Quality Leadership & Integration
15%of exam
Performance & Process Improvement
22%of exam
Population Health & Care Transitions
9%of exam
Health Data Analytics
21%of exam
Control ChartsRun-Chart RulesStatisticsBenchmarking
Patient Safety
14%of exam
Quality Review & Accountability
13%of exam
Regulatory & Accreditation
6%of exam
Quick Facts
- Exam
- CPHQ
- Body
- HQCC / NAHQ
- Questions
- 140 (125 scored)
- Time
- 3 hours
- Pass score
- 600 / 800 scaled
- Format
- PSI center or online
- Retake wait
- 14 days
- Blueprint
- 2024 Outline R2b
Domain Weight Order
Improve and Analytics lead; Regulatory lags most
Improve = 22% biggestAnalytics = 21%Leadership = 15%Regulatory = 6% smallest
Strategic Planning
- Quality plan
- Organization-wide roadmap
- Governance
- Oversight structure
- Business case
- Justify the investment
- Quality council
- Leadership steering committee
- Gap analysis
- Current vs target state
Stakeholder Engagement
- Culture of quality
- Shared safety values
- Physician engagement
- Clinical staff buy-in
- Board reporting
- Governance-level updates
- Change champion
- Local improvement advocate
- Interprofessional team
- Cross-discipline collaboration
PDSA Order
Plan, Do, Study, Act - repeat
Plan: predict changeDo: test smallStudy: compare resultAct: adopt or abandon
PDSA vs DMAIC
PDSA
- Quick small test
- Iterative frontline cycles
- Days to weeks
DMAIC
- Data-heavy project
- Six Sigma structure
- Weeks to months
Quick test vs rigorous project
QI Method Picker
- Need a rapid small test→PDSA cycle
- Need data-driven statistical overhaul→Six Sigma DMAIC
- Need to cut waste/flow→Lean or Kaizen
- Need to visualize causes→Fishbone diagram
- Need the vital few causes→Pareto chart
- Need to prevent future failure→FMEA
PDSA Cycle
- Plan
- Define change, predict result
- Do
- Test change small scale
- Study
- Compare results to prediction
- Act
- Adopt, adapt, or abandon
- Rapid cycle
- Repeat quickly, iterate
DMAIC Order
Define, Measure, Analyze, Improve, Control
Define: scope problemMeasure: baseline dataAnalyze: find causeImprove: fix itControl: sustain gain
Six Sigma DMAIC
- Define
- Scope the problem
- Measure
- Collect baseline data
- Analyze
- Find the root cause
- Improve
- Implement the fix
- Control
- Sustain the gains
- Sigma level
- Defects per million
Lean Tools
- Value stream map
- Flow and waste
- Kaizen
- Continuous small improvement
- 5S
- Workplace organization method
- Gemba walk
- Go observe the work
- Muda
- Eliminate waste
- Takt time
- Match customer demand pace
QI Root-Cause Tools
- Fishbone diagram
- Cause categories visual
- FMEA
- Proactive failure analysis
- Process map
- Visualize the workflow
- Pareto chart
- Vital few causes
- 5 Whys
- Drill to root cause
- Affinity diagram
- Group similar ideas
Population Health Mgmt
- SDOH
- Social determinants of health
- Population health mgmt
- Segment, then intervene
- Health disparities
- Unequal outcomes gap
- Health equity
- Fair opportunity for health
- Risk stratification
- Rank patients by risk
- Care coordination
- Align the care team
Care Transitions
- Readmission
- Return within 30 days
- Warm handoff
- Live provider-to-provider handoff
- Discharge planning
- Post-acute care prep
- Transitional care
- Bridges care settings
- HRRP
- Medicare readmission penalty program
Donabedian Measure Model
Structure feeds Process feeds Outcome
Structure: resources/systemsProcess: care stepsOutcome: patient result
Common Cause vs Special Cause
Common cause
- Normal system variation
- Predictable pattern
- Fix the process
Special cause
- Unusual assignable variation
- Signals a change
- Fix the cause
Random noise vs signal
Run Chart & SPC Signals
- 6+ points one side→Shift signal
- 5+ points trending→Trend signal
- Too few or many runs→Runs signal
- One extreme outlier point→Astronomical point signal
- Point outside control limits→Special cause (SPC)
Measure Types
- Structure measure
- Resources and systems present
- Process measure
- Care steps performed
- Outcome measure
- Patient result achieved
- Experience measure
- Patient-reported experience
- Numerator
- Events counted
- Denominator
- Eligible population
Core Statistics
- Mean
- Average value
- Median
- Middle value
- Mode
- Most frequent value
- Standard deviation
- Spread from the mean
- Correlation
- Strength of relationship
- Regression
- Predict from variables
- T-test
- Compare two means
Control Charts & SPC
- Common cause
- Normal system variation
- Special cause
- Unusual, assignable variation
- UCL/LCL
- Control limits
- P-chart
- Proportion defective
- C-chart
- Count of defects
- XmR chart
- Individual plus moving range
Benchmarking & Dashboards
- Benchmarking
- Compare to peers
- Scorecard
- Strategic goal tracker
- Dashboard
- Real-time metric view
- Case-mix index
- Patient complexity measure
- Risk adjustment
- Normalize for severity
RCA vs FMEA
RCA
- After the event
- Reactive analysis
- Finds root cause
FMEA
- Before the failure
- Proactive analysis
- Ranks failure risk
Reactive vs proactive
Safety Event Response
- Death or serious harm→Sentinel event process
- Preventable, should never occur→Never event review
- Caught before reaching patient→Near miss report
- Analyzing after harm occurs→RCA (reactive)
- Assessing before failure occurs→FMEA (proactive)
Safety Culture
- Just Culture
- Fair blame model
- Swiss cheese model
- Aligned failure holes
- High reliability org
- Consistently safe operations
- Systems thinking
- See the whole process
- Human factors
- Design for people
- Near miss
- Caught before harm
Sentinel Event vs Near Miss
Sentinel event
- Actual serious harm
- Death or permanent harm
- Mandatory review required
Near miss
- No harm reached patient
- Caught in time
- Learning opportunity
Harm occurred vs avoided
Safety Events
- Sentinel event
- Serious harm or death
- Never event
- Preventable serious error
- Adverse event
- Unintended patient harm
- RCA
- Find the system cause
- Proactive risk assessment
- FMEA before failure
- SBAR
- Structured handoff communication tool
OPPE vs FPPE
OPPE
- Ongoing routine review
- All practitioners
- Continuous monitoring
FPPE
- Focused time-limited review
- New or flagged practitioner
- Triggered by concern
Routine vs triggered review
Peer Review & Credentialing
- Peer review
- Practitioner performance evaluation
- Credentialing
- Verify qualifications
- Privileging
- Grant scope of practice
- OPPE
- Ongoing practitioner evaluation
- FPPE
- Focused practitioner evaluation
- Practitioner profile
- Performance data summary
Quality-Based Payment
- Value-based purchasing
- Pay for outcomes
- Pay-for-performance
- Incentivize quality results
- Confidentiality protection
- Peer review privilege
- Reportable event
- Must notify regulator
- Documentation review
- Verify record accuracy
Joint Commission vs CMS CoPs
Joint Commission
- Voluntary accreditation
- Deemed status option
- Standards plus surveys
CMS CoPs
- Mandatory Medicare rules
- Conditions of participation
- Federal baseline
Voluntary vs mandatory
Accreditor Picker
- Hospital seeking accreditation→Joint Commission
- Health plan accreditation→NCQA
- Utilization review accreditation→URAC
- ISO-based hospital survey→DNV Healthcare
- Medicare participation baseline→CMS CoPs
Accreditation Bodies
- Joint Commission
- TJC hospital accreditor
- CMS CoPs
- Medicare participation rules
- NCQA
- Health plan accreditor
- URAC
- Utilization review accreditor
- DNV Healthcare
- ISO-based accreditor
- HFAP
- Osteopathic-rooted accreditor
- Deemed status
- Accreditation meets CMS
Survey Readiness
- Survey readiness
- Always-ready state
- Tracer methodology
- Follow the patient path
- NPSG
- National Patient Safety Goals
- Mock survey
- Practice accreditation visit
- State licensing
- State-level requirement
Common Traps
RCA vs FMEA timing
RCA is reactive ≠ FMEA is proactive
Sentinel event vs near miss
Sentinel event caused harm ≠ Near miss caused no harm
Common cause vs special cause
Common cause is normal ≠ Special cause needs investigation
OPPE vs FPPE scope
OPPE is routine, ongoing ≠ FPPE is focused, triggered
Accreditation vs regulation
Accreditation is voluntary ≠ Regulation is mandatory
Scored vs unscored items
125 items are scored ≠ 15 pretest items are not
Structure vs process measure
Structure measures resources present ≠ Process measures care performed
Last Minute
- 1.140 total questions, 125 scored
- 2.3-hour time limit
- 3.Pass score is 600 of 800
- 4.Reapply 14 days after failing
- 5.Max 3 attempts per year
- 6.Improve domain weighs the most
- 7.Regulatory domain weighs the least
- 8.PDSA equals quick small test
- 9.DMAIC equals Six Sigma project
- 10.RCA is reactive, after harm
- 11.FMEA is proactive, before harm
- 12.Joint Commission is voluntary; CMS mandatory
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