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NAHQ Certified Professional in Healthcare Quality Practice Test

CPHQ exam Format | Course Contents | Course Outline | exam Syllabus | exam Objectives

The content validity of the CPHQ examination is based on a practice analysis which surveys healthcare quality professionals on the tasks they perform as a part of their job. Each question on the exam links directly to one of the tasks listed in the content outline. Each question is designed to test if the candidate possesses the knowledge necessary to perform the task and/or has the ability to apply it to a job situation.

1. Organizational Leadership (35 items)
A. Structure and Integration
1. Support organizational commitment to quality
2. Participate in organization-wide strategic planning related to quality
3. Align quality and safety activities with strategic goals
4. Engage stakeholders to promote quality and safety (e.g.- emergency preparedness- corporate compliance- infection prevention- case management- patient experience- provider network- vendors)
5. Provide consultative support to the governing body and clinical staff regarding their roles and responsibilities (e.g.- credentialing- privileging- quality oversight- risk management)
6. Facilitate development of the quality structure (e.g.- councils and committees)
7. Assist in evaluating or developing data management systems (e.g.- data bases- registries)
8. Evaluate and integrate external best practices (e.g.- resources from AHRQ- IHI- NQF- WHO- HEDIS- outcome measures)
9. Participate in activities to identify and evaluate innovative solutions and practices
10. Lead and facilitate change (e.g.- change theories- diffusion- spread)
11. Participate in population health promotion and continuum of care activities (e.g.- handoffs- transitions of care- episode of care- outcomes- healthcare utilization)
12. Communicate resource needs to leadership to Excellerate quality (e.g.- staffing- equipment- technology)
13. Recognize quality initiatives impacting reimbursement (e.g.- pay for performance- value-based contracts)
B. Regulatory- Accreditation- and External Recognition
1. Assist the organization in maintaining awareness of statutory and regulatory requirements (e.g.- CMS- HIPAA- OSHA- PPACA)
2. Identify appropriate accreditation- certification- and recognition options (e.g.- AAAHC- CARF- DNV GL- ISO- NCQA- TJC- Baldrige- Magnet)
3. Assist with survey or accreditation readiness
4. Participate in the process for evaluating compliance with internal and external requirements for:
a. clinical practice guidelines and pathways (e.g.- medication use- infection prevention)
b. service quality
c. documentation
d. practitioner performance evaluation (e.g.- peer review- credentialing- privileging)
e. gaps in patient experience outcomes (e.g.- surveys- focus groups- teams- grievance- complaints)
f. identification of reportable events for accreditation and regulatory bodies
5. Facilitate communication with accrediting and regulatory bodies Certified Professional in Healthcare Quality Detailed Content Outline1
C. Education- Training- and Communication
1. Design performance- process- and quality improvement training
2. Provide education and training on performance- process- and quality improvement (e.g.- including improvement methods- culture change- project and meeting management)
3. Evaluate effectiveness of performance/quality improvement training
4. Develop/provide survey preparation training (e.g.- accreditation- licensure- or equivalent)
5. Disseminate performance- process- and quality improvement information within the organization
2. Health Data Analytics (30 items)
A. Design and Data Management
1. Maintain confidentiality of performance/quality improvement records and reports
2. Design data collection plans:
a. measure development (e.g.- definitions- goals- and thresholds)
b. tools and techniques
c. sampling methodology
3. Participate in identifying or selecting measures (e.g.- structure- process- outcome)
4. Assist in developing scorecards and dashboards
5. Identify external data sources for comparison (e.g.- benchmarking)
6. Collect and validate data
B. Measurement and Analysis
1. Use data management systems (e.g.- organize data for analysis and reporting)
2. Use tools to display data or evaluate a process (e.g.- Pareto chart- run chart- scattergram- control chart)
3. Use statistics to describe data (e.g.- mean- standard deviation- correlation- t-test)
4. Use statistical process control (e.g.- common and special cause variation- random variation- trend analysis)
5. Interpret data to support decision-making
6. Compare data sources to establish benchmarks
7. Participate in external reporting (e.g.- core measures- patient safety indicators- HEDIS bundled payments)
3. Performance and Process Improvement (40 items)
A. Identifying Opportunities for Improvement
1. Facilitate discussion about quality improvement opportunities
2. Assist with establishing priorities
3. Facilitate development of action plans or projects
4. Facilitate implementation of performance improvement methods (e.g.- Lean- PDCA- Six Sigma)
5. Identify process champions
Certified Professional in Healthcare Quality
Detailed Content Outline1
B. Implementation and Evaluation
1. Establish teams- roles- responsibilities- and scope
2. Use a range of quality tools and techniques (e.g.- fishbone diagram- FMEA- process map)
3. Participate in monitoring of project timelines and deliverables
4. Evaluate team effectiveness (e.g.- dynamics- outcomes)
5. Evaluate the success of performance improvement projects
6. Document performance and process improvement results
4. Patient Safety (20 items)
A. Assessment and Planning
1. Assess the organization's culture of safety
2. Determine how technology can enhance the patient safety program (e.g.- electronic health record (EHR)- abduction/elopement security systems- smart pumps- alerts)
3. Participate in risk management assessment activities (e.g.- identification and analysis)
B. Implementation and Evaluation
1. Facilitate the ongoing evaluation of safety activities
2. Integrate safety concepts throughout the organization
3. Use safety principles:
a. human factors engineering
b. high reliability
c. systems thinking
4. Participate in safety and risk management activities related to:
a. incident report review (e.g.- near miss and real events)
b. sentinel/unexpected event review (e.g.- never events)
c. root cause analysis
d. failure mode and effects analysis

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CPHQ
NAHQ Certified Professional in Healthcare Quality
(CPHQ)
https://killexams.com/pass4sure/exam-detail/CPHQ
QUESTION: 155
Which of the following are hardware components that would be included in a
computerized management information system?
A. Binary and decimal coding
B. Flow chart and program
C. Instructions and data
D. Printer and random access memory
Answer: D
QUESTION: 156
Which of the following monitors provides patient outcome information?
A. Nosocomial infection rate
B. Degree of compliance with nursing care documentation
C. Degree of compliance with renewal of antibiotics therapy
D. Equipment malfunction rate
Answer: A
QUESTION: 157
One major difference between traditional quality assurance (QA) and quality
improvement (QI) is that QI:
A. Stresses peer review, while QA focuses on the customer
B. Focuses on the individual, while QA focuses on the process
C. Stresses management by objective, while QA stresses team management
D. Focuses on the process, while QA focuses on individual performance
Answer: D
QUESTION: 158
Measures of central tendency describe the:
54
A. Typical or middle data point
B. Extent to which the data points are scattered
C. Type and number of classes for dividing the data
D. Average distance of any point in the data set from the mean
Answer: A
QUESTION: 159
The following represents two samples of five hospitals� hysterectomy rates per 1,000
women aged 40-60 years of age:
Rates Mean Standard Deviation
Sample A 3, 5, 7, 8, 5 5.6 1.8
Sample B 4, 5, 6, 7, 5 5.4 1.1
In analyzing this information, it can be concluded that:
A. sample A has more variability than sample B
B. sample A�s performance is superior to sample B�s
C. There are more cases in sample B
D. There is a data collection error in sample B
Answer: A
QUESTION: 160
The primary benefit of adopting a countrywide or global uniform set of discharge data is
to:
A. Facilitate computerization of data
B. Validate data being collected from other sources
C. Facilitate collection of comparable health information
D. Assist medical records personnel in collecting internal data
Answer: C
QUESTION: 161
I n order to perform a task for which one is held accountable, there must be an equal
balance between responsibility and:
55
A. Authority
B. Education
C. Delegation
D. Specialization
Answer: A
QUESTION: 162
A patient was in the operating room when a piece of a surgical instrument broke off and
was left in the patient�s body. The patient was readmitted for removal of the foreign
object. Which of the following would most likely apply in this situation?
A. Res ipsa loquitur
B. Contributory negligence
C. Contractual liability
D. Tort liability
Answer: A
QUESTION: 163
Which of the following types of budgets itemizes the major equipment to be purchased in
the next year?
A. Capital
B. Variable
C. Operating
D. Zero-based
Answer: A
QUESTION: 164
A quality manager needs to assign a staff member to assist a medical director in the
development of a quality program for a newly established service. Which of the
following staff members is most appropriate for this project?
A. A newly hired staff member who has demonstrated competence and has time to
complete the task
56
B. A knowledgeable staff member who works best on defined tasks
C. A motivated staff member who is actively seeking promotion
D. A competent staff member who has good interpersonal skills
Answer: D
QUESTION: 165
A surgeon�s wound infection rate is 32%. Further examination of which of the following
data will provide the most useful information in determining the cause of this surgeon�s
infection rate?
A. Mortality rate
B. Facility infection rate
C. Use of prophylactic antibiotics
D. Type of anesthesia used
Answer: C
QUESTION: 166
The separate services of Pharmacy and Nursing are having difficulty developing an
action plan for medication errors. Pharmacy Services states that Nursing Services causes
the majority of the problems related to errors, while Nursing Services states the opposite.
The quality professional�s role in resolving this problem is to:
A. Provide them with directives on how to solve the problem
B. Facilitate discussion between the groups to enable them to assume ownership of their
portions of the problem
C. Assign the task to an uninvolved manager
D. Refer the problem to the facility wide quality council
Answer: B
QUESTION: 167
Which of the following is most likely to be a benefit of concurrent ambulatory surgical
case review?
A. Decreased medical record review at discharge
57
B. An increase in the number of cases failing screening criteria
C. An increase in reviewer competence
D. Decreased employee turnover
Answer: A
QUESTION: 168
The primary purpose of an emergency preparedness program is to
A. Conduct evaluations of emergency training
B. Provide evaluations of semiannual evacuation drills
C. Prevent internal disasters that disrupt the facility�s ability to provide care and
treatment
D. Manage the consequences of disasters that disrupt the facility�s ability to provide care
Answer: D
QUESTION: 169
According to Joint Commission standards, the safety program must include all of the
following EXCEPT:
A. Monthly safety committee meetings
B. Planned response to natural disasters
C. Orientation and continuing education on safety issues
D. Review of safety policies and procedures for all departments
Answer: A
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