Course curriculum

  • 1

    Welcome

    • Welcome to New Quality Director Fellowship

    • Course instructor, learning objectives, CE credits

    • CLIC hub FAQs

    • NQDF Student Workbook

  • 2

    Lesson 1 - Introduction & Syllabus Week

    • Lesson 1 - Introduction & Syllabus Week

    • Introduce yourself!

    • Lesson 1 - Scavenger Hunt

    • Quality Competency Assessment

    • DISCUSSION: What did you find?

  • 3

    Lesson 2 - Quality Director/Leader's Role in the Hospital

    • Lesson 2 - Quality Director/Leader's Role in the Hospital

    • Lesson 2 - Quality Director Relationship Tree

    • DISCUSSION: What does the role of a quality leader look like to you?

  • 4

    Lesson 3 - Accreditation & Licensing

    • Lesson 3 - Accreditation & Licensing

    • Lesson 3 Activities – Accreditation and Licensing

    • Accreditation & Licensing Survey/Corrective Action Plan

    • Quality Improvement Plan

    • DISCUSSION: Action plans & Improvement plans

  • 5

    Lesson 4 - Public, Government, and Private Entity Reporting

    • Lesson 4 - Public, Government, and Private Entity Reporting

    • Lesson 4 Activities - Public, Government, and Private Entity Reporting

    • Government and Outside Agency Reporting Inventory

    • DISCUSSION: Upload and assess the knowledge level of the organization about the reports that are available

  • 6

    Lesson 5 - Risk Management

    • Lesson 5 - Risk Management

    • Lesson 5 Activities - Risk Management

    • Review your organization's Risk Management Plan

    • FMEA Sample Scenario

    • FMEA Template

    • DISCUSSION: Learnings from the Sample Scenario

  • 7

    OFFICE HOURS (OPTIONAL)

    • Office Hours - #1 (Optional)

  • 8

    Lesson 6 - Emergency Preparedness & Environment of Care

    • Lesson 6 - Emergency Preparedness & Environment of Care

    • Lesson 6 Activities - Emergency Preparedness & Environment of Care

    • Review your organization's Emergency Preparedness Plan

    • World Health Organization Hospital Emergency Response Checklist

    • DISCUSSION: Assess your organization's current level of emergency preparedness

  • 9

    Lesson 7 - Medical Staff Services

    • Lesson 7 - Medical Staff Services

    • Lesson 7 Activities - Medical Staff Services

    • Review your organization's Peer Review Policy

    • DISCUSSION: Assess your organization's Peer Review Policy

  • 10

    Lesson 8 - Board of Directors/Governing Body

    • Lesson 8 - Board of Directors/Governing Body

    • Lesson 8 Activities - Board of Directors / Governing Body

    • Review the minutes of your organization's Board of Director meetings over the last 12 months

    • DISCUSSION: What have you identified as the main focus areas for Governing Body discussions over the past 12 months? (No patient or hospital identifying info)

  • 11

    Lesson 9 - The Science of Improvement and Your Organization's Improvement Methodology

    • Lesson 9 - Science of Improvement

    • Lesson 9 Activities - Science of Improvement

    • How do we improve?

    • The Model for Improvement

    • What does the Model for Improvement look like in action?

    • What other improvement methodologies are used in health care and other industries?

    • Back to the Model for Improvement: What are we trying to improve?

    • Guidelines for developing the AIM statement

    • What comes next after we develop an AIM statement?

    • What change can we make that will result in an improvement?

    • Plan - Do - Study - Act (PDSA) Cycle

    • Describe your organization's improvement methodology

    • DISCUSSION: Describe your organization's improvement methodologies

  • 12

    Lesson 10 - The Use of Data and Analysis in Health Care Quality and Patient Safety

    • Lesson 10 - Data

    • Lesson 10 Activities - The Use of Data and Analysis

    • Using data to tell the story of improvement

    • Types of measures for improvement

    • Types of measures: What's a "balancing measure"?

    • What's the difference between data for quality improvement and data for research?

    • Collecting the RIGHT data

    • What can we learn about data collection from a banana?

    • Data display

    • Data display techniques

    • Data display techniques

    • Common types of data display

    • Run charts and control charts

    • How do we use run charts and control charts to make decisions?

    • What about variation in data results?

    • How do we use run charts and control charts to make decisions?

    • What about variation in data results?

    • Run chart rules

    • Improvement Calculator

    • How to create a run chart in excel

    • Create a simple run chart and assess best data display

    • DISCUSSION: What challenges did you encounter when creating a run chart of your own? Any advice for your peers about making the process easier or simpler?

  • 13

    Lesson 11 - Tools of the Trade

    • Lesson 11 - Tools of the Trade

    • Lesson 11 Activities: Tools of the Trade

    • Tools of the Trade

    • What's a Driver Diagram?

    • RCA Tools: Staff Credentials and Information

    • RCA Tools: Sequence of Events

    • RCA Tools: Example Fishbone Diagram

    • RCA Tools: Blank Cause and Effect (Fishbone) Diagram

    • RCA Tools: 5 Whys Tool

    • RCA Tools: Root Cause Analysis Action Plan

    • QI Tools: Improvement Project Worksheet

    • QI Tools: Driver Diagram Worksheet

    • QI Tools: Discovery Tools

    • DISCUSSION: What is one tool or resource that you find yourself using regularly to assist with the activities of a Quality Improvement leader?

  • 14

    Lesson 12 - Patient Safety Science

    • Lesson 12 - Patient Safety Science

    • What does it mean to provide safe care?

    • Systems and safety

    • Systems focus

    • What can Swiss cheese teach us about errors?

    • What is a culture of safety?

    • Building a culture of safety

    • How do we measure and improve a culture of safety?

    • Fictional Sentinel Event Scenario for Root Cause Analysis Practice

    • Discussion Question: Experience with Root Cause Analysis Activity

    • DISCUSSION: What do you think might be one or two of the most crucial contributing factors to this event that a Quality Director would prioritize for an action plan?

  • 15

    Lesson 13 - Team Communication Strategies

    • Lesson 13 - Team Communication Strategies

    • Team Communication Inventory

    • DISCUSSION: Recommendations for improvement: Share the team communications strategies that have worked well in your experience, and the strategies that are most challenging

  • 16

    Lesson 14 - Patient Family Engagement & Patient Centered Care

    • Lesson 14 - Patient Family Engagement & Patient Centered Care

    • Patient Family Engagement and Patient Centered Care - Activities

    • Review your organization's HCAHPS reports

    • DISCUSSION: Assess the strengths and weaknesses of your organization's methods utilized to engage patients and families in outcomes of care

  • 17

    Lesson 15 - Health Equity

    • Lesson 15 - Health Equity

    • Health Equity: Activities for this lesson

    • HQIC Patient Family Engagement for Equity Hospital Self-Assessment

    • DISCUSSION: What did you learn from the Health Equity Organizational Assessment results?

  • 18

    Lesson 16 - Infection Prevention

    • Lesson 16 - Infection Prevention

    • Infection Prevention: Activities for this lesson

    • DISCUSSION: After reviewing past survey results and talking with the person in your organization most responsible for the oversight of infection prevention, what are the top 3 priorities for infection prevention that you have identified?

  • 19

    Lesson 17 - Case Management, Utilization Review

    • Lesson 17 - Case Management, Utilization Review

    • Case Management and Utilization Review: Activities for this lesson

    • DISCUSSION: Assess any differences between your organization's care transitions activities that actually occur, as well as priorities that have surfaced for case management.

  • 20

    Lesson 18 - Approach to Required and Basic Reporting

    • Lesson 18 - Approach to Required and Basic Reporting

    • Approach to Required and Basic Reporting: Activities for this lesson

    • DISCUSSION: Describe any challenges or barriers to regular reporting of required monitoring and how you might address those challenges

  • 21

    Lesson 19 - Professional Advancement

    • Lesson 19 - Professional Advancement

    • Profession Advancement: Activities for this lesson

    • DISCUSSION: What is the next step you would like to take in your journey as a Quality Improvement Director/Leader in your organization?