CPHQ FINAL EXAM QUESTIONS WITH
CORRECT ANSWERS 2025
The term "performance" as used in healthcare quality improvement activities refers to:
A. Interactive series of process steps
B. Statement of expectation
C. Effective execution of functions & processes
D. Demonstration during accreditation survey - CORRECT ANSWER -C
A key physician/licensed independent practitioner QM function is:
A. Determination of what constitutes a deviation from an accepted standard of care
B. Researching criteria options for peer review
C. Determination of data collection methodology
D. Tabulation of peer review data - CORRECT ANSWER -A
Of the following conclusions concerning a licensed independent practitioners care drawn from org QM
/QI activities would most likely be used during:
A. Case management
B. Re-privileging
C. Productivity management
D. Initial privileging - CORRECT ANSWER -B
The most effective way to ensure patient safety as a dimension of performance is to:
A. Sponsor a hotline
B. Focus on processes/minimize blame
C. Encourage patients & families to identify risks
D. Have leaders who commit to & foster a safe culture - CORRECT ANSWER -D
The responsibility to reduce risks of endemic & epidemic healthcare associated infection is vested in:
A. An interdisciplinary team
,B. A qualified infection control practitioner
C. The organization
D. A qualified infection control attending physician - CORRECT ANSWER -C
A trend has developed over the past year indicating that an internal medicine physician has significant
difficulty treating patients with out of control diabetes. After 10 months of peer case review & meeting
s what additional actions may be appropriate?
A. A letter
B. Required consultation for all of the physicians diabetic patients
C. Medical education
D. Summary suspension of privileges - CORRECT ANSWER -B
In any QM approach how can you best evaluate the effectiveness of action taken?
A. Formulate a new special study
B. Interview staff
C. Do nothing
D. Use the same performance measures to remonitor the process - CORRECT ANSWER -D
The Baldrige Healthcare Criteria for Performance Excellence establish standards for:
A. An award
B. Corporate compliance
C. A certification
D. An accreditation - CORRECT ANSWER -A
Based on most QI standards, those responsible to prioritize data collection to monitor org wide perfor
mance are:
A. The Quality Counsel
B. The leaders
C. The most knowledgeable
D. The most experienced - CORRECT ANSWER -B
, The phrase intensive analysis as used in QM/QI :
A. Applies only to peer review
B. Includes all defined sentinel events
C. Is an automatic indication of a problem
D. Means the trigger is never set at 0% - CORRECT ANSWER -B
Occurrence or event reporting is an example of:
A. Generic screening
B. Peer review
C. Root cause analysis
D. Special study - CORRECT ANSWER -A
A surgeon refuses to accept his postop site infection data & high rate for joint cases over the last year.
What additional step may be necessary?
A. Present data to all surgeons
B. Do nothing
C. Have peers review all cases
D. With the medical director show the surgeon the data compared to peers - CORRECT ANSWER -D
A hospital has decided to add indicators to measure performance for 10 diagnoses not previously asse
ssed. How can QM help them prioritize?
A. Provide volume & complication data
B. Just say no
C. Provide cost per case data
D. Provide liability claims data - CORRECT ANSWER -A
In order to resolve scheduling problems in the OR the first task should be to:
A. Write a letter
CORRECT ANSWERS 2025
The term "performance" as used in healthcare quality improvement activities refers to:
A. Interactive series of process steps
B. Statement of expectation
C. Effective execution of functions & processes
D. Demonstration during accreditation survey - CORRECT ANSWER -C
A key physician/licensed independent practitioner QM function is:
A. Determination of what constitutes a deviation from an accepted standard of care
B. Researching criteria options for peer review
C. Determination of data collection methodology
D. Tabulation of peer review data - CORRECT ANSWER -A
Of the following conclusions concerning a licensed independent practitioners care drawn from org QM
/QI activities would most likely be used during:
A. Case management
B. Re-privileging
C. Productivity management
D. Initial privileging - CORRECT ANSWER -B
The most effective way to ensure patient safety as a dimension of performance is to:
A. Sponsor a hotline
B. Focus on processes/minimize blame
C. Encourage patients & families to identify risks
D. Have leaders who commit to & foster a safe culture - CORRECT ANSWER -D
The responsibility to reduce risks of endemic & epidemic healthcare associated infection is vested in:
A. An interdisciplinary team
,B. A qualified infection control practitioner
C. The organization
D. A qualified infection control attending physician - CORRECT ANSWER -C
A trend has developed over the past year indicating that an internal medicine physician has significant
difficulty treating patients with out of control diabetes. After 10 months of peer case review & meeting
s what additional actions may be appropriate?
A. A letter
B. Required consultation for all of the physicians diabetic patients
C. Medical education
D. Summary suspension of privileges - CORRECT ANSWER -B
In any QM approach how can you best evaluate the effectiveness of action taken?
A. Formulate a new special study
B. Interview staff
C. Do nothing
D. Use the same performance measures to remonitor the process - CORRECT ANSWER -D
The Baldrige Healthcare Criteria for Performance Excellence establish standards for:
A. An award
B. Corporate compliance
C. A certification
D. An accreditation - CORRECT ANSWER -A
Based on most QI standards, those responsible to prioritize data collection to monitor org wide perfor
mance are:
A. The Quality Counsel
B. The leaders
C. The most knowledgeable
D. The most experienced - CORRECT ANSWER -B
, The phrase intensive analysis as used in QM/QI :
A. Applies only to peer review
B. Includes all defined sentinel events
C. Is an automatic indication of a problem
D. Means the trigger is never set at 0% - CORRECT ANSWER -B
Occurrence or event reporting is an example of:
A. Generic screening
B. Peer review
C. Root cause analysis
D. Special study - CORRECT ANSWER -A
A surgeon refuses to accept his postop site infection data & high rate for joint cases over the last year.
What additional step may be necessary?
A. Present data to all surgeons
B. Do nothing
C. Have peers review all cases
D. With the medical director show the surgeon the data compared to peers - CORRECT ANSWER -D
A hospital has decided to add indicators to measure performance for 10 diagnoses not previously asse
ssed. How can QM help them prioritize?
A. Provide volume & complication data
B. Just say no
C. Provide cost per case data
D. Provide liability claims data - CORRECT ANSWER -A
In order to resolve scheduling problems in the OR the first task should be to:
A. Write a letter
