Medical Quality Management
Theory and Practice
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Each chapter is designed for a review of the essential background, precepts, and exemplary practices within the topical area:
Basics of Quality Improvement
Data Analytics for the Improvement of Healthcare Quality
Utilization Management, Case Management, and Care Coordination
Economics and Finance in Medical Quality Management
External Quality Improvement - Accreditation, Certification, and Education
The Interface Between Quality Improvement and Law
Ethics and Quality Improvement
With the new edition of Medical Quality Management: Theory and Practice, the American College of Medical Quality presents the experience and expertise of its contributors to provide the background necessary for healthcare professionals to assume the responsibilities of medical quality management in healthcare institutions, provide physicians in all medical specialties with a core body of knowledge related to medical quality management, and serve as a necessary guide for healthcare administrators and executives, academics, directors, medical and nursing students and residents, and physicians and other health practitioners.
Forlag: Springer Nature Switzerland AG
Utgave: 3rd ed. 2021
Format: 24 x 16 cm
Basics of Quality Improvement 5Executive Summary 5Learning Objectives 6The History of the Health Care Quality Management Movement: Past to Present 6The Purpose and Philosophy of Quality Management 9Tools for Quality Improvement 10Lean 21Challenges 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 2Quality Measurement 31Executive Summary 31Interpreting Quality Measures 40Quality 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 3Patient Safety 48Executive Summary 48History 49Error as a Systems Issue 49Active Failures 50Medication Errors 52Strategies to Prevent Medication Errors 55Common Risks to Patient Safety 57Perioperative Complications and Iatrogenic Injuries 57Infections 59Site-Specific Infection Prevention 59Patient Safety Tools 60Retrospective Event Analysis 62Operational Interventions to Prevent Error 65Decision Support Systems 66Teamwork and Crew Resource Management 66Bundled Intervention and Patient Safety Collaboratives 68Future 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 4Health Informatics 78Executive Summary 78Learning Objectives 79History: The Evolution of Health Informatics in the United States 79Health 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 5Data Analytics for the Improvement of Health Care Quality 101Executive Summary 101Advancing data analytics maturity 102Learning 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 6Utilization Management, Case Management, and Care Coordination 117Executive Summary 117Learning Objectives 117Introduction: 118Components of Utilization Management Systems 118Effective Utilization Management 119Processes, Procedures, and Timing of Utilization Management 121Denials and Audits 122Organizational Design of Utilization Management 128Case Management and Care Coordination 129Models of Care and UM and CC 137Future 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 150Executive Summary 150Learning Objectives 151Clinical Microsystems-where the action is 153Leadership Responsibilities 157Leadership Roles and Strategies 158Quality Leadership Structure 159Governance and Quality Oversight 159The Challenge of Burnout 160Future 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, implementation, data analysis, and feedback are all presented clearly and-like all of the chapters-with an abundance of relevant references.
Chapter 8Economics and Finance in Medical Quality Management 165Executive Summary 165Learning Objectives 166Historical Perspective 166Basic Concepts in Business and Economics 168Types of Financial Accounting Reporting Tools 171Types of Accounting Systems 174Other General Business Principles 179Outcomes Categories for Presenting the Economic Impact of Quality Initiatives 183Clinical Outcomes 183Utilization Outcomes 184Intangible or Social Outcomes 185Productivity Based Outcome Measures 186Operational Outcome Measures 187Presenting the Economic Value of Quality and Medical Management 188Value and Compensation in Health Care 190Physician Payment Strategies 193Future Trends and the Evolving Process of Physician Payment 194
Chapter 8 presents the subject of economics and finance in relation to MQM and quality improvement with a detailed approach. The authors elaborate on major economic and business principles relevant to the future practice of MQM including those related to accounting and finance, value and compensation in health care, organizational planning and psychology, project management, the development of business plans and financial statements, and sensitivity analyses. MQM professionals will need to make the business case for clinical services, framed by quality management objectives and outcomes metrics. The authors elegantly frame the lessons in this chapter, including several instructive case studies.
Chapter 9External Quality Improvement: Accreditation, Certification, and Education 199Executive Summary 199Learning Objectives 200Quality Initiatives 202
Chapter 9 focuses on key external QI activities, including accreditation, quality improvement education, and professional certification. The authors highlight major healthcare standards-setting and accreditation organizations, including medical specialty board certification, state professional licensing, and prominent national accreditation organizations such as the National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), and the Joint Commission (TJC). The chapter discusses CMS' Center for Clinical Standards & Quality (CCSQ), the Physician Quality Reporting System (PQRS), the CMS Five-Star Quality Rating System, and Accountable Care Organizations (ACOs), and includes statistics from the 2016 Leapfrog Group Hospital Report. External QI resources serve to integrate the diverse number of utilization, quality, and risk management activities that frame clinical systems of care. The chapter includes a new focus on the importance of QI education for medical students and practicing physicians.
Chapter 10The Interface Between Quality Improvement and Law 223Learning Objectives 223History 224Role of Government 224Rules, Regulations, Laws, and Acts 226Regulation and Public Laws to Ensure Quality 226Patient Safety Act 228Patient Safety Organization activity 228Health Care Quality Improvement Act and Peer Review Protection 230Mis-use of the peer review process for economic purposes: A cautionary tale 232Credentialing 233The National Practitioner Data Bank 234HIPAA Rules 235The Privacy Rule 236The Transactions and Code Sets Rule 236Facilitated Health Care Fraud and Abuse Investigation and Reporting 236The Security Rule 237The Enforcement Rule 237HITECH Act 237Medical Errors and Transparency 237Basics of Malpractice 239Facility-Organizational Risk Management Issues 243Antitrust in Medicine 243Future Trends: 245
Chapter 10 addresses legal requirements, and the authors review several current, major national legal mechanisms for quality promotion such as the National Practitioner Data Bank, accreditation activities, peer review protections, the tort system, clinical practice guidelines, institutional review boards, and medical ethics programs. The chapter also provides thoughtful commentary about evolving trends aimed at improving the quality of healthcare services and delivery. Notable current movements that are evolving include how to handle apologies when a medical error has occurred, patient safety activities, and pay-for-performance initiatives.
Chapter 11Ethics and Quality Improvement 249Executive Summary 249Ethics in Healthcare: Basic Concepts 250Major Historical Milestones 251Ten Standards of the Nuremberg Code 251Clinical Frameworks for Ethical Analysis: 252Organizational Frameworks for Ethics 262Human Subjects in Research and Quality Improvement 264Characteristics of QI Initiatives 264Characteristics of Research Initiatives 265Institutional Review Boards 266QI Initiatives and IRB oversight 267Guidelines for Submitting QI Initiatives for IRB Review 268Determination of Research Component within a Quality Improvement Initiative 270Checklists to guide the IRB Review of QI Initiatives 270Institutional Approaches to Quality Improvement Initiatives 273Future Trends 276
Chapter 11 is also a new chapter for the third edition that provides an in-depth look at the prevailing values that affect quality ethics and the related clinical frameworks that guide decision-making and best practice in terms of patient safety and quality improvement efforts. The chapter also delves into ethics in research and describes effective, ethical, systematic investigation and, additionally, how research and quality improvement overlap in practice. Chapter themes also include a discussion of the Institutional Review Board (IRB) and their review of quality improvement projects as well as the foundational principles that guide the review and discussion of clinical dilemmas.
Julia Caldwell, MD, MHA, CMQ, Assistant professor of anesthesiology, pain, and perioperative medicine. She is board certified in anesthesiology, pain medicine and medical quality. She is deeply passionate about resident education, pain medicine and medical quality. Dr. Caldwell is an active leader on the educational and abstract committees within the American Medical College of Quality. She enjoys research as well as providing safe and quality care to her patients and the community
Kathleen Carberry, RN, MPH, is the Outcomes Program Officer at the Value Institute for Health and Care, at University of Texas at Austin's Dell Medical School and McCombs School of Business where she teaches outcome measurement. She also engages with health care teams to implement outcome measurement strategies that drive the creation of high-value health care services. She is passionate about measuring the outcomes that matter most to patients and partnering with health care teams to create measurement systems that readily demonstrate improved outcomes for patients.
Nancy Davis, PhD, Professor and Associate Dean, Faculty Development at the University of Kansas School of Medicine. She previously served as Director, Practice-Based Learning and Improvement, Association of American Medical Colleges; Executive Director, National Institute for Quality Improvement and Education; and Director, CME, American Academy of Family Physicians. She helped design the CME credit designation for clinical performance improvement. Dr. Davis earned a PhD in Adult and Continuing Education. She serves on the Editorial Board of the American Journal of Medical Quality; teaches, presents in national forums; and is widely published. She has been credentialed as a Certified Diabetes Educator, a Certified CME Professional and a Certified Professional in Healthcare Quality.
Elizabeth Fracica, MD, MPH is in her first year of residency training at Johns Hopkins Hospital and completed her medical training at the Mayo Clinic School of Medicine. She has already contributed to federal and state-level healthcare delivery reform efforts through her work on the Maryland All Payer Model. She looks forward to pursuing a career in academic Neurology and healthcare reform.
Philip J. Fracica, MD, MBA, FACP, is Chief Medical Officer at Bothwell Regional Health Center in Sedalia, Missouri. He also serves as Medical Director for Hospitalist Services. Dr. Fracica's experience includes 25 years as a Medical ICU Director at tertiary care academic medical centers. For the last 10 years he has served as Chief Medical Officer at institutions in Missouri, Texas and Arizona.
Donald Fetterolf, MD, MBA, FACP, Currently the Chief Medical Officer of MiMedx Group, Inc. Prior roles included EVP of Health Intelligence at Alere, Inc, EVP of Matria Healthcare, Chief Medical Officer of Highmark, Inc., and president of a multi-physician medical group practice. Dr. Fetterolf received undergraduate and medical degrees from the University of Pennsylvania and completed internal medicine training at the University of Pittsburgh, where he also received an MBA degree. He is Past President and a Distinguished Fellow of the American College of Medical Quality, and is Past Chairman of the American Board of Medical Quality. Dr. Fetterolf was the first recipient of the Brian Hayes Award of the Blue Cross Blue Shield Association, and was awarded the 2006 Annual Disease Management Association of America Award for Outstanding Individual Leadership. He is a Fellow of the American College of Physicians, and of the College of Physicians of Philadelphia.
Eileen R. Giardino, PhD, RN, APRN is an Associate Professor of Clinical Nursing in the Department of Graduate Studies at The University of Texas Health Science Center at Houston, TX. She earned a Bachelor of Science and PhD in Education from the University of Pennsylvania, a Master's in Nursing from Widener University, and family and adult nurse practitioner certification from La Salle University in Philadelphia. Dr. Giardino is board certified as an adult nurse practitioner and as a family nurse practitioner and she completed the Advanced Quality Improvement program at Texas Children's Hospital which is a sister program to the Intermountain Advanced Training Program. Academic accomplishments include authoring text books in the areas of child maltreatment, intimate partner violence, and advanced nursing practice. She is the nursing core faculty for the Leadership Education in Neurodevelopmental Disabilities (LEND) program at UT Health to provide the nursing perspective on caring for children on the Autism spectrum. Currently, Dr. Giardino primarily teaches in the Doctor of Nursing Practice (DNP) program where she works with doctoral students on their scholarly projects, many of which are quality improvement initiatives at the clinical teaching affiliates of DNP program.
Linda Harrington, PhD, DNP, RN-BC, CNS, CPHQ, CENP, UXC, CPHIMS, FHIMSS, is a Professor at Baylor College of Medicine where she teaches quality outcomes management, statistics and informatics. She holds a DNP and post-masters certificate in informatics from Duke University, a PhD from Texas Woman's University, and is certified in healthcare quality and informatics. Linda serves as the Technology Today column editor for the American Association of Critical-care Nurses' Advanced Critical Care and lead author of Usability Evaluation Handbook for Electronic Health Records.
Jennifer Hooks, MBA, Manager Performance Improvement at the Medical University of South Carolina, where she is responsible for the deployment of Lean Six Sigma throughout the organization. She is an adjunct faculty member in MUSC College of Health Professions and College of Nursing where she teaches Lean Six Sigma methodology. Ms. Hooks is a retired Air Force Chief Master Sergeant and a certified Six Sigma Master Black Belt and also holds a LEAN Sensei Certification from Villanova University.
Toni Kfuri, MD, MPH, FACOG, Currently serves as a senior medical director in the Clinical Analytics department at Inovalon. Dr. Kfuri is extensively involved in the clinical design, implementation, and improvement of Inovalon's portfolio of healthcare data analytics solutions, clinical data review tools, and clinical data integrity and quality oversight programs. Dr. Kfuri's medical expertise, coupled with his clinical experience and successful quality improvement programs and data analytics foster an effective patient-provider engagement and contribute to successful outcomes in areas of patient quality, utilization and cost management and reporting. Prior experience includes clinical practice for more than 20 years and time as a consultant in Healthcare Management leading to performance excellence awards. Dr. Kfuri is Board certified by the American Board of Obstetrics & Gynecology. He is certified in both Health Policy &Health Finance & Management by the Johns Hopkins School of Public Health and holds an MPH in Health Management & Leadership from the Johns Hopkins School of Public Health. Dr. Kfuri is also a Senior Alumni Examiner and Team Leader for the prestigious Baldrige National Performance Excellence Program (BPEP) and is a Senior Examiner and a Team Leader for the State of Maryland Performance Excellence Award Program (MPEA). He is also a senior fellow & Quality Judge in the Healthcare Division of the American Society of Quality (ASQ).
Michelle Lyn, M.D. FAAP, Associate Professor of Pediatrics Baylor College of Medicine, Medical Director of Care Management and Patient Flow, Pediatric Emergency Medicine Attending Texas Children's Hospital.
Charles G. Macias MD, MPH is an Associate Professor of Pediatrics at Baylor College of Medicine and Chief Clinical Systems Integration Officer for the Texas Children's Hospital enterprise. He is executive director of the national EMS for Children Innovation and Improvement Center, utilizing improvement science to help drive improved outcomes for ill or injured children in 58 states and territories. He chairs or co-chairs a number of Quality Improvement collaboratives, including the Improving Pediatric Sepsis Outcomes quality collaborative dedicated to decreasing mortality and morbidity from sepsis in greater than 50 hospitals. He was named HealthData Management's Clinical Visionary of the Year in 2014.
Robert McLean, MD, FACP, Currently an Associate Clinical Professor of Medicine at the Yale School of Medicine. He has practiced internal medicine and rheumatology in New Haven since 1994. In 2013, he became chair of the Clinical Integration Steering Committee for Yale New Haven Health System and chair of the Quality & Performance Improvement Committee for Northeast Medical Group. In 2016, he became Medical Director for Clinical Quality at Northeast Medical Group. He served on the American College of Physicians' Medical Practice & Quality Committee from 2013-17, and as Chairman from 2015-17.
Perry Ann Reed, MBA, MS, FACHE, Executive Director of WakeMed Children's Hospital, oversees strategy formulation and execution, financial performance and operational management. Previously, as Director of Ethics and Palliative Care at Texas Children's Hospital, she launched and led these two service lines. She holds an MBA in healthcare management from the University of Texas and an MS in Bioethics from Columbia University. Recent published chapters include "Law, Ethics and Clinical Judgment" in Rudolf's Pediatrics 23rd Edition. She and her husband John have 4 children.
Rahul K. Shah, MD, MBA, FACS, FAAP, Obtained a combined B.A/M.D. from Boston University School of Medicine and completed his Otolaryngology residency at Tufts University followed by a fellowship in Pediatric Otolaryngology at Children's Hospital Boston at Harvard University. After fellowship, he joined the faculty of Children's National Medical Center, rising to the rank of Professor. Dr. Shah's research interests include resource utilization and outcomes, patient safety, and medical errors; he has received numerous awards for his research. He is recognized as a leader in patient safety and quality improvement and has chaired and serves on several national committees related to patient safety and quality improvement. He was the Executive Director of an international not-for-profit quality improvement initiative, the Global Tracheostomy Collaborative. He was the inaugural Associate Surgeon-in-Chief (Chief, Perioperative Services) within the Joseph E. Robert, Jr. Center for Surgical Care at Children's National Medical Center and the Medical Director of Peri-operative Services from 2011-2014. He served as President of the Medical Staff at Children's National Medical Center from 2012-2014. In 2014, he was appointed the inaugural Vice-President, Chief Quality and Safety Officer for Children's National Health System. Under his leadership, Children's National has received numerous safety and quality distinctions and is a recognized leader in pediatric safety and quality.
Angelo P. Giardino, MD, PhD, CMQ, is the Wilma T. Gibson Presidential Professor and Chair of the Department of Pediatrics at the University of Utah School of Medicine in Salt Lake City, Utah, USA. He also serves as the Chief Medical Officer at Intermountain Primary Children's Hospital in Salt Lake City, UT. Prior to arriving in Utah, Dr. Giardino, served as Senior Vice President/Chief Quality Office at Texas Children's Hospital and was Professor of Pediatrics and Section Chief of Academic General Pediatrics at Baylor College of Medicine (BCM). He received his medical degree and doctorate in education from the University of Pennsylvania, completed his residency and fellowship training at The Children's Hospital of Philadelphia (CHOP), earned a Master's in Public Health from the University of Massachusetts, a Master's in Theology from Catholic Distance University (CDU), and is a Certified Physician Executive (CPE) within the American Association for Physician Leadership. He completed the Patient Safety Certificate Program from the Quality Colloquium, is certified in medical quality (CMQ) as designated by the American Board of Medical Quality and is a Distinguished Fellow of the American College of Medical Quality. He holds subspecialty certifications in Pediatrics and Child Abuse Pediatrics by the American Board of Pediatrics. He is a recipient of the Fulbright & Jaworski L. L. P. Faculty Excellence Award at BCM. His academic accomplishments include publishing several textbooks on child abuse and neglect and presenting on a variety of pediatric topics at national and regional conferences. Dr. Giardino serves as an Associate Editor for the 23rd edition of the classic Rudolph's Textbook of Pediatrics, is Co-Editor of the 4th edition of the Medical Evaluation of Child Sexual Abuse published by the American Academy of Pediatrics and serves as the Co-Editor-in-Chief of the Journal of Family Strengths. Dr. Giardino serves on the Board of Directors of Prevent Child Abuse America, CDU, and the US Center for Safe Sport.
Lee Ann Riesenberg, PhD, MS, RN, CMQ, is Professor and Associate Director Education, Anesthesiology and Perioperative Medicine at the University of Alabama at Birmingham in Birmingham, Alabama, USA. Dr. Riesenberg works as a medical educator and conducts medical education and quality and patient safety outcomes research. Dr. Riesenberg has worked in medical education for 25 years; received numerous recognition awards for her dedication to medical education and quality improvement in graduate medical education; and serves on the editorial board of the American Journal of Medical Quality.
Prathibha Varkey, MBBS, MPH, MHPE, MBA, is President and Chief Executive Officer at the Yale New Haven Health Northeast Medical Group in Stratford, Connecticut, USA. Dr. Varkey also is Senior Vice President at Yale New Haven Health, Professor of Medicine at Yale School of Medicine, and Professor of Health Policy and Management at Yale School of Public Health in New Haven, Connecticut, USA.
The American College of Medical Quality (ACMQ) is a national organization of healthcare professionals who are interested in the advancement of medical quality and patient safety as a field of study and practice. Origins of ACMQ date back to 1973, when it was first called the American College of Utilization Review Physicians (ACURP). It is formally recognized by the American Medical Association and holds a seat in its House of Delegates.