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Section 1
Advise leadership on organizational improvement opportunities
Preview
Preview: 1. Quality Leadership and Integration (19 scored-item blueprint)
Preview includes- 4 of 6 lesson topics
- 1 overview segment
- 3 core concepts
- 2 exam tips
Lesson Topics
- Strategic Planning Alignment
- Quality Governance Frameworks
- Organizational Culture Impact
- Resource Optimization for Improvement
Overview
This objective focuses on the CPHQ professional's role in identifying and recommending organizational improvements to leadership, leveraging a holistic understanding of quality governance and strategic alignment.
Core Concepts
- Quality leadership questions are usually about alignment, governance, influence, prioritization, and stakeholder ownership—not about the quality professional acting as the sole decision maker.
- Use a systems perspective: connect quality and safety work to organizational mission, strategic goals, patient needs, workforce capability, resources, risk, and measurable outcomes.
- Prioritize improvement work using objective criteria such as magnitude of the gap, severity/risk, strategic importance, feasibility, resource requirements, regulatory urgency, and likely impact.
Exam Tips
- Consider the organization's overall strategic direction when evaluating potential improvement opportunities. A recommendation that aligns with the strategy is more likely to be accepted.
- When recommending changes, clearly articulate the potential impact on key performance indicators (KPIs) and the organization's strategic goals.
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Section 2
Assist with the development of action plans or projects
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Section 3
Assist with establishing priorities
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Section 4
Participate in activities that support the quality governance infrastructure
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Section 5
Align quality and safety activities with strategic goals
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Section 6
Identify resource needs to improve quality
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Section 7
Assess the organization’s culture of quality and safety
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Section 8
Engage stakeholders to promote quality and safety
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Section 9
Provide consultative support to the governing body and key stakeholders regarding their roles and responsibilities related to quality improvement
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Section 10
Promote engagement and inter-professional teamwork
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Section 11
Implement quality improvement training
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Section 12
Communicate quality improvement information within the organization
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Section 13
Identify quality improvement opportunities
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Section 14
Establish teams, roles, responsibilities, and scope
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Section 15
Participate in activities to identify innovative or evidence-based practices
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Section 16
Lead and facilitate change
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Section 17
Use performance improvement methods (e.g., Lean, PDSA, Six Sigma)
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Section 18
Use quality tools and techniques (e.g., fishbone diagram, FMEA, process map)
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Section 19
Participate in monitoring of project timelines and deliverables
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Section 20
Evaluate team effectiveness
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Section 21
Evaluate the success of performance improvement projects and solutions
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Section 22
Identify data and resources that are important in determining the health status of defined populations
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Section 23
Identify population health management strategies to integrate into improvement initiatives
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Section 24
Incorporate prevention, wellness, and disease management solutions into improvement initiatives
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Section 25
Incorporate techniques to address health disparities and promote equity into improvement initiatives
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Section 26
Analyze and use clinical, cost, equity, and social determinants of health data to drive and monitor improvement efforts
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Section 27
Identify opportunities for improvement in care transitions
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Section 28
Collaborate with stakeholders to improve and optimize care processes and transitions
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Section 29
Incorporate concepts of social determinants of health into improvement activities
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Section 30
Assist in evaluating and developing data management systems to support quality improvement
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Section 31
Design data collection plans: measure development, tools and techniques, and sampling methodology
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Section 32
Identify and select measures (e.g., structure, process, outcome, experience)
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Section 33
Collect and validate quantitative and qualitative data
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Section 34
Identify external data sources for comparison and benchmarking
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Section 35
Design scorecards and dashboards for different audiences
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Section 36
Use data management systems for organization, analysis, and reporting of data
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Section 37
Use data visualization and display techniques
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Section 38
Use measurement tools to evaluate process improvement
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Section 39
Use statistics to describe data and examine relationships (e.g., measures of central tendency, standard deviation, correlation, regression, t-test)
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Section 40
Use statistical process control techniques and tools (e.g., common and special cause variation, control charts, trend analysis)
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Section 41
Compare data sources to establish benchmarks
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Section 42
Interpret data to support decision-making
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Section 43
Identify technology solutions to enhance patient safety
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Section 44
Facilitate the ongoing evaluation of safety activities
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Section 45
Apply techniques to enhance the culture of safety within the organization
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Section 46
Integrate safety concepts throughout the organization
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Section 47
Use safety principles (e.g., human factors engineering, high reliability, high-performance teams, systems thinking)
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Section 48
Participate in safety event/incident reporting
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Section 49
Participate in sentinel/unexpected event review
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Section 50
Participate in root cause analysis
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Section 51
Participate in proactive risk assessment
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Section 52
Apply standards, best practices, and other information from quality-related organizations
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Section 53
Evaluate compliance with internal and external requirements for clinical practice guidelines, pathways, and outcomes
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Section 54
Evaluate compliance with internal and external requirements for quality-based payment programs
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Section 55
Evaluate compliance with internal and external requirements for documentation
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Section 56
Evaluate compliance with internal and external requirements for practitioner performance evaluation
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Section 57
Evaluate compliance with internal and external requirements for patient experience
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Section 58
Evaluate compliance with internal and external requirements for identification of reportable events for accreditation and regulatory bodies
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Section 59
Maintain confidentiality of performance/quality improvement records and reports
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Section 60
Implement and evaluate quality initiatives that impact reimbursement
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Section 61
Evaluate appropriate accreditation, certification, and recognition options
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Section 62
Promote awareness of statutory and regulatory requirements within the organization
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Section 63
Support processes for evaluating, monitoring, and improving compliance with organizational, state, and federal requirements
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Section 64
Maintain survey or accreditation readiness
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