CPHQ Complete Review Guide 2026–2027

4. A project charter sets out the problem statement, a measurable aim, scope and its boundaries, team members and roles, timeline and resources. A clear scope prevents scope creep.
5. Improvement team roles: the executive sponsor removes barriers and provides resources, the team leader manages the work, the facilitator runs meetings and process, and the clinical and data experts supply technical knowledge.
6. Tuckman's stages of team development: forming, storming, norming, performing, then adjourning.
7. Lewin's change model: unfreeze, change, refreeze. Kotter's eight steps: create urgency, build a guiding coalition, form a vision, communicate it, empower action, generate short-term wins, consolidate gains, and anchor the change in the culture.
8. The Model for Improvement (IHI): three questions about aim, measures and changes, then PDSA cycles: Plan (and predict the result), Do (run the test on a small scale), Study (analyze the data against the prediction), Act (adopt, adapt or abandon).
9. A good improvement aim is specific, measurable and time-bound, naming the patient group or unit (SMART), for example reducing falls on a named unit by a stated percentage within six months.
10. DMAIC: Define (the problem and requirements), Measure (current performance), Analyze (root causes), Improve (implement and test solutions), Control (hold the gain with a control plan). Six Sigma level means about 3.4 defects per million opportunities.
11. The eight Lean wastes (DOWNTIME): Defects, Overproduction, Waiting, Non-utilized talent, Transportation, Inventory, Motion, Extra-processing.
12. Lean tools include the value stream map, kaizen (continuous improvement), the rapid kaizen event, and 5S: Sort, Set in order, Shine, Standardize, Sustain.
13. The seven basic quality tools: fishbone diagram, check sheet, control chart, histogram, Pareto chart, scatter diagram and flowchart. A run chart shows performance over time.
14. A control chart separates common from special cause variation. Common rules for signaling a special cause: a point outside the control limits, eight points in a row on one side of the center line, or six points in a row rising or falling.
15. FMEA identifies potential failure modes in a process, scores each for severity, occurrence and detection (often 1 to 10), and multiplies them to get the RPN. The highest RPN or highest severity is addressed first.
16. Timelines and deliverables are tracked with a Gantt chart, milestones and regular status meetings. When the project slips, it is raised to the sponsor with options for recovery.
17. Team effectiveness is judged by clarity of aim and roles, member participation, quality of decisions and progress toward the aim, using a member survey and regular feedback.
18. Judging project success compares results with the baseline and the aim, using outcome, process and balancing measures. Sustainability comes from writing the new way into policy, training staff, monitoring the indicator after the project ends and, where needed, a cost-benefit analysis.

Common mistakes in this chapter

• ✕ PDSA and PDCA share one origin (the Deming cycle). In PDSA the third step is Study, meaning analyzing what the test taught you, not just checking that the plan was carried out.
• ✕ Lean targets waste and flow, while Six Sigma targets variation and defects. A question about cutting waiting and unnecessary motion points to Lean; one about reducing variation in results points to Six Sigma.
• ✕ FMEA is proactive and used before harm occurs; root cause analysis (RCA) is retrospective and used after an event. Do not choose RCA to assess a new process that has not gone live.
• ✕ A Pareto chart ranks causes or problems by frequency and does not show cause and effect. The fishbone diagram is the one that groups possible causes into categories.
• ✕ Common cause variation is a normal part of the process and is addressed by changing the process itself. Special cause variation calls for investigating a specific event. Do not treat a point inside the control limits as an unusual event.
• ✕ A change is tested small first (one patient, one unit, one day) before it is scaled up. An answer that rolls the change out hospital-wide without testing is usually wrong.
• ✕ When people resist change, the right response is to understand the reasons and involve staff, not to impose the change by order or ignore those who object.
• ✕ An improved outcome measure alone does not prove success. Also check balancing measures and whether the gain holds after the project team steps back.