Certified Professional in Healthcare Quality Examination
Last Update Feb 28, 2026
Total Questions : 813
We are offering FREE CPHQ NAHQ exam questions. All you do is to just go and sign up. Give your details, prepare CPHQ free exam questions and then go for complete pool of Certified Professional in Healthcare Quality Examination test questions that will help you more.
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
A performance Improvement team has been formed and assigned to reduce wait time from clinic check-In to seeing a provider. Which tool would be most useful for the team to create at the first meeting?
A healthcare quality professional is provided the following data:
Cause of Surgical Delays
Cause
Jan
Feb
March
Incomplete paperwork
7
3
6
Surgeon unavailable/late
10
4
7
Anesthesia late
3
3
3
Surgical instruments incomplete
6
1
7
Pre-op laboratory results not present
2
4
7
Blood not available
1
0
2
Patient not NPO
7
4
6
What steps should be taken to prioritize areas of concern?
The design of a piece of equipment contributes to an error. Which of the following types of errors has occurred?
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 healthcare quality professional receives the following data on causes of surgical delays:
Cause
Jan
Feb
Mar
Incomplete paperwork
7
3
6
Surgeon unavailable/late
10
4
7
Anesthesia late
3
3
3
Surgical instruments incomplete
6
1
7
Pre-op lab results missing
2
4
7
Blood not available
1
0
2
Patient not NPO
7
4
6
What steps should be taken to prioritize areas of concern?
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?
The quality professional reviews the following data:
[Data not provided in the document]
Which of the following is the next step?
The quality improvement (QI) specialist recognizes that any documents related to medical peer review are:
To promote staff engagement In a new Initiative, educators should focus on staff
A healthcare quality professional Is assisting an organization with evaluating patient safety actions that will prevent errors of omission. Which of the following systems will most likely be effective?
The chart shown below is created for a project schedule.
What is the minimum number of days required to complete the project?
Which of the following actions will most effectively promote safety activities within an organization?
A healthcare quality professional has been asked to assess afacility's patient safety culture. Which of the following should be surveyed?
Based on this matrix, which of the following ideas should the team address first?
Ahospital is using the above chart to monitor the average length of stay (ALOS) for patients diagnosed with acute myocardial infarction (AMI). Which of the following conclusions should be made?
Which of the following is the best method for determining improvement priorities to benefit the health of the community?
Training priorities are being determined based on treatment record review results. The following weighted results are available:
Category
Item Weight
% Compliance
Assessment
1.5
90
External Communication
0.5
75
Care Plan
1.5
80
Progress Notes
1.0
75
Discharge Plan
1.0
80
Based on these results, which area should take priority for training?
A hospital received 50 Incident reports describing falls that occurred within aone-month period. Which of the following actions should be taken?
The ultimate responsibility for ensuring and maintaining patient safety in a healthcare organization lies with the:
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?
A multidisciplinary team has been convened to review delays in laboratory turnaround time between the medicine clinic and the laboratory. The team’s first step in evaluating the issue is to
Which of the following approaches to training for a new quality and performance improvement initiative is most likely to succeed based on adult learning principles?
A healthcare organization has two years of data on infection rates by month. Which of the following process tools would be best to use for analyzing this data?
Which of the following methods best links performance improvement activities with organizational strategic goals?
An organization is shifting paradigms from top-down leadership to participatory management. The process of moving forward includes the four identified phases below:
gathering baseline data
evaluating effectiveness and improvement
making the commitment
implementing the program
Which of the following is the most logical sequence for these phases?
Technology design that prevents a certain action, or requires that another action happen first, is said to have
A multidisciplinary team is focused on safe patient transfers to a long-term care facility and is performing a failure mode and effects analysis (FMEA). Which of the following should be the first step in the process?
A healthcare quality professional receives the following Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results:
Which of the following should be the next action by the professional?
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 actions target social determinants of health in an improvement project on asthma control?
A CEO and CNO have requested a new quality initiative to reduce patient falls. One of the first steps in starting this new quality improvement initiative should include:
The expectation to maintain continuous survey readiness must be supported and driven by the
A skilled nursing facility has implemented a process to address delays in diagnostic test result availability to the ordering provider. Which of thefollowing measurements will best document improvement in this process?
Providers in a clinic can earn incentives based on performance measure results. Based on the incentive structure and current performance below, which measure should providers focus on to maximize their incentive?
Measure
Weight
Target
Current
Breast Cancer Screening
30%
70%
70%
Colorectal Cancer Screening
10%
65%
62%
Controlling High Blood Pressure
40%
82%
83%
Childhood Immunization Status
20%
48%
44%
The chart below reflects the 12-week period following implementation of a new electronic health record (EHR) at an outpatient clinic.
Based on the information above, which of the following conclusions can be drawn?
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?
An infection prevention and control committee is developing an agenda for its next meeting. Which of the following items should be given priority?
The following data are known:
Which ofthe following accurately describes this chart?
Which tool is used to identify, explore, and display the possible causes of a specific problem or condition?
An organization is implementing a palliative care unit. As part of the planning and implementation processes, the board authorizes the following:
• Learning visits with existing programs to obtain information about best practices
• Formal training of all staff assigned to the unit in the principles of palliative care
• The development of a balanced scorecard to monitor program performance
The actions of the board best illustrate
Which of the following best describes the goal of the Healthy People Initiative?
To best achieve a low rate of harm in spite of inherent risks in healthcare, an organization must:
Which of the following tools Is most effective in assisting an organization seeking to evaluate the current culture of safety?
Accountable care organizations (ACOs) utilize "hot spotting" as a population health tool to:
In an aging population, one of the challenges associated with the use of practice guidelines is
Which of the following is the key responsibility of a healthcare quality professional in all types of facilities and organizations?
Which of the following actions demonstrate an organization working towards a just culture?
To gauge community perceptions regarding a hospital's response to a pandemic, the healthcare quality professional uses a random number generator to select 1,000 phone numbers and collect survey responses from the first 300 of those phone numbers where the call is answered. All calls are made between 9:00 am and 5:00 pm. This data collection approach is limited because:
During analysis of patient falls, a quality professional notes that there has been an increase in the fall rate over the last 3 months. What other data should be analyzed first to determine potential causes?
To determine the success of a transfusion quality improvement project, a healthcare quality professional should:
Prior to a regulatory or accreditation visit, a healthcare quality professional should:
Survey preparation is initiated by a quality professional for an organization's annual three-year accreditation. The executive committee and department managers are given an organizational schedule for training and accreditation activities. Which of the following is the best tool to use to manage this initiative?
A local health center is launching a community health assessment. What data is recommended to identify the potential needs of the population?
A performance improvement team is looking at data from similar medical centers to improve patterns of care. This method of assessment is known as:
Which of the following conclusions might be drawn from failure mode and effects analysis (FMEA)?
An infection prevention and control committee is developing the agenda for its next meeting. Which of the following items should be given priority?
A CEO and chief nursing officer have requested a new quality initiative to reduce patient falls. One of the first steps in starting this new quality Improvement Initiative should include
What is the first step in turning an organization’s long-term goals into an operational plan for improvement?
A team is conducting a failure mode and effects analysis (FMEA) to determine whether a hospital laboratory should continue performing therapeutic phlebotomy on an outpatient basis. Which task must occur prior to brainstorming failure modes?
An interdisciplinary team 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?
An outbreak of measles in a school district resulted in 58 cases over a period of 5 months. Which of the following data displays best illustrates the occurrence of student measles by month?
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?
Which of the following payment systems carries the most financial risk for a provider?
The healthcare quality professional is engaged with a leadership team. Which of the following will best help to establish performance improvement opportunities?
Within the strategic management process, which of the following actions is most relevant indetermining what projects are feasible for an organization?
An important responsibility of each team member working on a team project is to
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
A blood transfusion study shows:
100 patients
Transfusion time range: 2.5–5.0 hours
50% transfused within 4 hours
Which tool best displays the distribution of transfusion hours?
A blood transfusion study reveals the following data:
Total number of patients = 100
Range of blood transfusion time = 2.5 to 5.0 hours
50% of patients were transfused within 4 hours
Which of the following tools is most appropriate to display the distribution of transfusion hours?
An acute care facility has established an outpatient heart failure clinic. Which of the following will best define the success of the program?
Physician and nursing director compensation for a busy emergency department is tied to aggressive door-to-disposition times. Staff workarounds save time but have increased the potential for errors. Which of the following best describes this situation?
A managed care peer review committee should obtain which of the following first?
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?
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?
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?
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?
The consensus-building group of diverse stakeholders who reviews and endorses measures for public reporting in the U.S. is known as the
Which of the following is the most effective data display tool to demonstrate changes in monthly patient fall rates for the past fiscal year?
A treatment center has experienced an increasing number of adverse medication safety events. Review of the data shows a medication error rate for drug–drug interactions of 15.7 per 1,000 medications dispensed. The organizational goal is less than 5 per 1,000, and ultimately 0. Which of the following solutions is most appropriate to consider?
The office manager of a primary careoffice reviewed the performance of the providers and noted that one provider has not been completing depression screenings consistently for patients in the previous month. The manager's next action is to:
Training priorities are being determined based on treatment record review results shown below:
Category
Item Weight
% Compliance
Assessment
1.5
90
External Communication
0.5
75
Care Plan
1.5
80
Progress Notes
1.0
75
Discharge Plan
1.0
80
Which area should take priority for training?
During a regulatory survey, an organization received deficiencies in the handling of medical waste. What is the organization’s next step?
The strategic plan for an organization calls for expansion of information technology. The following information is available:
If equal weight is given to each consideration, which of the following options should be the primary choice?
A behavioral health hospital implemented restraint audits in each of its nursing units. After two months of data collection, what should the healthcare quality professional do next?
To gauge community perceptions regarding a hospital’s response to a pandemic, the healthcare quality professional uses a random number generator to select 1,000 phone numbers and collect survey responses from the first 300 of those phone numbers where the call is answered. All calls are made between 9:00 am and 5:00 pm. This data collection approach is limited because:
Which organization should be consulted when an organization wishes to expand diagnostic testing?
Which of the following is the best example of applying cultural diversity principles to patient safety?
In an improvement project to improve clinic flow, a spaghetti chart is best used to:
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:
Leadership wants to leverage technology as a strategy for improvement of patient safety. Which of the following best illustrates this is occurring?
In recent months, the amount of time It takes for Insurance claims to be submitted has increased significantly, resulting in the hospital not being paid in a timely manner. Which of the following Is the quality professional's best course of action?
Which of the following stages may cause continuous quality improvement teams to dissolve prematurely?
An organization has compiled the scatter plots below:
Based on these plots, which of the following conclusions can be made by the quality professional?
Which of the following organizations is a deemed status provider for hospital CMS participation?
An organization’s nursing units report the following needlestick injuries:
Unit
# Needlestick Injuries
# Admissions
A
2
1,000
B
12
800
C
5
752
Which response by leadership demonstrates a culture of safety?
A group of clinical staff has identified a new opportunity for improvement. The group is ready to identify a sponsor, and a meeting has been scheduled with the Chief Medical Officer to discuss the possibility for them to serve as the sponsor. What sponsor task should be discussed during the meeting?
A health system is designing a new wellness program and wants to incorporate social determinants of health. Which of the following should be considered?
Integration of a quality culture within an organization Is best demonstrated by
A nursing director for a unit in a cancer hospital Is reviewing and assessing outcomes data in the followingscatter diagram:
The relationship between the incidence of infection and the decrease in staffing targets is
Which of the following is the most effective method for communicating an organization’s quality improvement efforts?
An organization Is tracking Infection rates to determine the benchmarks for the next fiscal year. The team Is analyzing the data for Infection rates. Which key variables are missing to interpret the graph?
Key stakeholders for process improvement are selected during which phase of the Plan-Do-Study-Act (PDSA) model?
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
What action should be taken to align an organization’s safety culture with improvement activities?
Which of the following actions best illustrates an organization has begun the work necessary to achieve the Malcolm Baldrige Award?
In developing educational training in quality improvement, what components should be included?
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
To integrate performance improvement with organization planning, there must be alignment between
Which of the following methods best links performance improvement activities with organizational strategic goals?
In addition to the mean, which of the following are measures of central tendency?
A pulmonologist is gathering social determinants of health data from their patients. Which of the following best explains the purpose of collecting this data?
Which of the following should be presented to senior management to obtain support for a new quality improvement (QI) program?
A home health agency’s Performance Improvement Committee has decided to base staff educational programs onaggregated occurrence report data. Due to budgetary and time constraints, not every area identified from the data can be addressed. Which of the following would be most useful to the committee in determining their educational targets?
Four surgical centers formed a collaboration to reduce post-operative infection rates. The goal was to reduce infection rates by 20% from baseline.
Which center met the goal?
When reporting infection control indicators to a governing body, a healthcare quality professional should demonstrate improvement with which of the following tools?
A total joint replacement program is adding one outcome measure. Which measure would be the most appropriate?
A healthcare quality professional can conclude that clinical performance measures in disease specific certification programs are best supported by the
A recent analysis reveals that reimbursement projection is being negatively impacted by post-surgical respiratory failure rates. What is the first step to address this issue?
An ambulatory pulmonary division is in the final phase of a DMAIC project. The division head asked the team to present the performance of the project. Which chart demonstrates that change has occurred over time and the process has limited variation?
Choosing a small number of items to represent characteristics of the whole is an example of
Which of the following would provide the best information to a Quality Council interested in evaluating the effectiveness of quality improvement teams that were chartered during the past year?
Continued evaluation of a quality improvement initiative occurs within which of the following phases of the DMAIC process?
Data from an Incident reporting system compares Incident rates for one facility to similar facilities:
After reviewing the graph, which of the following should be done first?
While auditing a medical chart for breast cancer screening compliance using HEDIS, a quality professional questioned whether a patient’s last screening fell within the lookback period. Where should the quality professional look to ensure compliance?
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?
Which of the following approaches best allows an agency to align Its activities with organizational goals?
An organization has established an ambulatory diabetic management program. Which of the following will best define a successful outcome of the program?
Choosing a small number of items to represent characteristics of the whole is an example of
The most important initial step in preparing for an accreditation survey is:
The health department cited a clinic for storing used instruments improperly. From aquality perspective, which of the following should be done first?
A Rapid Process Improvement Team began a new process on January 7 to reduce targeted events per bed day outcome. The team asked the quality analyst to help determine whether the new process was successful and should be continued. Based on the control chart the quality analyst produced, which of the following is the best conclusion?
A quality improvement professional believes that their MRSA facility rates are high. What should the quality improvement professional do first?
A healthcare quality professional wants to find out whether the community served Is satisfied with the care provided. The organization serves patients who live within a 10-mile radius. The healthcare quality professional mails a survey to households within 3 miles of the organization. What type of bias has been Introduced?
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?
Which of the following is the best strategy for leaders to ensure compliance with changing regulations?
An organization should establish a cross-functional quality improvement team when
Senior leaders of a managed care organization have consulted a healthcare quality professional on the purchase of a clinical data management software system to support performance improvement. Which of the following should be considered first?
The collection, analysis, and Interpretation of data for planning, Implementing, and evaluating health programs is
With unannounced surveys, it is imperative that healthcare organizations create training programs to achieve continuous readiness. Developing readiness programs should include
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?
A rapid cycleimprovement team has met for six months. The team set a clear aim, gathered data, and identified barriers, but has not conducted any tests of change. Team members are also not completing assignments. Which of the following tools should be used to get the team back on track?
Which of the following provides support and subject matter expertise (or organizations that self-report sentinel events?
Data identify a need to reduce medication errors in an institution. When requesting support to form a medication error reduction team from executive leadership, a healthcare quality professional should demonstrate
In aligning an organization's performance Improvement plan with strategic goals, a healthcare quality professional should consider
The hospital administration has requested data to support an initiative to reduce barriers to healthcare In the community. Which of the following Information Is most appropriate for the quality professional to provide for initial planning?
An orthopedic surgeon performed surgery on the wrong finger. After the case, the surgeon took full responsibility, disclosed the error to the patient, and discussed the event with the Chief of Surgery. The Chief of Surgery believed the error occurred because the splint was not removed for preoperative site marking. The surgeon stated, “I have learned from the situation and will never repeat it.” Neither believed further analysis or action was needed. The healthcare quality professional should conclude that:
How can a healthcare system address social determinants of health to improve outcomes?
When analyzing nominal data, the quality professional uses a bar chart to display
Data for an organization's annual Influenza vaccine administration yields the following results:
What is the median for the organization's annual vaccine count?
Which of the following Is an algorithm that Is designed to classify patients according to their acuity?
When reporting infection control indicators to a governing body, a healthcare quality professional should demonstrate improvement with which of the following tools?
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:
Through routine collection of incident reports, an increase in medication errors was noted over a period of 6 months on 2 nursing units. Which of the following is the best method of displaying the data to illustrate this finding?
Which of the following is the best example of a patient-centered approach in healthcare?
A hospital’s Quality Council has prioritized four quality improvement initiatives using the following matrix:
Quality Improvement Initiative
Relation to Strategic Plan
Overall Positive Patient Impact
Degree of Risk to Patient
Reduce patient falls by 10%
100
20
60
Reduce wrong-site surgeries to zero
90
60
90
Reduce medication dispensing time by 20%
90
80
30
Reduce central line infections by 30%
40
90
90
Which initiative should be the highest priority?
The national benchmark for catheter-associated urinary tract infections (CAUTI) is 1.00. An organization’s current rate is 1.50. When beginning a process improvement project to reduce CAUTI, what rate should be set as the initial goal?
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 healthcareorganization has recently launched a diabetes center of excellence to address the needs of its patients with advanced diabetes. The implementation of this program would fall into which of the following types of prevention?
One of the first steps in preparing for an organizational accreditation survey Is to have a quality professional
The safety reporting system being used by an organization cannot produce reports or information in a usable format. After evaluating the existing system and other products on the market, which of the following should the quality professional do before making recommendations to leadership?
A quality professional is assessing team performance. Which of the following results would be associated when applying evaluation criteria to assess productivity?
A new urgent care clinic is setting up a quality management system. Which of the following is the bestchoice as a process measure to evaluate effective clinical care?
Which team role is responsible for maintaining improvements after the implementation of a quality initiative?
Priorities must be established for selecting processes for quality improvement because
After a sentinel event, a root cause analysis (RCA) is performed. Which of the following should be included in the RCA?
Which of the following is the best approach tomotivate stakeholders across the care continuum to take action?
The chart shown below is created for a project:
Task 1 → Task 3 (5 days, then 10 days)
Task 2 → Task 4 (10 days, then 8 days)
Task 5 → Task 6 (2 days, then 1 day)
What is the minimum number of days to complete the project?
The most important component of a successful performance improvement program is:
Which of the following should be a part of an organization's program of continuous readiness for accreditation?
Which of the following technology enhancements will help the hospital most accurately identify hospital-acquired condition rates?
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
A program to improve individuals' dietary habits has had success in some neighborhoods but not others. Based on the data (higher poverty and non-English speakers correlate with lower success), what is an approach that would make the program successful in more neighborhoods?
An extended carefacility measures the percent of time a comprehensive exam is completed within 96 hours of admission. This is an example of which of the following types of measure?
Which of the following Is the best approach to prepare care team members tor Interacting with accreditation surveyors?
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 success of performance improvement in an organization depends most on:
An improvement team is presented with the following information and tasked with deciding which improvement methodology would be most appropriate:
Medication Physician Order to Medication Arrival on Unit
Time in Minutes: Median: 45, Average: 44.3, Goal: 30
Staff Comments:
"The process is too complicated.”
"Why do I need to enter the order into two different systems? There are lots of non-value added steps.”
"We are constantly waiting for the medication to be delivered from the pharmacy, which delays patient care. Why can't we access this medication directly on the floor?”
"The pharmacy overproduces this medication in large batches, which goes wasted.”Based on the information available, which of the following methodologies is most appropriate to address the concerns about the 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:
Based on this information, which of the following conclusions is accurate?
An example of a safety practice that allows any worker to speak up when a rule is not being followed is:
Prior to discharge, which of the following provides patient information to improve education for heart failure patients?
Which of the following process improvement training methods would be effective to support a continuous survey readiness program?
Which of the following interventions has the greatest potential for positive impact due to its ability to address social determinants of health?
A hand surgeon is referred for peer review for a case of a wrong-site surgery. Which of the following professionals would be the best choice as a member of the peer review committee?
Which of the following is the best data source to assess an organization’s culture of safety?
An electronic medical records system was implemented in a department. Which of the following is the next step?
Which of the following is the best method of determining improvement priorities to benefit the health of the community?
A pharmacy staff member informs a healthcare quality professional that use of a particularly expensive drug has been increasing over the past six months. Which of the following is the next best step?
A department manager wants to improve customer service. In order to gain employee support, the manager should first
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?
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?
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.
Indicator
Percent of Bonus
Target
Breast Cancer Screening (BCS)
25%
≥74%
Controlling High Blood Pressure (CBP)
25%
≥72%
Childhood Immunization Status (CIS)
50%
≥63%
Provider performance:
Provider
BCS
CBP
CIS
A
75%
71%
63%
B
77%
69%
65%
C
79%
73%
64%
D
73%
74%
62%
Which of the following conclusions is accurate?
Which initiative should a quality professional promote in an organization seeking to optimize value-based reimbursement?
An orthopedic surgery practice has been working on improving patient safety for the last 3 years. The following data table is available:
Which of the following is the most appropriate conclusion about patient safety outcomes?
Even when appropriate processes are in place, errors can occur. Understanding this, leaders coordinating a patient safety program should focus on
Providers in a clinic have the opportunity to earn an incentive based on performance measure results. Based on the table below showing how the incentive is structured and current performance, the providers should focus on which of the following to maximize their incentive?
Measure
Weight
Target
Current Performance
Breast Cancer Screening
30%
70%
70%
Colorectal Cancer Screening
10%
65%
62%
Controlling High Blood Pressure
40%
82%
83%
Childhood Immunization Status
20%
48%
44%
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?
The quality improvement team at a hospital is prioritizing projects that could improve quality of care and reimbursement. Which project should the team prioritize?
Which of the following statements most accurately describes health literacy?
A strategic plan Is developed by making decisions about the future of the organization. Which of the following Is true about the strategic plan?
Care that does not vary in quality because of gender, ethnicity, geographic location, or socioeconomic status is said to be
Which of the following infection prevention techniques represents a human factors engineering solution?
An improvement project was implemented to expand utilization of primary care services in a rural area where only 5% of residents sought primary care. The team established a goal of 20% of residents using primary care. The table below shows the results for the four months following implementation of the improvement:
% Residents Using Primary Care
Time | %
Baseline | 5%
Month 1 | 15%
Month 2 | 20%
Month 3 | 21%
Month 4 | 22%
Which of the following should the quality professional recommend to the organization?
Which of the following best describes how a quality professional should conduct an organizational assessment to ensure safe transitions of care?
Which of the following characteristics best describes a learning organization?
A consistent and effective communication plan for a process improvement initiative facilitates
Evaluating data to determine high utilizers ofemergency departments and their related characteristics is a strategy that can best help with
Which of the following tools should be used to select an option from a group of alternatives?
A healthcare quality professional Is facilitating the establishment of a Quality Council for an outpatient surgery center. The following positions have been selected for membership: medical director, CEO. and CFO. Which of the following Is the most appropriate Individual to add?
TESTED 28 Feb 2026
