[2026] Use Valid New CPHQ Test Notes & CPHQ Valid Exam Guide [Q412-Q427]

Posted On October 12, 2026

[2026] Use Valid New CPHQ Test Notes & CPHQ Valid Exam Guide

CPHQ Actual Questions Answers PDF 100% Cover Real Exam Questions

NAHQ CPHQ Certification Exam is designed to assess the knowledge and skills of healthcare professionals who are responsible for ensuring the quality of healthcare services. CPHQ exam covers a wide range of topics including healthcare delivery systems, performance measurement and improvement, patient safety, risk management, and healthcare regulations and standards.

Q412. Weighting of scores is frequently recommended if members of a (patients) population have unequal probabilities of being selected for the sample. If necessary, weights are assigned to the different observations to provide a representation picture of the total population.
Weighting should be considered when

An equal distribution of patients exists by discharge service, nursing unit, or clinic

An unequal distribution of patients exists by discharge service, nursing unit, or clinic

An unequal distribution of patients exists by laboratories

An equal distribution of patients exists by ICUs

Q413. A performance improvement specialist at an ambulatory surgery center is facilitating a Plan-Do-Study-Act Cycle (PDSA) process to improve the rate of hand hygiene amongst surgical post-recovery staff to 90% or above. Data from the past 12 months are as follows:
Baseline: 60% compliance
Q1: 87% compliance
Q2: 79% compliance
Q3: 91% compliance
Q4: 72% compliance
The specialist is preparing to discuss aggregate results with the Quality Committee. To most accurately convey the results, the specialist highlights the

lack of overall change over the past 12 months indicates the process was unsuccessful.

contributing factors to the variation in results over the past 12 months.

sharp and consistent decline in results over the past 12 months.

overall improvement over the past 12 months.

Q414. When continuing unique events, one uses a p-chart. The number plotted on a chart would be either a proportion or a percentage. When counting total events (e.g., the number of falls per patient day each month), one plots a ratio on a u-chart. Examples of attributes data plotted as percentage on p-charts include figures such as:

Percentage of patients who died

Percentage of visits by every patient

Percentage of scripts that had one or more medication errors

Percentage of patients discharged

Q415. A healthcare quality professional is charged with facilitating a team. The goal of the team is to develop criteria for levels of care in behavioral/mental health. Which of the following is the most important characteristic of the facilitator?

ability to select team members

knowledge of behavioral/mental health

ability to moderate a work group

knowledge of levels of care

Q416. A quality professional’s key role in a performance improvement team is to serve as a:

Process owner

Decision maker

Group facilitator

Clinical champion

Q417. Which of the following Is true of a clinical pathway?

depicted using a value stream map

limited to one patient care setting

used to reduce variations in care

required for accountable care organizations

Q418. Physician quality data reports for all credentialed physicians disseminated at regular Intervals, as generally mandated by accreditation standards, are called

focused professional practice evaluation (FPPE).

CMS star ratings.

quality spot checks.

ongoing professional practice evaluation (OPPE).

Physician quality data reports for all credentialed physicians disseminated at regular intervals, as generally mandated by accreditation standards, are referred to as ongoing professional practice evaluation (OPPE).
* Ongoing Professional Practice Evaluation (OPPE): OPPE is a continuous evaluation of a provider’s performance at a frequency greater than every 12 months1. It involves a peer review process, where practitioners are reviewed by other practitioners of the same discipline and have personal knowledge of the applicant2. The purpose of OPPE is to ensure that the hospital, through the activities of its medical staff, assesses a practitioner’s clinical competence and professional behavior on an ongoing basis3.
* Focused Professional Practice Evaluation (FPPE): FPPE is a process whereby the medical staff evaluates the privilege-specific competence of the practitioner that lacks documented evidence of competently performing the requested privilege(s) at the organization4. It is not a regular, ongoing process, but rather is implemented whenever a question arises regarding a practitioner’s ability to provide safe, high-quality patient care5.
* CMS Star Ratings: The CMS Star Ratings system is a consumer-oriented system developed by the Centers for Medicare & Medicaid Services (CMS) to help consumers compare the quality of health and drug plans67. It is not a regular report disseminated for all credentialed physicians.
* Quality Spot Checks: Quality spot checks refer to a random inspection or review of a specific aspect or area within a company’s operations8. They are often used to monitor quality control, identify fraud, or ensure adherence to regulations. However, they are not specifically related to physician quality data reports910.
Therefore, the correct answer is D. ongoing professional practice evaluation (OPPE), as it best fits the description of physician quality data reports for all credentialed physicians disseminated at regular intervals, as generally mandated by accreditation standards.

Q419. After discharge, most patients with a mental health diagnosis have not been compliant with follow-up visits.
Which of the following Is the best way to Improve patient compliance?

Benchmark with other facilitiesinthe area to determine the rate of patient compliance.

Include handoutsinthe discharge documents on the Importance of keeping follow-up appointments.

Initiate a process where the discharge planners call patients prior to the follow-up visit

Communicate to noncompliant patients that appointments should be kept.

* According to the National Association for Healthcare Quality (NAHQ), one of the core competencies of healthcare quality professionals is patient safety, which includes ensuring effective transitions of care and reducing preventable readmissions12.
* One of the strategies to achieve this goal is to improve patient compliance with follow-up visits, which can help monitor patient outcomes, prevent complications, and provide continuity of care34.
* Among the four options given, the best way to improve patient compliance is to initiate a process where the discharge planners call patients prior to the follow-up visit. This is because:
* A phone call can serve as a reminder for the patient to keep the appointment, as well as an opportunity to address any barriers or concerns that the patient may have34.
* A phone call can also help establish rapport and trust between the patient and the discharge planner, which can increase patient satisfaction and adherence4.
* A phone call can also allow the discharge planner to confirm the patient’s understanding of the discharge instructions, medication regimen, and follow-up plan, and to provide any additional education or support that the patient may need34.
* The other options are less effective because:
* Benchmarking with other facilities in the area to determine the rate of patient compliance may provide some insight into the current performance and best practices, but it does not directly address the specific needs and preferences of the individual patient5.
* Including handouts in the discharge documents on the importance of keeping follow-up appointments may increase the patient’s awareness and knowledge, but it may not be sufficient to motivate the patient to act on the information, especially if the patient has low health literacy, cognitive impairment, or mental health issues.
* Communicating to noncompliant patients that appointments should be kept may sound authoritative and judgmental, which may alienate the patient and reduce their willingness to cooperate. Instead, a patient-centered and empathetic approach that acknowledges the patient’s challenges and preferences may be more effective. References: 1: [NAHQ Code of Ethics] 2:
[NAHQ HQ Principles] 3: The Importance of Patient Follow-Up | MagMutual 4: The Importance of Patient Follow-Up and Service Recovery 5: [The Financial Case for Quality as a Business Strategy] : [Utilization of Improvement Methodologies by Healthcare Quality Professionals During the COVID-19 Pandemic] : [Understanding the Evolving Landscape of Healthcare Quality] : https://nahq.org/about-nahq/code-of-ethics/ : https://nahq.org/products/hq-principles/ :
https://nahq.org/resources/the-financial-case-for-quality-as-a-business-strategy-2/ :
https://nahq.org/resources/journal-for-healthcare-quality/utilization-of-improvement-methodologies-
1: https://nahq.org/news-media/news/understanding-the-evolving-landscape-of-healthcare-quality/

Q420. The problem with using readily available, convenient data is that the data usually do a poor job of answering the questions necessary to access performance. Ten years ago this “good enough” approach to data collection might have been acceptable. Today, however, because of the increasing demand to demonstrate effectiveness of care and efficiency of healthcare processes, this mind set is not acceptable. Performance quality and excellence do not occur because organizations do what they have always done or what is convenient.
Most healthcare observers agree that:

Specific measures should not be used in data collection

Industry does not need perpetuation of status quo

Quality improvement efforts definitely end up with a positive result

Once you have resolved the issues, the data collection should go smoothly

Q421. An employee health program includes a pre-employment health assessment for all prospective employees.
The assessment is to be completed, and the results known prior to the assumption of duties. A retrospective study of 200 employees resulted in the information displayed in the following chart:

Review of this information indicates which of the following?

A significant number of terminations resulted from lack of completion of health assessments.

There is no problem since approximately 35% of health assessments are completed within 4 weeks of employment.

The provider is in significant compliance with the program.

Approximately 95% failed to meet the stated objectives.

Q422. A program to improve individuals’ dietary habits has had success in some neighborhoods but not others.
Based on the data (higher poverty and non-English speakers correlate with lower success), what is an approach that would make the program successful in more neighborhoods?

Increase efforts to disseminate program information at senior centers.

Distribute vouchers to subsidize the cost of healthy food.

Hire dieticians to specifically reach out to adults who have not completed college.

Make program-related information available in common languages spoken.

Q423. An organization Is tracking Infection rates to determine the benchmarks for the next fiscal year. The team Is analyzing the data for Infection rates. Which key variables are missing to interpret the graph?

the standardized infection ratio for the previous year and denominator for each measure

the timeframe for each data point and the source (or the target line

the mode of the data points and expected rate for external hospitals

the quality of patients and hospital compliance with handwashing

Q424. A provider’s Ongoing Professional Practice Evaluation (OPPE) profile is shown below. In this organization, if a provider partially meets or does not meet performance expectations, they are referred to peer review for a Focused Professional Practice Evaluation (FPPE).
Fully Meets: >80% of measures at threshold
Meets: 65% to 80% of measures at threshold
Partially Meets: 40% to 64% of measures threshold
Does Not Meet: <40% of measures at threshold

After reviewing this provider’s overall profile, what should the healthcare quality professional suggest?

The provider fully meets expectations; do nothing.

The provider does not meet expectations; refer to peer review.

The provider partially meets expectations; retain privileges.

The provider meets expectations; retain privileges.

Q425. An organization has compiled the scatter plots below:

Based on these plots, which of the following conclusions can be made by the quality professional?

Setting 2 has a significant correlation between complication rate and time to positive outcome.

Complication rates are not causing longer time to positive outcome at setting 2.

Setting 1 has a strong positive correlation between complication rate and time to positive outcome.

Complication rates are causing longer time to positive outcome at settling 1.

A scatter plot is a graphical tool that shows the relationship between two continuous variables by plotting data points at their corresponding values on the x-axis and y-axis1.
To interpret a scatter plot, we need to look at the direction, strength, and shape of the relationship between the variables2.
The direction of the relationship indicates whether the variables tend to increase or decrease together (positive correlation) or in opposite directions (negative correlation).
The strength of the relationship indicates how closely the data points cluster around a line or curve that best fits the data. A common measure of the strength of the linear relationship is the correlation coefficient , which ranges from -1 to 1. The closer the absolute value of R is to 1, the stronger the linear relationship2.
The shape of the relationship indicates whether the data points follow a straight line (linear relationship) or a curved pattern (nonlinear relationship).
Based on these criteria, we can analyze the scatter plots for Setting 1 and Setting 2 as follows: Setting 1:
The scatter plot shows a clear upward trend, indicating a positive correlation between complication rate and time to positive outcome. The data points are tightly clustered around a line, indicating a strong linear relationship. The R^2 value of 0.9533 on the plot is close to 1, which means that the linear model explains 95.33% of the variation in the complication rate. Therefore, we can conclude that Setting 1 has a strong positive correlation between complication rate and time to positive outcome.
Setting 2: The scatter plot shows a scattered pattern, indicating a weak or no correlation between complication rate and time to positive outcome. The data points are widely spread around a line, indicating a weak linear relationship. The R^2 value of 0.4923 on the plot is far from 1, which means that the linear model explains only 49.23% of the variation in the complication rate. Therefore, we cannot conclude that Setting 2 has a significant correlation between complication rate and time to positive outcome, or that complication rates are causing longer time to positive outcome at setting 2.
Reference: 1: 8.8 Scatter Plots, Correlation, and Regression Lines 2: Scatterplots: Using, Examples, and Interpreting

Q426. Which of the following is an example of a social determinant of health used to monitor a quality improvement initiative?

diabetes status

race

age

neighborhood

Q427. Through ___________ the data collection staff can spot patient trends as they develop rather than receive the information after the patient have been discharged.
For instance, the incidence of ventilator-associated pneumonia sooner, or it may spot an increase in the rate of aspiration in stroke patients as it occurs.

Medical record review (Retrospective)

Prospective chart review

Data collection forms

Scanners