CPHQ Certified Professional in Healthcare Quality
CPHQ – CERTIFIED PROFESSIONAL IN HEALTHCARE QUALITY |
VERIFIED EXAM QUESTIONS AND ANSWERS - LATEST VERSION
2026/2027
CERTIFIED PROFESSIONAL IN HEALTHCARE QUALITY (CPHQ)
1. Under CMS Conditions of Participation and accreditation standards,
which body holds ultimate accountability for the quality and safety
of care delivered in a hospital?
A. The chief nursing officer
B. The governing body
C. The quality management department
D. The medical staff executive committee
ANSWER : B. The governing body
The governing body (board) is legally accountable for the QAPI program
and the quality of care; other groups carry out and report on that work.
Page 1 of 64
,CPHQ Certified Professional in Healthcare Quality
2. A quality director is drafting the organization's annual quality plan.
Which element is most essential to include?
A. Detailed operating budgets for each clinical department
B. Individual physician performance profiles
C. Measurable goals aligned with the strategic plan, with defined
accountability and reporting structure
D. A complete list of every policy in the organization
ANSWER : C. Measurable goals aligned with the strategic plan, with
defined accountability and reporting structure
A quality plan should link to strategy, set measurable priorities, and
define who is accountable and how results flow to leadership and the
board.
3. Juran's quality trilogy consists of which three processes?
A. Inspection, correction, and prevention
B. Quality planning, quality control, and quality improvement
C. Structure, process, and outcome
D. Plan, do, and act
ANSWER : B. Quality planning, quality control, and quality
improvement
Juran described quality management as planning, control, and
improvement working together.
4. Which of the following is an example of a structure measure in the
Donabedian model?
A. The ratio of registered nurses to patients on a medical unit
B. Patient satisfaction with pain control
C. 30-day mortality after heart failure admission
D. Percentage of patients receiving written discharge instructions
ANSWER : A. The ratio of registered nurses to patients on a
medical unit
Structure measures describe the setting and resources of care, such as
staffing, equipment, and credentials.
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,CPHQ Certified Professional in Healthcare Quality
5. Which of the following is one of the six aims for improvement
identified in the Institute of Medicine report Crossing the Quality
Chasm?
A. Standardized
B. Profitable
C. Equitable
D. Accessible
ANSWER : C. Equitable
The six aims are safe, effective, patient-centered, timely, efficient, and
equitable.
6. When CMS grants deemed status to an accrediting organization,
what does this mean for a hospital accredited by that organization?
A. The hospital is exempt from all state licensure requirements
B. The hospital can never be subject to a complaint investigation
C. The hospital is deemed to meet the Medicare Conditions of
Participation without a routine state certification survey
D. The hospital no longer needs to report quality measures to CMS
ANSWER : C. The hospital is deemed to meet the Medicare
Conditions of Participation without a routine state certification
survey
Deemed status lets accreditation substitute for routine CMS certification
surveys, although validation and complaint surveys can still occur.
7. After a sentinel event, The Joint Commission expects the
organization to complete a comprehensive systematic analysis and
corrective action plan within what time frame?
A. 30 calendar days of the patient's discharge
B. 45 business days of the event or of becoming aware of it
C. 10 calendar days of the event
D. 90 business days of the event
ANSWER : B. 45 business days of the event or of becoming aware of
it
The Sentinel Event Policy expects the analysis and action plan within 45
business days.
Page 3 of 64
, CPHQ Certified Professional in Healthcare Quality
8. What is usually the first step in developing a strategic quality plan?
A. Writing department-level policies
B. Selecting improvement team members
C. Conducting an environmental assessment such as a SWOT analysis
D. Purchasing quality management software
ANSWER : C. Conducting an environmental assessment such as a
SWOT analysis
An environmental scan identifies internal strengths and weaknesses and
external opportunities and threats that shape priorities.
9. Which statement best describes an organization's vision?
A. A description of the desired future state the organization is working
toward
B. The organization's current reason for existing and whom it serves
C. The rules that govern employee conduct
D. A list of measurable objectives for the coming year
ANSWER : A. A description of the desired future state the
organization is working toward
Vision describes the aspirational future; the mission states current
purpose.
10. The balanced scorecard evaluates organizational performance from
which four perspectives?
A. Structure, process, outcome, and satisfaction
B. Financial, customer, internal business process, and learning and
growth
C. Safety, quality, cost, and access
D. Plan, do, study, and act
ANSWER : B. Financial, customer, internal business process, and
learning and growth
Kaplan and Norton's balanced scorecard links strategy to measures
across these four perspectives.
Page 4 of 64
CPHQ – CERTIFIED PROFESSIONAL IN HEALTHCARE QUALITY |
VERIFIED EXAM QUESTIONS AND ANSWERS - LATEST VERSION
2026/2027
CERTIFIED PROFESSIONAL IN HEALTHCARE QUALITY (CPHQ)
1. Under CMS Conditions of Participation and accreditation standards,
which body holds ultimate accountability for the quality and safety
of care delivered in a hospital?
A. The chief nursing officer
B. The governing body
C. The quality management department
D. The medical staff executive committee
ANSWER : B. The governing body
The governing body (board) is legally accountable for the QAPI program
and the quality of care; other groups carry out and report on that work.
Page 1 of 64
,CPHQ Certified Professional in Healthcare Quality
2. A quality director is drafting the organization's annual quality plan.
Which element is most essential to include?
A. Detailed operating budgets for each clinical department
B. Individual physician performance profiles
C. Measurable goals aligned with the strategic plan, with defined
accountability and reporting structure
D. A complete list of every policy in the organization
ANSWER : C. Measurable goals aligned with the strategic plan, with
defined accountability and reporting structure
A quality plan should link to strategy, set measurable priorities, and
define who is accountable and how results flow to leadership and the
board.
3. Juran's quality trilogy consists of which three processes?
A. Inspection, correction, and prevention
B. Quality planning, quality control, and quality improvement
C. Structure, process, and outcome
D. Plan, do, and act
ANSWER : B. Quality planning, quality control, and quality
improvement
Juran described quality management as planning, control, and
improvement working together.
4. Which of the following is an example of a structure measure in the
Donabedian model?
A. The ratio of registered nurses to patients on a medical unit
B. Patient satisfaction with pain control
C. 30-day mortality after heart failure admission
D. Percentage of patients receiving written discharge instructions
ANSWER : A. The ratio of registered nurses to patients on a
medical unit
Structure measures describe the setting and resources of care, such as
staffing, equipment, and credentials.
Page 2 of 64
,CPHQ Certified Professional in Healthcare Quality
5. Which of the following is one of the six aims for improvement
identified in the Institute of Medicine report Crossing the Quality
Chasm?
A. Standardized
B. Profitable
C. Equitable
D. Accessible
ANSWER : C. Equitable
The six aims are safe, effective, patient-centered, timely, efficient, and
equitable.
6. When CMS grants deemed status to an accrediting organization,
what does this mean for a hospital accredited by that organization?
A. The hospital is exempt from all state licensure requirements
B. The hospital can never be subject to a complaint investigation
C. The hospital is deemed to meet the Medicare Conditions of
Participation without a routine state certification survey
D. The hospital no longer needs to report quality measures to CMS
ANSWER : C. The hospital is deemed to meet the Medicare
Conditions of Participation without a routine state certification
survey
Deemed status lets accreditation substitute for routine CMS certification
surveys, although validation and complaint surveys can still occur.
7. After a sentinel event, The Joint Commission expects the
organization to complete a comprehensive systematic analysis and
corrective action plan within what time frame?
A. 30 calendar days of the patient's discharge
B. 45 business days of the event or of becoming aware of it
C. 10 calendar days of the event
D. 90 business days of the event
ANSWER : B. 45 business days of the event or of becoming aware of
it
The Sentinel Event Policy expects the analysis and action plan within 45
business days.
Page 3 of 64
, CPHQ Certified Professional in Healthcare Quality
8. What is usually the first step in developing a strategic quality plan?
A. Writing department-level policies
B. Selecting improvement team members
C. Conducting an environmental assessment such as a SWOT analysis
D. Purchasing quality management software
ANSWER : C. Conducting an environmental assessment such as a
SWOT analysis
An environmental scan identifies internal strengths and weaknesses and
external opportunities and threats that shape priorities.
9. Which statement best describes an organization's vision?
A. A description of the desired future state the organization is working
toward
B. The organization's current reason for existing and whom it serves
C. The rules that govern employee conduct
D. A list of measurable objectives for the coming year
ANSWER : A. A description of the desired future state the
organization is working toward
Vision describes the aspirational future; the mission states current
purpose.
10. The balanced scorecard evaluates organizational performance from
which four perspectives?
A. Structure, process, outcome, and satisfaction
B. Financial, customer, internal business process, and learning and
growth
C. Safety, quality, cost, and access
D. Plan, do, study, and act
ANSWER : B. Financial, customer, internal business process, and
learning and growth
Kaplan and Norton's balanced scorecard links strategy to measures
across these four perspectives.
Page 4 of 64
