Registered Health Information Administrator / Technician (RHIA / RHIT) Healthcare Delivery, Quality, and Performance Improvement Syllabus

Healthcare Delivery, Quality, and Performance Improvement syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Healthcare Delivery, Quality, and Performance Improvement in Registered Health Information Administrator / Technician (RHIA / RHIT), not a summary of it.

1. 1

   US Healthcare Delivery System

   3 topics

   • Structure of Healthcare Delivery
     • Provider types and care settings
     • Integrated delivery networks and ACOs
   • Healthcare Financing
     • Public versus private financing
     • Health policy and the Affordable Care Act
   • Regulatory and Accreditation Bodies
     • CMS, Joint Commission, and DNV
     • Licensure, certification, and accreditation distinctions
2. 2

   Quality Management

   3 topics

   • Quality Improvement Methodologies
     • PDSA, Lean, and Six Sigma
     • Root cause analysis and FMEA
   • Performance Measurement
     • Core measures and quality indicators
     • Value-based purchasing and pay-for-performance
   • Patient Safety
     • Sentinel events and never events
     • Incident reporting and risk management
3. 3

   Utilization and Case Management

   3 topics

   • Utilization Review
     • Medical necessity and level of care
     • Concurrent and retrospective review
   • Case Management
     • Care coordination and discharge planning
     • Clinical documentation improvement (CDI)
   • Accreditation and Survey Readiness
     • Standards compliance and tracer methodology
     • Survey preparation and corrective action

Healthcare Delivery, Quality, and Performance Improvement flashcards for Registered Health Information Administrator / Technician (RHIA / RHIT)

25 of 51 cards from the Healthcare Delivery, Quality, and Performance Improvement deck — real questions with worked answers.

1. What are the three main tiers of the U.S. healthcare delivery system?

   Primary care (first contact, prevention, routine care), secondary care (specialist/hospital care via referral), and tertiary care (highly specialized care such as advanced surgery, transplants, and trauma centers).

2. What is the difference between acute care and long-term care facilities?

   Acute care provides short-term treatment for severe injury, illness, or surgery (e.g., hospitals with average length of stay under 30 days), while long-term care provides ongoing services for chronic conditions and rehabilitation (e.g., skilled nursing facilities).

3. What is an Integrated Delivery System (IDS)?

   A network of healthcare organizations that provides or arranges a coordinated continuum of services to a defined population and is willing to be held clinically and financially accountable for outcomes and health status.

4. What distinguishes an Ambulatory Surgical Center (ASC) from inpatient surgery?

   An ASC provides same-day surgical care that does not require an overnight hospital stay; patients are admitted and discharged the same day.

5. What is the primary purpose of the Patient-Centered Medical Home (PCMH) model?

   To provide comprehensive, coordinated, patient-centered primary care led by a personal physician who manages the patient's overall care across settings to improve quality and reduce cost.

6. What is the difference between Medicare and Medicaid?

   Medicare is a federal program covering people 65+ and certain disabled individuals; Medicaid is a joint federal-state program providing coverage to low-income individuals and families based on financial need.

7. List the four parts of Medicare and what each covers.

   Part A: hospital/inpatient insurance; Part B: medical/outpatient insurance; Part C: Medicare Advantage (private plans); Part D: prescription drug coverage.

8. What is a prospective payment system (PPS)?

   A reimbursement method in which payment is determined in advance based on a fixed, predetermined rate for a category of service (e.g., MS-DRGs for inpatient care), regardless of actual cost incurred.

9. What classification system is the basis for the inpatient hospital prospective payment system?

   Medicare Severity Diagnosis-Related Groups (MS-DRGs), which group inpatient stays by diagnosis, procedures, comorbidities, and complications.

10. What is capitation as a reimbursement method?

    A payment arrangement where a provider is paid a fixed amount per enrolled patient per period (per member per month) regardless of the number or cost of services delivered.

11. What is the difference between fee-for-service and value-based reimbursement?

    Fee-for-service pays providers for each individual service delivered (volume-based), while value-based reimbursement ties payment to quality, outcomes, and cost-efficiency of care.

12. What is the Resource-Based Relative Value Scale (RBRVS) used for?

    It is the system Medicare uses to determine physician payment under Part B, assigning relative value units (RVUs) for physician work, practice expense, and malpractice, adjusted by a geographic factor and conversion factor.

13. What is the role of CMS (Centers for Medicare & Medicaid Services)?

    A federal agency within HHS that administers Medicare, Medicaid, CHIP, and the Health Insurance Marketplace, and sets Conditions of Participation and reimbursement policy.

14. What are the Medicare Conditions of Participation (CoP)?

    Minimum health and safety standards that healthcare organizations must meet to participate in and receive payment from Medicare and Medicaid programs.

15. What is deemed status in accreditation?

    Status granted when a healthcare organization is accredited by a CMS-approved accrediting body (e.g., The Joint Commission), allowing it to be deemed in compliance with Medicare Conditions of Participation without a separate CMS survey.

16. Which organization is the most widely recognized accreditor of U.S. hospitals?

    The Joint Commission (TJC), formerly JCAHO, which accredits and certifies healthcare organizations and programs.

17. What does the Joint Commission's tracer methodology evaluate?

    It follows (traces) the experience of a specific patient through the organization's care processes to assess compliance with standards and the actual delivery of care across departments.

18. What is ORYX in the context of Joint Commission accreditation?

    The initiative that integrates standardized core performance measures and outcomes data into the accreditation process for ongoing performance monitoring.

19. What does NCQA accredit and what tool does it use?

    The National Committee for Quality Assurance accredits managed care/health plans and uses HEDIS (Healthcare Effectiveness Data and Information Set) to measure plan performance.

20. What is the difference between accreditation, licensure, and certification?

    Licensure is mandatory government permission to operate; certification is meeting requirements to participate in a program (e.g., Medicare); accreditation is voluntary recognition of meeting standards by a private body.

21. What is the PDCA (Plan-Do-Check-Act) cycle?

    An iterative quality improvement method: Plan a change, Do (implement on small scale), Check (analyze results), and Act (adopt, adjust, or abandon), then repeat for continuous improvement.

22. What are the core principles of Lean methodology?

    Lean focuses on maximizing value and eliminating waste (non-value-added activities) in processes to improve efficiency and flow.

23. What does the DMAIC framework in Six Sigma stand for?

    Define, Measure, Analyze, Improve, and Control — a structured methodology for reducing process variation and defects.

24. What is the goal/defect level of Six Sigma?

    To reduce process variation so that there are no more than 3.4 defects per million opportunities (a 99.99966% defect-free rate).

25. What is benchmarking in quality improvement?

    The systematic comparison of an organization's performance, processes, or outcomes against best practices or industry leaders to identify improvement opportunities.

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