HIM professionals have always been actively involved in various aspects of healthcare quality management. In the decade since publication of To Err Is Human, the scope and volume of quality management activities have accelerated. Having quality at the forefront of the national agenda has inevitably created employment opportunities as well as expansion of professional responsibilities.
This article describes the contemporary quality-related functions of HIM professionals and the core competencies necessary to support these functions.
In 1928, the Association of Record Librarians of North America was organized under the sponsorship of the American College of Surgeons (ACS) to elevate the standards of clinical records in hospitals, dispensaries, and other distinctly medical institutions.1 The ACS Manual of Hospital Standards provided direction as to what must be documented in patient records, how records should be maintained, and how to use record information to evaluate whether practices are in accordance with present-day scientific medicine.2 To enable record librarians to effectively assist healthcare organizations in meeting these standards, educational programs for librarians included training in quality-related activities. This is evidenced by June Winton’s description of one of her practicum assignments at St. Mary’s Hospital in 1936, during her senior year in the record librarian program at the College of St. Scholastica in Duluth, Minnesota:
Each student makes a group study of twenty-five cases under the direction of a member of the staff. Once the subject has been chosen and the doctor’s outline made, cases of the type desired are traced through the proper indices. After finding the charts in the filing room, we then assist in analyzing the cases for desired statistics and facts. When necessary to analysis, follow-up letters are sent to patients to ascertain post-hospital progress. Finally, the paper is assembled into useful form and typed. Our course in statistics proves as valuable in compiling these group studies as it is in making up daily, monthly and annual statistical reports.3
During her practicum, Winton learned how to collaborate with other professionals to formulate a study question and define study criteria. She used the criteria to gather information from records and directly from patients. She applied knowledge gained in her statistical course to prepare a report of the study findings. Although healthcare delivery has changed enormously since 1936, the skills Winton learned during her record librarian courses are comparable to tasks HIM professionals are doing today to support quality activities. The fundamental skills of data capture and reporting are still vitally important core HIM competencies. What has changed is the need for HIM professionals to be able to interpret and analyze performance results and effectively use information to improve healthcare quality. Driving this change is the accelerating scope and size of the quality movement.
Providers in all settings are facing many new quality measurement and improvement mandates from certifying and purchasing groups.4 Insurers’ pay-for-performance initiatives are placing financial pressures on providers to achieve ever higher levels of quality.5 The beginnings of these rapid changes in healthcare quality improvement can be traced to the 2000 Institute of Medicine (IOM) report To Err Is Human.6 While healthcare quality activities have always undergone periodic revision, the IOM report created a sense of national urgency that swiftly led to a quality revolution. Evidence of this revolution can be found throughout the healthcare industry. For instance, in fiscal year 2009 the Medicare program will require hospitals to report on 30 performance measures in order to get the full annual payment update. The Centers for Medicare and Medicaid Services (CMS) proposed 43 new quality measures for fiscal year 2010, which would more than double the number of measures on which hospitals must report.7 In March 2007, CMS established the Physician Quality Reporting Initiative (PQRI), a voluntary program in which physicians are to collect and report their practice data in relation to a set of 74 performance measures. In 2008 the PQRI increased to 119 measures, and additional measures are expected to be added in future years.8
In addition to new measurement requirements, healthcare providers are expected to adopt new practices to improve quality. Practice change recommendations are coming from many sources. For instance, in 2003 the National Quality Forum (NQF), a public-private collaborative representing healthcare’s disparate stakeholders, published Safe Practices for Better Healthcare: A Consensus Report, which endorsed 30 practices that should be universally used in applicable clinical care settings to reduce the risk of harm to patients.9 The 2009 version includes 34 NQF-endorsed practices.10 The National Patient Safety Goals of the Joint Commission are examples of practice changes that must be implemented in all accredited organizations.11 To achieve respectable performance results for measures publicly reported on the Joint Commission and Medicare Web sites, healthcare organizations are initiating numerous improvement projects. 12, 13
Today’s rapidly changing and increasingly time-consuming healthcare quality management (QM) requirements are a far cry from what was deemed a “sweeping new mandate for quality assurance” issued in 1980 by the Joint Commission (then known as the Joint Commission on Accreditation of Hospitals).14, 15 The 1980 Quality Assurance Standard required hospitals to identify potential problems. When a problem was found, the scope and cause were to be determined and actions taken to correct deficiencies.16 If these accreditation requirements had been successful in achieving meaningful quality improvements, the report To Err Is Human might never have been written. The public’s lack of confidence in the willingness or ability of healthcare organizations to improve patient care practices has resulted in more prescriptive and far-reaching measurement and improvement requirements.
The increased scope and volume of quality requirements has workforce implications for all sectors of the healthcare industry. Providers must facilitate data collection, recruit and train staff, process and analyze data, and devote staff time for interpreting data, providing feedback, and using the findings for improvement activities.17 More than half of the 36 hospitals interviewed in a 2005 study had in the past year substantially increased the number of full-time equivalents (FTEs) devoted to performance measurement and improvement activities.18 Many of the medical groups participating in the Medicare PQRI have hired additional staff to support the program.19
Providers are not the only group experiencing the workload impact of new quality expectations. More than 90 percent of managed care organizations (MCOs) are involved in producing and submitting data for the Healthcare Effectiveness Data and Information Set (HEDIS).20 These MCOs have invested significant resources into data collection, including hiring of additional staff to conduct patient record reviews. State and national groups receiving data from providers and MCOs have added FTEs to analyze and report aggregate results for the growing number of quality measures. Nearly all state health agencies have increased staffing to conduct performance management activities aimed at improving the quality and outcomes of public health services.21
QM Professional Responsibilities
The increased focus on quality has responsibility and skill implications for healthcare QM professionals, who often now have tactical as well as functional duties. The most recent job analysis conducted by the Healthcare Quality Certification Board (HQCB) of the National Association for Healthcare Quality illustrates the wide range of tasks performed by QM professionals who have been employed in provider and managed care settings for at least two years.22 The more than 100 practice statements in the QM job analysis are distributed among the following domains and subdomains.23
Domain: Quality Program Leadership
Subdomains: Strategic, Operational
Domain: Information Management
Subdomains: Design and Data Collection; Measurement; Analysis; Communication
Domain: Performance Measurement and Improvement
Subdomains: Planning; Implementation; Education and Training; and Evaluation/Integration
Domain: Patient Safety
Subdomains: Strategic; Operational
Today’s QM professional must be competent to perform many more tasks than were needed to support an organization’s compliance with the 1980 Joint Commission quality assurance standards. Healthcare quality professionals must be able motivate and influence people at all levels of the organization. They must be able to apply information management and statistical analysis skills when measuring and analyzing performance. They must be able to manage improvement projects and employ process improvement techniques to resolve performance challenges. They must be able to develop, deploy, and evaluate evidence-based practice recommendations that support organization-wide continuous improvement efforts.
The HIM professional’s education, training, and experience have always provided a solid foundation for becoming a healthcare quality professional, although RHIAs and RHITs represent only about 7 percent of the more than 11,000 individuals that have achieved the status of Certified Professional in Healthcare Quality (CPHQ).24 HIM-credentialed individuals often cite personal growth and expanded career opportunities as reasons for taking the CPHQ examination.25
In years past, much of the quality-related work in an organization was done primarily by QM professionals. These individuals gathered and analyzed performance data and directed improvement efforts. Designated quality professionals continue to be essential contributors, but achieving today’s quality expectations requires everyone in the organization to lend a hand. When people work together to measure and improve performance, the organization is able to accomplish far more than it could if everything were done by just a few individuals.26 Many senior leaders now have regular contact with direct-care staff and physicians to better understand the problems in delivering high-quality care.27 Frontline caregivers—nurses, technicians, and other clinicians—are gathering data for performance measures. Experienced data gatherers, including HIM professionals, are facilitating targeted improvement projects using Lean Six Sigma tools. Today’s quality imperative is blurring some of the traditional dividing lines between professional roles and transforming long-held beliefs about professional responsibilities. These changes are affecting the QM-related functions and core competencies of HIM professionals.
Quality-Related HIM Functions
To understand the functions performed by HIM professionals with quality-related roles and responsibilities, in August 2008 a notice was posted on the online Quality Management Community of Practice (COP) inviting AHIMA members performing QM tasks to describe their jobs. The response was very small (five individuals); however, the results, summarized in Table 1, illustrate what I believe to be similar to the wide range of employers and job responsibilities that would have been reported if the response rate had been higher.
The contemporary QM responsibilities of HIM professionals, regardless of the setting, involve similar functions. Unlike June Winton in 1936, the HIM professional is doing much more than gathering and reporting performance data. Not only are HIM professionals locating and retrieving information for measurement purposes, they are also data literate. They are partnering with others to create valid and reliable measures of quality and patient safety. They are answering meaningful quality questions by collecting, analyzing, and making sense of performance data. HIM professionals are doing more than memorizing quality standards and audit criteria. They are thinking critically about healthcare performance expectations and drawing informed conclusions from measurement data. HIM professionals are selecting process improvement tools appropriate to a performance problem and using these tools to facilitate improvements. HIM professionals are exhibiting positive interpersonal skills to effectively communicate with colleagues and individuals in other departments and disciplines. HIM professionals are assisting organizations in meeting the shifting kaleidoscope of externally imposed quality requirements (state and federal regulations, accreditation standards, health plan contractual obligations, etc.). HIM professionals understand how seemingly unique HIM tasks such as coding and release of information are linked to the ability of the organization to achieve clinical quality and customer satisfaction goals.
An accurate estimate of the number of credentialed HIM professionals currently performing quality-related work is virtually impossible. Today HIM professionals are involved not only in healthcare quality activities at provider facilities but also in many nontraditional healthcare organizations and in associated industries. The diversity of quality-related job opportunities for HIM professionals makes it difficult for health information technology (HIT) and health information administration (HIA) educational programs to accurately assess the present and future needs of their community of interest, especially if provider settings make up the majority of professional practice sites. Similar challenges are likely inherent in the AHIMA-sponsored job analyses, which are conducted to identify the tasks currently performed by HIM professionals and the knowledge needed to adequately perform these tasks.28 Future AHIMA-sponsored employee research to evaluate marketability of HIM specialty skill sets will need to be carefully designed to ensure all present and potential future employers are adequately surveyed. 29
Quality-Related HIM Core Competencies
Some HIM professionals remain generalists throughout their career, and some choose to follow a specialty career that does not seem to require QM skills. Whatever the circumstance, HIM professionals must have a core set of quality-related competencies. All employees involved in healthcare services are likely to be involved, either directly or indirectly, in quality management activities at some point in their career. Plus, HIM professionals must be adequately prepared to take advantage of the rapidly growing number of QM job opportunities in nontraditional settings.
Some of the HIT/HIA entry level competencies, as described in AHIMA’s current HIM baccalaureate and associate degree entry-level competencies, are too limited in scope to enable HIM professionals to support future QM needs in the healthcare industry.30, 31 In a few instances this may be related more to the terminology than the intent. For example, HIM baccalaureate degree students are expected to learn “process engineering” techniques (task V.C.1 in the Project and Operations Management subdomain).32 The phrase “process engineering” is commonly used to describe the sometimes radical process redesigns popular in the early 1990s.33 It is hoped that today’s students are being taught more contemporary improvement approaches such as Lean Six Sigma, root cause analysis, and rapid cycle improvement. Future updates of the core competencies should avoid trendy or restrictive terminology.
Some entry-level competencies are too activity-specific. For example, HIM associate degree students are expected to be able to “perform data quality reviews to validate code assignment and compliance with reporting requirements such as outpatient prospective payment systems” (task I. D.2 in the Reimbursement Methodologies subdomain).34 Data quality reviews are important for purposes beyond coding and reimbursement purposes, and yet this activity is mentioned only under the reimbursement methodologies subdomain. HIM professionals should be able to validate the integrity of all types of health information. For instance, CMS will soon begin testing a standardized set of patient information that providers may be expected to share as patients transition from one level of care to another. The Medicare Continuity Assessment Record and Evaluation (CARE) tool contains information about the patient’s medical, functional, and cognitive status.35 If this tool is eventually required by CMS, the quality of patient assessment data at the provider level will be very important. HIM professionals should be prepared to work with clinicians to identify what assessment information is already being collected and how it corresponds to the language and data specifications in the CARE tool.36
To better prepare HIM professionals for quality-related jobs, revisions of the entry-level competencies should avoid language that can be misconstrued and task statements that focus on a particular activity. To ensure the quality-related HIM competencies sufficiently address all necessary core tasks, the knowledge and skills expected of quality professionals in healthcare and other industries must be considered.37 At a minimum, new HIM undergraduates should be able to function at the level of a Certified Quality Improvement Associate, one of the certifications offered by the American Society for Quality.38
Since the early 1930s, HIM professionals have had a role in healthcare quality-related activities. For decades this role primarily involved data collecting and reporting in hospital settings. Today, the quality movement has spread throughout the healthcare industry, and HIM professionals are involved in more aspects of QM in a variety of settings. There is rapidly growing use of new and existing data sources to identify opportunities to improve the delivery and safety of healthcare, to measure and compare quality and patient safety, and even to link reimbursement with quality of care. AHIMA must partner with policy makers driving these efforts to promote high standards of data integrity. Educators must ensure that HIM professionals possess a core set of contemporary QM competencies to effectively assist organizations in meeting the demands of the healthcare quality revolution.
Patrice L. Spath, RHIT, is a healthcare quality specialist in Forest Grove, OR, and an adjunct assistant professor in the Department of Health Services Administration at the University of Alabama in Birmingham, AL.
1. Gorgas, N. “Assessing the Medical Record’s Value Today.” Hospitals 19, no. 1 (January 1945): 58–60. In Medical Record Administration: A Collection of Readings Selected from the Literature in the Field. Chicago: American Hospital Association, 1948, pp. 17–23.
3. Winton, J. “Entering a New Profession.” Hospitals 11, no. 8 (August 1937): 58–60. In Medical Record Administration: A Collection of Readings Selected from the Literature in the Field. Chicago: American Hospital Association, 1948, pp. 11–16.
4. Spath, P. L. “Taming the Measurement Monster.” Frontiers of Health Services Administration 23, no. 4 (Summer 2007): 3–14.
5. National Committee for Quality Health Care. CEO Survival Guide: Pay for Performance. Washington, DC: National Committee for Quality Health Care, 2006.
6. L. T. Kohn, J. M. Corrigan, and M. S. Donaldson (Editors). To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine / National Academy Press, 2000.
7. American Hospital Association. “Redundant, Inconsistent and Excessive: Administrative Demands Overburden Hospitals.” TrendWatch, July 2008. Available at http://www.aha.org/aha/trendwatch/2008/twjuly2008admburden.pdf.
8. Centers for Medicare and Medicaid Services. “Physician Quality Reporting Initiative Overview.” September 16, 2008. Available at http://www.cms.hhs.gov/pqri/.
9. National Quality Forum. Safe Practices for Better Healthcare: A Consensus Report. Rockville, MD: Agency for Healthcare Research and Quality, August 2003. Available at http://www.ahrq.gov/qual/nqfpract.htm.
10. National Quality Forum. National Voluntary Consensus Standards for Safe Practices for Better Healthcare: 2009 Update. Washington, DC: National Quality Forum, 2009.
11. The Joint Commission. “2009 National Patient Safety Goals.” Available at http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/.
12. The Joint Commission QualityCheck. Available at http://www.qualitycheck.org.
13. Comparative performance data on hospitals, nursing homes, home health agencies, and dialysis units can be found on the Medicare Web site at http://www.medicare.gov.
14. Shannon, D. “Challenges in Patient Safety and Quality: Replacing Discouragement with Hope.” Physician Executive 33, no. 3 (2007): 15–21.
15. Skillicorn, S. A. Quality and Accountability: A New Era in American Hospitals. San Francisco, CA: Editorial Consultants, 1980, p. 17.
16. Skillicorn, S. A. Quality and Accountability: A New Era in American Hospitals, p. 19.
17. American Hospital Association. “Redundant, Inconsistent and Excessive: Administrative Demands Overburden Hospitals.”
18. Pham, H. H., J. Coughlan, and A. S. O’Malley. “The Impact of Quality-Reporting Programs on Hospital Operations.” Health Affairs 25, no. 5 (2006): 1412–1422
19. Medical Group Management Association. “Administrative Burden, Costs Come with Participating in Medicare Quality Program.” October 29, 2007. Available at http://www.mgma.com/press/article.aspx?id=15050.
20. Turk, A. “Using the HEDIS Asthma Measurement.” American Journal of Managed Care 6, no. 7 (suppl.) (2000): S347–S354.
21. Public Health Foundation. From Silos to Systems: Using Performance Management to Improve the Public’s Health. Seattle, WA: Turning Point, 2003. Available at http://www.turningpointprogram.org/toolkit/content/silostosystems.htm.
22. Healthcare Quality Certification Board, National Association for Healthcare Quality. CPHQ Candidate Examination Handbook. October 2007. p. 5. Available at http://www.cphq.org/documents/CPHQCandidateHandbook2008.pdf.
23. Healthcare Quality Certification Board of the National Association for Healthcare Quality. CPHQ Candidate Examination Handbook, pp. 16–18.
24. Wisconsin Association for Healthcare Quality. News and Views, Fall 1999. Available at http://www.wahq.org/docs/Newsletters/NewsFall1999.pdf.
25. Carruthers, D., and J. Elliott. “Benefits of Dual Certifications (RHIA and CPHQ): Our Experience.” CPHQ News, Fall 2005. Available at http://www.cphq.org/pdf/HQCBNews_Fall2005.pdf.
26. Thomas, M. B. “LOS Initiative Emphasizes Interdisciplinary Collaboration.” Hospital Case Management 16, no. 10 (2008): 151–152.
27. Spath, P. L. “Sustainable Patient Safety.” H&HN OnLine Magazine. December 12, 2006. Available at http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/PubsNewsArticle/data/2006December/061212HHN_Online_Spath&domain=HHNMAG.
28. American Health Information Management Association. “What is a Job Analysis?” 2008. Available at http://www.ahima.org/certification/crosswalks/.
29. American Health Information Management Association. Vision 2016: A Blueprint for Quality Education in Health Information Management. September 2007. Available at http://www.ahima.org/emerging_issues/Vision2016BlueprintforEduc.pdf.
30. American Health Information Management Association. HIM Baccalaureate Degree Entry-Level Competencies: Domains, Subdomains, and Tasks for 2005 and Beyond. Chicago: American Health Information Management Association, 2004.
31. American Health Information Management Association. HIM Associate Degree Entry-Level Competencies: Domains, Subdomains, and Tasks for 2006 and Beyond. Chicago: American Health Information Management Association, 2004.
32. American Health Information Management Association. HIM Baccalaureate Degree Entry-Level Competencies: Domains, Subdomains, and Tasks for 2005 and Beyond.
33. Hammer, M., and J. Champy. Reengineering the Corporation: A Manifesto for Business Revolution. New York: HarperCollins, 1993.
34. American Health Information Management Association. HIM Associate Degree Entry-Level Competencies: Domains, Subdomains, and Tasks for 2006 and Beyond. Chicago: American Health Information Management Association, 2004.
35. Booth, M. “CARE Tool Follows Patients Through Continuum.” Hospital Case Management 16, no. 9 (2008): 132–133.
36. Medicare Continuity Assessment Record and Evaluation (CARE). Available at http://www.pacdemo.rti.org/.
37. Healthcare Quality Certification Board, National Association for Healthcare Quality. CPHQ Candidate Examination Handbook, pp. 16–18.
38. American Society for Quality. Body of Knowledge: Certified Quality Improvement Associate. Milwaukee, WI: American Society for Quality, 2006. Available at http://www.asq.org/certification/quality-improvement-associate/bok.html.
Article citation: Perspectives in Health Information Management 6, Summer 2009