CPHQ Practice Test 4 — Questions and Answers
Question 1: A hospital implements a new hand hygiene protocol. Three months later, hand hygiene compliance rates have not improved. Which PDSA phase should the team enter?
- Plan a new intervention without analysis
- Study — analyze why the change failed before acting (Correct answer)
- Act — immediately scale up the protocol
- Do — re-train all staff on the unchanged protocol
Correct answer: Study — analyze why the change failed before acting
The Study phase involves analyzing test results before deciding whether to adopt, adapt, or abandon the change.
Question 2: Which type of hospital-acquired condition (HAC) was designated by CMS as 'Never Events,' meaning it should never occur in healthcare?
- Surgical site infections after elective surgery
- Wrong-site surgery (Correct answer)
- Catheter-associated urinary tract infections
- Pressure ulcers stage II
Correct answer: Wrong-site surgery
Wrong-site surgery is considered a Never Event — a serious preventable patient safety event that should never occur with proper verification protocols.
Question 3: Under HIPAA, which of the following is required when a covered entity discovers a breach of unsecured PHI affecting more than 500 individuals?
- Notify affected individuals only
- Notify HHS and prominent media outlets in the affected area within 60 days (Correct answer)
- Notify the FBI within 24 hours
- File a report with the state attorney general only
Correct answer: Notify HHS and prominent media outlets in the affected area within 60 days
For breaches affecting 500 or more individuals in a state, covered entities must notify HHS and prominent media outlets in the affected area within 60 days of discovery.
Question 4: Which data display tool is best for showing a trend in monthly patient satisfaction scores over a 12-month period?
- Pie chart
- Bar chart
- Run chart (Correct answer)
- Scatter diagram
Correct answer: Run chart
A run chart displays data over time and is ideal for identifying trends, shifts, or cycles in sequential measurements.
Question 5: A quality director wants to prioritize which of 20 patient safety issues to address first. Which tool would BEST help focus improvement efforts on the most impactful issues?
- Affinity diagram
- Pareto chart (Correct answer)
- Control chart
- FMEA
Correct answer: Pareto chart
The Pareto chart applies the 80/20 rule, helping teams identify the vital few causes that contribute to the majority of problems.
Question 6: In the context of accreditation, what does 'tracer methodology' involve?
- Tracking medications from pharmacy to patient
- Following a patient's care experience through the organization to evaluate standards compliance (Correct answer)
- Tracing infection sources in an outbreak investigation
- Auditing supply chain documentation
Correct answer: Following a patient's care experience through the organization to evaluate standards compliance
Tracer methodology, used by The Joint Commission, follows an individual patient's care path through an organization to evaluate adherence to standards.
Question 7: Which chart is used to determine whether a process is in statistical control and can predict future performance?
- Histogram
- Pareto chart
- Control chart (Shewhart chart) (Correct answer)
- Flowchart
Correct answer: Control chart (Shewhart chart)
Control charts display process data over time with upper and lower control limits to distinguish common cause variation from special cause variation.
CPHQ Practice Test 4
A hospital implements a new hand hygiene protocol.
Three months later, hand hygiene compliance rates have not improved.
Which PDSA phase should the team enter?