CPHQ Detailed Content Outline:

1. Organizational Leadership (35 items)

a. Structure and Integration
1. Support organizational commitment to quality
2. Participate in organization-wide Strategic Planning related to quality
3. Align quality and safety activities with strategic goals
4. Engage stakeholders to promote Quality and Safety
 Emergency preparedness
 Corporate compliance
 Infection prevention
 Case management
 Patient experience
 Provider Network
 Vendors
5. Provide consultative support to the governing body and clinical staff
regarding their roles and responsibilities
 Credentialing
 Privileging
 Quality oversight
 Risk Management

6. Facilitate development of the quality structure

 Councils and Committees

7. Assist in evaluating or developing data management systems

 Data bases
 Registries

8. Evaluate and Integrate External Best Practices - Resources from:

 AHRQ – Agency for Healthcare Research and Quality
o www.ahrq.gov
 IHI – Institute for Healthcare Improvement
o www.ihi.org
 NQF – National Quality Forum
o www.qualityforum.org
 WHO – World Health Organization
o www.who.int
 HEDIS – Healthcare Effectiveness Data and Information Set – Most
Widely used Performance Improvement Tool
o www.ncqa.org/hedis
 Outcome Measures -
o www.healthcatalyst.com
 o Top 7 Healthcare Outcome Measures – CMS Weighted by
Importance
1. Mortality 22%
2. Readmissions 22%

3. Safety of care 22%

- Skin breakdown & Hospital Acquired Infections (HAIs)
4. Patient experience 22%
- Patient-Reported Outcome Measures (PROMs)
5. Effectiveness of care 4%
6. Timeliness of care 4%
7. Efficient use of medical imaging 4%
* CMS used these 7 Outcome measures to calculate overall Hospital
Quality and arrive at its 2018 Hospital Star Ratings
* WHO defines an Outcome measure as a “change in the health of
an individual, group of people, or population that is attributable to
an intervention or series of interventions.”

9. Participate in activities to identify and evaluate innovative solutions and

practices
10. Lead and facilitate change:
 Change Theories
 Diffusion
 Spread
11. Participate in population health promotion and continuum of care
activities
 Handoffs
 Transition of care
 Episode of care
 Outcomes
 Healthcare utilization
12. Communicate resource needs to leadership to improve quality
 Staffing
 Equipment
 Technology

13. Recognize Quality Initiatives impacting Reimbursement

 Medicare “Pay For Performance” (P4P) Initiatives

 CMS 5 Original “Value-Based Contracts” – goals is to link provider

performance of Quality Measures to Provider Payment
 ESRD Quality Incentive Program (ESRD QIP)
 Hospital Value-Based Purchasing (VBP) Program
  Hospital Readmission Reduction Program (HRRP)
 Value Modifier (VM) Program (aka Physician Value-Based
Modifier or PVBM)
 Hospital Acquired Conditions (HAC) Reduction Program

Other Value-Based Programs:

 Skilled Nursing Facility Value-Based Program (SNFVBP)
 Home Health Value Based Program (HHVBP)
b. Regulatory, Accreditation, and External Recognition
1. Assist the organization in maintaining awareness of Statutory and
Regulatory Requirements
 CMS – Centers for Medicare & Medicaid Services
 HIPAA – Health Insurance Portability and Accountability Act
 OSHA – Occupational Safety and Health Administration
 PPACA – Patient Protection and Affordable Care Act

2. Identify appropriate Accreditation, Certification, and Recognition

Options
 AAAHC – Accreditation Association for Ambulatory Health Care
 CARF – Commission on Accreditation of Rehabilitation Facilities
 DNV GL – Det Norske Veritas (Norway) “The Norwegian Truth”
& Germanischer Lloyd (Germany) – Sep 2013 DNV officially
merged with GL
o NIAHO – National Integrated Accreditation for
Healthcare Organizations – name of DNV GL’s hospital
accreditation program
o The integration comes from integrating the CMS
Conditions of Participation (CoPs) with the International
Quality Management Standard ISO 9001.
o www.dnv.us
 ISO – International Organization for Standardization
 NCQA – National Committee for Quality Assurance
 TJC – The Joint Commission
o JCI – Joint Commission International is a division of the
Joint Commission Resources (JCR), the non-profit
affiliate of The Joint Commission.
 Baldrige – Baldrige Performance Excellence Program – the
Nation’s only Presidential Award
o www.nist.gov/baldrige
 Magnet Status– by ANCC (American Nurses Credential Center) /
American Nurses Association (ANA)

3. Assist with Survey or Accreditation Readiness

4. Participate in the process for Evaluating Compliance with Internal and

External Requirements for:
 Clinical practice guidelines and pathways:
 o Medication use
o Infection prevention
 Service Quality
 Documentation
 Practitioner Performance Evaluation
o Peer Review
o Credentialing
o Privileging
 Gaps in Patient Experience Outcomes:
o Surveys
o Focus groups
o Teams
o Grievance
o Complaints
 Identification of Reportable Events for Accreditation and
Regulatory bodies

5. Facilitate communication with accrediting and regulatory bodies

c. Education, Training, and Communication

1. Design Performance, Process, and Quality Improvement Training
2. Provide education and training on performance, process, and quality
improvement:
 Including Improvement Methods
 Culture change
 Project and Meeting Management
3. Evaluate effectiveness of Performance/Quality Improvement Training
4. Develop/Provide Survey Preparation Training:
 Accreditation, Licensure or Equivalent
5. Disseminate Performance, Process, and Quality Improvement
Information within the Organization

2. Health Data Analytics (30 items)

a. Design and Data Management
1. Maintain Confidentiality of Performance/Quality Improvement Records
and Reports
2. Design Data Collection Plans:
 Measure development (Definitions, Goals, and Thresholds)
 Tools and Techniques
 Sampling Methodology
3. Participate in Identifying or selecting measures:
 Structure
  Process
 Outcome
4. Assist in developing Scorecards and Dashboards
5. Identify External Data Sources for Comparison (Benchmarking)
6. Collect and Validate Data

b. Measurement and Analysis

1. Use Data Management Systems:
 Organized Data for Analysis and Reporting
2. Use Tools to Display Data or Evaluate a Process:
 Pareto Chart
 Run chart
 Scattergram
 Control chart
3. Use Statistics to Describe Data:
 Mean
 Standard Deviation (SD)
 Correlation
 T-test
4. Use Statistical Process Control:
 Common and Special Case Variation
 Random Variation
 Trend Analysis
5. Interpret Data to Support Decision-making
6. Compare Data Sources to Establish Benchmarks
7. Participate in External Reporting:
 Core Measures
 Patient Safety Indicators
 HEDIS Bundled Payments

3. Performance and Process Improvement (40 items)

a. Identifying Opportunities for Improvement
1. Facilitate discussion about Quality Improvement Opportunities

2. Assist with Establishing Priorities

3. Facilitate Development of Action Plans or Projects

4. Facilitate Implementation of Performance Improvement Methods:

 Lean -
 PDCA Cycle or Shewahrt Cycle
 Six Sigma –
 5. Identify Process Champions

b. Implementation and Evaluation

4. Patient Safety (20 items)

a. Assessment and Planning
1. Assess the Organization’s Culture of Safety (Patient Safety Culture)
2. Determine how technology can enhance the Patient Safety Program:
 EHR – Electronic Health Record
 Abduction/Development Security Systems
 Smart Pumps
 Alerts
3. Participate in Risk Management Assessment Activities:
 Identification and Analysis

b. Implementation and Evaluation

1. Facilitate the ongoing Evaluation of Safety Activities

2. Integrate Safety Concepts throughout the Organization

3. Use Safety Principles:

 Human Factors Engineering
 High Reliability
 Systems Thinking
4. Participate in Safety and Risk Management Activities related to:
 Incident Report Review:
o Near Miss
o Actual Events
 Sentinel / Unexpected Event Review:
o Never Events
 Root Cause Analysis:
 Failure Mode and Effects Analysis