Certified Professional in Health Care Quality

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 (e.g., 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 (e.g., credentialing, privileging, quality oversight, risk management)
6. Facilitate development of the quality structure (e.g., councils & committees)
7. Assist in evaluating or developing data management systems (e.g., data bases, registries).
8. Evaluate and integrate external best practices (e.g., resources from AHRQ, IHI, NQF, WHO, HEDIS, outcome measures)
9. Participate in activities to identify and evaluate innovative solutions and practices
10. Lead and facilitate change (e.g., change theories, diffusion, spread)
11. Participate in population health promotion and continuum of care activities (e.g., handoffs, transitions of care, episode of care, outcomes, healthcare utilization)
12. Communicate resource needs to leadership to improve quality (e.g., staffing, equipment, technology)
13. Recognize quality initiatives impacting reimbursement (e.g., pay for performance, value-based contracts)

B. Regulatory, Accreditation and External Recognition:

1. Assist the organization in maintaining awareness of statutory and regulatory
requirements (e.g., CMS, HIPAA, OSHA, PPACA)
2. Identify appropriate accreditation, certification, and recognition options (e.g.,
AAAHC, CARF, DNV GL, ISO, NCQA, TJC, Baldrige, Magnet)
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 (e.g., medication use, infection prevention) service quality, documentation ,practitioner performance evaluation (e.g., peer review, credentialing, privileging) gaps in patient experience outcomes (e.g., surveys, focus groups, teams, grievance, 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 (e.g., including improvement methods, culture change, project and meeting management)
3. Evaluate effectiveness of performance/quality improvement training
4. Develop/provide survey preparation training (e.g., accreditation, licensure, or equivalent)
5. Disseminate performance, process, and quality improvement information within the Organization