CPHQ TEST PAPER 2025/2026 QUESTIONS AND SOLUTION
RATED A+
✔✔o Seven key elements; start with leading change to anchoring change
o Assess readiness and develop strategies to move toward readiness and "go" -
✔✔Palmer Change Model
✔✔o Five stage model
o Progress and revert at any time
o Not a linear model various stages of change accept as is - ✔✔DeWeaver and
Gillespie Change Model
✔✔o Strong appreciation for human side
o 10 stage model strategically or grassroots driven - ✔✔Galpin's Human Side of
Change Model
✔✔o Ensure people fully accept change
o Incorporate change into their belief system
o Change is associated with the heart and emotions - ✔✔Kotter's Heart of Change
Model
✔✔o Integrates individual behavioral change with organizational change
o Six stages indicate individual's readiness to change behavior rather than process
change
o Works well with patients, individual staff members and providers - ✔✔Prochaska's
Transitional Model
✔✔o Narrow focus
o My way or the highway
o Short term outcomes - ✔✔Barrier to system change: Autocratic view
✔✔o Unsure of ability to relearn new
concepts, principles and
procedures - ✔✔Barrier to system change: Failure to adapt
✔✔o Superficial or weak solutions
about difficult problems
o Problems still exist - ✔✔Barrier to system change: Weak consensus
✔✔o Nurse/doctor vs system and
solution - ✔✔Barrier to system change: Identification with role rather than purpose
✔✔o Us vs them
,o Closed to change - ✔✔Barrier to system change: Feelings of victimization
✔✔o Already tried before
o New direction requires new
solutions - ✔✔Barrier to system change: Relying too heavily on past
✔✔A physician who has a high mortality rate compared to others in a facility should
first be:
A. Counseled by the department chairperson
B. Evaluated by the ongoing professional practice evaluation (OPPE) and focused
professional
evaluation (FPPE) committee
C. Suspended until further action can be determined in the interest of patient safety
D. Subjected to more in depth review of cases - ✔✔D. Subjected to more in depth
review of cases
✔✔To decrease costs, the hospital has hired outside consultants to perform many of its
tasks. There are concerns the performance of many of the consultants does not meet
the state's standards for the hospital's operation. What is the healthcare professional's
role in this situation?
A. Create simulated activities to test the consultants and see if they are meeting the
standards
B. Develop educational programs to assist the consultants and ensure the standards
are met
C. Supply the consultants with information about state standards and ensure full
compliance
D. Review activities of the consultants and report the results to the hospital
administration - ✔✔D. Review activities of the consultants and report the results to the
hospital administration
✔✔Which of the following should be included in an annual report to the governing
body?
A. Meeting minutes
B. Team achievements
C. Incident/occurrence reports
D. Physician peer reviews - ✔✔B. Team achievements
✔✔Aside from the Chief Compliance Officer, who else might be responsible to establish
and oversee processes to prevent or identify inaccurate billing practices or misbehavior
that might result in errors being investigated as fraudulent practice?
A. Chief Financial Officer and Chief Operations Officer
B. Quality Professional and Risk Management Professional
C. Chief Executive Office and Chief Medical Officer - ✔✔B. Quality Professional and
Risk Management Professional
,✔✔The activities of the Quality Improvement Organization (QIO) are known as the
SoW, which stands for:
A. Solicitation of Work
B. Scope of Work
C. Subcontract of Work - ✔✔B. Scope of Work
✔✔The purpose of developing a corrective action plan is to:
A. Keep a record of actions
B. Provide a reference point to look back on changes
C. Will solve all problems associated with a survey issues
D. Helps evaluate if changes are successful
E. Promotes program improvement
F. A, B, D and E only - ✔✔F. A, B, D and E only
✔✔The primary purpose of
an emergency preparedness program is to
A. Conduct evaluations of emergency training
B. Provide evaluations of semiannual evacuation drills
C. Prevent internal disasters that disrupt the facility's ability to provide care and
treatment
D. Manage the consequences of disasters that disrupt the facility's ability to provide
care - ✔✔D. Manage the consequences of disasters that disrupt the facility's ability to
provide care
✔✔Pharmacy and nursing are having difficulty developing an action plan for medication
errors. Pharmacy states nursing causes most of the problems related to errors ; nursing
states the opposite. What is the quality professional's role in this situation?
A. Provide them with directives on how to solve the problem
B. Facilitate discussion between the groups to enable them to assume ownership of
their portions of the problem
C. Assign the task to an uninvolved manager
D. Refer the problem to the facility wide quality council - ✔✔B. Facilitate discussion
between the groups to enable them to assume ownership of their portions of the
problem
✔✔A hospital has implemented a quality program to improve the overall quality of
patient care. The program is running over budget, so the board conducts a review of the
program to see if it should continue. What is the quality professional's role in this?
A. Prove to the administrative board the quality program should continue in the hospital
B. Assist the board in making a final decision about the quality program
C. Create a committee to review the quality program and develop a list of reasons to
keep it
D. Evaluate the financial benefits of the program and demonstrate these to the board -
✔✔D. Evaluate the financial benefits of the program and demonstrate these to the
board
, ✔✔Which of the following processes is most
cost effective in preventing unnecessary
resource consumption in the hospital?
A. Effective preadmission screening
B. Accurate DRG assignment at admission
C. Second opinions for all surgeries
D. Preadmission insurance benefit denials - ✔✔A. Effective preadmission screening
✔✔What are the reasons for evaluating the results of quality improvement training?
A. To improve future training
B. To determine whether participants' and organization's needs were met
C. To determine whether current training should be continued
D. All the above - ✔✔D. All the above
✔✔Volatility in nursing workload is less likely to be reported than other sources of waste
because:
A. Nurses are unlikely to complain
B. It can only be perceived using advanced metrics
C. It is less observable
D. It takes place infrequently - ✔✔C. It is less observable
✔✔The primary reason to analyze customer satisfaction surveys is to:
A. Provide data for the quality improvement program
B. Meet pay for performance requirements
C. Identify how perceptions relate to services provided
D. Assist with evaluation of employee performance - ✔✔C. Identify how perceptions
relate to services provided
✔✔One important driver of patient dissatisfaction in health care over the past
decade has been:
A. Introduction of online services
B. Lack of communication between physicians and patients
C. Rise in income inequality
D. Improvement of customer care in other service industries - ✔✔A. Introduction of
online services
✔✔Health Care Impact from this Federal Regulation:
•Hospitals participating in Medicare and offering emergency services must provide a
medical screening exam when requested for examination/treatment for emergency
medical condition (EMC), including active labor, regardless of patient's ability to pay
•Hospital is required to provide stabilizing treatment for patients with EMC's
•If hospital is unable to stabilize a patient or request is made to transfer, appropriate
transfer will be implemented - ✔✔Emergency Medical Treatment and Active
Labor Act (EMTALA)
RATED A+
✔✔o Seven key elements; start with leading change to anchoring change
o Assess readiness and develop strategies to move toward readiness and "go" -
✔✔Palmer Change Model
✔✔o Five stage model
o Progress and revert at any time
o Not a linear model various stages of change accept as is - ✔✔DeWeaver and
Gillespie Change Model
✔✔o Strong appreciation for human side
o 10 stage model strategically or grassroots driven - ✔✔Galpin's Human Side of
Change Model
✔✔o Ensure people fully accept change
o Incorporate change into their belief system
o Change is associated with the heart and emotions - ✔✔Kotter's Heart of Change
Model
✔✔o Integrates individual behavioral change with organizational change
o Six stages indicate individual's readiness to change behavior rather than process
change
o Works well with patients, individual staff members and providers - ✔✔Prochaska's
Transitional Model
✔✔o Narrow focus
o My way or the highway
o Short term outcomes - ✔✔Barrier to system change: Autocratic view
✔✔o Unsure of ability to relearn new
concepts, principles and
procedures - ✔✔Barrier to system change: Failure to adapt
✔✔o Superficial or weak solutions
about difficult problems
o Problems still exist - ✔✔Barrier to system change: Weak consensus
✔✔o Nurse/doctor vs system and
solution - ✔✔Barrier to system change: Identification with role rather than purpose
✔✔o Us vs them
,o Closed to change - ✔✔Barrier to system change: Feelings of victimization
✔✔o Already tried before
o New direction requires new
solutions - ✔✔Barrier to system change: Relying too heavily on past
✔✔A physician who has a high mortality rate compared to others in a facility should
first be:
A. Counseled by the department chairperson
B. Evaluated by the ongoing professional practice evaluation (OPPE) and focused
professional
evaluation (FPPE) committee
C. Suspended until further action can be determined in the interest of patient safety
D. Subjected to more in depth review of cases - ✔✔D. Subjected to more in depth
review of cases
✔✔To decrease costs, the hospital has hired outside consultants to perform many of its
tasks. There are concerns the performance of many of the consultants does not meet
the state's standards for the hospital's operation. What is the healthcare professional's
role in this situation?
A. Create simulated activities to test the consultants and see if they are meeting the
standards
B. Develop educational programs to assist the consultants and ensure the standards
are met
C. Supply the consultants with information about state standards and ensure full
compliance
D. Review activities of the consultants and report the results to the hospital
administration - ✔✔D. Review activities of the consultants and report the results to the
hospital administration
✔✔Which of the following should be included in an annual report to the governing
body?
A. Meeting minutes
B. Team achievements
C. Incident/occurrence reports
D. Physician peer reviews - ✔✔B. Team achievements
✔✔Aside from the Chief Compliance Officer, who else might be responsible to establish
and oversee processes to prevent or identify inaccurate billing practices or misbehavior
that might result in errors being investigated as fraudulent practice?
A. Chief Financial Officer and Chief Operations Officer
B. Quality Professional and Risk Management Professional
C. Chief Executive Office and Chief Medical Officer - ✔✔B. Quality Professional and
Risk Management Professional
,✔✔The activities of the Quality Improvement Organization (QIO) are known as the
SoW, which stands for:
A. Solicitation of Work
B. Scope of Work
C. Subcontract of Work - ✔✔B. Scope of Work
✔✔The purpose of developing a corrective action plan is to:
A. Keep a record of actions
B. Provide a reference point to look back on changes
C. Will solve all problems associated with a survey issues
D. Helps evaluate if changes are successful
E. Promotes program improvement
F. A, B, D and E only - ✔✔F. A, B, D and E only
✔✔The primary purpose of
an emergency preparedness program is to
A. Conduct evaluations of emergency training
B. Provide evaluations of semiannual evacuation drills
C. Prevent internal disasters that disrupt the facility's ability to provide care and
treatment
D. Manage the consequences of disasters that disrupt the facility's ability to provide
care - ✔✔D. Manage the consequences of disasters that disrupt the facility's ability to
provide care
✔✔Pharmacy and nursing are having difficulty developing an action plan for medication
errors. Pharmacy states nursing causes most of the problems related to errors ; nursing
states the opposite. What is the quality professional's role in this situation?
A. Provide them with directives on how to solve the problem
B. Facilitate discussion between the groups to enable them to assume ownership of
their portions of the problem
C. Assign the task to an uninvolved manager
D. Refer the problem to the facility wide quality council - ✔✔B. Facilitate discussion
between the groups to enable them to assume ownership of their portions of the
problem
✔✔A hospital has implemented a quality program to improve the overall quality of
patient care. The program is running over budget, so the board conducts a review of the
program to see if it should continue. What is the quality professional's role in this?
A. Prove to the administrative board the quality program should continue in the hospital
B. Assist the board in making a final decision about the quality program
C. Create a committee to review the quality program and develop a list of reasons to
keep it
D. Evaluate the financial benefits of the program and demonstrate these to the board -
✔✔D. Evaluate the financial benefits of the program and demonstrate these to the
board
, ✔✔Which of the following processes is most
cost effective in preventing unnecessary
resource consumption in the hospital?
A. Effective preadmission screening
B. Accurate DRG assignment at admission
C. Second opinions for all surgeries
D. Preadmission insurance benefit denials - ✔✔A. Effective preadmission screening
✔✔What are the reasons for evaluating the results of quality improvement training?
A. To improve future training
B. To determine whether participants' and organization's needs were met
C. To determine whether current training should be continued
D. All the above - ✔✔D. All the above
✔✔Volatility in nursing workload is less likely to be reported than other sources of waste
because:
A. Nurses are unlikely to complain
B. It can only be perceived using advanced metrics
C. It is less observable
D. It takes place infrequently - ✔✔C. It is less observable
✔✔The primary reason to analyze customer satisfaction surveys is to:
A. Provide data for the quality improvement program
B. Meet pay for performance requirements
C. Identify how perceptions relate to services provided
D. Assist with evaluation of employee performance - ✔✔C. Identify how perceptions
relate to services provided
✔✔One important driver of patient dissatisfaction in health care over the past
decade has been:
A. Introduction of online services
B. Lack of communication between physicians and patients
C. Rise in income inequality
D. Improvement of customer care in other service industries - ✔✔A. Introduction of
online services
✔✔Health Care Impact from this Federal Regulation:
•Hospitals participating in Medicare and offering emergency services must provide a
medical screening exam when requested for examination/treatment for emergency
medical condition (EMC), including active labor, regardless of patient's ability to pay
•Hospital is required to provide stabilizing treatment for patients with EMC's
•If hospital is unable to stabilize a patient or request is made to transfer, appropriate
transfer will be implemented - ✔✔Emergency Medical Treatment and Active
Labor Act (EMTALA)
