CPHQ key terms

The structures, policies, and processes a board and senior leaders use to set direction, delegate authority, oversee quality, safety, and finances, and remain accountable to patients and the community.

A written roadmap describing where the organization wants to go, the goals and priorities it will pursue, and the resources and timelines needed to get there.

Three guiding statements: mission explains why the organization exists, vision describes its desired future, and values name the principles that should shape everyday behavior and decisions.

A measurement framework that tracks performance across four perspectives - financial, patient or customer, internal processes, and learning and growth - so leaders balance short-term results with long-term capability.

The structured methods used to prepare people for a change, reduce resistance, and make new processes stick, such as building urgency, communicating a clear vision, and reinforcing gains.

A process of identifying everyone who affects or is affected by a decision, then assessing their interests, influence, and likely position so leaders can plan communication and engagement.

Credentialing verifies a clinician's education, licensure, training, and competence; privileging is the formal granting of permission to perform specific procedures or services at the organization.

The ongoing process of identifying, evaluating, and reducing exposures that could harm patients, staff, or the organization - clinical, financial, legal, and operational.

The policies, roles, and decision rights that determine who may define, collect, access, and use organizational data, so that information stays accurate, secure, and interpreted consistently.

A reference that defines each data element in a system - its name, meaning, format, allowed values, and source - so different users and systems interpret the data the same way.

The degree to which a measure or tool truly captures the concept it is meant to measure rather than something else.

The consistency of a measurement - whether repeating it, or having a different observer take it, produces a similar result.

The proportion of people who truly have a condition and are correctly identified by a test; a highly sensitive test rarely misses a true case.

The proportion of people who truly do not have a condition and are correctly identified as negative; a highly specific test rarely produces false positives.

The probability that a person with a positive test actually has the condition; it depends on both test accuracy and how common the condition is in the population tested.

A statistical method that accounts for differences in patient age, severity, and coexisting conditions so outcomes can be compared fairly across providers, units, or hospitals.

Comparing an organization's performance or processes with internal targets, external peers, or recognized best practice to find gaps and opportunities for improvement.

A line graph of data plotted over time with a median reference line, used to spot trends, shifts, and unusual patterns before applying formal statistical tests.

A time-ordered graph with statistically calculated upper and lower control limits that helps distinguish ordinary common-cause variation from special-cause signals in a process.

A visual display that consolidates selected performance indicators, often with targets and trends, so leaders can monitor results at a glance and act quickly.

Plan-Do-Study-Act: a rapid-cycle method in which a change is tested on a small scale, results are studied, and the change is then adopted, adapted, or abandoned.

Define, Measure, Analyze, Improve, Control: a structured Six Sigma roadmap for improving an existing process by finding root causes of defects and locking in the solution.

An improvement philosophy that removes waste - such as waiting, excess motion, overproduction, and rework - and improves flow from the patient's or customer's point of view.

A data-driven method that reduces defects and variation using statistical analysis and structured project roadmaps, often targeting fewer than four defects per million opportunities.

A visual map of every step, delay, and information flow needed to deliver a service, used to expose waste and design a better future-state process.

Also called a cause-and-effect or Ishikawa diagram: a tool that organizes possible causes of a problem into branches such as people, process, equipment, environment, and materials.

A bar chart ranking causes or categories from most to least frequent, with a cumulative line, showing where a few causes account for most of the effect.

Failure Mode and Effects Analysis: a proactive team method that lists ways a process could fail, scores each failure's severity, likelihood, and detectability, and prioritizes fixes before harm occurs.

A short authorizing document that defines an improvement project's problem, aim, scope, team, timeline, key measures, and expected benefit.

A simple technique of repeatedly asking why a problem occurred, usually about five times, to move past symptoms toward an underlying root cause.

A structured team investigation after a serious event that reconstructs what happened, identifies contributing system factors, and produces action plans to prevent recurrence.

An unexpected occurrence involving death or serious physical or psychological harm, or the risk of such harm, that requires immediate investigation and response.

An event that could have caused harm but did not reach the patient, or reached the patient without injury; reporting these exposes system weaknesses before real harm occurs.

A safety culture model that supports staff after honest human error, coaches at-risk behavior, and holds people accountable for reckless conduct, so problems get reported.

The shared beliefs, attitudes, and behaviors of staff about safety, visible in whether people speak up, report errors, and see safety as a leadership priority.

Situation, Background, Assessment, Recommendation: a structured handoff format that gives the receiver a concise, predictable picture and a clear request for action.

A small set of evidence-based practices, usually three to five, that when delivered reliably together produce better outcomes than any single practice alone.

The discipline of designing tools, tasks, and environments to fit human abilities and limits, so that ordinary slips and mistakes are less likely to harm patients.

An organization that sustains very low error rates in high-risk work by staying preoccupied with failure, resisting oversimplification, and deferring to frontline expertise.

The open conversation with a patient or family after harm, explaining what happened, expressing regret, and describing what will be done to prevent recurrence.