Free CPHQ Exam Flashcards

Quality leaders advise senior leadership on improvement opportunities, help set priorities, and align quality/safety initiatives with the organization's strategic goals - translating high-level strategy into an actionable quality agenda rather than working in isolation from leadership.

Unfreeze (build motivation and reduce resistance to the current state), Change (implement the new process/behavior), Refreeze (stabilize and reinforce the new state so it becomes the new normal). Skipping 'refreeze' is why many improvements quietly revert to the old way.

An 8-stage roadmap for large-scale organizational change: create urgency, build a guiding coalition, form a vision, communicate the vision, empower broad-based action, generate short-term wins, consolidate gains, and anchor the change in the culture. It is more granular than Lewin's model and built for enterprise-level transformation.

Explains how new practices spread through 5 adopter categories, from fastest to slowest: innovators, early adopters, early majority, late majority, laggards. Quality leaders target early adopters and opinion leaders first because their buy-in accelerates adoption by the majority.

Staff feel psychologically safe reporting errors without fear of blame, quality and safety are embedded into daily workflows rather than run as a separate program, and leaders visibly model and reward improvement behavior - the cultural foundation a High Reliability Organization is built on.

It must connect the proposed initiative's expected costs (staff time, technology, training) to measurable returns (cost avoidance, revenue protection, quality/safety outcome gains) so leadership can weigh competing priorities and approve resources.

The Board of Directors holds ultimate accountability for quality and safety, delegating oversight to a Quality Committee, which flows down through medical staff leadership and department-level structures - creating a reporting line so problems surface up to the Board, not just down to staff.

Engaging clinical staff, patients, and leadership early builds buy-in, surfaces resource needs and cultural barriers, and improves the odds an improvement sticks after the project team moves on - poor engagement is a leading cause of improvements that fail to sustain.

Plan (design a small test of change), Do (carry out the test on a small scale), Study (analyze the results against predictions), Act (adopt, adapt, or abandon the change). It's an iterative, small-scale test-and-learn cycle, not a one-time rollout.

The Six Sigma improvement methodology: Define the problem/goal, Measure current performance, Analyze root causes, Improve the process, Control the gains so they hold. Unlike PDSA's rapid small tests, DMAIC is a more rigorous, data-heavy framework typically used for complex, high-stakes processes.

The Lean term for waste - any activity that consumes resources without adding value for the customer or patient. Common categories include waiting, overproduction, defects, transportation, and unnecessary motion; eliminating muda is the central goal of Lean improvement work.

A Lean tool that visually maps every step of a process end-to-end, distinguishing value-added steps from non-value-added (waste) steps, so teams can see the whole system and target the biggest sources of delay or waste for improvement.

A Lean philosophy of continuous, incremental improvement, often delivered through short, focused 'Kaizen events' where a cross-functional team rapidly redesigns a specific process over a few days - contrasted with large, slow, top-down transformation projects.

A Lean workplace-organization method with 5 steps: Sort (remove unneeded items), Set in order (organize what remains), Shine (clean the area), Standardize (create consistent procedures), Sustain (maintain the discipline). Used to reduce waste and errors caused by disorganized workspaces.

A Lean practice of leaders going to 'the real place' where the work actually happens - the unit, the bedside, the lab - to observe the process firsthand rather than relying only on reports, revealing problems that don't show up in data.

The pace at which a process must produce output to meet customer/patient demand, calculated as available working time divided by demand. If a process runs slower than takt time it can't keep up with demand; running faster may signal overproduction or wasted resources.

A cause-and-effect diagram that sorts potential causes of a problem into categories (e.g., people, process, equipment, materials) branching off a central spine toward the effect. It's often paired with the 5 Whys technique, which instead drills down by repeatedly asking 'why' to trace one causal chain to its root, rather than mapping causes visually across categories.

A PROACTIVE tool used BEFORE a failure occurs: teams score each potential failure mode on severity, occurrence, and detectability to calculate a Risk Priority Number (RPN) and prioritize which risks to fix first - the opposite of root cause analysis, which is reactive and investigates AFTER an event.

A bar chart that ranks causes or problem categories from most to least frequent, applying the 80/20 rule - typically about 80% of problems come from roughly 20% of causes - so teams focus improvement effort on the 'vital few' bars, not the many trivial ones.

A framework focused on improving health outcomes for a defined group of people, not just individual patients - analyzing the distribution of those outcomes across the group and deploying strategies like risk stratification and care coordination to close gaps for high-risk segments.

Nonmedical factors - housing stability, transportation access, food security, education, income - that are attributed to a large share of overall health outcomes. Quality professionals incorporate SDOH data into improvement initiatives to address disparities, not just clinical care gaps.

A structured approach to coordinating a patient's handoff from one care setting to another (e.g., hospital to home), typically requiring contact with the patient within 2 business days of discharge and a follow-up visit within 7-14 days, to catch problems early and reduce preventable readmissions.

The process of classifying patients by their likelihood of an adverse outcome, such as 30-day readmission, using tools like the LACE index - so care-transition resources (follow-up calls, home visits) are targeted to the highest-risk patients rather than spread evenly across everyone.

A quality-measurement framework with 3 measure types: Structure (the resources/systems in place, e.g., staffing ratios), Process (what is actually done, e.g., % of patients screened per protocol), and Outcome (the result for the patient, e.g., infection rate). Good structure and process don't guarantee good outcomes, which is why all three are tracked together.

A Donabedian measure describing the resources or systems available to deliver care - for example, nurse-to-patient staffing ratios or having an EHR with clinical decision support. Structure measures are the easiest to count but the weakest predictor of actual care quality on their own.

A Donabedian measure describing what providers actually DO - for example, the percentage of eligible patients who received a recommended screening or medication. Process measures are usually easier to act on than outcome measures because clinicians directly control the process step being measured.

A Donabedian measure describing the result of care for the patient - for example, 30-day mortality or surgical-site infection rate. Outcome measures matter most to patients but are influenced by many factors outside a provider's control, so they often require risk adjustment for fair comparison.

Common cause variation is the natural, random noise inherent in a stable process - expected and NOT worth chasing individually. Special cause variation is an unusual, assignable signal (a spike, a shift) that indicates something specific changed and needs investigation.

A control chart plots data over time around a center line (the mean) with upper and lower control limits typically set at about plus-or-minus 3 standard deviations. Points that stay within the limits reflect common cause variation; points outside the limits, or unusual non-random patterns, signal special cause variation worth investigating.

A P-chart tracks a PROPORTION (e.g., percent of patients with an infection) when sample size varies. A C-chart tracks a COUNT of defects or events over a constant area of opportunity (e.g., falls per unit per month with a fixed bed count). An XmR (individuals-moving range) chart is used for continuous data or when you only have one data point per time period and can't form subgroups.

A shift is 6 or more consecutive data points all above or all below the median - a classic run-chart rule indicating the process has non-randomly changed, distinct from ordinary random scatter around the median.

A trend is 5 or more consecutive data points that are all increasing or all decreasing - signaling the process is steadily moving in one direction rather than just fluctuating randomly, which warrants investigation even if no single point looks extreme.

Benchmarking compares an organization's performance data against external reference points - peer institutions, national registries, or published targets - to reveal whether a 'good' internal number is actually mediocre compared to others, and to set realistic improvement targets.

Risk adjustment statistically accounts for differences in patient case-mix and severity, such as age, comorbidities, and acuity, between providers, so a hospital treating sicker patients isn't unfairly penalized when comparing raw outcome rates to a hospital treating a healthier population.

A framework that replaces a pure blame culture with a fair, consistent response based on behavior type: console and support for honest human error, coach for at-risk behavior (risky shortcuts), and discipline for reckless or willful violations - encouraging honest error reporting instead of concealment.

Root Cause Analysis (RCA) is REACTIVE - it investigates AFTER a sentinel or adverse event to find the systemic factors that allowed it to happen. FMEA is PROACTIVE - it evaluates potential failure modes BEFORE anything goes wrong to prevent the event in the first place.

A patient safety event resulting in death, permanent harm, or severe temporary harm requiring life-sustaining intervention, unrelated to the natural course of the patient's illness. Sentinel events trigger a mandatory root cause analysis and are reportable to the organization's accreditor within a defined timeframe.

A largely preventable, serious, unambiguous adverse event that should never occur in healthcare - such as wrong-site surgery or a retained surgical item - as defined by the National Quality Forum's list of Serious Reportable Events.

An adverse event means harm actually reached the patient. A near miss (or close call) means an error occurred but was caught before it reached the patient, or reached the patient without causing harm. Both should be reported and analyzed, since a near miss often reveals the same systemic gap that could cause harm next time.

Depicts an organization's safety defenses as multiple slices of cheese, each with random holes representing latent and active failures. An adverse event happens only when holes in several layers momentarily align - illustrating why safety depends on multiple system-level barriers, not on any single person or step being perfect.

Preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise. HROs use these 5 principles to operate with very few catastrophic errors despite working in high-risk, high-complexity environments.

A CONTINUOUS, data-driven review of a practitioner's performance, typically every 6-12 months, using metrics like complication rates or chart-documentation quality, used to catch performance trends early and inform decisions at the time of privilege renewal.

A TIME-LIMITED, targeted evaluation used either to confirm a new practitioner's competence when privileges are first granted, or to investigate an existing practitioner when a specific question about their performance arises - more intensive and narrowly scoped than routine OPPE.

The Health Care Quality Improvement Act (HCQIA) provides liability protection to practitioners who participate in good-faith peer review, encouraging candid evaluation of a colleague's care against professional standards without fear that honest findings will trigger a lawsuit against the reviewer.

Credentialing verifies a practitioner's education, license, training, and background - confirming they are who and what they claim to be. Privileging is the organization's separate decision to authorize that specific practitioner to perform specific procedures or services based on demonstrated current competence.

A CMS payment model that ties a portion of a hospital's Medicare reimbursement to performance on quality, cost, and patient-experience measures rather than paying purely for the volume of services delivered - a pay-for-performance approach.

A multidisciplinary, non-punitive case-review meeting where clinicians analyze deaths or poor outcomes to identify systemic and practice-level contributing factors and drive improvement - a recurring educational forum, distinct from a one-time formal root cause analysis of a single sentinel event.

The Joint Commission (TJC) accredits most hospitals; DNV integrates ISO 9001 standards with annual unannounced surveys; HFAP (AOA-affiliated) covers hospitals and behavioral health; NCQA recognizes health plans, ACOs, and patient-centered medical homes; URAC accredits health plans, PBMs, and telehealth programs. CMS itself is the federal regulator that sets the baseline Conditions of Participation (CoPs), not a voluntary accreditor.

A CMS designation granted to accrediting bodies such as TJC, DNV, and HFAP whose standards meet or exceed the CMS Conditions of Participation. Hospitals accredited by a deemed-status organization can satisfy Medicare/Medicaid certification requirements without a separate state CMS survey.

Tracer methodology is The Joint Commission's on-site survey technique of following one real patient's actual care path through multiple departments to test real compliance, rather than just reviewing policy binders. Surveyors commonly use tracers to verify compliance with NPSGs - TJC's annually updated list of high-priority safety requirements like correct patient identification and medication safety.