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

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.

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.

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.

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).

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.

What is a root cause analysis (RCA)?

A structured, retrospective process used after a sentinel or adverse event to identify the underlying causal factors and system failures, focusing on systems rather than individual blame.

What is a Failure Mode and Effects Analysis (FMEA)?

A proactive, prospective risk-assessment tool that identifies potential failures in a process, their causes and effects, and prioritizes them to prevent harm before it occurs.

What is the difference between a structure, process, and outcome measure (Donabedian model)?

Structure measures assess capacity/resources (e.g., staffing); process measures assess what is done to patients (e.g., aspirin given for MI); outcome measures assess results of care (e.g., mortality rates).

What is the difference between a numerator and denominator in a performance/rate measure?

The numerator is the number of cases meeting the measure criteria (the events counted), and the denominator is the total population eligible to be in the numerator (the at-risk population).

What is risk adjustment in performance measurement?

A statistical method that accounts for differences in patient characteristics (severity, comorbidities) across populations so outcomes can be fairly compared between providers.

What is HEDIS used to measure?

HEDIS (Healthcare Effectiveness Data and Information Set) measures health plan performance on care and service across domains such as effectiveness of care, access, and utilization.

What is the purpose of HCAHPS surveys?

The Hospital Consumer Assessment of Healthcare Providers and Systems survey measures patients' perspectives on their hospital care for public reporting and value-based purchasing.

What is a dashboard versus a scorecard in performance reporting?

A dashboard provides real-time, operational snapshots of current performance metrics; a scorecard (e.g., balanced scorecard) tracks performance against strategic goals over time across multiple perspectives.

What is a sentinel event according to The Joint Commission?

A patient safety event (not primarily related to the natural course of illness) that reaches a patient and results in death, permanent harm, or severe temporary harm; it requires immediate investigation and response.

What is a 'never event'?

A serious, largely preventable patient safety event (e.g., wrong-site surgery, retained foreign object) identified by the National Quality Forum that should never occur and for which Medicare may deny payment.

What are the National Patient Safety Goals (NPSGs)?

Joint Commission goals that highlight specific high-priority patient safety problems and evidence-based solutions (e.g., correct patient identification, medication safety, preventing infections).

What is a 'just culture' in patient safety?

An organizational culture that balances accountability and learning by distinguishing human error and at-risk behavior (managed by system fixes/coaching) from reckless behavior (which warrants discipline), encouraging error reporting.

What is the difference between an adverse event, a near miss, and a no-harm event?

An adverse event causes patient harm; a near miss (close call) is caught before reaching the patient; a no-harm event reaches the patient but causes no injury.

What are Hospital-Acquired Conditions (HACs) and why do they matter for payment?

HACs are reasonably preventable conditions acquired during hospitalization (e.g., certain infections, falls); Medicare does not provide additional payment for them and penalizes hospitals with high rates.

What are the three main types of utilization review based on timing?

Prospective (pre-admission/pre-certification, before care), concurrent (during the stay/ongoing care), and retrospective (after care and discharge) review.

What is the primary purpose of utilization review/management?

To ensure that healthcare services are medically necessary, delivered in the most appropriate/cost-effective setting, and at the appropriate level of care, controlling overutilization and underutilization.

What criteria sets are commonly used in utilization review for level-of-care decisions?

InterQual and MCG (Milliman Care Guidelines) — evidence-based clinical criteria used to determine medical necessity and appropriate level of care.

What is preauthorization (precertification)?

A utilization management requirement that a provider obtain approval from the payer before delivering a service or procedure to confirm coverage and medical necessity.

What is the role of a case manager?

To coordinate care, resources, and services across the continuum for individual patients to ensure quality, appropriate utilization, timely discharge, and cost-effective outcomes.

What are the core functions/steps of the case management process?

Assessment (screening), planning, implementation (coordination), monitoring/evaluation, and discharge/transition planning to ensure continuity of care.

What is discharge planning and when should it begin?

The process of arranging post-acute care, resources, and services for a patient's transition out of the facility; it should begin at or before admission to ensure a safe, timely transition.

How does case management differ from utilization review?

Utilization review focuses on medical necessity and appropriate use of resources/level of care; case management focuses on coordinating the patient's overall care and resources across the continuum to optimize outcomes.

What is a Joint Commission survey and how often does it occur for hospitals?

An on-site evaluation of compliance with accreditation standards conducted on an unannounced basis, typically every 3 years (39 months) for hospitals.

What is a mock survey in the context of accreditation readiness?

A simulated/practice survey conducted internally before the actual accreditation survey to identify deficiencies and prepare staff so the organization can correct issues in advance.

What is an Evidence of Standards Compliance (ESC) following a Joint Commission survey?

The written report an organization must submit to demonstrate it has corrected deficiencies (Requirements for Improvement) identified during the survey, typically within 60 days.

What is continuous survey readiness?

An ongoing organizational approach in which compliance with accreditation standards is maintained at all times (not just before a survey), embedding standards into daily operations.