Medical Quality Management: Theory and Practice

Foreword
Book Abstract
Preface
About the Book
Contents
About the Editors
Contributors
Chapter 1: Introduction
	References
Chapter 2: Basics of Quality Improvement
	Executive Summary
	Learning Objectives
	The History of the Healthcare Quality Management Movement: Past to Present
	The Purpose and Philosophy of Quality Management
	Implementing a Quality Improvement Project
	Tools for Quality Improvement
		Process Mapping
		Flow Charts
		Cause-and-Effect (Fishbone) Diagram
		Brainstorming and Affinity Diagrams
		Pareto Chart
		Histogram
		Bar Chart
		Scatter Diagram
		Statistical Control Chart
	Methods for Quality Improvement
		Plan, Do, Study, Act Methodology
		Six Sigma
		Lean
	Commonly Used Quality Improvement Strategies
		Academic Detailing
		Opinion Leaders
		Audit and Feedback
		Reminder Systems
		Patient Education
		Case Management
		Reengineering
		Incentives
	Quality Improvement Research
	Challenges to Successful Quality Improvement
		Technology
		Structure
		Psychological Climate
		Leadership
		Culture
		Legal Issues
	Future Trends
		Alternative Payment Models
		Accountable Care Organizations
	Final Thoughts
	References
		Additional Resources-Further Reading
Chapter 3: Quality Measurement
	Executive Summary
	Learning Objectives
	Introduction
	Quality Measurement Framework
	Desirable Characteristics of Quality Measurement
	History
	Types of Quality Measures
		Structural Measures
		Process Measures
		Outcome Measures
		Bundled Measures
		Balancing Measures
		Benchmarking
	Constructing a Measurement
		Proportion
		Ratio
		Mean and Median
		Count
	Timing of Measurements
		Baseline Measurement
		Trending Measurements
			Run Chart
		Control Chart
	Interpreting Quality Measures
		Appropriateness Model
		The 70% Standard Model
		Opportunity Model
	Program Evaluation
		Formative Evaluations
		Summative Evaluations
	Quality Measurement in the Digital Age
		Big Data
		Dark Data
		Deep Data
	Future Trends
	References
Chapter 4: Patient Safety
	Executive Summary
	Learning Objectives
	History
	Error as a Systems Issue
		Latent Conditions
		Active Failures
			Skill-Based Activity
			Rule-Based Activity
			Knowledge-Based Activity
	Human Factors as a Cause of Errors
		Fatigue
		Alarms
		Medication Errors
			Specific High-Profile Medication Errors
			Strategies to Prevent Medication Errors
	Common Risks to Patient Safety
		Invasive Procedures
		Perioperative Complications and Iatrogenic Injuries
		Infections
			Site-Specific Infection Prevention
		Ventilator-Associated Events
		Patient Falls
		Pressure (Decubitus) Ulcers
	Patient Safety Tools
		Tools for Data Acquisition
			Safety Surveys
			Error Reporting
			Self-Reporting Systems
			Record Review
			Situation Monitoring
		Analytic Tools
			Retrospective Event Analysis
			Prospective Event Analysis
	Disclosure of Errors
	Prevention of Errors
		Systems Approach
		Operational Interventions to Prevent Error
		Decision Support Systems
		Teamwork and Crew Resource Management
		Care Transitions
	High-Reliability Organizations (HROs)
	Bundled Interventions and Patient Safety Collaboratives
	Future Trends
	References
		Additional Resources-Further Readings
		Healthcare Quality Organizations that Include Patient Safety Information:
		Specific Sources of Current Patient Safety Information
Chapter 5: Health Informatics
	Executive Summary
	Learning Objectives
	History: The Evolution of Health Informatics in the United States
	Health Informatics Objectives
	Health Informatics Core Values
		System Usability
		Transparency
		Data Integrity
		Quality
	Electronic Health Records
		Documentation
		Order Entry/Communication
		Retrieval/Access
	Health Information Exchange
		Foundational
		Structural
		Semantic
	Clinical Decision Support
		Links to Expert Systems
		Documentation
		Orders
		Medication Management
		Clinical Alert
	Unintended Consequences
		Selecting vs. Writing Orders
		Alert Fatigue
		Copy-Paste/Cloning Patient Notes
		Note Bloat
		Privacy
	Data Warehousing
		Enterprise Model
		Independent Data Marts
		Late-Binding Architecture
	Patient Portals
	Future Trends
		Telemedicine
			Remote Interpretation
			Home Monitoring
			Remote Clinic Visit
			Remote House Call
		Genomics and Precision Medicine
		Value-Based Contracting vs. Volume-Based Reimbursement
		Natural Language Processing
		Personal Health Records
		Cloud Computing
	References
		Additional Resources: Further Reading
		Health Information Technology Standards (Abbreviated List)
Chapter 6: Data Analytics for the Improvement of Healthcare Quality
	Executive Summary
	Learning Objectives
	Current Analytics Landscape in Healthcare
	Advancing Data Analytics Maturity
	Data Analytics to Support Population Health Strategies
	Use Cases for Data Analytics in Quality Improvement
	Delivering Data for Local Quality Improvement Activities
	Measuring Healthcare Value
	Participation in Quality Improvement Activity Beyond the Local Institution
	Accuracy and Precision of Data
	Future Trends
	References
		Additional Resources-Further Reading
Chapter 7: Utilization Management, Case Management, and Care Coordination
	Executive Summary
	Learning Objectives
	Introduction
	Components of Utilization Management Systems
	Effective Utilization Management
	Processes, Procedures, and Timing of Utilization Management
		Prior Authorization or Precertification
		Concurrent Review and Discharge Planning
		Retrospective Review
		Interrater Reliability Assessment
		Denials and Audits
	Organizational Design of Utilization Management
	Measuring the Effectiveness of UM Programs
	Care Coordination and Case Management
		Care Plans: A Key Document
	Accreditation and Regulatory Oversight of Utilization Management and Care Coordination
	Frameworks for Understanding UM and CC
		Evidence-Based Medicine and Evidence-Based Management Process
		T3 Translational Science
		Best Clinical and Administrative Practices Quality Framework
		Chronic Care Model
		Patient-Centered Medical Home Model
	Future Trends
	Appendices
		Appendix A
		Appendix B
			A Summary of What NCQA Looks for When It Reviews an Organization
	References
		Additional Resources and Further Reading
Chapter 8: Organization Design and Management
	Executive Summary
	Learning Objectives
	Sociological Background
	How Systems Are Organized
		Learning Organizations
			Just Culture
			High Reliability Organizations
	Clinical Microsystems: Where the Action Is
	Quality Improvement Teams
		Leadership Responsibilities
		Leadership Roles and Strategies
		Quality Leadership Structure
	Governance and Quality Oversight
	The Challenge of Burnout
	Future Trends
	References
		Additional Reading
Chapter 9: Economics and Finance in Medical Quality Management
	Executive Summary
	Learning Objectives
	Historical Perspective
	Basic Concepts in Business and Economics
		Economics
			Macroeconomics
			Microeconomics
				Price Elasticity of Demand Among Purchasers of Health Insurance Services
				Monopoly and Monopsony Markets
		Accounting
			Types of Financial Accounting Reporting Tools
				Financial Statements
				Balance Sheets
				Income Statements
				Statement of Cash Flows
				Annual Reports
			Types of Accounting Systems
				Generally Accepted Accounting Principles
				Statutory Accounting Standards
				Managerial Accounting
			Accounting Skills Needed by Medical Managers and Quality Professionals
		Finance
			Cost of Capital
			Discounted Cash Flow Analysis
			Budgeting
		Other General Business Principles
			Organizational Planning
			Project Management
			Business Plans
			Pro Forma Financial Statements
			Sensitivity Analyses
			Organizational Psychology
	Making the Business Case for Quality Management
		Government Mandates
		Demands by the Business Community
		Requirements for Quality Oversight
		Demands of Business Partners
		Financial Effect
		Trade-Off Between a Higher Accreditation Standard and Lower Cost
		Social Goals
		Results of Estimates Using Mathematical Tools
	Outcomes Categories for Presenting the Economic Impact of Quality Initiatives
		Financial Outcomes
		Clinical Outcomes
		Utilization Outcomes
		Intangible or Social Outcomes
			Improvement of Sales
			Community Image
			Human Resources Impact
			Provider Relations
			Future Savings
			Accreditation Compliance
			Price Differential Effects
			Clinical Knowledge
		Productivity-Based Outcome Measures
		Operational Outcome Measures
		Comparative Effectiveness Studies
	Presenting the Economic Value of Quality and Medical Management
	Value and Provider Compensation in Healthcare
		Pay for Performance
		Methodology Issues with Pay for Performance
		Physician Payment Strategies
		Quality Bonuses
		Physician Consortium for Performance Improvement
		Medicare Access and CHIP Reauthorization Act
	Future Trends
	References
		Additional Resources-Further Reading
Chapter 10: External Quality Improvement: Accreditation, Certification, and Education
	Executive Summary
	Learning Objectives
	History
	Quality Initiatives
		Quality Improvement Organizations
		Accountable Care Organizations
		Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program
			Merit-Based Incentive Payment System
			Advanced Alternative Payment Models
		CMS Quality Rating Systems
		Healthcare Effectiveness Data and Information Set (HEDIS)
		Baldrige National Quality Program
	Accreditation and Certification
		National Committee for Quality Assurance
		Utilization Review Accreditation Commission
		The Joint Commission
		International Organization for Standardization
	Physician Profiling
	Public Reporting
	The Leapfrog Group
	Teaching Quality Improvement
		Undergraduate Medical Education
		Graduate Medical Education
		Continuing Medical Education
	Future Trends
	References
		Additional Reading-Further Resources
Chapter 11: The Interface Between Quality Improvement and Law
	Executive Summary
	Learning Objectives
	History
	Role of Government
	Public Laws and Regulation to Ensure Quality
		Patient Safety and Quality Improvement Act
	Patient Safety Organization Activity
		Healthcare Quality Improvement Act and Peer Review Protection
		The National Practitioner Data Bank
		Credentialing
		HIPAA Regulations
			The Privacy Rule
			The Security Rule
			The Enforcement Rule
			Administrative Simplification Rule
			Healthcare Integrity and Protection Data Bank
		The HITECH Act
	Basics of Malpractice
	Facility/Organizational Risk Management Issues
	Medical Errors and Transparency
	Alternative Dispute Resolution: Arbitration and Mediation
	Antitrust in Medicine
	Future Trends
	References
Chapter 12: Ethics and Quality Improvement
	Executive Summary
	Learning Objectives
	Ethics in Healthcare: Basic Concepts
		Respect for Autonomy
		Beneficence
		Nonmaleficence
		Justice and Fairness
	Major Historical Milestones
		The Nuremberg Code
		The Tuskegee Syphilis Study
		The Belmont Report
		The Declaration of Helsinki
		The American Medical Association Code of Medical Ethics
	Clinical Frameworks for Ethical Analysis
		Four Box Method
		CASES
		Pathway Approach
		Ethics Work-Up
	Organizational Framework for Ethics
	Human Subjects in Research and Quality Improvement
		Institutional Review Boards
		QI Initiatives and IRB Oversight
		Determination of Research Component Within a Quality Improvement Initiative
		Checklists to Guide the IRB Review of QI Initiatives
	Institutional Approaches to Quality Improvement Initiatives
	Future Trends
	Appendix
	References
		Additional Resources-Further Reading
Index