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