Mock 2021 Part B (WTE)

telegram: #cphq_motaz Test Review Report
Printed on: 2/26/2021
Test Name: CPHQ Practice Exam: Form B

Learner: Inas Selim
Your Score 63.08%

Status Failed
Initial Score* 63.08%
* Initial Score is based on the first attempt of each question
Question 1 of 65
A healthcare quality professional is conducting a study to determine how many patients contracted
influenza despite receiving flu shots. This study is evaluating
A. appropriateness.
B. process.
C. efficacy.
D. prevalence.
Note: correct answer is displayed in bold
Result:
Incorrect
Option B is not correct
Feedback
DOMAIN: Health Data Analytics
EXPLANATION:
A. Determining the number of patients that contracted influenza does not address appropriateness.
B. Process is the steps involved in an intervention or workflow.
C. Efficacy measures the effectiveness or ability of the intervention (influenza vaccination) to achieve the
desired results.
D. Prevalence measures the percent of a population with a specific disease at a given point in time.
Question 2 of 65
Which of the following obstetrical outcomes will result in a morbidity review?
A. normal deliveries
B. neonatal deaths
C. post-delivery septicemia
D. Cesarean
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Result:
Correct
Answer 2 is C
Feedback
DOMAIN: Patient Safety
EXPLANATION:
A. Not an example of morbidity.
B. Mortality related.
C. Post-delivery septicemia is a complication and morbidity issue.
D. Not an example of morbidity.
Question 3 of 65
A healthcare network has implemented an electronic medical record system allowing data to be
transmitted, on demand, from one facility to another. Which of the following will best promote both cost
effectiveness and patient satisfaction?
A. decreasing repeat tests when a patient is seen in more than one facility
B. eliminating the need for patients to hand-carry records

C. improving the accuracy of medication reconciliation
D. increasing the security of confidential patient information
Result:
Correct
Answer 3 is A
Feedback
EXPLANATION:
A. Decreasing the rate for repeating tests is the best way for a network to decrease cost and increase
patient satisfaction.
B. While decreasing paper records and increasing patient satisfaction, it's not the biggest way to
decrease cost.
C. telegram: #cphq_motaz
While data transmission of medications across the network might benefit patient telegram: #cphq_motaz
satisfaction of the
choices, it's not the most cost effective.

D. While an EMR can increase security, it may also be used inappropriately and create more issues.
Question 4 of 65
The following data has been provided to a healthcare quality professional: Which of the following is the
best choice for beginning clinical-pathways implementation in an organization?
A. diabetes
B. total knee replacement

C. heart failure
D. gastroenteritis
Result:
Incorrect
Option A is not correct
Feedback
EXPLANATION:
A. Although a physician champion is present, the volume for this condition is small with no loss variance
and low readmission rate.
B. See explanation for C. The project lacks a physician champion.
C. Physician champions are key in the development of clinical pathways. Heart failure should be
prioritized because they not only have a champion but have data supporting the need for outcome
improvements with LOS variance and a readmission rate of 10%.
D. See explanation for C. The project lacks a physician champion.
Question 5 of 65
The clinical competency of a physician is determined by
A. a committee of peers.
B. the CEO.
C. the hospital governing body.
D. a Quality Management Committee.
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Result:
Correct
Answer 5 is A
Feedback
DOMAIN: Organizational Leadership
EXPLANATION:
A. Competence is demonstrated in knowledge and understanding of skills required to perform the job.
Peer review is a component of initial and ongoing performance evaluation conducted by a professional or
professionals with similar experience, education, and expertise based on criteria established by the
medical staff or medical executive committee.
B., C., and D. The CEO, Governing Body, and Quality Committee do not have the same clinical
experience, expertise, and education to determine competency.
Question 6 of 65
A 69-year-old female admitted for hip replacement is taken to surgery. The patient is identified, the
surgical site is marked incorrectly, and equipment/x-rays are present. A near miss was most likely
identified as a result of
A. a surgical team 'time-out.'
B. informed consent documentation.

C. an equipment check.
D. a root cause analysis.
Result:
Correct
Answer 6 is A
Feedback
EXPLANATION:
A. Correct, as the "time-out" is a team briefing conducted by the surgeon before the procedure starts and
includes verification of the surgical site.
B. Incorrect, as this document may be erroneous as well.
C. Incorrect, as the equipment function would not identify an incorrect surgical site.
D. Incorrect, as this is a function of investigating a sentinel event.
Question 7 of 65
Leaders enhance employee commitment to organizational values by fostering which of the following
types of communication?
A. face-to-face, oral, scheduled

B. timely, open, two-way
C. clear, written, top-down

D. formal, electronic, 'need to know'
Result:
Correct
Answer 7 is B
Feedback
EXPLANATION:
A. The scheduled component of the response can be considered inflexible.
B.
Best answer for leadership to have visibility and to promote engagement with staff.
C. Top down might not be most effective in some organizations. B is still a better answer.
D.
"Need to know" and formal may not be encouraging transparency and promoting communication.
Question 8 of 65
A strategy used in brainstorming is that ideas are
A. prioritized as they occur.

B. discussed when they are mentioned.
C. progressively eliminated.
D. all recorded.

Result:
Correct
Answer 8 is D
Feedback
DOMAIN: Performance and Process Improvement
EXPLANATION:
A. Prioritization takes place later in the process. Idea generation should not be disrupted by prioritizing
ideas during the brainstorming process.
B. Discussion takes place later in the process. Idea generation should not be disrupted by discussion
during the brainstorming process.
C. Idea elimination takes place later in the process. Idea generation should not be disrupted by
eliminating ideas during the brainstorming process.
D. Brainstorming is an idea generation tool intended to allow for all ideas to be considered without
judgment, censoring, or prioritization. It is critical to the process that no ideas or participation is
discouraged. All ideas should be recorded.
Question 9 of 65
The perception of how an organization operates, including how employees relate to internal and external
customers, is the organizational
A. structure.
B. mission.
C. vision.
D. culture.
Result:
Correct
Answer 9 is D
Feedback
EXPLANATION:
A. Structure subscribes to organization chart and departmental structure, not how the organization
functions.
B. Mission is organization's purpose.

C. Vision is organization’s future state.
D. Best answer. Culture includes behavioral norms and how staff interacts with all parties.
Question 10 of 65
The success of a performance improvement program will be most influenced by the
A. reliability of data management software.

B. educational preparation of quality leaders.
C. culture of the organization.
D. people skills of the facility leaders.

Result:
Correct
Answer 10 is C
Feedback
EXPLANATION:
A. This may be a factor, but not the best answer.
B. See A.
C. Significant factor that must be considered when implementing any program.
D. This may be factor, but culture will be the strongest influencer for any program success.
Question 11 of 65
A staff member reports that a colon perforation occurred during a colonoscopy. Which of the following is
a healthcare quality professional's next step?
A. Review 100% of colonoscopy procedures.

B. Refer the case for peer review.
C. Modify the physician's privileges.

D. Assign a proctor to the physician.
Result:
Correct
Answer 11 is B
Feedback
EXPLANATION:
A. Not necessary. A focused review on the specific case is more appropriate initially.
B. It is a single episode which is appropriate for peer review.
C. Not appropriate until further assessment or physician performance has been completed.
D. Not appropriate until further assessment or physician performance has been completed.
Question 12 of 65
Informed consent for hip surgery was obtained and documented for an elderly patient. In the recovery
room, a nurse discovered the wrong hip had been replaced. A healthcare quality professional should
A. conduct a failure mode and effects analysis (FMEA).

B. initiate the disciplinary action process.
C. review the practitioner's qualifications and licensure.
D. perform a root cause analysis.
Result:
Correct
Answer 12 is D
Feedback
EXPLANATION:
A. Incorrect, as FMEA is a tool to design or redesign a process.
B. Incorrect, as exploration of system and process issues should be primary in identifying root causes of
error, not only disciplinary actions.
C. Incorrect, as this is a function of the medical staff credentialing process and should have been
completed.
D. Correct, as exploration of a system and process issues should be primary in identifying root causes of
error.

Question 13 of 65
A failure mode and effects analysis (FMEA) provides which of the following types of review?
A. proactive
B. retrospective
C. concurrent
D. retroactive
Result:
Correct
Answer 13 is A
Feedback
EXPLANATION:
A. Correct, as the FMEA tool is used to proactively design or redesign a process.
B. Incorrect, as the FMEA is not a retrospective tool.
C. Incorrect as the FMEA is not a concurrent tool.
D. Incorrect, as the FMEA is not a retroactive tool.
Question 14 of 65
Which of the following is used to summarize a characteristic in a population?
A. frequency distribution
B. regression analysis
C. case control study
D. control chart
Result:
Incorrect
Option D is not correct
Feedback
EXPLANATION:
A. A frequency distribution can be used to summarize data into categories; for example, we could
summarize insurance type into Medicare, Medicaid and private insurance.
B. Regression analysis is used to measure the relationship between variables.
C. A case control study is involved in research/study decision and not the data analysis.
D. A control chart is used to monitor data over time and process variation.
Question 15 of 65
A hospice agency conducted a satisfaction survey of all 200 patients currently receiving pain
management services. When asked if they were satisfied with their pain management, 170 patients said
yes, and 30 said no. A target satisfaction rate of 90% has been set. In this situation, a healthcare quality
professional should
A. review all dissatisfied responses for similarities.
B. collect more data to ensure statistical significance.

C. discontinue monitoring because an 85% satisfaction rate is excellent.
D. continue monitoring because a 15% dissatisfaction rate is acceptable.
Result:
Correct
Answer 15 is A
Feedback
EXPLANATION:
A. The goal was not reached. Further examination of potential trends to identify opportunities for
improvement is a component of continuous quality improvement.
B. A target rate (goal) was established regardless of statistical significance.
C. The target rate was not met. 90% satisfaction was the established goal.
D. The target rate was not met. 15% dissatisfaction is not considered acceptable per the established
goal.
Question 16 of 65
A health plan is required to have a mechanism for members to submit complaints. Which of the following
actions must be included in the complaint analysis to ensure the plan makes full use of this type of
information?

A. Total each complaint category at least on an annual basis.

B. Calculate the average number of complaints per office site.
C. Review complaints to find system problems that can be improved.
D. Determine the date/time the complaint occurred and the person responsible.
Result:
Incorrect
Feedback
EXPLANATION:
A. Summation of complaints is a single element of complaint analysis, but does not assist in the
identification of trends.
B. Average rate of complaints is a single element of complaint analysis, and is helpful for benchmarking,
but not identification of trends.
C. Analysis of system trends is the key to identification of system-wide barriers to member satisfaction
that may be improved by the organization and affect a larger percentage of health plan members.
D. Causation of individual complaint issues of dissatisfaction is an important step of identification of
individual member satisfaction, but not potential system processes that have the potential to positively
affect collective member perception of health plan operations.
Question 17 of 65
A review was conducted following a postoperative surgical infection rate increase. The following
information was obtained about four physicians: Which of the following should be done next?
A. Suspend privileges for physician A.

B. Suspend privileges for physician C.
C. Initiate peer review with physician A.
D. Initiate peer review with physician C.
Result:
Correct
Answer 17 is D
Feedback
EXPLANATION:
A. See explanation for D.
B. See explanation for D.
C. See explanation for D.
D. Provider C has the highest infection rate. Low number of patients with high incidence of events; peer
review would be first step in process.
Question 18 of 65
A culture of patient safety in an organization will have been successfully created when
A. personal accountability is removed from the organization.
B. near miss reporting of safety issues declines.

C. staff members serve as safety advocates.
D. a root cause analysis is performed regularly.
Result:
Incorrect
Feedback
EXPLANATION:
A. Personal accountability is a component of culture of safety.
B. An organization would want to see an increase in reporting.
C. Front line staff are key to identifying safety issues and to be able to report out.
D. Volume or frequency of root cause analyses are not relevant. What is important is how the root cause
analyses are done and improvements are made as a result.
Question 19 of 65
Which of the following is always true regarding a sentinel event?
A. The cause is established as a deviation from standards.

B. The occurrence requires an immediate investigative response.
C. The incident is a result of a medical error.

D. The findings must be reported to a regulatory body.
Result:
Correct
Answer 19 is B
Feedback
EXPLANATION:
A. Incorrect, as the deviation from standard may not always be the root cause.
B. Correct, as a sentinel event should be as high a priority as a reactive response to a sentinel event.
C. Incorrect, as a sentinel event may be something besides a medical error.
D. Incorrect, as the regulatory body may not require reporting.
Question 20 of 65
Which of the following sampling techniques selects participants based on their availability in a certain
place during a specific time frame?
A. quota
B. random
C. volunteer
D. convenience
Result:
Incorrect
Feedback
EXPLANATION:
A. Quota is not related to a specific timeframe; only related to a required number of participants.
B. Random selection of participants would not necessarily allow for selection within a specific time frame.
C. Volunteer would not ensure selection based on a specific time or place.

D. Selection based on convenience would help ensure selection based on time and place.
Question 21 of 65
A Quality Council has examined data on patient falls and determined that a comprehensive falls
prevention program is needed. The first step in increasing staff awareness of this initiative is to
A. require staff to sign that they have read and understood the falls policy.
B. use an educator to teach falls prevention.
C. share unit-specific data on falls.
D. conduct a medication review of patients who have fallen.

Result:
Correct
Answer 21 is C
Feedback
EXPLANATION:
A. Incorrect; this function does not communicate the data to the applicable team.
B. Incorrect; see A.
C. Correct; characteristic of an effective team includes communication.
D. Incorrect; this would not be a first step.
Question 22 of 65
Which of the following is the primary benefit of using external quality consultants?
A. promoting effective communication

B. bridging knowledge gaps
C. maintaining performance standards for the organization

D. clarifying the mission and vision of the organization
Result:
Correct
Answer 22 is B
Feedback
EXPLANATION:
A. This is an internal benefit.
B. Consultant provides external assistance with filling in knowledge gaps.
C. This is an internal benefit.
D. This is an internal benefit
Question 23 of 65
Problem-solving, cross-functional understanding, expanded areas of expertise, and increased span of
knowledge are examples of
A. strategic alliances.
B. customer expectations.
C. resource requirements.
D. the benefits of teams.
Result:
Correct
Answer 23 is D
Feedback
EXPLANATION:
A. Strategic alliances are not related to problem solving.
B. Customer expectations have nothing to do with the above concepts.
C. Resource requirements are addressed as part of the team's overall performance efforts.
D. All of the above are key benefits of a performance improvement team
Question 24 of 65
A healthcare quality professional is attempting to refine the differences between an organization's
objectives and the stakeholder needs. Which of the following tools is most appropriate?
A. gap analysis
B. Ishikawa diagram
C. Gantt chart
D. Kanban method
Result:
Correct
Answer 24 is A
Feedback
EXPLANATION:
A. Whenever there is an evaluation between current state and future state/requirements, gap analysis is
the tool of choice.
B. cause and effect for contributing or root causes
C. timeline project management tool
D. lean tool for inventory management.
Question 25 of 65
Performance improvement teams should always be required to
A. evaluate data.
B. include senior leadership.
C. perform root cause analyses.

D. write mission and vision statements.
Result:
Incorrect
Feedback
EXPLANATION:
A. part of the process
B. not unless executive decisions barriers need removal
C. telegram:
special cause would be required
D. not addressed by this term
Question 26 of 65
The evolution of quality improvement in healthcare has shifted the primary focus from performance of
individuals to the performance of the
A. medical staff.
B. governing body.
C. ancillary departments.
D. organization's systems.
Result:
Correct
Answer 26 is D
Feedback
EXPLANATION:
A. Medical staff is a group of individuals and not systems.
B. Governing body is a collection of individuals and not systems.
C. Ancillary departments are a collection of individuals.
D. The quality improvement concept focus is on systems and processes where individuals work, not
individual performance.
Question 27 of 65
Timeliness and compliance of documentation were discussed at a multidisciplinary team meeting. To
evaluate the effectiveness of the team's action plan, which of the following will provide the most useful
information?
A. physician attendance
B. number of complaints
C. frequency of meetings
D. medical record review
Result:
Correct
Answer 27 is D
Feedback
EXPLANATION: D is the only mechanism to determine compliance and timeliness of documentation

through credit.
Question 28 of 65
Empowerment gives employees the opportunity to
A. solve problems.
B. make more money.

C. gain respect of peers.
D. achieve upward mobility.
Result:
Correct
Answer 28 is A
Feedback
EXPLANATION:
A. Empowerment is giving people autonomy and determination to enable people to overcome their sense
of powerlessness and lack of influence, and to recognize and use their resources.
B. May be a result, but not the best answer.
C. May be a result, but not the best answer.
D. May be a result, but not the best answer.
Question 29 of 65
Which of the following is the best example of use of human factors engineering?
A. designing products to prevent tubing misconnections
B. implementing a Kaizen process to reduce inventory

C. eliminating waste through reduction in motion
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D. using PDCA to improve compliance with hand hygiene telegram: #cphq_motaz
Result:
Correct
Answer 29 is A
Feedback
EXPLANATION:
A. Human factor engineering takes into account the interactions between humans and product.
B. This is a LEAN tool that promotes efficiencies.
C. This is a LEAN concept not directly related to human factor engineering.
D. This is an example of process improvement.
Question 30 of 65
Data collected about surgical cases shows significant delays. Further analysis shows the following chart:
Which of the following should a healthcare quality professional do first?
A. Perform a focused professional practice evaluation (FPPE) on every surgeon.

B. Provide the service chief with further analyses of surgeon-specific data.
C. Ask the nurse manager to write a memo encouraging promptness.

D. Form a multidisciplinary team to develop recommendations for improvement.
Result:
Correct
Answer 30 is B
Feedback
EXPLANATION:
A. Not required.
B. The quality professional should first notify the service chief so peer-to-peer feedback can be provided
to the surgeon.
C. Not beneficial.
D. This could be done if further analysis is required.
Question 31 of 65
Which of the following adverse events is NOT considered a sentinel event?
A. death due to a medication error

B. suicide threat by a patient in a confined 24-hour care setting
C. surgery on the wrong patient or body part

D. hemolytic transfusion reaction
Result:
Correct
Answer 31 is B
Feedback
EXPLANATION:
A. Incorrect; this is a sentinel event.
B. Correct; this is a clinical behavior expression and not an unanticipated event.
C. Incorrect; See A.
D. Incorrect; See A.
Question 32 of 65
A healthcare quality professional has been asked to examine a new method of reviewing adverse events
in an organization. It has been decided that a system of triggers will be established to alert the Quality
Council of a potential problem. The best example of a trigger that should be set with a threshold of zero is
a
A. medical record not completed by a physician.

B. staff member not using proper handwashing technique.
C. near miss from failure to perform a 'time-out.'
D. patient complaint regarding wait times.

Result:
Correct
Answer 32 is C
Feedback
EXPLANATION:
A. Incorrect; this not an adverse event.
B. Incorrect; see explanation for A.
C. Correct; this event should trigger further action by the Quality Council.
D. Incorrect; see explanation for A.
Question 33 of 65
A quality improvement manager must decide how to present data that demonstrates the relationship
between two process characteristics. Which of the following data display techniques is most appropriate?
A. bar chart
B. scatter diagram
C. Pareto chart
D. line graph
Result:
Incorrect
Feedback
EXPLANATION:
A. A bar chart is used to present grouped data using rectangular bars.
B. A scatter diagram is used to depict the relationship between two variables.
C. A Pareto chart is used to help determine priority by showing grouped data in descending order and
overlaying a line graph with the cumulative totals.
D. A run chart or line graph is used to depict data over time for a single variable.
Question 34 of 65
In profiling length-of-stay data for benchmarking, it is important that data be
A. raw numbers.
B. equal
telegram: numbers.
C. reported monthly.
D. severity adjusted.
Result:
Incorrect
Option C is not correct
Feedback
EXPLANATION:
A. When comparing data, it is most important for the data to be adjusted for accurate comparison. Raw
unadjusted data without the sample/population size will limit accurate comparisons
B. Equal numbers are not necessary if the data is adjusted.
C. Data could be provided in any time increment. It is more important for it to be severity adjusted for fair
comparison.
D. Benchmarking data should be severity adjusted to allow for meaningful comparisons while reducing
bias and incorrect comparisons due to differences in the patient population across organizations.
Question 35 of 65
Failure modes can be prioritized by calculating the criticality index. Which of the following three
categories are normally used to calculate a criticality index?
A. probability, likelihood, and criticality

B. frequency, severity, and ease of detection
C. effectiveness, risk, and priority

D. response, evidence, and outcome
Result:
Correct
Answer 35 is B
Feedback
EXPLANATION:
A. Incorrect, as these are not part of the criticality index.
B. Correct, as these are the components of the criticality index.

C. Incorrect. See A.
D. Incorrect. See A.
Question 36 of 65
Upon completion of a performance improvement project, who is the best person to compile and write a
report?
A. quality manager
B. team leader
C. facilitator
D. recorder
Result:
Incorrect
Feedback
EXPLANATION:
A. The quality manager generally serves in an advisory capacity.
B. Team leaders are responsible for completion of the projects, based on the charter of the project. They
may delegate aspects of the report to others on the team, but ultimately are responsible for the project.
C. Facilitators are involved with moving the process along and have no formal authority over the project.
D. Recorders only document the outcomes or activities of the team.
Question 37 of 65
A physician complains to a healthcare quality professional that the nursing staff did not strictly follow
orders for a patient. The physician requests that the quality professional speak with the nurse manager.
To facilitate improved communication, the quality professional should
A. arrange a meeting with the physician and nurse manager.

B. speak with the nurse manager on behalf of the physician.
C. evaluate the patient outcome to determine organizational risk.
D. review the patient record to determine legibility of the physician's orders.

Result:
Incorrect
Feedback
EXPLANATION:
A. Best answer to facilitate communication between parties.
B. Not the quality professional’s role to be the physician’s representative.
C. This does not address the physician’s concerns, nor promote collaboration and teamwork.
D. Not relevant for the healthcare professional to make the determination when communication is what is
needed.
Question 38 of 65
Which of the following is the best tool to begin an investigation into the causes of laboratory labeling
errors?
A. affinity diagram
B. prioritization matrix
C. flow chart
D. histogram
Result:
Correct
Answer 38 is C
Feedback
EXPLANATION:
A. Incorrect, an affinity diagram is used when group consensus is necessary.
B. Incorrect, a prioritization matrix is used when there is a list of solutions that must be reduced to one of
the few choices.
C. Correct, a flow chart provides a picture of the separate steps of the labeling process in a sequential
order.
D. Incorrect, a histogram is used to determine whether the output of a process is distributed

approximately normally.
Question 39 of 65
A summary of antibiotic usage for the fourth quarter showed that an internal medicine department did not
meet pre-established criteria in 82% of the patients reviewed. Following review, the Pharmacy and
Therapeutics Committee should recommend that the results be shared first with the
A. Quality Council.
B. governing body.
C. utilization committee.
D. chief of the department.
Result:
Incorrect
Feedback
EXPLANATION:
A. Doing this will bypass the owners of this process.
B. See A.
C. Utilization committee is not typically the first group that would be addressing the pharmaceutical issue.
D. In a medical staff hierarchy, the chief or chair of the department has responsibilities for addressing
departmental performance.
Question 40 of 65
When conducting a sentinel event review, a root cause analysis
A. provides judgment of staff behaviors.

B. identifies gaps in patient care processes.
C. requires team consensus.

D. proactively identifies causes and effects.

Result:
Correct
Answer 40 is B
Feedback
EXPLANATION:
A. Incorrect, as a root cause analysis does not provide judgments of staff behavior.
B. Correct, as a root cause analysis is a structured facilitated team process that identifies gaps in
processes.
C. Incorrect, as team consensus is not needed for a sentinel event review.
D. Incorrect, as a root cause analysis does not identify cause and effect.
Question 41 of 65
The primary objective of the operational linkage between risk management and quality/performance
improvement is to
A. meet regulatory requirements.

B. develop a plan of action for individual cases.
C. develop a comprehensive plan to prevent future occurrences.
D. alert the hospital attorney of a potentially compensable event.
Result:
Incorrect
Feedback
EXPLANATION:
A. No regulatory requirement for this.
B. Not beneficial for individual cases.
C. Expectation is to align quality and risk to address quality and safety activities.
D. No regulatory requirement for this.

Question 42 of 65
The phrase "reaching consensus" is often used in performance improvement. The term consensus refers
to
A. unanimous agreement.
B. support by all members.

C. everyone being totally satisfied.
D. a majority vote of those present.
Result:
Incorrect
Feedback
EXPLANATION:
A. Consensus is the general support from those concerned. They may support without unanimously
agreeing.
B. Consensus is general support from those concerned.
C. Consensus implies partial satisfaction from those involved, but is not total satisfaction.
D. Although consensus includes support from those concerned, it does not require agreement by a
majority.
Question 43 of 65
A hospital has recently moved to a paperless system. It is noted that some data is missing from the
obstetrics delivery record. A healthcare quality professional should recommend
A. assessing the need for additional education.

B. evaluating the computerized data entry process.
C. providing a paper trail.

D. designating one data entry person per shift.
Result:
Correct
Answer 43 is B
Feedback
EXPLANATION:
A. Until further analysis of the problem is completed, it is not known whether additional education is
needed.
B. Further analysis is necessary to determine the root causes of the missing data.
C. Providing a paper trail does not address the electronic loss of data to solve the problem.
D. Until further analysis of the problem is completed, it is not known whether additional data entry is the
issue. In addition, designating one data entry person per shift does not address the problem within the
current workflow.
Question 44 of 65
A facility is becoming part of a healthcare network. Which of the following employee education programs
is most important?
A. quality teams
B. organizational change
C. consumer expectations
D. conflict resolution
Result:
Correct
Answer 44 is B
Feedback
EXPLANATION: During times of significant change, it is critical to facilitate training on organizational

change to set overarching organizational expectations and address culture changes before addressing
quality teams, consumer expectations, or conflict resolution.
Question 45 of 65
A valid data collection tool should incorporate
A. a minimum of 20 data elements.

B. a reliable
telegram: graphic presentation.
C. the definition of data elements.
D. allowance for variance of interpretation.

Result:
Correct
Answer 45 is C
Feedback
EXPLANATION:
A. Number is not relative.
B. Graphics are not relative to a data collection tool.
C. All data elements need to be defined to ensure data collection accuracy, reliability, and validity.
D. Variation reduces data validity and reliability.
Question 46 of 65
Comparing healthcare organizations by using medical error rates
A. may present bias due to differences in reporting practices.

B. must include a minimum of 10 different facilities.
C. cannot be performed by facilities with less than 100 beds.
D. provides the best method for benchmarking patient safety.
Result:
Incorrect
Feedback
EXPLANATION:
A. Bias will be present if there are no standards for reporting.
B. There does not need to be 10 organizations for comparing rates.
C. Facilities could still be compared in a category within its number of beds.
D. Using medical error rates is not necessarily the best method.
Question 47 of 65
For health information technology to be most effective in reducing harm, the technology needs to be
A. integrated with clinical workflow.

B. able to correct claims data.
C. flexible and accessible.
D. numeric and easy to use.
Result:
Incorrect
Feedback
EXPLANATION:
A. Best answer, since staff at the line has to know how to use the tool with their daily work.
B. This is necessary, but does not reduce harm.
C. Nice component, but not something that will reduce harm.
D. This does not help reduce harm.
Question 48 of 65
Which of the following principles applies to continuous quality improvement in an organization?
A. Twenty percent of trouble comes from 80% of the problems.

B. Systems, not poor job performance, are responsible for most problems.
C. Causes of nonconformance must be identified and corrected temporarily.

D. Empowerment automatically occurs upon implementation of the program.
Result:
Correct
Answer 48 is B
Feedback
EXPLANATION:
A. This is the opposite of the Pareto principle and does not apply.
B. Foundation of what quality improvement programs should be built on.
C. It would not be appropriate to do the improvement work to have it last only temporarily.
D. The program does not cause empowerment. It is leadership behavior and actions that will change the
culture.
Question 49 of 65
Which of the following topics are discussed at a morbidity and mortality conference?
A. healthcare-acquired infections and perioperative mortality
B. planned readmissions and newborn mortality rates

C. Cesarean section rates and number of physicians
D. inpatient mortality and admissions
Result:
Correct
Answer 49 is A
Feedback
EXPLANATION:
A. Both healthcare-acquired infections and perioperative mortality are concerns to be addressed at a
morbidity and mortality conference.
B. Planned readmissions are expected occurrences and not appropriate to be discussed at a morbidity
and mortality conference.
C. Cesarean section rates alone without complications and number of physicians are not issues
appropriate for discussion at a morbidity and mortality conference.
D. Admissions are not appropriate for a discussion on morbidity and mortality.
Question 50 of 65
A critical difference between quality assurance (QA) and quality improvement is a shift in focus from
A. retrospective review to concurrent screening.

B. nonclinical aspects to customer satisfaction.
C. identifying poor performers to improving group performance.

telegram:
D. QA #cphq_motaz
coordinators to teams. telegram: #cphq_motaz
Result:
Incorrect
Feedback
EXPLANATION: Quality improvement is focused on systems, processes, and groups to improve. Quality
assurance is focused on monitoring problem areas or individuals.
Question 51 of 65
When using cost-benefit analysis in decision-making, it is important to remember that
A. consideration of the benefit is more important than cost.

B. return on investment should be at least 10 to 1.
C. implementation costs are more important than return on investment.
D. qualitative and quantitative data should be used.
Result:
Correct
Answer 51 is D
Feedback
EXPLANATION:
A. Benefit and cost should be equally considered.
B. Return on investment decisions vary by organization.
C. Importance of implementation costs vs return on investment vary by organization.
D. In addition to quantitative data such as cost, qualitative information such as patient experience should
be considered when performing a cost-benefit analysis.
Question 52 of 65
Results of physician practice pattern studies are most likely to promote behavior changes when
disseminated to the
A. practitioners.
B. administration.
C. governing body.
D. quality committee.
Result:
Incorrect
Feedback
EXPLANATION:
A. Practitioners have vested interest in this information since the data is about them.
B. Not the best answer, because it bypasses the party most vested in the information.
C. See B.
D. See B.
Question 53 of 65
When examining the relationship between staff and patient outcomes, which of the following is the most
appropriate to assess?
A. staff turnover and budget

B. patient safety data and overtime data
C. overtime data and absenteeism rates

D. occurrence reports and sentinel events
Result:
Correct
Answer 53 is B
Feedback
EXPLANATION:
A. telegram: #cphq_motaz
The budget telegram: #cphq_motaz
has little effect on the correlation between staff and patient outcomes.
B. Using patient safety data and correlation to overtime data are appropriate indicators to identify a
relationship between the two.
C. Only reviewing overtime data and absenteeism rates will not provide and information on patient
outcomes.
D. Occurrence reports and sentinel events review alone do not promote any correlation with staffing
levels and patient outcomes.
Question 54 of 65
Frequency distribution can best be displayed through use of
A. a histogram.
B. a flow chart.
C. a force field analysis.
D. an interrelationship diagram.
Result:
Correct
Answer 54 is A
Feedback
EXPLANATION:
A. A histogram displays data in a bar chart by frequency distribution.
B. A flow chart is a diagram of a process.
C. A force field analysis is a method for listing, discussing and evaluating various forces for and against a
proposed change.
D. An interrelationship diagram shows how different issues are related to one another.
Question 55 of 65
Staff has been trained and oriented on a new electronic incident reporting system. In the past, staff could
report anonymously. The new system requires staff to sign in with an individualized username and
password. Three months after implementation, there is a sharp reduction in the number of reported
incidents. Which of the following reasons for underreporting of incidents is of greatest concern?
A. staff fear of negative consequences of reporting
B. lack of knowledge about how to use the system

C. time required to complete an incident report

D. incomplete understanding about required reporting
Result:
Correct
Answer 55 is A
Feedback
EXPLANATION:
A. This is a reflection of organization's culture.
B. This is an operational/educational issue and not necessarily reflective of organization's culture.
C. See B.
D. See B.
Question 56 of 65
The best reason to evaluate team meetings is to
A. assess progress.
B. rate leader performance.

C. keep participants interested.
D. assess accuracy of the minutes.
Result:
Correct
Answer 56 is A
Feedback
EXPLANATION:
A. Assessing team progress is critical to determining whether the team is on track to meet established
goals.
B., C., and D. Evaluating leader performance, participant interest, and accuracy of minutes may impact
team effectiveness, but are not the best reasons to evaluate team meetings.
Question 57 of 65
In managed care, the most widely used performance measures are
A. Uniform Hospital Discharge Data Set (UHDDS).

B. Healthcare Effectiveness Data and Information Set (HEDIS).
C. Agency for Healthcare Research and Quality (AHRQ).

D. National Quality Forum (NQF).
Result:
Correct
Answer 57 is B
Feedback
EXPLANATION:
A. UHDDS are hospital-based measures.
B. HEDIS provides data for managed care performance measures.
C. AHRQ is the agency that does not establish managed care performance measures.
D. NQF measures are not the most widely used performance measures for managed care.
Question 58 of 65
A consulting firm has been selected by a healthcare Board of Directors to assess the quality
improvement program. Before starting the assessment, the quality professional should first
A. set up a project plan.

B. develop potential action plans.
C. define expectations and outcomes.

D. design a dashboard.
Result:
Incorrect
Feedback
EXPLANATION: All answers could be done, however, expectations and outcomes should be established
FIRST.
Question 59 of 65
A patient safety program can best be enhanced by which of the following technologies?
A. computers on wheels at the patients' bedsides

B. barcode system for medication administration
C. digital medication reference materials

D. online evidence-based medicine guidelines
Result:
Correct
Answer 59 is B
Feedback
EXPLANATION:
A. Increase nurse efficiencies, but not necessarily impactful on patient safety.
B. Best answer. A technology that forces a double checking of patients against medication orders.
C. Having information readily available, not the best answer for promoting patient safety.
D. Same as C.
Question 60 of 65
Which of the following should be included in an annual performance improvement report to a governing
body?
A. meeting minutes
B. team achievements
C. physician peer reviews
D. incident/occurrence reports
Result:
Incorrect
Feedback
EXPLANATION:
A. Meeting minutes provide documentation of discussions and actions, but are too detailed to include in a
report to a governing body.
B. A report to the governing body is an overview of accomplishments in relation to established strategic
goals. Team achievements are a critical component of the annual report.
C. Physician peer review is not included in an annual report to the governing body.
D. An overview of incident/occurrence reports patterns and trends may be included. However, individual
event detail would not be included in an annual report to the governing body.
Question 61 of 65
A performance improvement (PI) training program for supervisors should include
A. results of a failure mode and effects analysis (FMEA).
B. budget-variance reporting.
C. rapid-cycle process.
D. review of patient falls.
Result:
Incorrect
Feedback
EXPLANATION:
A. This item may need to have PI, but is not part of PI.
B. Supervisors need to know, but not a concept for PI.
C. This is a key fundamental "need to know" concept.
D. See explanation A.

Question 62 of 65
A monitoring system is being designed in which data will be collected and compared to criteria. Which of
the following will best enhance the validity and reliability of the data?
A. establishing criteria that are based on the most recent changes in medical science and technology
B. using a computerized system to substitute data for missing responses
C. assigning one staff member to identify, collect, enter, and interpret all data
D. providing a practice-based definition and specific instructions for each element
Result:
Incorrect
Feedback
EXPLANATION:
A. Evidence-based criteria does not make a data collection tool valid or reliable.
B. Adding inaccurate data to a data collection tool makes the data invalid.
C. This process could create bias in the data.
D. Data element definitions and instructions are essential in ensuring data validity and reliability.
Question 63 of 65
An outpatient clinic is attempting to measure the quality of a newly developed diabetes disease
management program. To accomplish this, laboratory results will be measured over time. The best way
to display the data is to use a
A. Gantt chart.
B. control chart.
C. Pareto chart.
D. flow chart.
Result:
Incorrect

Feedback
EXPLANATION:
A. A Gantt chart is used in project management to show a project timeline and deliverable.
B. A control chart is used to display data over time with upper and lower control limits to help monitor
process variability.
C. A Pareto chart is used to help determine priorities by showing data in descending order with a line
chart overlaid, depicting the cumulative percent.
D. A flow chart is a diagram of a process in sequential order.
Question 64 of 65
Human factors engineering is defined as the study of humans and their interaction with
A. the tools they use and the environment.

B. medical technology and the organizational systems.
C. adverse events and latent errors.

D. patients and the organization.
Result:
Incorrect
Feedback
EXPLANATION:
A. This is the most comprehensive definition of human factors engineering.
B. These are elements of human factors, but A is more comprehensive.
C. These items are outcomes of human factor failures.
D. Patients and the organization are not part of human factors engineering.
Question 65 of 65
For a continuous quality improvement team to be successful, who must be included on the team?
A. person performing the process
B. department supervisor
C. administrator
D. quality management representative
Result:
Correct
Answer 65 is A
Feedback
EXPLANATION:
A. Individuals closest to the process must be included as they have the most in-depth knowledge of the
process being evaluated.
B. Although the supervisor may have some knowledge, they are not the experts on how the process is
actually performed.
C. Administrators lend support to the team, but do not have the expertise and typically are not part of the
team evaluating a process unless their support is needed to remove barriers.
D. A quality management representative often serves as a team facilitator. However, they do not have
the direct process expertise, and other staff may perform this role if trained.

Mock 2021 Part B (WTE)

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Mock 2021 Part B (WTE)

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telegram: #cphq_motaz Test Review Report

Printed on: 2/26/2021

Test Name: CPHQ Practice Exam: Form B

Your Score 63.08%

* Initial Score is based on the first attempt of each question

Printed on: 2/26/2021

Note: correct answer is displayed in bold

B. eliminating the need for patients to hand-carry records

Printed on: 2/26/2021

choices, it's not the most cost effective.

B. total knee replacement

telegram: #cphq_motaz telegram: #cphq_motaz

Printed on: 2/26/2021

A. a surgical team 'time-out.'

B. informed consent documentation.

Printed on: 2/26/2021

D. Incorrect, as this is a function of investigating a sentinel event.

A. face-to-face, oral, scheduled

C. clear, written, top-down

A. prioritized as they occur.

Note: correct answer is displayed in bold

telegram: #cphq_motaz telegram: #cphq_motaz

Printed on: 2/26/2021

Note: correct answer is displayed in bold

Printed on: 2/26/2021

B. Mission is organization's purpose.

A. reliability of data management software.

D. people skills of the facility leaders.

A. Review 100% of colonoscopy procedures.

C. Modify the physician's privileges.

Printed on: 2/26/2021

A. conduct a failure mode and effects analysis (FMEA).

Note: correct answer is displayed in bold

telegram: #cphq_motaz telegram: #cphq_motaz

Printed on: 2/26/2021

Note: correct answer is displayed in bold

Printed on: 2/26/2021

A. review all dissatisfied responses for similarities.

B. collect more data to ensure statistical significance.

telegram: #cphq_motaz telegram: #cphq_motaz

Printed on: 2/26/2021

A. Total each complaint category at least on an annual basis.

Note: correct answer is displayed in bold

A. Suspend privileges for physician A.

Note: correct answer is displayed in bold

Printed on: 2/26/2021

A. personal accountability is removed from the organization.

B. near miss reporting of safety issues declines.

A. The cause is established as a deviation from standards.

Printed on: 2/26/2021

B. The occurrence requires an immediate investigative response.

C. The incident is a result of a medical error.

Printed on: 2/26/2021

C. Volunteer would not ensure selection based on a specific time or place.

D. conduct a medication review of patients who have fallen.

A. promoting effective communication

C. maintaining performance standards for the organization

Printed on: 2/26/2021

Note: correct answer is displayed in bold

Printed on: 2/26/2021

C. perform root cause analyses.

Printed on: 2/26/2021

D. not addressed by this term