CHL cheat sheet

Leadership style continuum: telling/directing (low follower maturity) → selling/coaching → participating/supporting → delegating (high follower maturity); style is selected by the follower's task-specific readiness, not by the leader's preference.

Situational leadership defines readiness by two independent axes: ability (knowledge, skill, experience) and willingness (confidence, commitment, motivation); a follower can be high on one and low on the other.

Transformational leadership comprises four components: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration; transactional leadership instead relies on contingent reward and management-by-exception.

Lewin's three styles: autocratic (leader decides), democratic (group input, leader decides), laissez-faire (group decides); autocratic is defensible in emergencies and code situations, democratic for quality improvement and change adoption.

Tuckman's team stages - forming, storming, norming, performing, adjourning - are sequential but not strictly linear; regression to storming is expected after membership change or a major process change.

Conflict modes (Thomas–Kilmann): competing, collaborating, compromising, avoiding, accommodating; collaborating is the only mode that seeks a fully win-win outcome and is preferred for important issues with time available.

Grievance and discipline progression: verbal counseling → written warning → final written warning → suspension → termination; documentation must state the observed behavior, the standard violated, the corrective action, and the consequence of recurrence.

Delegation requires transfer of both authority and accountability for the task outcome while the manager retains overall responsibility; delegating a task without defined authority or deadline is abdication.

Change management: unfreeze–change–refreeze (Lewin); expect resistance to peak at the transition from planning to implementation, and address it with information, participation, and visible leadership support.

Competency validation has three elements: initial verification of education/experience/credentials, periodic performance review, and retraining/reassessment when a deficiency is identified.

Adult learning (andragogy) principles: adults need to know why the content matters, learn best from problem-centered and experience-based content, and require immediate applicability to their work.

Kirkpatrick's four evaluation levels - reaction, learning, behavior, results - measure training from trainee satisfaction up to organizational outcomes; a post-test score measures learning, not behavior or results.

Bloom's taxonomy cognitive levels, ascending: remember, understand, apply, analyze, evaluate, create; assessment items should match the level of the objective they test.

Continuing education and certification maintenance depend on documented contact hours or credits within a defined renewal cycle; lapsed credentials usually require a reinstatement process rather than simple payment.

A learning needs assessment should triangulate at least three sources: performance appraisal data, competency assessment gaps, and organizational/regulatory requirements.

Preceptor selection criteria typically include current clinical competence, a minimum tenure in the role (commonly one year), documented preceptor training, and no active corrective action.

Return demonstration is the preferred validation method for psychomotor skills; written testing validates knowledge but does not confirm safe performance of a procedure.

Orientation versus competency: orientation is time-bound onboarding to the organization and unit; competency is ongoing verification that the individual can perform the task to standard.

PDSA cycle: Plan (state the change and prediction) → Do (small-scale test) → Study (compare results to prediction) → Act (adopt, adapt, or abandon); a single PDSA is a test, not a completed improvement.

Model for Improvement requires three questions before any change: What are we trying to accomplish? How will we know a change is an improvement? What changes can we make that will result in improvement?

Run charts flag non-random variation by: a shift (six or more consecutive points on one side of the median), a trend (five or more consecutive increasing or decreasing points), or too few or too many runs.

Control chart selection: p-chart for proportion defective with variable sample size, np-chart for count defective with constant sample size, c-chart for defect counts per unit, u-chart for defects per unit with variable unit size, X-bar/S for continuous data.

Common-cause variation is inherent to the process and requires process redesign; special-cause variation is signaled by a control-chart rule violation and requires investigation of that specific event.

Root cause analysis is retrospective and reactive; failure mode and effects analysis (FMEA) is prospective and prioritizes by risk priority number = severity × occurrence × detection.

Structure measures describe capacity (staffing, equipment, facilities); process measures describe what is done (hand hygiene compliance); outcome measures describe results (infection rate).

Staffing calculation: required FTEs = (annual workload hours) ÷ (productive hours per FTE); productive hours per FTE = paid hours − benefit/vacation/education hours.

Benchmarking requires case-mix or acuity adjustment before comparing units; unadjusted comparisons of raw rates across units with different acuity are invalid.

Sentinel event: an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof; the event is analyzed through root cause analysis, and the analysis (not the event) is what triggers reporting obligations.

Never events are a defined subset of serious reportable events (for example wrong-site surgery, retained foreign object, transfusion with the wrong blood type) that are largely preventable and usually reportable to a state or accrediting body.

Root cause analysis is due within a defined window after a sentinel event (commonly 45 calendar days for accrediting-body purposes); the action plan must include measurable, assigned, time-bound corrective actions.

Plan of correction elements: what will be done, who is responsible, when it will be completed, and how effectiveness will be monitored; the monitoring element is the most frequently deficient part.

Informed consent requires capacity, disclosure of material risks and alternatives (including the alternative of no treatment), comprehension, and voluntariness; a signature alone does not establish informed consent.

HIPAA minimum necessary standard limits uses and disclosures to the least information needed for the purpose; treatment, payment, and health care operations are the permitted core uses, and psychotherapy notes require separate authorization.

A breach is presumed reportable unless a risk assessment demonstrates low probability of compromise of protected health information, based on the nature of the data, the recipient, whether it was actually acquired or viewed, and the extent of mitigation.

Quality assurance differs from quality improvement: QA is retrospective, individual-focused, and threshold-based; QI is prospective, system-focused, and continuous.

Accreditation surveys use tracer methodology, following the actual experience of selected patients across departments to test whether documented processes match practice.

Leadership style continuum: telling/directing (low follower maturity) → selling/coaching → participating/supporting → delegating (high follower maturity); style is selected by the follower's task-specific readiness, not by the leader's preference.

Situational leadership defines readiness by two independent axes: ability (knowledge, skill, experience) and willingness (confidence, commitment, motivation); a follower can be high on one and low on the other.

Transformational leadership comprises four components: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration; transactional leadership instead relies on contingent reward and management-by-exception.

Lewin's three styles: autocratic (leader decides), democratic (group input, leader decides), laissez-faire (group decides); autocratic is defensible in emergencies and code situations, democratic for quality improvement and change adoption.

Tuckman's team stages - forming, storming, norming, performing, adjourning - are sequential but not strictly linear; regression to storming is expected after membership change or a major process change.

Conflict modes (Thomas–Kilmann): competing, collaborating, compromising, avoiding, accommodating; collaborating is the only mode that seeks a fully win-win outcome and is preferred for important issues with time available.

Grievance and discipline progression: verbal counseling → written warning → final written warning → suspension → termination; documentation must state the observed behavior, the standard violated, the corrective action, and the consequence of recurrence.

Delegation requires transfer of both authority and accountability for the task outcome while the manager retains overall responsibility; delegating a task without defined authority or deadline is abdication.

Change management: unfreeze–change–refreeze (Lewin); expect resistance to peak at the transition from planning to implementation, and address it with information, participation, and visible leadership support.

Competency validation has three elements: initial verification of education/experience/credentials, periodic performance review, and retraining/reassessment when a deficiency is identified.

Adult learning (andragogy) principles: adults need to know why the content matters, learn best from problem-centered and experience-based content, and require immediate applicability to their work.

Kirkpatrick's four evaluation levels - reaction, learning, behavior, results - measure training from trainee satisfaction up to organizational outcomes; a post-test score measures learning, not behavior or results.

Bloom's taxonomy cognitive levels, ascending: remember, understand, apply, analyze, evaluate, create; assessment items should match the level of the objective they test.

Continuing education and certification maintenance depend on documented contact hours or credits within a defined renewal cycle; lapsed credentials usually require a reinstatement process rather than simple payment.

A learning needs assessment should triangulate at least three sources: performance appraisal data, competency assessment gaps, and organizational/regulatory requirements.

Preceptor selection criteria typically include current clinical competence, a minimum tenure in the role (commonly one year), documented preceptor training, and no active corrective action.

Return demonstration is the preferred validation method for psychomotor skills; written testing validates knowledge but does not confirm safe performance of a procedure.

Orientation versus competency: orientation is time-bound onboarding to the organization and unit; competency is ongoing verification that the individual can perform the task to standard.

PDSA cycle: Plan (state the change and prediction) → Do (small-scale test) → Study (compare results to prediction) → Act (adopt, adapt, or abandon); a single PDSA is a test, not a completed improvement.

Model for Improvement requires three questions before any change: What are we trying to accomplish? How will we know a change is an improvement? What changes can we make that will result in improvement?

Run charts flag non-random variation by: a shift (six or more consecutive points on one side of the median), a trend (five or more consecutive increasing or decreasing points), or too few or too many runs.

Control chart selection: p-chart for proportion defective with variable sample size, np-chart for count defective with constant sample size, c-chart for defect counts per unit, u-chart for defects per unit with variable unit size, X-bar/S for continuous data.

Common-cause variation is inherent to the process and requires process redesign; special-cause variation is signaled by a control-chart rule violation and requires investigation of that specific event.

Root cause analysis is retrospective and reactive; failure mode and effects analysis (FMEA) is prospective and prioritizes by risk priority number = severity × occurrence × detection.

Structure measures describe capacity (staffing, equipment, facilities); process measures describe what is done (hand hygiene compliance); outcome measures describe results (infection rate).

Staffing calculation: required FTEs = (annual workload hours) ÷ (productive hours per FTE); productive hours per FTE = paid hours − benefit/vacation/education hours.

Benchmarking requires case-mix or acuity adjustment before comparing units; unadjusted comparisons of raw rates across units with different acuity are invalid.

Sentinel event: an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof; the event is analyzed through root cause analysis, and the analysis (not the event) is what triggers reporting obligations.

Never events are a defined subset of serious reportable events (for example wrong-site surgery, retained foreign object, transfusion with the wrong blood type) that are largely preventable and usually reportable to a state or accrediting body.

Root cause analysis is due within a defined window after a sentinel event (commonly 45 calendar days for accrediting-body purposes); the action plan must include measurable, assigned, time-bound corrective actions.

Plan of correction elements: what will be done, who is responsible, when it will be completed, and how effectiveness will be monitored; the monitoring element is the most frequently deficient part.

Informed consent requires capacity, disclosure of material risks and alternatives (including the alternative of no treatment), comprehension, and voluntariness; a signature alone does not establish informed consent.

HIPAA minimum necessary standard limits uses and disclosures to the least information needed for the purpose; treatment, payment, and health care operations are the permitted core uses, and psychotherapy notes require separate authorization.

A breach is presumed reportable unless a risk assessment demonstrates low probability of compromise of protected health information, based on the nature of the data, the recipient, whether it was actually acquired or viewed, and the extent of mitigation.

Quality assurance differs from quality improvement: QA is retrospective, individual-focused, and threshold-based; QI is prospective, system-focused, and continuous.

Accreditation surveys use tracer methodology, following the actual experience of selected patients across departments to test whether documented processes match practice.

Leadership style continuum: telling/directing (low follower maturity) → selling/coaching → participating/supporting → delegating (high follower maturity); style is selected by the follower's task-specific readiness, not by the leader's preference.

Situational leadership defines readiness by two independent axes: ability (knowledge, skill, experience) and willingness (confidence, commitment, motivation); a follower can be high on one and low on the other.

Transformational leadership comprises four components: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration; transactional leadership instead relies on contingent reward and management-by-exception.

Lewin's three styles: autocratic (leader decides), democratic (group input, leader decides), laissez-faire (group decides); autocratic is defensible in emergencies and code situations, democratic for quality improvement and change adoption.

Tuckman's team stages - forming, storming, norming, performing, adjourning - are sequential but not strictly linear; regression to storming is expected after membership change or a major process change.

Conflict modes (Thomas–Kilmann): competing, collaborating, compromising, avoiding, accommodating; collaborating is the only mode that seeks a fully win-win outcome and is preferred for important issues with time available.

Grievance and discipline progression: verbal counseling → written warning → final written warning → suspension → termination; documentation must state the observed behavior, the standard violated, the corrective action, and the consequence of recurrence.

Delegation requires transfer of both authority and accountability for the task outcome while the manager retains overall responsibility; delegating a task without defined authority or deadline is abdication.

Change management: unfreeze–change–refreeze (Lewin); expect resistance to peak at the transition from planning to implementation, and address it with information, participation, and visible leadership support.

Competency validation has three elements: initial verification of education/experience/credentials, periodic performance review, and retraining/reassessment when a deficiency is identified.

Adult learning (andragogy) principles: adults need to know why the content matters, learn best from problem-centered and experience-based content, and require immediate applicability to their work.

Kirkpatrick's four evaluation levels - reaction, learning, behavior, results - measure training from trainee satisfaction up to organizational outcomes; a post-test score measures learning, not behavior or results.

Bloom's taxonomy cognitive levels, ascending: remember, understand, apply, analyze, evaluate, create; assessment items should match the level of the objective they test.

Continuing education and certification maintenance depend on documented contact hours or credits within a defined renewal cycle; lapsed credentials usually require a reinstatement process rather than simple payment.

A learning needs assessment should triangulate at least three sources: performance appraisal data, competency assessment gaps, and organizational/regulatory requirements.

Preceptor selection criteria typically include current clinical competence, a minimum tenure in the role (commonly one year), documented preceptor training, and no active corrective action.

Return demonstration is the preferred validation method for psychomotor skills; written testing validates knowledge but does not confirm safe performance of a procedure.

Orientation versus competency: orientation is time-bound onboarding to the organization and unit; competency is ongoing verification that the individual can perform the task to standard.

PDSA cycle: Plan (state the change and prediction) → Do (small-scale test) → Study (compare results to prediction) → Act (adopt, adapt, or abandon); a single PDSA is a test, not a completed improvement.

Model for Improvement requires three questions before any change: What are we trying to accomplish? How will we know a change is an improvement? What changes can we make that will result in improvement?

Run charts flag non-random variation by: a shift (six or more consecutive points on one side of the median), a trend (five or more consecutive increasing or decreasing points), or too few or too many runs.

Control chart selection: p-chart for proportion defective with variable sample size, np-chart for count defective with constant sample size, c-chart for defect counts per unit, u-chart for defects per unit with variable unit size, X-bar/S for continuous data.

Common-cause variation is inherent to the process and requires process redesign; special-cause variation is signaled by a control-chart rule violation and requires investigation of that specific event.

Root cause analysis is retrospective and reactive; failure mode and effects analysis (FMEA) is prospective and prioritizes by risk priority number = severity × occurrence × detection.

Structure measures describe capacity (staffing, equipment, facilities); process measures describe what is done (hand hygiene compliance); outcome measures describe results (infection rate).

Staffing calculation: required FTEs = (annual workload hours) ÷ (productive hours per FTE); productive hours per FTE = paid hours − benefit/vacation/education hours.

Benchmarking requires case-mix or acuity adjustment before comparing units; unadjusted comparisons of raw rates across units with different acuity are invalid.

Sentinel event: an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof; the event is analyzed through root cause analysis, and the analysis (not the event) is what triggers reporting obligations.

Never events are a defined subset of serious reportable events (for example wrong-site surgery, retained foreign object, transfusion with the wrong blood type) that are largely preventable and usually reportable to a state or accrediting body.

Root cause analysis is due within a defined window after a sentinel event (commonly 45 calendar days for accrediting-body purposes); the action plan must include measurable, assigned, time-bound corrective actions.

Plan of correction elements: what will be done, who is responsible, when it will be completed, and how effectiveness will be monitored; the monitoring element is the most frequently deficient part.

Informed consent requires capacity, disclosure of material risks and alternatives (including the alternative of no treatment), comprehension, and voluntariness; a signature alone does not establish informed consent.

HIPAA minimum necessary standard limits uses and disclosures to the least information needed for the purpose; treatment, payment, and health care operations are the permitted core uses, and psychotherapy notes require separate authorization.

A breach is presumed reportable unless a risk assessment demonstrates low probability of compromise of protected health information, based on the nature of the data, the recipient, whether it was actually acquired or viewed, and the extent of mitigation.

Quality assurance differs from quality improvement: QA is retrospective, individual-focused, and threshold-based; QI is prospective, system-focused, and continuous.

Accreditation surveys use tracer methodology, following the actual experience of selected patients across departments to test whether documented processes match practice.

Leadership style continuum: telling/directing (low follower maturity) → selling/coaching → participating/supporting → delegating (high follower maturity); style is selected by the follower's task-specific readiness, not by the leader's preference.

Situational leadership defines readiness by two independent axes: ability (knowledge, skill, experience) and willingness (confidence, commitment, motivation); a follower can be high on one and low on the other.

Transformational leadership comprises four components: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration; transactional leadership instead relies on contingent reward and management-by-exception.

Lewin's three styles: autocratic (leader decides), democratic (group input, leader decides), laissez-faire (group decides); autocratic is defensible in emergencies and code situations, democratic for quality improvement and change adoption.

Tuckman's team stages - forming, storming, norming, performing, adjourning - are sequential but not strictly linear; regression to storming is expected after membership change or a major process change.

Conflict modes (Thomas–Kilmann): competing, collaborating, compromising, avoiding, accommodating; collaborating is the only mode that seeks a fully win-win outcome and is preferred for important issues with time available.

Grievance and discipline progression: verbal counseling → written warning → final written warning → suspension → termination; documentation must state the observed behavior, the standard violated, the corrective action, and the consequence of recurrence.

Delegation requires transfer of both authority and accountability for the task outcome while the manager retains overall responsibility; delegating a task without defined authority or deadline is abdication.

Change management: unfreeze–change–refreeze (Lewin); expect resistance to peak at the transition from planning to implementation, and address it with information, participation, and visible leadership support.

Competency validation has three elements: initial verification of education/experience/credentials, periodic performance review, and retraining/reassessment when a deficiency is identified.

Adult learning (andragogy) principles: adults need to know why the content matters, learn best from problem-centered and experience-based content, and require immediate applicability to their work.

Kirkpatrick's four evaluation levels - reaction, learning, behavior, results - measure training from trainee satisfaction up to organizational outcomes; a post-test score measures learning, not behavior or results.

Bloom's taxonomy cognitive levels, ascending: remember, understand, apply, analyze, evaluate, create; assessment items should match the level of the objective they test.

Continuing education and certification maintenance depend on documented contact hours or credits within a defined renewal cycle; lapsed credentials usually require a reinstatement process rather than simple payment.

A learning needs assessment should triangulate at least three sources: performance appraisal data, competency assessment gaps, and organizational/regulatory requirements.

Preceptor selection criteria typically include current clinical competence, a minimum tenure in the role (commonly one year), documented preceptor training, and no active corrective action.

Return demonstration is the preferred validation method for psychomotor skills; written testing validates knowledge but does not confirm safe performance of a procedure.

Orientation versus competency: orientation is time-bound onboarding to the organization and unit; competency is ongoing verification that the individual can perform the task to standard.

PDSA cycle: Plan (state the change and prediction) → Do (small-scale test) → Study (compare results to prediction) → Act (adopt, adapt, or abandon); a single PDSA is a test, not a completed improvement.

Model for Improvement requires three questions before any change: What are we trying to accomplish? How will we know a change is an improvement? What changes can we make that will result in improvement?

Run charts flag non-random variation by: a shift (six or more consecutive points on one side of the median), a trend (five or more consecutive increasing or decreasing points), or too few or too many runs.

Control chart selection: p-chart for proportion defective with variable sample size, np-chart for count defective with constant sample size, c-chart for defect counts per unit, u-chart for defects per unit with variable unit size, X-bar/S for continuous data.

Common-cause variation is inherent to the process and requires process redesign; special-cause variation is signaled by a control-chart rule violation and requires investigation of that specific event.

Root cause analysis is retrospective and reactive; failure mode and effects analysis (FMEA) is prospective and prioritizes by risk priority number = severity × occurrence × detection.

Structure measures describe capacity (staffing, equipment, facilities); process measures describe what is done (hand hygiene compliance); outcome measures describe results (infection rate).

Staffing calculation: required FTEs = (annual workload hours) ÷ (productive hours per FTE); productive hours per FTE = paid hours − benefit/vacation/education hours.

Benchmarking requires case-mix or acuity adjustment before comparing units; unadjusted comparisons of raw rates across units with different acuity are invalid.

Sentinel event: an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof; the event is analyzed through root cause analysis, and the analysis (not the event) is what triggers reporting obligations.

Never events are a defined subset of serious reportable events (for example wrong-site surgery, retained foreign object, transfusion with the wrong blood type) that are largely preventable and usually reportable to a state or accrediting body.

Root cause analysis is due within a defined window after a sentinel event (commonly 45 calendar days for accrediting-body purposes); the action plan must include measurable, assigned, time-bound corrective actions.

Plan of correction elements: what will be done, who is responsible, when it will be completed, and how effectiveness will be monitored; the monitoring element is the most frequently deficient part.

Informed consent requires capacity, disclosure of material risks and alternatives (including the alternative of no treatment), comprehension, and voluntariness; a signature alone does not establish informed consent.

HIPAA minimum necessary standard limits uses and disclosures to the least information needed for the purpose; treatment, payment, and health care operations are the permitted core uses, and psychotherapy notes require separate authorization.

A breach is presumed reportable unless a risk assessment demonstrates low probability of compromise of protected health information, based on the nature of the data, the recipient, whether it was actually acquired or viewed, and the extent of mitigation.

Quality assurance differs from quality improvement: QA is retrospective, individual-focused, and threshold-based; QI is prospective, system-focused, and continuous.

Accreditation surveys use tracer methodology, following the actual experience of selected patients across departments to test whether documented processes match practice.

Leadership style continuum: telling/directing (low follower maturity) → selling/coaching → participating/supporting → delegating (high follower maturity); style is selected by the follower's task-specific readiness, not by the leader's preference.

Situational leadership defines readiness by two independent axes: ability (knowledge, skill, experience) and willingness (confidence, commitment, motivation); a follower can be high on one and low on the other.

Transformational leadership comprises four components: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration; transactional leadership instead relies on contingent reward and management-by-exception.

Lewin's three styles: autocratic (leader decides), democratic (group input, leader decides), laissez-faire (group decides); autocratic is defensible in emergencies and code situations, democratic for quality improvement and change adoption.

Tuckman's team stages - forming, storming, norming, performing, adjourning - are sequential but not strictly linear; regression to storming is expected after membership change or a major process change.

Conflict modes (Thomas–Kilmann): competing, collaborating, compromising, avoiding, accommodating; collaborating is the only mode that seeks a fully win-win outcome and is preferred for important issues with time available.

Grievance and discipline progression: verbal counseling → written warning → final written warning → suspension → termination; documentation must state the observed behavior, the standard violated, the corrective action, and the consequence of recurrence.

Delegation requires transfer of both authority and accountability for the task outcome while the manager retains overall responsibility; delegating a task without defined authority or deadline is abdication.

Change management: unfreeze–change–refreeze (Lewin); expect resistance to peak at the transition from planning to implementation, and address it with information, participation, and visible leadership support.

Competency validation has three elements: initial verification of education/experience/credentials, periodic performance review, and retraining/reassessment when a deficiency is identified.

Adult learning (andragogy) principles: adults need to know why the content matters, learn best from problem-centered and experience-based content, and require immediate applicability to their work.

Kirkpatrick's four evaluation levels - reaction, learning, behavior, results - measure training from trainee satisfaction up to organizational outcomes; a post-test score measures learning, not behavior or results.

Bloom's taxonomy cognitive levels, ascending: remember, understand, apply, analyze, evaluate, create; assessment items should match the level of the objective they test.

Continuing education and certification maintenance depend on documented contact hours or credits within a defined renewal cycle; lapsed credentials usually require a reinstatement process rather than simple payment.

A learning needs assessment should triangulate at least three sources: performance appraisal data, competency assessment gaps, and organizational/regulatory requirements.

Preceptor selection criteria typically include current clinical competence, a minimum tenure in the role (commonly one year), documented preceptor training, and no active corrective action.

Return demonstration is the preferred validation method for psychomotor skills; written testing validates knowledge but does not confirm safe performance of a procedure.

Orientation versus competency: orientation is time-bound onboarding to the organization and unit; competency is ongoing verification that the individual can perform the task to standard.

PDSA cycle: Plan (state the change and prediction) → Do (small-scale test) → Study (compare results to prediction) → Act (adopt, adapt, or abandon); a single PDSA is a test, not a completed improvement.

Model for Improvement requires three questions before any change: What are we trying to accomplish? How will we know a change is an improvement? What changes can we make that will result in improvement?

Run charts flag non-random variation by: a shift (six or more consecutive points on one side of the median), a trend (five or more consecutive increasing or decreasing points), or too few or too many runs.

Control chart selection: p-chart for proportion defective with variable sample size, np-chart for count defective with constant sample size, c-chart for defect counts per unit, u-chart for defects per unit with variable unit size, X-bar/S for continuous data.

Common-cause variation is inherent to the process and requires process redesign; special-cause variation is signaled by a control-chart rule violation and requires investigation of that specific event.

Root cause analysis is retrospective and reactive; failure mode and effects analysis (FMEA) is prospective and prioritizes by risk priority number = severity × occurrence × detection.

Structure measures describe capacity (staffing, equipment, facilities); process measures describe what is done (hand hygiene compliance); outcome measures describe results (infection rate).

Staffing calculation: required FTEs = (annual workload hours) ÷ (productive hours per FTE); productive hours per FTE = paid hours − benefit/vacation/education hours.

Benchmarking requires case-mix or acuity adjustment before comparing units; unadjusted comparisons of raw rates across units with different acuity are invalid.

Sentinel event: an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof; the event is analyzed through root cause analysis, and the analysis (not the event) is what triggers reporting obligations.

Never events are a defined subset of serious reportable events (for example wrong-site surgery, retained foreign object, transfusion with the wrong blood type) that are largely preventable and usually reportable to a state or accrediting body.

Root cause analysis is due within a defined window after a sentinel event (commonly 45 calendar days for accrediting-body purposes); the action plan must include measurable, assigned, time-bound corrective actions.

Plan of correction elements: what will be done, who is responsible, when it will be completed, and how effectiveness will be monitored; the monitoring element is the most frequently deficient part.

Informed consent requires capacity, disclosure of material risks and alternatives (including the alternative of no treatment), comprehension, and voluntariness; a signature alone does not establish informed consent.

HIPAA minimum necessary standard limits uses and disclosures to the least information needed for the purpose; treatment, payment, and health care operations are the permitted core uses, and psychotherapy notes require separate authorization.

A breach is presumed reportable unless a risk assessment demonstrates low probability of compromise of protected health information, based on the nature of the data, the recipient, whether it was actually acquired or viewed, and the extent of mitigation.

Quality assurance differs from quality improvement: QA is retrospective, individual-focused, and threshold-based; QI is prospective, system-focused, and continuous.

Accreditation surveys use tracer methodology, following the actual experience of selected patients across departments to test whether documented processes match practice.

Leadership style continuum: telling/directing (low follower maturity) → selling/coaching → participating/supporting → delegating (high follower maturity); style is selected by the follower's task-specific readiness, not by the leader's preference.

Situational leadership defines readiness by two independent axes: ability (knowledge, skill, experience) and willingness (confidence, commitment, motivation); a follower can be high on one and low on the other.

Transformational leadership comprises four components: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration; transactional leadership instead relies on contingent reward and management-by-exception.

Lewin's three styles: autocratic (leader decides), democratic (group input, leader decides), laissez-faire (group decides); autocratic is defensible in emergencies and code situations, democratic for quality improvement and change adoption.

Tuckman's team stages - forming, storming, norming, performing, adjourning - are sequential but not strictly linear; regression to storming is expected after membership change or a major process change.

Conflict modes (Thomas–Kilmann): competing, collaborating, compromising, avoiding, accommodating; collaborating is the only mode that seeks a fully win-win outcome and is preferred for important issues with time available.

Grievance and discipline progression: verbal counseling → written warning → final written warning → suspension → termination; documentation must state the observed behavior, the standard violated, the corrective action, and the consequence of recurrence.

Delegation requires transfer of both authority and accountability for the task outcome while the manager retains overall responsibility; delegating a task without defined authority or deadline is abdication.

Change management: unfreeze–change–refreeze (Lewin); expect resistance to peak at the transition from planning to implementation, and address it with information, participation, and visible leadership support.

Competency validation has three elements: initial verification of education/experience/credentials, periodic performance review, and retraining/reassessment when a deficiency is identified.

Adult learning (andragogy) principles: adults need to know why the content matters, learn best from problem-centered and experience-based content, and require immediate applicability to their work.

Kirkpatrick's four evaluation levels - reaction, learning, behavior, results - measure training from trainee satisfaction up to organizational outcomes; a post-test score measures learning, not behavior or results.

Bloom's taxonomy cognitive levels, ascending: remember, understand, apply, analyze, evaluate, create; assessment items should match the level of the objective they test.

Continuing education and certification maintenance depend on documented contact hours or credits within a defined renewal cycle; lapsed credentials usually require a reinstatement process rather than simple payment.

A learning needs assessment should triangulate at least three sources: performance appraisal data, competency assessment gaps, and organizational/regulatory requirements.

Preceptor selection criteria typically include current clinical competence, a minimum tenure in the role (commonly one year), documented preceptor training, and no active corrective action.

Return demonstration is the preferred validation method for psychomotor skills; written testing validates knowledge but does not confirm safe performance of a procedure.

Orientation versus competency: orientation is time-bound onboarding to the organization and unit; competency is ongoing verification that the individual can perform the task to standard.

PDSA cycle: Plan (state the change and prediction) → Do (small-scale test) → Study (compare results to prediction) → Act (adopt, adapt, or abandon); a single PDSA is a test, not a completed improvement.

Model for Improvement requires three questions before any change: What are we trying to accomplish? How will we know a change is an improvement? What changes can we make that will result in improvement?

Run charts flag non-random variation by: a shift (six or more consecutive points on one side of the median), a trend (five or more consecutive increasing or decreasing points), or too few or too many runs.

Control chart selection: p-chart for proportion defective with variable sample size, np-chart for count defective with constant sample size, c-chart for defect counts per unit, u-chart for defects per unit with variable unit size, X-bar/S for continuous data.

Common-cause variation is inherent to the process and requires process redesign; special-cause variation is signaled by a control-chart rule violation and requires investigation of that specific event.

Root cause analysis is retrospective and reactive; failure mode and effects analysis (FMEA) is prospective and prioritizes by risk priority number = severity × occurrence × detection.

Structure measures describe capacity (staffing, equipment, facilities); process measures describe what is done (hand hygiene compliance); outcome measures describe results (infection rate).

Staffing calculation: required FTEs = (annual workload hours) ÷ (productive hours per FTE); productive hours per FTE = paid hours − benefit/vacation/education hours.

Benchmarking requires case-mix or acuity adjustment before comparing units; unadjusted comparisons of raw rates across units with different acuity are invalid.

Sentinel event: an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof; the event is analyzed through root cause analysis, and the analysis (not the event) is what triggers reporting obligations.

Never events are a defined subset of serious reportable events (for example wrong-site surgery, retained foreign object, transfusion with the wrong blood type) that are largely preventable and usually reportable to a state or accrediting body.

Root cause analysis is due within a defined window after a sentinel event (commonly 45 calendar days for accrediting-body purposes); the action plan must include measurable, assigned, time-bound corrective actions.

Plan of correction elements: what will be done, who is responsible, when it will be completed, and how effectiveness will be monitored; the monitoring element is the most frequently deficient part.

Informed consent requires capacity, disclosure of material risks and alternatives (including the alternative of no treatment), comprehension, and voluntariness; a signature alone does not establish informed consent.

HIPAA minimum necessary standard limits uses and disclosures to the least information needed for the purpose; treatment, payment, and health care operations are the permitted core uses, and psychotherapy notes require separate authorization.

A breach is presumed reportable unless a risk assessment demonstrates low probability of compromise of protected health information, based on the nature of the data, the recipient, whether it was actually acquired or viewed, and the extent of mitigation.

Quality assurance differs from quality improvement: QA is retrospective, individual-focused, and threshold-based; QI is prospective, system-focused, and continuous.

Accreditation surveys use tracer methodology, following the actual experience of selected patients across departments to test whether documented processes match practice.

Leadership style continuum: telling/directing (low follower maturity) → selling/coaching → participating/supporting → delegating (high follower maturity); style is selected by the follower's task-specific readiness, not by the leader's preference.

Situational leadership defines readiness by two independent axes: ability (knowledge, skill, experience) and willingness (confidence, commitment, motivation); a follower can be high on one and low on the other.

Transformational leadership comprises four components: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration; transactional leadership instead relies on contingent reward and management-by-exception.

Lewin's three styles: autocratic (leader decides), democratic (group input, leader decides), laissez-faire (group decides); autocratic is defensible in emergencies and code situations, democratic for quality improvement and change adoption.

Tuckman's team stages - forming, storming, norming, performing, adjourning - are sequential but not strictly linear; regression to storming is expected after membership change or a major process change.

Conflict modes (Thomas–Kilmann): competing, collaborating, compromising, avoiding, accommodating; collaborating is the only mode that seeks a fully win-win outcome and is preferred for important issues with time available.

Grievance and discipline progression: verbal counseling → written warning → final written warning → suspension → termination; documentation must state the observed behavior, the standard violated, the corrective action, and the consequence of recurrence.

Delegation requires transfer of both authority and accountability for the task outcome while the manager retains overall responsibility; delegating a task without defined authority or deadline is abdication.

Change management: unfreeze–change–refreeze (Lewin); expect resistance to peak at the transition from planning to implementation, and address it with information, participation, and visible leadership support.

Competency validation has three elements: initial verification of education/experience/credentials, periodic performance review, and retraining/reassessment when a deficiency is identified.

Adult learning (andragogy) principles: adults need to know why the content matters, learn best from problem-centered and experience-based content, and require immediate applicability to their work.

Kirkpatrick's four evaluation levels - reaction, learning, behavior, results - measure training from trainee satisfaction up to organizational outcomes; a post-test score measures learning, not behavior or results.

Bloom's taxonomy cognitive levels, ascending: remember, understand, apply, analyze, evaluate, create; assessment items should match the level of the objective they test.

Continuing education and certification maintenance depend on documented contact hours or credits within a defined renewal cycle; lapsed credentials usually require a reinstatement process rather than simple payment.

A learning needs assessment should triangulate at least three sources: performance appraisal data, competency assessment gaps, and organizational/regulatory requirements.

Preceptor selection criteria typically include current clinical competence, a minimum tenure in the role (commonly one year), documented preceptor training, and no active corrective action.

Return demonstration is the preferred validation method for psychomotor skills; written testing validates knowledge but does not confirm safe performance of a procedure.

Orientation versus competency: orientation is time-bound onboarding to the organization and unit; competency is ongoing verification that the individual can perform the task to standard.

PDSA cycle: Plan (state the change and prediction) → Do (small-scale test) → Study (compare results to prediction) → Act (adopt, adapt, or abandon); a single PDSA is a test, not a completed improvement.

Model for Improvement requires three questions before any change: What are we trying to accomplish? How will we know a change is an improvement? What changes can we make that will result in improvement?

Run charts flag non-random variation by: a shift (six or more consecutive points on one side of the median), a trend (five or more consecutive increasing or decreasing points), or too few or too many runs.

Control chart selection: p-chart for proportion defective with variable sample size, np-chart for count defective with constant sample size, c-chart for defect counts per unit, u-chart for defects per unit with variable unit size, X-bar/S for continuous data.

Common-cause variation is inherent to the process and requires process redesign; special-cause variation is signaled by a control-chart rule violation and requires investigation of that specific event.

Root cause analysis is retrospective and reactive; failure mode and effects analysis (FMEA) is prospective and prioritizes by risk priority number = severity × occurrence × detection.

Structure measures describe capacity (staffing, equipment, facilities); process measures describe what is done (hand hygiene compliance); outcome measures describe results (infection rate).

Staffing calculation: required FTEs = (annual workload hours) ÷ (productive hours per FTE); productive hours per FTE = paid hours − benefit/vacation/education hours.

Benchmarking requires case-mix or acuity adjustment before comparing units; unadjusted comparisons of raw rates across units with different acuity are invalid.

Sentinel event: an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof; the event is analyzed through root cause analysis, and the analysis (not the event) is what triggers reporting obligations.

Never events are a defined subset of serious reportable events (for example wrong-site surgery, retained foreign object, transfusion with the wrong blood type) that are largely preventable and usually reportable to a state or accrediting body.

Root cause analysis is due within a defined window after a sentinel event (commonly 45 calendar days for accrediting-body purposes); the action plan must include measurable, assigned, time-bound corrective actions.

Plan of correction elements: what will be done, who is responsible, when it will be completed, and how effectiveness will be monitored; the monitoring element is the most frequently deficient part.

Informed consent requires capacity, disclosure of material risks and alternatives (including the alternative of no treatment), comprehension, and voluntariness; a signature alone does not establish informed consent.

HIPAA minimum necessary standard limits uses and disclosures to the least information needed for the purpose; treatment, payment, and health care operations are the permitted core uses, and psychotherapy notes require separate authorization.

A breach is presumed reportable unless a risk assessment demonstrates low probability of compromise of protected health information, based on the nature of the data, the recipient, whether it was actually acquired or viewed, and the extent of mitigation.

Quality assurance differs from quality improvement: QA is retrospective, individual-focused, and threshold-based; QI is prospective, system-focused, and continuous.

Accreditation surveys use tracer methodology, following the actual experience of selected patients across departments to test whether documented processes match practice.