Advanced Quality Improvement for Leadership


All health centers funded by the Health Resources and Services Administration (HRSA) must have in place a system to improve patient care and outcomes. This system is your center’s quality improvement (QI) program. While improving patient care and outcomes is the primary benefit of QI programs, there are also financial benefits for your center. In fact, the Department of Health and Human Services (2014) has appointed $36.3 million in funding to centers that meet or exceed quality improvement measures. Although most health centers have some QI functions established, many have not implemented a comprehensive, organization-wide quality improvement program. This course will enable your health center to take a comprehensive approach to implementing QI systems. In this course, you will learn about the essential elements of the QI infrastructure, systems, and programs. You’ll learn how to identify quality-related problems using proactive strategies, such as peer review and patient satisfaction surveys, as well as reactive strategies, such as patient complaint tracking systems. Additionally, you will see how you can put the FOCUS-PDSA model into action.


Hours: 1.75


Certificates provided by accrediting body (0 Match)

Course Details

Course Code: REL-HHS-0-AQIL
Hours: 1.75
Type: Online Course
Content Expiration Date: 5/31/2019
Learning Objectives:
Describe the components essential to a successful quality improvement program.
Use specific proactive and reactive QI strategies in your health centers QI program.
Use the FOCUS-PDSA model to put a QI initiative into action.

Section 1: Introduction A. About This Course B. Learning Objectives Section 2: Quality Improvement Infrastructure A. John’s Phone Message B. QI Infrastructure C. QI Coordinator D. QI Committee E. QI Principles F. Identify & Analyze G. Proactive & Reactive Strategies H. Develop & Implement I. Evaluate J. Data Collection and Tracking K. Data Display: The Dashboard Format L. Data Reporting M. The Role of Leadership N. Review O. Summary Section 3: Proactive Strategies A. Peer Review B. Peer Review Goal #1: Answering Clinical Questions C. Peer Review Goal #2: Comparing Your Data to Benchmarks D. Peer Review Audit Questions E. Examples F. Audit Types G. Aggregating and Analyzing Your Peer Review Data H. Responding to Peer Review Findings I. HRSA Core Clinical Measures J. Integration of CPM with QI Systems K. Patient Satisfaction Surveys L. Ideal Survey Topic Areas M. Patient Satisfaction Survey Tips N. Patient Satisfaction Survey Response and Follow-Up O. Other Patient Satisfaction Strategies P. Review Q. Summary Section 4: Reactive Strategies A. Documenting Patient Complaints B. Resolving Patient Complaints C. Patient Complaint Tracking, Types and Trending D. Incident Response and Tracking E. Types of Incidents F. Incident Response G. Case Study: Medication-Related Incidents H. What is a Sentinel Event? I. Examples of Sentinel Events J. Incidents vs. Sentinel Events K. Root Cause Analysis L. Review M. Summary Section 5: Putting QI into Action A. QI Models B. FOCUS C. PDSA D. Case Study: FOCUS E. Case Study: PDSA F. Review G. Summary Section 6: Conclusion A. Summary B. Congratulations

Staff Writer: Jennifer Moore, RN-BC, DNS-CT, CDP
Jennifer Moore, RN-BC, DNS-CT, CDP started working in the senior care industry in 2000. She is a certified Gerontological Nurse, a Director of Nursing Services – Certified, and a Certified Dementia Practitioner. She has held positions including MDS Coordinator, Director of Nursing, Medicare Nurse Coordinator, Nurse Consultant, Area Manager, and Director of Quality Assurance. Her overall responsibility within each of these positions was to ensure residents received the highest quality of care. This included active participation in quality improvement initiatives, review of clinical records to identify areas of weakness, corroboration with the medical director to institute policies and procedures for resident care, and staff education/training. Additionally, she was responsible for maintaining an effective compliance program under a Quality of Care Corporate Integrity Agreement with the Office of Inspector General for a period of five years. She currently serves as the manager of curriculum design for post-acute care for Relias. Within this position, her responsibility is to oversee the development of online training modules for the post-acute care industry. She has served as the subject matter expert for courses on re-hospitalization, clinical skill reviews, and various OSHA and regulatory compliance topics. In addition, she has presented at various state conferences on mandatory compliance, quality assessment and assurance (QA&A), and quality assurance and performance improvement (QAPI). Disclosure: Jennifer Moore, RN-BC, DNS-CT, CDP has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: intermediate and advanced level Alcohol and Drug Counselors; intermediate and advanced level Nurses; intermediate and advanced level Professional Counselors; intermediate and advanced level Social Workers; in the following settings: Health and Human Services.
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
If you require special accommodations to complete this module, please contact Relias Support by completing the web form ( or by using the chat functionality.
All courses offered by Relias, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.
All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
If you require special accommodations to complete this module, please contact Relias Customer Support here.