The Janet A. Brown Healthcare Quality Handbook: A Professional Resource and Study Guide, 29th Edition

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The 29th Edition of Janet's Handbook has been completely revised, updated, and reorganized under the leadership of Dr. Susan Mellott. Our 29th Edition is current and updated for the current Content Outline for the CPHQ Exam. You can learn more about Dr. Mellott and her qualifications on our HomePage. The Handbook is revised annually to provide the most current information available for those seeking a comprehensive look at the field of healthcare quality/or preparing for CPHQ Certification


Important Note and Disclaimer:
Purchasing this Handbook does not guarantee that you will pass the CPHQ Examination. The only Exam information available to the author is the same Content Outline provided to you in the Candidate Handbook. However, the material encompasses all Content Outline topic areas and is the only comprehensive resource that is annually revised to provide current information.


Content Outline

CHAPTER 1 - HEALTHCARE QUALITY BASICS                                  

HISTORY OF HEALTHCARE QUALITY

BASIC CONCEPTS OF HEALTHCARE QUALITY

Quality Management Principles

The Basic Principles

Distinguishing Services from Products

Total Quality Management

Continuous Quality Improvement Process

National Quality Strategy

The Concept of Customer

Healthcare Quality and Customer Satisfaction

The Responsibility of the Healthcare Quality Professional

Integrating Quality Functions

Today’s Healthcare Quality Environment and the Healthcare Quality Professionals

Competencies of the Healthcare Quality Professional

Healthcare Quality Essentials

Quality and Safety Education for Nurses (QSEN)

Core Competencies for Performance Improvement Managers in Public Health

Comparison of these Competencies

CERTIFICATION FOR THE HEALTHCARE PROFESSIONAL

Certification Benefits for Individuals

Certification Benefits for Patients and Families

Certification Benefits for Employers

Healthcare Quality Certifications

CPHQ Certification

HCQM Certification

American Society for Quality (ASQ) Certification

Related Certifications

Certificate Programs

Institute for Healthcare Improvement

George Washington University

CHAPTER 2 - QUALITY LEADERSHIP AND STRUCTURE 

THE IMPORTANCE OF LEADERSHIP IN AN ORGANIZATION

Systems Perspective

Systems Theory

Systems Thinking

Strategic Leadership

Anticipate

Challenge

Interpret

Decide

Align

Learn

TYPES OF ORGANIZATIONS

United States Healthcare Organizational Infrastructure

Challenges

Governance

High Reliability Organizations

Learning Organizations

Personal Mastery

Shared Vision

Telling

Selling

Testing

Heard

Re-establish as a team

Mental Models

Team Learning

Systems Thinking

High Performance Organizations

LEADERSHIP STYLES

Styles

Autocratic

Democratic

Transactional

Transformational

Situational

Participative

Laissez-faire

Qualities of a Successful Leader

Being a Manager

Financial Benefits of a Quality Program

STRATEGIC PLANNING

Forecasting

Prioritization

Predictive Analytics

Strategic Planning Process

LEADERSHIP IN QUALITY

Goal of Leadership

Processes for Leadership

Standards, Regulations, Guidelines for Leadership Involvement

Centers for Medicare & Medicaid (CMS)

Accrediting Bodies

EXPECTATIONS OF PROFESSIONAL ORGANIZATIONS

National Association for Healthcare Quality (NAHQ) Leadership Development Model

Roles of Organizational Quality Leaders

Positional Leadership

Influential Leadership/Importance

Roles & Responsibilities of Quality Leaders

 CHANGE MANAGEMENT

Coaching

Communicating

Involving others

Motivating

Rewarding

Promoting Teamwork

COMMUNICATION

Communication Structure

Two-way

Closing the loop

Based on needs of organization and leaders

           Styles

Top down

Bottom-up

Matrixed

Diffusion

Spread

Processes

Oral

Written

Reports

Emails

Paper versus electronic

 

CHAPTER 3 - PERFORMANCE MANAGEMENT AND PROCESS IMPROVEMENT

PERFORMANCE IMPROVEMENT PROGRAM STRUCTURE

Preparation for Quality Management/Performance Improvement

Determine the Definition of Quality for the Organization

Clarify Leadership Roles

Quality Council

Councils and Committees

Create an Accountability Structure

Determine the Quality Language

Identify the Organizational Important Functions

Initiatives and Collaboration

The Organization’s Approach(es) to Performance Improvement  

Shewart Cycle – PDCA Cycle or PDSA Cycle

Accelerated/Rapid Change Approach

Lean

Six Sigma®

Develop an Information Flow Chart

Establish Reporting Routines

Integrate Quality Principles into the Organization’s Policies and Procedures

Identify Educational Needs

QUALITY, RISK, UTILIZATION, AND PATIENT SAFETY PLANS

Quality/Performance Improvement Plan              

Risk Management Plan

Utilization Management Plan

The Role of the Quality/Utilization/Risk Professional in Organizational Preparation for          Quality Management/Performance Improvement  

MEASUREMENT/PERFORMANCE IMPROVEMENT PROCESS

Concept of Performance Measurement

Structure, Process, & Outcome Measure

Key Points in Indicator Selection/Development

Developing Indicators

Triggers

 Characteristics of Triggers

Selecting Indicators to Support the Strategic Goals and Objectives of the Organization

Benchmarking

Balanced Scorecards/Dashboards

Evidence-Based Practice

Clinical Guidelines and Pathways

Clinical Practice Guideline (CPG)

Clinical Pathway and Clinical Algorithm Development

Accreditation & Regulations

Clinical Pathways

Acute Care versus Other Settings Clinical Pathways

Adjusting for Severity/Complexity of Illness

Organization Measurements/Monitors

Organization Review Processes

Clinical Process Review

Operative and Procedure Review

Medication Management

Blood and Blood Component Use

Mortality Review

Specific Department Reviews

Utilization Management

Utilization/Resource Review/Management

Action Process

Appeal Process

Handoffs

Transition of Care

Episodes of Care

Population Health

Risk Management

Risk Identification

Occurrence/Event/Incident Reporting Systems

Risk Analysis

Enterprise Risk Management

Infection Prevention and Control

Environment Safety Programs

Medical Record Review Process

Physician Monitoring

Nursing Monitoring

Patient Satisfaction Review

Patient Satisfaction

Patient/Member Satisfaction Surveys

Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Surveys

Patient Interviews

Focus Groups

Patient Complaints & Grievances

National Performance Review

National Quality Initiatives – CMS Quality Initiatives

Hospital Quality Initiative

Home Health Quality Initiative (Home Health Compare)

Nursing Home Quality Initiative

End-Stage Renal Disease (ESRD) Quality Initiative

Inpatient Rehabilitation Facilities (IRF) Quality Reporting Program

Physician Quality Reporting Program

Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN)

Accreditation Required Measures

Core Measures

HEDIS

THE ANALYSIS PROCESS

Initial Analysis

Intensive Analysis

Outcomes of the Analysis Process

Analysis Process Steps

DISSEMINATION OF PERFORMANCE IMPROVEMENT INFORMATION

REPORTING MECHANISMS

Summary Reports of QM/PI Activities

Reporting to the Governing Board

Integration within the Organization

Transparency

Public Reporting

The Joint Commission’s Quality Check and Quality Reports

NCQA’s Quality Compass®

HealthGrades

Consumer Reports

US News & World Reports

Truven 100 Top Hospitals Reports

PEOPLE IN THE PERFORMANCE IMPROVEMENT PROCESS

Managing Relationships

MOTIVATION THEORIES

TEAMS & MEETINGS

Teams

Teamwork and Group Process

The Role of Teams in Quality Management

Types of QI Teams

Roles within Quality Improvement Teams

Facilitator/Coach

Team Leader

Team Member

Recorder & Timekeeper Roles

Sponsor

Role of the Healthcare Quality Professional

Performance Improvement Team Establishment

Problem Statement/Charter

Ground Rules

Orient/Educate the Team

Team Process

TeamSTEPPS

Evaluation of Team Performance

Meeting Management  

Effective Meetings

Before the Meeting

During the Meeting

Meeting Minutes & Documentation

THE PRACTITIONER APPRAISAL PROCESS

Appointment/Reappointment

Medical Staff Membership

Process Leading to Appointment

Initial Appointment

Reappointment

Credentialing of Licensed Independent Practitioners

Primary source verification

Credentialing in Managed Care Settings

Privileging of Licensed Independent Practitioners

Delineation of Privileges

Special Privilege Statuses

Temporary Privileges

Emergency & Disaster Privileges

Evaluation of the Practice of Licensed Independent Practitioners

Practitioner Profiling

Ongoing Professional Practice Evaluation (OPPE)

Focused Professional Practice Evaluation (FPPE)

Peer Review

INTERACTING WITH CONSULTANTS

Selection of a Consultant

Communication with Hired Consultants

Deliverables

QM/PI ORIENTATION, TRAINING, AND EDUCATION

Orientation of Quality, Risk and Utilization Management

Orientation and Training Topics

Education/Training Program Development Process

 CHAPTER 4 - INFORMATION MANAGEMENT

DATA

Where is this data found?

           Aggregate Data

Data Definitions

Data Inventory

Potential Data Sources

Benchmarking

GENERAL DATA COLLECTION METHODOLOGY

Timeframes

Prospective

Concurrent

Retrospective

Focused

Population and Sampling

Types of Probability Sampling Techniques

Simple Random

Stratified Random

Systematic Random

Types of Nonprobability Sampling Techniques

Convenience

Quota

Purposive

Sampling Size

Data Collection Tools

Data Sheets/Work Sheets

Check Sheets/Tally Sheets

Surveys/Questionnaires

Focus Group

Collection Principles and Concepts

Data Collection Process

Coordinate Data Collection

Validate Data Integrity

Using Excel to Validate Data Collected

LEGAL AND ETHICAL CHALLENGES WHEN DEALING WITH DATA

Protected Health Information

Common Formats

Health Information Exchange (HIE)

The Medical Record

Confidentiality and Security of Patient Information

Confidential Information

Protected Information

Consent and Use of Patient Information

Informed Consent

Internal Use

External Use

           Meaningful Use

ICD-10

Indexes

Registers

Information Technology and Systems

Information Management Functions

Framework for Enterprise Information Management

Computerization & Software Selection andImplementation

Evaluating an d Selecting Software to Support QM/PI

Evaluate Potential Vendors

Evaluate and Select Software

MEASUREMENT

Data Basics

Categorical Data

Continuous Data

Basic Statistics

Descriptive Statistics

Central Tendency – Mean, Median, Mode, Weighted Mean

Dispersion of Data – Range, Frequency, Standard Deviation

Parametric & Non-Parametric Statistical Tests

Chi square (X2) & T-test – Tests of Statistical Significance

Type I and Type II Errors

Regression Analysis – Scatter Diagrams

Multiple Regression Analysis

Confidence Interval

Interpercentile (Interquartile Range - IQR) Measure

Statistical Process Control

Random or Common Cause

Assignable or Special Cause

Statistical Thinking

                     Display and Statistical Tools

Quality Improvement Tools

Tables

Pie Graph

Frequency Plots

Dot Plot

Stem & Leaf Plot

Histogram

Bar Chart

Pareto

Pareto Drill Down

Run Chart

Control Chart

Process Tools

Brainstorming

Nominal Group Technique

Multivoting

Delphi Technique

Cause & Effect Diagram (Ishikawa)

Interrelationship Diagram

Affinity Diagram

Lotus Diagram

Flowchart

Value Stream Map

Process Map

A3 Problem Solving Tool

Force Field Analysis

Checklist/Task List

Gantt Chart

Prioritization Matrix

THE DATA IS COLLECTED AND DISPLAYED. NOW WHAT? 

Analysis and Interpretation  

Intensive Analysis

Pattern

Trend

Analysis by interdisciplinary teams or peers

Documentation, Reports, & Meeting Minutes

CHAPTER 5 – PATIENT SAFETY

WHAT IS PATIENT SAFETY? 

WHAT DOES IOM REPORT STATE THAT WE SHOULD DO?

WHAT HAVE WE DONE & HOW EFFECTIVE HAS IT BEEN?

Government & Accreditation Efforts

Accreditation Standards

Patient Safety Goals and Safe Practices

WHO Collaborating Centre for Patient Safety Solutions

National Quality Forum (NQF)

The Institute for Healthcare Improvement (IHI)

AHRQ Patient Safety Indicators

National Patient Safety Goals

Patient Safety Management – The Program

Leadership

Generic Components of the Program

Physician Participation

Patient Safety Officer

Role of the Quality Professional

Patient Safety Plan

Documenting How You Incorporate Patient Safety Throughout the Organization

           Patient Safety Management

Safety Culture

Just Culture

Establish Learning Boards

Patient Safety Leadership Rounds

           Technology and Its Effects on Patients Safety

Top Patient Safety Issues and Hazards - 2015

Computerized Physician/Provider [AHRQ]/Prescriber [NQF] Order Entry (CPOE)

Bar Code Medication Administration (BCMA) Systems

Radio Frequency Identification (RFID)

Abduction/Elopement Security Systems

           Human Factors

           Sentinel Event Process

Apology & Disclosure

Root Cause Analysis (RCA)

           Failure Mode Effectiveness Analysis (FMEA)

Patient Safety Tools & Resources

Josie King Foundation

Institute for Healthcare Improvement – Open School

TeamSTEPPS

Crew Resource Management

Comprehensive Unit-based Safety Program (CUSP)

Centers for Medicare and Medicaid – Partnership for Patients: Better Care,

            Lower Costs

The Joint Commission – Sentinel Event Alerts, and Quick Safety Issues

Joint Commission Center for Transforming Healthcare

Institute for Safe Medication Practices

Agency for Healthcare Research and Quality – Patient Safety Net

The Veterans Administration National Center for Patient Safety

Pennsylvania Patient Safety Authority

WHAT REMAINS LEFT FOR HEALTHCARE TO DO?

CHAPTER 6 - ACCREDITATION, LICENSURE, AND SURVEYS

ACCREDITATION CONCEPTS  

Deemed Status

Healthcare Licensure in the U.S.

Compliance with Standards

ACCREDITATION SURVEY READINESS

Preparedness/Continuous Readiness

Accreditation/Regulatory Readiness Teams

Accreditation/Regulatory Readiness Team Activities/Process Improvements

Learning the Regulations

Document Preparation

Tracers

Education of Staff, Leaders, and Practitioners

Regulatory Compliance Leaders Meetings

Preparation for the Days of Survey

SURVEY PROCESS

Surveyor Arrival

Entrance Interview

Surveyor Work Room

Command Center

Staff Interviews with the Surveyor

Patient Interviews with the Surveyor

End of the Survey Day

At the End of the Survey

After the Surveyors Leave

Continuous Improvement and Sustainability

U.S. HEALTHCARE ACCREDITING AGENCIES

Disease Specific Certification

Hospital Accreditation Organizations with Deemed Status

The Joint Commission (TJC)

Det Norske Veritas Healthcare (DNV Healthcare)

ISO 9001Standards

The Healthcare Facilities Accreditation Program (HFAP)

Center for Improvement in Healthcare Quality (CIHQ)

Accreditation for Health Plans and other Managed Care Organizations, especially those actively involved the Health Insurance Marketplace, Medicare or Medicaid

                    National Committee for Quality Assurance (NCQA)

Utilization Review Accreditation Commission (URAC)

Accreditation Association for Ambulatory Health Care (AAHC)

Other Healthcare Accreditation Agencies

Commission on Accreditation of Rehabilitation Facilities (CARF)

Accreditation Commission for Health Care, Inc. (ACHC)

Community Healthcare Accreditation Program, Inc. (CHAP), a subsidiary of the National League of Nursing (NLN)

International Accreditation

Joint Commission International Standards (JCI)

External Quality Awards

Quality Professional Role

Baldrige Performance Excellence Program (U.S.)

Magnet Recognition Program®

Pathway to Excellence

CHAPTER 7 - LEGISLATION INITIATIVES

CORPORATE LIABILITY IN THE U.S.

Accountability and Liability Pressures

Torts

Negligence

REGULATORY AND LEGAL HINTS

Case Law Resources

U.S. HISTORICAL REVIEW – SAMPLE OF LAWS INVOLVING HEALTHCARE

LEGAL FOUNDATIONS FOR QUALITY PRACTICE

Federal Program Participation and Quality Improvement Organizations

Medicare and Medicaid

Medicare System

Medicaid System

Prospective Payment System (PPS)

Quality Improvement Organization and Medicare Scopes/Statements of Work

History of Professional Standards Review Organizations (PRSO)

Scope of Work

American Recovery and Reinvestment Act (ARRA) of 2009 (P.L. 111-5)

Health Information Technology for Economic and Clinical Health (HITECH) Act

Medicare and Medicaid Health Information Technology

Patient Protection and Affordable Care Act (PPACA)

Provisions

Accountable Care Organizations

LEGAL FOUNDATIONS FOR PATIENT PROTECTION

Patient Self-Determination Act (PSDA) of 1990

Patient Rights and Responsibilities Legislation

Health Insurance Portability and Accountability Act (HIPAA) of 1996

Americans With Disabilities Act (ADA) of 1990

LEGISLATION IMPACTING ORGANIZATIONAL ACTIVITIES

Corporate Compliance

False Claims Act (FCA) of 1863 and 1986

Stark Law

Medicare and Medicaid Patient Protection Act of 1987 (P.L. 100-93)

Compliance Programs

OIG Compliance Program Guidance

Elements of Compliance

Self-Disclosure

Healthcare Quality Professionals & Compliance Information

National Practitioner Data Bank (NPDB)

Clinical Laboratory Improvement Act (CLIA) of 1988

Safe Medical Device Act (SMDA) of 1990 and FDA Safety Innovation Act (FDASIA) of 2012

Resources for the Full Federal Food, Drug and Cosmetic Act (FFDCA)

Federal Occupational Safety and Health Act (OSHA) of 1970 

CPHQ Exam Content Outline & Task Statements

Acronyms

Glossary

Index


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