1. Quality Leadership and Integration

A. Strategic Planning

• Advise leadership on organizational improvement opportunities
• Assist with the development of action plans or projects
• Assist with establishing priorities
• Participate in activities that support the quality governance infrastructure
• Align quality and safety activities with strategic goals

B. Stakeholder Engagement

• Identify resource needs to improve quality
• Assess the organization’s culture of quality and safety
• Engage stakeholders to promote quality and safety
• Provide consultative support to the governing body and key stakeholders regarding their roles and responsibilities related to quality improvement
• Promote engagement and inter-professional teamwork

2. Performance and Process Improvement

• Implement quality improvement training
• Communicate quality improvement information within the organization
• Identify quality improvement opportunities
• Establish teams, roles, responsibilities, and scope
• Participate in activities to identify innovative or evidence-based practices
• Lead and facilitate change
• Use performance improvement methods (e.g., Lean, PDSA, Six Sigma)
• Use quality tools and techniques (e.g., fishbone diagram, FMEA, process map)
• Participate in monitoring of project timelines and deliverables
• Evaluate team effectiveness
• Evaluate the success of performance improvement projects and solutions

3. Population Health and Care Transitions

• Identify data and resources that are important in determining the health status of
  defined populations
• Identify population health management strategies to integrate into improvement
  initiatives
• Incorporate prevention, wellness, and disease management solutions into
  improvement initiatives
• Incorporate techniques to address health disparities and promote equity into
  improvement initiatives
• Analyze and use clinical, cost, equity, and social determinants of health data to drive and monitor improvement efforts
• Identify opportunities for improvement in care transitions
• Collaborate with stakeholders to improve and optimize care processes and
  transitions
• Incorporate concepts of social determinants of health into improvement activities

4. Health Data Analytics

A. Data Management Systems

• Assist in evaluating and developing data management systems to support quality
  improvement
• Design data collection plans:
  1. Measure development (e.g. definitions, goals, thresholds, numerators,
     and denominators)
  2. Tools and techniques
  3. Sampling methodology
• Identify and select measures (e.g. structure, process, outcome, experience)
• Collect and validate quantitative and qualitative data
• Identify external data sources for comparison and benchmarking
• Design scorecards and dashboards for different audiences

B. Measurement and Analysis

• Use data management systems for organization, analysis, and reporting of data
• Use data visualization and display techniques
• Use measurement tools to evaluate process improvement
• Use statistics to describe data and examine relationships (e.g., measures of central tendency, standard deviation, correlation, regression, t-test)
• Use statistical process control techniques and tools (e.g., common and special cause variation, control charts, trend analysis)
• Compare data sources to establish benchmarks
• Interpret data to support decision-making

5. Patient Safety

• Identify technology solutions to enhance patient safety
• Facilitate the ongoing evaluation of safety activities
• Apply techniques to enhance the culture of safety within the organization
• Integrate safety concepts throughout the organization
• Use safety principles (e.g., human factors engineering, high reliability, high-performance teams, systems thinking)
• Participate in safety and risk management activities related to:
  1. Safety event/incident reporting
  2. Sentinel/unexpected event review
  3. Root cause analysis
  4. Proactive risk assessment

6. Quality Review and Accountability

• Apply standards, best practices, and other information from quality-related organizations
• Evaluate compliance with internal and external requirements for:
  1. Clinical practice guidelines, pathways, and outcomes
  2. Quality-based payment programs
  3. Documentation
  4. Practitioner performance evaluation
  5. Patient experience
  6. Identification of reportable events for accreditation and regulatory bodies
• Maintain confidentiality of performance/quality improvement records and reports
• Implement and evaluate quality initiatives that impact reimbursement

7. Regulatory and Accreditation

• Evaluate appropriate accreditation, certification, and recognition options
• Promote awareness of statutory and regulatory requirements within the organization
• Support processes for evaluating, monitoring, and improving compliance with organizational, state, and federal requirements
• Maintain survey or accreditation readiness