Module 1 : Organizational Leadership
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 and 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:
  a. clinical practice guidelines and pathways (e.g., medication use, infection prevention)
  b. service quality
c. documentation
  d. practitioner performance evaluation (e.g., peer review, credentialing, privileging)
  e. gaps in patient experience outcomes (e.g., surveys, focus groups, teams, grievance, complaints)
  f. 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 
3. Evaluate effectiveness of performance/quality improvement training
4. Develop/provide survey preparation training 
5. Disseminate performance, process, and quality improvement information within the organization

Module 2 : Health Data Analytics
A. Design and Data Management
1. Maintain confidentiality of performance/quality improvement records and reports
2. Design data collection plans:
   a. measure development 
   b. tools and techniques
   c. sampling methodology
3. Participate in identifying or selecting measures 
4. Assist in developing scorecards and dashboards
5. Identify external data sources for comparison 
6. Collect and validate data

B. Measurement and Analysis
1. Use data management systems
2. Use tools to display data or evaluate a process 
3. Use statistics to describe data 
4. Use statistical process control
5. Interpret data to support decision-making
6. Compare data sources to establish benchmarks
7. Participate in external reporting 

Module 3 : Performance and Process Improvement
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 
5. Identify process champions
B. Implementation and Evaluation
1. Establish teams, roles, responsibilities, and scope
2. Use a range of quality tools and techniques 
3. Participate in monitoring of project timelines and deliverables
4. Evaluate team effectiveness 
5. Evaluate the success of performance improvement projects
6. Document performance and process improvement results

Module 4 : Patient Safety
A. Assessment and Planning
1.Assess the organization's culture of safety
2. Determine how technology can enhance the patient safety program 
3. Participate in risk management assessment activities 
B. Implementation and Evaluation
1. Facilitate the ongoing evaluation of safety activities
2. Integrate safety concepts throughout the organization
3. Use safety principles:
   a. Human factors engineering
   b. High reliability
   c. systems thinking
4. Participate in safety and risk management activities related to:
   a. Incident report review 
   b. sentinel/unexpected event review 
   c. Root cause analysis
   d. Failure mode and effects analysis