CPHQ STUDY GUIDE
H Appointment - Answers - Selection for membership in a medical professional staff or
to a practitioner panel.
H Appraisal - Answers - Initial evaluation by peers of a practitioner's competency to
provide care and services to patients in or for a healthcare origination. Appraisal may
include credentialing, privileging, proctoring and appointment.
H Benchmark - Answers - A comparative "best" as baseline for improvement.
H Clinical Path - Answers - A prospective, detailed, strategic treatment regimen, or
daily/intermittent protocol for patient care, designed to identify and integrate key
activities, interventions, and services for certain patient conditions. Clinical paths are
applicable across the continuum of care, e.g., in acute care form pre-admission and pre-
operative treatment through the hospital stay to discharge and post-discharge phases of
care, including home care. Clinical/critical paths are designed to include clinical
performance criteria for specified time periods of intervals, organized by categories of
care needs, e.g., diagnostics, treatments, activity, medications, psychosocial, etc. They
are useful tools for measuring actual performance.
H Crisis Management - Answers - 1) Forecasting potential crisis and planning how to
deal with them (proactive) and 2) When a crisis occurs, identifying its full nature,
intervening to minimize damage, and recovering (reactive).
H Dephi Technique - Answers - A structured communication technique, a systematic,
interactive forecasting method which relies on a panel of experts. The experts answer
questionnaires in two or more rounds. After each round, a facilitator provides an
anonymous summary of the experts' forecasts from the previous round as well as the
reasons they provided for their judgments. Thus, experts are encouraged to revise their
earlier answers in light of the replies of other members of their panel. It is believed that
during this process the range of the answers will decrease and the group will converge
towards the "correct" answer. Finally, the process is stopped after a pre-defined stop
criterion (e.g. number of rounds, achievement of consensus, stability of results) and the
mean or median scores of the final rounds determine the results.
H Demand Management - Answers - Term from economics; in project management it
refers to meeting customer expectations; in managed care it refers to influencing access
to medical care.
H Disease Management - Answers - Disease management is a system of coordinated
healthcare interventions and communications for populations with conditions in which
patient self-care efforts are significant.
,H Ethic - Answers - A set of principles of right conduct.
H Ethics - Answers - Rules or standards governing conduct.
H Event - Answers - An occurrence that is either deemed to be, or results in a
significant problem. e.g., sentinel event, adverse event, near miss event.
H E&CF Chart - Answers - Events and Causal Factors: Used to find root causes.
Combines a flowchart and affinity diagram to identify both the sequence of events and
relevant conditions affecting each event.
H Failure Mode - Answers - The way a process can fail to function or fail to provide the
desired result; an undesirable variation in a process.
H FMEA - Answers - Failure Mode and Effects Analysis: A team-based quality
improvement tool hat prospectively assesses, identifies, and improves steps in a
process to reasonably ensure a safe and clinically desirable outcome [NCPS]: A
systematic mechanism to identify and prevent product and process failures before they
occur.
H Flowchart - Answers - A pictorial representation displaying the actual-sequence of
steps and their inter-relationships in a specific process in order to identify hand-offs,
inefficiencies, redundancies, inspections, and waiting steps and/or the ideal-sequence
of steps, once the actual process is known.
H Force Field Analysis - Answers - A change management tool. Looks at forces for and
against a change; 1) to decide if the change should be attempted or 2) used to create
strategies to increase support and decrease opposition.
H Gantt Chart - Answers - Project planning tool for developing schedules; a graphic
display of individual parts of a quality improvement process as bars on a horizontal time
scale.
H HAI - Answers - Healthcare-Associated Infection: Replaces "nosocomial infection"
(hospital-acquired) because it implies all health care and is not limited to hospitals.
{More general Healthcare-Acquired Conditions {HAC}}
H Iatrogenic - Answers - An infection or other complication of treatment induced in a
patient by a physician's or other licensed independent practitioner's activity, manner, or
therapy.
H Indicator - Answers - "Performance Measure": Includes data definitions, as well as
numerator and denominator statements, to accurately specify what is being measured.
, H Integrated Delivery System - Horizontal - Answers - Multi-institutional entity with
coordinated functions, activities, or operating units that are at the same stage or
segment of the continuum of care, e.g., hospital system.
H Integrated Delivery System - Vertical - Answers - A network of entities that provide
and coordinate healthcare to a defined population across the entire continuum of care:
prevention, ambulatory, subacute, acute, and long term.
H Interrelationship Diagram - Answers - A tool that allows a team to analyze all the
interrelated cause-and-effect relationships and factors involved in a complex problem;
distinguish between issues that serve as drivers and those that are outcomes; and
describe desired outcomes.
H Leadership Group - Answers - "Individuals in senior positions with clearly defined,
unique responsibilities." Possible groups include governance, management, medical
staff, nursing, other clinical staff. An individual may be a member of more than one
group.
H LIP - Answers - Licensed Independent Practitioner: Any individual who is
professionally licensed by the state (US) and permitted by the organization to provide
patient care services without direction or supervision, within the scope of that license.
H Management - Answers - The sum of the activities of: planning, organizing, staffing,
directing, coordinating, and working to improve human and material resources toward
the achievement of stated goals.
H Medicare - Answers - Age 65+, permanent kidney failure, and disabled. Managed by
CMS.
H Medicaid - Answers - Low-income, managed by each state.
H Mission - Answers - The written expression of the origination's overall, broad purpose
and role (what/who the organization is). In a quality improvement environment it is
expected that the statement of mission will express a high-priority, comprehensive
commitment to patient care, to quality in all activities, and to service to the community.
The mission statement is the basis for the formation of organizational vision, values,
goals, and objectives.
H Monitoring and Evaluation - Answers - Historically a data collection process that
focused on high-priority quality-of-care issues and was designed to facilitate problem
solving and the identification of opportunities to improve.
H Negligence - Answers - Lack of proper care, as judged by peers.
A person who alleges negligent medical malpractice must prove four elements: (1) a
duty of care was owed by the physician; (2) the physician violated the applicable
H Appointment - Answers - Selection for membership in a medical professional staff or
to a practitioner panel.
H Appraisal - Answers - Initial evaluation by peers of a practitioner's competency to
provide care and services to patients in or for a healthcare origination. Appraisal may
include credentialing, privileging, proctoring and appointment.
H Benchmark - Answers - A comparative "best" as baseline for improvement.
H Clinical Path - Answers - A prospective, detailed, strategic treatment regimen, or
daily/intermittent protocol for patient care, designed to identify and integrate key
activities, interventions, and services for certain patient conditions. Clinical paths are
applicable across the continuum of care, e.g., in acute care form pre-admission and pre-
operative treatment through the hospital stay to discharge and post-discharge phases of
care, including home care. Clinical/critical paths are designed to include clinical
performance criteria for specified time periods of intervals, organized by categories of
care needs, e.g., diagnostics, treatments, activity, medications, psychosocial, etc. They
are useful tools for measuring actual performance.
H Crisis Management - Answers - 1) Forecasting potential crisis and planning how to
deal with them (proactive) and 2) When a crisis occurs, identifying its full nature,
intervening to minimize damage, and recovering (reactive).
H Dephi Technique - Answers - A structured communication technique, a systematic,
interactive forecasting method which relies on a panel of experts. The experts answer
questionnaires in two or more rounds. After each round, a facilitator provides an
anonymous summary of the experts' forecasts from the previous round as well as the
reasons they provided for their judgments. Thus, experts are encouraged to revise their
earlier answers in light of the replies of other members of their panel. It is believed that
during this process the range of the answers will decrease and the group will converge
towards the "correct" answer. Finally, the process is stopped after a pre-defined stop
criterion (e.g. number of rounds, achievement of consensus, stability of results) and the
mean or median scores of the final rounds determine the results.
H Demand Management - Answers - Term from economics; in project management it
refers to meeting customer expectations; in managed care it refers to influencing access
to medical care.
H Disease Management - Answers - Disease management is a system of coordinated
healthcare interventions and communications for populations with conditions in which
patient self-care efforts are significant.
,H Ethic - Answers - A set of principles of right conduct.
H Ethics - Answers - Rules or standards governing conduct.
H Event - Answers - An occurrence that is either deemed to be, or results in a
significant problem. e.g., sentinel event, adverse event, near miss event.
H E&CF Chart - Answers - Events and Causal Factors: Used to find root causes.
Combines a flowchart and affinity diagram to identify both the sequence of events and
relevant conditions affecting each event.
H Failure Mode - Answers - The way a process can fail to function or fail to provide the
desired result; an undesirable variation in a process.
H FMEA - Answers - Failure Mode and Effects Analysis: A team-based quality
improvement tool hat prospectively assesses, identifies, and improves steps in a
process to reasonably ensure a safe and clinically desirable outcome [NCPS]: A
systematic mechanism to identify and prevent product and process failures before they
occur.
H Flowchart - Answers - A pictorial representation displaying the actual-sequence of
steps and their inter-relationships in a specific process in order to identify hand-offs,
inefficiencies, redundancies, inspections, and waiting steps and/or the ideal-sequence
of steps, once the actual process is known.
H Force Field Analysis - Answers - A change management tool. Looks at forces for and
against a change; 1) to decide if the change should be attempted or 2) used to create
strategies to increase support and decrease opposition.
H Gantt Chart - Answers - Project planning tool for developing schedules; a graphic
display of individual parts of a quality improvement process as bars on a horizontal time
scale.
H HAI - Answers - Healthcare-Associated Infection: Replaces "nosocomial infection"
(hospital-acquired) because it implies all health care and is not limited to hospitals.
{More general Healthcare-Acquired Conditions {HAC}}
H Iatrogenic - Answers - An infection or other complication of treatment induced in a
patient by a physician's or other licensed independent practitioner's activity, manner, or
therapy.
H Indicator - Answers - "Performance Measure": Includes data definitions, as well as
numerator and denominator statements, to accurately specify what is being measured.
, H Integrated Delivery System - Horizontal - Answers - Multi-institutional entity with
coordinated functions, activities, or operating units that are at the same stage or
segment of the continuum of care, e.g., hospital system.
H Integrated Delivery System - Vertical - Answers - A network of entities that provide
and coordinate healthcare to a defined population across the entire continuum of care:
prevention, ambulatory, subacute, acute, and long term.
H Interrelationship Diagram - Answers - A tool that allows a team to analyze all the
interrelated cause-and-effect relationships and factors involved in a complex problem;
distinguish between issues that serve as drivers and those that are outcomes; and
describe desired outcomes.
H Leadership Group - Answers - "Individuals in senior positions with clearly defined,
unique responsibilities." Possible groups include governance, management, medical
staff, nursing, other clinical staff. An individual may be a member of more than one
group.
H LIP - Answers - Licensed Independent Practitioner: Any individual who is
professionally licensed by the state (US) and permitted by the organization to provide
patient care services without direction or supervision, within the scope of that license.
H Management - Answers - The sum of the activities of: planning, organizing, staffing,
directing, coordinating, and working to improve human and material resources toward
the achievement of stated goals.
H Medicare - Answers - Age 65+, permanent kidney failure, and disabled. Managed by
CMS.
H Medicaid - Answers - Low-income, managed by each state.
H Mission - Answers - The written expression of the origination's overall, broad purpose
and role (what/who the organization is). In a quality improvement environment it is
expected that the statement of mission will express a high-priority, comprehensive
commitment to patient care, to quality in all activities, and to service to the community.
The mission statement is the basis for the formation of organizational vision, values,
goals, and objectives.
H Monitoring and Evaluation - Answers - Historically a data collection process that
focused on high-priority quality-of-care issues and was designed to facilitate problem
solving and the identification of opportunities to improve.
H Negligence - Answers - Lack of proper care, as judged by peers.
A person who alleges negligent medical malpractice must prove four elements: (1) a
duty of care was owed by the physician; (2) the physician violated the applicable
