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Section One: Healthcare Quality Introduction

The healthcare industry is constantly evolving, and with it comes the need for quality professionals to ensure that patients receive the best possible care. This section will introduce the concept of healthcare quality and the various aspects that contribute to it. We will discuss the importance of value in healthcare and the shift towards a value-based system. We will also introduce the principles of total quality management and how they can be applied in the healthcare setting to improve the quality of care.

Section Two: Organizational Leadership

Effective leadership is essential in the healthcare industry, as it plays a crucial role in the overall quality of care provided to patients. This section will delve into the importance of leadership in the healthcare system and how it affects the quality of care. We will discuss different leadership styles and the role of strategic planning and change management in healthcare organizations. We will also cover the concept of a learning organization and the importance of effective communication in the quality improvement process.

Section Three: Performance and Process Improvement

Continuous improvement is key to ensuring that patients receive the highest quality of care. This section will introduce the essential components of the performance and process improvement process, including the role of quality councils, initiatives, and performance improvement approaches. We will discuss the use of quality/performance improvement plans, risk management, and occurrence reporting systems to identify and address potential issues. We will also cover the importance of infection prevention and control, utilization management, and patient safety in the quality improvement process.

Section Four: Data Analysis

Data plays a crucial role in the healthcare industry, as it allows quality professionals to identify trends and patterns and to measure the effectiveness of interventions. This section will introduce the basics of data analysis in healthcare, including different types of data, basic statistics, and the use of statistical tests to measure the significance of findings. We will also discuss the importance of data definition and sources, as well as the various methods used to collect data in the healthcare setting.

Section Five: Patient Safety

Ensuring patient safety is a top priority in the healthcare industry, and this section will delve into the various strategies and approaches used to improve patient safety. We will discuss the role of risk management and occurrence reporting systems in identifying and addressing potential issues, as well as the importance of infection prevention and control and medication management in ensuring patient safety. We will also cover the use of adverse patient occurrence reporting and the global trigger tool to identify and address potential safety concerns.

Section Six: Accreditation and Legislation

Compliance with regulatory standards is essential in the healthcare industry, and this section will introduce the various accreditation and legislation bodies that oversee the quality of healthcare services. We will discuss the role of organizations such as the Joint Commission and the Centers for Medicare and Medicaid Services in ensuring compliance with standards, as well as the importance of adhering to laws and regulations such as HIPAA and the Affordable Care Act. We will also cover the appeal process for addressing patient concerns and the importance of maintaining confidentiality, privacy, and security in the healthcare setting.

Table of Contents

Section One : Healthcare Quality Introduction Page 11

• Quality Definition 
• Healthcare Quality Concepts
• Aspects of Quality 
• Key Dimensions of Quality 
• Value In Healthcare
• Value Based Healthcare System
• Total Quality Management Principles 
• Poor Quality In Healthcare
• ISO Principles of Quality Management System
• Products and Services 
• Total Quality Management Philosophy 
• Continuous Quality Improvement Process 
• Healthcare Customers and Quality Professionals 
• Quality Professionals Roles In QM, UM, RM, and IC
• Early Strategies of Quality Management 
• Quality Management Pioneers

Section Two : Organizational Leadership Page 82

• Healthcare System
• Importance of Leadership 
• Leadership and Strategy
• HealthCare Organization 
• Leadership Styles
• Learning Organization 
• Strategic Planning
• Change Management
• Communication

Section Three : Performance and Process Improvement Page 141

• Process Essential Components
• Quality Improvement Program
• Quality Council 
• Quality Initiatives 
• Performance Improvement Approaches 
• Quality/Performance Improvement Plans (QPIPs)
• Risk management 
• Occurrence/Event/Incident Reporting Systems
• An Adverse Patient Occurrence (APO)
• Global Trigger Tool 
• Infection Prevention and Control
• Utilization management
• Patient Safety 
• Measurement Improvement Process 
• Performance Improvement Process 
• Standards and Guidelines 
• Performance Databases
• Key Performance Indicators (KPIs)
• Structure, Process, and Outcome Measures
• Triggers 
• Benchmarking 
• Balanced Scorecard (BSC) 
• Evidence-based practice (EBP)
• Clinical Practice Guideline (CPG)
• Organization Review Process 
• Clinical Peer Review
• Medication Management
• Blood transfusion management 
• Mortality rate
• Morbidity rate
• Appeal Process 
• Handoffs 
• Transition of care
• Episodes of care
• Population health 
• Environment Safety Programs
• Medical Record Review Process
• Patient Satisfaction
• Patient satisfaction surveys
• Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surveys
• Patient interviews
• Focus Groups
• Patient Complaints & Grievances
• Hospital Quality Initiative
• Value-Based Payment (VBP) 
• Performance Analysis Process 
• Reports of QM/PI activities
• Reporting to the Governing Board
• Public reporting
• People and The Performance Improvement Process
• Motivation Theories 
• Maslow’s Hierarchy of Needs
• Theory X and Theory Y
• Herzberg’s Motivation-Hygiene Theory
• Teams
• Types of QI Teams
• Team Roles 
• Evaluation of Team Performance
• Meeting management
• Types of meeting agenda items
• Effective meetings
• Meeting Minutes & Documentation
• Orientation Topics in Healthcare Quality
• Adult Learning Concepts
• Effective Teaching

Section Four : Data Analysis Page 291

• Data introduction 
• Data Versus Information
• Administrative Information System (AIS) 
• Clinical information system
• Decision Making System
• Aggregate Data
• Decision-making process
• Data Definitions
• Data Inventory
• Data Sources
• Data Collection Methods
• Population & Sampling in Healthcare
• Probability Sampling 
• Non-Probability Sampling
• Sampling Size 
• Data Collection Tools
• Data Collection Process 
• Protected Health Information
• Health Information Exchange (HIE)
• Confidentiality, privacy, and security
• Health Level Seven (HL7)
• Patient Consent 
• Protected Health Information (PHI) 
• Meaningful Use (MU)
• The International Classification of Diseases (ICD)
• Indexes and Registers 
• Health Information Management (HIM)
• Health Information Management (HIM) Professionals 
• Health Information Management in Quality measurement and improvement
• The life cycle of a patient medical record
• Information Governance
• Computerization and software selection and implementation 
• System Features to Consider in Selecting Health Information Software
• Evaluate Potential Vendors for Selecting Health Information Software
• Data Measurement
• Basic types of data
• Basic Statistics
• Descriptive statistics
• Central Tendency (Mean, Median, Mode, Weighted Mean)
• Dispersion of Data (Range. Frequency, Standard Deviation)
• Ratio 
• The Standard Bell Curve
• Parametric & Nonparametric Statistical Tests
• Chi Square (X2) & t-Test – Tests of Statistical Significance
• Type l and Type II Errors
• Regression Analysis
• P-score
• Correlation Coefficient
• Scatter Diagram
• Confidence interval
• Interpercentile (Interquartile Range – IQR) Measure
• Statistical Process Control (SPC)
• Common cause and Random variation
• Statistical thinking
• Display and statistical tools
• Root Cause Analysis (RCA) 
• Analysis and interpretation
• Action plan 
• Management of documentation of meetings and reports
• Meeting Minutes
• Meeting Agendas

Section Five : Patient Safety Page 431

• Patient Safety Definitions 
• Medical errors 
• Adverse event (AE)
• Swiss Cheese Model
• To Err is Human
• (WHO) Centre for Patient Safety
• Patient safety and high reliability
• Patient Safety Program
• Patient Safety Officer (PSO)
• Patient Safety Plan
• Patient Safety Leadership WalkRounds
• Technology and Patient Safety
• Computerized physician order entry (CPOE)
• Bar Code Medication Administration (BCMA)
• Radio Frequency Identification (RFID)
• Abduction and elopement security
• Human Factors
• Perceptual and action-based errors
• Red Rules 
• Apology and disclosure
• Root Cause Analysis (RCA)
• Failure Mode Effectiveness Analysis (FMEA)
• Patient Safety Tools & Resources
• TeamSTEPPS
• Crew Resource Management (CRM)
• Comprehensive Unit-based Safety Program (CUSP)

Section Six : Accreditation and Legislation Page 478

• Accreditation 
• Compliance with Standards
• Accreditation regulatory survey
• Accreditation and regulatory readiness 
• Learning the Regulations
• Document Preparation for accreditation 
• Education of Staff, Leaders, and Practitioners
• Survey Process
• Correction Plan Questions 
• The Joint Commission (TJC) 
• ISO 9001 standards
• External Quality Awards
• Legislation Initiatives
• Liability 
• Prospective Payment System (PPS)
• Accountable Care Organizations (ACOs) 
• Patient Rights and Responsibilities
• Health Insurance Portability and Accountability Act (HIPAA) 
• Self-Disclosure  

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