HITT 2343 - Quality Assessment and Performance Improvement

After studying all materials and resources presented in the course, the student will be able to: complete all objectives listed below with a minimum competency of 70% on assignments and exams.

1. Defining a Performance Improvement Model (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 2a-i, ii, iii. 2b- i,ii, iv,v,vi. 2c-i, ii, iii, iv.)
   1. To explain the cyclical nature of performance improvement activities.
   2. To introduce terminology and standards common to performance improvement activities.
   3. To describe the distinction between organization-wide performance improvement activities and team-based performance improvement activities.
   4. To outline the organization-wide performance improvement cycle.
   5. To outline the team-based performance improvement cycle.
2. Identifying Improvement Opportunities Based on Performance Measurement (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2a-i, iii. 2b-i, ii, iii, iv,v,vi. 2d-i,ii,iii.)
   1. To explain the principal aspects of healthcare that are targeted for performance measurement.
   2. To describe the significance of outcomes and proactive risk reduction in performance improvement methodology.
   3. To explain how brainstorming and the nominal group technique can be used in performance improvement activities.
3. Using Teamwork in Performance Improvement (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2a-i, iii. 2b-i, ii, iii, iv,v,vi. 2d-i,ii,iii.)
   1. To identify the effective use of teams in performance improvement activities.
   2. To enumerate the differences between the roles of the leader and the members in performance improvement teams.
   3. To describe the contributions that team charters, team roles, ground rules, listening, and questioning can make to improve the effectiveness of performance improvement teams.
4. Aggregating and Analyzing Performance Improvement Data (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2a-i, iii. 2c-i, ii, iii, iv.)
   1. To differentiate between internal and external benchmark comparisons.
   2. To identify common healthcare data collection tools.
   3. To introduce the concept of data aggregation in support of data analysis.
   4. To describe the various data types.
   5. To recognize the correct graphic presentation for a specific data type.
   6. To design graphic displays for a given set of data.
   7. To analyze the data for changes in performance displayed in graphic form.
5. Communicating Performance Improvement Activities and Recommendations(1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2a-i, iii. 2c-i, ii, iii, iv.)
   1. To apply communication tools such as minutes, quarterly reports, and storyboards in performance improvement processes.
   2. To recognize the key elements in a storyboard and critique a storyboard layout.
6. Measuring Customer Satisfaction (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2a-i, iii. 2c-i, ii, iii, iv.)
   1. To identify the differences between internal and external customers.
   2. To outline the reasons why customers’ perspectives are important to the performance improvement process.
   3. To describe the difference between surveys and interviews.
   4. To outline the characteristics that make surveys and interviews effective.
   5. To critique a survey or interview format.
7. Refining the Continuum of Care (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2a-i, iii. 2c-i, ii, iii, iv. 2d-i,ii,iii.)
   1. To explain the reasons why processes have been developed to optimize the continuum of care.
   2. To identify and discuss the steps in the case management function.
   3. To describe how criteria sets/core measures contribute to the management of care in the U.S. healthcare system.
8. Preventing and Controlling Infectious Disease (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2a-i, iii. 2c-i, ii, iii, iv.)
   1. To describe why the control of infection is so important in healthcare organizations.
   2. To differentiate healthcare-associated infections (HAI) from community-acquired infections.
   3. To identify the governmental organizations that develops regulations in this area, and explains the regulatory approaches often taken by healthcare facilities.
   4. To explore the National Patient Safety Goals related to infectious disease and their impact on healthcare providers.
9. Decreasing Risk Exposure (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2a-i, iii. 2c-i, ii, iii, iv.)
   1. To describe the importance of managing risk exposure in today’s healthcare organization.
   2. To explain the importance of using occurrence reporting to decreasing risk exposure.
   3. To define the concept of a sentinel event.
   4. To understand how sentinel events can point to important opportunities to improve safety in healthcare organizations.
   5. To explain how risk managers use their skills in patient advocacy to lessen the impact that potentially compensable events can have on healthcare organizations.
   6. To emphasize the importance of National Patient Safety Goals for healthcare organizations and strategies for proactive risk reduction activities.
10. Improving the Provision of Care, Treatment, and Services (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2a-i, iii. 2c-i, ii, iii, iv.)
    1. To identify four core processes or elements in the care, treatment, and service of patients and to recognize the common means by which healthcare organizations monitor and improve the quality of these elements of care.
    2. To understand the roles that clinical practice guidelines and evidence-based medicine play in standardizing patient care.
    3. To explore how partnering with agencies and consumer groups has improved the quality of patient care.
11. Building a Safe Medication Management System (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2a-i, iii. 2c-i, ii, iii, iv. 2d-i,ii,iii. 2e-i,ii,iii.)
    1. To identify how health policy, national initiative, the private sector, and professional advocacy all contribute to the design of safe medication management systems.
    2. To recognize the important functions included in a safe and effective medication management system.
    3. To use the failure mode and effects analysis (FMEA) tool as a proactive risk reduction strategy in anticipating medication system failures.
    4. To become familiar with the process of monitoring and reporting medication errors and adverse drug events.
    5. To understand patient safety issues and the legal consequences associated with medication errors and adverse drug events.
12. Improving Care Environment and Life Safety (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2ai, iii. 2c-i, ii, iii, iv. 2d-i,ii,iii.)
    1. To identify the relationship between the environment of care and patient safety.
    2. To list the seven safety functions outlined by the Joint Commission on Accreditation of Healthcare Organizations.
    3. To describe a risk assessment and a hazard vulnerability analysis.
    4. To describe the safety monitoring process.
13. Developing Staff and Human Resources (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2a-i, iii. 2c-i, ii, iii, iv.)
    1. To recognize the need to integrate performance improvement and patient safety data into the management of the human resources function in healthcare.
    2. To identify the tools commonly used to manage the recruitment and retention of human resources.
    3. To outline the credentialing process for independent practitioners and employed clinical staff.
14. Navigating the Accreditation, Certification, or Licensure Process (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2a-i, iii. 2c-i, ii, iii, iv.2d-i,ii,iii.)
    1. To differentiate between compulsory and voluntary reviews.
    2. To explain the performance improvement perspectives of accreditation, certification, and licensure organizations.
    3. To describe the various approaches of accreditation, certification, and licensure agencies to the site visit and survey.
    4. To identify approaches that lead to success in the survey process.
15. Managing the Human Side of Change (1a-i, ii, iv, v. 1b-ii, iii, iv, v, vi. 1c-i, ii, iv, v. 2a-i, iii. 2c-i, ii, iii, iv. 2d-i,ii,iii. 2e-i,ii,iii.)
    1. To apply change management techniques to implement performance improvements.
    2. To describe the three phases of change.
    3. To identify key steps in change management.