CPHQ Practice Exam Questions
with Answers
Role of Quality in Credentialing - Answer-1. Input into process
2. Track oversight activities
3. Ensure work is completed
4. Manage quality files for renew and appointment
Focused Professional Practice Evaluation (FPPE) - Answer-Purpose: To demonstrate
competency in delivering safe, effective care
Time limited process for organization to evaluate and confirm current competence for
initially requested privileges
When is FPPE used? - Answer-1. Time of initial appointment to medical staff practice
2. At time new privileges requested to existing provider
3. provide specific issues affecting provision of safe, effective patient care identified
FPPE Categories - Answer-1. patient care
2. medical/ clinical knowledge
3. interpersonal and communication skills
4. professionalism
5. systems based practice
Ongoing Professional Practice Evaluation (OPPE) - Answer-to demonstrate ongoing
competency in delivering safe, effective care
Effective Peer Review Process - Answer-1. confidential and governed by state laws
2. consistent - done according to defined procedures
3.defensible- conclusions reached through process are supported by rationale
4. balanced- minority opinions in views of the person being reviewed are considered
and recorded
Practitioner profiles - Answer-1. used to rack outcomes and manage costs
2. provided to practitioners on regular basis
3. may use software with risk adjusted algorithms
4. used at the time of reappointment to identify practitioner practices during years
between reappointment
,Quality Portion of Practitioner Files - Answer-1. reports of disruptions w/ staff or patients
2. treatment errors
3. mortalities
4. adherences to best practices, policies and procedures and medical staff bylaws
Benefits of Accreditation - Answer-1. Moves the organization toward better quality of
care
2. competitive advantages and community confidence in quality of care, safety,
treatment and services
The Joint Commission (TJC) - Answer-1. Derived status exceeds MC & MA
requirements
2. To receive MC & MA payment, need certification of compliance with conditions of
participation or conditions of coverage
DNV GL - Answer-national integrated accreditation for health care organizations:ISO
9001 standards
accreditation program to accred hospitals
critical access hospitals and aquire ISO 9001 certification y 4th year
ISO - Answer-International organization for standards; voluntary
Healthcare Facilities Accreditation Program (HFAP) - Answer-CMS authorized
organization to survey hospitals on compliance with MC conditions of participation.
Applicable to:
- hospitals and their clinical labs
- ambulatory care/ surgical facilties
- mental health and substance abuse facilities
- physical rehab facilities and clinical labs
CIHQ - Answer-Center for Improvement in Healthcare Quality
- acute care, CAH and membership based organization
- CMS approved deeming authority for acute care hospitals
AAAHC- Accreditation Association for Ambulatory Health Care - Answer-focuses
exclusively on ambulatory; peer review based accreditation program
Magnet Recognition Program - Answer-Recognition by the American Nurses
Credentialing Center that an organization provides quality nursing care.
5 Components to Magnet Recognition - Answer-1. transformational leadership
2. structural empowerment
3. exemplary professional practice
,4. new knowledge, innovation and improvements
5. empirical quality results
National Quality Forum (NQF) - Answer-- voluntary consensus standards setting
organization
- established 34 safety practices to reduce harm
- 1999 to promote and ensure patient protections and healthcare quality through
measurement and public reporting
Leapfrog Group - Answer-A voluntary program aimed at mobilizing employer purchasing
power to alert the U.S. health industry on leaps in healthcare safety, quality, and
customer value so they will be recognized and rewarded. Among other initiatives,
leapfrog works with its employer members to encourage transparency and easy access
to healthcare information as well as providing rewards for hospitals that have a proven
record of high quality care.
Leapfrog Group Leaps - Answer-1. computerized physician order entry
2. evidence based hospital referral
3. ICU physician staffing
4. safe practices score
AHRQ (Agency for Healthcare Research and Quality) - Answer-An agency within the
Department of Health and Human Services charged with improving the quality, safety,
and effectiveness of health care for all Americans.
IHI (Institute for Healthcare Improvement) - Answer-A nonprofit organization dedicated
to leading the improvement of healthcare throughout the world. Its goals include health
care for all with no needless deaths, no needless pain or suffering, no helplessness in
those served or serving, no unwanted waiting, and no waste.
IHI 5 key areas - Answer-1. improve capability
2. person and family centered care
3. patient safety
4. quality, cost and value
5. triple aim for populations ( improve care, improve population health, reduce costs)
World Health Organization (WHO) - Answer-the most widely recognized international
governmental health organization; initiated on 4/7/1948. Goal is to build a better
healthier future for people all over the world .
Main areas of work:
1. health systems
2. promotion and health through life course
3. non-communicable diseases
4. preparedness, surveillance, response
, Quality Information health Leaders - Answer-1. assess process toward mission and
values
2. understand changes in needs, resources and technology
3. develop a vision and evaluation program competencies
4. prioritize strategic goals
5.judge progress toward strategic goals
Culture Committed to Quality - Answer-1. Quality improvement is discussed at the
beginning of meetings and agendas
2. mistakes are opportunities for learning which supports a no blame policy
3. quality measures are found in performance reviews
4. line staff are willing to speak up
5. frontline workers are involved in quality improvement efforts
Characteristics of an organization that supports quality - Answer-1. leadership
involvement and allocation of resources
2. reward for quality focused behaviors
3. involvement in quality improvement activities
4. time and discussion spent on quality improvement activities
5. prevailing quality focused attitude
6. recognition of internal customers
7. reduction of hierarchy
8. creation of a team based organization
9. councils and steering committees
10. agile organization
IOM - Answer-Institute of Medicine;1863 under congressional charter
- national academies of sciences, engineering, medicine health and medicare division
- to err is human and crossing the quality chasm
- building on heritage of IOMS work in medicare while emphasizing increased focus on
wider range of health matters
Donabedian - Answer-first to describe an approach to assess quality through a systems
framework
Structure - Answer--factors affecting context in which healthcare is delivered
- controls how providers and patients in a healthcare system act
- measures the average quality of care within a system
- often easy to measure and observe
Process - Answer-- sum of all actions that make up healthcare
- technical process- how care is delivered
- interpersonal process- manner in which care is delivered
- measurement of process nearly equivalent to measure of quality
Outcome - Answer--Effects of healthcare on patients or populations
with Answers
Role of Quality in Credentialing - Answer-1. Input into process
2. Track oversight activities
3. Ensure work is completed
4. Manage quality files for renew and appointment
Focused Professional Practice Evaluation (FPPE) - Answer-Purpose: To demonstrate
competency in delivering safe, effective care
Time limited process for organization to evaluate and confirm current competence for
initially requested privileges
When is FPPE used? - Answer-1. Time of initial appointment to medical staff practice
2. At time new privileges requested to existing provider
3. provide specific issues affecting provision of safe, effective patient care identified
FPPE Categories - Answer-1. patient care
2. medical/ clinical knowledge
3. interpersonal and communication skills
4. professionalism
5. systems based practice
Ongoing Professional Practice Evaluation (OPPE) - Answer-to demonstrate ongoing
competency in delivering safe, effective care
Effective Peer Review Process - Answer-1. confidential and governed by state laws
2. consistent - done according to defined procedures
3.defensible- conclusions reached through process are supported by rationale
4. balanced- minority opinions in views of the person being reviewed are considered
and recorded
Practitioner profiles - Answer-1. used to rack outcomes and manage costs
2. provided to practitioners on regular basis
3. may use software with risk adjusted algorithms
4. used at the time of reappointment to identify practitioner practices during years
between reappointment
,Quality Portion of Practitioner Files - Answer-1. reports of disruptions w/ staff or patients
2. treatment errors
3. mortalities
4. adherences to best practices, policies and procedures and medical staff bylaws
Benefits of Accreditation - Answer-1. Moves the organization toward better quality of
care
2. competitive advantages and community confidence in quality of care, safety,
treatment and services
The Joint Commission (TJC) - Answer-1. Derived status exceeds MC & MA
requirements
2. To receive MC & MA payment, need certification of compliance with conditions of
participation or conditions of coverage
DNV GL - Answer-national integrated accreditation for health care organizations:ISO
9001 standards
accreditation program to accred hospitals
critical access hospitals and aquire ISO 9001 certification y 4th year
ISO - Answer-International organization for standards; voluntary
Healthcare Facilities Accreditation Program (HFAP) - Answer-CMS authorized
organization to survey hospitals on compliance with MC conditions of participation.
Applicable to:
- hospitals and their clinical labs
- ambulatory care/ surgical facilties
- mental health and substance abuse facilities
- physical rehab facilities and clinical labs
CIHQ - Answer-Center for Improvement in Healthcare Quality
- acute care, CAH and membership based organization
- CMS approved deeming authority for acute care hospitals
AAAHC- Accreditation Association for Ambulatory Health Care - Answer-focuses
exclusively on ambulatory; peer review based accreditation program
Magnet Recognition Program - Answer-Recognition by the American Nurses
Credentialing Center that an organization provides quality nursing care.
5 Components to Magnet Recognition - Answer-1. transformational leadership
2. structural empowerment
3. exemplary professional practice
,4. new knowledge, innovation and improvements
5. empirical quality results
National Quality Forum (NQF) - Answer-- voluntary consensus standards setting
organization
- established 34 safety practices to reduce harm
- 1999 to promote and ensure patient protections and healthcare quality through
measurement and public reporting
Leapfrog Group - Answer-A voluntary program aimed at mobilizing employer purchasing
power to alert the U.S. health industry on leaps in healthcare safety, quality, and
customer value so they will be recognized and rewarded. Among other initiatives,
leapfrog works with its employer members to encourage transparency and easy access
to healthcare information as well as providing rewards for hospitals that have a proven
record of high quality care.
Leapfrog Group Leaps - Answer-1. computerized physician order entry
2. evidence based hospital referral
3. ICU physician staffing
4. safe practices score
AHRQ (Agency for Healthcare Research and Quality) - Answer-An agency within the
Department of Health and Human Services charged with improving the quality, safety,
and effectiveness of health care for all Americans.
IHI (Institute for Healthcare Improvement) - Answer-A nonprofit organization dedicated
to leading the improvement of healthcare throughout the world. Its goals include health
care for all with no needless deaths, no needless pain or suffering, no helplessness in
those served or serving, no unwanted waiting, and no waste.
IHI 5 key areas - Answer-1. improve capability
2. person and family centered care
3. patient safety
4. quality, cost and value
5. triple aim for populations ( improve care, improve population health, reduce costs)
World Health Organization (WHO) - Answer-the most widely recognized international
governmental health organization; initiated on 4/7/1948. Goal is to build a better
healthier future for people all over the world .
Main areas of work:
1. health systems
2. promotion and health through life course
3. non-communicable diseases
4. preparedness, surveillance, response
, Quality Information health Leaders - Answer-1. assess process toward mission and
values
2. understand changes in needs, resources and technology
3. develop a vision and evaluation program competencies
4. prioritize strategic goals
5.judge progress toward strategic goals
Culture Committed to Quality - Answer-1. Quality improvement is discussed at the
beginning of meetings and agendas
2. mistakes are opportunities for learning which supports a no blame policy
3. quality measures are found in performance reviews
4. line staff are willing to speak up
5. frontline workers are involved in quality improvement efforts
Characteristics of an organization that supports quality - Answer-1. leadership
involvement and allocation of resources
2. reward for quality focused behaviors
3. involvement in quality improvement activities
4. time and discussion spent on quality improvement activities
5. prevailing quality focused attitude
6. recognition of internal customers
7. reduction of hierarchy
8. creation of a team based organization
9. councils and steering committees
10. agile organization
IOM - Answer-Institute of Medicine;1863 under congressional charter
- national academies of sciences, engineering, medicine health and medicare division
- to err is human and crossing the quality chasm
- building on heritage of IOMS work in medicare while emphasizing increased focus on
wider range of health matters
Donabedian - Answer-first to describe an approach to assess quality through a systems
framework
Structure - Answer--factors affecting context in which healthcare is delivered
- controls how providers and patients in a healthcare system act
- measures the average quality of care within a system
- often easy to measure and observe
Process - Answer-- sum of all actions that make up healthcare
- technical process- how care is delivered
- interpersonal process- manner in which care is delivered
- measurement of process nearly equivalent to measure of quality
Outcome - Answer--Effects of healthcare on patients or populations
