Midland College
Fall 2008 Syllabus
HITT 2343 – Quality Assessment and Performance Improvement
(2-3-0)
Course
Description
This course is a study of the many facets of quality standards and methodologies in the
health information management environment. Topics include licensing, accreditation,
compilation and presentation of data in statistical formats, quality improvement functions,
quality tools, utilization management, risk management, and medical staff data quality
issues. PREREQUISITES: HITT 1401, HITT1255
Text,
References
and Supplies
Textbooks:
Fundamentals of Health Care Quality Management, and Health Care Quality Management
Student Workbook, Patrice L. Spath. 2005. (Referenced in Readings and Assignments as
“FHCQM” and “HCQM WB”)
Health Information Management: Concepts, Principles, and Practice, 2nd Edition, with
Student Workbook, Kathleen M. LaTour, MA, RHIA, FAHIMA and Shirley EichenwaldMaki, MBA, RHIA, FAHIMA, Editors, AHIMA, 2006. (Referenced in Readings and
Assignments as “LaTour” and “LaTour WB”)
Case Studies in Health Information Management, 1st Edition. Charlotte McCuen; Nanette
B. Sayles; Patricia Schnering. 2008 Cengage Delmar Learning. (Referenced in Readings
and Assignments as “CS-HIM)
Supplies (optional) for Virtual Office: Headset with microphone. To use SKYPE,
students need to purchase either a headset with microphone, or a separate microphone to
add to your PC (the PC must also have speakers). Headsets can be purchased at most
outlets stores that sell electronics (Wal-Mart, Radio Shack, etc). The headsets cost
approximately $15.00 to $20.00, and the stand-alone microphones cost approximately
$26.00. The LogiTech brand is recommended. Using this option, students will be able to
speak to the instructor or other students (or anyone in the world) using SKYPE free of
charge through the internet. You will need to go to www.SKYPE.com and download the
program. (Most HITT courses have elected to use SKYPE as an additional communication
option for students).
Course Goals/
Objectives
Upon completion of this course, the student will be able to:
1.
Describe the evolution of quality assessment/performance improvement, utilization
review, and risk management and peer review programs within the health care system.
2. Distinguish between the activities of performance assessment and improvement.
3. Summarize the steps of an improvement project.
4. Explain the differences between the three types of performance measures used in
clinical quality improvement (QI): structure, process, and outcome.
5. Design survey instruments and forms for collection of patient related and/or other
data.
6. Collect and compile data for quality management, utilization management, and risk
management.
7. Apply statistical principles, methods, software, and tools for assessing patient care
quality and effectiveness.
8. Explain the role of case management, clinical paths, computer decision support
modules, and other initiatives in achieving utilization management goals.
9. Monitor accreditation/licensing survey results.
10. Utilize data monitoring and compliance reporting.
11. Formulate the design and implementation of contingency planning and data
recovery procedures.
12. Explain how ORYX and performance measure data used in the accreditation
process.
13. Review current Joint Commission survey processes.
14. Review the standards of Material Safety Data Sets (MSDS).
15. Identify and differentiate performance improvement initiatives of accrediting
agencies, regulatory bodies, and payers.
16. Describe the significance of core performance measures in regard to data
comparison, performance improvement and data-driven accreditation.
17. Review the rationale behind the patient safety initiatives and the role played by the
private sector and the government.
18. Explain Six Sigma as a quality measurement system and why its success in
healthcare is dependent on physician and higher-level management buy-in.
19. Explain the significance of outcomes management, case management, clinical
practice guidelines, and benchmarking in quality management.
20. Review the concept of sentinel events.
21. Recognize when root-cause analysis is required.
22. Describe the impact of the concepts of medical staff appointment/reappointment,
credentialing, and clinical privileges on quality of care.
23. Recognize the functions of the executive committee and to discuss the relevance of
medical staff bylaws/rules and regulations in quality improvement.
24. Review medical staff quality applications required by JACHO standards and to
summarize the medical staff’s patient care review functions.
25. Explain the utilization review process and its impact of quality of care.
26. Review the importance of integrating risk management into any QI program and
the importance of keeping QI data confidential and secure.
27. Describe the impact of the Agency for Healthcare Research and Quality on
performance improvement.
DOMAINS, SUBDOMAINS, AND TASKS:
I. Domain: Health Data Management
A. Subdomain: Health Data Structure, Content and Standards
I.A.2. Conduct analysis to ensure that documentation in the health record supports the
diagnosis and reflects the patient’s progress, clinical findings and discharge status.
I.A.3. Apply policies and procedures to ensure the accuracy of health data.
B. Subdomain: Healthcare Information Requirements and Standards
I.B.1. Monitor and apply organization-wide health record documentation guidelines.
I.B.2. Apply policies and procedures to ensure organizational compliance with regulations
and standards.
I.B.3. Report compliance findings according to organizational policy.
I.B.4. Maintain the accuracy and completeness of the patient record as defined by
organizational policy and external regulations and standards.
II. Domain: Health Statistics, Biomedical Research and Quality Management
A. Subdomain: Healthcare Statistics and Research
II.A.2. Collect, organize and present data for quality management, utilization management,
risk management, and other patient care related studies.
II.A.3. Compute and interpret healthcare statistics.
B. Subdomain: Quality Management and Performance Improvement
II.B.1. Abstract and report data for facility-wide quality management and performance
improvement programs.
II.B.2. Analyze clinical data to identify trends that demonstrate quality, safety and
effectiveness of healthcare.
III. Domain: Health Services Organization and Delivery
A. Subdomain: Healthcare Delivery Systems
II.A.2. Apply current laws, accreditation, licensure and certification standards related to
health information initiatives from the national, state, local and facility levels.
III.A.3. Differentiate the roles of various providers and disciplines throughout the
continuum of healthcare and respond to their information needs.
IV. Domain: Information Technology & Systems
A. Subdomain: Information and Communication Technologies
IV.A. 2. Use common software applications such as spreadsheets, databases, word
processing, graphics, presentation, email and so on in the execution of work processes.
IV.A.3. Use specialized software in the completion of HIM processes such as record
tracking, release of information, coding, grouping, registries, billing, quality improvement,
and imaging.
D. Subdomain: Data Security
IV.D.4. Use and summarize data compiled from audit trail and data quality monitoring
programs.
IV.D.5. Contribute to the design and implementation of risk management, contingency
planning, and data recovery procedures.
V. Domain: Organizational Resources
A. Subdomain: Human Resources
V.A.1. Apply the fundamentals of team leadership.
V.A.8. Use quality improvement tools and techniques to monitor, report and improve
processes
Student
Contributions
and Class
Policies
ACCESSING AN ONLINE COURSE: Refer to www.bb01.edu
1.
Using Microsoft Mozilla or Netscape Navigator, access the Midland College Home
page at www.midland.edu. There have been problems in the past with Internet
Explorer and AOL browsers.
2. On the right side of the Midland College home page, click “Blackboard.”
3. Update your personal profile by clicking on “Edit Personal Profile”. Verify that your
contact information is correct especially your web address and your address and phone
number.
4. When the Blackboard page appears, you will need to login to the program. In order to
login you must have a login name and password. Your login name will be the first
letter of your first name plus the first 3 letters of your last name and the last three
numbers of your social security number. For example: the login name for John Smith,
social security number 101-000-1111, will be jsmi111. Your password will be your
social security number using dashes. (101-00-1111)
5. After you have logged in, your home page will appear on the screen. On the right side
of the page in the box titles “My Courses” double click on the course you want to
view.
6. The course home page will appear. Areas you will want to check frequently are:
Announcements, Course Documents, and Assignments. Do not open exams until you
are ready to take the test. You can access each exam only one time.
7. In the tools section you can access your grades once they are submitted. Go to “Tools”
then “Check Grades”. Click on the test or assignment to see comments and feedback.
DISCUSSION BOARD: This is the online classroom. Students will respond to discussion
questions, post weekly summaries, and communicate with your instructor in the discussion
board. Questions about content and assignments should be posted on the discussion board.
The posts will be answered daily. Please allow 24 hours for a response. Posts made on the
weekend MAY NOT BE answered until Monday. This form of communication is
important in online courses. This tool will help you stay “connected” to other classmates
and it will help students to ask those questions just as if you were in an actual classroom
setting. Discussion board will also be used as a participation tool, and part of the semester
grade is based on participation. When posting a response to the discussion board about a
topic, post your original response before reviewing other classmate’s postings. Then, read
the other postings and respond to at least two other students for full credit for participation.
Only when the content of the question is personal in nature should the instructor be
emailed. When sending email, use the Course Name such as QA in your subject line so that
the instructor can identify the course being addressed in the email followed by the subject
matter.
Example:
To:
Instructor’s email address
From: Your email address
Subject: HITT 2343 – Regarding _________________________
Also be sure to sign your name at the end of the email. Remember some email addresses
give instructors absolutely no clue as to who sent it.
ATTENDANCE: Because this is strictly an internet course, attendance will be substituted
by participating on the discussion board. You will be required to respond to 2 posts in the
discussion board 4 out of 7 days of the week. Answers to the discussion questions, and
weekly summaries are counted as a posting. Participation is part of your semester grade.
ACADEMIC HONESTY: Students are expected to follow the Academic Honesty policy
of Midland College. Using textbooks, assignments and other students, or assistance from
others while taking an exam is cheating. Any student cheating will be removed from the
class, given an “F”, and reported to the Registrar’s office. Plagiarism will not be tolerated.
For more information, review Student Conduct/Misconduct in the MC catalog at
http://www.midland.edu/adminssions/images/mc_cataolg 2008-2009.pdf .
TESTING PHILOSOPHY: Students may politely challenge the instructor on questions
they feel were poorly worded. If the instructor concedes the argument, scores will be
adjusted for the entire class. Assignments consist of multiple formats including multiple
choice, open-ended questions and some true/false. The final examination will be
comprehensive over all the material presented during the course.
ADA POLICY: Students needing additional time to test due to a documented learning
disability, contact Dale Williams, Counselor, at 432-685-5598 or dwilliams@midland.edu
at the beginning of the course to make accommodations. See the current Midland College
catalog for more information.
COURSE WITHDRAWAL: Students electing to withdraw from course are required to
complete a Course Withdraw Form at http://www.midland.edu/admissions/forms.php
before the last day to withdraw with a grade of “W”.
Last day to withdrawal for this semester: November 13, 2008
ONLINE COURSE INFORMATION:
PERSONAL INFORMATION: Every semester it is important to update your personal
information listed in Blackboard. Check your personal information by going to Personal
Information under the MY MC BLACKBOARD tab located directly below the Midland
College Logo on your Blackboard screen. Go to Edit Personal Information and update.
Once updated, scroll to the bottom of the page and click SUBMIT. Next, click OK. This
information is used to contact students. Be sure your e-mail address (the one you choose to
us for this class) is correct.
As stated in the student handbook, “Midland College encourages high academic standards,
including student responsibility for original work.” See the Midland College Student
Handbook for more information on the definitions and consequences of cheating,
plagiarism, and collusion. Any student found cheating in this course will be removed and a
letter grade of “F” will be posted for the course along with a letter of explanation added in
the student file for the offense.
Computer Requirements: Students should have access to Microsoft Word and Excel for
assignment submission. Students taking online courses are responsible to have access to a
computer for submission of assignments and postings. For specific computer requirements,
see Blackboard System Requirements for Midland College courses at www.bb01.edu.
AOL, MSN, and Prodigy browsers will not work with Blackboard. These browsers will
lock up or lock you out of assignments and tests. Instead, download Mozilla at
www.mozilla.com or Netscape 7.0.
Computer Downtime: This is an online course. Each student is required to have a
functioning computer for the entirety of the semester. Having computer problems does not
exempt students from completing work by the due date. If the Blackboard system goes
down or is unavailable, an announcement will be posted as the due date will be extended.
If your system goes down, find another computer to submit your homework/posts before
the due date. It is strongly suggested that assignments are to be submitted early to avoid
any technical difficulties.
SUBMITTING ASSIGNMENTS IN BLACKBOARD:
1. Use a word document format.
2. Save assignment in a rich text file (.rtf). You will find this on your computer under File,
Save As, Save Type As (under the name of your document). If you have questions
about rtf files, see Course Documents for more information.
3. Each assignment should be submitted through Blackboard under “View/Complete
Assignment” as an attachment. If there is more than one task due with the assignment
such as CH1A (Workbook 1-1, 1-3, and 1-4), all these tasks should be submitted in one
word document. DO NOT send three different files.
4. Each assignment should have a header that includes your name, date, course number,
and assignment name. Failure to include this content will result in points deducted
from your grade.
To save:
Ch1mct.rtf
Ch2jwj.rtf
Chapter 1 by Melody Cheryl Thompson (rtf file)
Chapter 2 by James W. Johnson (rtf file)
Header:
Your name
Date
Course
Assignment Name
Example:
Mary Martinez
9-21-06
HITT1253
WB: 5-1
EMAIL: Individual email is discouraged when it involves course assignments and
questions about the reading material. These should be posted on the discussion board
under the thread “Questions to Instructor” so that the class may also receive the
information since many questions posed to the instructor are commonly asked by more
than one individual. In sharing responses with the class, there is equal opportunity (or
equitable responses) to receive information from the instructor.
If, however, there is a need to send an email to the instructor, (due to a personal nature)
include in the subject line the course number and the content of the question such as
“HITT2343 Question on Ch1 assignment”. It is also important that you sign your name at
the end of the email since many emails give no indication of the author.
Evaluation of
Students
SCANS
Information
Discussion Board/Participation
Group Project(s)
Assignments/Quizzes
Sections Exams
Final Exam
Total
11 %
8%
40 %
21 %
20 %
100%
The following SCANS skills will be taught and/or reinforced in this course:
reading, writing, mathematics, listening/speaking, thinking skills, personal qualities,
workplace competencies, and basic use of computers.
Safety
Statement
Students will receive annual training in the following: blood and air borne pathogens,
electrical safety, back safety, hazardous chemicals, latex allergies, fire and disaster
procedures, security and personal safety procedures and safety requirements of clinical
facilities. Students must maintain current CPR, immunizations, and health insurance during
all clinical courses.
Instructors
Information
Name: Shawnda Meshirer, RHIT, CCS
Office Location: A15 Aaron Medical Science Building
E-mail Address: smeshirer@midland.edu
Office Telephone: 432-685-5578 or SKYPE @ smeshirer
Office Hours: Monday 9:00–11:00 a.m. & 1:00-3:00 p.m.;
Wednesday & Thursday 9:00-11:00 am
Virtual Office Hours on SKYPE @ shawnda.him:
Monday Evenings 7:00-8:00 p.m. and Tuesday 9:00-11:00 am
HITT Director
Information
Program Director: Melinda Teel, BSHIM, RHIT, CCS
Office Location: A33 Aaron Medical Science Building
Office Telephone: 432-685-5573
E-mail Address: mteel@midland.edu
Health Sciences
Division Dean
Information
Division Dean: Dr. Becky Hammack
Health Sciences Division Secretary and Clerk: Kay Floyd and Alma Guyse
Division Office Location and Telephone: 209 Davidson Health Sciences Building
Office Telephone: 432-685-4600
Students are encouraged to contact the instructor at any time; however, making an
appointment will guarantee the instructor’s availability at a specific time.
Course
Schedule
The course schedule has due dates and it is imperative each student submit
assignments/tests on or before midnight Central Standard time (CST) of the due date.
There is no formal provision for make-up work or extra credit in this course. Work
submitted after the deadline will not be accepted. Once the assignment date closes,
assignments cannot be submitted. A zero will be placed in the grade book for late
assignments.
DO NOT wait until the last minute to attempt assignments. Computers and computer
networks have a bad habit of crashing at the very time you need them the most.
Due dates and assignments may change at the discretion of instructor. Any change will be posted in Announcements.
Due Date:
Readings and Assignments
8/28/08
Read FHCQM Ch 1: Introduction to Quality Management and Review Power Point
Read LaTour Ch 17 pages 489-504: Overview of Clinical Quality Management
Complete Pre-Test and Orientation Quiz
Discussion Board (DB): Student Introductions
9/2/08
Assignment #1:
1) Complete LaTour WB Ch 17 Application Exercise #2
2) Complete HCQM WB Exercise 1-1 Elements of a Successful Quality Effort
DB Ch 1: Quality Improvement Organization (QIO) Web Review
9/4/08
Read FHCQM Ch 2: Performance Measurement and Review Power Point
Read LaTour Ch 23 pages 657-668: Performance and Work Measurement Standards
Assignment #2: Complete HCQM WB Exercises:
Ex 2-1 Numerator and Denominator for Behavior Health Performance Measures
Ex 2-2 Types of performance measures
No DB – work on Group Project
9/11/08
Assignment #3:
1) Complete LaTour WB Ch 23 Application Exercise #2
2) Complete HCQM WB Exercise 2-5 Identify Measures of Performance
DB Ch 2 Group Project #1:
HCQM WB Exercise 2-7 Compliance with Clinical Practice Guidelines
9/18/08
Assignment #4: Complete HCQM WB Exercises:
Ex 2-11 Risk-adjusted Performance Measures
Ex 2-12 Health-related Quality of Life Measures
DB Ch 2: National Patient Safety Goals and Measures
9/23/08
Section Exam #1
9/25/08
Read FHCQM Ch 3: Performance Assessment and Review Power Point
Read LaTour Ch 23 pages 668-679: Performance Improvement Methodologies
Assignment #5:
1) Complete LaTour WB Ch 23 Real-World Case Discussion Questions
2) Complete HCQM WB Exercise 3-3 Hospital Efficiency Profile
DB Ch 3: Joint Commission Article Review
*9/30/08
*First Response DB: HCQM WB Ex 2-10 Performance Measurement Data Sources
Assignment #6: Complete HCQM WB Exercises:
10/2/08
Exercise 3-6 Bar Graph; Exercise 3-7 Pie Chart; and, Exercise 3-8 Histogram
Complete DB: Ch 2: HCQM WB Exercise 2-10 Performance Measurement Data Sources
10/9/08
Group Project #2 – Complete CS-HIM Case Studies:
Case 1-16 ORYX Performance Measures for the Joint Commission
Case 1-17 Joint Commission Mock Survey
No DB – work on Group Project
10/16/08
Assignment #7: Complete CS-HIM Case Studies:
Case 2-29 Case Mix Index (CMI) Trends
Case 2-35 Qualification for Insurance
DB Ch 3: Brown & Spath Article Review #1
10/23/08
Read FHCQM Ch 4: Performance Improvement and Review Power Point
Read LaTour Ch 23 pages 647-657 Work Design
Assignment #8: Complete HCQM WB Exercises:
Exercise 4-5 Root Cause Analysis
Exercise 4-8 Patient Incidence/Near Miss, Adverse Event, & Sentinel Event.
Complete LaTour Ch 23 Review Quiz
No DB for this week
10/28/08
Section Exam #2
10/30/08
11/6/08
11/13/08
11/20/08
11/24/08
12/2/08
12/4/08
12/8/08
Six Sigma Paper
DB Ch 4: HCQM WB Exercise 4-3 Measuring Effectiveness of Improvement Initiatives
Read FHCQM Ch 5: Assuring Individual Competence and Review Power Point
Read LaTour Ch 17 pages 504-509: Quality Management in Clinical Applications
Assignment #9:
1) Complete CS-HIM Case 5-43 Audit Triggers
2) Complete HCQM WB Exercise 5-3 Peer Review Process
DB Ch 5 Article Review on Data Recovery
Group Project #3: Complete HCQM WB Exercise:
Exercise 5-1 Occurrence Screening
No DB – work on Group Project
Read FHCQM Ch 6: Resource Management and Review Power Point
Read LaTour Ch 17 pages 509-511: Utilization Management
Assignment #10:
1) Complete LaTour WB Ch 17 Application Exercise #4
2) Complete HCQM WB Exercise 6-1 Case Management Processes
DB Ch 6: HCQM WB Ex 6-3: Utilization Review
Section Exam #3
Read FHCQM Ch 7: Risk Management and Review Power Point
Read LaTour Ch 17 pages 511-517: Risk Management
Assignment #11:
1) Web Review - Compliance
2) Complete LaTour WB Ch 17 Real-World Case Discussion Questions
Complete LaTour Ch 17 Review Quiz
DB Ch 7: Risk Management Issues
Group Project #4: Complete HCQM WB Exercises:
Ex 7-1 Patient Incident Reports
Ex 7-3 Reporting Patient Incidents
Complete Post-Test
DB Ch 7: Material Safety Data Sets (MSDS)
DB: QA Review
Final Examination