CPHQ cheat sheet

The board of directors holds ultimate accountability for quality and patient safety; medical staff bylaws govern credentialing, privileging, and peer review.

Strategic hierarchy: mission (why we exist), vision (future state), values, goals, objectives, tactics; objectives should be SMART (specific, measurable, achievable, relevant, time-bound).

Transformational leadership uses idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration; transactional leadership uses contingent reward and management-by-exception.

Kotter's eight steps: urgency, guiding coalition, vision, communicate, empower action, short-term wins, consolidate gains, anchor in culture.

Baldrige Health Care Criteria categories: leadership; strategy; customers; measurement, analysis, and knowledge management; workforce; operations; results.

ANCC Magnet Recognition requires transformational leadership, structural empowerment, exemplary professional practice, new knowledge and innovation, and empirical quality outcomes.

Thomas-Kilmann conflict modes: competing, collaborating, compromising, avoiding, accommodating; collaborating fits win-win outcomes when trust and time permit.

Shared governance councils distribute decision authority to frontline staff; span of control is the number of direct reports per manager, with wider spans flattening hierarchy.

Joint Commission surveys use tracer methodology; CMS Conditions of Participation must be met for Medicare reimbursement, and accreditation may substitute for CMS survey.

Measurement scales: nominal (unordered categories), ordinal (rank order), interval (equal intervals, no true zero), ratio (true zero); only ratio data support all arithmetic operations.

Sensitivity = TP/(TP+FN); specificity = TN/(TN+FP); PPV = TP/(TP+FP); NPV = TN/(TN+FN). PPV and NPV vary with prevalence; sensitivity and specificity do not.

Prevalence = existing cases / total population at a point or period; incidence = new cases / population at risk over a defined time.

Mean, median, standard deviation, and range are descriptive; t-tests, chi-square, and ANOVA are inferential. A p-value below 0.05 is a decision threshold, not proof of clinical importance.

Validity is measuring the intended construct; reliability is consistency or repeatability. Reliability is necessary but not sufficient for validity.

SPC chart selection: p-chart for proportion defective, c-chart for defect counts per unit, X-bar and S charts for continuous data. Special cause is signaled by points beyond 3 sigma, 8 consecutive points on one side of the centerline, or trends.

HIPAA Privacy Rule limits use and disclosure of PHI; the Security Rule covers administrative, physical, and technical safeguards for electronic PHI.

Analytics maturity levels: descriptive (what happened), diagnostic (why it happened), predictive (what will happen), prescriptive (what action to take).

Risk adjustment models such as APR-DRG and HEDIS adjust for patient severity and case mix before comparing outcomes across providers or plans.

PDSA: Plan states a prediction, Do runs a small-scale test, Study compares results with the prediction, Act adopts, adapts, or abandons the change.

DMAIC phases - Define, Measure, Analyze, Improve, Control - address existing processes; DMADV (Define, Measure, Analyze, Design, Verify) is used for new process design.

Lean waste categories (TIMWOODS): transportation, inventory, motion, waiting, overproduction, overprocessing, defects, skills underuse.

Six Sigma performance equals 3.4 defects per million opportunities; higher sigma levels correspond to lower DPMO.

FMEA risk priority number = severity x occurrence x detection, each scored 1-10; prioritize highest RPNs plus any failure mode with severity 9 or 10.

Pareto principle: roughly 80% of effects come from 20% of causes; a Pareto chart ranks causes in descending frequency with a cumulative percentage line.

Process capability: Cp = (USL - LSL)/6 sigma; Cpk adjusts for centering. Cpk of 1.33 or higher is commonly the minimum acceptable capability.

Balanced scorecard perspectives are financial, customer, internal process, and learning and growth; leading indicators predict, lagging indicators confirm.

SIPOC maps suppliers, inputs, process, outputs, and customers at project scoping; the control phase standardizes gains through monitoring, standard work, and mistake-proofing.

IOM report To Err Is Human (1999) estimated 44,000-98,000 annual U.S. deaths from medical errors and reframed error as a system failure rather than individual fault.

The IOM six aims for improvement are safe, effective, patient-centered, timely, efficient, and equitable care.

Reason's Swiss cheese model: harm occurs when holes in multiple defensive layers, representing latent conditions and active failures, align.

Sentinel event: unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof; it requires immediate investigation and root cause analysis.

HRO principles: preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, deference to expertise.

Adverse event causes harm; a near miss reaches the patient without harm or is intercepted before reaching the patient. Both belong in a nonpunitive reporting system.

Just culture distinguishes human error (console), at-risk behavior (coach), and reckless behavior (sanction), rather than judging severity by outcome alone.

Care bundles (CLABSI central line, VAP, CAUTI) combine evidence-based practices; compliance is measured as all-or-none for the eligible patient.

Joint Commission National Patient Safety Goals address patient identification, handoff communication, medication reconciliation, infection prevention, and fall and pressure injury risk.