# Healthcare and Medical Management - Processes Backlog

## Overview

This backlog contains key processes for the Healthcare and Medical Management specialization, organized by functional area. Each process represents a distinct methodology or workflow that healthcare professionals use to deliver quality care, ensure compliance, and optimize operations.

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## Clinical Operations Processes

- [ ] **Patient Flow Optimization** - Systematic approach to managing patient movement through healthcare facilities, from arrival to discharge, using Lean principles to reduce wait times, improve throughput, and enhance patient experience. [Reference](https://www.ihi.org/resources/Pages/Changes/OptimizePatientFlow.aspx)

- [ ] **Care Coordination Protocol** - Framework for organizing patient care activities and sharing information among all participants to achieve safer and more effective care, including care transitions, handoffs, and interdisciplinary team communication. [Reference](https://www.ahrq.gov/ncepcr/care/coordination.html)

- [ ] **Clinical Pathway Development** - Evidence-based multidisciplinary management plans that display goals for patients and provide a sequence of interventions for achieving these goals within an expected timeframe for specific diagnoses or procedures. [Reference](https://qualitysafety.bmj.com/content/22/11/924)

- [ ] **Discharge Planning Process** - Comprehensive approach to preparing patients for safe transition from hospital to home or other care settings, including patient education, medication reconciliation, follow-up appointments, and post-acute care coordination. [Reference](https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Discharge-Planning)

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## Quality and Safety Processes

- [ ] **PDSA Cycle Implementation** - Plan-Do-Study-Act methodology for testing and implementing changes in healthcare settings, enabling rapid-cycle improvement through iterative testing of small-scale changes before broader implementation. [Reference](https://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx)

- [ ] **Root Cause Analysis (RCA)** - Structured method for identifying the underlying causes of adverse events and near-misses in healthcare, using systematic investigation techniques to prevent recurrence and improve patient safety. [Reference](https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/root-cause-analysis/)

- [ ] **Failure Mode and Effects Analysis (FMEA)** - Proactive risk assessment tool that identifies potential failures in healthcare processes before they occur, prioritizes them by severity and likelihood, and develops preventive actions. [Reference](https://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx)

- [ ] **Patient Safety Event Reporting** - Systematic process for capturing, classifying, and analyzing patient safety events including adverse events, near-misses, and unsafe conditions to drive organizational learning and improvement. [Reference](https://www.ahrq.gov/patient-safety/resources/reporting/index.html)

- [ ] **High Reliability Organization (HRO) Implementation** - Framework for achieving consistent safety and quality through preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise. [Reference](https://psnet.ahrq.gov/primer/high-reliability)

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## Health Informatics Processes

- [ ] **EHR Implementation Methodology** - Structured approach to planning, implementing, and optimizing Electronic Health Record systems, including workflow analysis, system configuration, data migration, training, go-live support, and ongoing optimization. [Reference](https://www.healthit.gov/topic/health-it-and-health-information-exchange-basics/ehr-implementation-steps)

- [ ] **Clinical Documentation Improvement (CDI)** - Program to improve the accuracy and completeness of clinical documentation through concurrent and retrospective review, provider education, and query processes to ensure documentation supports accurate coding and quality reporting. [Reference](https://www.ahima.org/topics/cdi)

- [ ] **Health Information Exchange (HIE) Integration** - Process for establishing secure electronic sharing of patient health information between healthcare organizations, including technical connectivity, data governance, consent management, and interoperability standards implementation. [Reference](https://www.healthit.gov/topic/health-it-and-health-information-exchange-basics/health-information-exchange)

- [ ] **Clinical Decision Support Implementation** - Methodology for designing, implementing, and optimizing clinical decision support systems that provide clinicians with knowledge and patient-specific information at the point of care to enhance decision-making. [Reference](https://www.healthit.gov/topic/safety/clinical-decision-support)

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## Revenue Cycle Processes

- [ ] **Medical Coding Compliance** - Framework for ensuring accurate and compliant assignment of ICD-10, CPT, and HCPCS codes through coder education, audit programs, documentation improvement, and compliance monitoring to optimize reimbursement and avoid fraud. [Reference](https://www.ahima.org/topics/coding)

- [ ] **Claims Management Workflow** - End-to-end process for managing healthcare claims from charge capture through payment posting, including clean claim submission, denial management, appeals, and accounts receivable follow-up. [Reference](https://www.hfma.org/topics/revenue-cycle.html)

- [ ] **Denial Prevention and Management** - Systematic approach to analyzing denial patterns, implementing prevention strategies, and managing appeals processes to reduce revenue leakage and improve first-pass claim acceptance rates. [Reference](https://www.aaham.org/)

- [ ] **Prior Authorization Workflow** - Standardized process for obtaining payer approval for medical services, medications, and procedures, including eligibility verification, clinical documentation, submission tracking, and appeals management. [Reference](https://www.ama-assn.org/practice-management/prior-authorization)

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## Regulatory Compliance Processes

- [ ] **HIPAA Compliance Program** - Comprehensive framework for ensuring compliance with HIPAA Privacy, Security, and Breach Notification Rules, including risk analysis, policies and procedures, workforce training, business associate management, and incident response. [Reference](https://www.hhs.gov/hipaa/for-professionals/security/guidance/index.html)

- [ ] **Joint Commission Survey Readiness** - Continuous compliance program for maintaining accreditation standards, including tracer methodology preparation, environment of care rounds, National Patient Safety Goals implementation, and mock survey activities. [Reference](https://www.jointcommission.org/accreditation-and-certification/health-care-settings/hospital/learn/survey-process/)

- [ ] **CMS Conditions of Participation Compliance** - Process for ensuring healthcare facilities meet federal requirements for Medicare and Medicaid participation, including quality assessment, patient rights, infection control, and emergency preparedness standards. [Reference](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_a_hospitals.pdf)

- [ ] **Quality Reporting Program Compliance** - Systematic approach to meeting CMS quality reporting requirements including Hospital Inpatient Quality Reporting, Hospital Outpatient Quality Reporting, and value-based purchasing programs through data collection, validation, and submission. [Reference](https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo)

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## Strategic Planning Processes

- [ ] **Service Line Strategic Planning** - Framework for developing and managing clinical service lines, including market analysis, competitive assessment, physician alignment, program development, and performance monitoring to drive growth and improve outcomes. [Reference](https://www.shsmd.org/)

- [ ] **Population Health Management Program** - Comprehensive approach to improving health outcomes for defined populations through risk stratification, care management, chronic disease programs, health promotion, and data analytics to support value-based care transitions. [Reference](https://www.ncqa.org/programs/health-plans/population-health-management/)

- [ ] **Healthcare Workforce Planning** - Strategic process for forecasting workforce needs, developing recruitment and retention strategies, succession planning, and competency management to ensure adequate staffing with skilled healthcare professionals. [Reference](https://www.aha.org/center/workforce)

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## Summary

| Category | Process Count |
|----------|---------------|
| Clinical Operations | 4 |
| Quality and Safety | 5 |
| Health Informatics | 4 |
| Revenue Cycle | 4 |
| Regulatory Compliance | 4 |
| Strategic Planning | 3 |
| **Total** | **24** |

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## Priority Recommendations

### High Priority (Phase 2a)
1. PDSA Cycle Implementation - Foundation for all quality improvement
2. Patient Flow Optimization - High impact on operations and experience
3. HIPAA Compliance Program - Critical regulatory requirement
4. Medical Coding Compliance - Revenue and compliance impact

### Medium Priority (Phase 2b)
5. Root Cause Analysis (RCA) - Patient safety foundation
6. EHR Implementation Methodology - Digital transformation enabler
7. Care Coordination Protocol - Care quality improvement
8. Claims Management Workflow - Revenue cycle optimization

### Standard Priority (Phase 2c)
9-24. Remaining processes based on organizational needs

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## Implementation Notes

- Each process should be implemented with quality gates and verification loops
- Processes should integrate with existing healthcare IT systems (EHR, RCM, etc.)
- Regulatory processes require ongoing monitoring and continuous compliance
- Clinical processes should include measurable outcome indicators
- All processes should support value-based care transformation goals
