CPHQ QUESTIONS AND CORRECT ANSWERS
Adverse Event - Answers - Unintended harm resulting from medical care.
What does SMART stand for? - Answers - Specific, Measureable, Achievable, Relevant,
Time-Bound
Accreditation - Answers - formal recognition by a authorized body indicating a
compliance with standards
Benchmarking - Answers - Comparing performance metrics against industry standards.
Balanced Scorecard - Answers - A strategic planning tool tracking financial, customer
process, and learning metrics
CAUTI - Answers - catheter associated urinary tract infection
Control Chart - Answers - Statistical tool monitoring process variation over time
Dashboard - Answers - Visual display of real time data (infection rates, readmission) for
decision making
DMAIC - Answers - Define, Measure, Analyze, Improve, Control - Is the Six Sigma
framework for process improvement
EBP - Answers - evidence based practice- Clinical decisions grounded in research,
patient preferences, and clinical expertise.
EQRO - Answers - External Quality Review Organization, Entity auditing Medicaid/CHIP
programs for CMS compliance
FMEA - Answers - Failure Mode and Effects Analysis: process used to identify potential
failures before they result with the intent to minimize or eliminate them
Forcing Function - Answers - Design element preventing errors ( ehr alert requiring
dose confirmation)
Gemba - Answers - Lean term meaning the real place ( example: observing workflows
at the nurses' station)
Global Trigger Tool - Answers - Method for retrospective adverse event detection in
medical records
, HRO - Answers - High Reliability Organization: Institution prioritizing safety via
mindfulness, reluctance to simplify, and deference to expertise
HEDIS - Answers - Healthcare Effectiveness Data and Information Set
IHI - Answers - Institute for Healthcare Improvement
Nonprofit organization focused on patient safety
IRB - Answers - Institutional Review Board, review research in advance to ensure
ethical considerations are met
Just Culture - Answers - Accountability framework balancing system flaws and
individual responsibility for errors
Joint Commission Sentinel Event - Answers - Unexpected occurrence involving death,
severe harm, requiring RCA within 45 days
KSA - Answers - Knowledge, skills, or abilities needed to effectively perform a job.
Key Driver - Answers - Primary factor influencing the success of a quality initiative.
(example: leadership buyin)
Lean - Answers - Methodology minimizing waste (overproduction, waiting) in workflows
LOS - Answers - Length of stay- metric tied to resource utilization and reimbursement
penalties
Morbidity and Mortality Conference - Answers - Forum for clinicians to review
complications/deaths and identify improvements
Meaningful Use - Answers - the use of certified electronic health record technology to
improve care quality
NPSG - Answers - National Patient Safety Goals: Annual joint commission priorities
(example: suicide risk assessments)
Never Event - Answers - A preventable error, treatment of which is not reimbursed by
Medicare and Medicaid.
Oryx - Answers - An initiative of TJC that implements 5 core measures to improve
safety and quality of health care in hospitals
Outcome Measures - Answers - Metrics reflecting patient health or the results of the
care provided (example: mortality rates, functional status)
PDSA - Answers - Plan-Do-Study-Act
Adverse Event - Answers - Unintended harm resulting from medical care.
What does SMART stand for? - Answers - Specific, Measureable, Achievable, Relevant,
Time-Bound
Accreditation - Answers - formal recognition by a authorized body indicating a
compliance with standards
Benchmarking - Answers - Comparing performance metrics against industry standards.
Balanced Scorecard - Answers - A strategic planning tool tracking financial, customer
process, and learning metrics
CAUTI - Answers - catheter associated urinary tract infection
Control Chart - Answers - Statistical tool monitoring process variation over time
Dashboard - Answers - Visual display of real time data (infection rates, readmission) for
decision making
DMAIC - Answers - Define, Measure, Analyze, Improve, Control - Is the Six Sigma
framework for process improvement
EBP - Answers - evidence based practice- Clinical decisions grounded in research,
patient preferences, and clinical expertise.
EQRO - Answers - External Quality Review Organization, Entity auditing Medicaid/CHIP
programs for CMS compliance
FMEA - Answers - Failure Mode and Effects Analysis: process used to identify potential
failures before they result with the intent to minimize or eliminate them
Forcing Function - Answers - Design element preventing errors ( ehr alert requiring
dose confirmation)
Gemba - Answers - Lean term meaning the real place ( example: observing workflows
at the nurses' station)
Global Trigger Tool - Answers - Method for retrospective adverse event detection in
medical records
, HRO - Answers - High Reliability Organization: Institution prioritizing safety via
mindfulness, reluctance to simplify, and deference to expertise
HEDIS - Answers - Healthcare Effectiveness Data and Information Set
IHI - Answers - Institute for Healthcare Improvement
Nonprofit organization focused on patient safety
IRB - Answers - Institutional Review Board, review research in advance to ensure
ethical considerations are met
Just Culture - Answers - Accountability framework balancing system flaws and
individual responsibility for errors
Joint Commission Sentinel Event - Answers - Unexpected occurrence involving death,
severe harm, requiring RCA within 45 days
KSA - Answers - Knowledge, skills, or abilities needed to effectively perform a job.
Key Driver - Answers - Primary factor influencing the success of a quality initiative.
(example: leadership buyin)
Lean - Answers - Methodology minimizing waste (overproduction, waiting) in workflows
LOS - Answers - Length of stay- metric tied to resource utilization and reimbursement
penalties
Morbidity and Mortality Conference - Answers - Forum for clinicians to review
complications/deaths and identify improvements
Meaningful Use - Answers - the use of certified electronic health record technology to
improve care quality
NPSG - Answers - National Patient Safety Goals: Annual joint commission priorities
(example: suicide risk assessments)
Never Event - Answers - A preventable error, treatment of which is not reimbursed by
Medicare and Medicaid.
Oryx - Answers - An initiative of TJC that implements 5 core measures to improve
safety and quality of health care in hospitals
Outcome Measures - Answers - Metrics reflecting patient health or the results of the
care provided (example: mortality rates, functional status)
PDSA - Answers - Plan-Do-Study-Act
