CPHQ Exam
H Appointmentcorrect answerSelection for membership in a medical professional staff or to a
practitioner panel.
H Appraisalcorrect answerInitial 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 Benchmarkcorrect answerA comparative "best" as baseline for improvement.
H Clinical Pathcorrect answerA 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 Managementcorrect answer1) 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 Techniquecorrect answerA 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 Managementcorrect answerTerm from economics; in project management it refers to
meeting customer expectations; in managed care it refers to influencing access to medical care.
H Disease Managementcorrect answerDisease management is a system of coordinated healthcare
interventions and communications for populations with conditions in which patient self-care efforts are
significant.
H Ethiccorrect answerA set of principles of right conduct.
H Ethicscorrect answerRules or standards governing conduct.
H Eventcorrect answerAn 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 Chartcorrect answerEvents 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 Modecorrect answerThe way a process can fail to function or fail to provide the desired result;
an undesirable variation in a process.
H FMEAcorrect answerFailure 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 Flowchartcorrect answerA 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 Analysiscorrect answerA 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 Chartcorrect answerProject planning tool for developing schedules; a graphic display of
individual parts of a quality improvement process as bars on a horizontal time scale.
H HAIcorrect answerHealthcare-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 Iatrogeniccorrect answerAn 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 Indicatorcorrect answer"Performance Measure": Includes data definitions, as well as numerator and
denominator statements, to accurately specify what is being measured.
H Integrated Delivery System - Horizontalcorrect answerMulti-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 - Verticalcorrect answerA 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 Diagramcorrect answerA 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 Groupcorrect answer"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 LIPcorrect answerLicensed 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 Managementcorrect answerThe 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 Medicarecorrect answerAge 65+, permanent kidney failure, and disabled. Managed by CMS.
H Medicaidcorrect answerLow-income, managed by each state.
H Missioncorrect answerThe 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 Evaluationcorrect answerHistorically 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 Negligencecorrect answerLack 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 standard of care; (3) the person suffered
a compensable injury; and (4) the injury was caused in fact and proximately caused by the substandard
conduct. The burden of proving these elements is on the plaintiff in a malpractice lawsuit.
H Negligent Conductcorrect answerDoing what a reasonable person would not do: failure to do what a
reasonable person would do (based on set standards and under like circumstances and training)
Gross Negligence: is failure to act if there is known or suspected risk resulting in adverse impact or
death.
H Nominal Group Processcorrect answerA technique used to give everyone on the team/group an equal
voice in brainstorming, problem selection, or resolution.
-Highly structured process to obtain primary data
-Few representatives from the priority population respond to questions based on specific needs.
-Small groups of 5 to 7
-Rank proposed ideas privately and share the rankings with the group
H Appointmentcorrect answerSelection for membership in a medical professional staff or to a
practitioner panel.
H Appraisalcorrect answerInitial 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 Benchmarkcorrect answerA comparative "best" as baseline for improvement.
H Clinical Pathcorrect answerA 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 Managementcorrect answer1) 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 Techniquecorrect answerA 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 Managementcorrect answerTerm from economics; in project management it refers to
meeting customer expectations; in managed care it refers to influencing access to medical care.
H Disease Managementcorrect answerDisease management is a system of coordinated healthcare
interventions and communications for populations with conditions in which patient self-care efforts are
significant.
H Ethiccorrect answerA set of principles of right conduct.
H Ethicscorrect answerRules or standards governing conduct.
H Eventcorrect answerAn 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 Chartcorrect answerEvents 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 Modecorrect answerThe way a process can fail to function or fail to provide the desired result;
an undesirable variation in a process.
H FMEAcorrect answerFailure 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 Flowchartcorrect answerA 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 Analysiscorrect answerA 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 Chartcorrect answerProject planning tool for developing schedules; a graphic display of
individual parts of a quality improvement process as bars on a horizontal time scale.
H HAIcorrect answerHealthcare-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 Iatrogeniccorrect answerAn 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 Indicatorcorrect answer"Performance Measure": Includes data definitions, as well as numerator and
denominator statements, to accurately specify what is being measured.
H Integrated Delivery System - Horizontalcorrect answerMulti-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 - Verticalcorrect answerA 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 Diagramcorrect answerA 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 Groupcorrect answer"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 LIPcorrect answerLicensed 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 Managementcorrect answerThe 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 Medicarecorrect answerAge 65+, permanent kidney failure, and disabled. Managed by CMS.
H Medicaidcorrect answerLow-income, managed by each state.
H Missioncorrect answerThe 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 Evaluationcorrect answerHistorically 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 Negligencecorrect answerLack 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 standard of care; (3) the person suffered
a compensable injury; and (4) the injury was caused in fact and proximately caused by the substandard
conduct. The burden of proving these elements is on the plaintiff in a malpractice lawsuit.
H Negligent Conductcorrect answerDoing what a reasonable person would not do: failure to do what a
reasonable person would do (based on set standards and under like circumstances and training)
Gross Negligence: is failure to act if there is known or suspected risk resulting in adverse impact or
death.
H Nominal Group Processcorrect answerA technique used to give everyone on the team/group an equal
voice in brainstorming, problem selection, or resolution.
-Highly structured process to obtain primary data
-Few representatives from the priority population respond to questions based on specific needs.
-Small groups of 5 to 7
-Rank proposed ideas privately and share the rankings with the group
