Management and Leadership (28 items or 22%) :

A. Strategic:

1. Facilitate development of leadership values and commitment

2. Facilitate assessment and development of the organization’s quality culture

3. Participate in organization-wide strategic planning

4. Identify internal customer/supplier relationships

5. Identify external customer/supplier relationships

6. Participate in developing an organizational vision statement

7. Participate in developing an organizational mission statement

8. Develop goals and objectives

9. Develop and use performance measures (e.g., balanced scorecards, Dashboards, core measures)

10. Determine lines of authority/accountability

11. Evaluate applicability of performance improvement models (e.g., FOCUS, PDCA, Six Sigma)

12. Evaluate applicability of national/international excellence/quality models

13. Facilitate evaluation and/or selection of appropriate voluntary accreditation process(es)

14. Develop a performance improvement plan

15. Link performance improvement activities with strategic goals

16. Demonstrate financial benefits of a quality program

17. Facilitate change within the organization

B. Operational

1. Facilitate establishment of a performance improvement oversight group (e.g., Quality Council, Steering Council, QM Committee)

2. Identify the need for a performance improvement team or teams

3. Identify the appropriate team structure (e.g., cross functional, self-directed)

4. Identify champions (e.g., process owners, quality, and patient safety)

5. Monitor the activities of consultants (e.g., quality and patient safety)

6. Assist in developing objective performance measures/indicators

7. Contribute to development and revision of a written plan for a risk management program

8. Contribute to development and revision of a written plan for a case/care/disease/utilization management program

9. Coordinate survey processes (i.e., accreditation, licensure, or equivalent)

10. Participate in cost analysis

11. Participate in developing and managing a budget for a department

Information Management (30 items or 24%)

Design and Data Collection

1. Maintain confidentiality of performance improvement activities, records, and reports

2. Organize information for committee meetings (e.g., agendas, reports, minutes)

3. Assess customer needs/expectations (e.g., surveys, focus groups, teams)

4. Perform or coordinate data inventory listing activities (i.e., what is available from which sources?)

5. Perform or coordinate data definition activities

6. Perform or coordinate data collection methodology

7. Assist with the evaluation of computer software applications

8. Evaluate computerized systems for data collection and analysis

9. Implement computerized systems for data collection and analysis

10. Use epidemiological theory in data collection and analysis

11. Collect qualitative and quantitative data

12. Aggregate/summarize data for analysis

B. Measurement

1. Use or coordinate the use of process analysis tools to display data (e.g., fishbone, Pareto chart, run chart, scattergram, control

chart)

2. Use basic statistical techniques to describe data (e.g., mean, standard deviation)

3. Use or coordinate the use of statistical process control components (e.g., common and special cause variation, random variation, trend analysis)

4. Use the results of statistical techniques to evaluate data (e.g., t-test, regression)

C. Analysis

1. Use comparative data to measure or analyze performance

2. Interpret benchmarking data

3. Interpret incident/occurrence reports

4. Interpret outcome data

5. Interpret data to support decision making

D. Communication

1. Interact with medical staff and support personnel regarding individual patient management issues

2. Promote organizational values and commitment among staff

3. Compile and write performance improvement reports

4. Integrate quality concepts within the organization

5. Coordinate the dissemination of performance improvement information within the organization

6. Ensure accuracy in public reporting activities (e.g., organizational transparency, website content)

7. Facilitate communication with accrediting and regulatory bodies

3. Performance Measurement and Improvement (47 items or 38%)

A. Planning

1. Facilitate establishment of priorities for process improvement activities

2. Facilitate development of performance improvement action plans and projects

3. Facilitate development or selection of process and outcome measures

4. Facilitate evaluation or selection of evidence-based practice guidelines (e.g., for standing orders or as guidelines for physician

ordering practice)

5. Participate in the development of clinical/critical pathways or guidelines

6. Aid in evaluating the feasibility to apply for external quality awards (e.g., Malcolm Baldrige, Magnet)

B. Implementation

1. Coordinate the performance improvement process

2. Lead performance improvement teams

3. Facilitate performance improvement teams

4. Participate on performance improvement teams

5. Participate in the credentialing and privileging process

6. Coordinate or participate in quality improvement projects

7. Participate in the process of:

a. medication usage review

b. medical record review

c. infection control processes

d. peer review

e. service specific review (e.g., pathology,radiology, pharmacy, nursing)

f. patient advocacy (e.g., patient rights, ethics)

8. Perform or coordinate risk management:

a. risk prevention

b. risk identification

c. mortality review

d. failure mode and effects analysis

e. collaborate with quality department

9. Perform or coordinate risk management: risk prevention

C. Education and Training

1. Develop organizational performance improvement training (e.g., quality, patient safety)

2. Provide performance improvement training

3. Evaluate effectiveness of performance improvement training

4. Facilitate change within the organization through education

5. Develop/provide survey preparation training (e.g., accreditation, licensure, or equivalent)

D. Evaluation/Integration

1. Evaluate team performance

2. Analyze/interpret performance/productivity reports

3. Analyze patient/member/customer satisfaction

4. Conduct or coordinate practitioner profiling

5. Perform or coordinate complaint analysis

6. Incorporate performance improvement into the employee performance appraisal system

7. Incorporate findings from performance improvement into the credentialing/appointment/privilege delineation process

8. Integrate results of data analysis into the performance improvement process

9. Integrate outcome of risk management assessment into the performance improvement process

10. Integrate outcome of utilization management assessment into the performance improvement process

11. Integrate quality findings into governance and management activities (e.g., bylaws, administrative policies, and procedures)

12. Integrate accreditation and regulatory recommendations into the organization

4. Patient Safety (20 items or 16%)

A. Strategic

1. Facilitate assessment and development of the organization’s patient safety culture

2. Identify applicability of patient safety goals (e.g., Joint Commission, JCI, NQF, IHI)

3. Facilitate development of a patient safety program

4. Link patient safety activities with strategic goals

5. Integrate patient safety concepts within the organization

6. Integrate patient safety findings into governance and management activities (e.g., bylaws, administrative policies, and procedures)

B. Operational

1. Contribute to development and revision of a written plan for a patient safety program

2. Coordinate a patient safety program

3. Assess how technology can enhance the patient safety program (e.g., computerized physician order entering (CPOE), barcode medication administration (BCMA), electronic medical record (EMR))

4. Integrate technology to enhance the patient safety program

5. Integrate patient safety goals into organizational activities (e.g., Joint Commission, JCI, NQF, IHI)

6. Participate in the process of
patient safety goals review

7. Perform or coordinate risk management

a. incident report review

b. sentinel/unexpected event review

c. root cause analysis

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