Certified Professional in Healthcare Quality Examination
Last Update Nov 30, 2025
Total Questions : 685
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After discharge, most patients with a mental health diagnosis have not been compliant with follow-up visits. Which of the following Is the best way to Improve patient compliance?
The process used in management in which organizations evaluate aspects of their processes in relation to best practice in order to make improvements is known as:
Which initiative should a quality professional promote in an organization seeking to optimize value-based reimbursement?
A quality improvement coordinator is asked to develop a training session on team facilitation based onadult learning principles. Which of the following would be the best approach to include?
Which of the following quality improvement tools is best suited for communicating the scope of a proposed quality improvement project?
A customer complains to the health care quality professional about a service in the organization. Which of the following actions should be taken first?
Reviewing organizational priorities, addressing regulatory requirements, and identifying goals for the next year are important components in the development of which of the following?
An organization recently lost its deemed status due to non-compliance with grievance process regulations. Which of the following standards would thequality professional research to identify grievance process requirements to correct the cited opportunities for improvement?
A team has identified that labeled cutting boards are needed in a kitchen to decrease cross-contamination. After a new process has been implemented, it is discovered that the labeled cutting boards are not being used. Which of the following is the next action the team should take?
A Quality Council has received the following requests for establishing performance improvement teams:
Maintenance: Overtime reductions
Dietary: Meal delivery process
Housekeeping: Room turnaround times
Biomedical: Identification of malfunctioning equipment
Human Resources: Competency assessments
Which of the following should the Quality Council do first?
Over the past 2 months, a trend has been detected in medication errors. The preferred method of presenting data to the nursing Quality Council will identify the nurse by:
A local health center is launching a community health assessment. What data is recommended to identify the potential needs of the population?
A nurse inadvertently hung an IV medication on the wrong patient’s IV pump, but discovered the error prior to initiating the infusion. Patient harm was averted, and the nurse disclosed the error to a healthcare quality professional. The quality professional should
Which of the following should a healthcare plan use to collect satisfaction data from its health plan members?
A quality professional is leading a rapid process improvement event to reduce central line infections. Which of the following actions should be taken?
An organization has a goal to increase profitability of services covered under bundled payments. Which of the following aspects of quality should a healthcare quality professional recommend as a starting point for an analysis?
A team has completed several tests of change and has arrived at a recommendation. In order to facilitate change, which of the following should occur first?
A patient’s weight is incorrectly documented in the electronic medical record. As a result, 10 times the appropriate medication dose is ordered for the patient. A nurse identifies the error and notifies the ordering physician. The medication is not administered to the patient. This is an example of
Which of the following is a regulatory requirement to be undertaken by nonprofit hospitals?
What tool displays performance outside of expected values to merit a deeper analysis?
Before patient outcome data can be used for benchmarking, the data should be
An increased number of outpatient surgery patients present to the emergency department with complaints of pain. Which would be the best strategy to address these occurrences?
Which of the following measures would best evaluate the health of a metropolitan area?
The following chart represents readmission data for 2nd quarter. Given the results, which of the following would help the quality manager identify opportunities for improvement?
When recommending a quality improvement project, the quality professional must first consider
A quality professional is conducting a root cause analysis related to a sentinel event. Which tool would be most useful to identify potential causes of the event?
In order to make effective long-term changes, performance Improvement emphasizes the need to study and understand
Which of the following data sources can be used to assess a population's health status?
A quality improvement team has been trained on writing SMART aim statements. Below are the team’s aim statements:
Reduce adverse drug events in critical care by 10% within 12 months.
Reduce the time from 911 call to intervention for cardiac complaints by 15%.
Reduce30-day readmissions from 20% to 15%.Which of the following key elements in aim development appears to have been lost after the training?
The quality manager needs to identify a set of process measures to improve wound cate outcomes. The firststep should be to
Which of the following regulatory agencies overseedevelopment of electronic clinical quality measures (eCQMs)?
After in-depth data analysis, there is evidence of overutilization of computerized tomography to diagnose acute appendicitis. A team has been formed to develop a performance improvement plan for emergency department physicians. Which of the following leadership styles is most effective to implement best practice guidelines?
When reviewing the outcome measures of five regional psychiatric centers, variables such as illness severity, comorbid psychiatric and medical diagnoses, and substance-use issues are identified. Which of the following methods best controls for these variables?
An effective method to increase an organization’s board of directors engagement in patient safety is to
A study was performed to compare quality outcomes between case/care managed groups and non-case/care managed groups tor elective coronary artery bypass. The results are as follows:
What is the median length of stay (or non-case/care managed patients?
When developing objectives for an educational program, the quality professional should recommend
A facility’s performance on a clinical outcome measure has deteriorated. The healthcare quality professional’s initial action should be to
The data below shows 30-day readmission rates for heart failure patients by the primary language spoken and by gender with 95% confidence intervals in parentheses. Which group should be the priority target for reducing disparities in readmission rates?
Once pilot testing is complete and the actions are determined to be effective, which of the following is the next step using a rapid cycle methodology?
An important responsibility of each team member working on a team project is to
Which of the following is most important to include in a project to reduce post-operative infections?
In a data set, the difference between the highest and lowest observed values is known as the
There is an increasedincidence of type 2 diabetes among patients living near a healthcare organization as compared to the state. Considering social determinants of health, which of the following strategies can be used to address this problem?
The quality professional is preparing for the annual review of a quality management program. The most important objective of the review is to evaluate the:
Each department in a hospital self-monitors and reports hand hygiene data each quarter. Results typically fall within the 58-72% range, with the exception of Respiratory Therapy, which consistently reports 100% compliance. Which of the following steps should a healthcare quality professional take next?
A quality improvement professional believes that their MRSA facility rates are high. What should the quality improvement professional do first?
A healthcare quality professional identifies a need to improve compliance with colon cancer screening among primary care patients. Which of the following interventions should be used?
A patient sustained a skull fracture as a result of an attack by another patient. A risk manager initiates a root cause analysis. Which of the following is the intended outcome of the investigation?
The collection, analysis, and Interpretation of data for planning, Implementing, and evaluating health programs is
A performance improvement project was initiated at the beginning of the flu season to increase the influenza vaccinations given in a pediatric clinic. The organization implemented a template to document patient influenza vaccine status and to offer the vaccine to any patients identified as not having been vaccinated. To evaluate and document the process improvement results over time, the quality professional should use which of the following?
The following hospital Medicare readmission findings are available:
Based on the provided information and an understanding of factors that drive readmissions, the hospital should first
Where in the process of ensuring correct surgery does a "time-out" take place?
The purpose of considering social determinants of health during quality improvement activities is to achieve
A hospital has just implemented a physician order entry system. Three days into implementation, the users begin having major technical issues with the system. The nurse manager instructs staff to submit troubleshooting requests to the help desk. This is an example of which high-reliability principle?
How can a quality professional best engage stakeholders in the organization's quality efforts?
A patient safety officer is developing a patient safety program. The following information has been reviewed:
Incident report data
Performance indicators
Customer complaintsWhich of the following additional information is needed prior to writing the patient safety plan?
An acute care facility has established an outpatient heart failure clinic. Which of the following will best define the success of the program?
Even when appropriate processes are in place, errors can occur. Understanding this, leaders coordinating a patient safety program should focus on
In aligning an organization's performance Improvement plan with strategic goals, a healthcare quality professional should consider
An internal customer of the admission process in a skilled nursing facility is the
Managed care outcomes related to HEDIS measures are most commonly obtained through
An organization has a three-year accreditation cycle. The highest priority for the first year of the cycle by the accreditation team is:
A hospital collects patient satisfaction data by mailing surveys to patients discharged home and analyzes the responses they receive. What is the most significant limitation of this sampling methodology?
A hospital received 50 Incident reports describing falls that occurred within aone-month period. Which of the following actions should be taken?
Which of the following action plans contains all key components of a SMART goal to support a strategic plan initiative?
Which of the following should be a part of an organization's program of continuous readiness for accreditation?
An organization wants to promote Six Sigma across its enterprise with all staff members having general exposure to Six Sigma methods. Which of the following best differentiates the role of the various belts?
A home health agency has purchased an automated phone notification system to alert nurses that a patient has been discharged from a healthcare facility. The healthcare quality professional should complete which process as a next step?
A performance Improvement team has been meeting to examine delays in getting admissions from theemergency room to the nursing units. After six months of collecting data, the upper control limit was ISO minutes, and the lower control limit was 60 minutes. The next month's data shows a time of 155 minutes. The team should understand that this represents what type of variation?
A Pharmacy and Therapeutics Committee has reviewed the following control chart for presentation to a governing body:
Which of the following conclusions is most appropriate?
The ultimate responsibility for ensuring and maintaining patient safety in a healthcare organization lies with the:
An organization decides to transition from a departmental quality assurance model to a multidisciplinary quality improvement model. The first step to ensure successful change is to:
The greatest motivator for organization leaders to use a balanced scorecard is that it
Which management accountability action should be Implemented to ensure continuous readiness tor accreditation survey?
Which of the following regulatory agencies oversee development of electronic clinical quality measures (eCQMs)?
A long-term care facility has experienced an Increase in occupational Injuries among nursing staff and increased patient harm as aresult of unsafe patient handling. Which of the following is the best example of a human factors design solution this facility could Implement?
A patient was found unresponsive on a medical-surgical floor. Upon review of the patient's medical record, it was found that the patient had accidentally been given two doses of a sedating agent that had not been ordered. Which of the following would have helped prevent this error?
A health system is designing a new wellness program and wants to incorporate social determinants of health. Which of the following should be considered?
A healthcare quality professional is looking at a control chart and notices that last November the number of admissions for flu symptoms exceeded the upper control limit. This most likely represents:
Which of the following conclusions might be drawn from failure mode and effects analysis (FMEA)?
A healthcare quality professional is charged with facilitating a team. The goal of the team is to develop criteria for levels of care in behavioral/mental health. Which of the following is the most important characteristic of the facilitator?
The process used in management in which organizations evaluate aspects of their processes in relation to best practice in order to make improvements is known as:
A recent Journal article has Identified three new patient safety Initiatives. When reviewing these Initiatives, the first action of a healthcare quality professional Is to
Which of the following approaches best allows an agency to align Its activities with organizational goals?
Which of the following is a regulatory requirement to be undertaken by nonprofit hospitals?
Which of the following is the best way to evaluate the success of a performance improvement team?
A physician group with a patient population of 10,000 during the fourthquarter of a year reviewed 100 complaints regarding access to specialty care. During the fourth quarter of the next year, the patient population had grown to 60,000 with 360 complaints regarding access to specialty care. The group has a target goal of five complaints per 1,000 patients. Which of the following should a healthcare quality professional conclude based on the data?
Which of the following tools is most appropriate to analyze a medication administration process?
A researcher decides to look at every fourth patient admitted each day and record if the IV is properly labeled, starting with a randomly selected patient. This is known as which of the following types of random selection?
Which of the following will help determine the health status of a defined population?
Which of the following is the best approach tomotivate stakeholders across the care continuum to take action?
Which of the following recommendations best supports effective transitions of care from hospital to home for patients?
Which of the following is an example of a social determinant of health used to monitor a quality improvement initiative?
Key stakeholders for process improvement are selected during which phase of the Plan-Do-Study-Act (PDSA) model?
A patient safety manager provided training on hand hygiene guidelines. The clinical manager Is confident that staff are following the guidelines. Which of the following Is the best method to evaluate the current compliance with the guidelines?
The most important initial step in preparing for an accreditation survey is
Which of the following demonstrates interrater reliability and construct validity for an instrument designed to capture data for a publicly reported measure set?
Interrater Reliability
Construct Validity
Which of the following are the most important characteristics of quality metrics?
A sentinel event is a situation that reaches the patient and results in either a death, severe or temporary harm, or:
A quality coordinator was asked to evaluate team effectiveness for a struggling quality improvement team. When interviewed about the team, members say they are frustrated because they do not know what the team is supposed to accomplish. Which of the following should be explored first?
The most effective method of communicating compliance with clinical practice guidelines is to disseminate results to
A healthcare quality professional has identified a gap In practice from regulatoryrequirements. The quality professional should
A quality professional is leading a team that was recently formed to identify ways to decrease length of stay. The team members have started arguing with each other over whose approach is best. Each team member thinks the team should focus on a different part of the patient journey first, and members are not listening to each other. Which of the following should the team leader do?
A healthcare organization had three medication incidents associated with narcotics. None of the events led to permanent loss of function or death, but could be considered near misses. Which of the following would be the best tool to use to identify influencing factors?
The health quality professional recognizes that which of the following events should be reported to regulatory or accreditation organizations?
Which of the following is most relevant to addressing social determinants of health?
Which of the following represents a quality management system with criteria that serve as a tool to assess and award best-in-class organizations?
An organization Is shirting paradigms fromtop-down leadership to participatory management. The process of moving forward Includes the four Identified phases below:
1. gathering baseline data
2. evaluating effectiveness and Improvement
3. making the commitment
4. Implementing the program
Which of the following Is the most logical sequence for these phases?
Which of the following is the best strategy to increase a community's annual influenza vaccination rate?
A healthcare quality Improvement team is working on an action plan to address medication system defects. Based on the data from the chart below, what would be the next step?
The healthcare quality professional has been asked to participate in the organizations population health program related to cost and utilization.
Based on this Information, what Is the next action the quality professional should take?
Six months after implementing a new cardiac rehabilitation program, an organization notes many patients that meet criteria are not enrolled. Which of the following is the most effective strategy to increase the enrollment rate?
In a healthcare organization Implementing ongoing performance Improvement (PI), which of the following will most likely benefit the PI goals of the organization?
A public health agency is developing a proposal to provide free flu Vaccinations to anyone who requests one. Which of the following would be considered an intangible benefit?
A strategic plan Is developed by making decisions about the future of the organization. Which of the following Is true about the strategic plan?
A patient safety program can best be enhanced by which of the following technologies?
Choosing a small number of items to represent characteristics of the whole is an example of
Several leaders in a healthcare facility have differing opinions regarding the pursuit of alternative certifications and recognitions. The Chief Quality Officer (CQO) has opted to retain an external quality consultant to determine relevance, appropriateness, and readiness for an alternative certification. The most appropriate role for an external consultant is to
Which of the following is most effective to sustain knowledge gained from performance improvement training?
What Is the Initial step the quality professional should take when the organization's performance on a patient satisfaction strategic goal Is below the desired performance?
Which of the following best describes the goal of the Healthy People Initiative?
An outpatient medical clinic wants to test whether a relationship exists between two factors: lack of available transportation and the number of times patients do not keep appointments. Which of the following tools should be used?
To best achieve a low rale of harm In spite of Inherent risks In healthcare, an organization must
When reporting infection control indicators to a governing body, a healthcare quality professional should demonstrate improvement with which of the following tools?
Which of the following tools is most useful for an organization to complete prior to implementation of a new device for administration of intravenous chemotherapy?
The following data are known:
Which ofthe following accurately describes this chart?
A provider’s Ongoing Professional Practice Evaluation (OPPE) profile is shown below. In this organization, if a provider partially meets or does not meet performance expectations, they are referred to peer review for a Focused Professional Practice Evaluation (FPPE).
Fully Meets: >80% of measures at threshold
Meets: 65% to 80% of measures at threshold
Partially Meets: 40% to 64% of measures threshold
Does Not Meet: <40% of measures at threshold
After reviewing this provider’s overall profile, what should the healthcare quality professional suggest?
Clinical staff at a hospital inconsistently document the fall risk assessment upon admission. What approach should the quality improvement professional recommend as a priority?
An interdisciplinary learn met to review readmission rates at a health system. Issues were identified withcommunication across care providers. The team is interested in improving the coordination of care process and is now reviewing four candidates to serve in the role of process champion:
Of the four candidates, which represents the most effective choice to serve as a process champion?
Which of the following types of surveillance refers to relying on another person to report a safety concern?
To determine how much variability in a process Is due to random variation and how much Is due to unique events, the most appropriate tool would be a
Identification of quality Improvement opportunities can best be Identified through
A department analyzed Its process for distributing paychecks to employees. The analysis showed there were multiple checkpoints tor approval, delays In processing of the checks, and errors that caused extra work for staff. Which of the following types of waste were identified during the analysis?
A healthcare quality professional, previously employed by a hospital, has been hired by an ambulatory surgery center to create a continuous readiness program. Both employers are Medicare certified and are accredited by the same accrediting organization. The healthcare quality professional should first
A quality professional needs to select a new project from a list of requests. An organization has determined that new projects should focus on patient safety and cost-reduction. Which tool would help Identify the project that best meets these criteria?
Which of the following is the appropriate group to review care delivered by an individual physician to a patient who suffered a serious adverse event?
An organization Is looking for a creative approach at Improving heart failure outcomes to reduce readmissions. Several clinician's express concerns that nothing can be done to Improve this. Two clinicians recommend a set of clinical practiceguidelines recently developed by a specialty organization. Which of the following would the two clinicians be considered?
Using the data below, which issue would be identified as a priority for further performance improvement?
Issue
High Risk
High Strategic Priority
Cost
Customer Satisfaction
Quality Concern
Pressure Injuries
4
4
1
4
5
Medication Errors
3
1
2
1
5
Transfer to Higher Level of Care Within One Hour of Admission
2
5
4
1
3
Miscommunication of Abnormal Findings
4
3
5
1
4
Which of the following is the best example of a non-value added step in the healthcare environment?
There has been an increase in readmissions and chart reviews show that it is related to medication non-adherence post-discharge. To improve medication adherence, the quality professional recommends staff:
A healthcare organization wishes to develop an education plan for quality and patient safety. Based on adult learning principles, the plannededucation Is most likely to be effective when
In reviewing information offered by the Agency for Healthcare Research and Quality (AHRQ), the quality improvement (QI) specialist recognizes that the three broad aims pursued by the National Quality Strategy are
In preparation for a provider organization accreditation survey, the most effective method for identifying training needs for staff is
Following a procedure, a patient is returned to the operating room for removal of a sponge. If no incident report is completed, which of the following will most reliably identify the occurrence?
A quality Improvement team has Identified specific changes to Implement for a quality Improvement Initiative. As the next step, the team would like to establish a concrete timeline for implementation. Which of the following is the best tool to use for this step?
Which tool is used to establish and track timelines for project completion?
To determine the success of a transfusion quality improvement project, a healthcare quality professional should:
Quality teams can be an important component in an organization’s quality/performance improvement program by providing an avenue for
Which of the following actions best illustrates an organization has begun the work necessary to achieve the Malcolm Baldrige Award?
Which of the following is most relevant to addressing social determinants of health?
The design of a piece of equipment contributes to an error. Which of the following types of errors has occurred?
Each department in a hospital self-monitors and reports hand hygiene data each quarter. Results typically fall within the 58-72% range, with the exception of Respiratory Therapy, which consistently reports 100% compliance. Which of the following steps should a healthcare quality professional take next?
A root cause analysts (RCA) was conducted tor an event related to a delayed high-priority alarm response. Alarm fatigue was determined to be a root cause. Which of the following Is the most appropriate first Intervention?
Which of the following should be used to show beginning and ending times for an activity along a timeline?
Leadership wants to leverage technology as a strategy for improvement of patient safety. Which of the following best illustrates this is occurring?
Which of thefollowing tools would best display nosocomial infection rates over time?
A managed care peer review committee should obtain which of the following first?
Which of the following quality Improvement Tools Is best for riskassessment of a new or modified process?
An organization IsImplementing a new electronic medical record and has employed a project manager. At the first meeting, the project manager observes the following:
• The team estimates It Is one-fourth finished with Identifying benchmark organizations.
• Team members have not yet begun to identify the current state.
- They are halfway through collecting public data, which puts them slightly behind schedule for that task.
Which of the following tools should the quality Improvement project manager recommend?
Which of the following tools provides the best way to display quarterly comparisons of patient satisfaction surveys?
Which of the following quality initiatives impacts an organization’s reimbursement?
Following the formation of a team, the success of the project will be most highly influenced by:
Which of the following is an example of addressing a social determinant of health to improve outcomes in patients with type 2 diabetes?
Which Is a source of data tor analyzing staff flu vaccination trends for an accountable care organization?
The tool used to graphically rank causes from most significant to least significant by using a vertical bar graph is known as a
Education sessions were held to improve bar code medication administration (BCMA) performance. Six months after completion of education, an analysis showed continued BCMA improvement. What is the key to sustaining this improvement?
Which of the following is the most effective data display tool to demonstrate changes in monthly patient fall rates for the past fiscal year?
The clinic has a goal to reduce the Healthcare Effectiveness Data and Information Set (HEDIS) measure of ' the percent of diabetic patients with a HgA1c greater than 9.0% for accreditation. Who should be Included on the quality Improvement team?
Which of the following Is an essential step in the strategic planning process?
Each provider in a primary care practice has the potential of earning a $20,000 bonus based on individual performance on select Healthcare Effectiveness Data and Information Set (HEDIS) indicators as outlined below:
Percent of bonus earned for meeting target
Indicator
Performance Target (met goal if ≥ target)
25%
Breast Cancer Screening (BCS)
74%
25%
Controlling High Blood Pressure (CBP)
72%
50%
Childhood Immunization Status (CIS)
63%
The performance for the providers is as follows:
Provider
BCS
CBP
CIS
A
75%
71%
63%
B
77%
69%
65%
C
79%
73%
64%
D
73%
74%
62%
Based on this information, which of the following conclusions is accurate?
Which of the following is the best example of a patient-centered approach in healthcare?
Which of the following is the best example of population health management?
Which of the following best describes the goal of the Healthy People Initiative?
TESTED 30 Nov 2025
