Your FREE CPHQ Flashcards 2026 – 150+ Cards

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM definition).

Care that is Safe, Timely, Effective, Efficient, Equitable, and Patient-centered (STEEEP).

Setting the strategic vision, culture, structure, and resources for quality and safety across an organization, integrating quality into governance and operations.

A long-range roadmap defining an organization's mission, vision, goals, and priorities; the quality plan must align with it.

A written document describing how an organization will measure, assess, and improve quality and safety, including structure, scope, accountability, and reporting.

Mission = why the organization exists today (its purpose); vision = the aspirational future state it is working toward.

A culture that balances accountability and learning: it distinguishes human error (console), at-risk behavior (coach), and reckless behavior (discipline), instead of blaming individuals for system failures.

A shared organizational commitment in which staff feel safe to report errors and near misses without fear of blame, supporting learning and prevention.

Ultimate accountability for the quality and safety of care; sets the quality agenda, allocates resources, and reviews performance.

A structured approach to transitioning individuals and the organization from a current state to a desired future state (e.g., Lewin: Unfreeze → Change → Refreeze; Kotter's 8 steps).

Three stages: Unfreeze (create readiness), Change (implement the new way), Refreeze (embed and sustain the change).

Linking quality goals and measures to the organization's strategic priorities so improvement work supports the overall mission.

Any person or group with an interest in or affected by a process or its outcomes — patients, staff, providers, payers, regulators, community.

Facilitator, coach, consultant, educator, data analyst, and change agent — supporting teams rather than owning every improvement.

A strategic assessment of internal Strengths and Weaknesses and external Opportunities and Threats.

A cross-functional leadership group that prioritizes, oversees, and coordinates the organization's quality and safety initiatives.

The continuous study and improvement of processes to better meet the needs of patients and other stakeholders.

Prioritizing time, staff, and budget toward the highest-impact quality and safety initiatives (often guided by risk and strategic priority).

A leadership style focused on serving and developing staff first, which supports a culture of engagement and safety.

The shared values, beliefs, and behaviors that shape how work is done; a key driver of quality and safety outcomes.

Demonstrating the financial and value return of a quality initiative (reduced harm, lower cost, better reimbursement) to justify investment.

Embedding quality and safety into daily operations, governance, and every department rather than treating it as a separate siloed function.

Building staff competency in QI methods, measures, and safety practices so improvement is owned at the front line.

Plan–Do–Study–Act: an iterative, small-scale method to test and refine a change before spreading it. The engine of the Model for Improvement.

The IHI framework: three questions (What are we trying to accomplish? How will we know a change is an improvement? What change can we make?) plus PDSA cycles.

The Six Sigma improvement sequence: Define, Measure, Analyze, Improve, Control.

A data-driven methodology focused on reducing variation and defects, aiming for no more than 3.4 defects per million opportunities.

An improvement philosophy focused on maximizing value and eliminating waste (non-value-added steps) and improving flow.

Defects, Overproduction, Waiting, Non-utilized talent, Transportation, Inventory, Motion, Excess processing.

A combined approach using Lean to remove waste and Six Sigma (DMAIC) to reduce variation.

A Lean tool that diagrams every step in a process to distinguish value-added from non-value-added activity and target waste.

A structured, retrospective process to identify the underlying system causes of an adverse event or near miss, focusing on systems rather than individuals.

An RCA technique that repeatedly asks 'why' (about five times) to move from a symptom to its underlying root cause.

A tool that organizes possible causes of a problem into categories (e.g., People, Process, Equipment, Environment, Materials, Management) to find root causes.

Failure Mode and Effects Analysis: a proactive, prospective method to identify how a process could fail, the effects, and priorities for prevention before harm occurs.

In FMEA, the Risk Priority Number (RPN) equals Severity times Occurrence times Detection. Higher-RPN failure modes are prioritized for mitigation.

RCA is reactive/retrospective (after an event); FMEA is proactive/prospective (before an event, on a high-risk process).

A diagram showing the sequence of steps in a process as it actually occurs; used to understand and find improvement opportunities.

A more detailed flowchart that shows inputs, outputs, roles (swim lanes), and decision points across a process.

A tool that groups large numbers of ideas (e.g., from brainstorming) into natural categories to organize and prioritize them.

A group technique for generating many ideas quickly without immediate judgment.

A structured brainstorming/prioritization method where members generate ideas silently, then rank them to reach group consensus.

A prioritization technique that narrows a large list of options to a few through successive rounds of voting.

A tool that maps the driving forces for and restraining forces against a change to plan how to strengthen drivers and reduce barriers.

Comparing current performance to a desired or benchmark state to identify the gap and plan improvement.

Taking an improvement that worked in a pilot and reliably implementing it across other units or the whole organization.

Running many small, fast PDSA tests of change in quick succession to learn and adapt rapidly.

Establishing a single, agreed-upon best way to perform a process to reduce variation and error.

Define the objective, predict what will happen, and plan the test of change and the data to collect.

Analyze the data from the test, compare results to the prediction, and summarize what was learned.

An ongoing, never-ending effort to improve processes and outcomes, built on data and team involvement.

The 80/20 rule: roughly 80% of problems come from 20% of causes — focus improvement on the vital few.

A Lean philosophy of continuous, incremental improvement involving everyone; a 'Kaizen event' is a focused rapid-improvement workshop.

A document that defines an improvement project's problem, scope, goals, team, and timeline; aligns and authorizes the work.

The health outcomes of a group of individuals, including the distribution of outcomes within the group; managed by addressing clinical care, behaviors, and social factors.

Coordinating care and resources across a defined population to improve outcomes and reduce cost, often using risk stratification and registries.

Non-medical conditions where people live, work, and age — economic stability, education, healthcare access, environment, and social context — that shape health outcomes.

The movement of a patient between settings or providers (e.g., hospital → home); high-risk points for errors and readmissions.

Deliberately organizing patient-care activities and sharing information among all participants to deliver safer, more effective care.

A set of actions designed to ensure continuity and coordination of care as patients transfer between locations or levels of care.

An unplanned return to inpatient care, often within 30 days; a key outcome and value-based payment measure tied to transition quality.

Comparing a patient's medication orders to all medications they are taking at each transition to prevent omissions, duplications, and interactions.

Classifying a population by health risk so resources and interventions can be targeted to the highest-need patients.

An organized system that collects data on patients with a particular condition to track and improve their care.

A primary-care model providing comprehensive, coordinated, patient-centered care with enhanced access and a team approach.

A group of providers who jointly accept accountability for the quality and cost of care for a defined population, sharing in savings.

Everyone having a fair and just opportunity to be as healthy as possible, requiring removal of obstacles such as poverty and discrimination.

A preventable difference in health outcomes or burden of disease experienced by disadvantaged populations.

The degree to which individuals can obtain, process, and understand basic health information needed to make decisions.

Asking patients to explain instructions in their own words to confirm understanding; a core health-literacy and safety tool.

Arranging the services, follow-up, education, and supports a patient needs after leaving a facility to ensure a safe transition.

A framework for proactive, planned care of chronic disease emphasizing self-management support, delivery design, decision support, and clinical information systems.

Involving patients as active partners in their own care and in organizational improvement; associated with better outcomes.

Services (screenings, immunizations, counseling) aimed at preventing disease or detecting it early, central to population health.

A systematic assessment of a community's health needs, required of nonprofit hospitals to guide improvement priorities.

Standardized transfer of patient information and responsibility between caregivers (e.g., SBAR, I-PASS) to prevent transition errors.

A standardized handoff/communication format: Situation, Background, Assessment, Recommendation.

Data are raw facts/numbers; information is data that has been processed and given context so it is meaningful for decisions.

Structure = capacity/resources; Process = what is done (e.g., aspirin given); Outcome = the result (e.g., mortality). The classic quality-measurement framework.

Reflects the result of care on a patient's health status (e.g., mortality, readmission, infection rate).

Reflects whether a recommended care step was performed (e.g., % of patients given prophylactic antibiotics on time).

A measure that checks whether improving one part of a system causes problems elsewhere (an unintended consequence).

Comparing performance to a reference point — internal, competitive, or best-in-class — to identify improvement opportunities.

A line graph of data plotted over time with a median, used to detect trends, shifts, and patterns (non-random variation).

A run chart with a center line (mean) and upper and lower control limits, used to distinguish common-cause from special-cause variation.

Statistically calculated boundaries on a control chart, most commonly set at plus or minus 3 standard deviations (3 sigma) from the mean.

Natural, expected, random variation inherent to a stable process; points stay within control limits. Address by redesigning the process.

Variation from a specific, assignable cause outside the normal process (a point beyond control limits or a non-random pattern). Investigate the specific cause.

Non-random signals include a shift (6 or more consecutive points on one side of the median), a trend (5 or more points steadily rising or falling), and too few or too many runs.

A bar chart showing the frequency distribution of continuous data, revealing its shape, center, and spread.

A bar chart ordering causes from most to least frequent, with a cumulative line, to identify the 'vital few' causes.

A plot of two variables used to show the strength and direction of a relationship (correlation) between them.

Mean = arithmetic average; median = middle value when ordered; mode = most frequent value. Median resists outlier distortion.

A measure of how spread out data are around the mean; larger σ means more variation.

Categorical data with no inherent order (e.g., blood type, gender).

Categorical data with a meaningful order but unequal intervals (e.g., pain scale, satisfaction 'poor→excellent').

Numeric data measured on a scale with equal intervals (e.g., blood pressure, length of stay).

A ratio with a defined numerator over a denominator and time/population (e.g., falls per 1,000 patient-days).

Statistically accounting for differences in patient mix (severity, comorbidities) so outcomes can be fairly compared across providers.

The consistency of a measure — the degree to which it gives the same result on repeat measurement.

The degree to which a measure actually captures what it is intended to measure.

The accuracy, completeness, and consistency of data throughout its lifecycle; essential for trustworthy quality reporting.

A visual display of an organization's key performance indicators at a glance to support monitoring and decisions.

A performance tool tracking measures across multiple perspectives (financial, customer, internal process, learning/growth) tied to strategy.

Data combined or summarized across cases (e.g., a unit's average), as opposed to individual record-level data.

Collecting data from a representative subset of a population to draw conclusions efficiently when full census is impractical.

The use of run and control charts to monitor a process over time and detect non-random (special-cause) variation.

In a measure, the numerator is the count meeting the criterion (e.g., patients who received the care); the denominator is the eligible population.

Examining data over time to identify the direction and pattern of performance.

A bar chart compares categories (gaps between bars); a histogram shows the distribution of continuous data (bars touch).

The prevention of errors and harm to patients during the provision of health care; a core dimension of quality.

An injury caused by medical management (rather than the underlying disease) that results in harm to the patient.

An event or error that could have caused harm but did not, by chance or timely intervention; a key learning opportunity.

A patient-safety event (not primarily related to the natural course of illness) reaching a patient and resulting in death, permanent harm, or severe temporary harm.

A serious, largely preventable, and clearly identifiable adverse event (e.g., wrong-site surgery, retained foreign object); NQF's 'serious reportable events.'

Active failures are unsafe acts by frontline staff; latent conditions are hidden system weaknesses (design, staffing) that set the stage for failure.

Reason's model: harm occurs when gaps ('holes') in multiple layers of defense line up, letting a hazard pass through to the patient.

Designing systems, tasks, and devices to fit human capabilities and limitations, reducing the chance of error.

A design that makes an error impossible or very hard (e.g., incompatible connectors that prevent wrong-route administration). A strong error-proofing strategy.

Strongest = forcing functions/automation; moderate = standardization, checklists, reminders; weakest = education and policies alone.

An organization that operates in complex, high-risk conditions yet has very few adverse events, through preoccupation with failure and a strong safety culture.

Preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise.

Joint Commission goals updated annually that target specific high-risk safety problems (e.g., patient ID, communication, medication safety, infection prevention).

An NPSG requiring at least two identifiers (e.g., name and date of birth — never the room number) before care, medications, or procedures.

Joint Commission requirements to prevent wrong-site, wrong-procedure, wrong-person surgery: pre-procedure verification, site marking, and a time-out.

A pause immediately before a procedure for the whole team to confirm correct patient, site, and procedure.

Drugs that bear a heightened risk of significant harm when used in error (e.g., insulin, anticoagulants, opioids, concentrated electrolytes).

Right patient, right drug, right dose, right route, right time (often expanded with right documentation and right reason).

A condition a patient acquires during a hospital stay (e.g., CAUTI, CLABSI, pressure injury, falls) that is often preventable; tied to CMS payment.

Central line-associated bloodstream infection / catheter-associated urinary tract infection — common, largely preventable healthcare-associated infections.

An infection a patient acquires while receiving care for another condition; a major patient-safety focus.

A small set of evidence-based practices that, performed together reliably, improve outcomes (e.g., a central-line insertion bundle).

Communicating with patients/families honestly and promptly when harm occurs, including what happened, the consequences, and steps taken.

A confidential internal report documenting an error, near miss, or unsafe condition, used for learning and trending — not part of the medical record.

A team that responds to early signs of patient deterioration to prevent codes and deaths outside the ICU.

Repeating a verbal or telephone order back to the prescriber to confirm accuracy; an NPSG communication safeguard.

Informal shortcuts staff use to bypass a process barrier; they may complete a task but often defeat safety controls and signal a flawed system.

The systematic evaluation of the quality and appropriateness of care against established standards and criteria.

Evaluation of a practitioner's clinical performance by professional peers to assess and improve quality; typically confidential and protected.

Evaluating the medical necessity, appropriateness, and efficiency of health services against criteria, via prospective, concurrent, and retrospective review.

Prospective = before care (prior authorization); concurrent = during the stay; retrospective = after care is delivered.

Verifying a practitioner's qualifications — education, training, licensure, and experience — before granting them the ability to practice.

Authorizing a credentialed practitioner to perform specific procedures or services based on demonstrated competence.

Confirming a practitioner's credentials directly with the issuing source (e.g., the medical school or licensing board), required in credentialing.

Routine, continuous monitoring of practitioner performance data used in privileging decisions.

A time-limited, focused evaluation of a practitioner (new privileges or a performance concern) to confirm competence.

Care that is reasonable and necessary to diagnose or treat a condition, judged against evidence-based criteria such as InterQual or MCG.

A collaborative process of assessment, planning, coordination, and advocacy to meet a patient's health needs efficiently across the continuum.

Identifying, evaluating, and reducing risks of loss or harm to patients, staff, and the organization (clinical, financial, and legal).

An organization-wide approach to identifying and managing all categories of risk (clinical, operational, financial, strategic, reputational).

Handling actual or potential legal claims against the organization to minimize loss and learn from events.

Many quality, peer-review, and incident-report records are legally protected from discovery to encourage candid review (varies by state and PSO).

An entity certified under the Patient Safety and Quality Improvement Act to collect and analyze patient-safety data with federal confidentiality protection.

Aggregating performance data by individual provider or group to compare practice patterns and outcomes.

Sharing performance data with regulators, payers, or the public (e.g., Hospital Compare) to drive accountability and improvement.

Holding individuals, teams, and the organization responsible for performance and outcomes, balanced with a just, learning culture.

A structured case review of deaths and complications to identify opportunities for improvement and learning.

Reporting certain events to required external entities (state agencies, the FDA via MedWatch, or accreditors) per regulation.

A major U.S. accrediting body that surveys and accredits hospitals and other organizations against standards of quality and safety.

Voluntary review by an external body confirming an organization meets defined quality and safety standards.

Status granted when an accreditor's standards are recognized as meeting Medicare's Conditions of Participation, so the organization need not undergo a separate CMS survey.

Federal health and safety requirements that providers must meet to participate in (and be paid by) Medicare and Medicaid.

The federal agency administering Medicare and Medicaid; sets CoPs, quality measures, and value-based payment programs.

A Joint Commission survey technique that follows ('traces') an individual patient's care experience through the organization to evaluate compliance.

Standards (e.g., TJC) are typically voluntary best-practice requirements; regulations (e.g., CMS CoPs, OSHA) are legally mandated.

The Health Insurance Portability and Accountability Act, protecting patient health information through the Privacy and Security Rules.

Individually identifiable health information protected under HIPAA; share only the minimum necessary.

The Emergency Medical Treatment and Labor Act, requiring Medicare hospitals to screen and stabilize emergency patients regardless of ability to pay.

The Occupational Safety and Health Administration, setting and enforcing workplace safety standards (e.g., bloodborne pathogens, hazard communication).

The National Committee for Quality Assurance, which accredits health plans and develops the HEDIS performance measures.

The Healthcare Effectiveness Data and Information Set — NCQA's standardized measures used to compare health-plan quality.

CMS programs that tie a portion of payment to quality and outcomes rather than volume, rewarding better performance.

Reimbursement model that financially rewards providers for meeting quality and efficiency targets.

A CMS program that reduces payments to hospitals with excess 30-day readmissions for targeted conditions.

Besides The Joint Commission, CMS recognizes other accreditors (e.g., DNV Healthcare, HFAP) that can confer deemed status.

Maintaining continuous compliance with standards (not just before a survey) so the organization is always survey-ready.

An organization's documented plan to fix deficiencies cited during an accreditation or regulatory survey, with actions and timelines.

The Agency for Healthcare Research and Quality — a federal agency producing patient-safety tools, measures, and evidence to improve care.

Standardized, nationally endorsed clinical process/outcome measures hospitals report (originated with TJC/CMS aligned measure sets).