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American Society for Quality Confidential 6e75c6a0-1f93-466b-ae2d-978236c6d1ae.xls LEADERSHIP OPERATIONS CONTINUOUS IMPROVEMENT/PERF EXCELLENCE REGULATORY /COMPLIAN HEALTHCARE: Quality Job FunctionFunction & Competency Matrix Leadership Team Facilities, resources, ADT, Business Excellence, Six Sigma, Project Management Gen. Product, Serv/stands. (Reg) C Organization Change Managers Hospital Quality Council Chair/ COO Chief Operations Officer, Auditor - Internal (QC/QA Mgt) Auditor - External (Regulatory) CIO Chief Information Officer Safety and Quality MD leader CEO, Chief Executive Officer Director of Quality, PI, Safety Departmental Administrators CFO, Chief Financial Officer Hospital Department Heads CMO Chief Medical Officer Advanced Practice Nurses Hospital Director (Hospital CNO Chief Nursing officer CAO Chief Administrative Lead Auditor (Regulatory Quality Improvement /PI Consultant (Regulatory) Utilization Management Medical Staff Executive Six- Sigma Black Belt, Hospital Administrator Specialist/Coordinator Operations Managers Six Sigma Green Belt Chief Strategy Officer Facilities/Engineering Legend: Quality Coordinators Discharge Planners Committee Leaders Infectionus Control A=awareness: is familiar with content but does not necessarily apply on a daily basis Project Managers Master Black Belt Clinical Directors Nurse Managers Case Managers W=working knowledge: is familiar with and able to apply content to situations PMO Director Data Analyst E=expert: is very comfortable, skilled and competent in area of expertise Admistrator) Specialists Facilators Auditor) VP Ops Officer Auditing Types A E W W E A W W W W W W W W W A W A A W A A E E E W A W A W A W A A W E E E E Roles and Responsibilities A W W W W W W W A W A W W W A A W A A W A A W W W W A A A A A W A A A E E E E Planning and Implementation W W W W W W W W W W A W W W A A W W W W W W E E E W A A W W W W W A A E E E E Reporting and Follow-up W W W W W W W W W W W W W W W W W W W W W W E E E W A E W W W W W A W E E E E Continuous Improvement Tools Improvement Models & Methods (PDCA, Six Sigma, Lean, Kaizen) A A A A A A A A A W A A A A A A A W A W W W W W E E E E E W A W W W E W W W W Basic Seven Quality (pareto, histogram, fishbone/cause&effect, checksheet, scattergrams, control charts, flow charts) W E W W W W W W W W W W W W W W A W A W W W E E E E E E E W E W W W W W E E E Seven Management and Planning Tools (affinity diagram, relationship diagram, tree diagram, matrix, L-shape matrix, Process Decision Program Chart, arrow diagram) W W W W W W W W W W W W W W W W W W W W W W W W E W E E E E E W W W W W E E E Benchmarking W W E W E W W E E E W W E E W E W W A W W W W W E E E E E W W A W A E W E E E Elements of corrective and preventive action (Correction/Containment, Root Cause Analysis, Recurrence Prevention, Verification & Validation) A A A A A A W W W W W W A W W W A W A W A A E E E E E E W W W W A W E W W W W Voice of the Customer W W W W W W W W W W W W E W W W W E E W E W E E W E E E E E W A A E E W W W W Process & Product Management Capability Analysis (Performance vs Spec, Indices) A A A A A W A W A W A A A A A W A A A W A E W W E A E E A w W A A A W W E E E Statistical Process Control (Objectives & Benefits, Common & Special Causes, Variable Selection, Rational Subgrouping) W W W W W W W W W W W A W A W W W W W W W W E E E W E E W W E W A A W E E E E Process Analysis (SIPOC) W W W W W W W W W W W W W W W W W W W W W W W W W W E E W W A A A A W E E E E Material Control (Traceability, Segregation, Classification of Defects, Material Review Board) N A N N N N N N N A A A A A A A N A N A N W A A A A E W A A A A A A A A W W W Measurement, Inspection & Testing (Basic Concepts, NDT, Inspection Planning) A A A A A A A A A A A A A A A A A A A A A E A A A A E W A A A A A A A W W W W Metrology (Calibration, Measurement methods, Measurement Tools) N N N N N N N N N N N N A A A A A A A A A E N N N N E W A A A W A A A W E E E Quality Characteristic Classification W W W W W W W W W W W W W W W A W W A A W E A W W W E W A E W W A A A W W A W Innovation and Creativity TRIZ A A W A A A A A A A A A A A A A A A A A A A A A A W E W A W A na A A W A A A A Axiomatic Design W A A A A A A A A A A A A A A A W W A A E A A A A W E W A W A na A A W E E E E Systems Thinking W W E W W W W E E E W W W W W W W W W W W W E E W E E E W E A A W A E E W W W Quality Function Deployment A W A A A A A A A A A A A A A A A A A W A W W W W W E E W E W na A A W E W W W Types & Tools (Brain Storming, 6 Thinking Hats ) W W W W W W W W W W W W A A W A A A A W A W W W W W E W W W A W W E W E E W E Leadership Organizational structures & cultures E E E E E E E E E E E E W W W W A W W W W W E E W W W W W E A W W E W A A A A Roles and Responsibilities (leaders & managers) E E E E E E E E E E E E E E E E W W A W W W E E A E W E W E A W W E W E E E E Change Management E W E W W W W E W W W W W W W W W W A W A W E E E A W E W E A A A E E E E E E Ethics E E E E E E E E E E E E E E E E W E W W E W E E E E W E W E W A W E W E W W W Empowerment, Motivation, Influencing E E E E E E E E E E E E E E E E W E A W A E W E W W E W W E A A W E W E E E E Prioritization E E E E E E E E E E E E E E E E W W A W W E W E W A E E W E A W E E A W W A W Corporate Social Responsibility E E E E E E E E E E E E E E E E W W W W E E E E E W E W W W W W W E W E E E E Management Principles, theories E E E E E E E E E E E E E E E W E E W W W E E W W A E W W E W A W W A E E E E Time Management E E E E E E E E E E E E E W E W W W W W W E E E W A E E W E W A E W W E E E E HR Management W E W W E W A W W W W A E W W W W W A W W W W W A W E W A E W A W E W A A A A Finance Management W E E W E W A W W A A W E W A W W W A A W W W W W W E W A E E A W A W E E W E Knowledge Management W E E W E W W W W A A W W W A W W W W W W A A E E E E W A E W A W W W E E E E Communication Skills W E E W E W W W W W W W W W W W W W A W W W W E E A E W W E W W W E W W W W W Supplier Management W W W W A E A A W A W A A W A A A A A A A W A A W A W W A A A A W A A A A A A Project Management Project planning and estimation tools E E E E E E E E E E E E E E E E E E W W W E E E E W E E W E W A E W W W W W W Project Integration & Scope Management E E W E W E W W W E W W W W W W A W A W W E E E W E E W W W A A E W W W W W W Project Time & Cost Management W E W E W W A W W W W W W E E E A W A W W E E E W W W W A W A A E W W W W W W Project Quality Management A W W W W W W W W E E E W W W W A W A W W E E E E E E W W W W A E W E E E E E Project Risk Management W E W W W W A E W W W W W W W W W W A W A E E W W W E W W W A A E E E E E E E Project Procurement Management W W A W W E A W W W W W W E E E A W A W A E W W W W W W A W A A E A W E E E E Project Communications Management W W E W E W W E W W W W W W W W A W W W A E E E W W E W W W A A E E W W W W W Measure and monitor project activity W E E W E E W E W E E E W W W W W W W W W E E E W W E E W E W A E W E W W W W Project documentation W W W W W W W W E E E W W W W W E E W W E E E E E E E E W E W A E W E E E E E Quality Basics Benefits of Quality E E E E E E E E E E E E W W E W W W A W W W E E E W E E W E W A W E W E E E E Quality Philosophies, Models & Theories (Juran, Crosby, Deming, Feigenbaum) A A W A A A A A A A A A W A A A A W W W A W A E W W E E W E A A A W E E E E E Terms, Concepts, and Principles E E W E E E E E E E E E W W E W W W A W W W E E E E E E W E W A A W E E W W W Quality standards, requirements, and specifications A A A A A A W W W W W W W W W W A W W W A W E E A W E E A E W A A W E E W W W Quality planning W E E E E E E E E E E E W W E E W W W W A W E E E W E E W E W W A W W E W W W Documentation systems A A A A A A W W W W W W W W W W A W W A A W W W A W E E A E W W A W E E E E E Barriers to Quality W W W W W W W W W W W W W W W W A W W W A W E E A W E E W E A A A W W E E E E Management of the Quality System Elements of the Quality System W W W W W W W W W E W W W E W W E E W W W E E E E W E E W E W W A A W E E E E Documentation of the Quality System W W W W W W W W W E W W W A A A W A A W A E A A W W E W W W A A A A A E E E E Quality Standards and Other Guidelines A A A A A A A W A W A W W W A A E W E W E E E E W A E W W W W E A A W E E E E Deployment techniques W W W W W W W W W W W W W W W W A W A A W W W W E E E W W W A W A E W E E E E Quality Audits W E W W W W W W W W W W A A W A W A W A W W W W W A E W A W W E A W W E E E E Quality Training A A A A A A A A A A A A W W A W W W A W A A A A A W E W W W A W A E W W A A A Management Reviews W E E W W W A E E W E W W E E E A W A W A W E E W W E W W E A W W E W W W W W Quality Information System (QIS) W W A W E W A W W W W A W A W W W A W A E A W W A W W W A E A E W A W W E E E Strategic Planning W W E W E E E E E E E E E E E E W E W W A W E E W W E W A W A A W E W W W W W Training Development and Delivery Training Plans A A A A A A W W W W W W E W W W W W A W A A W W W W W W W W A W W E E E A A A Needs Analysis A A A A A A A A W W E E E W E W W W A W A A E A W W W W A W A W A E E E A A A Training Materials/Curriculum Development and Delivery A A A A A A A A A A A A A W A A W W A W A A A A E A E W A W A W A E E E E E E Training Effectiveness and Evaluation A A A A A A A A A A A A A W A W A W A W A A W W E A E W W W A W A E W A W A W Adult Learning Theories A A A A A A A A A A A A A W A W A W A W A A W W E A W W A W A A A E W E E E E Product and Process Design Classification of Quality Characteristics W W W W W W W W W N W W W W W W W W W A W E W W W W E E W W A A A A W W W W W Design Inputs and Reviews A A A A A A A A A A A A A A A A A A A A A E W W W W E W W W A na W A W W W W W 1 of 4 American Society for Quality Confidential 6e75c6a0-1f93-466b-ae2d-978236c6d1ae.xls LEADERSHIP OPERATIONS CONTINUOUS IMPROVEMENT/PERF EXCELLENCE REGULATORY /COMPLIAN HEALTHCARE: Quality Job FunctionFunction & Competency Matrix Leadership Team Facilities, resources, ADT, Business Excellence, Six Sigma, Project Management Gen. Product, Serv/stands. (Reg) C Organization Change Managers Hospital Quality Council Chair/ COO Chief Operations Officer, Auditor - Internal (QC/QA Mgt) Auditor - External (Regulatory) CIO Chief Information Officer Safety and Quality MD leader CEO, Chief Executive Officer Director of Quality, PI, Safety Departmental Administrators CFO, Chief Financial Officer Hospital Department Heads CMO Chief Medical Officer Advanced Practice Nurses Hospital Director (Hospital CNO Chief Nursing officer CAO Chief Administrative Lead Auditor (Regulatory Quality Improvement /PI Consultant (Regulatory) Utilization Management Medical Staff Executive Six- Sigma Black Belt, Hospital Administrator Specialist/Coordinator Operations Managers Six Sigma Green Belt Chief Strategy Officer Facilities/Engineering Legend: Quality Coordinators Discharge Planners Committee Leaders Infectionus Control A=awareness: is familiar with content but does not necessarily apply on a daily basis Project Managers Master Black Belt Clinical Directors Nurse Managers Case Managers W=working knowledge: is familiar with and able to apply content to situations PMO Director Data Analyst E=expert: is very comfortable, skilled and competent in area of expertise Admistrator) Specialists Facilators Auditor) VP Ops Officer Technical Drawings and Specifications N N N N N N N N N N N N N N N N N N N A N E N N N N W A A A N na W A N W W W W Design Verification & Validation A A A A A A A A A A A A A A A A A A A A A E A W W A W W A W A na W A A W W W W Testing A A A A A A A A A A A A A A A A A A A A A E A A E A W E W W A na W A A W W W W Reliability and Maintainability A A W A W A A A A A A A W W A W W W W A W E W W W E W E W W A na W A A W W W W Basic Statistics (Data Analysis) Terms and definitions W W W W W W W W W W W W W W W W W W W W W W W W W W E E W E E W W W E W W W W Data types and collection methods W W W W W W A W W W W W W W W W W W W W W W W W W W E E W E E W A W E W E W W Basic distributions A W W A W A A A A A A A W W A W W W A W W W W W W W E E W E E W A W E W E E E Probability W W W W W W A W A W A A W W A W A A W W W W W W W W E E W E E W A W W W E E E Sampling W W W A W A A A A A A A W W A W W W W W A W A W W W E E W E E W A A W W W W W Regression and correlation W W W W W W W W W W W W W A W W A A A W W A E E W W E E A W E W A A W W W W W Hypothesis testing W W W W W W W W W W W W W W W W W W A W W A W W W A E E A W E W A A A W W W W Advanced Statistics (Quantitative Methods and Tools ) Analysis of variance (ANOVA) W E A W W W W W W W A W W W A A A A A W W A W W W A E E A W E W A A W W W W W Contingency tables W W A W W W W W W W W W E W W A A W W W W A W W W A E E A W E W A A W W W W W Process and Performance Capability (capability studies, performance vs. specifications, capability indices, performance indices) A A A A A A A A A A A A A A A A A A A W W W W W W A E E A W E W A A A W W W W Design and Analysis of Experiments (terminology, one-factor, full-factorial, 2- level fractional factorial) A A A A A A A A A W A A A A A A A A A W W A W A W A E E A W E A A A A W W W W Teams and Team Processes Types of teams W W W W W W W W W W W W W A W W A W A W A A W W E E E E E E A A W E E W A A A Stages of team development A A A A A A A A W W A A A A A W A W A W A A E W E E E E E E A A W E E E A A A Team-building techniques W A A W W W W W W W W W A A W W A W A W A A W W E E E E E E A A W E E W A A A Team roles and responsibilities A A A A A A A A A A A A A W A W W W A W A A W W E E E E E E A A W E E E W W W Team performance and evaluation W A A W A A A W W W W W A W W W W E A W A A W W E E E E E E A A W E E E A A A Customer Service Customer Relationship Management CRM (customer focus, relationships, needs, satisfaction, QFD, CPVM, deploying VOC information & managing multiple customers) W W E W A A A W A W W A W W A A A A W A A A W W W W E W A W A A A E A A A W A Customer Identification and Segmentation (internal and external customers) A A W A W W A W W A W A W W W W A A W W A A A W W W E W W W A A W W A A A W A 2 of 4 American Society for Quality Confidential 6e75c6a0-1f93-466b-ae2d-978236c6d1ae.xls REGULATORY /COMPLIANCE EDU/TRAIN PATIENT CARE SYSTEMS AND DOCUMENTATION SUPPORT oduct, Serv/stands. (Reg) Compliance ORG DEV Service Delivery, Advocacy,Marketing EMR/ Systems & Procedures/ Knowledge Mngmt. Health Information Technologist Human Resources recruitment Clinical Educators/Unit based Unit secretaries/ Health Unit Director of Development and CME Specialists (Continuing Safty Engineer (QC/QA), fire Coordinators, Administrative Health Information Director JCAHO & Mandatory Data Quality Control Technician Quality Control Specialist Value Analysis (product) Clinical Documentation patient advocate/service NES Nursing Education Marketing Strategist Medical Education ) Systems Analyst Analysts (RHIT) reporting Mngr Billing/ coding Risk Manager Statisticians Assistants, Specialists Educators Specialist Training safety RHIA A E W E E W W W A A N A N W E W W W E A A E A E W A A A A A N A N W E W W A E A A E W W E A A A A A N A N W E E W A W W W E W W E W W W W A N A N W E E W A W W A W W A E W A W A A N A A A W W A W W A W W W W W A A A A A W A W W E A A W W A W W W W W W W W W A A A W W W W A W W W E E W A E A A A A W E A W W E E A A A W W E W W E A A W W E A A A W W W A A A E W E E A W W W W W W W A W W E E W E W W E A E W E N N N N N N N N N A N N W A A E W W W W W W A W W A A A W W W A E A A E E E A W W A A A A A A A A W W A W A A A A E A W N N N N N N N N N N N N W A A A W E W W N N N N N N N N N N N N W A A A A E A W N N N N N N N N N N N N A N A W E E W E A A A A A A N N W W W W A N A A A A A A W W A W W W N A A A A A A A A A W A A A W W A W W A N A A W A A A A A W W W W W E E W E W E A A W E W W W W W W E W W E A A W A W W A A W W W W A A A W A W W A W W W W W W A A A W A A A A A A A A A A A W W A E E W A W W W A W W A A E A A E W E W W E E W A W E E A W A A A W A W A A W W A E E A A W W E A W A A W E A W A W W W W E W A W W E E W W W A A W A A A W W W A W W A A A W W A W W A A W W W A W W W A W W W A A W W A A A A W E W W W W W W W E E A E A W W W A A W W E A A W W E W W E W A A W W E A A A W W W A W W W E W W W W W W W W E A W W W A W A A W A E W A E W A W A W E A A A E W W A A W A E A A W A A A A W E A E A E A E W W E W E A A W E A W A E E A W E E A E W W W W E W W W E W E A E W W W W W A A A A A A A A A A W A A A A A A E A W W E W W W W E W W E A A A W E A A W A E A W W W W W W W A A W A A A W A E W W E W W W W A W W W A W W A A A A A A E A W A E W W E W W W A W W A A W W W W E W W A E W E W A A W A W E A A A E W A E W W A A A A A A W W W W A A A W A A W E A W A E W E A W W W W W E A A A A W W W A E A W W E W A W W W E W W A W E W W W W W A E W E E W W W W E W W A W E E W W E E A E W W E W W W W W W W W W E W A E E W A E W W E A W W A W W A A W E W W W W W W W A W E W W W W W W W A W E W A W E W A E E E E A W W A W W A A W E W W W E W A E W W E W W W W W W A A W E W A E W W A E E E E A W W A W W W W W E W W E E E A E W W E A A W A W W W E A E W W E E E W E E W E W E W E E W W W W E A W E A E A E E E E A A W A A W W A A E W E W E E A W E W E A W W A W W W A W E W E W W E A W W W A A A W A A W A W A A A A W A E A E E E E A A A A A A A A W W W W W W W W A W A E E E E E A A W A W W A A A W A W W W A W W W A W W A A A W W A A A A W A W W W W W A W W W A A E W E E A W E A W W A A A W A W E W A A A W E A A A A A E A A W E E E E E W A W A W E A A A W A E A A W E E E E E E A A A E E A A A W A A A A E E E E E E W A A A E W A A A A A A A A E E E E E E W A A A E W A A A A A A A A E E E E E E W A W A E W A A A A W A W W E W E A W E A N A W W W W E A W A A W W W A A A A A A N A A A A A E A A 3 of 4 American Society for Quality Confidential 6e75c6a0-1f93-466b-ae2d-978236c6d1ae.xls REGULATORY /COMPLIANCE EDU/TRAIN PATIENT CARE SYSTEMS AND DOCUMENTATION SUPPORT oduct, Serv/stands. (Reg) Compliance ORG DEV Service Delivery, Advocacy,Marketing EMR/ Systems & Procedures/ Knowledge Mngmt. Health Information Technologist Human Resources recruitment Clinical Educators/Unit based Unit secretaries/ Health Unit Director of Development and CME Specialists (Continuing Safty Engineer (QC/QA), fire Coordinators, Administrative Health Information Director JCAHO & Mandatory Data Quality Control Technician Quality Control Specialist Value Analysis (product) Clinical Documentation patient advocate/service NES Nursing Education Marketing Strategist Medical Education ) Systems Analyst Analysts (RHIT) reporting Mngr Billing/ coding Risk Manager Statisticians Assistants, Specialists Educators Specialist Training safety RHIA A A E A A N N N N N N N N N A N N E A A A A W A A A A A A A A N A A A A A E A A W A W A E W E A W E A N A W W W W E A E W A E A W A E A A W A N A W W W A E A E E W W W W W A W W W W A A W E W W W W W E W W W E W A W W W E A A W E W W W W W E W W W E W A W W W W A A W E W W W A W E W A W E W A W W W W A A W E W W A A W E A A W E W A W W W E A A W E W A A A W E W A W W A A A A W W A A A E W A A A E E W W W W W A A A A W A A A W W W A A W E A A A W W W A W W W A A W E W W A A W E W A A E W W A W W W A A W E E W A A W E A W A E W W A A W W A A A E E W A A A E A A A E A A A A W W A A A W E W A A A A W A A E W E E W W W W W W W W W W W A A W A A W W E E W E W W W A W W W W W A A W A A E E E E W W W A W A W W W W W A A W A A W E E E W E W A W A W W W W W A A W A A W E E E W E W A W A W W W W W A W W A A A A W W W W E A E A W A A W A W W W A A A A W A W W E A E A W A A W A W 4 of 4
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