Free CPHQ practice test

14 questions · 7 domains · about 15 minutes. Pick an answer to see whether you’re right and why.

1. Question 1 of 14 · Quality leadership and integrationIn healthcare quality management, a 'driver diagram' is used to:

   A.Map supply chain logisticsB.Document adverse eventsC.Visually link improvement goals to key drivers and change ideasD.Track regulatory citations
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   Answer: C. Visually link improvement goals to key drivers and change ideas

   A driver diagram is an IHI improvement tool that shows the relationship between the aim, primary drivers, secondary drivers, and specific change ideas—helping teams stay strategically aligned.

2. Question 2 of 14 · Quality leadership and integrationThe concept of 'spread' in healthcare quality improvement refers to:

   A.Infection transmission ratesB.Scaling a successful improvement to other units or organizationsC.The distribution of adverse events across departmentsD.Variance in patient outcomes
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   Answer: B. Scaling a successful improvement to other units or organizations

   Spread is the process of taking a practice tested and proven effective in one setting and intentionally implementing it across other areas to achieve broad impact.

3. Question 3 of 14 · Performance and process improvementA run chart showing a series of 8 or more consecutive data points above or below the median is called:

   A.A random patternB.Common cause variationC.A run or shiftD.A control limit breach
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   Answer: C. A run or shift

   A run of 8 or more consecutive points above or below the median on a run chart is a signal of non-random (special-cause) variation, suggesting a real change has occurred in the process.

4. Question 4 of 14 · Performance and process improvementWhich element is NOT typically included in an FMEA risk priority number (RPN) calculation?

   A.SeverityB.OccurrenceC.DetectionD.Cost of failure
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   Answer: D. Cost of failure

   The RPN in FMEA is calculated by multiplying Severity × Occurrence × Detection, each scored on a 1–10 scale. Cost of failure is not part of the standard FMEA RPN formula.

5. Question 5 of 14 · Population health and care transitionsWhich federal program penalizes hospitals for excess 30-day readmissions in specific conditions?

   A.Hospital Value-Based Purchasing ProgramB.Hospital Readmissions Reduction Program (HRRP)C.Meaningful Use ProgramD.Merit-Based Incentive Payment System (MIPS)
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   Answer: B. Hospital Readmissions Reduction Program (HRRP)

   The HRRP, established by the ACA and administered by CMS, reduces Medicare payments to hospitals with excess readmissions for conditions including heart failure, AMI, pneumonia, COPD, hip/knee replacement, and CABG.

6. Question 6 of 14 · Population health and care transitionsThe 'teach-back' method is used during discharge education to:

   A.Assess physician knowledge of discharge criteriaB.Confirm that patients can explain their care instructions in their own wordsC.Test nursing competency for discharge planningD.Verify completeness of the discharge summary
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   Answer: B. Confirm that patients can explain their care instructions in their own words

   Teach-back asks patients to explain instructions back in their own words—not to test them, but to verify understanding and identify gaps in education that the care team can then address before discharge.

7. Question 7 of 14 · Health data analyticsWhich measure of central tendency is MOST resistant to the effect of extreme outliers?

   A.MeanB.ModeC.MedianD.Range
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   Answer: C. Median

   The median (middle value when data is ordered) is not affected by extreme values, making it more representative of the typical case when a dataset contains outliers—common in healthcare data such as length of stay.

8. Question 8 of 14 · Health data analyticsA hospital's observed-to-expected (O/E) mortality ratio is 0.78. This means:

   A.78% of patients survivedB.The hospital's observed mortality is lower than expected given its patient populationC.The hospital has a 22% mortality rateD.The hospital has more deaths than expected
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   Answer: B. The hospital's observed mortality is lower than expected given its patient population

   An O/E ratio below 1.0 indicates that observed deaths are fewer than expected based on the patients' risk profiles—suggesting better-than-expected performance after adjusting for case mix.

9. Question 9 of 14 · Patient safetyIn the hierarchy of patient safety interventions, which type of action is considered MOST effective and reliable?

   A.Education and trainingB.Policies and proceduresC.Forcing functions and constraints (physical design changes)D.Checklists and reminders
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   Answer: C. Forcing functions and constraints (physical design changes)

   The hierarchy of effectiveness places system-level interventions (forcing functions, constraints, automation, standardization) at the top because they do not rely on human memory or compliance. Education and reminders are considered the weakest, most failure-prone strategies.

10. Question 10 of 14 · Patient safetyIn patient safety event classification, which category describes an event that reached the patient but caused NO harm?

    A.Near missB.Adverse eventC.No Harm eventD.Sentinel event
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    Answer: C. No Harm event

    A No Harm event (also called an 'unsafe condition reached') is one that reached the patient but did not cause harm—either because it was not capable of causing harm or because the patient was fortunate. It provides valuable learning without the severity of an adverse event.

11. Question 11 of 14 · Quality review and accountabilityOngoing Professional Practice Evaluation (OPPE) is designed to:

    A.Replace the credentialing process for new practitionersB.Provide a continuous, data-driven review of each practitioner's performance to inform privilege renewal decisionsC.Investigate specific adverse events on a case-by-case basisD.Audit medical records for documentation completeness only
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    Answer: B. Provide a continuous, data-driven review of each practitioner's performance to inform privilege renewal decisions

    OPPE uses ongoing performance data—volume, outcomes, adherence to evidence-based care—collected at regular intervals (typically every 6–12 months) to monitor each practitioner's competency and guide privilege renewal.

12. Question 12 of 14 · Quality review and accountabilityA hospital's quality committee reviews cases where outcomes varied significantly from expected. This process is called:

    A.Utilization reviewB.Occurrence screening / variance analysisC.Sentinel event reviewD.Discharge planning audit
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    Answer: B. Occurrence screening / variance analysis

    Occurrence screening uses predefined criteria (e.g., unexpected return to OR, unplanned ICU transfer) to systematically identify cases for quality review. Cases meeting criteria are then evaluated for care quality, not assumed to represent an error.

13. Question 13 of 14 · Regulatory and accreditationAn organization that has been granted 'deemed status' by CMS means that:

    A.It is exempt from all state health inspectionsB.Its accreditation by an approved body is accepted as meeting CMS Conditions of ParticipationC.It has achieved Magnet Nursing recognitionD.It qualifies for automatic Level I Trauma designation
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    Answer: B. Its accreditation by an approved body is accepted as meeting CMS Conditions of Participation

    Deemed status means CMS recognizes that accreditation by an approved accrediting organization (e.g., The Joint Commission, DNV, ACHC) demonstrates compliance with Medicare CoPs, waiving routine government surveys.

14. Question 14 of 14 · Regulatory and accreditation'Immediate Jeopardy' in a CMS survey context means:

    A.The organization will be immediately closed by government orderB.Non-compliance has placed or is likely to place patients in serious risk of harm, impairment, or deathC.The organization is under investigation for Medicare fraudD.Survey findings must be reported to the public within 48 hours
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    Answer: B. Non-compliance has placed or is likely to place patients in serious risk of harm, impairment, or death

    Immediate Jeopardy (IJ) is the most serious level of CMS survey finding, triggered when a deficiency has caused or is likely to cause serious injury, harm, impairment, or death. It requires immediate corrective action to avoid termination from Medicare/Medicaid.