Midland College Fall 2008 Syllabus HITT 2343 Quality Assessment and Performance Improvement (2-3-0)

Midland College Fall 2008 Syllabus HITT 2343 Quality Assessment and Performance Improvement (2-3-0) Course Description Text, References and Supplies 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 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, 2 nd Edition, with Student Workbook, Kathleen M. LaTour, MA, RHIA, FAHIMA and Shirley Eichenwald- Maki, 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 Example: Mary Martinez Date 9-21-06 Course HITT1253 Assignment Name 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. Evaluation of Students 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. Discussion Board/Participation 11 % Group Project(s) 8 % Assignments/Quizzes 40 % Sections Exams 21 % Final Exam 20 % Total 100% SCANS Information Safety Statement Instructors Information HITT Director Information Health Sciences Division Dean Information 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. 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. 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 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 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 10/2/08 *First Response DB: HCQM WB Ex 2-10 Performance Measurement Data Sources Assignment #6: Complete HCQM WB Exercises: 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 Six Sigma Paper DB Ch 4: HCQM WB Exercise 4-3 Measuring Effectiveness of Improvement Initiatives 11/6/08 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 11/13/08 Group Project #3: Complete HCQM WB Exercise: Exercise 5-1 Occurrence Screening No DB work on Group Project 11/20/08 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 11/24/08 Section Exam #3 12/2/08 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 12/4/08 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 12/8/08 Final Examination