HANDBOOK CONTENT OUTLINE CO-10
THE HEALTHCARE QUALITY HANDBOOK:
A PROFESSIONAL RESOURCE & STUDY GUIDE
2008/2009 23rd Annual Edition
CONTENT OUTLINE
CONTENT OUTLINES
The Healthcare Quality Handbook Content Outline
The International CPHQ Examination Content Outline
INTRODUCTION
Study Questions, Addenda, and Attachments at end of Chapters I - VII
Chapter I: HEALTHCARE QUALITY CONCEPTS
I - 1. Thoughts on Quality
1.1 Quotes on Quality
1.2 Definitions of Quality in Healthcare
1.3 Three Aspects of Quality
1.4 Key Dimensions of Quality Care/Performance
I - 2. Movements in Quality in the U.S.: A Brief Look Since the 1970s
2.1 The Joint Commission Evolution
2.2 Change in Emphasis
2.3 The Wave of Change in Utilization Management
2.4 The Risk Reality
2.5 The Concept of Value
2.6 Quality, Cost, and Risk Integration
2.7 The Traditional Departmental or Compartmentalized Approach
2.8 Distinguishing Services from Products
2.9 Where is Quality Going Next?
2.10 The IOM Report: Crossing the Quality Chasm
I - 3. The Quality Umbrella
3.1 Definition of Quality Management/Improvement
3.2 An Integrated Perspective
3.3 Quality Management Principles
3.4 Total Quality Management Philosophy
3.5 Continuous Quality Improvement Process
3.6 The Juran Model of Quality Management
I - 4. Structure, Process, and Outcome
4.1 The Paradigm
4.2 The Process Approach
4.3 The Concept of Process Variation
4.4 The Concept of Process Reliability
4.4 Outcomes Management
I - 5. Systems Thinking
5.1 Concepts of Systems Thinking
5.2 Processes in Systems Thinking
5.3 System, Function, Process, Step
5.4 Lean Thinking
I - 6. The Concept of Customer
6.1 Definitions
6.2 Customers of a Healthcare Provider Organization
6.3 Healthcare Consumer Expectations in the 21st Century
6.4 The Customer Focus
6.5 Tools Used to Identify Customers and Their Needs
I - 7. The Healthcare Organization
7.1 Corporate Accountability and Liability
7.2 Ownership
7.3 Organizational Culture
7.4 Redesigning the Organization
7.5 Integrated Delivery Systems
7.6 A "Seamless" Continuum of Care
I - 8. Healthcare Delivery Settings
8.1 Care Stages and Delivery Settings
8.2 Ambulatory or Primary Care
8.3 Home Care
8.4 Hospice Care
8.5 Subacute Care/Transitional Care
8.6 Long Term Care/Supportive Services
I - 9. Insurance Coverage
9.1 Universal Coverage
9.2 U.S. Coverage
9.3 Managed Competition
9.4 The Continuum of Insurance Coverage (U.S.)
I - 10. Managed Care
10.1 Managed Care Concepts
10.2 Managed Care Systems
10.3 Managed Care Outside the U.S.
I - 11. Reimbursement Systems
11.1 Types of Reimbursement Systems in the U.S.
11.2 Prospective Payment Systems
11.3 The Resource-Based Relative Value Scale (RBRVS)
11.4 Managed Care Provider Reimbursement
11.5 Pay-For-Performance (P4P)
I - 12. Historical Review
12.1 The Pursuit of Quality
12.2 The Ambulatory Care Quality Pursuit in Brief
Chapter II: STRATEGIC LEADERSHIP
II - 1. Leadership and Commitment to Quality
1.1 Leadership Concepts
1.2 Leadership Styles
1.3 Leadership Links to Organizationwide Quality
1.4 The Joint Commission Leadership Function
1.5 NCQA Standards Related to Leadership
1.6 The Baldrige Award Criteria for Leadership
1.7 The ISO 9000:2000 Leadership Principle
II - 2. The Role of the Healthcare Quality Professional
2.1 The Healthcare Quality Professional
2.2 The HQF’s Year 2000 QM Professional
2.3 Professional Contributions to QM/PI
2.4 Gaining and Giving Support for Healthcare Quality Activities
II - 3. Organizational Infrastructure in the U.S.
3.1 Governance
3.2 Management
3.3 Licensed Independent Practitioners in the U.S.
II - 4. Organizational Ethics
4.1 Definitions and Description
4.2 W. Edwards Deming's Quality Values Applied to Ethics
4.3 External Criteria and Standards
4.4 The Healthcare Quality Professional's Role
II - 5. Organizationwide Functions
5.1 Definitions and Description
5.2 The Joint Commission’s Perspective on Functions
5.3 The Functional Approach
II - 6. Strategic Planning and Quality Planning
6.1 Strategic Alignment
6.2 Strategic Planning Basics
6.3 Traditional Strategic Planning Process
6.4 An Alternative Strategic Planning Process
6.5 The ABCDE Strategic Planning Model
6.6 Strategic Quality Planning
6.7 Strategic Quality Initiatives
6.8 The Strategy-Focused Organization
6.9 Strategy Execution: One Implementation Model
6.10 Lean-Six Sigma
II - 7. The Organizational Plan for Patient Care Services
7.1 The Joint Commission Standard
7.2 Organizational Plan Content
CHAPTER III: QUALITY SYSTEMS MANAGEMENT
III - 1. Principles of Management
1.1 Definition
1.2 General Management Processes
1.3 Management Obligations for Effectiveness
III - 2. Planning the Quality Strategy
2.1 Influences and Prerequisites
2.2 Planning and Design
2.3 Building Effective Structure
2.4 Integration of Quality Functions
2.5 Quality Management and Accreditation
III - 3. The Quality Strategy: The Written Plan
3.1 Requirements for Written Plans
3.2 QM/PI Plan Sample Content Outline for Provider Organizations
3.3 QM/QI Plan Sample Content Outline for Health Plans
III - 4. The "Quality Resource Center"
4.1 Organizationwide Resource
4.2 Internal Quality Management
III - 5. Implementation of the Quality/Performance Improvement Strategy
5.1 Quality/PI Council
5.2 QM/PI Information Flow
5.3 QM/PI Plans and Documents
III - 6. Utilization/Resource Management
6.1 Background
6.2 Description
6.3 Components of Utilization Management
6.4 Effective Utilization Management
6.5 Resource Management
6.6 Managed Care Utilization Management
6.7 The Written Plan
6.8 Utilization Management and Accreditation
III - 7. Care Coordination
7.1 Overview
7.2 Case Management
7.3 Population Management
7.4 Patient Flow Management
7.5 Patient-Centered Care
7.6 Discharge Planning/Transition Management
7.7 Skilled and Long-Term Care Assessment
7.8 Accreditation Standards
III - 8. Risk Management
8.1 Definitions and Goals
8.2 Governance Oversight Responsibilities
8.3 Professional Liability
8.4 Risk Management as an Organizationwide Performance Improvement Process (Providers)
8.5 Program Components Overview
8.6 Clinical Component: Loss Prevention and Reduction
8.7 Administrative Components
8.8 Organizationwide Early Warning Systems
8.9 The Written Plan
8.10 Risk Management and Accreditation
III - 9. Patient Safety Management
9.1 A Patient Safety Culture
9.2 Medical Error
9.3 Patient Safety Goals and Safe Practices
9.4 The Patient Safety Program
9.5 The Role of Technology in Patient Safety
9.6 Sentinel Event Process
III - 10. Corporate Compliance
10.1 Background and Concept
10.2 Compliance Programs
10.3 The Healthcare Integrity and Protection Data Bank (HIPDB)
III - 11. Financial Management
11.1 Financial Management
11.2 Financial Planning
11.3 Financial Monitoring and Reporting
11.4 Financial Decision Making
11.5 The Financial Side of Quality
III - 12. Quality Management Elements in Contracts
12.1 QM Elements at the Provider Level
12.2 Management of QM Elements within Managed Care Contracts
Chapter IV: PERFORMANCE IMPROVEMENT PROCESSES
IV - 1. Quality Management and Performance Improvement
1.1 The Quality Management Trilogy Revisited
1.2 Performance Improvement Concepts
1.3 The QM/PI Function and the Juran Model
1.4 The Design Process
1.5 The Measurement Process
1.6 The Analysis Process
1.7 The Improvement Process
1.8 The Joint Commission Standards for Performance Improvement
1.9 The NCQA Quality Management/Improvement Process
1.10 The Baldrige Award Criteria for Process Management and Results
1.11 The ISO 9001:2000 Standards for Quality Management
1.12 Prioritizing for Performance Improvement
IV - 2. U.S. Federal Quality Improvement Programs
2.1 Health Care Quality Improvement Program (HCQIP)
2.2 Quality Improvement System for Managed Care (QISMC)
IV - 3. The Organization’s Approach(es) to Process Improvement
3.1 Characteristics of all Approaches/Models
3.2 Approaches/Models Discussed
IV - 4. Performance Measurement
4.1 Concept of Performance Measurement
4.2 Tools of a Performance-Based QM System
4.3 Performance Measurement in the Juran Quality Management Cycle
4.4 Characteristics of Performance Measures/Indicators
4.5 Performance Measure Selection/Development
4.6 Performance Measurement Systems
4.7 Transparency and Public Reporting
4.8 Sharing Performance Measure Resources
IV - 5. Outcomes Measurement
5.1 Definition and Description
5.2 Possible Healthcare Outcomes
5.3 Outcomes Measurement as a Component of Quality Improvement
IV - 6. Clinical Process Improvement
6.1 Clinical Standards Development and/or Use
6.2 Clinical Pathway Development
6.3 Adjusting for Severity/Complexity of Illness
IV - 7. Organizationwide Monitoring and Analysis Processes
7.1 General Review Process
7.2 Organizationwide Clinical Review Processes
7.3 Infection Prevention and Control
IV - 8. Patient Safety Analysis and Risk Reduction
8.1 Root Cause Analysis
8.2 Failure Mode and Effects Analysis (FMEA)
8.3 Rapid Response Teams
8.4 Examples: New Ideas and Innovations
IV - 9. Benchmarking and "Best Practice"
9.1 Definitions
9.2 Concepts
IV - 10. Department Service Responsibilities
10.1 Collaboration
10.2 The Joint Commission Service-Specific Leadership Standards
10.3 Performance Improvement (All Settings)
10.4 Hospital Department/Service Performance Improvement
IV - 11. Nursing Responsibilities
11.1 Quality Nursing Care
11.2 Nurse Executive Leadership in Hospitals
11.3 Performance Improvement
IV - 12. Physician/Licensed Independent Practitioner Leadership Responsibilities
for Quality of Care
12.1 Performance Improvement
12.2 “Cross-Functional” Reports and Agendas
IV - 13. The Practitioner Appraisal Process
13.1 Credentialing of Licensed Independent Practitioners
13.2 Clinical Privileging/Reprivileging Process
13.3 Accreditation Standards for Credentialing and Privileging
13.4 Practitioner Profiling
13.5 Peer Review
13.6 Appointment/Reappointment
IV - 14. Patient/Member Advocacy and Feedback Processes
14.1 Patient/Member Rights and Responsibilities
14.2 Patient/Member Feedback Processes
14.3 Patient and Family Education Process
IV - 15. Communication and Reporting
15.1 Communication of QM/PI Activities
15.2 Consideration of Confidentiality and Nondisclosure
15.3 Reporting Mechanisms
15.4 Reporting to the Governing Body
15.5 Integration within the Organization
IV - 16. Evaluation of the Quality Management/Performance Improvement Function
16.1 Components of Excellence
16.2 Evaluation of PI Processes and Outcomes
Chapter V: INFORMATION MANAGEMENT
V - 1. Information Management
1.1 Definition and Goal
1.2 Why Data and Information Management?
1.3 Information Management Process
1.4 Decision Making Processes
V - 2. Information Resources and Education
2.1 Types of Information Available
2.2 Indexes
2.3 Registers
2.4 National/International Resources
2.5 Health Information Management Professionals
2.6 Networking
2.7 Potential Data Sources
2.8 Data Inventory Process
2.9 Electronic Health Record/Information Technology
2.10 Organizationwide Information Management Education
V - 3. The Joint Commission Standards for Information Management
3.1 Information Management Standards Focus
3.2 Planning Standards
3.3 Privacy, Security, and Accuracy Standards
3.4 Collection and Management Standards
3.5 Aggregate Information
V - 4. Management of the Legal Aspects
4.1 Confidentiality of Patient Information
4.2 Security of Electronic Patient Information
4.3 Conflict of Interest
4.4 Peer Review Immunity in the U.S.
V - 5. Informed Consent
5.1 Description
5.2 Process
V - 6. Management of Documentation
6.1 Types of Documentation
6.2 Content and Format of Minutes
6.3 Joint Commission Information Accuracy and Truthfulness Policy
V - 7. The Medical Record
7.1 Purposes of the Medical Record
7.2 Content of the Medical Record
7.3 The Medical Record as a Monitoring/Review Tool
7.4 Medical Record Review Process
V - 8. Epidemiological Theory and Methods
8.1 Definitions of Epidemiology
8.2 Contributions of Epidemiology to Quality Management
8.3 Epidemiological Concepts and Methods
V - 9. Defining the Population
9.1 Entire Population
9.2 Sampling
V - 10. Data Collection Techniques
10.1 Desired Characteristics of Data Collection
10.2 Collection Principles and Concepts
10.3 General Collection Methods
10.4 Focusing
10.5 Data Collection Tools
10.6 Organization of Data
10.7 Special Considerations
V - 11. Basic Statistics
11.1 Definitions
11.2 Types of Data
11.3 Statistical Process Control
11.4 Statistical Handling of Numbers
V - 12. Display Techniques
12.1 Tables
12.2 Graphs
V - 13. Analysis and Interpretation
13.1 Analysis Process
13.2 Pattern/Trend Analysis
13.3 Group Analysis Techniques
13.4 Conclusions
13.5 QM Coordination
V - 14. Using Quality Improvement Tools
14.1 Ishikawa's Seven Tools
14.2 Use in Quality Management
14.3 QI Team Tools
14.4 Brainstorming
14.5 Affinity Diagram
14.6 Delphi Technique
14.7 Multivoting/Nominal Group Process
14.8 Prioritization Matrix
14.9 Flowchart
14.10 Cause-and-Effect Diagram
14.11 Events and Causal Factors Chart
14.12 Force Field Analysis
14.13 Task List
14.14 Gantt Chart
14.15 Storyboard
14.16 Lotus Diagram
14.17 QI Process Tool Selection Matrix
V - 15. Reporting Techniques
15.1 Reporting
15.2 QI Project Reporting
15.3 Technical Report Preparation
V - 16. Computerization
16.1 Goals and Objectives
16.2 Design and Implementation Issues
16.3 Evaluating and Selecting Software to Support QM/PI
16.4 Computer Hardware Systems and Terminology
Chapter VI: PEOPLE MANAGEMENT
VI - 1. Leader as Motivator
1.1 Setting the Climate
1.2 Motivation Theories
VI - 2. Time Management
VI - 3. People in the Performance Improvement Process
3.1 The Value of People
3.2 Three Types of Healthcare Processes
3.3 The "Triple Role" in Performance Improvement
3.4 Participative Management
VI - 4. Empowerment, Decision Making, and Problem Solving
4.1 Empowerment
4.2 Decision Making
4.3 Problem Solving
VI - 5. Change Management
5.1 Organizational Change
5.2 Change Strategies
VI - 6. Team Coordination
6.1 Teamwork and Group Process
6.2 QI Team Structure
6.3 Roles within Quality Improvement Teams
6.4 QI Team Process
6.5 Meeting Management
6.6 Crew (Team) Resource Management
VI - 7. Communication
7.1 Description
7.2 Organizational Communication
7.3 Effective Communication
7.4 Written Communication
7.5 Effective Verbal Presentations
VI.-.8. Working with Consultants
8.1 Selection
8.2 Deliverables
VI - 9. Employee Selection
9.1 Human Resource Management
9.2 Labor Practice Legislation
9.3 The Employee Selection Process
9.4 Essential Job Functions and Skills
VI - 10. QM/PI Orientation, Training, and Education
10.1 Organizationwide QM/PI Understanding
10.2 QM/PI Orientation and Training
10.3 Adult Learning Concepts
10.4 Dimensions of Effective Teaching
10.5 Teaching Tactics
10.6 Program Development Process
VI - 11. Staff Performance
11.1 Recognition and Reward for QM/PI
11.2 Productivity
11.3 Performance Appraisal, Competency Assessment, and Counseling
11.4 Staffing Effectiveness
Chapter VII: STANDARDS AND SURVEYS
VII - 1. Accreditation Concepts
1.1 Definition and Purpose
1.2 Motivations to Participate
1.3 Compliance with Standards
1.4 Accreditation Determinations
1.5 Deemed Status
VII - 2. Accrediting Agencies
2.1 U.S. Listing
2.2 The Joint Commission
2.3 National Committee for Quality Assurance
2.4 URAC/American Accreditation for Health Care Commission
2.5 Healthcare Facilities Accreditation Program
VII - 3. Accreditation Survey Readiness
3.1 Preparedness/Continuous Readiness
3.2 Periodic Self-Assessment/Pre-Survey Prep
VII - 4. Survey Process
4.1 The Joint Commission Onsite Process
4.2 The NCQA Survey Process
VII - 5. Healthcare Licensure in the U.S.
5.1 Key Licensure Issues
5.2 Types of Licensed Organizations
5.3 Issues in Managed Care
VII - 6. International accreditation
6.1 ISQua International Accreditation Program
6.2 Joint Commission International Standards
VII - 7. ISO 9000:2000 Standards
7.1 Background
7.2 Standards
7.3 Registration
VII - 8. External Quality Awards
8.1 Malcolm Baldrige National Quality Award
8.2 European Foundation for Quality Management
8.3 Magnet Recognition Program®
Chapter VIII: U.S. PROGRAMS AND LEGISLATION
VIII - 1. Federal Program Participation and Quality Improvement Organizations
1.1 HCFA Name Change to CMS
1.2 Medicare/Medicaid Conditions of Participation
1.3 Medicare Acute Hospital Inpatient Prospective Payment System
1.4 Outpatient Prospective Payment System (OPPS)