of gestation.

B Exclusive breastfeeding at hospital discharge.
C Deep venous thrombosis prophylaxis for women having a Cesarean birth.
D Elective delivery prior to 39 weeks.
Answer: C
The Joint Commission's website provides more information on
its Core Measure Sets.
Content Category: Management and Leadership
question is linked:Coordinate survey processes (i.e.
accreditation, licensure, or equivalent)
Question 7
For the purpose of improvement, assessment of safety culture in a
hospital is best conducted at the level of the
A individual.
B unit.
C hospital.
D system.
Answer: B
Assessment of safety culture within a hospital should be at the unit
level. There is more variability between units in a typical hospital
than there is between hospitals. Because interventions to improve
safety are implemented at the clinical area level, it is critical to
understand culture at that level.
Content Category: Patient Safety

question is linked:Facilitate assessment and development of the
organization’s patient safety culture
Question 8
Within a hospital, which units are the preferred locations to target
improvement work in patient safety?
Units with high rates of adverse events and less positive patient
A
safety culture.
Units with high rates of adverse events and more positive patient safety
B
culture.
Units with low rates of adverse events and less positive patient safety
C
culture.
Units with low rates of adverse events and more positive patient safety
D
culture.
Answer: A
The areas with high rates of adverse events and low patient safety
culture scores, i.e. less positive patient safety culture, are the
preferred locations to conduct improvement work in patient safety.
This is because the opportunity for improvement is greatest in
these areas.

question is linked:Facilitate the ongoing development and
enhancement of a patient safety program
Question 9
The entire surgical staff of an organization has been working on its
teamwork and communication skills. One day during a procedure,
a surgeon lost his temper with the circulating nurse because he
thought the nurse was not moving fast enough and was slowing
him down by asking him to clarify the situation. As she continued
to ask for clarification, he flung a bloody sponge at her and yelled
for her to stop talking for one minute so he could think.
As the patient safety officer of the organization, what would you

recommend be done immediately?
A The surgeon be monitored for similar behavior over the next few months.
The surgeon be asked by the organization's leadership to
B
apologize to the nurse.
The surgeon be required to undergo further training in teamwork and

C
communication skills.
A thorough review of the teamwork and communication skills training

D
provided to the surgical staff.
Answer: B
Following such disrespectful behavior, the leadership has to
intervene immediately by asking the surgeon to apologize to the
nurse instantly. This would strongly reinforce the desired behaviors
and send a powerful message to the rest of the organization.

Question 10
For which of the following situations is closed-loop communication
most beneficial?
A When administering intravenous medications and fluids.

During a handoff from operating room to the Intensive Care
B
Unit.
When trying to get the physician's attention during an intense patient
C
care period.
D While obtaining informed consent from a patient.
Answer: B
Closed loop communication helps improve the reliability of
communication by having the person receiving the communication
restate what the sender has said to confirm understanding. One
specific type of closed loop communication is repeat back. The tool
involves four distinct actions:
 The ―sender‖ concisely states information to the

―receiver.‖
 The receiver then repeats back what he or she heard.
 The sender then acknowledges the repeat back was

correct or makes a correction.
 The process continues until a shared understanding is

verified.
Organizations requiring this type of closed-loop communication

during times in which communication must be reliable and
effective can help smooth the communication process and ensure
no critical information is lost. Closed-loop communication can be
particularly helpful in situations such as during surgery to confirm
sponge count, during high-risk patient handoffs to ensure
comprehensive information exchange (e.g. handoffs from operating
room to the Intensive Care Unit), and during medication ordering
to ensure that the right medication, right dose, and right route are
communicated.

question is linked:Integrate patient safety concepts within the
organization
Question 11
In improving safety and reliability in the operating room, the
organization has designated a clinical leadership group to own and
drive the work. What should the next step be?
A Develop performance measures for the operating room.

Implement structured communication techniques in the operating
B
room.
Review the cultural assessment information about the
C
operating room.
D Provide teamwork training for operating room staff.
Answer: C
According to the collective opinions, research, and tested theories
of a panel of experts1, the following sequence is recommended for
improving safety and reliability:
Step 1. Engage leaders, both senior and physician.
Step 2. Systematically survey the culture and identify risk areas.
Step 3. Provide targeted team training that combines specific tools
and behaviors, which are embedded within clinical domain-specific
processes of care.
Step 4. Reliably design processes.
Step 5. Apply direct observation and feedback to observe
teamwork behaviors and monitor the success of initiatives.
Step 6. Define, implement, monitor, and establish a feedback
mechanism for process, outcome, and organizational measures to
show success and drive improvement.
Step 7. Use performance improvement strategies to structure
continuous improvement.
organization
Question 12
An acute care facility is tracking the monthly rate of ventilator-
associated pneumonia in the adult ICU. What is the most sensitive
tool for identifying special cause variation?
A Line chart
B Run chart
C Control chart
D Pareto chart
Answer: C
Time series data, such as the monthly rate of ventilator-associated
pneumonia, may be plotted on a line chart, run chart, or control
chart (but not a Pareto chart, which displays categorical data).
Among these options, a control chart is the most sensitive for
identifying special cause variation.

control chart)
Question 13
What is the most common reason for a team to struggle to develop
a data collection plan?
A Lack of leadership support.

B Lack of motivation and enthusiasm among team members.
C Inadequate expertise in the methods and tools of data collection.
D The team's goals are too ambitious.
Answer: C
Teams often encounter difficulty in developing a data collection
plan because team members are not well versed in the methods and
tools of data collection.

Improvement
question is linked:Design organizational performance/quality
improvement training (e.g. quality, patient safety)
Question 14
How can the Chief Executive Officer best contribute to the success
of a key improvement project in her organization?
A Assign a quality professional to assist in the project.
B Conduct regular, in-person reviews of the project.
C Offer financial incentives.
D Personally select members of the improvement team.
Answer: B
A key ingredient to the success of any improvement effort is
executive review. A Chief Executive Officer's active, in-person, real-
time engagement in key quality projects in their organization has a
larger effect on their success, scale, and spread than other tactics.

question is linked:Facilitate development of leadership values
and commitment to quality
Question 15
Which of the following is an organizational measure?
A Prophylactic antibiotic received within one hour prior to surgical incision
B Unplanned return to theatre
C Percent of clean surgery patients with surgical infection
D Percent of surgical cases that were started on time

Answer: D
Organizational measures, as opposed to process and outcome
measures, reflect system issues. An example is how often surgical
cases were started on time. ―Prophylactic antibiotic received within
one hour prior to surgical incision‖ is an example of process
measures (which show whether the processes of care were
followed). ―Unplanned return to theatre‖ and ―percent of clean
surgery patients with surgical infection‖ are examples of outcome
measures.

question is linked:Identify performance measures/key
performance/quality indicators (e.g. balanced scorecards,
dashboards)
Question 16
Progress of an improvement project has stalled. One of the main
issues identified was that a few loud naysayers were blocking
implementation of ideas by the rest of the team, which suggests
A absence of strong enough ideas for improvement.

B failure to execute changes.
C a lack of organizational will.
D too many physicians on the team.
Answer: C
If a project is not achieving the intended results, it is probably due
to one (or more) of only three problems:
 Lack of organization will
 Absence of strong enough ideas for improvement
 Failure to execute changes
Inability or unwillingness to effectively manage a few loud

naysayers who are blocking implementation of ideas by the rest of
the team suggests lack of organizational will.

question is linked:Facilitate program/project development and
evaluation (e.g. enterprise risk management, patient safety,
infection prevention and control, new service lines)
Question 17
In failure mode and effects analysis, what does the Risk Priority
Number refer to?
A Each failure mode and the process

B Each failure mode and its effects
C The potential causes of each failure mode only
D None of the above
Answer: A
A Risk Priority Number (RPN), or Criticality Index, should be
assigned to each failure mode. In addition, the overall RPN for the
process is the sum of the RPNs for the failure modes.

question is linked:Perform or coordinate risk management:
failure mode and effects analysis
Question 18
Which of the following is NOT an appropriate red rule?
When a midwife is concerned at the bedside and asks the obstetrician to

A
come to the bedside, he or she should come in a timely manner.
Elective induction of labor prior to 39 weeks for nonmedical reasons is
B
not permitted.
If there is a discrepancy in the sponge count during surgery, the patient
C
should have an X-ray before leaving the operating room.
Nurses should observe the “5 Rights” of medication
D
administration when administering any drug.
Answer: D
Red rules are rules that cannot be broken. Therefore, if a red rule is
violated, the organization should be prepared to stop further
patient care associated with the red rule, no matter how
inconvenient or costly, in order to protect the patient or employee
from harm.
Among the four answer options, the ―5 Rights‖ of medication

administration, though almost universally adopted, frequently do
not prevent medication errors, partly because the ―5 Rights‖ do not
offer adequate procedural guidance. Therefore, they are the least
appropriate candidate for a red rule.
organization
Question 19
As part of its initiative to improve prophylactic perioperative
antibiotic utilization, an acute care facility aimed to administer
perioperative antibiotics within 1 hour of surgical incision in 100%
of cases.
To whom should the responsibility of timely perioperative

antibiotic administration be assigned?
A Anesthesiologist
B Surgeon
C Scrub nurse
D Circulating nurse
Answer: A
Adherence to the clinical protocol can be enhanced by making the
performance measure of interest (timely perioperative antibiotic
administration, in this case) part of the everyday work of
caregivers. The anesthesiologist would be the most appropriate
person to ensure satisfactory performance in the timing of
antibiotic administration, as he/she may administer the
antibiotic(s) with induction of anesthesia.

organization
Question 20
An acute care facility performed failure mode and effects (FMEA)
analysis of the medication administration process.
For the final step of the process, an identified possible failure mode
was the availability of discontinued medications for use. Its
likelihood of occurrence, likelihood on detection, and severity of
impact were given a rating on a scale of 1 to 10:
 Occurrence 4
 Detection 8
 Severity 6
What action should the FMEA team recommend to reduce the
occurrence of failure?
A Introduce dedicated medication nurses.

B Implement an automated medication dispensing system.
C Train staff to recognize early signs of drug toxicity.
Implement pharmacy rounds to remove discontinued
D medications from patient care units within 1 hour of
discontinuation.
Answer: D
In this case, detection of the failure mode is, in relative terms, the
biggest problem (the higher the rating, the lower the likelihood the
failure will be detected). In general, if the failure mode is unlikely
to be detected, strategies that should be considered include:
 Identifying other events that may occur prior to the
failure mode and can serve as ―flags‖ that the failure
mode might happen;
 Adding a step to the process that intervenes at the earlier

event to prevent the failure mode (removing
discontinued medications soon after discontinuation is
an example of this); and
 Technological alerts.
Dedicated medication nurses and an automated dispensing system

may reduce theoccurrence of the failure mode.
Training staff to detect an event soon after its occurrence, and
therefore provide opportunity for early mitigating intervention, is
most appropriate if the failure is likely to cause severe harm.
failure mode and effects analysis
Question 21
The system level measures of a hospital include overall mortality
rate and emergency room (ER) waiting time. The projects that are
being implemented include:
 Use of evidence-based bundles in ICU care
 ER flow management
 Surgical wound infection reduction
After 12 months, the weekly average percentage of under-4-hour

waits has increased significantly. However, the mortality rate has
not shown any change. What should the hospital do next?
A Abandon one or more projects
B Add one or more projects
C Modify the existing projects
D Continue to monitor the mortality rate

Answer: C
After 12 months, the hospital should have witnessed a change in
the mortality rate ifthe projects selected were linked to mortality
(e.g. improving flow would reduce mortality in this
hospital) and the projects were properly implemented, as
evidenced by their process measures. It would be reasonable to
assume that the three projects listed above would impact the
mortality rate. Therefore, the most appropriate next step would be
to review and modify the current projects.
Improvement
Question 22
The number of pressure ulcers, number of admissions, and annual
mean length of stay at a hospital are shown below.
What is your conclusion about the annual incidence of pressure
ulcers in this hospital from 2010 through 2012?
A The incidence of pressure ulcers was unchanged.

B The incidence of pressure ulcers increased.
C The incidence of pressure ulcers decreased.
D The incidence of pressure ulcers demonstrated common cause variation.
Answer: A
Incidence is the number of new cases over the period of interest
(each year in this example). To calculate the incidence, the number
of cases is the numerator and the number of admissions is the
denominator. For example, in 2010, there were 1,200 cases and
24,000 admissions. Therefore, the incidence of pressure ulcers was
5% (1,200/24,000) in 2010. The incidence of pressure ulcers in the
next two years is also 5%. Therefore, the annual incidence did not
change between 2010 and 2012.
The length of stay would only have been relevant if the question
required us to calculate the incidence rate.
question is linked:Interpret data to support decision making
(e.g. benchmarking, outcome data)
Question 23
What element(s) of care should patients be asked to teach back?
A Contact information for getting help

B The importance of keeping the follow-up visit
C Self-care on return home
D All of the above
Answer: D
Some of the critical elements of care that patients should be asked
to teach back are:
 The importance of keeping the follow-up visit
 Self-care on return home
 Contact information for getting help, if needed
 Use and doses of prescribed medications

question is linked:Integrate patient safety initiatives into
organizational activities
Question 24
The office layout at an acute care facility was restricting the work
flow and was not customer friendly. The management decided that
a redesign of both the layout and the process in which patients are
registered and receive care was required.
What is the greatest barrier to success?
A Lack of knowledge and skills in quality improvement

B Misallocation of staff time
C Suboptimal team composition
D Mind-set about the work
Answer: D
The most challenging aspect of redesign—as opposed to
incremental improvements—is changing the mind-set about the
work and establishing new ways of doing the work. Redesign
requires more time, more effort, and a new mind-set. It includes
changing the culture and engaging in a new dialogue.

Improvement
Question 25
―Workdays lost per 100 employees per year‖ is a measure of
A timeliness.
B safety.
C effectiveness.
D efficiency.
Answer: B
―Workdays lost per 100 employees per year‖ is a measure of safety,
in particular staff safety.

dashboards)
Question 26
Tacrolimus is an immunosuppresive drug used in transplant
patients. The drug has a narrow therapeutic range: administering
too little of the drug may result in the transplanted organ being
rejected; administering too much of the drug risks damaging the
patient's kidneys or weakening his or her defenses against
infection.
Among the following methods of administering tacrolimus, which

is the safest?
Start on a dose based on a guideline, measure blood levels of tacrolimus

A
on a regular basis, and adjust the dose according to the blood level.
Measure the patient's renal function before treatment to determine the

B initial dose, measure renal function on a regular basis, and modify the
dose according to renal function.

C tacrolimus on a regular basis, create run charts for each patient
and establish statistical rules for adjusting the dose.
Start on a dose based on a guideline and adjust the dose according to

D
clinical response.
Answer: C
The usual method of administering tacrolimus involves starting on
a dose based on a guideline, measuring blood levels of tacrolimus
at regular intervals, and adjusting the dose according to the blood
level. However, this standard method is associated with a relatively
low frequency of tacrolimus levels being in the desired therapeutic
range.
Applying statistical process control (SPC) to the problem will more

likely yield better results. Healthcare providers can create run
charts for each patient and establish statistical rules for adjusting
dosage. These rules, based on SPC, determine whether any given
blood level is just ―noise‖ (common cause variation) or is a ―signal‖
(special cause variation).

control chart)
Question 2
Question 1
Clinical practice guidelines reduce
random variation.
A
anticipated variation.
B
assignable variation.
C
all types of variation.

D
Question 2
The scientific method in quality improvement is represented by
Failure Mode and Effects Analysis.

A
statistical process control.
B
sequential problem solving.
C
the PDCA cycle.
D
Question 3
The figure below shows the time period between admission to the
Emergency Room and receipt of thombolytic therapy by patients with
acute myocardial infarction. Control limits are set at 3 sigma.
What is your interpretation of the results?
There was successive reduction in average time between admission and the
receipt of thrombolytic therapy in Phase 2 and Phase 3, and reduction in
A
variability in Phase 2 but not in Phase 3.
There was successive reduction in variability in Phase 2 and Phase 3, but no
reduction in average time between admission and the receipt of thrombolytic
B
therapy in Phase 2 or Phase 3.
There was reduction in variability and average time between admission and
the receipt of thrombolytic therapy in Phase 2 but no further reduction in
C
variability or average time in Phase 3.
There was successive reduction in both variability and average time between
D admission and the receipt of thrombolytic therapy in Phase 2 and Phase 3.
Question 4
Team members are divided about the next course of action in an
important project. It appears that the conflict is severe enough to
warrant intervention. Who is responsible for managing the conflict?
Sponsor or Team Leader

A
Team Leader or Coach
B
Coach or Sponsor
C
Team Leader only
D
Question 5
Variance analysis refers to
the method of measuring care against a clinical pathway.

A
the degree of variation in a control chart.
B
healthcare professionals' deviation from the standard of care.
C
all of the above.
D
Question 6
Criteria for the first stage of ―meaningful use‖ of electronic health
records focus on all of the following EXCEPT
tracking key clinical conditions.

A
reporting of clinical quality measures.
B
standardizing the capture of health data.
C
transmitting patient care summaries across multiple healthcare settings.
D
Question 7
Why are surgeons who perform few procedures excluded from
comparisons?
Low-volume surgeons tend to be highly selective of their patients

A
Inability to adjust for risk factors when there are only a few procedures
B
Higher patient mortality rates among surgeons who perform only a few
C procedures
All of the above
D
Question 8
Variance in a clinical pathway is the result of
omission of an action by a care provider.

A
change in the patient's condition.
B
factors relating to the patient's personal circumstances.
C
any of the above.
D
Question 9
In a hospital accredited by The Joint Commission, ultimate
responsibility for all medical credentialing decisions lies with the
governing body.
A
medical staff department.
B
Medical Executive Committee.
C
credentialing committee.
D
Question 10
Which of the following is an advantage of using a Credentials
Verification Organization?
Greater control over the credentialing verification process.
A
Greater reliability in turnaround times for the credentialing verification
B process.
More cost-effective than if the credentialing verification process was
C performed internally.
Reduction of duplication of information required of the practitioner in the
D credentialing verification process.
Question 11
Which of the following factors is LEAST likely to contribute to the
success of a team?
Clear and well-articulated objectives

A
Regular feedback given to the team
B
Feedback provided on the performance of individual team members
C
Team members having common responsibility of individual tasks
D
Question 12
Peer review refers to an in-depth review of care involving:
an individual patient.
A
an identifiable group of patients.
B
an individual practitioner.
C
any of the above.
D
Question 13
During a TJC accreditation survey, which of the following is NOT an
individual patient tracer selection criterion?
Clinical or service group identified from the Priority Focus Process.

A
Patient, client, or resident who crosses different programs.
B
Patient, client, or resident who experiences a serious adverse event.
C
Patient, client, or resident who relates to an infection control system tracer.
D
Question 14
Which body is responsible for evaluating the competency of a
physician seeking medical staff privileges in the Department of
Cardiology at a hospital?
Department of Cardiology
A
Credentialing department
B
Credentialing committee
C
Medical executive committee
D
Question 15
Which of the following tools is most useful for linking an
organization's strategy to action and desired outcomes?
Brainstorming
A
Gantt chart
B
Balanced scorecard
C
Pareto chart
D
Question 16
Which of the following statements best defines a quality problem?
The gap between what is and what is expected by the customer.

A
The gap between what is and what is desired by the organization.
B
The gap between what is and what is the benchmark.
C
The gap between what is and what is expected by accreditation bodies.
D
Question 17
Data on length of stay of 251 randomly-selected admitted patients are
summarized in the figure below.
(Assume N = 251, and not N = 25 as stated in the figure.)
What should the next step be?
Investigate lengths of stay of 5 days.

A
B
C
Investigate lengths of stay of 9 days or more.
D
Question 18
For which of the following care processes will evidence-based
medicine most likely result in quality improvement?
Treatment of acute myocardial infarction (heart attack)

A
Organ transplantation
B
Total hip replacement surgery
C
Administration of influenza vaccines
D
Question 19
How do PDCA cycles for implementing a change differ from test
PDCA cycles?
Cycles for implementing a change take longer than test cycles.

A
Failures are expected when the change is implemented.
B
Less resistance to the change can be expected during PDCA cycles for
C implementing a change.
The two types of PDCA cycles are the same.
D
Question 20
A diagnostic colonoscopy within 60 days is recommended among
patients with a positive fecal occult blood test. Which measure most
closely reflects this goal?
Proportion of patients with a positive fecal occult blood test receiving a

A diagnostic colonoscopy within 60 days.
Average waiting time for patients with a positive fecal occult blood test to
B receive a diagnostic colonoscopy.
C diagnostic colonoscopy within the maximum logical timeframe.
The 5-year survival rate among patients with a positive fecal occult blood
D test.
Question 21
Processing times at a laboratory are shown in the figure below. An
improvement project commenced at time period 31, and this resulted
in a new standardized operating procedure being implemented. The
observation at time period 40 falls below the lower control limit.
Besides monitoring the data, what should the improvement team do
next?
Begin another improvement project

A
Validate the data
B
Calculate new control limits
C
Do nothing
D
Question 22
When implementing a Continuous Quality Improvement (CQI)
program in an acute care facility, surveys are used to better
understand
customer needs.
A
the demographics of the population.
B
the organization's level of performance.
C
business processes.
D
Question 23
A performance improvement team aims to reduce the rate of post-
surgical infection rates in a small rural acute care facility. Which of
the following should the team use as a reference?
The post-surgical infection rates among individual surgeons.

A
Postoperative antibiotic use among the surgeons.
B
National benchmark post-surgical infection rates based on the most recent
C research.
Post-surgical infection rates in similar facilities.
D
Question 24
An organization's balanced scorecard is best described as
a graphical display of departmental performance.

A
an integrated report of the best performing teams.
B
a summary of key performance indicators.
C
a tool that helps prioritize customer needs.
D
Question 25
The outcomes of cardiopulmonary resuscitation (CPR) at an acute
care facility in the past 12 months have been poorer than similar
organizations in the area. How can the facility assess
multidisciplinary team performance during CPR?
Survey of team members

A
Review of the facility's Code policy
B
Direct observation
C
Review of medical records
D
Question 26
Responsibility for providing organizational direction for a facility's
Continuous Quality Improvement program rests with the
quality improvement teams.

A
medical staff.
B
Director of Quality.
C
Quality Council.
D
Question 27
An organization has achieved a culture of patient safety when
fear of reprisals for reporting incidents has been eliminated.

A
its patient safety goals have been implemented.
B
patient safety training of employees has completed.
C
reports of incidents and near misses have decreased.
D
Question 1
A random variation.
B anticipated variation.
C assignable variation.
D all types of variation.
Answer: C
Clinical practice guidelines reduce assignable variation. The latter
arises from identifiable causes that can be tracked and eliminated. In
the context of clinical practice guidelines, assignable variation
represents inappropriate variation.
Content Category: Performance Measurement and Improvement
question is linked:Facilitate evaluation/selection of evidence-
based practice guidelines (e.g. for standing orders or as guidelines for
physician ordering practice)
Question 2
A Failure Mode and Effects Analysis.

B statistical process control.
C sequential problem solving.
D the PDCA cycle.
Answer: D
The Plan-Do-Check-Act (PDCA) Cycle exemplifies the scientific
method in quality improvement: planning a
change, doing it, checking to see its effect, and then actingon what we
have learned by either rejecting the change or making it a standard
part of the process.
question is linked:Determine applicability of performance
improvement models (e.g. PDCA, Six Sigma, Lean)
Question 3
The figure below shows the time period between admission to the
Emergency Room and receipt of thombolytic therapy by patients with
acute myocardial infarction. Control limits are set at 3 sigma.
What is your interpretation of the results?
There was successive reduction in average time between admission and the
A receipt of thrombolytic therapy in Phase 2 and Phase 3, and reduction in
variability in Phase 2 but not in Phase 3.
There was successive reduction in variability in Phase 2 and Phase 3, but no
B reduction in average time between admission and the receipt of thrombolytic
therapy in Phase 2 or Phase 3.
There was reduction in variability and average time between admission and
C the receipt of thrombolytic therapy in Phase 2 but no further reduction in
variability or average time in Phase 3.
There was successive reduction in both variability and average time between
D
admission and the receipt of thrombolytic therapy in Phase 2 and Phase 3.
Answer: D
There is successive reduction in variation in both Phase 2 and Phase
3, as evidenced by the narrower control limits and the points
generally falling increasingly closer to the center line.
There is clearly successive reduction in the average time between
admission and the receipt of thrombolytic therapy, as evidenced by
the increasingly lower center lines in Phase 2 and Phase 3.

control chart)
Question 4
Team members are divided about the next course of action in an
important project. It appears that the conflict is severe enough to
warrant intervention. Who is responsible for managing the conflict?
A Sponsor or Team Leader

B Team Leader or Coach
C Coach or Sponsor
D Team Leader only
Answer: B
The most appropriate persons to manage conflict within a team are
the Team Leader or the Coach. Either or both of these individuals are
responsible for intervening when there is severe conflict within the
team.

Question 5
Variance analysis refers to
A the method of measuring care against a clinical pathway.

B the degree of variation in a control chart.
C healthcare professionals' deviation from the standard of care.
D all of the above.
Answer: A
Variance analysis, in the context of healthcare quality management,
usually refers to the method of measuring care against a clinical
pathway.

question is linked:Facilitate or participate in the development of
clinical/critical pathways or guidelines
Question 6
Criteria for the first stage of ―meaningful use‖ of electronic health
records focus on all of the following EXCEPT
A tracking key clinical conditions.

B reporting of clinical quality measures.
C standardizing the capture of health data.
D transmitting patient care summaries across multiple healthcare settings.
Answer: D
―Meaningful use‖ of electronic health records will evolve in three
stages over five years, or more. In Stage 1, eligible healthcare
professionals and hospitals are expected to meet criteria that focus
on:
 Electronically capturing health information in a
standardized format
 Using that information to track key clinical conditions
 Communicating that information for care coordination

processes
 Initiating the reporting of clinical quality measures and

public health information
 Using information to engage patients and their families in

their care
(CMS has delayed the onset of Stage 2 criteria until 2014.)

question is linked:Link performance/quality improvement
activities with strategic goals
Question 7
Why are surgeons who perform few procedures excluded from
comparisons?
A Low-volume surgeons tend to be highly selective of their patients

B Inability to adjust for risk factors when there are only a few procedures
Higher patient mortality rates among surgeons who perform only a few
C
procedures
D All of the above
Answer: B
Small sample sizes usually means that adjustment for risk factors is
not possible. Therefore, measured health outcomes may be
statistically less reliable for a low-volume surgeon. For this reason,
surgeons who perform few procedures are often excluded from
comparisons.

question is linked:Facilitate development or selection of process
and outcome measures
Question 8
Variance in a clinical pathway is the result of
A omission of an action by a care provider.

B change in the patient's condition.
C factors relating to the patient's personal circumstances.
D any of the above.
Answer: D
There are several potential reasons for variance in a clinical pathway.
Many variances are due to omission of an action or the performance
of an action that is late on the part of the nurse or other care provider.
However, variances may also be due to the patient's condition
(necessitating other action that deviates from the pathway), personal
and social circumstances of the patient or family, factors outside the
organization that delay the progress of the patient, as well as factors
that relate to the departments and processes that operate within an
organization and result in delays.
Question 9
In a hospital accredited by The Joint Commission, ultimate
responsibility for all medical credentialing decisions lies with the
A governing body.
B medical staff department.
C Medical Executive Committee.
D credentialing committee.
Answer: A
The Joint Commission's standards for the Governing Body state that
the governing body is ultimately accountable for all medical
credentialing decisions.

question is linked:Facilitate or participate in the credentialing and
privileging process (e.g. Focused Professional Practitioner Evaluation
(FPPE), Ongoing Professional Practitioner Evaluation (OPPE))
Question 10
Which of the following is an advantage of using a Credentials
Verification Organization?
A Greater control over the credentialing verification process.

Greater reliability in turnaround times for the credentialing verification
B
process.
More cost-effective than if the credentialing verification process was performed
C
internally.
Reduction of duplication of information required of the practitioner in the
D
credentialing verification process.
Answer: D
One of the main advantages of using a Credentials Verification
Organization (CVO) is reduction, or even elimination, of information
required of the practitioner. If a CVO processes the majority of
practitioner applications in one area, the practitioner may be required
to complete only one application and possibly one recredentialing
application.
Delegating the credentialing verification process is associated with

less control and usually greater cost. The CVO may not be able to
reliably meet the turnaround time required by NCQA.

Question 11
Which of the following factors is LEAST likely to contribute to the
success of a team?
A Clear and well-articulated objectives

B Regular feedback given to the team
C Feedback provided on the performance of individual team members
D Team members having common responsibility of individual tasks
Answer: D
Answer options A, B, and C are recognized factors that lead to
successful teams. In successful teams, members are given unique and
meaningful tasks.
improvement teams (i.e., as a coordinator or team
Question 12
Peer review refers to an in-depth review of care involving:
A an individual patient.
B an identifiable group of patients.
C an individual practitioner.
D any of the above.
Answer: D
Peer review refers to an in-depth review of an individual practitioner
by persons with similar training, skills, and experience, in care that
involves:
 An individual practitioner;
 An individual patient; or
 A group of identifiable patients.

question is linked:Participate in the process of organizational
reviews or audits for peer review
Question 13
During a TJC accreditation survey, which of the following is NOT an
individual patient tracer selection criterion?
A Clinical or service group identified from the Priority Focus Process.

B Patient, client, or resident who crosses different programs.
C Patient, client, or resident who experiences a serious adverse event.
Patient, client, or resident who relates to an infection control system
D
tracer.
Answer: C
The following are selection criteria for individual patient tracers:
 Clinical or service group identified from the Priority Focus

Process
 Patient, client, or resident who received complex services
 Patient, client, or resident who crossed different programs

(e.g. hospital to long-term)
 Patient, client, or resident who relates to system tracers

(medication management; infection control)

question is linked:Aid in evaluating survey readiness for
accrediting and regulatory bodies
Question 14
Which body is responsible for evaluating the competency of a
physician seeking medical staff privileges in the Department of
Cardiology at a hospital?
A Department of Cardiology
B Credentialing department
C Credentialing committee
D Medical executive committee
Answer: A
In a hospital, competency evaluation is the responsibility of the
department where privileges are being sought.

Question 15
Which of the following tools is most useful for linking an
organization's strategy to action and desired outcomes?
A Brainstorming
B Gantt chart
C Balanced scorecard
D Pareto chart
Answer: C
The balanced scorecard links the organization's strategy to action, i.e.
execution of the strategy. None of the other options (A, B, D) do this.
Question 16
Which of the following statements best defines a quality problem?
A The gap between what is and what is expected by the customer.

B The gap between what is and what is desired by the organization.
C The gap between what is and what is the benchmark.
D The gap between what is and what is expected by accreditation bodies.
Answer: B
The term "quality problem" is usually used interchangeably with
"area for improvement." It is usually defined as the gap between what
is and what is desired by the organization. It does not necessarily
have to be in response to customer feedback. A quality problem may
not necessarily arise from a deficiency or defect; in fact, things can be
quite satisfactory but the organization may choose to aim for a higher
level of quality. The gap is not defined by any benchmark or
accreditation standard.
question is linked:Facilitate establishment of priorities for
performance/quality improvement activities
Question 17
Data on length of stay of 251 randomly-selected admitted patients are
summarized in the figure below.
(Assume N = 251, and not N = 25 as stated in the figure.)

What should the next step be?
A Investigate lengths of stay of 5 days.

B Investigate lengths of stay of 6 days.
C Investigate lengths of stay of 8 days.
D Investigate lengths of stay of 9 days or more.
Answer: C
The Pareto chart shows a surprisingly high incidence of LOS = 8. One
would have expected a lower incidence of LOS = 8, compared with
LOS = 6 or LOS = 7. Therefore, cases with a LOS = 8 should be
investigated.

Cognitive level required for a response: Analysis
question is linked:Interpret data to support decision making (e.g.
benchmarking, outcome data)
Question 18
For which of the following care processes will evidence-based
medicine most likely result in quality improvement?
A Treatment of acute myocardial infarction (heart attack)
B Organ transplantation
C Total hip replacement surgery
D Administration of influenza vaccines
Answer: D
Evidence-based medicine (EBM) is likely to work best on care
processes with relatively low levels of uncertainty. As uncertainty
within a care process increases, the utility of EBM (and other
methods that reduce special-cause variation) decreases. Among the
four answer options, the administration of influenza vaccines is the
care process associated with the least amount of uncertainty. The
administration of influenza vaccinations is an example of a standard
care process, i.e. one with little uncertainty and that can be repeated
without significant deviation. The uncertainty in each of the other
answer options (A, B, and C) stems largely from the disease process
and/or the patient.
Improvement
Question 19
How do PDCA cycles for implementing a change differ from test
PDCA cycles?
A Cycles for implementing a change take longer than test cycles.

B Failures are expected when the change is implemented.
Less resistance to the change can be expected during PDCA cycles for
C
implementing a change.
D The two types of PDCA cycles are the same.
Answer: A
PDCA cycles for implementing a change differ from test cycles in the
following ways:
 Support processes need to be developed to support the

change as it is implemented.
 Failures are not expected when the change is implemented.
 Increased resistance to the change can be expected as it

affects more people.
 Cycles for implementing a change take longer than test

cycles.
Improvement
Question 20
A diagnostic colonoscopy within 60 days is recommended among
patients with a positive fecal occult blood test. Which measure most
closely reflects this goal?

A
diagnostic colonoscopy within 60 days.
Average waiting time for patients with a positive fecal occult blood test to
B
receive a diagnostic colonoscopy.
C
diagnostic colonoscopy within the maximum logical timeframe.
D The 5-year survival rate among patients with a positive fecal occult blood test.
Answer: A
Answer option A most closely reflects the goal (of a diagnostic
colonoscopy within 60 days of a positive fecal occult blood test).
Average waiting time (answer option B) can be influenced by rare
cases. Answer option C does not reflect the targeted time frame goal.
Answer option D is not closely related to the goal (in this case);
survival will depend on multiple factors other than early diagnosis.

Improvement
Question 21
Processing times at a laboratory are shown in the figure below. An
improvement project commenced at time period 31, and this resulted
in a new standardized operating procedure being implemented. The
observation at time period 40 falls below the lower control limit.
Besides monitoring the data, what should the improvement team do

next?
A Begin another improvement project

B Validate the data
C Calculate new control limits
D Do nothing
Answer: C
The control chart indicates that there was improvement (reduction)
in the processing times after the new standardized operating
procedure was implemented. Because the values have improved, new
control limits should be calculated (using the improved values) to
maintain the quality gains.
Beginning another improvement project seems premature because

the new process has not been shown to be stable yet (too few data
points). Data validation should have been done at a much earlier
stage.

question is linked:Use or coordinate the use of statistical process
control components (e.g. common and special cause variation,
random variation, trend analysis)
Question 22
When implementing a Continuous Quality Improvement (CQI)
program in an acute care facility, surveys are used to better
understand
A customer needs.
B the demographics of the population.
C the organization's level of performance.
D business processes.
Answer: A
In the context of CQI, the primary use of surveys is to gain greater
insight into customer needs.
question is linked:Assess customer needs/expectations (e.g.
surveys, focus groups, teams) to ensure the voice of the customer is
heard
Question 23
A performance improvement team aims to reduce the rate of post-
surgical infection rates in a small rural acute care facility. Which of
the following should the team use as a reference?
A The post-surgical infection rates among individual surgeons.

B Postoperative antibiotic use among the surgeons.
National benchmark post-surgical infection rates based on the most recent
C
research.
D Post-surgical infection rates in similar facilities.
Answer: D
The number of surgeons in the facility cannot be high (it's a small
rural facility) and their patients and procedures are likely to be
different. All these factors will contribute to variation in post-surgical
infection rates among the surgeons.
Postoperative antibiotic use is not a good indicator of infection rates

due to wide variation in antibiotic prescription among physicians.
National benchmarks are inappropriate because the patient

populations of the top performing hospitals are likely to be different
(compared with that of this hospital) and, therefore, not comparable.
Infection rates in similar facilities are probably the best comparison
in this case.

Question 24
An organization's balanced scorecard is best described as
A a graphical display of departmental performance.

B an integrated report of the best performing teams.
C a summary of key performance indicators.
D a tool that helps prioritize customer needs.
Answer: C
A balanced scorecard summarizes key performance indicators.
dashboards)
Question 25
The outcomes of cardiopulmonary resuscitation (CPR) at an acute
care facility in the past 12 months have been poorer than similar
organizations in the area. How can the facility assess
multidisciplinary team performance during CPR?
A Survey of team members

B Review of the facility's Code policy
C Direct observation
D Review of medical records
Answer: C
In this case, direct observation is the best way to evaluate team
performance.

Improvement
question is linked:Evaluate team performance
Question 26
Responsibility for providing organizational direction for a facility's
Continuous Quality Improvement program rests with the
A quality improvement teams.

B medical staff.
C Director of Quality.
D Quality Council.
Answer: D
The Quality Council is responsible for direction and oversight of the
organization's quality improvement program.

question is linked:Facilitate establishment of a
performance/quality improvement oversight group (e.g. Quality
Council, Steering Council, QM Council, Patient Safety Committee)
Question 27
An organization has achieved a culture of patient safety when
A fear of reprisals for reporting incidents has been eliminated.

B its patient safety goals have been implemented.
C patient safety training of employees has completed.
D reports of incidents and near misses have decreased.
Answer: A
Elimination of fear of reprisals for reporting incidents among staff is
a feature of an organizational culture of patient safety.
Implementing patient safety goals or patient safety training alone

does not necessarily translate to a culture of patient safety.
A reduction in the number of incident reports could mean that

patient safety has improved. But it could also mean a culture of fear
that discourages many staff members from reporting.

Question
3
Question 3
Question 1
Staff members of a medical unit are working to improve patient
satisfaction, the scores for which have been significantly lower than
the system's mean for 2 consecutive years. In dealing with a small
group of cynical employees, your advice to the Chief Nursing Officer
would be to
exclude them from the improvement design team.

A
include them on the improvement design team but only in the initial phases.
B
include them on the improvement design team but only in the final phases.
C
include them on the improvement design team throughout the initiative.
D
Question 2
Which of the following factors is LEAST likely to contribute to poorly
executed transitional care?
Incomplete communication among providers and across healthcare agencies.

A
Recent implementation of an electronic health record system.

B
Inadequate patient and caregiver education and involvement in decision
C making.
Multiple chronic medical conditions and complex medication regimens.

D
Question 3
Which of the following is likely to have the greatest impact on quality
of care and cost savings?
Clinical integration of patient care services.

A
Administrative reengineering.
B
Management reengineering.
C
Corporate restructuring.
D
Question 4
Ultimate responsibility for quality improvement in a healthcare
organization rests with the
Chief Executive Officer.

A
Quality Council.
B
governing body.
C
medical staff.
D
Question 5
In implementing a program to improve patient flow in a high-volume
ambulatory care clinic, the team measured office visit cycle time, i.e.
the amount of time in minutes that a patient spends at the clinic. The
cycle time can be divided into time spent with the nonclinical team
(clerical/administrative personnel) and actual time spent with the
patient care team. Patients with chronic medical conditions such as
hypertension, diabetes, and high cholesterol constitute a majority of
the clinic volume.
For this program, measurement of which of the following is LEAST

appropriate?
Staffing ratio for both clinical and nonclinical staff.

A
Patient satisfaction.
B
Blood pressure control.
C
No-show rate.
D
Question 6
A retrospective cross-sectional study was conducted to evaluate the
criterion validity of the Agency for Healthcare Research and Quality's
Patient Safety Indicator (PSI) 7. Of the 191 abstracted records that
met criteria for PSI 7 based on hospital-reported ICD-9-CM codes,
review of the medical records verified that 104 or 54.5% (95%
confidence interval: 40–69%) experienced an infection or
inflammatory reaction due to medical care that began during the
same hospitalization.
What was being measured in this study?
Prevalence
A
Incidence
B
Sensitivity
C
Positive Predictive Value
D
Question 7
Among the following factors, nurse response to alerts by a
computerized drug utilization review system is LEAST likely to be
associated with
the number of alerts.

A
the appropriateness of alerts.
B
a perception that the system is unhelpful and annoying.
C
the patient's primary medical condition.
D
Question 8
In discussing ways to improve patient flow in the Operating Room
(OR)—a potentially controversial issue due to a possible change in the
OR schedule—which of the following techniques should a team
employ?
Affinity Diagram
A
Brainstorming
B
Nominal Group Technique
C
Multivoting
D
Question 9
Which of the following is a characteristic of error-reducing
industries?
Relying on events that cause serious injury and death more than reports of
A errors and ―near misses.‖
Investigating all errors but not necessarily thoroughly for each of them.
B
Tolerating high-error rates if they can be explained by human factors
C psychology.
Recognizing that solutions often come from unexpected sources.

D
Question 10
An improvement team has been working on an initiative to reduce the
use of seclusion and restraint in an acute inpatient psychiatric service.
After 9 months, the use of seclusion and restraint has reduced but the
rate of physical assaults on patients and staff was found to have
increased significantly.
At this stage, the team should
abandon the initiative to reduce the use of seclusion and restraint.

A
recommend an increase in the use of seclusion and restraint.
B
consider strategies aimed at timely behavioral management.
C
recommend a review of patients' pharmacotherapy.
D
Question 11
The rate of patient falls in an acute care facility has been above the
mean for a group of 20 hospitals in the State for the past 12 months.
In designing and implementing a new fall prevention program, which
of the following changes is MOST likely to have the greatest impact on
preventing falls?
Visual identifiers for high risk patients.

A
Close monitoring of program compliance and outcomes.
B
Changing the fall risk assessment tool.
C
Introduction of floor pads.
D
Question 12
In a survey of patient satisfaction, p control charts may be used to
measure stability over time, compare findings with a threshold, and
A determine why a threshold was not met.
measure individual patient responses, compare findings with a threshold, and
B determine why a patient was not satisfied.
measure individual patient responses, compare each individual's result with
C all other patients, and determine type of variation.
D determine type of variation.
Question 13
Which of the following statements about conflict is the MOST
appropriate?
Conflict should be promoted in most teams.

A
The most effective way to manage any conflict is by compromise.
B
The most effective way to manage any conflict is by problem solving.
C
Avoiding a conflict can sometimes be useful.
D
Question 14
An improvement team has split into two factions over a trivial issue.
Which of the following strategies is the most appropriate for team
members to adopt?
Problem solving
A
Compromising
B
Smoothing over the conflict
C
Avoiding the conflict
D
Question 15
Which of the following actions is the most appropriate for the Team
Leader to take during the Norming stage of team development?
Fully utilize Team Members' skills, knowledge, and experience.

A
Represent, and advocate for, the team with other groups and individuals.
B
Develop and implement agreements about how decisions are made and who
C makes them.
Provide clear direction and purpose.

D
Question 16
In a three year period, mortality rates at Hospital X, a
multidisciplinary tertiary referral center, was found to be
unacceptably high. Which of the following would you LEAST expect
in an investigation conducted by a committee?
Tracking of process measures and targets.

A
Considerable attention given to throughput.
B
Training of staff at the lowest levels in the hierarchy.
C
Staff being unclear about their roles and responsibilities.
D
Question 17
Which of the following is LEAST useful as an early sign of system
failure in an organization?
Adverse patient feedback.

A
Concerns by healthcare professionals.
B
Incident reports.
C
Mortality rates.
D
Question 18
Computer-based diagnostic decision support systems
have been shown to reduce diagnostic errors in real life settings.

A
have limited utility in clinical situations.
B
relieve the clinician of the burden of mental filtering.
C
have received much interest among clinicians.
D
Question 19
Healthcare workers should perform hand hygiene
before entering a patient's room.

A
before entering a patient's room and again immediately before touching a
B patient.
after touching a patient's bedside table.

C
after leaving a patient's room.

D
Question 20
Which of the following statements about hand hygiene is the most
appropriate?
Hand rubbing with an alcohol-based formulation is the preferred hand

A hygiene technique in most clinical situations.
Hand washing with soap and water is the preferred hand hygiene technique
B in most clinical situations.
Each clinician should use a technique of hand hygiene with which he/she is
C most familiar.
The preferred hand hygiene technique in most clinical situations depends on
D whether gloves were used.
Question 21
In Hospital X, surgical site infections were found to be common
among patients who underwent coronary artery bypass grafting
(CABG), with an incidence risk of 9.2%, compared to 1.7% for non-
CABG surgery, P-value < 0.001. (Level of significance = 0.05)
Which of the following statements is MOST appropriate?
In Hospital X, CABG surgery causes surgical site infection in 9.2% of patients.

A
In Hospital X, CABG surgery causes surgical site infection in about 9.2% of
B patients who undergo the procedure.
C patients who undergo the procedure.
In Hospital X, there is insufficient evidence that CABG surgery causes surgical
D site infection in patients who undergo the procedure.
Question 22
Which of the following statements about the practice of evidence-
based nursing is FALSE?
Evidence-based nursing should take into account patients' expectations.

A
Evidence-based nursing will lead to better outcomes and cost savings.
B
The first step in evidence-based nursing is to formulate a question.
C
The expertise of the clinician is required.
D
Question 23
Which of the following statements about care bundles is most
appropriate?
Care bundles represent a way to implement clinical guidelines.

A
Implementation of each element of a care bundle is compulsory.
B
A key feature of care bundles is the ability to measure the outcomes of care.
C
Care bundles that have been proven to be effective should be implemented
D universally without alteration.
Question 24
In the patient's care path, the wait time between initial suspicion of a
problem and seeing a doctor is
a delay.
A
an unavoidable step.
B
a non-value-added step.
C
a necessary step.
D
Question 25
Which of the following is NOT associated with single rooms?
Reduced medical errors

A
Reduced nosocomial infections
B
Increased patient satisfaction
C
Reduced failure to rescue
D
Question 26
Before a healthcare quality manager concludes that a process is
within control limits or that there is some deviation from normal
which needs to be addressed, which of the following considerations is
the LEAST appropriate?
The need for further statistical analysis, e.g. autoregression.

A
The type of error that might be made.
B
The probability that an error might be made.
C
The consequences associated with making an inferential error.
D
Question 27
Which among the following is NOT a primary driver of exceptional
patient and family inpatient hospital experience?
Fully engaged staff and care providers.
A
Sufficient staff with the available tools and skills.
B
Reliable delivery of care.
C
Evidence-based care.
D
Question 28
Which of the following is NOT a condition for using existing data, as
opposed to collecting new data?
You should be confident that the data were collected using procedures
A consistent with your operational definition.
The data must be representative of the process.

B
There must be at least 30 data points to make your conclusions valid.

C
You must be able to show that conditions have not changed significantly
D since they were collected.
Question 29
The best metric of time efficiency for a nursing drug round is
Process Cycle Efficiency.

A
Total Lead Time.
B
Workstation Turnover Time.
C
Value-add Time.
D
Question 30
Which of the following best describes a bottleneck?
Time trap.
A
Capacity constraint
B
Time trap or capacity constraint
C
Time trap due to capacity constraint
D
Question 31
Percentage of children two years of age who had one or more capillary
or venous lead blood tests for lead poisoning by their second birthday
is a
structural measure.
A
process measure.
B
outcome measure.
C
composite measure.
D
Question 32
A new sphygmomanometer has been developed. To assess its value in
the diagnosis of hypertension, the new sphygmomanometer was
applied to 360 hospital patients.
These results were compared with those obtained in the same

patients with intra-arterial catheters (taken as the gold standard).
Diastolic blood pressure ≥ 90 mmHg was taken as the cut-off point to
define hypertension. The results are shown in the table below:
+ indicates results ≥ cut-off value

- indicates results < cut-off value
Calculate the specificity of the new sphygmomanometer to the nearest
whole percentage.
53%
A
70%
B
89%
C
100%
D
Question 33

Diastolic blood pressure (DBP) ≥ 90 mmHg was taken as the cut-off
point to define hypertension. The results are shown in the table
below:

If the cut-off value for DBP is later changed to 140 mmHg,
both the sensitivity and specificity of the new sphygmomanometer will

A increase.
B decrease.
the sensitivity of the sphygmomanometer will decrease while its specificity
C will increase.
the sensitivity of the sphygmomanometer will increase while its specificity
D will decrease.
Question 34
Which of the following statements about affinity diagrams is
UNTRUE?
Affinity diagrams help to organize a lot of ideas.
A
Affinity diagrams help to identify central themes in a set of ideas.

B
Affinity diagrams can help to identify priorities.

C
Affinity diagrams can be used when a breakthrough is needed beyond traditional

D
Question 1
Staff members of a medical unit are working to improve patient
satisfaction, the scores for which have been significantly lower than
the system's mean for 2 consecutive years. In dealing with a small
group of cynical employees, your advice to the Chief Nursing Officer
would be to
A exclude them from the improvement design team.

B include them on the improvement design team but only in the initial phases.
C include them on the improvement design team but only in the final phases.
D include them on the improvement design team throughout the initiative.
Answer: D
There will almost always be naysayers in any improvement effort.
Including such individuals on the team should (paradoxically) reduce
resistance to change. Having two of the more cynical employees on
the team shows that management is not front-loading the team with
its ―pets.‖ In addition, naysayer resistance may be functional in that
the resister can assume the role of devil's advocate and challenge the
team to fully consider decisions, thereby avoiding groupthink. It's not
unusual for naysayers to become some of the more enthusiastic and
vocal supporters of the process.

Question 2
Which of the following factors is LEAST likely to contribute to poorly
executed transitional care?
A Incomplete communication among providers and across healthcare agencies.

B Recent implementation of an electronic health record system.
Inadequate patient and caregiver education and involvement in decision
C
making.
D Multiple chronic medical conditions and complex medication regimens.
Answer: B
Transitional care refers to the broad range of services and
environments designed to promote the safe and timely transfer of
patients from levels of care (e.g. acute to subacute) or across settings
(e.g. hospital to home).
The major factors associated with poor-quality transitional care are:
 Incomplete communication among providers and across

healthcare agencies;
 Inadequate patient and caregiver education and

involvement in decision making;
 Limited continuity of care; and
 Decreased access to essential services.
Language barriers, literacy issues, and cultural differences further

exacerbate the problem.
An electronic health record system may improve the quality of
transitions across settings by providing accurate and timely transfer
of information. However, research has shown that even with an
electronic health record system in place, the integration of
information systems across healthcare settings is rare.

Question 3
Which of the following is likely to have the greatest impact on quality
of care and cost savings?
A Clinical integration of patient care services.

B Administrative reengineering.
C Management reengineering.
D Corporate restructuring.
Answer: A
Clinical integration refers to the coordination of functions, activities
and operating units in the provision of healthcare across the
continuum of care. Of the four answer options, clinical integration
(answer option A) is most likely to lead to the largest improvements
in health outcomes and quality of care, and the greatest cost
savings.Corporate restructuring and administrative and
management reengineering are similar in nature, essentially
describing a multi-dimensional process of taking a system (or part of
a system) apart and redesigning it.
Question 4
Ultimate responsibility for quality improvement in a healthcare
organization rests with the
A Chief Executive Officer.

B Quality Council.
C governing body.
D medical staff.
Answer: C
The governing body, widely recognized as the legal authority, is
ultimately responsible for quality improvement in healthcare
organizations.

question is linked:Facilitate development of leadership values and
commitment to quality
Question 5
In implementing a program to improve patient flow in a high-volume
ambulatory care clinic, the team measured office visit cycle time, i.e.
the amount of time in minutes that a patient spends at the clinic. The
cycle time can be divided into time spent with the nonclinical team
(clerical/administrative personnel) and actual time spent with the
patient care team. Patients with chronic medical conditions such as
hypertension, diabetes, and high cholesterol constitute a majority of
the clinic volume.
For this program, measurement of which of the following is LEAST

appropriate?
A Staffing ratio for both clinical and nonclinical staff.
B Patient satisfaction.
C Blood pressure control.
D No-show rate.
Answer: D
The staffing ratio for both clinical and nonclinical staff helps to
determine what is optimal to improve patient flow. Patient
satisfaction is a valuable balancing measure as other aspects of
customer service may be compromised while reducing cycle time.
Blood pressure control, likewise, serves as a balancing measure—
reduction in cycle time should be achieved while maintaining quality
of care. Improvement in no-show rates can be expected to accompany
reduced overall cycle time but, relative to the other answer options,
their measurement is not essential for the success of the program.

Question 6
A retrospective cross-sectional study was conducted to evaluate the
criterion validity of the Agency for Healthcare Research and Quality's
Patient Safety Indicator (PSI) 7. Of the 191 abstracted records that
met criteria for PSI 7 based on hospital-reported ICD-9-CM codes,
review of the medical records verified that 104 or 54.5% (95%
confidence interval: 40–69%) experienced an infection or
inflammatory reaction due to medical care that began during the
same hospitalization.
What was being measured in this study?
A Prevalence
B Incidence
C Sensitivity
D Positive Predictive Value
Answer: D
This study evaluated the positive predictive value of PSI 7. The "gold
standard" was a review of the medical records. There were 104 true-
positive cases and 87 (191 minus 104) false-positive cases in this
study.
Read our article on statistics for diagnostic tests.

question is linked:Use epidemiological principles in data collection
and analysis
Question 7
Among the following factors, nurse response to alerts by a
computerized drug utilization review system is LEAST likely to be
associated with
A the number of alerts.

B the appropriateness of alerts.
C a perception that the system is unhelpful and annoying.
D the patient's primary medical condition.
Answer: A
Inappropriate or trivial alerts create ―noise‖ that diminishes the
effectiveness of clinically important alerts because high noise to signal
ratio leads to ―alert fatigue‖ among practitioners. Clinicians have been
shown to undermine the potential benefits of electronic decision
support systems if they find them ―annoying, unhelpful, or
inefficient.‖ The level of noise varies across conditions. For example,
Feldman et al.1found that the rate of trivial and inappropriate
duplicative therapy alerts in diabetics was 19 times higher than in
hypertensive patients. The number of alerts (answer option A) does
not appear to be a significant factor for nurse follow-up; instead, the
appropriateness of the alerts is more important.
question is linked:Determine how technology can enhance the
patient safety program (e.g. CPOE, BCMA/barcoding, EMR,
abduction/elopement security systems, human factors engineering)
Reference
1. Feldman PH, McDonald M, Rosati RJ, Murtaugh C, Kovner C,
Goldberg JD, King L. (2006). Exploring the utility of automated drug
alerts in home healthcare. J Healthc Qual, 28(1), 29–40.
Question 8
In discussing ways to improve patient flow in the Operating Room
(OR)—a potentially controversial issue due to a possible change in the
OR schedule—which of the following techniques should a team
employ?
A Affinity Diagram
B Brainstorming
C Nominal Group Technique
D Multivoting
Answer: C
Affinity diagrams are useful in the narrowing phase of discussions
and are, therefore, not relevant in this situation.
Brainstorming might be suitable in this (exploratory) phase but it is

not the best answer.
Nominal Group Technique (NGT) is a more structured method of

generating a list of options and narrowing it down. It is called
―nominal‖ because during the session, the group does not engage in
the usual amount of interaction typical of a team. Because of its
relatively low level of interaction, the NGT is good for highly
controversial issues. This is the best answer.
Multivoting is useful in both the narrowing and defining phases of

discussion, but not the exploratory phase, and is therefore not really
appropriate here.
Question 9
Which of the following is a characteristic of error-reducing
industries?
Relying on events that cause serious injury and death more than reports of
A
errors and ―near misses.‖
B Investigating all errors but not necessarily thoroughly for each of them.
Tolerating high-error rates if they can be explained by human factors
C
psychology.
D Recognizing that solutions often come from unexpected sources.
Answer: D
Characteristics of error-reducing industries include:
 tolerating no high-error rates and setting ambitious targets

for error reducing initiatives.
 Developing tracking mechanisms that expose errors.
 Relying on the abundant reports of errors and ―near

misses.‖ In organizations thatdon't have a dysfunctional
safety culture, reports of errors and ―near misses‖ occur far
more frequently than other events that cause serious injury
or death. The opportunities to learn from errors and ―near
misses‖ are, therefore, far greater in number.
 Applying a systems approach to error reduction that
embraces a wide array of human factors and technical and
organizational remedies.
 Focusing on systems' solutions that do not seek to find

individual fault and blame.
 Thoroughly investigating errors, including root cause

analyses.
 Changing the organizational culture so that it enhances

safety and error reduction.
 Allocating adequate resources to error prevention

initiatives and developing the knowledge base to support
them.
 Recognizing that solutions often come from unexpected

sources, ―out of the box‖ thinking, and new combinations
of disciplines (e.g. human factors psychology and
aeronautical engineering))

Question 10
An improvement team has been working on an initiative to reduce the
use of seclusion and restraint in an acute inpatient psychiatric service.
After 9 months, the use of seclusion and restraint has reduced but the
rate of physical assaults on patients and staff was found to have
increased significantly.
At this stage, the team should

A abandon the initiative to reduce the use of seclusion and restraint.
B recommend an increase in the use of seclusion and restraint.
C consider strategies aimed at timely behavioral management.
D recommend a review of patients' pharmacotherapy.
Answer: C
In general, the use of seclusion and restraint (S & R) should be
minimized and reserved for emergent situations in which there is
imminent risk of danger to the patient or others. Therefore, the goal
of reducing S & R is appropriate—this eliminates answer options A
and B. Pharmacotherapy alone is unlikely to lead to a reduction in the
rate of patient and staff harm (without other adverse consequences).
Key factors in minimizing the use of S & R in any setting include:
organizational culture, milieu management, early assessment, and
timely behavioral management.

Question 11
The rate of patient falls in an acute care facility has been above the
mean for a group of 20 hospitals in the State for the past 12 months.
In designing and implementing a new fall prevention program, which
of the following changes is MOST likely to have the greatest impact on
preventing falls?
A Visual identifiers for high risk patients.
B Close monitoring of program compliance and outcomes.
C Changing the fall risk assessment tool.
D Introduction of floor pads.
Answer: A
Another way of phrasing this question might be, ―What is the top
reason for patient harm?‖ According to most authorities, including
The Joint Commission, the lack of communication is the most
frequent cause of serious patient safety events.
Visual identifiers are a common and effective way of identifying and
communicating those patients at high risk of falls. These identifiers
may be placed outside the patient's door, on the white board at the
nurses' station, and on the patient's admission armband.
Monitoring alone will not lead to any improvement, but is necessary

to inform the team whether tests of change have been successful or
otherwise.
Changing the fall risk assessment tool will have little impact on the
actual rate of patient falls—these tools have similar predictive values.
Floor pads, often placed next to the bed, may cushion the impact of a
fall, but may also increase the risk of falling, especially while the
patient is getting into bed.

organization
Question 12
In a survey of patient satisfaction, p control charts may be used to
A
determine why a threshold was not met.
measure individual patient responses, compare findings with a threshold,
B
and determine why a patient was not satisfied.
measure individual patient responses, compare each individual's result with
C
all other patients, and determine type of variation.
D
determine type of variation.
Answer: D
On the actual exam, you might encounter questions that have within
each answer option a combination of items. These questions tend to
be quite simple because you can eliminate incorrect answer options
quite easily.
p Control charts, or ―p-charts,‖ are used to monitor proportions.

Therefore, they involve aggregate data. This fact eliminates answer
options B and C because these two options mention ―individual
patient responses.‖
The difference between the two remaining answer options (A and D)
is ―determine why a threshold was not met‖ (A) and ―determine type
of variation‖ (D). It should be quite obvious that D is the correct
answer option and A cannot be correct because a control chart cannot
give the reason(s) why performance has or has not reached a certain
level.

Question 13
Which of the following statements about conflict is the MOST
appropriate?
A Conflict should be promoted in most teams.
B The most effective way to manage any conflict is by compromise.
C The most effective way to manage any conflict is by problem solving.
D Avoiding a conflict can sometimes be useful.
Answer: D
Avoiding a conflict can be useful if there is little chance for successful
problem solving or compromise.
Conflict should not be ―promoted‖ but its absence is a sign of

―groupthink,‖ in which case the Team Leader should encourage Team
Members to generate alternative viewpoints.
There is no ―best‖ or ―most effective‖ way of managing conflict—it

depends on the circumstances. Read our article on responses to
conflict for more information.
Improvement
Question 14
An improvement team has split into two factions over a trivial issue.
Which of the following strategies is the most appropriate for team
members to adopt?
A Problem solving
B Compromising
C Smoothing over the conflict
D Avoiding the conflict
Answer: C
Smoothing over this conflict (answer option C) is probably the most
appropriate strategy, followed by avoiding the conflict (answer option
A). Compromising and problem solving have no role in this situation.
Read our article on responses to conflictfor details.
Improvement
Question 15
Which of the following actions is the most appropriate for the Team
Leader to take during the Norming stage of team development?
A Fully utilize Team Members' skills, knowledge, and experience.

B Represent, and advocate for, the team with other groups and individuals.
Develop and implement agreements about how decisions are made and
C
who makes them.
D Provide clear direction and purpose.
Answer: A
In the CPHQ exam, you will be lucky to see straightforward questions,
such as ―What is the first stage of team development called?‖ This
example is a recall question that most people should be able to
answer.
A more challenging question (like the one above) is one that tests
your ability to both (a) recall what the stages of team development
are, and (b) manage the various stages in practice. Information to
answer this type of question can also be memorized (I suppose) but
rote learning is generally not a good strategy for the CPHQ exam.
Instead, focus on the basics (e.g. in this case, you should know the
stages of team development) and then think about the things you
would do as the Team Leader in each stage. By leading a team (e.g. at
work, church, soccer), you would almost certainly experience the four
stages—for most people, applying the theory in practice will reinforce
the learning more effectively than relying purely on recall.
Read the article on the stages of team growth for details and an
explanation of the answer to the question above.
Improvement
Question 16
In a three year period, mortality rates at Hospital X, a
multidisciplinary tertiary referral center, was found to be
unacceptably high. Which of the following would you LEAST expect
in an investigation conducted by a committee?
A Tracking of process measures and targets.
B Considerable attention given to throughput.
C Training of staff at the lowest levels in the hierarchy.
D Staff being unclear about their roles and responsibilities.
Answer: C
We would expect some serious systemic issues to be uncovered by the
investigation. Therefore, the correct answer should be something
positive or the least negative symptom of organizational failure. Quite
clearly, answer option D is not the correct answer and can be
eliminated. The other three options appear to be ―good things,‖ which
makes them all possible correct answers. Usually, hospitals that have
serious systemic problems focus on some things (e.g. promotion of
the organization with considerable attention given to marketing and
public relations). They're just not the ―right things,‖ i.e. quality of
patient care. There is also often an over reliance on process measures,
targets and throughputs, instead of patient outcomes and the
experience of patients and their families. Therefore, answer options A
and B could be things that one expects to find. On the other hand,
valuing relevant knowledge and skills of staff, no matter where they
lie in an organization (even if at the lowest levels in a hierarchy) is a
key characteristic of high reliability organizations.
Question 17
Which of the following is LEAST useful as an early sign of system
failure in an organization?
A Adverse patient feedback.
B Concerns by healthcare professionals.
C Incident reports.
D Mortality rates.
Answer: D
Answer options A, B, and C can potentially give early indication that
an organization is failing. By the time an increase in mortality is
evident, the systemic problems are likely to be quite advanced.

Question 18
Computer-based diagnostic decision support systems
A have been shown to reduce diagnostic errors in real life settings.
B have limited utility in clinical situations.
C relieve the clinician of the burden of mental filtering.
D have received much interest among clinicians.
Answer: B
In summary, the literature points to a perception among clinicians
that computer-based diagnostic decision support systems are useful
diagnostic suggestions. Although there are anecdotes of how they
helped the clinician to recognize a rare disease, to date their use in
actual clinical situations has been limited to those times that the
clinician is puzzled by a diagnostic problem. Because such puzzles
occur rarely, there is not enough use of the systems in real practice
situations to truly evaluate their effectiveness. Therefore, answer
option A can be eliminated and answer option B remains a viable
option.
Now, let's take a look at the other two answer options (C and D).
Contrary to the statement in C, the output of most decision-support
programs requires subsequent mental filtering, because what is
usually displayed is a (sometimes lengthy) list of diagnostic
considerations. Answer option C is not the correct choice.
Interest in these systems has been limited, leading to several

commercial ventures being unsustainable.
Therefore, answer option B is our best answer.
Content Category: Patient safety

patient safety program (e.g. CPOE, BCMA/barcoding, EMR,
Question 19
Healthcare workers should perform hand hygiene
A before entering a patient's room.

before entering a patient's room and again immediately before touching a
B
patient.
C after touching a patient's bedside table.
D after leaving a patient's room.
Answer: C
Every healthcare quality professional is expected to know common
clinical processes. These include processes in infection control and
medication management. Not surprisingly, the CPHQ exam will
include some questions that appear to be ―clinical‖ and not related to
quality management. Answering such questions may be
straightforward to those with plenty of clinical experience but
challenging for others.
The question above addresses the indications for the use of hand
hygiene. Hand hygiene should be performed:
 Immediately before touching a patient (close to the site of

care to avoid recontamination) or when entering a ―patient
zone,‖ i.e. the patient and his/her immediate surroundings.
 Just after touching a patient and before touching any

object located outside the patient zone.
 After touching objects located in the vicinity of the patient.

(Answer option C for the question above.)
 Immediately before touching non-intact skin.
 Before manipulating invasive devices
 After contact with body fluids, mucous membranes,

nonintact skin, or wound dressings—even in the absence of
visible soiling and even when gloves have been used.
This video on hand hygiene provides an excellent synopsis of hand

hygiene.
Answer option C is the best answer.

reviews or audits for infection prevention and control processes
Question 20
Which of the following statements about hand hygiene is the most
appropriate?
Hand rubbing with an alcohol-based formulation is the preferred hand

A
hygiene technique in most clinical situations.
Hand washing with soap and water is the preferred hand hygiene technique
B
in most clinical situations.
Each clinician should use a technique of hand hygiene with which he/she is
C
most familiar.
The preferred hand hygiene technique in most clinical situations depends on
D
whether gloves were used.
Answer: A
Hand rubbing with an alcohol-based formulation is the preferred
hand hygiene technique in most clinical situations.
Please refer to the video on hand hygiene.

reviews or audits for infection prevention and control processes
Question 21
In Hospital X, surgical site infections were found to be common
among patients who underwent coronary artery bypass grafting
(CABG), with an incidence risk of 9.2%, compared to 1.7% for non-
CABG surgery, P-value < 0.001. (Level of significance = 0.05)
Which of the following statements is MOST appropriate?

A In Hospital X, CABG surgery causes surgical site infection in 9.2% of patients.
B
patients who undergo the procedure.
C
patients who undergo the procedure.
In Hospital X, there is insufficient evidence that CABG surgery causes surgical
D
site infection in patients who undergo the procedure.
Answer: D
Association or correlation does not mean causation. In this case,
there appears to be a strong association between CABG surgery and
surgical site infection but there are other explanations for the
increased surgical site infection rate other than the procedure, i.e.
 Confounders (e.g. comorbidities, overall physiological

status, duration of stay in ICU);
 Bias (in the way the study was conducted); and
 Chance.
Answer options A, B, and C offer common interpretations of such

results—all imply causality, for which there is insufficient
information.

Question 22
Which of the following statements about the practice of evidence-
based nursing is FALSE?
A Evidence-based nursing should take into account patients' expectations.
B Evidence-based nursing will lead to better outcomes and cost savings.
C The first step in evidence-based nursing is to formulate a question.
D The expertise of the clinician is required.
Answer: B
The components of evidence-based practice (medicine, nursing,
physical therapy, pharmacy, etc.) are summarized by 3 E's:
 Evidence (the scientific findings);

 Expertise and experience of the clinical decision makers;
and
 Expectations and values of the patients/people.
There are 4 key steps in evidence-based practice, summarized by 4
A's:
 Ask for the required information by formulating your

question;
 Acquire the information by searching resources;
 Appraise/Analyze the relevance, quality and importance of
the information; and
 Apply the information in your practice and/or with your
patient.
Evidence-based practice may or may not lead to better outcomes and
reduced costs.

Question 23
Which of the following statements about care bundles is most
appropriate?
A Care bundles represent a way to implement clinical guidelines.

B Implementation of each element of a care bundle is compulsory.
C A key feature of care bundles is the ability to measure the outcomes of care.
Care bundles that have been proven to be effective should be implemented
D
universally without alteration.
Answer: A
Bundles of care are based on the best available evidence and/or
expert opinion, i.e. clinical guidelines. However, unlike guidelines
(that tend to be all-inclusive and sometimes confusing), care bundles
consist of actionable items that can be measured and improved.
The goal is to implement each component of the bundle. However,

exceptions are permitted for individual cases (patients) in which the
care component is clinically inappropriate.
Measurement of the implementation of each care process, rather than

outcomes, is a feature of care bundles.
Even if a care bundle has been shown to be effective in improving

quality of care, it should be adapted and tested locally. Care bundles
should not be implemented blindly in all settings.

question is linked:Facilitate development of performance/quality
improvement action plans and projects
Question 24
In the patient's care path, the wait time between initial suspicion of a
problem and seeing a doctor is
A a delay.
B an unavoidable step.
C a non-value-added step.
D a necessary step.
Answer: C
Every element of the patient's care path should be considered as a
step. Therefore, the wait time between initial suspicion of a problem
and seeing a doctor is one step. This is a non-value-added step,
however, and thus must be minimized or eliminated. It is not
considered as a ―delay‖ as there is no reference point.

Question 25
Which of the following is NOT associated with single rooms?
A Reduced medical errors

B Reduced nosocomial infections
C Increased patient satisfaction
D Reduced failure to rescue
Answer: D
Answer options A, B, and C give potential benefits of single rooms, all
of which thought to be due to the effects of reducing the need for
transfers. Each transfer is an opportunity for missed or delayed
treatment, miscommunication that can lead to errors or omissions of
care, patient falls, or other problems that are not only bad for patients
but also consume additional staff time and resources.
However, potential disadvantages of single rooms include patient

isolation, less surveillance by staff, and increased failure to rescue.
organization
Question 26
Before a healthcare quality manager concludes that a process is
within control limits or that there is some deviation from normal
which needs to be addressed, which of the following considerations is
the LEAST appropriate?
A The need for further statistical analysis, e.g. autoregression.

B The type of error that might be made.
C The probability that an error might be made.
D The consequences associated with making an inferential error.
Answer: A
Before concluding that a process is within control limits or that there
is some deviation from normal (an unusual event) which needs to be
addressed, healthcare quality professionals should consider:
 what type of error they are likely to make,
 under what circumstances errors are likely to be made,
 the factors that influence the probability of making an

error,
 the probability of making an error, and
 the full range of consequences (administrative and clinical)

associated with making an inferential error (Type I or Type
II).
Although various statistical techniques have been developed to

handle autocorrelated time-series data, they require large data sets to
provide acceptable levels of inferential accuracy. Data sets of such
magnitude are not commonly seen in healthcare quality work.

Question 27
Which among the following is NOT a primary driver of exceptional
patient and family inpatient hospital experience?
A Fully engaged staff and care providers.

B Sufficient staff with the available tools and skills.
C Reliable delivery of care.
D Evidence-based care.
Answer: B
The Institute for Healthcare Improvement (IHI) recently published
a white paper on Achieving an Exceptional Patient and Family
Experience of Inpatient Hospital Care. The authors identified five
primary drivers of exceptional patient and family inpatient hospital
experience of care:
 Leadership
 Hearts and Minds (i.e. staff and provider engagement)
 Respectful Partnership
 Reliable Care
 Evidence-Based Care
One of the secondary drivers associated with leadership is having

sufficient staff available with the tools and skills to deliver the care
patients need when they need it.

Question 28
Which of the following is NOT a condition for using existing data, as
opposed to collecting new data?
You should be confident that the data were collected using procedures
A
consistent with your operational definition.
B The data must be representative of the process.
C There must be at least 30 data points to make your conclusions valid.
You must be able to show that conditions have not changed significantly since
D
they were collected.
Answer: C
Using existing data is quicker and cheaper than gathering new data
but several conditions must be met:
 The data must be in a form you can use.
 Either the data must be relatively recent or you must be

able to show that conditions have not changed significantly
since they were collected.
 You should know when and how the data were collected
(and that it was done in a way consistent with the
questions you want to answer).
 You should be confident that the data were collected using

procedures consistent with your operational definition.
 They must be truly representative of the process, group,

and measurement system.
 There must be sufficient data to make your conclusions

valid.
If any of these conditions are not met, you should strongly think
about collecting new data.

question is linked:Perform or coordinate data collection
methodology (qualitative, quantitative)
Question 29
The best metric of time efficiency for a nursing drug round is
A Process Cycle Efficiency.

B Total Lead Time.
C Workstation Turnover Time.
D Value-add Time.
Answer: A
The best measure of overall process health is Process Cycle Efficiency
(PCE), the percentage of value-add time (work that changes the form,
fit, or function as desired by the customer), i.e.
Process Cycle Efficiency = (Value-add Time) / (Total Lead

Time)
Total Lead Time is also called Process Cycle Time, Process Lead Time,
or Total Cycle Time. It is the time from when a work item (product,
order, service, etc.) enters a process until it exits.
Workstation Turnover Time for a given process step or workstation is

the amount of time needed to set up and complete one cycle of work
on all the different things at that step.
Value-add Time is the time consumed by any process step or activity

that transforms the form, fit, or function of the product or service for
which the customer is willing to pay.

Question 30
Which of the following best describes a bottleneck?
A Time trap.
B Capacity constraint
C Time trap or capacity constraint
D Time trap due to capacity constraint
Answer: C
The term bottleneck cannot distinguish between steps that inject
delays (time traps) and those that cannot operate at required levels
(capacity constraints).

Question 31
Percentage of children two years of age who had one or more capillary
or venous lead blood tests for lead poisoning by their second birthday
is a
A structural measure.
B process measure.
C outcome measure.
D composite measure.
Answer: B
This is an example of a process measure. You may learn more about
this evidence-based measure here.
Question 32

Diastolic blood pressure ≥ 90 mmHg was taken as the cut-off point to
define hypertension. The results are shown in the table below:

Calculate the specificity of the new sphygmomanometer to the nearest
whole percentage.
A 53%
B 70%
C 89%
D 100%
Answer: A
90 out of the 170 ―true‖ negatives were identified as such by the new
sphygmomanometer, so the specificity is 90/170 = 53%.
and analysis
Question 33

Diastolic blood pressure (DBP) ≥ 90 mmHg was taken as the cut-off
point to define hypertension. The results are shown in the table
below:

If the cut-off value for DBP is later changed to 140 mmHg,

A
increase.
B
decrease.
the sensitivity of the sphygmomanometer will decrease while its specificity will
C
increase.
the sensitivity of the sphygmomanometer will increase while its specificity will
D
decrease.
Answer: C
The table below shows the (hypothetical) results after changing the
cut-off value for DBP to 140 mmHg.
In this hypothetical situation, the sensitivity is now only 95/190 =

50% (vs 100% previously) and the specificity is 170/170 = 100% (vs
53% previously).
By raising the cut-off value to classify hypertension, the sensitivity of

the new sphygmomanometer decreases while its specificity increases.
Similarly, by lowering the cut-off values, sensitivity increases but
specificity decreases.

and analysis
Question 34
Which of the following statements about affinity diagrams is
UNTRUE?
A Affinity diagrams help to organize a lot of ideas.

B Affinity diagrams help to identify central themes in a set of ideas.
C Affinity diagrams can help to identify priorities.
Affinity diagrams can be used when a breakthrough is needed beyond
D
traditional thinking.
Answer: C
Affinity diagrams can be used:
 To help organize a lot of ideas.
 To help identify central themes in a set of ideas.
 When information about a problem is not well organized.
 When a breakthrough is needed beyond traditional

thinking.

Question 4
Question 1
At one of its meetings, the team has digressed from its original
discussion. Who is responsible for bringing the conversation back to
the meeting agenda?
Team sponsor
A
Team leader
B
Team facilitator
C
Team members
D
Question 2
An organization is tracking medication occurrence report forms
completed over time. Which of the following is the most appropriate
measure?
Number of medication occurrence report forms completed

A
Number of medication occurrence report forms completed per total number of
B patient admissions
C medication doses
D patient beds
Question 3
Which of the following activities is NOT usually part of project
closure?
Evaluating the team's process

A
Evaluating the team's results
B
Exploring alternative solutions
C
Organizing files
D
Question 4
Process improvement is new to a team leader and her team. How
should the team move forward with their improvement project?
Train the team leader and her team before commencing the project
A
Enlist the help of a coach who will be active during the team's initial
B meetings
Allow the team leader and her team to execute the project while learning
C new skills
Abandon the improvement project
D
Question 5
Which of the following may be represented by the upper or lower
control limit on a control chart?
The budget for calibration equipment

A
The target resident falls rate in a nursing home
B
The benchmark patient satisfaction score among similar facilities
C
None of the above
D
Question 6
Which of the following is an additional use of a dot plot, compared
with a histogram?
Reveals the underlying distribution of the data

A
Points out potential opportunities for improvement
B
Shows how often specific data values occur
C
Informs the choice of statistical tests that can be performed
D
Question 7
A healthcare network aims to reduce the length of stay in its acute
care setting. Which of the following measures is LEAST appropriate?
Patient satisfaction in acute care

A
Number of visits for home care
B
Functional independence measure
C
Index of activities of daily living
D
Question 8
Which of the following best demonstrates the commitment of senior
leaders to patient safety in an acute care facility?
Reviewing the reports of the Patient Safety Committee
A
Participating in Patient Safety Executive Walkrounds
B
Interviewing personnel involved in patient safety incidents
C
Communicating the importance of patients safety through regular newsletters
D
Question 9
Coronary artery bypass graft volume is a
structure measure.
A
process measure.
B
outcome measure.
C
balancing measure.
D
Question 10
Which of the following best demonstrates use of the Plan-Do-Check-
Act (PDCA) performance improvement model?
Collect baseline data, form a committee to develop a plan, validate audit data,
A and formalize the change.
Identify a problem, implement a change, train staff in the change, and rewrite
B policies and procedures to augment the change.
Prioritize opportunities for improvement, pilot the change, compare data
collected before and after the change, and roll out the change to the entire
C
organization.
Review current practice, form a multidisciplinary committee, meet to develop a
D plan of action, and decide who will be responsible for specific tasks.
Question 11
Facility X is a large skilled nursing and rehabilitation facility that
provides inpatient and outpatient services. In the last quarter of the
year, only 75% of therapy visits were completed on time, and follow-
up calls were made only 50% of the time. A performance
improvement team had two aims: to improve the timeliness of the
initial therapy evaluation visit and to improve the timeliness of the
initial therapy evaluation telephone conference to the home care
nurse manager.
Which of the following is an appropriate performance measure?
The number of patients who received education about the need for a specific type of
A therapy, divided by the total number of admissions.
The number of visits made within the required time frame, divided by the total number
B of admissions.
The number of patients who reported a patient satisfaction score of 8 or higher, on a 0-
C to 10- point scale, divided by the total number of admissions.
The number of completed therapy referral forms, divided by the total number of
D admissions.
Question 12
How is monitoring of quality of care in asthma usually conducted?
Retrospective review of medical records

A
Direct observation of providers
B
Review of asthma mortality data
C
Prospective monitoring of asthma symptoms and medication use
D
Question 13
Cleft lip and palate can be treated with surgery. Success depends on
how soon after birth the surgery is performed. The national
benchmark for cleft lip and palate surgery is 21 days of postnatal life.
What is a disadvantage of measuring average waiting time for cleft lip

and palate surgery?
Does not reflect the targeted time frame goal.

A
Requires a longer period of data collection than measuring the proportion of
B patients receiving surgery within 21 days.
Will not capture positive shifts in timeliness falling short of the targeted
C timeframe goal.
Potential to decrease motivation to reach patients who miss the target.
D
Question 14
Who has the responsibility of determining improvement priorities in
a healthcare organization?
The Quality Council

A
The Governing Body
B
The Chief Executive Officer
C
The Quality Director
D
Question 15
For which of the following activities is a care bundle most
appropriate?
Implementation of the do-not-use list for harzardous abbreviations

A
Management of patients with acute stroke

B
Prevention of complications during and after elective surgery

C
Resuscitation of patients with severe sepsis within 3 hours of the time of
D presentation
Question 16
The relationship between patient falls and nursing staffing ratios was
examined in 135 hospitals. The rate of patient falls was plotted
against nurse-to-patient ratio in a scatterplot.
What does a Pearson product-moment correlation coefficient

(commonly known as ―correlation coefficient‖) of zero (0) mean?
As the nurse-to-patient ratio increases, the rate of patient falls increases.

A
As the nurse-to-patient ratio increases, the rate of patient falls decreases.

B
There is no relationship between the nurse-to-patient ratio and the rate of
C patient falls.
None of the above.

D
Question 17
Which of the following statements about a process with common
cause variation is TRUE?
To reduce common cause variation in the process, process redesign will be

A necessary so that a different mix of factors affects the output.
To reduce common cause variation in the process, causes that are non-
B random will have to be identified and removed systematically.
Reducing common cause variation will result in the process being ―in
C control‖ and therefore acceptable to the customer.
There is no way of reducing or eliminating common cause variation in the
D process.
Question 18
Which of the following is NOT a factor that affects the size of the
sample when surveying the accuracy of discharge medication lists?
Objective(s) of the study

A
Patient turnover
B
Level of desired certainty
C
Mean number of discharge medications
D
Question 19
In a 250-bed acute care facility, the length of each admission is
measured in days. Which of the following is most appropriate for
displaying the data for the past 12 months?
Bar chart
A
Stem-and-leaf display
B
Dot plot
C
Histogram
D
Question 20
Which of the following is NOT an appropriate criterion for an
inservice training program on pain management?
Financial support from the organization

A
Potential to advance the career prospects of staff
B
Consideration of adult teaching principles
C
The objectives of the program reflect the organizational goal(s)
D
Question 21
What is the expected effect of having too many intervals when
plotting a histogram?
Exaggerate the amount of variation

A
Obscure the amount of variation
B
No effect on the amount of variation
C
The effect on the amount of variation is unpredictable
D
Question 22
An improvement team plotted the weekly number of complaints
received by a clinic on a run chart. After four months, the number of
runs was found to be larger than expected. Assuming none of the
following has already been done, what should the team do next?
Plot the data on a control chart

A
Plot the data on a histogram
B
Conduct a focus group
C
Conduct a root cause analysis
D
Question 23
A study has concluded that nurses who commit a medication
administration error suffer long-term loss of confidence which puts
them at greater risk of committing another medication
administration error in the future.
What impact, if any, do the conclusions of the study have on the

interpretation of a control chart of medication administration errors
committed by nurses in a Med/Surg Unit?
The risk of making a Type I error is increased

A
The risk of making a Type II error is increased
B
The control limits cannot be used to detect out-of-control conditions
C
There is no impact on the interpretation of the control chart
D
Question 24
Which of the following statements about the 5 Whys is TRUE?
The 5 Whys is used to find the root cause of a defect or problem.

A
The 5 Whys is used to identify root causes of, or solutions to, a problem.
B
The 5 Whys requires five or more whys to be asked.
C
The 5 Whys is used in conjunction with a cause-and-effect diagram.
D
Question 1
At one of its meetings, the team has digressed from its original
discussion. Who is responsible for bringing the conversation back to
the meeting agenda?
A Team sponsor
B Team leader
C Team facilitator
D Team members
Answer: C
The team facilitator is responsible for bringing the conversation back
to the meeting agenda in such a situation.

Question 2
An organization is tracking medication occurrence report forms
completed over time. Which of the following is the most appropriate
measure?
A Number of medication occurrence report forms completed

Number of medication occurrence report forms completed per total number
B
of patient admissions
C
of medication doses
D
of patient beds
Answer: C
The absolute number of occurrence report forms is not appropriate
because it fails to account for the number of opportunities for error to
occur.
The number of patient beds is fixed, and therefore will not be helpful
when used as a ratio.
That leaves ―patient admissions‖ and ―medication doses‖ as the other
two remaining choices. Between these two, ―medication doses‖ is
more sensitive to opportunities for error and is, therefore, a better
choice.

and analysis
Question 3
Which of the following activities is NOT usually part of project
closure?
A Evaluating the team's process

B Evaluating the team's results
C Exploring alternative solutions
D Organizing files
Answer: C
Activities when closing a project include:
 Evaluating the team's process
 Evaluating the team's results
 Organizing files
 Updating records and the storyboard
 Making the final presentation
 Recommending follow-up activities

Question 4
Process improvement is new to a team leader and her team. How
should the team move forward with their improvement project?
A Train the team leader and her team before commencing the project
Enlist the help of a coach who will be active during the team's initial
B
meetings
Allow the team leader and her team to execute the project while learning
C
new skills
D Abandon the improvement project
Answer: B
Training the team leader and members in process improvement
before commencing the project will likely take too long.
A coach who is active during the team's initial meetings can be helpful
to get the project started while the team leader and her team develop
their skills in process improvement.
Letting a team with insufficient skills execute the project unassisted is

a recipe for failure.
Unfamiliarity with process improvement is rarely a good reason to

abandon an improvement project.
Question 5
Which of the following may be represented by the upper or lower
control limit on a control chart?
A The budget for calibration equipment

B The target resident falls rate in a nursing home
C The benchmark patient satisfaction score among similar facilities
D None of the above
Answer: D
Control limits on a control chart only indicate process capability, and
have no relationship to targets, budgets, or desired customer
satisfaction ratings.

control chart)
Question 6
Which of the following is an additional use of a dot plot, compared
with a histogram?
A Reveals the underlying distribution of the data
B Points out potential opportunities for improvement
C Shows how often specific data values occur
D Informs the choice of statistical tests that can be performed
Answer: C
Both histograms and dot plots:
 Provide information about the underlying distribution of

the data;
 Inform the choice statistical tests that can be performed;

and
 Highlight opportunities for improvement.
A histogram displays bars representing the count within different

ranges of data rather than plotting individual data points. Dot plots
show you how often specific data values occur.

display data (e.g., fishbone, Pareto chart, run chart, scattergram,
control chart)
Question 7
A healthcare network aims to reduce the length of stay in its acute
care setting. Which of the following measures is LEAST appropriate?
A Patient satisfaction in acute care

B Number of visits for home care
C Functional independence measure
D Index of activities of daily living
Answer: A
Efforts to reduce length of stay in the network's acute care setting
may result in increased visit numbers for home care, or more intense
care needs for residents in long term care settings. The latter is
assessed by measures of activities of daily living (ADL), e.g. Barthel
ADL Index or the Functional Independence Measure (FIM).
We expect a reduction in length of stay in acute care to be associated

with higher patient satisfaction scores. Patient satisfaction has no
direct relationship to the goal, whereas the other measures are
balancing measures in this initiative.

Question 8
Which of the following best demonstrates the commitment of senior
leaders to patient safety in an acute care facility?
A Reviewing the reports of the Patient Safety Committee

B Participating in Patient Safety Executive Walkrounds
C Interviewing personnel involved in patient safety incidents
D Communicating the importance of patients safety through regular newsletters
Answer: B
Among the four options, Patient Safety Executive Walkrounds will
provide the strongest demonstration of senior leaders' commitment
to the patient safety agenda.

Question 9
Coronary artery bypass graft volume is a
A structure measure.
B process measure.
C outcome measure.
D balancing measure.
Answer: A
Procedure volume indicators, e.g. the raw volume of coronary artery
bypass grafts (an AHRQ Inpatient Quality Indicator), are structure
measures.
Question 10
Which of the following best demonstrates use of the Plan-Do-Check-
Act (PDCA) performance improvement model?
Collect baseline data, form a committee to develop a plan, validate audit data,
A
and formalize the change.
Identify a problem, implement a change, train staff in the change, and rewrite
B
policies and procedures to augment the change.
Prioritize opportunities for improvement, pilot the change, compare data
C collected before and after the change, and roll out the change to the entire
organization.
Review current practice, form a multidisciplinary committee, meet to develop
D
a plan of action, and decide who will be responsible for specific tasks.
Answer: C
The PDCA cycle is characterized by:
 Defining specifications (goals), i.e. the ―planned state‖
 Testing small changes
 Observing the execution and results of tests of each change
 Adjusting or correcting the change and/or scope of the

work for the next iteration of the cycle
 Spreading changes that yield desired results, i.e. results

that close the difference between current state and planned
state

Question 11
Facility X is a large skilled nursing and rehabilitation facility that
provides inpatient and outpatient services. In the last quarter of the
year, only 75% of therapy visits were completed on time, and follow-
up calls were made only 50% of the time. A performance
improvement team had two aims: to improve the timeliness of the
initial therapy evaluation visit and to improve the timeliness of the
initial therapy evaluation telephone conference to the home care
nurse manager.
Which of the following is an appropriate performance measure?
The number of patients who received education about the need for a specific
A
type of therapy, divided by the total number of admissions.
The number of visits made within the required time frame, divided by the total
B
number of admissions.
The number of patients who reported a patient satisfaction score of 8 or higher,
C
on a 0- to 10- point scale, divided by the total number of admissions.
The number of completed therapy referral forms, divided by the total number
D
of admissions.
Answer: B
This improvement project had two different aims. Therefore, the
team needed at least two performance measures. We are only asked
to select one that would be appropriate for either aim.
The number of patients who received education (answer option A)

and the number of patients who gave high patient satisfaction scores
(answer option C) are not relevant to the project's aims. The number
of completed therapy referral forms (answer option D) is relevant but,
unlike answer option B, does not take into account the element of
timeliness. The number of visits made within the required time frame
will help the team measure its performance on the first aim.

Question 12
How is monitoring of quality of care in asthma usually conducted?
A Retrospective review of medical records

B Direct observation of providers
C Review of asthma mortality data
D Prospective monitoring of asthma symptoms and medication use
Answer: A
Retrospective monitoring is the method most frequently used.
Quality of asthma care is usually assessed retrospectively by a review

of patients' medical records.
Direct observation of providers in asthma care is impractical in most

settings.
Prospective monitoring, though ideal, is not often done.

reviews or audits for medical records.
Question 13
Cleft lip and palate can be treated with surgery. Success depends on
how soon after birth the surgery is performed. The national
benchmark for cleft lip and palate surgery is 21 days of postnatal life.
What is a disadvantage of measuring average waiting time for cleft lip

and palate surgery?
A Does not reflect the targeted time frame goal.

Requires a longer period of data collection than measuring the proportion of
B
patients receiving surgery within 21 days.
Will not capture positive shifts in timeliness falling short of the targeted
C
timeframe goal.
D Potential to decrease motivation to reach patients who miss the target.
Answer: B
In general, measuring the average waiting time, as opposed to
measuring the proportion of patients receiving a desired service
within the targeted timeframe, has two disadvantages:
A. The average waiting time can be influenced by rare cases,

e.g. a patient who had surgery only at the age of 8 years.
B. The average waiting time requires more time for data

collection than the proportion of patients receiving the
desired service within the targeted timeframe. This is
because measurement of the average waiting time requires
a larger sample to obtain statistically meaningful results.

methodology
Question 14
Who has the responsibility of determining improvement priorities in
a healthcare organization?
A The Quality Council

B The Governing Body
C The Chief Executive Officer
D The Quality Director
Answer: A
Although the governing body is ultimately responsible for the quality
management/improvement program, the Quality Council (the
performance/quality improvement oversight body) is responsible for
determining improvement priorities in the organization.

Improvement
Question 15
For which of the following activities is a care bundle most
appropriate?
A Implementation of the do-not-use list for harzardous abbreviations

B Management of patients with acute stroke
C Prevention of complications during and after elective surgery
Resuscitation of patients with severe sepsis within 3 hours of the time of
D
presentation
Answer: D
A bundle is not simply a set of individual processes.
The do-not-use-list for hazardous abbreviations is not a good
candidate for a bundle because it is essentially only one element. If
you treated each abbreviation as an element, then the ―bundle‖ would
be too large. Furthermore, the intervention would not likely be
conducted within a relatively small space or within a relatively short
period of time.
The care of a patient with acute stroke has many elements, i.e. the
number of elements will be too large to be appropriate for a bundle.
Likewise, there are many evidence-based elements of care that need

to be done to prevent complications of surgery. Furthermore, they are
not closely related, e.g. identification of the patient, site marking,
anesthesia safety check, assessment of airway/aspiration risk,
assessment of risk of large blood loss, etc.
Resuscitation of patients with severe sepsis within 3 hours of the time

of presentation meets the criteria for a bundle. Read details of the
bundle here.
Improvement
Question 16
The relationship between patient falls and nursing staffing ratios was
examined in 135 hospitals. The rate of patient falls was plotted
against nurse-to-patient ratio in a scatterplot.
What does a Pearson product-moment correlation coefficient

(commonly known as ―correlation coefficient‖) of zero (0) mean?
A As the nurse-to-patient ratio increases, the rate of patient falls increases.
B As the nurse-to-patient ratio increases, the rate of patient falls decreases.
There is no relationship between the nurse-to-patient ratio and the rate of

C
patient falls.
D None of the above.
Answer: D
This example involves only two variables, and the ―correlation
coefficient‖ used in this case measures the linear association between
the two variables.
A correlation coefficient of zero (i.e. r = 0) does not mean that there is
no relationship. It only means that there is no linear relationship. A
correlation coefficient of zero can mean that the data points are
scattered randomly in the chart (zero linear relationship; the two
variables are independent of each other) (graph (c) below), or it can
mean that there is a curvilinear relationship (graphs (d) and (e)
below).
control chart)
Question 17
Which of the following statements about a process with common
cause variation is TRUE?
To reduce common cause variation in the process, process redesign will be

A
necessary so that a different mix of factors affects the output.
To reduce common cause variation in the process, causes that are non-
B
random will have to be identified and removed systematically.
Reducing common cause variation will result in the process being ―in
C
control‖ and therefore acceptable to the customer.
There is no way of reducing or eliminating common cause variation in the
D
process.
Answer: A
Reduction of common cause variation is possible and is achieved by
redesigning the process so that a different mix of factors affects the
output.
Removing non-random (―assignable‖ or ―special‖) causes will help to

reduce special cause variation, not common cause variation.
A process with only common cause variation is already in statistical

process control. However, the range within which the common cause
variation occurs may not meet customer specifications.

control components (e.g., common and special cause variation,
Question 18
Which of the following is NOT a factor that affects the size of the
sample when surveying the accuracy of discharge medication lists?
A Objective(s) of the study

B Patient turnover
C Level of desired certainty
D Mean number of discharge medications
Answer: D
The sample size, in this case, depends on:
 The objectives of the study;

 Patient turnover, which serves as a proxy for turnover of
discharge medication lists (since each discharged patient
will have a medication list); and
 Level of confidence desired.
The absolute number of discharge medications does not affect the

sample size calculation. In other words, the sample size should not
change whether the mean number of discharge medications is high or
low, other things being equal.

and analysis
Question 19
In a 250-bed acute care facility, the length of each admission is
measured in days. Which of the following is most appropriate for
displaying the data for the past 12 months?
A Bar chart
B Stem-and-leaf display
C Dot plot
D Histogram
Answer: D
A facility this size can be expected to have at least a few thousand
admissions over a 12-month period. Therefore, neither a stem-and-
leaf display nor a dot plot is appropriate because these should only be
used for a small dataset.
A bar chart is not appropriate because bar charts are suitable for
nominal data only. The length of stay (LOS) data are both discrete
and ordinal (i.e. 1, 2, 3, ... ) and can be classified into ranges, e.g. 1–2
days, 3–4 days, etc. As such, the LOS data can be presented on a
histogram.

control chart)
Question 20
Which of the following is NOT an appropriate criterion for an
inservice training program on pain management?
A Financial support from the organization

B Potential to advance the career prospects of staff
C Consideration of adult teaching principles
D The objectives of the program reflect the organizational goal(s)
Answer: B
An inservice training program is training provided to a staff member
while he or she is employed to perform a specific job. The training is
planned to meet the needs of the organization, remove shortcomings
in learning or correct shortcomings in skills of staff. It should have
the financial support of the organization, focus on more effective
functioning of employees and the organization, and take adult
teaching principles into consideration. The philosophy and objectives
of any inservice training program should reflect the goals of the
organization.
Career advancement, while a possible consequence, should not be a

criterion for inservice training.
Improvement
Question 21
What is the expected effect of having too many intervals when
plotting a histogram?
A Exaggerate the amount of variation

B Obscure the amount of variation
C No effect on the amount of variation
D The effect on the amount of variation is unpredictable
Answer: A
To create a histogram, you will need to take the difference between
the minimum and maximum values in your dataset to get the range.
You will then divide the range into evenly spaced intervals. Too many
intervals will exaggerate the variation, and too few intervals will
obscure the amount of variation.

control chart)
Question 22
An improvement team plotted the weekly number of complaints
received by a clinic on a run chart. After four months, the number of
runs was found to be larger than expected. Assuming none of the
following has already been done, what should the team do next?
A Plot the data on a control chart

B Plot the data on a histogram
C Conduct a focus group
D Conduct a root cause analysis
Answer: B
If the number of runs on a run chart is greater than expected, there
may be special cause variation. However, another reason for having
more runs than expected is that the distribution of the data is not
normal. The distribution of the data can be examined by using a
histogram. You should exclude the possibility of the distribution not
being normal before attributing what you found on the run chart to
possible special cause variation.

control chart)
Question 23
A study has concluded that nurses who commit a medication
administration error suffer long-term loss of confidence which puts
them at greater risk of committing another medication
administration error in the future.
What impact, if any, do the conclusions of the study have on the

interpretation of a control chart of medication administration errors
committed by nurses in a Med/Surg Unit?
A The risk of making a Type I error is increased
B The risk of making a Type II error is increased
C The control limits cannot be used to detect out-of-control conditions
D There is no impact on the interpretation of the control chart
Answer: C
This hypothetical study suggests that medication administration
errors are NOT independent, i.e. a person who commits an error is
more prone to making the same error in the future. If medication
administration errors were independent, each event should have no
relationship with (i.e. ―independent‖of) the nurse's error history.
Lack of independence is problematic when interpreting control charts
because ALL tests for special causes assume independent
observations. If the data are not independent, the data values will not
be random. As such, the rules for determining special cause variation
are not applicable (because these rules are based on statistical
probability).
If the explanation above sounds like Greek to you, the following is my

Cliff's notes version:
In order to apply the rules for detecting special cause
variation on a control chart, your observations must be
independent.

control chart)
Question 24
Which of the following statements about the 5 Whys is TRUE?
A The 5 Whys is used to find the root cause of a defect or problem.
B The 5 Whys is used to identify root causes of, or solutions to, a problem.
C The 5 Whys requires five or more whys to be asked.
D The 5 Whys is used in conjunction with a cause-and-effect diagram.
Answer: A
The 5 Whys technique is used to identify the potential root cause of a
defect or problem. It is not used to find possible solutions.
The 5 Whys does not require 5 whys to be asked. A root cause may be
identified after two or three whys, or after 20 whys.
The first ―cause‖ (―Why 1‖) may be selected from a cause-and-effect

diagram, or some other tool, e.g. Pareto chart. A cause-and-effect
diagram is not absolutely necessary.

question is linked:Perform or coordinate risk management: root
cause analysis
Question 5
Question 1
The senior management team of an acute care facility is setting a
breakthrough goal for efficiency.
Which measure is the most appropriate?
Length of stay
A
Hospital costs
B
Cost per capita
C
Cost per case
D
Question 2
How far from the center line should the upper limit of a control chart
be?
1.96 standard deviations

A
2 standard deviations
B
3 standard deviations
C
none of the above.
D
Question 3
What is the most frequent cause of failure in any improvement effort?
Inadequate or improper training

A
Lack of senior and middle management involvement
B
Poor communication across the organization
C
Unrealistic expectations
D
Question 4
A team is developing a checksheet to record the reasons patients are
readmitted within 48 hours of discharge.
What is the best way of ensuring the checksheet is effective?
Carefully plan the form to make it as complete as possible before using it full-
A scale.
Review forms used in other organizations and adopt them for implementation
B in the present organization.
Test the form on dummy patients before using it full-scale.

C
Try out the form on a small sample of patients before using it full-scale.
D
Question 5
The Centers for Medicare & Medicaid Services (CMS) Five-Star
Quality Rating System for nursing homes consists of an overall 5-star
rating and a separate rating for each of the following sources of
information EXCEPT
consumer surveys.
A
staffing.
B
quality measures.
C
inspection results.
D
Question 6
Which of the following is LEAST likely to be a patient perspective of
quality?
Following the standard of care

A
Responsiveness and empathy
B
Safety and freedom from injury
C
Provision of clear information
D
Question 7
Consider a four-step treatment process with yields for each step:
Step 1 — Yield 99%

On average, what percentage of the organization's effort in this
process requires rework?
5%
A
6%
B
15%
C
16%
D
Question 8
Failure modes and effects analysis can be done
from causes forward to effects.

A
from effects back to causes.
B
from causes forward to effects or from effects back to causes.
C
by none of the above approaches.
D
Question 9
An acute care facility has found that the incidence rate of pressure
ulcer cases, although low, is not as low as the incidence rate reported
by comparable organizations. Because the incidence of pressure
ulcers may detract from the organization's reputation for giving good
care, management decides to take this matter seriously and assigns a
project manager and analyst.
On review of the records, the project team decides that the existing
policy is the right one and something is going wrong in the
implementation.
Which of the following options is most appropriate?
Develop a new policy.

A
Failure modes and effects analysis.
B
Root cause analysis.
C
Review the data on pressure ulcers.
D
Question 10
Which of the following statements about queuing and the bottleneck
of a workflow is TRUE?
Queuing at the bottleneck is desirable.

A
Queuing at the bottleneck should be eliminated.
B
Queuing at the bottle should be minimized.
C
Queuing at the bottleneck is unavoidable.
D
Question 11
From a study of a sample of patient records for the prior 20 months,
the medication error rate was found to be 1 per 1000, with a 90%
confidence interval between zero and 3.4 errors per 1000.
What is the chance that the true value is NOT covered by the interval?
0%
A
3.4%
B
10%
C
90%
D
Question 12
At the office of a family dentist, he was the sole practitioner with an
established practice. From a quality improvement perspective, what is
the expected effect of another dentist joining the practice?
Increase in capacity with no effect on the bottleneck.

A
Expansion of the bottleneck with no effect on capacity.
B
Increase in capacity and tightening of the bottleneck.
C
Increase in capacity and expansion of the bottleneck.
D
Question 13
The primary goal of a program to assist with appropriate antibiotic
selection and dosing is to
minimize adverse events.

A
reduce cost.
B
prevent the misuse and overuse of antibiotics.
C
reduce the average length of stay.
D
Question 14
In an acute care facility, the delivery times of x-ray results were
higher on Saturday and Sunday, compared with the other days of the
week. What should the management do next to improve weekend
performance?
Increase the number of staff in the Radiology Department.

A
Provide more training for staff in the Radiology Department.
B
Use a process flow chart to better understand the process.
C
Review the productivity of each staff member involved in the process.
D
Question 15
The upper and lower control limits of a process control chart are
three standard deviations from the mean. A data point that falls
outside these limits
will be found 5% of the time even if the process is in statistical control.

A
will be found 5% of the time if the process is out of statistical control.
B
indicates the presence of a sentinel event.
C
is a signal for further investigation.
D
Question 16
The current error rate is one per 1000 pharmacy orders. The hospital
has 200 acute beds plus an outpatient service. The number of
pharmacy orders is 2000 orders per month (4 weeks).
A trial of a handheld device is planned. An analyst recommends a

sample of 3000 pharmacy orders for the trial. The two patient care
units being tested generate about one-third of the total pharmacy
orders each.
How long will the trial take?
6 weeks
A
9 weeks
B
10 weeks
C
12 weeks
D
Question 17
Which of the following statements about Six Sigma is TRUE?
Six Sigma is based on the premise that getting the process right will eventually
A lead to the desired outcomes.
Six Sigma aims to achieve 6 errors per million opportunities or less.

B
Six Sigma focuses on achieving the desired outcomes from the outset.
C
Six Sigma projects are suitable for redesigning processes only.

D
Question 18
The medication administration process at an acute care facility was
deemed to be unacceptable due to frequent errors associated with
patient harm. A subsequent trial of a handheld device, conducted at
the same facility, showed that use of the device in two patient care
units significantly reduced the rate of medication administration
errors.
How should the facility conduct a cost-benefit analysis to the change

from the old process to the new process?
The facility should compare the benefits and costs of the old and new
A processes based on the results of the trial only.
The facility should perform a cost-benefit analysis only after the use of the
B handheld device is extended to the whole facility.
The facility should take into account other improvements besides the
handheld device when comparing the benefits and costs of the old and new
C
processes.
The facility should not perform a cost-benefit analysis.
D
Question 19
In which of the following scenarios is rule-based sampling most
appropriate?
Obtaining customer feedback.

A
Assessing compliance to the time-out procedure.
B
Measuring patient falls.
C
Functional testing of laboratory machines.
D
Question 20
The accounting system of an organization has an error rate of 25
errors per million transactions, and there are 200 accounting
transactions in the typical patient record.
The treatment stage has an error rate of seven per million

opportunities, and there are an average of 500 opportunities for error
in the average patient's treatment.
What is the process yield, considering both accounting and
treatment?
(You may wish to use a calculator.)

99.9%
A
99.2%
B
98.3%
C
91.5%
D
Question 21
When dealing with data sets with fewer than 20 samples, which
statistical method is applied for confidence intervals for the
population standard deviation?
Binomial method and distribution

A
Chi-square method and distribution
B
Student's t method and distribution
C
Z method and distribution
D
Question 22
Where in a process is the ideal placement of the bottleneck?
First step in the process.

A
Middle of the process.
B
Penultimate step in the process.
C
Final step in the process.
D
Question 23
The intentional grouping of patients so that one setup can be used
several times
increases variability in the overall service performance time.
A
increases the overall service performance time.
B
decreases variability in the overall service performance time.
C
decreases the overall service performance time.
D
Question 24
In project management, achieving the proper balance of cost,
schedule, and quality is under the control of
the project sponsor alone.

A
the project manager alone.
B
the customers alone.
C
all stakeholders.
D
Question 25
What is the most likely effect of tampering when dealing with control
charts?
Reducing variation when the process is stable

A
Increasing variation when the process is stable
B
Failing to recognize special cause variation when it is present
C
Falsely identifying special cause variation when none exists
D
Question 26
Diverting traffic away from wet floors until dry in a hospital is an
example of
risk transfer.
A
risk reduction.
B
risk avoidance.
C
risk adjustment.
D
Question 1
The senior management team of an acute care facility is setting a
breakthrough goal for efficiency.
Which measure is the most appropriate?
A Length of stay
B Hospital costs
C Cost per capita
D Cost per case
Answer: C
Cost per capita assumes responsibility for the total cost of care, rather
than a specific aspect of care (e.g. hospital costs, length of hospital
stay, cost per case. It would be the most appropriate measure for a
breakthrough goal because of its level of ambition and scope—setting
aims for total cost of care requires design concepts that relate to the
whole system.

Question 2
How far from the center line should the upper limit of a control chart
be?
A 1.96 standard deviations

B 2 standard deviations
C 3 standard deviations
D none of the above.
Answer: D
The upper (and lower) limit of a control chart is usually 3 standard
deviations from the mean, but this does not necessarily have to be the
case. Depending on the process being studied, the control limits may
be more or less than 3 standard deviations from the mean.

control chart)
Question 3
What is the most frequent cause of failure in any improvement effort?
A Inadequate or improper training

B Lack of senior and middle management involvement
C Poor communication across the organization
D Unrealistic expectations
Answer: B
The most frequent cause of failure in any improvement effort is
indifferent or uninvolved senior and middle management.

Question 4
A team is developing a checksheet to record the reasons patients are
readmitted within 48 hours of discharge.
What is the best way of ensuring the checksheet is effective?
Carefully plan the form to make it as complete as possible before using it full-
A
scale.
Review forms used in other organizations and adopt them for
B
implementation in the present organization.
C Test the form on dummy patients before using it full-scale.
D Try out the form on a small sample of patients before using it full-scale.
Answer: D
In general, when developing a data collection tool, it is best to test it
on a small sample of actual patients (not dummy ones) and make any
necessary changes before full implementation. Some teams spend a
lot of time trying to develop the ―perfect‖ tool/form (either on their
own or adopting one from elsewhere) and then attempt to implement
it (full-scale)—this is usually not the best approach.

methodology (e.g. qualitative, quantitative)
Question 5
The Centers for Medicare & Medicaid Services (CMS) Five-Star
Quality Rating System for nursing homes consists of an overall 5-star
rating and a separate rating for each of the following sources of
information EXCEPT
A consumer surveys.
B staffing.
C quality measures.
D inspection results.
Answer: A
The CMS Five-Star Quality Rating System for nursing homes consists
of three domains: nursing home inspection results, staffing, and
quality measures. In addition there is an overall rating calculated
from the three domains.
question is linked:Participate in public reporting activities (e.g.
organizational transparency, website content, ensuring accuracy)
Question 6
Which of the following is LEAST likely to be a patient perspective of
quality?
A Following the standard of care

B Responsiveness and empathy
C Safety and freedom from injury
D Provision of clear information
Answer: A
Patient perspectives of quality include safety and freedom of injury,
access to care, responsiveness and empathy, good communication,
clear information provision, appropriate treatment, relief of
symptoms, and improvement of health status. Patients are less likely
to focus on whether providers follow a set standard of care.

Question 7
Consider a four-step treatment process with yields for each step:

On average, what percentage of the organization's effort in this
process requires rework?
A 5%
B 6%
C 15%
D 16%
Answer: D
Yield is defined as the ratio of desired outcomes to all outcomes.
In this process, only 84%, i.e. 0.99 × 0.95 × 0.95 × 0.94, of patients
are getting their treatment right the first time all the way through.
Therefore, 16% of patients, on average, are being held up for
additional treatment or to fix paperwork or something else
unplanned. On first approximation, 16% of the organization's effort is
going toward rework.

Question 8
Failure modes and effects analysis can be done
A from causes forward to effects.

B from effects back to causes.
C from causes forward to effects or from effects back to causes.
D by none of the above approaches.
Answer: C
Failure modes and effects can be done from effects back to causes or
from causes forward to effects.
For example, consider this effect: a wheel comes off the mail cart.
What can cause this? The wheel itself could break, the cart leg could
break, the axle could break, the cotter pin could come out of the axle,
or the shank of the leg down where the axle goes through it could get
bent so that the axle could pop out. We could then go further back to
ask, what would cause the axle to break? Well, the answer may be
poor lubrication, material defect, destructive handling during
assembly, abrasion against the strut, chemical attack by disinfectant
used to wash the cart, and so on. Similar lists could be developed for
each of the other causes of the wheel coming off.
Alternatively, we could go in the other direction and ask, what

happens if the wheel comes off? Well, the cart might tip, mail could
be dumped on the floor, mail would be held up, some mail might get
lost, the aisle could be blocked by the wreckage, the cart user might be
injured by the spill, another cart going might be tipped in turn, the
floor might get gouged, or a passerby might get a pocketful of mail.

question is linked:Perform or coordinate risk management: failure
mode and effects analysis
Question 9
An acute care facility has found that the incidence rate of pressure
ulcer cases, although low, is not as low as the incidence rate reported
by comparable organizations. Because the incidence of pressure
ulcers may detract from the organization's reputation for giving good
care, management decides to take this matter seriously and assigns a
project manager and analyst.
On review of the records, the project team decides that the existing
policy is the right one and something is going wrong in the
implementation.
Which of the following options is most appropriate?
A Develop a new policy.

B Failure modes and effects analysis.
C Root cause analysis.
D Review the data on pressure ulcers.
Answer: B
Because the existing policy is deemed to be the right one, developing
a new policy is not the best option at this stage.
FMEA is appropriate because it will help to identify ways that the

current process may fail and therefore help plan improvement.
Root cause analysis is not appropriate because there is no evidence of

special-cause variation, i.e. evidence to indicate that the process is out
of control.
Reviewing the data is not appropriate because a conclusion has

already been made about the incidence rate.
question is linked:Facilitate program development, evaluation,
planning, projects, and activities
Question 10
Which of the following statements about queuing and the bottleneck
of a workflow is TRUE?
A Queuing at the bottleneck is desirable.

B Queuing at the bottleneck should be eliminated.
C Queuing at the bottle should be minimized.
D Queuing at the bottleneck is unavoidable.
Answer: A
Queuing is waiting for service. Queuing is appropriate and even
necessary at the bottleneck because it is important to the organization
that the bottleneck never runs out of work.

Question 11
From a study of a sample of patient records for the prior 20 months,
the medication error rate was found to be 1 per 1000, with a 90%
confidence interval between zero and 3.4 errors per 1000.
What is the chance that the true value is NOT covered by the interval?
A 0%
B 3.4%
C 10%
D 90%
Answer: C
A 90% confidence interval means that the likelihood that the true
value lies within this interval is 90%. Therefore, there is a 10% chance
that the true value is not covered by the interval.
Question 12
At the office of a family dentist, he was the sole practitioner with an
established practice. From a quality improvement perspective, what is
the expected effect of another dentist joining the practice?
A Increase in capacity with no effect on the bottleneck.

B Expansion of the bottleneck with no effect on capacity.
C Increase in capacity and tightening of the bottleneck.
D Increase in capacity and expansion of the bottleneck.
Answer: D
Addition of another dentist will increase capacity.
When the first dentist was working by himself, the workflow had a
bottleneck (as with any workflow). For the purpose of answering this
question, we need not concern ourselves about the nature of this
bottleneck. When the second dentist joins the practice, he/she will
expand the bottleneck.
Therefore, the overall effect of a second dentist joining the practice is
an increase in capacity and expansion of the bottleneck.

question is linked:Integrate the results of the performance/quality
improvement process into strategic planning for the organization
Question 13
The primary goal of a program to assist with appropriate antibiotic
selection and dosing is to
A minimize adverse events.

B reduce cost.
C prevent the misuse and overuse of antibiotics.
D reduce the average length of stay.
Answer: A
The goal of an antibiotic stewardship program is to minimize the risk
of adverse events, such as Clostridium difficile infection and
antibiotic toxicity. The program will also probably result in cost
reduction and a decrease in the average length of stay. The program
will lead to the prevention of misuse and overuse of antibiotics but
this is not the goal; it may be viewed as a means to achieve the desired
result.
reviews or audits for: infection prevention and control processes
Question 14
In an acute care facility, the delivery times of x-ray results were
higher on Saturday and Sunday, compared with the other days of the
week. What should the management do next to improve weekend
performance?
A Increase the number of staff in the Radiology Department.

B Provide more training for staff in the Radiology Department.
C Use a process flow chart to better understand the process.
D Review the productivity of each staff member involved in the process.
Answer: C
The problem is probably due to a mismatch between workload and
staff or staff skills. However, more work is required to gain a better
understanding of the problem.
A process flow chart helps management as well as participants from

diverse departments to understand what is going on in the process.
The chart may even help the knowledgeable participants to
understand more fully what is going on because they may never have
thought about things in just the way they were presented in the chart.
This type of analysis is often the first step in trying to improve a
process.
At this stage in the improvement effort, it is best to assume that staff

are working as productively as they can in the current process.

Question 15
The upper and lower control limits of a process control chart are
three standard deviations from the mean. A data point that falls
outside these limits
A will be found 5% of the time even if the process is in statistical control.

B will be found 5% of the time if the process is out of statistical control.
C indicates the presence of a sentinel event.
D is a signal for further investigation.
Answer: D
This question tests your understanding of (process) control charts
and control limits.
In general, 99.7% of the data points will fall within the control limits
if the latter are three standard deviations above and below the mean
because a normal distribution is assumed (See central limit theorem).
Therefore, there is only a 0.3% chance that data points may show up
outside these limits even if the process in ―in control.‖ In other words,
it is possible for a data point to fall outside the control limits even if
there is no ―sentinel event‖ but it will be extremely rare, and therefore
warrants further investigation. If the data points stay within these
limits, everything can be considered to be working the way it is
expected to work given the system as it currently exists.
control chart)
Question 16
The current error rate is one per 1000 pharmacy orders. The hospital
has 200 acute beds plus an outpatient service. The number of
pharmacy orders is 2000 orders per month (4 weeks).
A trial of a handheld device is planned. An analyst recommends a

sample of 3000 pharmacy orders for the trial. The two patient care
units being tested generate about one-third of the total pharmacy
orders each.
How long will the trial take?
A 6 weeks
B 9 weeks
C 10 weeks
D 12 weeks
Answer: B
This is clearly a practical math question—such questions appear on
the CPHQ examination.
To answer this question, we merely have to pick out the relevant

information.
3000 pharmacy orders are required for the trial. Only two patient
care units are being tested and together, they generate two-thirds of
the total pharmacy orders, i.e. (1/3 +1/3) × 2000 = 2/3 * 2000 = 1333
orders every 4 weeks, or 333 orders per week. Therefore, the total
number of weeks to obtain a sample of 3000 orders is 3000/333 = 9
weeks.
Question 17
Which of the following statements about Six Sigma is TRUE?
Six Sigma is based on the premise that getting the process right will
A
eventually lead to the desired outcomes.
B Six Sigma aims to achieve 6 errors per million opportunities or less.
C Six Sigma focuses on achieving the desired outcomes from the outset.
D Six Sigma projects are suitable for redesigning processes only.
Answer: C
Unlike Total Quality Management, Six Sigma focuses on getting the
outcomes (output) right immediately, i.e. 3.4 errors per million
opportunities or less.
Six Sigma may be used for redesigning processes, solving problems,

instituting a change, or monitoring key processes.

Question 18
The medication administration process at an acute care facility was
deemed to be unacceptable due to frequent errors associated with
patient harm. A subsequent trial of a handheld device, conducted at
the same facility, showed that use of the device in two patient care
units significantly reduced the rate of medication administration
errors.
How should the facility conduct a cost-benefit analysis to the change
from the old process to the new process?
The facility should compare the benefits and costs of the old and new processes based
A
on the results of the trial only.
The facility should perform a cost-benefit analysis only after the use of the handheld
B
device is extended to the whole facility.
The facility should take into account other improvements besides the handheld device
C
when comparing the benefits and costs of the old and new processes.
D The facility should not perform a cost-benefit analysis.
Answer: D
A cost-benefit analysis in this case will not be meaningful because the
old process was unacceptable, no matter how favorable its costs. Cost-
benefit analysis is appropriate only when comparing sufficient
solutions.

question is linked:Demonstrate financial benefits of a quality
program
Question 19
In which of the following scenarios is rule-based sampling most
appropriate?
A Obtaining customer feedback.

B Assessing compliance to the time-out procedure.
C Measuring patient falls.
D Functional testing of laboratory machines.
Answer: D
Rule-based sampling focuses attention on key times and key events,
which are times when random sampling or periodic sampling would
not provide sufficient insight.
When a machine is turned on, the obvious thing to do is to check it

and its setup immediately to see if it is operable. Electronics are
known to fail most often just when the machine is turned on, so the
fact that the machine ran yesterday is not sufficient to know that it
will run today. Indeed, most computerized machines check
themselves upon boot-up for this very reason.
A functional test, which involves running the equipment against a

known standard, is good practice every time any machine is turned
on.

methodology
Question 20
The accounting system of an organization has an error rate of 25
errors per million transactions, and there are 200 accounting
transactions in the typical patient record.
The treatment stage has an error rate of seven per million

opportunities, and there are an average of 500 opportunities for error
in the average patient's treatment.
What is the process yield, considering both accounting and

treatment?
(You may wish to use a calculator.)
A 99.9%
B 99.2%
C 98.3%
D 91.5%
Answer: B
This question tests your understanding of cumulative process
performance, which is called the first-time-through yield when
expressed quantitatively.
The error rate is the error count divided by the total number of
opportunities for error. Yield is then defined as the complement of
the error rate (the error rate subtracted from one); an error rate of
0.1% means a yield of 99.9%.
For low error rates (as in this question), the error rates for several
stages can be added together without appreciable loss of precision in
the result.
For the accounting system, the error rate is 25/1,000,000, and there are
200 opportunities for error. Therefore, the expected number of
accounting errors per patient is: 25/1,000,000 × 200 = 0.005.
For the treatment stage, the error rate is 7/1,000,000, and there are 500
opportunities for error. Therefore, the expected number of treatment
errors per patient is 7/1,000,000× 500 = 0.0035.
The composite error rate is calculated by finding the sum of the two
error results from above, i.e. 0.005 + 0.0035 = 0.0085.
The process yield is the complement of the error rate, i.e. 1 − 0.0085
= 0.9915 or 99.2%.
This question could have been answered without the use of a
calculator. However, using a calculator reduces the chance of making
an error, e.g. misplacement of a decimal point. A simple calculator
may be brought into the test center and used during the CPHQ
exam—you should declare it to the proctor when you enter the center.
I recommend that candidates bring a simple electronic calculator to
the exam with them—most people have one lying around the office or
at home, and it may save you from making a silly calculation error.

Question 21
When dealing with data sets with fewer than 20 samples, which
statistical method is applied for confidence intervals for the
population standard deviation?
A Binomial method and distribution

B Chi-square method and distribution
C Student's t method and distribution
D Z method and distribution
Answer: B
For small samples (e.g. fewer than 20), the confidence interval for the
population average value is calculated using the Student's t method
and distribution. On the other hand, for confidence intervals for the
population standard deviation, the chi-squaremethod and
distribution are applied.
and analysis
Question 22
Where in a process is the ideal placement of the bottleneck?
A First step in the process.

B Middle of the process.
C Penultimate step in the process.
D Final step in the process.
Answer: A
In almost any process, there will be a bottleneck. However, placement
of the bottleneck may be beyond the control of management.
Nevertheless, the ideal place to have a bottleneck is at the first step in

the process. For example, some theme parks throttle the number of
patrons allowed into the park so that the patrons will not have to wait
interminably in queue to ride the popular rides. They put the
bottleneck at the first step of their service process; this is the best
place to have it.
The best place for the bottleneck is not at the end of the process.
Everyone who shops at a grocery store is infuriated by the grocery
store bottleneck: the checkout counters.

Question 23
The intentional grouping of patients so that one setup can be used
several times
A increases variability in the overall service performance time.

B increases the overall service performance time.
C decreases variability in the overall service performance time.
D decreases the overall service performance time.
Answer: A
Batching is the intentional grouping of patients or other work so that
one setup can be used several times. Batching the work of the
bottleneck is appropriate if some setup time is required at the
bottleneck because that setup time is non-productive. Using the same
setup several times in a row by batching the work minimizes the
nonproductive portion of the day and maximizes production.
Therefore, the overall service performance time may increase or
decrease with batching, depending on where the latter is placed.
Batching increases variability in the overall service performance time.
Patients at the head of the batch are processed in less overall time
than patients at the end of the batch.

Question 24
In project management, achieving the proper balance of cost,
schedule, and quality is under the control of
A the project sponsor alone.

B the project manager alone.
C the customers alone.
D all stakeholders.
Answer: D
At the start of any project, three things need to be agreed upon: what
should be built/designed, the cost or price of the product/service, and
when it must be delivered. This cost-schedule-quality equilibrium is
also known as the triple constraint. These three variables define the
overall goals of a project. After a balance between these variables is
struck, a change to one will affect the other two.
All stakeholders, especially those involved in project selection,
influence the choices and trade-offs that make up the triple
constraint.

question is linked:Facilitate or participate in organization-wide
strategic planning
Question 25
What is the most likely effect of tampering when dealing with control
charts?
A Reducing variation when the process is stable

B Increasing variation when the process is stable
C Failing to recognize special cause variation when it is present
D Falsely identifying special cause variation when none exists
Answer: B
Tampering refers to over-responding to individual common cause
data points as if they signified special causes—asking for explanations
or making changes based on the individual data points. When a
process is stable and well targeted, tampering is likely to increase
variation.

Question 26
Diverting traffic away from wet floors until dry in a hospital is an
example of
A risk transfer.
B risk reduction.
C risk avoidance.
D risk adjustment.
Answer: C
Because wet floors are usually slippery, accidents can occur. By
diverting traffic away from wet floors, the chance of an accident
occurring as a result of the floor being wet is eliminated, i.e. risk
avoidance.
Risk transfer refers to transferring the risk to another party, e.g. an

insurance company.
Risk reduction is a risk management strategy that attempts to

optimize or mitigate the risk.
Risk adjustment, in the context of healthcare risk management, is a

―statistical process that takes into account the underlying health
status and health spending of the enrollees in an insurance plan when
looking at their health care outcomes or health care costs.‖
Question 6
Question 1
A hospital system is participating in a regional nursing quality
measurement database. Data are collected for a variety of nursing-
sensitive quality indicators in the following categories: nurse staffing,
RN education level, certification, patient falls, pressure ulcers, use of
restraints, central line-associated bloodstream infections, and
medication administration.
For which indicators should graphs be used to summarize

comparative hospital performance?
All indicators in the database.

A
Only indicators in the database prioritized for performance improvement.
B
Only indicators in the database for which the data suggest underperformance.
C
Only indicators in the database for which the data suggest outperformance.
D
Question 2
Falls per 1,000 patient-days in an acute care facility has remained
stable in the last 14 months. Management concluded that the falls
rate in the facility is satisfactory. What other analysis, if any, is useful
to support the management's conclusion?
Review of the actual number of falls per month during the 14 months.
A
Comparison of the falls rate to other similar organizations.
B
Breakdown of the falls rate according to patient care unit.
C
Breakdown of the falls rate according to patient age.
D
Question 3
The degree to which the average temperature in refrigerators in a
hospital falls outside specification on any given day may be displayed
in a
bar chart.
A
Pareto chart.
B
control chart.
C
histogram.
D
Question 4
You are the Director of Quality Management at an acute care facility
that will soon open. The Chief Executive Officer has asked you to
select the organization's key performance indicators.
What information will you request first?
The human resource available for data collection

A
The organization's strategy and goals
B
Management's commitment to act on performance reports
C
The timeline for preparing the list of performance indicators
D
Question 5
Which of the following statements about capability analysis of a
process is TRUE?
Capability analysis requires that the process is in statistical control.

A
Capability analysis requires the presence of a special cause of variation.
B
Capability analysis compares current process performance with past
C performance.
Capability analysis is used to identify the limits of the current process.
D
Question 6
There were 260 sharps injuries at an acute care facility in the past 3
years. The number of worked full-time-equivalent employees (WFTE)
during this period was 1050. The WFTE in the next 12 months is
expected to increase to 1200. Other things being equal, how many
sharps injuries can the facility expect in the next 12 months?
You may wish to use a calculator.

87
A
99
B
275
C
297
D
Question 7
An acute care facility aims to reduce postsurgical infection rates by
implementing a list of evidence-based practices. Which of the
following goals is most likely to gain commitment and buy-in if
reinforced?
Improved patient care

A
Reduced cost of care
B
Compliance with insurance carrier's rules
C
Compliance with accreditation standards
D
Question 8
Secular variation of a time series is represented graphically by
cyclic movements.
A
sporadic motions.
B
a trend line.
C
staying within control limits.
D
Question 9
An acute care facility decided to improve the reliability of evidence-
based care for acute myocardial infarction (AMI). ―Perfect care‖ is
defined as delivery of all six indicated evidence-based interventions
for AMI patients. The facility's performance on AMI perfect care is
shown in the graph below.
In January 2013 (red arrow in the graph), the facility introduced

education, communication, data feedback to medical staff, and
training for nurses and other professionals to improve its
performance.
What should be the next course of action?
Continue to monitor perfect care but make no further changes.

A
Abandon the initiative to improve the reliability of evidence-based care for
B AMI.
Stop the changes that were introduced in January 2013 and try new ones.
C
Continue the changes that were introduced in January 2013 and take
D additional actions.
Question 10
Which of the following methods is MOST appropriate for the
structured assessment of nontechnical skills in a ward-based hospital
environment at a team level?
Administering a computer-based standardized test

A
Using a behavioral marker tool
B
Implementing a staff satisfaction survey
C
Implementing a patient satisfaction survey
D
Question 11
Which of the following is a possible benefit of hospital accreditation
by The Joint Commission (TJC)?
Discount on insurance
A
Reduced frequency of state hospital licensing surveys
B
―Deemed status‖ by the Centers for Medicare & Medicaid Services
C
All of the above are benefits of accreditation by TJC
D
Question 12
Which of the following organizations does NOT have authority by the
Centers for Medicare & Medicaid Services (CMS) to grant ―deemed
status‖ to hospitals?
The Joint Commission

A
American Osteopathic Association

B
Det Norske Veritas
C
All three organizations listed above are authorized to grant ―deemed status‖ to
D hospitals
Question 13
A medical staff peer review committee has concluded that the care
provided in the case reviewed had a marginal deviation from the
standard of care.
What is the ―standard of care‖?
Care that is consistent with best practice

A
Care that is minimally accepted practice
B
Care that a reasonable physician in similar circumstances would provide
C
Care that can generally be expected by patients in similar circumstances
D
Question 14
A multidisciplinary team is tasked to implement a picture archiving
and communication system (PACS) in a large acute care facility. Staff
in the outpatient department are resisting the necessary changes.
Who should the team leader approach about this issue in the first
instance?
Team sponsor
A
Team facilitator
B
Chief Operating Officer
C
Chief Executive Officer
D
Question 15
The completeness of credentialing activities can be assessed by
file audits.
A
a practitioner satisfaction survey.
B
productivity reports.
C
review of quality improvement information.
D
Question 16
Reappointment or recredentialing in a hospital accredited by The
Joint Commission should be conducted
annually or more frequently.

A
every two years or more frequently.
B
every three years or more frequently.
C
on an ongoing basis.
D
Question 17
How does clinical peer review differ from quality improvement?
Clinical peer review monitors activities of physicians while quality

A improvement is focused on organizational activity.
Clinical peer review is focused on individual practitioners while quality
B improvement focuses on process.
Peer review identifies outliers to standard practice while quality improvement
C is concerned with the process in which outliers will be addressed.
There is no difference between the two activities.

D
Question 18
Primary source verification may include
a faxed copy.
A
a copy from the practitioner.
B
a copy forwarded by another hospital.
C
none of the above.
D
Question 19
What information will be considered a caution flag in credentialing
activities?
A missing peer recommendation.

A
Missing dates or gaps in practice.
B
Licensure in more than one state.
C
All of the above.
D
Question 20
When using quality measures, for which purpose are the
requirements for validity and reliability the highest?
Accountability
A
Quality improvement
B
Research
C
The requirements for validity and reliability are the same when using
D measures for accountability, quality improvement, or research.
Question 21
Benchmarking is a tool that compares current performance with
performance of industry leaders.

A
performance in similar organizations.
B
performance goals.
C
all of the above.
D
Question 22
How should a team leader manage a disruptive member?
Discuss general group-process concerns without pointing out individuals.

A
Confront the offending team member in the presence of the team.
B
Talk privately with the disruptive team member.
C
Dismiss the offending team member.
D
Question 23
random variation.
A
anticipated variation.
B
assignable variation.
C
all types of variation.
D
Question 24
Failure Mode and Effects Analysis.

A
statistical process control.
B
sequential problem solving.
C
the PDCA cycle.
D
Question 1
A hospital system is participating in a regional nursing quality
measurement database. Data are collected for a variety of nursing-
sensitive quality indicators in the following categories: nurse staffing,
RN education level, certification, patient falls, pressure ulcers, use of
restraints, central line-associated bloodstream infections, and
medication administration.
For which indicators should graphs be used to summarize

comparative hospital performance?
A All indicators in the database.

B Only indicators in the database prioritized for performance improvement.
C Only indicators in the database for which the data suggest underperformance.
D Only indicators in the database for which the data suggest outperformance.
Answer: B
Graphs should not be used to summarize all data. Although
commonly done, creating many pages of graphs often leads to people
missing key analyses.
Graphs should only be used for those indicators prioritized for

performance improvement. Displaying data that do not demonstrate
underperformance or outperformance may still be valuable.

question is linked:Organize information for committee meetings
(e.g. agendas, reports, minutes)
Question 2
Falls per 1,000 patient-days in an acute care facility has remained
stable in the last 14 months. Management concluded that the falls
rate in the facility is satisfactory. What other analysis, if any, is useful
to support the management's conclusion?
A Review of the actual number of falls per month during the 14 months.
B Comparison of the falls rate to other similar organizations.
C Breakdown of the falls rate according to patient care unit.
D Breakdown of the falls rate according to patient age.
Answer: B
Monitoring only trend reports is not sufficient. Even if performance
remains stable, i.e. a flat slope, comparison to other organizations is
still important to gauge whether the bar has risen. The overall group
of facilities may raise the bar or benchmark. Even if individual
performance is stable, relative performance may decline because the
rest of the group in the data set improved.

Question 3
The degree to which the average temperature in refrigerators in a
hospital falls outside specification on any given day may be displayed
in a
A bar chart.
B Pareto chart.
C control chart.
D histogram.
Answer: D
A histogram is appropriate in this case because it can show the shape
of distribution of the temperature readings on any given day. It can
also help one to determine whether the spread of the readings falls
within specification, and, if not, how much falls outside of
specifications.
A bar chart or Pareto chart is more appropriate for attribute data. In

our case above, the data have not been categorized. Hence, a bar chart
or Pareto chart cannot be used to examine the degree of variability.
The example above deals with cross-sectional data (average
temperature on any given day), and not time-series data. Therefore, a
control chart is not appropriate.
control chart)
Question 4
You are the Director of Quality Management at an acute care facility
that will soon open. The Chief Executive Officer has asked you to
select the organization's key performance indicators.
What information will you request first?
A The human resource available for data collection

B The organization's strategy and goals
C Management's commitment to act on performance reports
D The timeline for preparing the list of performance indicators
Answer: B
As suggested in this article on performance indicators, in this
situation, it is probably best to first gain a clear understanding of the
organization's strategy and goals.
dashboards)
Question 5
Which of the following statements about capability analysis of a
process is TRUE?
A Capability analysis requires that the process is in statistical control.
B Capability analysis requires the presence of a special cause of variation.

Capability analysis compares current process performance with past
C
performance.
D Capability analysis is used to identify the limits of the current process.
Answer: A
Capability analysis of a process is used to determine whether a
process is able to meet its specifications or requirements. In order to
perform a capability analysis, the process needs to be in statistical
control. Process capability compares process performance with
process requirements.
control chart)
Question 6
There were 260 sharps injuries at an acute care facility in the past 3
years. The number of worked full-time-equivalent employees (WFTE)
during this period was 1050. The WFTE in the next 12 months is
expected to increase to 1200. Other things being equal, how many
sharps injuries can the facility expect in the next 12 months?
You may wish to use a calculator.

A 87
B 99
C 275
D 297
Answer: B
This is a relatively straightforward math-based question. This task (of
anticipating the impact of a particular problem) is sometimes asked
of quality professionals. Further, some candidates report being
stumped by such math-based questions on the CPHQ exam.
The average annual number of sharps injuries is 260/3. We need not

calculate this figure immediately.
The historical annual rate of sharps injuries is, therefore, 260/3 ÷ 1050.
The unit of measurement here is ―sharps injuries/WFTE.‖ Again, we
need not calculate this figure.
We are told that everything other than the WFTE has remained
constant. Therefore, we can assume that the rate of sharps injuries
will be the same in the next 12 months.
To calculate the number of sharps injuries in the next 12 months, we

simply multiply the historical rate of sharps injuries with the WFTE:
260/3 ÷ 1050 × 1200 = 99

Question 7
An acute care facility aims to reduce postsurgical infection rates by
implementing a list of evidence-based practices. Which of the
following goals is most likely to gain commitment and buy-in if
reinforced?
A Improved patient care

B Reduced cost of care
C Compliance with insurance carrier's rules
D Compliance with accreditation standards
Answer: A
All four answer options give commonly cited goals for conducting
quality improvement initiatives. However, reinforcing goals that are
linked to improved patient care is most likely to result in staff
becoming more amenable to changes.

question is linked:Facilitate assessment, development, and design
of the organization's quality culture
Question 8
Secular variation of a time series is represented graphically by
A cyclic movements.
B sporadic motions.
C a trend line.
D staying within control limits.
Answer: C
Secular movements, or secular variation, refer to the general
direction in which the graph of a time series appear to be going over a
long interval of time. Secular movements are indicated by a trend
line.
control chart)
Question 9
An acute care facility decided to improve the reliability of evidence-
based care for acute myocardial infarction (AMI). ―Perfect care‖ is
defined as delivery of all six indicated evidence-based interventions
for AMI patients. The facility's performance on AMI perfect care is
shown in the graph below.
In January 2013 (red arrow in the graph), the facility introduced

education, communication, data feedback to medical staff, and
training for nurses and other professionals to improve its
performance.
What should be the next course of action?
A Continue to monitor perfect care but make no further changes.

Abandon the initiative to improve the reliability of evidence-based care for
B
AMI.
C Stop the changes that were introduced in January 2013 and try new ones.
Continue the changes that were introduced in January 2013 and take
D
additional actions.
Answer: D
The graph indicates that baseline performance on AMI perfect care
from January 2012 through December 2012 was about 80%. In the
same month the changes were introduced (January 2013), perfect
care rose to above 95%. But this improvement in performance lasted
only 3 months, and then returned to the baseline level. This is
suggestive of a ―Hawthorne effect.‖ The actions that had been taken in
the early part of 2013 are fairly standard, and there is no reason to
stop doing them (answer option C). To improve performance,
additional actions need to be taken.
Question 10
Which of the following methods is MOST appropriate for the
structured assessment of nontechnical skills in a ward-based hospital
environment at a team level?
A Administering a computer-based standardized test

B Using a behavioral marker tool
C Implementing a staff satisfaction survey
D Implementing a patient satisfaction survey
Answer: B
Behavioral marker tools define observable behaviors exhibited by
individuals or teams. By comparing performance against a set of
required skills, these tools facilitate the structured assessment of
nontechnical skills in the clinical environment.
Question 11
Which of the following is a possible benefit of hospital accreditation
by The Joint Commission (TJC)?
A Discount on insurance
B Reduced frequency of state hospital licensing surveys
C ―Deemed status‖ by the Centers for Medicare & Medicaid Services
D All of the above are benefits of accreditation by TJC
Answer: D
A number of liability insurers offer a discount to organizations that
are accredited by TJC.
TJC accreditation reduces or eliminates the need for hospitals

accredited by TJC to undergo surveys to assess compliance with state
hospital licensing regulations.
―Deemed status‖ is a recognized benefit of accreditation by TJC.

question is linked:Facilitate evaluation and/or selection of
appropriate accreditation or recognition program(s) (e.g. The Joint
Commission (TJC), Magnet, Baldrige, Det Norske Veritas (DNV),
American Osteopathic Association (AOA), Healthcare Facility
Accreditation Program (HFAP))
Question 12
Which of the following organizations does NOT have authority by the
Centers for Medicare & Medicaid Services (CMS) to grant ―deemed
status‖ to hospitals?
A The Joint Commission
B American Osteopathic Association
C Det Norske Veritas

All three organizations listed above are authorized to grant ―deemed status‖
D
to hospitals
Answer: D
Three organizations have the authority to grant ―deemed status‖ to
hospitals:
 The Joint Commission;
 American Osteopathic Association (through its Healthcare

Facilities Accreditation Program (HFAP)); and
 Det Norske Veritas.

Question 13
A medical staff peer review committee has concluded that the care
provided in the case reviewed had a marginal deviation from the
standard of care.
What is the ―standard of care‖?
A Care that is consistent with best practice

B Care that is minimally accepted practice
C Care that a reasonable physician in similar circumstances would provide
D Care that can generally be expected by patients in similar circumstances
Answer: C
The term of ―standard of care‖ is generally accepted to mean ―the
caution that a reasonable person in similar circumstances would
exercise in providing care to a patient.‖

privileging process (e.g., Focused Professional Practitioner Evaluation
Question 14
A multidisciplinary team is tasked to implement a picture archiving
and communication system (PACS) in a large acute care facility. Staff
in the outpatient department are resisting the necessary changes.
Who should the team leader approach about this issue in the first
instance?
A Team sponsor
B Team facilitator
C Chief Operating Officer
D Chief Executive Officer
Answer: A
One of the key roles of the team sponsor is to represent team interests
to the organization. This includes obtaining the support of executive
managers and the staff with whom they work.
In this case, it would be inappropriate for the team leader to

immediately approach the medical staff, COO, or CEO.

Question 15
The completeness of credentialing activities can be assessed by
A file audits.
B a practitioner satisfaction survey.
C productivity reports.
D review of quality improvement information.
Answer: A
The completeness of credentialing activities can be assessed by file
audits. Credentialing files may be selected randomly or according to
some criteria, e.g. initial appointments, current temporary privileges,
practitioners who perform invasive procedures.
Question 16
Reappointment or recredentialing in a hospital accredited by The
Joint Commission should be conducted
A annually or more frequently.

B every two years or more frequently.
C every three years or more frequently.
D on an ongoing basis.
Answer: D
In the past, recredentialing and reappointment in TJC-accredited
hospitals were expected to be done every 2 years or more frequently.
However, since 2007, TJC standards require that practitioners’
performance be evaluated on an ongoing basis.
Question 17
How does clinical peer review differ from quality improvement?
Clinical peer review monitors activities of physicians while quality improvement is

A
focused on organizational activity.
Clinical peer review is focused on individual practitioners while quality

B
improvement focuses on process.
Peer review identifies outliers to standard practice while quality improvement is

C
concerned with the process in which outliers will be addressed.
D There is no difference between the two activities.
Answer: B
Clinical peer review may be considered part of an organization's
quality improvement activities. Its focus is not confined to physicians
only (answer option A) but also nurses, pharmacists, and other health
care professionals. Peer review does not only aim to identify outliers
to standard practice (answer option C), e.g. it may include evaluation
of evidence-based practice.

Question 18
Primary source verification may include
A a faxed copy.
B a copy from the practitioner.
C a copy forwarded by another hospital.
D none of the above.
Answer: D
Primary source verification may be accomplished by ―mail, secure
electronic communication (including secure websites), or by
telephone if the details of the verification are documented.‖ The
practitioner or another hospital is not a primarysource of
information
Question 19
What information will be considered a caution flag in credentialing
activities?
A A missing peer recommendation.

B Missing dates or gaps in practice.
C Licensure in more than one state.
D All of the above.
Answer: D
Caution flags are those pieces of data or information that should send
up warning signals to the credentialing staff and the reviewers.
Missing peer information, missing dates or gaps in practice, and
licensure in more than one state are all caution flags.

Question 20
When using quality measures, for which purpose are the
requirements for validity and reliability the highest?
A Accountability
B Quality improvement
C Research
The requirements for validity and reliability are the same when using
D
measures for accountability, quality improvement, or research.
Answer: A
In general, the requirements for validity and reliability are highest
when using quality measures for accountability. According to the
AHRQ, ―uses of quality measures for the purpose of accountability
include purchaser and/or consumer decision making, variation in
payment in relation to the level of performance and/or certification of
professionals or organizations.‖

dashboards)
Question 21
Benchmarking is a tool that compares current performance with
A performance of industry leaders.

B performance in similar organizations.
C performance goals.
D all of the above.
Answer: A
In general, benchmarking means ―measuring an organization's
performance against that of best-in-class companies, determining
how the best in class achieve those performance levels and using the
information as a basis for one's own company targets, strategies and
implementation.‖

question is linked:Integrate the results of performance/quality
improvement process into strategic planning for the organization
Question 22
How should a team leader manage a disruptive member?
A Discuss general group-process concerns without pointing out individuals.

B Confront the offending team member in the presence of the team.
C Talk privately with the disruptive team member.
D Dismiss the offending team member.
Answer: C
The best approach to disruptive behavior is to talk privately to the
offending team member, pointing out that disruptive behavior seems
inconsistent with a commitment to help the team succeed.

Question 23
A random variation.
B anticipated variation.
C assignable variation.
D all types of variation.
Answer: C
Clinical practice guidelines reduce assignable variation. The latter
arises from identifiable causes that can be tracked and eliminated. In
the context of clinical practice guidelines, assignable variation
represents inappropriate variation.
Question 24
A Failure Mode and Effects Analysis.

B statistical process control.
C sequential problem solving.
D the PDCA cycle.
Answer: D
The Plan-Do-Check-Act (PDCA) Cycle exemplifies the scientific
method in quality improvement: planning a
change, doing it, checking to see its effect, and then actingon what we
have learned by either rejecting the change or making it a standard
part of the process.
Question 7
Question 1
In deciding whether to apply for an external quality award, the first
step is to determine if the award criteria
are approved by the Board of Directors.
A
demonstrate excellence in quality.
B
are aligned with the organization's strategic plan.
C
require more policies to be drafted.
D
Question 2
Who among the following should be appointed to a Quality
Improvement Council to deal effectively with conflict?
Senior Leader
A
Chief Operating Officer
B
Risk Manager
C
Facilitator
D
Question 3
Patient satisfaction scores for a community hospital demonstrate
multiple areas for improvement including a need to improve
attractiveness of the facility, responsiveness to patient needs, and
physician and nursing communication. Which of the following should
the healthcare quality professional also expect to find?
Administration prioritizing and leading units to achieve organizational goals.

A
Unit managers who openly discuss patient satisfaction scores.
B
Units operating independently with little communication between units.
C
Employee satisfaction scores in the 80th percentile compared to other peer
D organizations.
Question 4
An example of integrating the results of a utilization management
assessment in the performance improvement process is
assessing results of patient satisfaction surveys.

A
educating case managers in discharge planning.
B
hiring more nurses.
C
reporting assessment results to executive staff.
D
Question 5
Which of the following is the BEST way for a healthcare quality
professional to involve nursing staff in the restructuring of a patient
care unit?
Present at a department meeting

A
Ask the nurse leader for recommendations
B
Conduct a focus group
C
Survey the nursing staff
D
Question 6
Which of the following is the FIRST step in the strategic planning
process?
Defining organizational structure

A
Setting goals and objectives
B
Determining productivity indicators
C
Establishing and controlling a budget
D
Question 7
Which of the following technologies has been shown to offer the
greatest potential to improve patient safety?
Barcode medication administration

A
Computerized physician order entry with decision support
B
―Smart‖ intravenous devices
C
Electronic medical record
D
Question 8
Team performance is BEST evaluated by
the team leader.

A
senior leadership.
B
the PDCA process.
C
the nominal group technique.
D
Question 9
The use of clinical pathways and guidelines in hospitals should
minimize variation in patient care.

A
reduce length of stay.
B
improve patient satisfaction.
C
identify errors in patient care.
D
Question 10
Which of the following does an outcome indicator measure?
What happens as the result of a process

A
The steps leading to the process
B
Individual performance of the process
C
Priority areas to improve the process
D
Question 11
Data regarding the relationship between patient satisfaction and
hours per patient day on a medical unit were reported to be (r = 0.60,
p < 0.05). What is the correlation coefficient between these two
measures?
0.05
A
0.55
B
0.60
C
0.36
D
Question 12
Quality improvement requires healthcare quality professionals to
recognize that
quality improvement generates its own change.

A
the process is an ongoing continuous and dynamic change.
B
the process requires radical change in a short period of time.
C
quality improvement is managed by senior leaders.
D
Question 13
Which of the following is the primary goal of risk management?
Identify high risk areas of the organization

A
Maintain an effective incident reporting system
B
Perform failure mode and effects analyses
C
Reduce financial loss within the organization
D
Question 14
The evaluation of the quality and appropriateness of patient care in
the radiology department is the responsibility of the
medical director of radiology.

A
chief medical officer.
B
medical director of the quality department.
C
administrator of clinical services.
D
Question 15
A computer report generated to assess the type of patients served
shows 72% of visits were for obstetrical services. Which of the
following codes should be reviewed to verify the accuracy of this
percentage?
Procedural
A
Diagnostic
B
Medication
C
Attending physician
D
Question 16
Measuring the time it takes a nurse to perform a procedure addresses
which of the following?
Monitoring
A
Process
B
Outcome
C
Structure
D
Question 17
Which of the following is essential to an effective Quality Council?
Involvement of leadership
A
Consultation of the legal advisor
B
Participation of the Strategic Planning Committee
C
Direction from the organization's Quality Department
D
Question 18
The BEST way to facilitate change within a healthcare organization is
to
arrange presentations by senior leaders.

A
communicate through group meetings.
B
involve the individuals directly affected by the change.
C
communicate through group e-mail.
D
Question 19
A team approach to problem solving is most useful when
the organization's goals are unclear.

A
multiple areas of expertise are required.
B
communication challenges exist.
C
there are ample resources within the organization.
D
Question 20
The concept of organizational liability is important to the field of
healthcare quality because it holds the organization responsible for
ensuring confidentiality of all documents.

A
requiring physicians to carry adequate malpractice insurance.
B
maintaining a process to identify deficiencies in the provision of care.
C
assuring that peer review physicians have no vested interest in cases being
D reviewed.
Question 21
A healthcare quality professional is reviewing data with a wide range
of values between the highest and lowest points. The BEST way to
rank order is using a
line graph.
A
simple frequency distribution.
B
grouped frequency distribution.
C
bar graph.
D
Question 22
Each of the following activities are part of an organization's patient
safety program, EXCEPT
teams conducting Failure Mode and Effects Analysis (FMEA).

A
physicians developing criteria for identifying specific cases with potential
B clinical and safety risk.
fire safety drills.
C
a policy for support of staff involved in a sentinel event.
D
Question 23
A facility is providing a new service for patients with chronic pain.
What is the primary role of the healthcare quality professional in
evaluating this new service?
Comparing outcomes to benchmark data

A
Evaluating cost-benefit ratios
B
Assuring that staff are adequately trained
C
Developing performance monitoring criteria
D
Question 24
Which of the following are measures of central tendency?
Grouped data, bell curve, and distribution

A
Standard deviation, variance, and standard error
B
Mean, mode, and median
C
Correlation, regression, and t-test
D
Question 25
Which of the following charts is used to institute quality improvement
and monitor cost reduction on an ongoing basis?
Pie
A
Control
B
Pareto
C
Fishbone
D
Question 26
The main purpose of conducting a focus group is to
direct attention to an identified problem.

A
determine customer needs.
B
track and trend occurrences.
C
obtain a clear picture of a recurring problem.
D
Question 27
Standards of care based on the knowledge and experience of
recognized experts and healthcare research are known as
benchmark data.
A
generic screens.
B
pre-established criteria.
C
evidence-based guidelines.
D
Question 28
The most effective way for a healthcare quality professional to
communicate quality improvement activities to the medical staff is by
developing professional relationships.

A
inviting medical staff to an in-service training on quality tools.
B
evaluating physician participation on quality teams.
C
providing outcome data at medical staff meetings.
D
Question 29
A reengineering effort occurred at a facility. Activities, particularly
those regarding staff layoffs, were carefully planned, communicated,
and implemented according to the plan. One year later, the business
is stable, but staff morale is very low. A healthcare quality
professional has been asked to consult in determining where the
effort went wrong. Based on the concepts of change theory, the cause
is most likely
a failure to address the needs of the staff who were retained.

A
that the reengineering decision was a mistake.
B
that leadership was not properly trained in the change process.
C
that a few disgruntled staff are instigating dissension in the ranks.
D
Question 30
A critically ill patient is admitted and requires a specialized
procedure; however, the surgeon does not have privileges at the
facility. Which of the following documents will be most helpful in
identifying the course of action the hospital should take?
Patient safety manual

A
Risk management plan
B
Medical staff bylaws
C
Surgical policies and procedures
D
Question 31
Which of the following is the BEST way to determine whether a
quality improvement initiative is successful?
Compare outcomes with pre-established goals

A
Conduct a survey of employees
B
Present findings to the Quality Council
C
Survey patients and customers
D
Question 32
Hospital A has recently merged with Hospital B. Hospital A has
successfully transitioned their staff to new organizational values after
6 months, but Hospital B still struggles. Hospital A's success can
BEST be attributed to
requiring adoption of new values by all staff.

A
support of both hospitals' mission statements.
B
acceptance of the shared mission statement and vision.
C
integrating technology and databases.
D
Question 33
With which of the following does quality leadership start, in contrast
to management by results?
Profit and loss

A
Return on investment
B
Current products and services
C
Customer needs and expectations
D
Question 34
Reported data on patient falls are shown below:
Which of the following assumptions do these data demonstrate?
The overall number of falls declined, but there is no trend demonstrated.

A
The decreasing rate of falls is not significant because the last reported data is abo
B target.
The only demonstrated trend was above the target.
C
The overall rates demonstrate a positive trend.
D
Question 35
Which of the following sampling techniques involves selecting the
medical record of every fifth patient undergoing cardiovascular
bypass?
Convenience
A
Systematic
B
Stratified
C
Simple random
D
Question 1
In deciding whether to apply for an external quality award, the first
step is to determine if the award criteria
A are approved by the Board of Directors.
B demonstrate excellence in quality.
C are aligned with the organization's strategic plan.
D require more policies to be drafted.
Answer: C
As a general principle, all quality initiatives should be aligned with
the organization's strategic goals and plan. By determining if the
award criteria are aligned with the organization's strategic plan, the
healthcare quality professional is ensuring the highest possible
likelihood of success in achieving the quality award. In addition, any
activities required to achieve the award would fit with the other
(strategic) activities of the organization. The alternative answers in
the question are also probably necessary (approval from the Board,
demonstration of quality excellence, new policies) but they are not
the first step in applying for an external quality award.
This question, like many in the CPHQ exam, requires judgement,
which is acquired through experience and coaching/training.

Question 2
Who among the following should be appointed to a Quality
Improvement Council to deal effectively with conflict?
A Senior Leader
B Chief Operating Officer
C Risk Manager
D Facilitator
Answer: D
You might find the following references helpful in explaining the
answer:
 When Leaders Should Step Aside and Use an Outside

Facilitator
 Working With Group Conflict [PDF—184 KB]
Using a senior leader may be seen as an authoritarian approach,
which is sometimes required in emergency situations or when
emotions are high and issues will require widespread unpopular
decisions. The facilitator in a conflict may be a third party or a senior
leader. ―Facilitator‖ is therefore the best answer for this question. The
other options ―Chief Operating Officer‖ and ―Risk Manager‖ do not
appear to be relevant to the question.

Question 3
Patient satisfaction scores for a community hospital demonstrate
multiple areas for improvement including a need to improve
attractiveness of the facility, responsiveness to patient needs, and
physician and nursing communication. Which of the following should
the healthcare quality professional also expect to find?
A Administration prioritizing and leading units to achieve organizational goals.
B Unit managers who openly discuss patient satisfaction scores.
C Units operating independently with little communication between units.
Employee satisfaction scores in the 80th percentile compared to other peer
D
organizations.
Answer: C
For this question, the candidate should be looking for other
symptoms or possible causes of the ―multiple areas for improvement.‖
Among the four choices, the third one is clearly the correct answer. It
is also important to note that the other answers are indicators of good
quality management.

Question 4
An example of integrating the results of a utilization management
assessment in the performance improvement process is
A assessing results of patient satisfaction surveys.

B educating case managers in discharge planning.
C hiring more nurses.
D reporting assessment results to executive staff.
Answer: D
Reporting the results of selected assessments to executive staff is a
key component of any performance improvement program.
To answer this question correctly, you'd need to identify its key

elements: ―integration‖, ―in the performance improvement process‖,
and ―results of utilization management‖ (UM). ―Hiring more nurses‖
does not represent integration in the PI process, and assessing the
results of patient satisfaction surveys is not considered part of UM.
―Educating case managers in discharge planning‖ isn't the best
answer as these individuals are expected to understand discharge
planning (part of UM) and the latter is not as significant to PI process
as reporting assessment results to executive staff.

planning projects, and activities
Question 5
Which of the following is the BEST way for a healthcare quality
professional to involve nursing staff in the restructuring of a patient
care unit?
A Present at a department meeting

B Ask the nurse leader for recommendations
C Conduct a focus group
D Survey the nursing staff
Answer: C
For the purpose of passing the CPHQ exam and your future practice
in healthcare quality, you should know what a focus group is. The best
answer is ―Conduct a focus group‖ because the information that can
be gathered is more comprehensive and richer compared to a survey
of the nurses. Although the following webpage is referring to web
design, the difference between focus groups and (survey)
questionnaires is well
explained: http://www.doublespark.co.uk/blog/focus-groups-vs-
questionnaires/
In a restructuring exercise, the rôle of the healthcare quality
professional is usually notto present to department staff. Asking the
nurse leader for recommendations might be useful but not as effective
in gathering information as conducting a focus group!
heard
Question 6
Which of the following is the FIRST step in the strategic planning
process?
A Defining organizational structure

B Setting goals and objectives
C Determining productivity indicators
D Establishing and controlling a budget
Answer: B
There are a number of steps in strategic planning. The traditional
approach would include:
 External and internal analysis
 Issue analysis
 Development, review and/or revision of the organisation's

mission, vision, and values
 Organizational goals, critical success factors, and

objectives
However, for this question, among the choices, ―Setting goals and
objectives‖ is the best answer. The other options follow the setting of
goals and objectives

question is linked:Facilitate or participate in organization-wide
strategic planning
Question 7
Which of the following technologies has been shown to offer the
greatest potential to improve patient safety?
A Barcode medication administration

B Computerized physician order entry with decision support
C ―Smart‖ intravenous devices
D Electronic medical record
Answer: B
This question is one that I call an ―either-you-know-it-or-you-don't‖
question. If you know the answer, you'll pick it straight away, but if
you don't it becomes a guessing exercise. In our training, we
emphasize key facts that CPHQ candidates mustabsolutely know for
―recall questions‖ in the exam.
patient safety program (e.g. computerized physician order entering
(CPOE), BCMA/barcoding, electronic medical record (EMR),
Question 8
Team performance is BEST evaluated by
A the team leader.

B senior leadership.
C the PDCA process.
D the nominal group technique.
Answer: C
Working knowledge of the PDCA process is essential. The Plan-Do-
Check-Act (PDCA) process involves making small tests of change (Do)
and seeing the results of those changes (Check) before trying another
test or spreading the change (Act). Team performance is not best
evaluated by Nominal Group Technique. Although team performance
should be evaluated by the team leader and senior leadership, neither
of these two options in this question is the best answer.

Question 9
The use of clinical pathways and guidelines in hospitals should
A minimize variation in patient care.

B reduce length of stay.
C improve patient satisfaction.
D identify errors in patient care.
Answer: A
Note: According to the CPHQ Candidate Handbook: clinical
pathways = clinical/critical pathways/guidelines.
Recall questions, such as this one, often require knowledge of the
facts. Guessing the answer or attempting to pick the correct answer
by a process of elimination is usually not effective. With regard to this
question, pathways might reduce length of stay, improve patient
satisfaction and identify errors in care, but the main purpose of
pathways is to minimize variation.

Question 10
Which of the following does an outcome indicator measure?
A What happens as the result of a process

B The steps leading to the process
C Individual performance of the process
D Priority areas to improve the process
Answer: A
For an explanation of the answer, read our article ―Assessing Quality
of Care: Structure, Process, and Outcome.‖
Question 11
Data regarding the relationship between patient satisfaction and
hours per patient day on a medical unit were reported to be (r = 0.60,
p < 0.05). What is the correlation coefficient between these two
measures?
A 0.05
B 0.55
C 0.60
D 0.36
Answer: C
Read our article on correlation. The Pearson product-moment
correlation coefficient, or "Pearson's correlation", is often denoted as
the letter r.
question is linked:Use the results of statistical techniques to
evaluate data (e.g. t-test, regression)
Question 12
Quality improvement requires healthcare quality professionals to
recognize that
A quality improvement generates its own change.

B the process is an ongoing continuous and dynamic change.
C the process requires radical change in a short period of time.
D quality improvement is managed by senior leaders.
Answer: B
This is another recall question. Quality improvement does not usually
generate its own change - changes are made and tested. Radical
changes are sometimes done but not usually. Quality improvement is
managed by a variety of people, not only senior leaders. Quality
improvement is undoubtedly an ongoing continuous process that
often involves making small tests of change, checking their results,
and acting on those results (i.e. it is a dynamic process).

planning, projects, and activities
Question 13
Which of the following is the primary goal of risk management?
A Identify high risk areas of the organization

B Maintain an effective incident reporting system
C Perform failure mode and effects analyses
D Reduce financial loss within the organization
Answer: D
―Risk management in healthcare is a formal attempt to control
liability, prevent financial loss, and protect the financial assets of the
organization.‖ Some of my trainees have suggested alternative
answers and justified their answers eloquently. However, for the
purpose of taking the CPHQ exam, I recommend the definition for
risk management above. If you follow this definition of risk
management, you will not only get the right answer to this question
but also understand why the other options should be eliminated.

question is linked:Perform or coordinate risk management: risk
prevention
Question 14
The evaluation of the quality and appropriateness of patient care in
the radiology department is the responsibility of the
A medical director of radiology.

B chief medical officer.
C medical director of the quality department.
D administrator of clinical services.
Answer: A
This is an application question that calls for judgment. Some may
argue that quality assessment is everyone's responsibility. Let's have a
look at the options: The medical director of the department (that is
being assessed) appears to be the best answer. The chief medical
officer is not the best answer as the first option is ―closer to the
action‖ and would be considered ―more responsible.‖ The medical
director of the quality department may be involved in the evaluation
of patient care in the radiology department but, like the chief medical
officer, is a little removed. The administrator of clinical services is not
the best person to evaluate the quality of patient care as he/she may
not be familiar with the patients and/or services of the department.
question is linked:Identify champions (e.g. stakeholders, process
owners, quality, patient safety)
Question 15
A computer report generated to assess the type of patients served
shows 72% of visits were for obstetrical services. Which of the
following codes should be reviewed to verify the accuracy of this
percentage?
A Procedural
B Diagnostic
C Medication
D Attending physician
Answer: B
The last two options can be eliminated as they are not directly
relevant to visits for obstetric services. Some obstetrics patients may
require procedures but this question asked for the percentage of
visits. Visits are usually categorized by diagnostic codes.
Question 16
Measuring the time it takes a nurse to perform a procedure addresses
which of the following?
A Monitoring
B Process
C Outcome
D Structure
Answer: C
For an explanation of the answer, read our article ―Assessing Quality
of Care: Structure, Process, and Outcome.‖
Question 17
Which of the following is essential to an effective Quality Council?
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
Answer: A
Key terms are ―essential‖ and ―effective.‖ Consultation of the legal
advisor and participation of the Strategic Planning Committee are not
essential for an effective Quality Council. ―Direction from the
organization's Quality Department‖ is not the best answer for two
reasons:
1. Direction should come from the Quality Council not the Quality
Department; and
2. Some organizations don't have a Quality Department but they
should have a Quality Council (quality is not a department).
Involvement of leadership, on the other hand, is essential to an
effective Quality Council.

Question 18
The BEST way to facilitate change within a healthcare organization is
to
A arrange presentations by senior leaders.

B communicate through group meetings.
C involve the individuals directly affected by the change.
D communicate through group e-mail.
Answer: C
This question addresses change management. Arranging
presentations by senior leaders, and communicating through group
meetings and through group e-mail may all be required but the most
effective change management activity is to involve the people directly
affected by the change. This may be considered a change management
principle.

question is linked:Lead and facilitate change within the
organization
Question 19
A team approach to problem solving is most useful when
A the organization's goals are unclear.

B multiple areas of expertise are required.
C communication challenges exist.
D there are ample resources within the organization.
Answer: B
The final option is clearly not the correct one. A team approach to
problem solving might be required when communication problems
exist and to give clarity to the organization's goals. However, among
the four options, the strongest reason to use a team approach is
because ―multiple areas of expertise are required.‖
Question 20
The concept of organizational liability is important to the field of
healthcare quality because it holds the organization responsible for
A ensuring confidentiality of all documents.
B requiring physicians to carry adequate malpractice insurance.
C maintaining a process to identify deficiencies in the provision of care.
assuring that peer review physicians have no vested interest in cases being
D
reviewed.
Answer: C
Another recall question, the correct answer is clearly ―maintaining a
process to identify deficiencies in the provision of care.‖

question is linked:Perform or coordinate risk management: risk
analysis and evaluation
Question 21
A healthcare quality professional is reviewing data with a wide range
of values between the highest and lowest points. The BEST way to
rank order is using a
A line graph.
B simple frequency distribution.
C grouped frequency distribution.
D bar graph.
Answer: C
Optimal display of data is a key skill for a healthcare quality
professional. In this question, line and bar graphs are not appropriate
to display a range of data, and a simple frequency distribution is not
as good as a grouped frequency distributionbecause we are dealing
with ―a wide range of values.‖
display data (e.g. fishbone, Pareto chart, run chart scattergram,
control chart)
Question 22
Each of the following activities are part of an organization's patient
safety program, EXCEPT
A teams conducting Failure Mode and Effects Analysis (FMEA).

physicians developing criteria for identifying specific cases with potential
B
clinical and safety risk.
C fire safety drills.
D a policy for support of staff involved in a sentinel event.
Answer: C
Of the four options, only ―fire safety drills‖ are not part of a patient
safety plan. On the other hand, the alternative answers should/could
be included in a patient safety plan.

Question 23
A facility is providing a new service for patients with chronic pain.
What is the primary role of the healthcare quality professional in
evaluating this new service?
A Comparing outcomes to benchmark data

B Evaluating cost-benefit ratios
C Assuring that staff are adequately trained
D Developing performance monitoring criteria
Answer: A
Neither evaluating cost-benefit ratios nor training of staff in a chronic
pain service is the primary rôle of a healthcare quality professional. A
healthcare quality professional may assist in developing performance
monitoring criteria. However, between ―developing performance
monitoring criteria‖ and ―comparing outcomes to benchmark data,‖
the latter is the better option to evaluate the new service.
A new service is best evaluated using outcome measures and

comparing the data to the best in the industry.

Question 24
Which of the following are measures of central tendency?
A Grouped data, bell curve, and distribution

B Standard deviation, variance, and standard error
C Mean, mode, and median
D Correlation, regression, and t-test
Answer: C
Measures of central tendency, also known as measures of location, are
an important CPHQ exam issue.
question is linked:Use basic statistical techniques to present data
(e.g. mean, standard deviation)
Question 25
Which of the following charts is used to institute quality improvement
and monitor cost reduction on an ongoing basis?
A Pie
B Control
C Pareto
D Fishbone
Answer: B
The use of control charts is almost always tested in the CPHQ exam.
Pie, Pareto and Fishbone charts are not the most appropriate to
monitor any measure on an ongoing basis, the latter implying the
need for the measure to be tracked over time.

Question 26
The main purpose of conducting a focus group is to
A direct attention to an identified problem.

B determine customer needs.
C track and trend occurrences.
D obtain a clear picture of a recurring problem.
Answer: B
For the purpose of sitting the CPHQ exam and for your future
practice in healthcare quality, you should know what a focus group is.
Previous comments about recall questions apply here as well.
heard
Question 27
Standards of care based on the knowledge and experience of
recognized experts and healthcare research are known as
A benchmark data.
B generic screens.
C pre-established criteria.
D evidence-based guidelines.
Answer: D
The correct answer is ―evidence-based guidelines.‖ The alternative
answers are clearly not correct: generic screens and pre-established
criteria have no relevance to ―standards of care based on the
knowledge and experience.‖ Benchmark data represent data that are
best in the field, and are used for comparison. They are not ―based on
the knowledge and experience of recognized experts and healthcare
research.‖

Question 28
The most effective way for a healthcare quality professional to
communicate quality improvement activities to the medical staff is by
A developing professional relationships.

B inviting medical staff to an in-service training on quality tools.
C evaluating physician participation on quality teams.
D providing outcome data at medical staff meetings.
Answer: D
Presenting outcome data to physicians is an extremely effective way
to engage them in quality improvement work. The other options may
also be helpful but the question asked for the most effective way to
communicate quality improvement activities to the medical staff.
question is linked:Coordinate and promote the dissemination of
performance/quality improvement information within the
organization
Question 29
A reengineering effort occurred at a facility. Activities, particularly
those regarding staff layoffs, were carefully planned, communicated,
and implemented according to the plan. One year later, the business
is stable, but staff morale is very low. A healthcare quality
professional has been asked to consult in determining where the
effort went wrong. Based on the concepts of change theory, the cause
is most likely
A a failure to address the needs of the staff who were retained.

B that the reengineering decision was a mistake.
C that leadership was not properly trained in the change process.
D that a few disgruntled staff are instigating dissension in the ranks.
Answer: A
This is an analysis question. Analysis questions ―test the candidate’s
ability to evaluate, problem solve or integrate a variety of information
and/or judgment into a meaningful whole.‖
Business process reengineering is a common CPHQ examination

topic.
For this question, there is insufficient information to conclude that
the ―reengineering decision was a mistake.‖ It appears that leaders
were properly trained, as activities were carefully planned,
communicated and implemented. There is no evidence that a few
disgruntled staff are instigating dissension. From experience in the
field, as well as by a process of eliminating the other options, the
correct answer is ―a failure to address the needs of the staff who were
retained.‖

organization
Question 30
A critically ill patient is admitted and requires a specialized
procedure; however, the surgeon does not have privileges at the
facility. Which of the following documents will be most helpful in
identifying the course of action the hospital should take?
A Patient safety manual

B Risk management plan
C Medical staff bylaws
D Surgical policies and procedures
Answer: C
Important facts of this question include: the patient was in a critical
condition; he/she required a specialized procedure; the surgeon
probably had the skills to perform the procedure; the surgeon does
not have privileges to perform the procedure. The issue is related to
the last point: What are the steps required for the surgeon to perform
the procedure, for which he currently does not have privileges? How
the hospital should address this situation is most likely to be found in
the medical staff bylaws.
Question 31
Which of the following is the BEST way to determine whether a
quality improvement initiative is successful?
A Compare outcomes with pre-established goals

B Conduct a survey of employees
C Present findings to the Quality Council
D Survey patients and customers
Answer: A
One way to answer this question is to eliminate the improbable
answers. ―Present findings to the Quality Council‖ does not appear to
be correct, as there is no indication of assessment by the Council.
Conducting a survey of the employees seems unlikely as it is not an
objective method of evaluation. Similarly, a survey of patients and
customers, although possibly beneficial, lacks objectivity. Even if the
surveys of employees and of patients and customers were conducted
properly, they would not be better than ―comparing outcomes with
pre-established goals.‖ The latter is objective and deals with
outcomes, considered by most as the gold-standard measure.

Improvement
Question 32
Hospital A has recently merged with Hospital B. Hospital A has
successfully transitioned their staff to new organizational values after
6 months, but Hospital B still struggles. Hospital A's success can
BEST be attributed to
A requiring adoption of new values by all staff.

B support of both hospitals' mission statements.
C acceptance of the shared mission statement and vision.
D integrating technology and databases.
Answer: C
Some level of judgement is required to answer this question. Firstly,
we can eliminate ―support of both hospital's mission statements‖ and
―integrating technology and databases.‖ In a merger, there will be one
common mission statement for the merged entity (not two mission
statements). Integration of technology and databases is important but
this is not usually the main reason for successful staff transitions.
―Adoption of new values by all staff‖ is a possible answer, but
―acceptance of the shared mission statement and vision‖ is the best
answer. Having established the mission statement and vision, values
of the merged hospital follow.
question is linked:Facilitate or participate in developing an
organizational vision and mission statement
Question 33
With which of the following does quality leadership start, in contrast
to management by results?
A Profit and loss

B Return on investment
C Current products and services
D Customer needs and expectations
Answer: D
This is a recall question, the answer to which depends on your
knowledge of quality management and ―management by results.‖

Question 34
Reported data on patient falls are shown below:
Which of the following assumptions do these data demonstrate?
A The overall number of falls declined, but there is no trend demonstrated.

The decreasing rate of falls is not significant because the last reported data is abo
B
target.
C The only demonstrated trend was above the target.
D The overall rates demonstrate a positive trend.
Answer: A
To answer this question, you need to understand run charts and know
how to evaluate a run chart for trends. Both are beyond the scope of
this CPHQ Exam Practice Quiz.

Question 35
Which of the following sampling techniques involves selecting the
medical record of every fifth patient undergoing cardiovascular
bypass?
A Convenience
B Systematic
C Stratified
D Simple random
Answer: B
This is an example of systematic sampling (equal-probability
method). You can learn more about sampling techniques in
our Epidemiology Series.
question is linked:Use epidemiological theory in data collection
and analysis
Question 8
Question 1
The rate of Cesarean section performed at a facility over the past 5
years is best presented in a
run chart.
A
control chart.
B
Pareto chart.
C
stratified histogram.
D
Question 2
A large acute care facility has fostered a culture of patient safety
through staff education, support of process improvements at the
departmental level, and implementation of a non-punitive approach
to error reporting. Compliance with patient safety goals in
departments range from 75—100%.
How should the organization assess its culture of patient safety?
Review post-surgical infection rate data

A
Review data collected through incident reports
B
Survey patients admitted in the last 6 months
C
Survey employees and physicians
D
Question 3
What should staff members do first when dealing with an angry
patient?
Acknowledge the patient's feelings

A
Terminate the episode as soon as possible
B
Ask the patient to calm down
C
Redirect the topic of discussion
D
Question 4
A process indicator is one that measures
the appropriateness of a procedure or treatment.

A
unexpected or negative variation.
B
an activity to provide care or service.
C
events that require further investigation.
D
Question 5
An acute care facility plans to use a survey to evaluate its level of
customer satisfaction. The facility has an urgent care center, dialysis
unit, operating room, cardiac catheterization lab, and six
Medical/Surgical inpatient units.
Which of the following methods provides the most reliable data?
A random sample of 5% of all annual discharges/visits per unit

A
A random sample of 20% of all annual discharges/visits per unit

B
All discharges/visits of patients with a last name beginning with the letters A–
C E
All discharges/visits in January and July

D
Question 6
Data on medication errors at a facility over the past month are shown
in the table below:
Which unit is most likely to have the highest incidence of using only
one patient identifier?
Emergency Room
A
Intensive Care Unit
B
Medical Unit
C
Surgical Unit
D
Question 7
A curriculum for staff education in organizational change should
include all of the following EXCEPT
project and time management.

A
the negotiation process.
B
budgeting techniques.
C
conflict resolution.
D
Question 8
An acute care facility has had an increase in the rate of patient falls in
the past six months. The healthcare quality professional should
recommend
creating a focus group of medical staff to discuss fall risk.

A
revising the fall risk assessment tool.
B
increasing nurse staffing levels on nights and weekends.
C
sharing the data with staff to provide feedback.
D
Question 9
Situation-Background-Assessment-Recommendation (SBAR) is a
tool to improve communication between caregivers.

A
software package commonly used in quality improvement.
B
method for measuring process variation.
C
Six Sigma tool.
D
Question 10
Team building exercises for the first meeting should include all of the
following EXCEPT
reviewing the improvement plan.

A
setting meeting ground rules.
B
learning to work as a team.
C
getting to know one another.
D
Question 11
In the development of department-specific performance indicators,
the healthcare quality professional in her role as a consultant should
prioritize the quality indicators for selection by the department head.

A
conduct a literature search and select appropriate quality indicators.

B
review the mission statement and seek physician input.

C
ensure that the numerator and denominator of each indicator are clearly
D defined.
Question 12
To introduce performance improvement concepts throughout the
organization, a healthcare quality professional should consider
implementing all of the following steps EXCEPT
distributing a newsletter containing applicable quality topics.

A
meeting with each department head on a regular basis.
B
mandating staff participation in self-study activities related to quality.
C
providing lectures on quality.
D
Question 13
Which of the following is an example of a leadership strategy to
integrate the patient safety program into the organization's overall
performance improvement system?
Apply failure mode and effects analysis (FMEA) in the healthcare system
A
Conduct root cause analysis to identify risks
B
Evaluate training data to plan leadership retreats
C
Review the rate of hospital discharges
D
Question 14
On which of the following areas should a trend analysis of incidents at
an acute care facility focus?
Case mix index and staffing patterns

A
Timeliness of reporting and data accuracy
B
Severity level and occurrence types
C
Practitioner profile and diagnostic codes
D
Question 15
A quality improvement team has brainstormed a list of many ideas.
Which tool should the team use to identify which ideas to test first?
Cost-benefit analysis
A
Multivoting
B
Affinity diagram
C
Flowchart
D
Question 16
A team approach to quality improvement activities is preferred when
financial resources are lacking.

A
the process has many owners.
B
when a large amount of data is involved.
C
when complex quality improvement tools are used.
D
Question 17
The following data on falls were obtained from a facility with units
that have similar average daily censuses.
Unit A—9%
Unit B—4%
Unit C—6%
Unit D—8%
What other information is needed to help determine the cause of the
falls?
Compliance with the fall prevention protocol

A
Time of day the falls occurred
B
Number of falls
C
Medication education
D
Question 18
Which of the following questions should be asked first when
reviewing an organization's performance improvement (PI) plan?
Does the PI plan include communication of its intent to employees?

A
Are there sufficient resources to support the PI plan?

B
Does the PI plan include statistical methods to monitor change?

C
Is the PI plan consistent with the organization's mission and strategic priorities?
D
Question 19
The prevalence of a disease depends on the
number of new cases and the population at risk.

A
the incidence and duration of the disease.
B
incidence and change in the etiological factors.
C
total number of cases and the population at risk.
D
Question 20
Conclusions in a statistical study are generalized to the
unit.
A
sample.
B
population.
C
hospital.
D
Question 21
In medical staff credentialing, which of the following sources is NOT
appropriate for primary source verification?
Original medical school diploma provided by the practitioner

A
American Board of Medical Specialties (ABMS)
B
State licensing board
C
Educational Commission for Foreign Medical Graduates (ECFMG)
D
Question 22
Which of the following statements about patient falls in a long term
care facility is TRUE?
If a patient is confused, the best way to protect them is to keep all bed
A siderails elevated.
The use of restraints will protect the hospital and staff from a lawsuit if a
B patient falls or is injured.
Patients who climb over raised siderails are more seriously injured if they
C fall than those who fall from a bed without siderails raised.
Once a patient falls, they usually "learn their lesson" and are less likely to
D fall again than patients who have not experienced a fall.
Question 23
A major drawback of using raw data to present the results of quality
monitoring is that they
cannot be displayed graphically.

A
may only be used for focused review.
B
lack proper reference points for interpretation.
C
may only be used to measure compliance with established criteria.
D
Question 24
According to the 80/20 rule, 80% of an organization's problems are
related to
systems.
A
education.
B
staffing.
C
training.
D
Question 25
Quality improvement teams are responsible for all of the following
EXCEPT
communicating results.
A
setting goals and the timetable of the project.
B
defining the roles and duties of members.
C
establishing the need for the team.
D
Question 26
Which of the following behaviors is LEAST likely to require the use of
restraints?
Trying to get out of chair when not able to do so

A
Agitation associated with poor memory and attention span
B
Pulling at essential lines and tubes
C
Physically aggressive behavior toward staff
D
Question 1
The rate of Cesarean section performed at a facility over the past 5
years is best presented in a
A run chart.
B control chart.
C Pareto chart.
D stratified histogram.
Answer: B
Data on Cesarean section that are collected over time may be
presented in either a run chart or a control chart. Between these two
charts, a control chart is preferable.
A Pareto chart is not suitable because it deals with categorical data.
A histogram (stratified or not) should not be your first choice for

displaying time-series data.

control chart)
Question 2
A large acute care facility has fostered a culture of patient safety
through staff education, support of process improvements at the
departmental level, and implementation of a non-punitive approach
to error reporting. Compliance with patient safety goals in
departments range from 75—100%.
How should the organization assess its culture of patient safety?
A Review post-surgical infection rate data

B Review data collected through incident reports
C Survey patients admitted in the last 6 months
D Survey employees and physicians
Answer: D
Patient safety culture is assessed by a survey of staff, including
medical staff, using instruments such as the AHRQ Hospital Survey
on Patient Safety Culture.

Question 3
What should staff members do first when dealing with an angry
patient?
A Acknowledge the patient's feelings

B Terminate the episode as soon as possible
C Ask the patient to calm down
D Redirect the topic of discussion
Answer: A
When dealing with an angry patient, staff members should remain
calm and demonstrate empathy, e.g. by acknowledging the patient's
feelings, as soon as possible. Attempting to terminate the
conversation, asking the patient to calm down, or redirecting the
discussion may aggravate the situation further.

question is linked:Interact with staff regarding quality issues (e.g,
patient issues, service delivery, human resources)
Question 4
A process indicator is one that measures
A the appropriateness of a procedure or treatment.

B unexpected or negative variation.
C an activity to provide care or service.
D events that require further investigation.
Answer: C
A process indicator measure, in the context of healthcare quality,
measures an activity to provide care or service.

dashboards)
Question 5
An acute care facility plans to use a survey to evaluate its level of
customer satisfaction. The facility has an urgent care center, dialysis
unit, operating room, cardiac catheterization lab, and six
Medical/Surgical inpatient units.
Which of the following methods provides the most reliable data?
A A random sample of 5% of all annual discharges/visits per unit

B A random sample of 20% of all annual discharges/visits per unit
C All discharges/visits of patients with a last name beginning with the letters A–E
D All discharges/visits in January and July
Answer: B
For a short period (3 years?), questions requiring sample size
calculations were not included in the CPHQ exam. However, it
appears that questions on sampling methods have made a come-back.
In this example, the facility is fairly large and will no doubt exceed
1,000 visits/admissions for the year. As a general rule of thumb, for a
population size greater than 30, a sampling method is appropriate,
i.e. you need not survey the entire population.
To obtain a representative sample, the method in which patients are

selected should be random, i.e. a "random sample" (answer options A
and B). Furthermore, the random selection should be unit-based, i.e.
a random sample from each unit. Selecting patients according to their
last name or the month of their discharge/visit may lead to biased
data.
The question asked for the method that would produce the most
reliable data, not the most efficient one. A larger sample would be
more reliable. Therefore, a sample that consists of 20% of the
population would be more reliable than one that has 5% of the
population.
heard
Question 6
Data on medication errors at a facility over the past month are shown
in the table below:
Which unit is most likely to have the highest incidence of using only
one patient identifier?
A Emergency Room
B Intensive Care Unit
C Medical Unit
D Surgical Unit
Answer: D
Use of only one patient identifier would be expected to result in a
higher number of wrong-patient medication errors. Within each unit,
data on three types of errors are shown. Among the four units, you
will have to look for the one with the highest percentage of wrong-
patient medication errors. The Surgical Unit has the highest
percentage of wrong-patient medication errors (6/9 or 66.7%), and is
therefore most likely to have the highest incidence of using only one
patient identifier among its staff.
incident report review
Question 7
A curriculum for staff education in organizational change should
include all of the following EXCEPT
A project and time management.

B the negotiation process.
C budgeting techniques.
D conflict resolution.
Answer: C
Organizational change requires a set of skills including project and
time management, negotiation, and conflict resolution. Budgeting
may be defined as a "process of expressing quantified resource
requirements (amount of capital, amount of material, number of
people) into time-phased goals and milestones." It may first seem to
be relevant in organizational change as well—it probably is at a senior
executive level. However, budgeting as part of the curriculum for
general staff education in organizational change seems to be the least
important among the four answer options given.

organization
Question 8
An acute care facility has had an increase in the rate of patient falls in
the past six months. The healthcare quality professional should
recommend
A creating a focus group of medical staff to discuss fall risk.

B revising the fall risk assessment tool.
C increasing nurse staffing levels on nights and weekends.
D sharing the data with staff to provide feedback.
Answer: D
A focus group of medical staff only is not likely to improve the patient
fall rate. The fall risk assessment tool may need review but this should
not be done first in response to an increase in the fall rate. Without
knowing when the falls occurred, we cannot be sure that an increase
in staffing levels will reduce the fall rate.
In general, it's a good idea to provide feedback to frontline staff about

the data that they collect. They are also in the best position to suggest
possible reasons for the increase in falls.

question is linked:Coordinate and promote the dissemination of
performance/quality improvement information within the
organization
Question 9
Situation-Background-Assessment-Recommendation (SBAR) is a
A tool to improve communication between caregivers.

B software package commonly used in quality improvement.
C method for measuring process variation.
D Six Sigma tool.
Answer: A
SBAR is a structured communication technique for organizing
important patient information.
Question 10
Team building exercises for the first meeting should include all of the
following EXCEPT
A reviewing the improvement plan.

B setting meeting ground rules.
C learning to work as a team.
D getting to know one another.
Answer: A
This question tests your knowledge on the agenda for the team's first
meeting. During the first meeting, the team should review the charter
and the project's goals but not the improvement plan (which it will
develop later). Team members should set ground rules for future
meetings, learn how to work as a team, and get to know each other.

Question 11
In the development of department-specific performance indicators,
the healthcare quality professional in her role as a consultant should
A prioritize the quality indicators for selection by the department head.

B conduct a literature search and select appropriate quality indicators.
C review the mission statement and seek physician input.
D ensure that the numerator and denominator of each indicator are clearly
defined.
Answer: B
As a consultant, the healthcare quality professional should assist the
department head to select appropriate quality indicators based on the
latest scientific research. Prioritization is not the responsibility of the
quality professional. Reviewing the mission statement (to ensure that
the indicators are relevant) and seeking physician input should be
done by the department head. Ensuring that the numerator and
denominator of each indicator are clearly defined should be done by
the department head, who would be more familiar with the nuances
of the indicators as they are meant to be applied in their specific
specialty or department.

Question 12
To introduce performance improvement concepts throughout the
organization, a healthcare quality professional should consider
implementing all of the following steps EXCEPT
A distributing a newsletter containing applicable quality topics.

B meeting with each department head on a regular basis.
C mandating staff participation in self-study activities related to quality.
D providing lectures on quality.
Answer: C
Among the four answer options, the least effective in disseminating
performance improvement concepts is self-study (answer option C)
because it requires a significant amount of motivation and the
learning from self-study (both in terms of quality and quantity)
cannot be standardized.

Question 13
Which of the following is an example of a leadership strategy to
integrate the patient safety program into the organization's overall
performance improvement system?
A Apply failure mode and effects analysis (FMEA) in the healthcare system
B Conduct root cause analysis to identify risks
C Evaluate training data to plan leadership retreats
D Review the rate of hospital discharges
Answer: A
FMEA is a proactive process which identifies potential process or
product failures before any error occurs. It can inform the
organization's performance improvement system, e.g. in the selection
of quality improvement initiatives.
Root cause analysis looks at past process or product failures, and is

therefore less useful than FMEA going forward.
Reviewing training data or hospital discharge rates (alone) does not

help to integrate the patient safety program into the organization's
performance improvement system.
Question 14
On which of the following areas should a trend analysis of incidents at
an acute care facility focus?
A Case mix index and staffing patterns

B Timeliness of reporting and data accuracy
C Severity level and occurrence types
D Practitioner profile and diagnostic codes
Answer: B
As this question is on ―trend analysis,‖ you should be looking for a
pair of variables that may have a (linear) relationship between each
other, and knowledge of this relationship is relevant to incidents. In
the context of the CPHQ exam, the ―trend analysis‖ would involve a
scatter plot and a ―Line of Best Fit,‖ also called a ―Trend Line.‖
Therefore, the variables should be quantitative (numerical), as
opposed to categorical or descriptive. Only one answer option gives a
pair of variables that are clearly quantitative: timeliness of reporting
and data accuracy (the latter measured as a percentage) (answer
option B). The facility would be interested to know if there is a trend
between these two variables because one expects an inverse
relationship, i.e. timely reports that are less accurate or late reports
that are more accurate. A different type of ―trend‖ seen on the scatter
plot would warrant investigation.
Case mix index (not ordinal or continuous) and staffing patterns (A);
occurrence types (C); and practitioner profile and diagnostic codes
(D), are all difficult/impossible to represent on a scatter plot.

control chart)
Question 15
A quality improvement team has brainstormed a list of many ideas.
Which tool should the team use to identify which ideas to test first?
A Cost-benefit analysis
B Multivoting
C Affinity diagram
D Flowchart
Answer: B
For this question, you are required to pick the tool that would help
the team prioritize its ideas. The best choice is multivoting. None of
the other answer options is suitable for prioritizing ideas.

control chart)
Question 16
A team approach to quality improvement activities is preferred when
A financial resources are lacking.
B the process has many owners.
C when a large amount of data is involved.
D when complex quality improvement tools are used.
Answer: B
Among the four answer options, the best reason for a team approach
is that the process has multiple owners. In such a scenario, it is best
to have the input of the various parties, i.e. a team approach.
Financial resources, the amount of data, and the tools used should
not influence whether a team approach is used or not.

Question 17
The following data on falls were obtained from a facility with units
that have similar average daily censuses.
Unit A—9%
Unit B—4%
Unit C—6%
Unit D—8%
What other information is needed to help determine the cause of the
falls?
A Compliance with the fall prevention protocol

B Time of day the falls occurred
C Number of falls
D Medication education
Answer: A
We are told that the units have similar average daily censuses. We are
not told whether the units differ in terms of patient case mix, so we
can assume the case mix is similar. Over time, one would expect the
falls rate to be similar among the units. Clearly, the falls rate among
the units differ; Unit B's falls rate is significantly lower than that of
Unit A.
Variation in the compliance with the fall prevention protocol may be

an important reason for the difference in falls rate.
Knowing the time of day the falls occurred will not be helpful;
patients are at higher risk of falls at night. Therefore, even if there
were a difference in the number of patient falls at night, this would
not be particularly helpful in identifying the major cause of falls.
Knowing the number of falls will not be helpful because we were told
that the average daily census was similar among the units.
Medication education is not likely to be helpful in preventing falls in

the inpatient setting.

incident report review
Question 18
Which of the following questions should be asked first when
reviewing an organization's performance improvement (PI) plan?
A Does the PI plan include communication of its intent to employees?
B Are there sufficient resources to support the PI plan?
C Does the PI plan include statistical methods to monitor change?
D Is the PI plan consistent with the organization's mission and strategic priorities?
Answer: D
This is a common question on the CPHQ exam—there are several
variations but they test the same principle, i.e. the quality
improvement (or performance improvement) plan should, above all
else, be aligned with the organization's mission and strategic goals.

Question 19
The prevalence of a disease depends on the
A number of new cases and the population at risk.

B the incidence and duration of the disease.
C incidence and change in the etiological factors.
D total number of cases and the population at risk.
Answer: B
As explained in our article on measures of occurrence, the (point)
prevalence of a disease (or other condition) depends on a number of
factors. Two of these factors are the incidence and the duration of the
disease.
and analysis
Question 20
Conclusions in a statistical study are generalized to the
A unit.
B sample.
C population.
D hospital.
Answer: C
In most epidemiological studies (including improvement work), it is
necessary to select a sample from the population. It is important that
the sample is representative in order to extrapolate results from the
study population to the population from which the sample was
drawn. In this case, the most accurate answer is ―population,‖ i.e.
population under study. Depending on the goals of the study, the
population may be a unit, a hospital, the entire town, etc.
Note: You may wonder if such questions are asked on the actual
exam—this question may not seem to be obviously related to
healthcare quality. There is a question similar to the one above in the
current pool of questions used in the CPHQ exam. So, in short, you
can expect to see such questions. My primary goal is to help you to
succeed in the exam, not explain how the HQCC selects the questions.
and analysis
Question 21
In medical staff credentialing, which of the following sources is NOT
appropriate for primary source verification?
A Original medical school diploma provided by the practitioner
B American Board of Medical Specialties (ABMS)
C State licensing board
D Educational Commission for Foreign Medical Graduates (ECFMG)
Answer: A
Primary sources are the original source or an approved agent of that
source of a specific credential that can verify the accuracy of a
qualification that an individual health care practitioner reports.
Examples of primary sources include medical school, state medical
board, and federal and state licensing boards. In additional, primary
source verification may be done through secondary but ―designated
equivalent sources,‖ examples of which include the AMA Physician
Masterfile, ABMS, ECFMG, and the American Osteopathic
Association (AOA) Physician Database.
Documents provided by the practitioner are not suitable for primary

source verification.

Improvement
Question 22
Which of the following statements about patient falls in a long term
care facility is TRUE?
If a patient is confused, the best way to protect them is to keep all bed
A
siderails elevated.
The use of restraints will protect the hospital and staff from a lawsuit if a
B
patient falls or is injured.
Patients who climb over raised siderails are more seriously injured if they
C
fall than those who fall from a bed without siderails raised.
Once a patient falls, they usually "learn their lesson" and are less likely to fall
D
again than patients who have not experienced a fall.
Answer: C
Elevated siderails alone rarely keep a patient in bed.
The use of restraints will not protect the hospital or staff from lawsuit
if a patient is injured.
The added height from which a patient will fall when the siderails are
elevated will increase the amount of injury.
The most likely time for a patient to fall is in the 72 hours following
the first fall.

Question 23
A major drawback of using raw data to present the results of quality
monitoring is that they
A cannot be displayed graphically.

B may only be used for focused review.
C lack proper reference points for interpretation.
D may only be used to measure compliance with established criteria.
Answer: C
The main problem with raw data is that they are not standardized and
therefore cannot be compared with other data. For example, if there
were 18 patient falls in January, 21 in February, and 23 in March, we
cannot draw any conclusions about the effectiveness of the falls
prevention program. On the other hand, if we knew the number of
patients at risk of falls in each of those months, we would then be able
to calculate the risk of falls for each month and compare them. The
calculation of fall risk is an example of data analysis—for the purpose
of quality monitoring and improvement, data usually need to be
analyzed in order to be interpretable.

Question 24
According to the 80/20 rule, 80% of an organization's problems are
related to
A systems.
B education.
C staffing.
D training.
Answer: A
The 80/20 rule, also called the Pareto Principle, states that roughly
80% of the effects come from 20% of the causes.
This question requires you to understand and apply the Pareto
Principle. It also tests your understanding of a contemporary quality
management principle: a focus on systems and processes.

Question 25
Quality improvement teams are responsible for all of the following
EXCEPT
A communicating results.
B setting goals and the timetable of the project.
C defining the roles and duties of members.
D establishing the need for the team.
Answer: D
Quality improvement teams are responsible for all the above
activities exceptestablishing the need for the team. The leaders of the
organization should have identified a need for a project/initiative
before forming the team to complete the project or carry out the
initiative.
Improvement
improvement teams
Question 26
Which of the following behaviors is LEAST likely to require the use of
restraints?
A Trying to get out of chair when not able to do so

B Agitation associated with poor memory and attention span
C Pulling at essential lines and tubes
D Physically aggressive behavior toward staff
Answer: B
Answer options A, C, D give relatively strong indications for the use of
restraints. On the other hand, alternatives for restraint of an agitated
patient with poor memory and attention span include regular
toileting, providing something to hold, and a location near the nurses
station.

organization
Question 9
Question 1
Which of the following should be omitted from a performance
improvement project report?
A Project objectives
B Meeting minutes
C Methods used
D Improvement achieved
Question 2
A healthcare organization's strategic plan includes, as one of its
objectives, a customer satisfaction rating of at least 85% in
each unit. The overall customer satisfaction rating for the past
quarter in 3 units are shown below.
Unit A — 88%
Unit B — 80%
Unit C — 62%
Which of the following should the quality professional
recommend?
A Provide incentives to the staff of Unit B and Unit C

B Share Unit A's practices with the other units
C Review the performance of the manager of Unit C
D Change the target for customer satisfaction rating to 90%
Question 3
When selecting an improvement project in a healthcare
organization, which of the following criteria is the LEAST
relevant to internal customers?
A Project addresses business goals of the organization

B Project is achievable using existing resources and budgets
C Project will reduce costs
Projects will improve some area that involves team members' work or
D compensation
Question 4
A monitoring plan for a physician recovering from alcohol or
drug addiction should incorporate which of the following
elements?
A List of symptoms noted
B Release of information
C Reasons given by physician as to why he or she became impaired
D Length of time of impairment
Question 5
Proctoring is
A a mechanism to facilitate benchmarking among competing physicians.

B a requirement established by NCQA.
a means to observe and assess new appointees or someone with new
C privileges.
D a completely objective process of evaluating physician performance.

Question 6
Which of the following is NOT a reason for evaluating blood
and blood product usage?
A Blood and blood products are a precious commodity

B Blood and blood products are always readily available
C Blood and blood products can cause harm
D Blood and blood products can save lives
Question 7
Before introducing a Continuous Quality Improvement (CQI)
Program, the Chief Executive Officer must first
A assess the organization's readiness for change.

B obtain funding from the governing body.
C educate managers in CQI principles.
D reach consensus with the staff.
Question 8
Which of the following parties has final decision-making
authority in the medical staff credentialing process?
A Credentials committee
B Medical staff clinical department chair
C Governing body
D Medical staff executive committee
Question 9
A healthcare system has decided to centralize its credentialing
departments. What is the main purpose for doing so?
A Streamline jobs
B Reduce costs
C Meet NCQA requirements
D Eliminate duplication of credentialing
Question 10
In which of the following situations is Focused Professional
Practice Evaluation (FPPE) NOT applicable?
A Initial appointment of a practitioner

B A practitioner requests a new privilege
C A potential practice problem has been identified with a practitioner
D FPPE is applicable in all the above situations
Question 11
A quality improvement activities, including the implementation of voluntary

practice changes.
a process in which the practitioner is given notice of the allegations and
B procedural rights of review.
summary or emergency corrective action before affording the practitioner any
C procedural rights of review.
private discussion between the affected practitioner and the Medical Director
D of the clinical service.
Question 12
Concerns regarding the quality of services provided by a
member of the medical staff are ideally addressed through
A physician, who has had no activity at Hospital X in the past

12 months, has applied for reappointment with clinical
privileges. What should the hospital do?
A Deny reappointment to the medical staff
B Offer the physician membership status without clinical privileges

Grant reappointment based on information available in his existing
C credentials file
D Request documentation of a hospital-based practice in another facility

Question 13
In which of the following quality functions does The Joint
Commission NOT require the medical staff to be involved?
A Patient safety
B Nursing staffing levels
C Use of blood and blood products
D Use of developed criteria for autopsies
Question 14
Which of the following is NOT a reason for using external peer
review?
A Conflict of interest with internal peer review
B Conflicting or ambiguous recommendations from peer reviewers
C Internal peer review has not been effective in improving performance
D Adequate expertise in the specialty under review
Question 15
Patient safety in an organization is promoted through
willingness to pay overtime, open communication, and performance

A reviews.
B encouragement to report errors, staff education, and reliable systems.
C reliable systems, open communication, and performance reviews.

performance reviews, encouragement to report errors, and willingness
D to pay overtimes.
Question 16
Which of the following is a measure of process capability?
A Process output
B Process sigma
C Process steps
D Process variation
Question 17
A Gantt chart shows
A a breakdown of the tasks to achieve the goal.

B the prioritized tasks of a project.
C who has main responsibility for each task.
D the order and duration of tasks.
Question 18
The Director of Quality Management at Hospital ABC, a new
230-bed acute care facility, is responsible for gaining the
support and commitment to the organizationwide quality
management strategy from
A the governing body.

B the medical directors.
C the clinical and support service managers.
D all of the above.
Question 19
A team that uses the scientific approach ideally does all of the
following EXCEPT
A employing basic statistical tools to investigate problems.

B seeking root causes of problems.
C utilizing established improvement approaches and strategies.
D looking for the quickest possible solutions to identified problems.
Question 20
Decision making in a team should be done by
A all members of the team.

B the team leader.
C the team sponsor.
D any of the above.
Question 21
A surgeon was reported to have used profanity while waiting
for instruments to be sterilized. This was the first report of
such behavior for this physician. Which of the following
interventions is the most appropriate?
A Collegial intervention
B Letter of warning
C Limitation of privileges
D Supervision and retrospective chart review
Question 22
What is the most frequently used accrediting body for
managed care organizations?
A American Managed Care Association

B National Managed Care Association
C National Committee for Quality Assurance
D National Association for Managed Care
Question 23
Credentialing requirements may be described in
A medical staff bylaws.

B credentialing policies and procedures.
C delineation of privileges forms.
D all of the above.
Question 24
The number of referral calls received by a hospital each month
is shown in the graph below.

What type of graph is this?
A Line graph
B Run chart
C Control chart
D None of the above
Question 25
The chart below shows the number of referral calls received by
a hospital each month.
How can this chart be transformed into a run chart?
A Drawing in the median measurement value as the center line
B Drawing in the mean measurement value as the center line

Drawing in the median measurement value as the center line and the
C upper and lower control limits
Drawing in the mean measurement value as the center line and the
D upper and lower control limits
Question 1
Which of the following should be omitted from a performance

improvement project report?
A Project objectives
B Meeting minutes
C Methods used
D Improvement achieved
Answer: B
A performance improvement project report should include, at
the least, the names of the team members, the project goals
and objectives, the measures, the methods used, and the
results. Meeting minutes are not necessary in the report.

question is linked:Compile and write performance/quality
improvement reports
Question 2
A healthcare organization's strategic plan includes, as one of its
objectives, a customer satisfaction rating of at least 85% in
each unit. The overall customer satisfaction rating for the past
quarter in 3 units are shown below.
Unit A — 88%
Unit B — 80%
Unit C — 62%
Which of the following should the quality professional
recommend?
A Provide incentives to the staff of Unit B and Unit C

B Share Unit A's practices with the other units
C Review the performance of the manager of Unit C
D Change the target for customer satisfaction rating to 90%
Answer: B
Unit A appears to be the best performing unit. It is possible
that the difference in ratings is associated with a difference in
practices. Therefore, learning the practices of Unit A may help
both Unit B and Unit C to meet or exceed the target customer
satisfaction rating of 85%. Providing incentives to
underperforming units is not a sustainable strategy. The
performance of the manager alone may not explain the
relatively low customer satisfaction rating of Unit C. Raising
the target for customer satisfaction rating when 2 out of 3 units
are not meeting the existing target is inappropriate.

Improvement
Question 3
When selecting an improvement project in a healthcare
organization, which of the following criteria is the LEAST
relevant to internal customers?
A Project addresses business goals of the organization

B Project is achievable using existing resources and budgets
C Project will reduce costs
Projects will improve some area that involves team members' work or
D
compensation
Answer: C
In the selection of projects, different groups—internal
customers (staff, including medical staff), external customers,
executive management, regulators, accreditors—will prioritize
criteria differently. Criteria important to internal customers
include:
 Project is achievable using existing resources and
budgets
 Project will improve some area that involves the
individual's work or compensation
 Cycle time is short so that results can be produced
quickly
 Process to be improved is not already being
transformed
 Interventions require minimal reeducation or
reengineering
 Interventions have been piloted on smaller systems
prior to implementation systemwide
 Project addresses business goals of the organization
In general, cost reduction is less of a consideration as a project
selection criterion for internal staff, compared with external
customers or perhaps executive management.

Improvement
question is linked:Facilitate program development,
evaluation, planning, projects, and activities
Question 4
A monitoring plan for a physician recovering from alcohol or
drug addiction should incorporate which of the following
elements?
A List of symptoms noted

B Release of information
C Reasons given by physician as to why he or she became impaired
D Length of time of impairment
Answer: B
The list of symptoms the physician had experienced in the past
is not useful when monitoring because he or she may develop
new/other symptoms in a relapse. Also self-reported
information (including symptoms, as opposed to signs, which
are objective) may be unreliable.
If the physician allows release of his/her information,

including lab reports, then it is possible for the organization to
check whether there was evidence of alcohol or drug in urine
or blood during the monitoring period.
The reasons that the physician became impaired and the length
of time of their impairment is irrelevant to the monitoring
process.

Improvement
question is linked:Facilitate or participate in the credentialing
and privileging process (e.g. Focused Professional Practitioner
Evaluation (FPPE), Ongoing Professional Practitioner
Evaluation (OPPE))
Question 5
Proctoring is
A a mechanism to facilitate benchmarking among competing physicians.

B a requirement established by NCQA.
a means to observe and assess new appointees or someone with new
C
privileges.
D a completely objective process of evaluating physician performance.
Answer: C
Clinical proctoring is a peer review tool used to evaluate the
clinical competence of new physicians seeking privileges or
existing medical staff members requesting new privileges.

Improvement
Evaluation (OPPE))
Question 6
Which of the following is NOT a reason for evaluating blood
and blood product usage?
A Blood and blood products are a precious commodity

B Blood and blood products are always readily available
C Blood and blood products can cause harm
D Blood and blood products can save lives
Answer: B
Blood and blood products are usually limited in their
availability. They have the potential to cause harm, e.g.
transfusion reactions, but may be life saving when used
appropriately.
Improvement
Question 7
Before introducing a Continuous Quality Improvement (CQI)
Program, the Chief Executive Officer must first
A assess the organization's readiness for change.

B obtain funding from the governing body.
C educate managers in CQI principles.
D reach consensus with the staff.
Answer: A
Before introducing a CQI program (or any other quality
improvement program, e.g. Lean, Six Sigma), an assessment of
the organization's readiness for change is required.

Improvement
Question 8
Which of the following parties has final decision-making
authority in the medical staff credentialing process?
A Credentials committee
B Medical staff clinical department chair
C Governing body
D Medical staff executive committee
Answer: C
In the medical staff credentialing process, the completed
application form and all supporting information is evaluated
by the following parties, who then provide an indication of
approval, approval with stated exceptions, or disapproval (and
the rationale for the disapproval):
 Medical staff clinical department chair;

 Credentials committee or the body performing the
credentialing function;
 Medical staff executive committee; and
 Governing body.
The governing body has the authority to make the final
decision on the application.

Improvement
or privileging process (e.g. Focused Professional Practitioner
Evaluation (OPPE))
Question 9
A healthcare system has decided to centralize its credentialing
departments. What is the main purpose for doing so?
A Streamline jobs
B Reduce costs
C Meet NCQA requirements
D Eliminate duplication of credentialing
Answer: D
The main purpose for having a centralized credentialing
department is to avoid duplication of credentialing.

Improvement
Evaluation (OPPE))
Question 10
In which of the following situations is Focused Professional
Practice Evaluation (FPPE) NOT applicable?
A Initial appointment of a practitioner

B A practitioner requests a new privilege
C A potential practice problem has been identified with a practitioner
D FPPE is applicable in all the above situations
Answer: D
FPPE is conducted when:
 a practitioner does not have documented evidence of

competently performing the requested privilege at
the organization, e.g. a new practitioner or a
practitioner requesting a new privilege; or
 a question arises regarding a currently privileged
practitioner's ability to provide high-quality patient
care.
Improvement
Evaluation (OPPE))
Question 11
Concerns regarding the quality of services provided by a
member of the medical staff are ideally addressed through
quality improvement activities, including the implementation of voluntar

A
practice changes.
a process in which the practitioner is given notice of the allegations and
B
procedural rights of review.
summary or emergency corrective action before affording the practitione
C
procedural rights of review.
private discussion between the affected practitioner and the Medical Dire
D
of the clinical service.
Answer: A
Problems or concerns regarding the quality of services
provided by a member of the medical staff are ideally
addressed through the quality improvement process. This
should include collecting data related to the practitioner and
working with the practitioner to implement voluntary practice
changes, if possible, to address the identified quality issues.

Improvement
Question 12
A physician, who has had no activity at Hospital X in the past
12 months, has applied for reappointment with clinical
privileges. What should the hospital do?
A Deny reappointment to the medical staff

B Offer the physician membership status without clinical privileges
Grant reappointment based on information available in his existing crede
C
file
D Request documentation of a hospital-based practice in another facility
Answer: D
Practitioners with little or no activity need to provide some
documentation of a hospital-based practice in another facility,
and then references need to be obtained from that other
facility to ensure that granting privileges to the provider is
appropriate.

Improvement
Evaluation (OPPE))
Question 13
In which of the following quality functions does The Joint
Commission NOT require the medical staff to be involved?
A Patient safety
B Nursing staffing levels
C Use of blood and blood products
D Use of developed criteria for autopsies
Answer: B
The Joint Commission requires the medical staff to be involved
in the following functions:
 Medical assessment and treatment of patients

 Use of information about adverse privileging
decisions for any practitioner privileged through the
medical staff process
 Use of medications
 Use of blood and blood components
 Operative and other procedures
 Appropriateness of clinical practice patterns
 Significant departures from established patterns of
clinical practice
 Use of developed criteria for autopsies
 Sentinel event information
 Patient safety
Improvement
Question 14
Which of the following is NOT a reason for using external peer
review?
A Conflict of interest with internal peer review

B Conflicting or ambiguous recommendations from peer reviewers
C Internal peer review has not been effective in improving performance
D Adequate expertise in the specialty under review
Answer: D
Indications for using external peer review include:
 Internal peer review being ineffective in improving

performance;
 Recommendations from (internal) peer reviewers
being conflicting or ambiguous; and
 Conflict of interest with internal peer review.
External peer review is not used to ensure adequate expertise
in the specialty under review.

Improvement
Evaluation (OPPE))
Question 15
Patient safety in an organization is promoted through
A willingness to pay overtime, open communication, and performance revie

B encouragement to report errors, staff education, and reliable systems.
C reliable systems, open communication, and performance reviews.
performance reviews, encouragement to report errors, and willingness to
D
overtimes.
Answer: B
There are several ways of answering questions that contain
multiple elements, such as the one above. One way is
to eliminate those answer options that have elements that do
not fit the question stem. In this example, the following
elements don't seem quite right, in that they do not promote
patient safety:
 Willingness to pay overime; and
 Performance reviews.
This would leave B as the only viable answer option.
Encouragement to report errors, staff education, and reliable
systems (e.g. in pharmacy and surgery) promote patient safety.

question is linked:Facilitate assessment and development of
the organization’s patient safety culture
Question 16
Which of the following is a measure of process capability?
A Process output
B Process sigma
C Process steps
D Process variation
Answer: B
Among the answer options, only process sigma is a measure of
process performance. Process sigma measures process
performance relative to customer specifications.

Improvement
Question 17
A Gantt chart shows
A a breakdown of the tasks to achieve the goal.

B the prioritized tasks of a project.
C who has main responsibility for each task.
D the order and duration of tasks.
Answer: D
A Gantt chart is a chart of a project schedule that shows not
only the breakdown of tasks, but also the order and duration of
those tasks, and the relationship between them.

question is linked:Facilitate the use of process analysis tools
to display data (e.g., fishbone, Pareto chart, run chart,
scattergram, control chart)
Question 18
The Director of Quality Management at Hospital ABC, a new
230-bed acute care facility, is responsible for gaining the
support and commitment to the organizationwide quality
management strategy from
A the governing body.

B the medical directors.
C the clinical and support service managers.
D all of the above.
Answer: D
When implementing a new quality management strategy, the
healthcare quality professional is responsible for gaining the
support and commitment of all key leaders in the organization.

Question 19
A team that uses the scientific approach ideally does all of the
following EXCEPT
A employing basic statistical tools to investigate problems.

B seeking root causes of problems.
C utilizing established improvement approaches and strategies.
D looking for the quickest possible solutions to identified problems.
Answer: D
A team that uses the scientific approach:
 employs basic (and advanced) statistical tools to

investigate problems;
 seeks permanent solutions instead of relying on
quick fixes;
 attempts to identify the root causes of problems; and
 utilizes established quality improvement approaches
and strategies.
Improvement
Question 20
Decision making in a team should be done by
A all members of the team.

B the team leader.
C the team sponsor.
D any of the above.
Answer: D
Decision making may be done by one member of the team, the
entire team, the team leader, a subgroup of the team, a
manager or group of managers outside the team, or another
team or group, depending on the nature of the decision.

Improvement
Question 21
A surgeon was reported to have used profanity while waiting
for instruments to be sterilized. This was the first report of
such behavior for this physician. Which of the following
interventions is the most appropriate?
A Collegial intervention
B Letter of warning
C Limitation of privileges
D Supervision and retrospective chart review
Answer: A
A practitioner who exhibits disruptive behavior, such as that in
this example, is usually initially given collegial or informal
intervention.

Improvement
Evaluation (OPPE))
Question 22
What is the most frequently used accrediting body for
managed care organizations?
A American Managed Care Association

B National Managed Care Association
C National Committee for Quality Assurance
D National Association for Managed Care
Answer: C
The National Committee for Quality Assurance (NCQA) is the
most frequently used accrediting body for managed care
organizations.

appropriate accreditation or recognition program(s) (e.g. The
Joint Commission (TJC), Magnet, Baldrige, Det Norske Veritas
(DNV), American Osteopathic Association (AOA), Healthcare
Facility Accreditation Program (HFAP))
Question 23
Credentialing requirements may be described in
A medical staff bylaws.

B credentialing policies and procedures.
C delineation of privileges forms.
D all of the above.
Answer: D
Credentialing requirements are described in medical staff
bylaws, credentialing policies and procedures, delineation of
privileges forms, general rules and regulations, and
department-specific rules and regulations.

Improvement
Evaluation (OPPE))
Question 24
What type of graph is this?
A Line graph
B Run chart
C Control chart
D None of the above
Answer: A
This is an example of a line graph.

to display data (e.g. fishbone, Pareto chart, run chart,
Question 25
The chart below shows the number of referral calls received by
a hospital each month.
How can this chart be transformed into a run chart?

A Drawing in the median measurement value as the center line
B Drawing in the mean measurement value as the center line
Drawing in the median measurement value as the center line and the upp
C
lower control limits
Drawing in the mean measurement value as the center line and the upper
D
lower control limits
Answer: A
Transforming this line graph into a run chart only requires
drawing in the median measurement value as the center line.

Question 10
Question 1
When an organization's leadership uses an advanced
prioritization matrix to select the improvement projects for the
next 12–24 months,
A the criteria used will be equally important.

all options should be rank ordered even if some are unanimously
B considered unworkable initially.
the solutions should be based on the different rankings under each
C criterion only.
differences in rankings by the leaders for the various criteria should
D be discussed.
Question 2
Work-flow diagrams are used to illustrate the movements of
A people.
B documents.
C materials.
D all of the above.
Question 3
When creating a fishbone diagram, why is it important to
refine the definition of the problem before trying to explore its
causes?
A The effort to create the diagram will be more manageable.

B It is easier to identify possible causes to take action on.
C Verifying the causes will be more manageable.
D All of the above.
Question 4
When gathering data on adverse events in an acute care facility
over time, why is it necessary to measure the number of
patients admitted and their length of stay?
A To make the data more valid.
B To make the data more reliable.
C To make the data more comparable.

It is not necessary to measure the number of patients and/or their
D length of stay.
Question 5
What is the benefit of studying a process?
A To highlight obvious problems.
B To arrive at a common understanding among team members.
C To eliminate inconsistencies.
D All or the above.
Question 6
In a project to improve the safety of surgical care in an acute
care facility, which of the following is a responsibility of the
healthcare quality professional?
Teaches the collection and analysis techniques, showing the team

A what conclusions may or may not be drawn from the data.
Carry out assignments between meetings, interview customers,
B observe processes, gather and chart data, and write and present
reports
C Calls meetings, and handles or assigns administrative details.

Ensures that changes made by the team are monitored, and
D implements any changes the team is not authorized to make.
Question 7
IHI Global Trigger Tool record reviewers found an unreported
case of a radiologist inadvertently causing a small
pneumothorax (collapsed lung) by incorrectly positioning a
percutaneous small-bowel feeding tube.
To whom should the reviewers report this finding?
A Chief Medical Officer

B Chief of Radiology
C Risk Manager
D Director of Quality
Question 8
Which of the following statements about unannounced surveys
by The Joint Commission is TRUE?
A primary goal of unannounced surveys is to detect evidence of non-

A compliance.
B Unannounced surveys include initial surveys.

Unannounced surveys reduce the unnecessary costs associated with
C survey preparation.
An organization may undergo an unannounced survey between 12
D and 24 months after its previous survey.
Question 9
The purpose of quality outcome measurement is
A quality improvement.
B marketing.
C staff performance appraisal.
D all of the above.
Question 10
Consensus requires
A active participation of all team members.

B communication skills.
C creative thinking.
D all of the above.
Question 11
Implementation of an influenza vaccination program for staff
across multiple sites should ideally be
A customized to be suitable to each site.
B overseen by a single site champion.
C carried out simultaneously.
D standardized to unify evaluation metrics.
Question 12
The first step in collecting meaningful data is
A establishing the goals of data collection.

B developing operational definitions.
C planning for data consistency.
D evaluating the resources available.
Question 13
As an external consultant, you have completed a gap analysis of
an acute care facility that is preparing for TJC accreditation.
Which of the following charts will you use to summarize your

findings in six of the chapters of standards for the Hospital
Accreditation Program?
A Line chart
B Radar chart
C Bar chart
D Pareto chart
Question 14
A shared accountability model in which every employee has
the opportunity to make decisions about care processes will
likely result in
A increased conflict among staff.
B lower staff satisfaction scores.
C greater staff innovation.
D increased staff workload.
Question 15
For which aspect of care are patient-reported measures most
credible?
A Communication between providers

B Patient-provider interactions
C Adherence to clinical practice guidelines
D Appropriateness of therapy
Question 16
The Hospital Consumer Assessment of Healthcare Providers
and Systems (HCAHPS) Survey is administered
A within 48 hours post-discharge.

B between 48 hours and 21 days post-discharge.
C between 48 hours and 42 days post-discharge.
D after 28 days post-discharge.
Question 17
Antibiotics for a coronary artery bypass graft (CABG) surgery
patient should be discontinued within
A 24 hours after surgery end time.

B 48 hours after surgery end time.
C 72 hours after surgery end time.
D 1 week after surgery end time.
Question 18
In healthcare quality improvement, common causes, in
comparison to special causes, are
A easily identified.
B infrequent.
C extrinsic to the normal process.
D difficult to solve.
Question 19
The criticality index in failure mode and effect analysis is
A a measure of the effectiveness of control measures.

a product of the estimated likelihood of occurrence of the failure mode
B and the severity of effect.
C a measure of anticipated severity of the effect of the failure mode.
D reflected in the Risk Priority Number.

Question 20
Which of the following may be a trigger for intensive analysis?
A Management literature
B Staff feedback
C Sentinel event
D All of the above
Question 21
A team used a cause-and-effect diagram in their root cause
analysis of a retained surgical instrument. They should next
A develop corrective action for each cause identified on the diagram.
B use a Pareto chart to determine which causes to tackle first.
C develop solutions to the deepest causes identified on the diagram.
D verify the causes.
Question 22
You have been asked to observe a team meeting to better
understand how the team is interacting. Which of the following
actions will you perform?
A Ignore the discussion of topics

B Guide the team through the meeting process
C Record your interpretations of comments and behaviors
D Share observations with the team during the meeting
Question 23
Which of the following is an example of inventory in healthcare
quality management?
A Patients waiting in an emergency room

B Staff hired to support the risk management program
C A newly implemented electronic medical record system
D There is no “inventory” in healthcare quality
Question 24
Which of the following information should an organization
consider first when developing the Quality Management and
Patient Safety plan?
A The organization's mission

B The available resources
C Plans from other organizations
D Staff morale
Question 25
Which of the following measures is most effective in
preventing infant abduction in a hospital?
A Electronic ankle bracelets for babies

B Panic buttons at the nursing station
C Access to the maternity ward by key card
D Closed circuit TV monitoring
Question 1
When an organization's leadership uses an advanced
prioritization matrix to select the improvement projects for the
next 12–24 months,
A the criteria used will be equally important.

all options should be rank ordered even if some are unanimously
B
considered unworkable initially.
the solutions should be based on the different rankings under each
C
criterion only.
differences in rankings by the leaders for the various criteria should be
D
discussed.
Answer: D
When using an advanced prioritization matrix, some criteria
will be considered more important than others, and the team
will need to weigh the criteria. The criteria will not carry equal
weight.
The team should review the list of options being considered

and eliminate items that everyone agrees are unworkable.
The selection of the best options should not be based on the
math alone, i.e. taking the average of the different rankings by
the team members only. Differences should be explored to
arrive at the best decision.

Improvement
Question 2
Work-flow diagrams are used to illustrate the movements of
A people.
B documents.
C materials.
D all of the above.
Answer: D
A work-flow diagram is a pictorial representation of the
movements of people, materials, documents, or information in
a process.

Question 3
When creating a fishbone diagram, why is it important to
refine the definition of the problem before trying to explore its
causes?
A The effort to create the diagram will be more manageable.

B It is easier to identify possible causes to take action on.
C Verifying the causes will be more manageable.
D All of the above.
Answer: D
It's important that the team refines the definition of the
problem before trying to explore its causes because:
 The effort to create the diagram will be more

manageable.
 It will be easier to come up with possible causes to
take action on.
 The effort to verify the causes will be more
manageable.
 Time and resources are used more effectively.
Question 4
When gathering data on adverse events in an acute care facility
over time, why is it necessary to measure the number of
patients admitted and their length of stay?
A To make the data more valid.
B To make the data more reliable.
C To make the data more comparable.
It is not necessary to measure the number of patients and/or their length
D
stay.
Answer: C
When gathering data over time, the data need to be
standardized to compare the data collected at different points.
In this case, the rate of adverse events is compared over time—
the numerator is the number of adverse events and the
denominator is the number of patient-days. The latter is
usually calculated from the number of patient admissions and
the average length of stay for the period of interest.
Measuring the number of patients admitted and/or their

length of stay does not improve validity or reliability.

question is linked:Use epidemiological principles in data
collection and analysis
Question 5
What is the benefit of studying a process?
A To highlight obvious problems.

B To arrive at a common understanding among team members.
C To eliminate inconsistencies.
D All or the above.
Answer: D
Benefits of studying a process include:
 Highlighting obvious problems.
 Eliminating inconsistencies.
 Arriving at a common understanding.
Improvement
improvement teams (i.e. as a coordinator
Question 6
In a project to improve the safety of surgical care in an acute
care facility, which of the following is a responsibility of the
healthcare quality professional?
Teaches the collection and analysis techniques, showing the team what
A
conclusions may or may not be drawn from the data.
Carry out assignments between meetings, interview customers, observe
B
processes, gather and chart data, and write and present reports
C Calls meetings, and handles or assigns administrative details.
Ensures that changes made by the team are monitored, and implements a
D
changes the team is not authorized to make.
Answer: A
On an improvement team, the role of the healthcare quality
professional is usually as the Team Facilitator/coach.
The other responsibilities listed above should belong to other

persons:
 Carry out assignments between meetings, interview
customers, observe processes, gather and chart data,
and write and present reports: Team Members
 Calls meetings, and handles or assigns administrative
details: Team Leader

 Ensures that changes made by the team are
monitored, and implements any changes the team is

not authorized to make: Team Sponsor
Improvement
improvement teams (i.e. as a coordinator, or team
Question 7
IHI Global Trigger Tool record reviewers found an unreported
case of a radiologist inadvertently causing a small
pneumothorax (collapsed lung) by incorrectly positioning a
percutaneous small-bowel feeding tube.
To whom should the reviewers report this finding?
A Chief Medical Officer

B Chief of Radiology
C Risk Manager
D Director of Quality
Answer: B
Such a case should be reported to the Chief of Radiology
because he is in the best position to evaluate whether further
action is appropriate.

question is linked:Interact with staff regarding quality issues
(e.g. patient issues, service delivery, human resources)
Question 8
Which of the following statements about unannounced surveys
by The Joint Commission is TRUE?
A primary goal of unannounced surveys is to detect evidence of non-

A
compliance.
B Unannounced surveys include initial surveys.
Unannounced surveys reduce the unnecessary costs associated with surv
C
preparation.
An organization may undergo an unannounced survey between 12 and 24
D
months after its previous survey.
Answer: C
For the CPHQ exam, you should be aware of the basic facts of
The Joint Commission's unannounced surveys.
Improvement
evaluation, planning, projects, and activities.
Question 9
The purpose of quality outcome measurement is
A quality improvement.
B marketing.
C staff performance appraisal.
D all of the above.
Answer: A
The measurement of outcomes should be done for the purpose
of internal quality improvement, not marketing or staff
performance appraisal.

Question 10
Consensus requires
A active participation of all team members.

B communication skills.
C creative thinking.
D all of the above.
Answer: D
Consensus requires
 Time
 Active participation of all team members
 Skills in communication, listening, conflict resolution,
and facilitation
 Creative thinking and open-mindedness
Improvement
Question 11
Implementation of an influenza vaccination program for staff
across multiple sites should ideally be
A customized to be suitable to each site.

B overseen by a single site champion.
C carried out simultaneously.
D standardized to unify evaluation metrics.
Answer: A
Customization of the implementation may be necessary to fit
the unique characteristics of the individual site/facility. This
might entail editing, dropping, or creating one or more items.
Customization will facilitate multi-site implementation.
According to Rogers' Diffusion of Innovation theory, ideally,

there should be a champion for each site, i.e. the
implementation spanning multiple sites should not be
overseen by only one champion.
Implementation of any program or change across multiple

sites does not need to be done simultaneously. This would
make the implementation more complex and possibly increase
the chance of failure.
Many organizations attempt to standardize implementation of
a program at multiple sites for the sole purpose of maintaining
the same measures. The latter is unnecessary if the aim is to
implement the program across multiple sites, and not compare
performance between sites.

Improvement
Question 12
The first step in collecting meaningful data is
A establishing the goals of data collection.

B developing operational definitions.
C planning for data consistency.
D evaluating the resources available.
Answer: A
The first step in collecting meaningful data is clarifying the
data collection goals.

Question 13
As an external consultant, you have completed a gap analysis of
an acute care facility that is preparing for TJC accreditation.
Which of the following charts will you use to summarize your

findings in six of the chapters of standards for the Hospital
Accreditation Program?
A Line chart
B Radar chart
C Bar chart
D Pareto chart
Answer: B
A radar chart is ideal in this situation. It can be used to display
the performance gaps, i.e. both current and target
performance, in multiple areas of interest. Performance in 5–
10 areas is usually graphically represented on a radar chart.
question is linked:Compile and write performance/quality
improvement reports
Question 14
A shared accountability model in which every employee has
the opportunity to make decisions about care processes will
likely result in
A increased conflict among staff.

B lower staff satisfaction scores.
C greater staff innovation.
D increased staff workload.
Answer: C
Shared accountability is a feature of participatory
management. Shared accountability has been shown to
improve staff motivation and innovation, and lead to greater
staff satisfaction.

question is linked:Facilitate assessment, development, and
design of the organization’s quality culture
Question 15
For which aspect of care are patient-reported measures most
credible?
A Communication between providers

B Patient-provider interactions
C Adherence to clinical practice guidelines
D Appropriateness of therapy
Answer: B
The aspect of care for which patient-reported measures are
most credible is patient-provider interactions.

surveys, focus groups, teams) to ensure the voice of the
customer is heard
Question 16
The Hospital Consumer Assessment of Healthcare Providers
and Systems (HCAHPS) Survey is administered
A within 48 hours post-discharge.

B between 48 hours and 21 days post-discharge.
C between 48 hours and 42 days post-discharge.
D after 28 days post-discharge.
Answer: C
The HCAHPS is administered between 48 hours and six weeks
post-discharge.
surveys, focus groups, teams) to ensure the voice of the
customer is heard
Question 17
Antibiotics for a coronary artery bypass graft (CABG) surgery
patient should be discontinued within
A 24 hours after surgery end time.

B 48 hours after surgery end time.
C 72 hours after surgery end time.
D 1 week after surgery end time.
Answer: B
Current literature suggests that, in most surgical cases,
antibiotics should be discontinued within 24 hours after
surgery end time. However, for cardiac procedures, antibiotics
should be discontinued within 48 hours. Duration of
prophylactic perioperative antibiotics is a performance
measure in the Surgical Care Improvement Project (SCIP).

Improvement
reviews for audits for infection prevention and control
processes
Question 18
In healthcare quality improvement, common causes, in
comparison to special causes, are
A easily identified.
B infrequent.
C extrinsic to the normal process.
D difficult to solve.
Answer: D
“Common causes,” as opposed to special causes, are more
difficult to identify, are pervasive and less infrequent than
“special causes.” Unlike special causes, common causes are
intrinsic to the process. Common causes are considered more
difficult to resolve.

question is linked:Use or coordinate the use of statistical
process control components (e.g. common and special cause
variation, random variation, trend analysis)
Question 19
The criticality index in failure mode and effect analysis is
A a measure of the effectiveness of control measures.

a product of the estimated likelihood of occurrence of the failure mode an
B
severity of effect.
C a measure of anticipated severity of the effect of the failure mode.
D reflected in the Risk Priority Number.
Answer: D
The Risk Priority Number (RPN) is calculated by multiplying
three items:
 Occurrence rating;
 Severity rating; and
 Detection rating.
The RPN is an indication of the criticality index. The failure
modes with the highest RPNs are usually selected for
corrective action.
failure mode and effect analysis
Question 20
Which of the following may be a trigger for intensive analysis?
A Management literature
B Staff feedback
C Sentinel event
D All of the above
Answer: D
Triggers for intensive analysis may be based on quantitative or
qualitative data. Management literature, staff feedback, and
sentinel events may all trigger intensive analysis.

Improvement
Question 21
A team used a cause-and-effect diagram in their root cause
analysis of a retained surgical instrument. They should next
A develop corrective action for each cause identified on the diagram.

B use a Pareto chart to determine which causes to tackle first.
C develop solutions to the deepest causes identified on the diagram.
D verify the causes.
Answer: D
The cause-and-effect diagram only identifies potential causes.
Before taking action, the team needs to verify which potential
causes are actual causes.

Question 22
You have been asked to observe a team meeting to better
understand how the team is interacting. Which of the following
actions will you perform?
A Ignore the discussion of topics

B Guide the team through the meeting process
C Record your interpretations of comments and behaviors
D Share observations with the team during the meeting
Answer: A
The healthcare quality professional may be asked to observe a
team meeting to assess how well the team is interacting. The
observer does not participate in the meeting content. He/She
merely pays attention to the discussion methods and
interactions among members.
The observer notices behaviors and verbatim comments but

does not interpret or judge them.
The observer does not share observations with the team

during the meeting, but does so only at the scheduled meeting
evaluation time.

Improvement
Question 23
Which of the following is an example of inventory in healthcare
quality management?
A Patients waiting in an emergency room
B Staff hired to support the risk management program
C A newly implemented electronic medical record system
D There is no “inventory” in healthcare quality
Answer: A
Inventory is usually thought of being tangible, e.g.
manufactured care parts in the warehouse. However, the
concept of inventory can also be applied to the healthcare
industry. For example, patients waiting in an emergency room
is often considered “inventory,” i.e. something that you would
like to reduce by streamlining the process. On the other hand,
risk management staff and a new EMR are generally
considered desirable, and are therefore not usually thought of
as “inventory.”

Improvement
Question 24
Which of the following information should an organization
consider first when developing the Quality Management and
Patient Safety plan?
A The organization's mission

B The available resources
C Plans from other organizations
D Staff morale
Answer: A
When developing the Quality Management and Patient Safety
plan, one of the first things the team should consider is the
organization's mission. Goals should be consistent with the
mission.

Improvement
Question 25
Which of the following measures is most effective in
preventing infant abduction in a hospital?
A Electronic ankle bracelets for babies

B Panic buttons at the nursing station
C Access to the maternity ward by key card
D Closed circuit TV monitoring
Answer: C
In reality, a multipronged approach is often used to prevent
infant abduction. Among the answer options, key card access to
the maternity ward represents a physical barrier. The latter is
thought to be a more effective strategy than electronic aids,
panic buttons, or closed circuit TV monitoring.

question is linked:Determine how technology can enhance
the patient safety program (e.g. CPOE, BCMA/barcoding, EMR,
abduction/elopement security systems, human factors
engineering)

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Question 1

A the shape of data.

A Engage leaders around transparency and continuous learning.

A Unplanned return to surgery

Antenatal steroids for births between 24 and 32 weeks of

As the patient safety officer of the organization, what would

A When administering intravenous medications and fluids.

B During a handoff from operating room to the Intensive Care Unit.

D While obtaining informed consent from a patient.

A Develop performance measures for the operating room.

D Provide teamwork training for operating room staff.

A Lack of leadership support.

A Assign a quality professional to assist in the project.

Prophylactic antibiotic received within one hour prior to surgical

C Percent of clean surgery patients with surgical infection

D Percent of surgical cases that were started on time

A absence of strong enough ideas for improvement.

A Each failure mode and the process

When a midwife is concerned at the bedside and asks the

To whom should the responsibility of timely perioperative

For the final step of the process, an identified possible failure

What action should the FMEA team recommend to reduce

B Implement an automated medication dispensing system.

C Train staff to recognize early signs of drug toxicity.

 Use of evidence-based bundles in ICU care

A Abandon one or more projects

A The incidence of pressure ulcers was unchanged.

B The incidence of pressure ulcers increased.

C The incidence of pressure ulcers decreased.

A Contact information for getting help

What is the greatest barrier to success?

Among the following methods of administering tacrolimus,

Start on a dose based on a guideline, measure blood levels of

Content Category: Information Management

A frequency plot may be used to examine

A the shape of data.

Content Category: Information Management

Successful implementation of a standardized process requires

Development of a written policy while trying to implement a

Initial standardization of a care process will never be perfect, and

Content Category: Performance Measurement and

A team plans to improve the reliability of the ―time-out‖ procedure in

A Engage leaders around transparency and continuous learning.

B Reliably design processes.

C Provide targeted team training.

Content Category: Performance/Quality Measurement and

A Unplanned return to surgery

B Transfusion or use of blood products

C Transfer to higher level of care

Content Category: Performance/Quality Measurement and

A Antenatal steroids for births between 24 and 32 weeks of gestation.

Content Category: Patient Safety

Content Category: Patient Safety

As the patient safety officer of the organization, what would you

The surgeon be required to undergo further training in teamwork and

A thorough review of the teamwork and communication skills training

Content Category: Patient Safety

A When administering intravenous medications and fluids.

 The ―sender‖ concisely states information to the

 The receiver then repeats back what he or she heard.

 The sender then acknowledges the repeat back was

 The process continues until a shared understanding is

Organizations requiring this type of closed-loop communication