Upon completion of these 6 Courses, candidates will be able to:

1. Know, the bulk of knowledge about healthcare quality and its vocabulary used within application
2. Know how ?, the ability to recall knowledge, analyze it and find out the logic behind application
3. Show how? , the ability to apply such knowledge in practice
4. Do and sustain doing, the ability to assimilate knowledge, sustain practice and achieve targets
5. Sit and succeed in CPHQ exam or any other professional exam in quality

Period: 6 months - 2 days/week – 5 hours/day

Credit hours: 60 hours

Contact hours: 240 hours

Study time: 9 AM – 2 PM or 4 PM – 9 PM

Accreditation: By National Quality Institute (NQI) Egypt.& approved by National Association for Healthcare Quality (NAHQ)USA.

Diploma Graduation Exam: MCQ, CPHQ mimic Exam, 90 marks for passing

On- Going assessment: active participation, assignments, mini-project

A. Strategic

1. Facilitate development of leadership values and commitment
2. Facilitate assessment and development of the organization’s quality culture
3. Participate in organization-wide strategic planning
4. Identify internal customer/supplier relationships
5. Identify external customer/supplier relationships
6. Participate in developing an organizational vision statement
7. Participate in developing an organizational mission statement
8. Develop goals and objectives
9. Develop and use performance measures (e.g. balanced scorecards, dashboards, core measures)
10. Determine lines of authority/accountability
11. Evaluate applicability of performance improvement models (e.g., FOCUS, PDCA, Six Sigma)
12. Evaluate applicability of national/international excellence/quality models
13. Facilitate evaluation and/or selection of appropriate voluntary accreditation process (es)
14. Develop a performance improvement plan
15. Link performance improvement activities with strategic goals
16. Demonstrate financial benefits of a quality program
17. Facilitate change within the organization

B- Operational

1. Facilitate establishment of a performance improvement oversight group (e.g., Quality Council, Steering Council, QM Committee)
2. Identify the need for a performance improvement team or teams
3. Identify the appropriate team structure (e.g., cross functional, self-directed)
4. Identify champions (e.g., process owners, quality, patient safety)
5. Monitor the activities of consultants (e.g., quality and patient safety)
6. Assist in developing objective performance measures/indicators
7. Contribute to development and revision of a written plan for a risk management program
8. Contribute to development and revision of a written plan for a case/care/disease/utilization management program
9. Coordinate survey processes (i.e., accreditation, licensure, or equivalent)
10. Participate in cost analysis
11. Participate in developing and managing a budget for a department

A. Design and Data Collection

1. Maintain confidentiality of performance improvement activities, records, and reports
2. Organize information for committee meetings (e.g., agendas, reports, and minutes)
3. Assess customer needs/expectations (e.g., surveys, focus groups, teams)
4. Perform or coordinate data inventory listing activities (i.e., what is available from which sources?)
5. Perform or coordinate data definition activities
6. Perform or coordinate data collection methodology
7. Assist with the evaluation of computer software applications
8. Evaluate computerized systems for data collection and analysis
9. Implement computerized systems for data collection and analysis
10. Use epidemiological theory in data collection and analysis
11. Collect qualitative and quantitative data
12. Aggregate/summarize data for analysis

B. Measurement

1. Use or coordinate the use of process analysis tools to display data (e.g., fishbone, Pareto chart, run chart, scatter diagram, control chart)
2. Use basic statistical techniques to describe data (e.g., mean, standard deviation)
3. Use or coordinate the use of statistical process control components (e.g., common and special cause variation, random variation, trend analysis)
4. Use the results of statistical techniques to evaluate data (e.g., t-test, regression)

A. Planning

1. Facilitate establishment of priorities for process improvement activities
2. Facilitate development of performance improvement action plans and projects
3. Facilitate development or selection of process and outcome measures
4. Facilitate evaluation or selection of evidence-based practice guidelines (e.g., for standing orders or as guidelines for physician ordering practice)
5. Participate in the development of clinical/critical pathways or guidelines
6. Evaluate the feasibility to apply for external quality awards (e.g., Malcolm Baldrige, Magnet)

B. Implementation

1. Coordinate the performance improvement process
2. Lead performance improvement teams
3. Facilitate performance improvement teams
4. Participate on performance improvement teams
5. Participate in the credentialing and privileging process
6. Coordinate or participate in quality improvement projects
7. Participate in the process of:
   • medication usage review
   • medical record review
   • infection control processes
   • peer review
   • service specific review (e.g., pathology, radiology, pharmacy, nursing)
   • patient advocacy (e.g., patient rights, ethics)
   • Perform or coordinate risk management:
   • risk prevention
   • risk identification
   • mortality review
   • failure mode and effects analysis
   • collaborate with quality department
8. Perform or coordinate risk management: risk Prevention

Education and Training

1. Develop organizational performance improvement training (e.g., quality, patient safety)
2. Provide performance improvement training
3. Evaluate effectiveness of performance improvement training
4. Facilitate change within the organization through education
5. Develop/provide survey preparation training (e.g., accreditation, licensure, or equivalent)

C. Evaluation/Integration

1. E valuate team performance
2. Analyze/interpret performance/productivity reports
3. Analyze patient/member/customer satisfaction
4. Conduct or coordinate practitioner profiling
5. Perform or coordinate complaint analysis
6. Incorporate performance improvement into the employee performance appraisal system
7. Incorporate findings from performance improvement into the credentialing/appointment/privilege delineation process
8. Integrate results of data analysis into the performance improvement process
9. Integrate outcome of risk management assessment into the performance improvement process
10. Integrate outcome of utilization management assessment into the performance improvement process
11. Integrate quality findings into governance and management activities (e.g., bylaws, administrative policies, and procedures)
12. Integrate accreditation and regulatory recommendations into the organization