Chapter 1
Basics of Quality Improvement 5
Executive Summary 5
Learning Objectives 6
The History of the Health Care Quality Management Movement: Past to Present 6
The Purpose and Philosophy of Quality Management 9
Tools for Quality Improvement 10
Lean 21
Challenges to Successful Quality Improvement 24
Chapter 1 sets the tone and foundation for the book by highlighting the basic historical drivers of medical quality assurance and quality improvement by reviewing the major concepts and common applications of quality improvement (QI) methods and strategies, and by outlining the challenges and opportunities within the rapidly evolving field of medical quality management. The chapter opens the door to a sometimes-complex field of quality measurement methods and systems, operational processes, and strategies.
Chapter 2
Quality Measurement 31
Executive Summary 31
Interpreting Quality Measures 40
Quality Measurement in the Digital Age 41
Chapter 2 focuses on the history, types, characteristics, processes, and interpretations of quality measurements. This chapter provides a framework for understanding the basic components of quality measurement within direct care and policy-making settings, exemplified by illustrative case studies and provides new information on the criteria for successful process measures, bundled measures, and balancing measures. The author effectively correlates the critical interface of quality measurement strategies and methods to areas highlighted in other chapters, especially medical informatics, utilization and quality management, patient safety, and health policy development.
Chapter 3
Patient Safety 48
Executive Summary 48
History 49
Error as a Systems Issue 49
Active Failures 50
Medication Errors 52
Strategies to Prevent Medication Errors 55
Common Risks to Patient Safety 57
Perioperative Complications and Iatrogenic Injuries 57
Infections 59
Site-Specific Infection Prevention 59
Patient Safety Tools 60
Retrospective Event Analysis 62
Operational Interventions to Prevent Error 65
Decision Support Systems 66
Teamwork and Crew Resource Management 66
Bundled Intervention and Patient Safety Collaboratives 68
Future Trends 68
Chapter 3 provides a detailed overview of the major patient safety concepts; specific, high-profile medication errors and failures; and causal factors including analysis methodologies and root-cause analysis strategies. The chapter discusses perioperative complications and iatrogenic Injuries, care transitions, bundles and patient-safety collaboratives, techniques and tools for systematic patient safety enhancement (PSE), and future trends in patient safety measures. The authors also focus on attributes of high-reliability organizations and operational interventions for PSE and the national momentum towards substantive investments in patient safety promotion tracking and educational systems representing a true megatrend in health care and a core area of focus in medical quality management (MQM).
Chapter 4
Health Informatics 78
Executive Summary 78
Learning Objectives 79
History: The Evolution of Health Informatics in the United States 79
Health Informatics 80
Chapter 4 addresses updated developments and challenges within medical informatics, a central component of MQM that has become a pivotal aspect of health care in the 21st century. The authors concretely summarize the major developments of medical informatics infrastructures including health information exchange, data warehousing, coding classification systems, clinical decision support, data integrity, transparency, quality control and innovation, and analysis. A discussion of documentation modalities and updates to EHR (electronic health record) information are also presented in addition to a brief history of health informatics in the United States and current trends.
Chapter 5
Data Analytics for the Improvement of Health Care Quality 101
Executive Summary 101
Advancing data analytics maturity 102
Learning Objectives: 102
Chapter 5 is a new chapter produced for the third edition that addresses the growing sophistication of data analytics and its role in improving patient outcomes. This chapter summarizes the importance of mining big data and converting it to a useable form that coalesces technology and expertise in a manner that can be effectively applied to clinical and population health settings. The authors present timely formation on the benefits of data analytics to healthcare systems and how accurate, precise data serve to measure healthcare value, discover areas in which quality improvement strategies could have a measureable impact, advance analytic maturity within an organization, and improve health outcomes.
Chapter 6
Utilization Management, Case Management, and Care Coordination 117
Executive Summary 117
Learning Objectives 117
Introduction: 118
Components of Utilization Management Systems 118
Effective Utilization Management 119
Processes, Procedures, and Timing of Utilization Management 121
Denials and Audits 122
Organizational Design of Utilization Management 128
Case Management and Care Coordination 129
Models of Care and UM and CC 137
Future Trends 141
Chapter 6 describes the essential processes, tasks, and common systems of Utilization Management (UM) and Care Coordination (CC). UM focuses on prior authorization, and concurrent and retrospective forms of utilization review to establish “medical necessity” of care. Medical necessity criteria, processes for determining the effectiveness and value of UM procedures (e.g., over- and under-utilization markers), common organizational structures for UM activities, and accreditation standards and programs are also detailed. New sections in this chapter include a discussion of the role of UM in disease management, pay-for-performance programs, and models of care. This section is particularly important due to the current focus on the coordination of care models to make improvements in cost and quality. Care coordination focuses on the deliberate integration of personnel, providers, information, and resources to facilitate and require patient care activities and the efficient delivery of healthcare services both within and across systems.
Chapter 7Organization Design and Management 150
Executive Summary 150
Learning Objectives 151
Clinical Microsystems—where the action is 153
Leadership Responsibilities 157
Leadership Roles and Strategies 158
Quality Leadership Structure 159
Governance and Quality Oversight 159
The Challenge of Burnout 160
Future Trends 161
Chapter 7 focuses on organizational design and leadership in quality management. Most of the publications in these areas tend to be theoretical and descriptive rather than framed by the numbers and the facts with which most health professionals are familiar. The discussions on quality management leadership, collaboration, strategic and operational planning
