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NAHQ Code of Ethics and Standards of Practice ©Copyright 2011 NAHQ All rights reserved.

Appendix 3 Code of Ethics and Standards of Practice for Healthcare Quality Professionals Copyright © 2011 National Association for Healthcare Quality All rights reserved. No part of this white paper may be modified, reproduced, or used in any form or by any means, electronic or mechanical, including photocopying, recording, or by any means of information storage and retrieval system, without written permission from the copyright holder.   NAHQ Code of Ethics and Standards of Practice ©Copyright 2011 NAHQ All rights reserved.

Code of Ethics for Healthcare Quality Professionals 1 Healthcare Quality Professionals are defined by a standard of conduct deep-rooted in commitment, confidentiality, and relationships. Committed to performance improvement and maintaining integrity, the Healthcare Quality Professional recognizes personal accountability and moral obligation to all customers served—clients, employees, employers, physicians, organizations, and the public.

Healthcare Quality Professionals promote the dignity of the profession and are committed to practicing the profession with honesty, integrity, and accountability…respecting all laws and refusing to participate in or conceal any unethical 2, false, fraudulent, or deceptive activity… • practicing the profession with honesty, integrity, and accountability • maintaining the level of competency as outlined in the Standards of Practice for Healthcare Quality Professionals • seeking the trust and confidence of all customers • supporting the Standards of Practice for Healthcare Quality Professionals • respecting all laws and avoiding involvement in any false, fraudulent, or deceptive activity • promoting the right of privacy for all individuals and protecting the maintenance of confidential information to the fullest extent permitted by law • using expertise to inform employers or clients of possible positive and negative outcomes of management decisions in an effort to facilitate informed decision making • giving credit for the work of others to whom it is due • aiding the professional development and advancement of colleagues • using the Certified Professional in Healthcare Quality (CPHQ) designation only after passing the written examination, adhering to standards established by the Healthcare Quality Certification Board (HQCB), and continuing to maintain those standards through the recertification process • maintaining membership in professional organizations as a means of promoting quality and professional growth and avoiding the use of such membership for the sole purpose of solicitation of business or for personal financial gain. • Healthcare Quality Professionals’ primary commitment is to the health, well being, and safety of patients. 3 They must take appropriate actions regarding any instances of incompetent, unethical, illegal, or impaired practice. 4 They work to promote cultural change that encourages the reporting of events that may result in actual or potential harm to patients or others. 5                                                               1 www.nahq.org/about/content/code.html 2 Reference: American Health Information Management Association 3 Reference: American Nurses Association 4 ibid 5 Reference: American Society for Healthcare Risk Management NAHQ Code of Ethics and Standards of Practice ©Copyright 2011 NAHQ All rights reserved.

Standards of Practice for Healthcare Quality Professionals 6 Fundamental to practice, the Healthcare Quality Professional • maintains active personal and professional development programs in the field of healthcare quality and exhibits a broad range of knowledge • creates and supports an environment that fosters teamwork, emphasizes quality, recognizes the customer, and promotes learning • maintains a commitment to the improvement of the professional through participation in, and active support of, the local, state, and national professional organizations • addresses concerns and takes formal actions to resolve or report the unethical or questionable practices to the appropriate channels. • Supports the Code of Ethics for Healthcare Quality Professionals. In the area of leadership, the Healthcare Quality Professional • pursues certification through a formal program that enhances professional competencies and recognizes leadership in healthcare • provides for performance and quality management training and education for organization leaders • establishes specific quality-related goals for management to measure the organization's processes and outcomes • demonstrates management skills in the administration of programs that focus on improved outcomes of patient care or healthcare delivery systems. In the area of information and analysis, the Healthcare Quality Professional • exhibits skill in health information fundamentals, including application of basic statistical processes, data analysis and reporting, and computer use • possesses excellent written and verbal communication skills, applicable in both individual and organizational development • supports access to medical information by appropriate health providers, researchers, and public health agencies, balanced with appropriate consumer protections. In the area of strategic quality planning, the Healthcare Quality Professional • provides leadership and consultative services to departments and services within the organization in achieving regulatory, accreditation, and organizational compliance in quality and in performance management and improvement activities • seeks management involvement in the development of a planning approach that supports healthcare quality and patient safety • establishes quality as the guiding principle when exploring organizational efforts to control healthcare costs.                                                               6 www.nahq.org/about/content/code.html NAHQ Code of Ethics and Standards of Practice ©Copyright 2011 NAHQ All rights reserved.

In the area of human resource development and management, the Healthcare Quality Professional • supports programs developed to recognize achievements related to healthcare quality • exhibits a commitment to the Code of Ethics for Healthcare Quality Professionals • ensures staff involvement in all healthcare quality team efforts • mentors others in the principles of healthcare quality. In the area of management of process quality, the Healthcare Quality Professional • ensures that customer expectations guide the development and continuous improvement of processes, products, and services • acts as an agent of change and is effective in the change process, including the identification of opportunities to improve, the resolution of problems, and the evaluation of the effectiveness of change • integrates training, recognition, team approach, and customer satisfaction to create a standard approach to the continuous improvement of organizational process. In the area of quality and operational results, the Healthcare Quality Professional • promotes quality efforts as a proactive—not reactive—undertaking • ensures that personnel have the appropriate and necessary skills and tools to evaluate problems and achieve improvements • seeks to identify root causes of problems rather than focus on individual members or events. In the area of customer focus and satisfaction, the Healthcare Quality Professional • establishes customer satisfaction as a primary goal for the organization's quality activities • standardizes the approach for determining customer expectations • serves as a customer advocate in resolution of concerns and initiation of performance improvement activities.