NAHQ CPHQ 2026 STUDY GUIDE QUESTIONS AND
ANSWERS RATED A+
✔✔A quality improvement manager must decide how to present data that demonstrates
the relationship between two process characteristics. Which of the following data
display techniques is most appropriate? - ✔✔scatter diagram
✔✔The clinical competency of a physician is determined by - ✔✔a committee of peers.
✔✔When conducting a sentinel event review, a root cause analysis - ✔✔identifies gaps
in patient care processes.
✔✔The perception of how an organization operates, including how employees relate to
internal and external customers, is the organizational - ✔✔culture
✔✔Staff has been trained and oriented on a new electronic incident reporting system. In
the past, staff could report anonymously. The new system requires staff to sign in with
an individualized username and password. Three months after implementation, there is
a sharp reduction in the number of reported incidents. Which of the following reasons
for underreporting of incidents is of greatest concern? - ✔✔staff fear of negative
consequences of reporting
✔✔Which of the following should be included in an annual performance improvement
report to a governing body? - ✔✔Team achievements
✔✔A monitoring system is being designed in which data will be collected and compared
to criteria. Which of the following will best enhance the validity and reliability of the
data? - ✔✔providing a practice-based definition and specific instructions for each
element
✔✔Results of physician practice pattern studies are most likely to promote behavior
changes when disseminated to the - ✔✔practitioners
✔✔Human factors engineering is defined as the study of humans and their interaction
with - ✔✔the tools they use and the environment
✔✔The following data has been provided to a healthcare quality professional: Which of
the following is the best choice for beginning clinical-pathways implementation in an
organization? - ✔✔Heart failure
✔✔An outpatient clinic is attempting to measure the quality of a newly developed
diabetes disease management program. To accomplish this, laboratory results will be
measured over time. The best way to display the data is to use a - ✔✔Control chart
, ✔✔A healthcare quality professional has been asked to examine a new method of
reviewing adverse events in an organization. It has been decided that a system of
triggers will be established to alert the Quality Council of a potential problem. The best
example of a trigger that should be set with a threshold of zero is a - ✔✔near miss from
failure to perform a 'time-out.'
✔✔Empowerment gives employees the opportunity to - ✔✔Solve problems
✔✔Comparing healthcare organizations by using medical error rates - ✔✔may present
bias due to differences in reporting practices.
✔✔Which of the following topics are discussed at a morbidity and mortality conference?
- ✔✔healthcare-acquired infections and perioperative mortality
✔✔A patient safety program can best be enhanced by which of the following
technologies? - ✔✔barcode system for medication administration
✔✔A strategy used in brainstorming is that ideas are - ✔✔All recorded
✔✔A health plan is required to have a mechanism for members to submit complaints.
Which of the following actions must be included in the complaint analysis to ensure the
plan makes full use of this type of information? - ✔✔Review complaints to find system
problems that can be improved
✔✔Informed consent for hip surgery was obtained and documented for an elderly
patient. In the recovery room, a nurse discovered the wrong hip had been replaced. A
healthcare quality professional should - ✔✔perform a root cause analysis.
✔✔In managed care, the most widely used performance measures are - ✔✔Healthcare
Effectiveness Data and Information Set (HEDIS).
✔✔Data collected about surgical cases shows significant delays. Further analysis
shows the following chart: Which of the following should a healthcare quality
professional do first? - ✔✔Provide the service chief with further analyses of surgeon-
specific data.
✔✔A critical difference between quality assurance (QA) and quality improvement is a
shift in focus from - ✔✔identifying poor performers to improving group performance
✔✔Problem-solving, cross-functional understanding, expanded areas of expertise, and
increased span of knowledge are examples of - ✔✔the benefits of teams.
ANSWERS RATED A+
✔✔A quality improvement manager must decide how to present data that demonstrates
the relationship between two process characteristics. Which of the following data
display techniques is most appropriate? - ✔✔scatter diagram
✔✔The clinical competency of a physician is determined by - ✔✔a committee of peers.
✔✔When conducting a sentinel event review, a root cause analysis - ✔✔identifies gaps
in patient care processes.
✔✔The perception of how an organization operates, including how employees relate to
internal and external customers, is the organizational - ✔✔culture
✔✔Staff has been trained and oriented on a new electronic incident reporting system. In
the past, staff could report anonymously. The new system requires staff to sign in with
an individualized username and password. Three months after implementation, there is
a sharp reduction in the number of reported incidents. Which of the following reasons
for underreporting of incidents is of greatest concern? - ✔✔staff fear of negative
consequences of reporting
✔✔Which of the following should be included in an annual performance improvement
report to a governing body? - ✔✔Team achievements
✔✔A monitoring system is being designed in which data will be collected and compared
to criteria. Which of the following will best enhance the validity and reliability of the
data? - ✔✔providing a practice-based definition and specific instructions for each
element
✔✔Results of physician practice pattern studies are most likely to promote behavior
changes when disseminated to the - ✔✔practitioners
✔✔Human factors engineering is defined as the study of humans and their interaction
with - ✔✔the tools they use and the environment
✔✔The following data has been provided to a healthcare quality professional: Which of
the following is the best choice for beginning clinical-pathways implementation in an
organization? - ✔✔Heart failure
✔✔An outpatient clinic is attempting to measure the quality of a newly developed
diabetes disease management program. To accomplish this, laboratory results will be
measured over time. The best way to display the data is to use a - ✔✔Control chart
, ✔✔A healthcare quality professional has been asked to examine a new method of
reviewing adverse events in an organization. It has been decided that a system of
triggers will be established to alert the Quality Council of a potential problem. The best
example of a trigger that should be set with a threshold of zero is a - ✔✔near miss from
failure to perform a 'time-out.'
✔✔Empowerment gives employees the opportunity to - ✔✔Solve problems
✔✔Comparing healthcare organizations by using medical error rates - ✔✔may present
bias due to differences in reporting practices.
✔✔Which of the following topics are discussed at a morbidity and mortality conference?
- ✔✔healthcare-acquired infections and perioperative mortality
✔✔A patient safety program can best be enhanced by which of the following
technologies? - ✔✔barcode system for medication administration
✔✔A strategy used in brainstorming is that ideas are - ✔✔All recorded
✔✔A health plan is required to have a mechanism for members to submit complaints.
Which of the following actions must be included in the complaint analysis to ensure the
plan makes full use of this type of information? - ✔✔Review complaints to find system
problems that can be improved
✔✔Informed consent for hip surgery was obtained and documented for an elderly
patient. In the recovery room, a nurse discovered the wrong hip had been replaced. A
healthcare quality professional should - ✔✔perform a root cause analysis.
✔✔In managed care, the most widely used performance measures are - ✔✔Healthcare
Effectiveness Data and Information Set (HEDIS).
✔✔Data collected about surgical cases shows significant delays. Further analysis
shows the following chart: Which of the following should a healthcare quality
professional do first? - ✔✔Provide the service chief with further analyses of surgeon-
specific data.
✔✔A critical difference between quality assurance (QA) and quality improvement is a
shift in focus from - ✔✔identifying poor performers to improving group performance
✔✔Problem-solving, cross-functional understanding, expanded areas of expertise, and
increased span of knowledge are examples of - ✔✔the benefits of teams.
