Medical Quality Management: Theory and Practice

ISBN-13: 9783030480790 / Angielski / Twarda / 2020 / 367 str.

Angelo P. Giardino; Lee Ann Riesenberg; Prathibha Varkey

Spis treści

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 7

Organization 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, implementation, data analysis, and feedback are all presented clearly and—like all of the chapters—with an abundance of relevant references.

Chapter 8

Economics and Finance in Medical Quality Management 165

Executive Summary 165

Learning Objectives 166

Historical Perspective 166

Basic Concepts in Business and Economics 168

Types of Financial Accounting Reporting Tools 171

Types of Accounting Systems 174

Other General Business Principles 179

Outcomes Categories for Presenting the Economic Impact of Quality Initiatives 183

Clinical Outcomes 183

Utilization Outcomes 184

Intangible or Social Outcomes 185

Productivity Based Outcome Measures 186

Operational Outcome Measures 187

Presenting the Economic Value of Quality and Medical Management 188

Value and Compensation in Health Care 190

Physician Payment Strategies 193

Future 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 9

External Quality Improvement: Accreditation, Certification, and Education 199

Executive Summary 199

Learning Objectives 200

Quality 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 10

The Interface Between Quality Improvement and Law 223

Learning Objectives 223

History 224

Role of Government 224

Rules, Regulations, Laws, and Acts 226

Regulation and Public Laws to Ensure Quality 226

Patient Safety Act 228

Patient Safety Organization activity 228

Health Care Quality Improvement Act and Peer Review Protection 230

Mis-use of the peer review process for economic purposes: A cautionary tale 232

Credentialing 233

The National Practitioner Data Bank 234

HIPAA Rules 235

The Privacy Rule 236

The Transactions and Code Sets Rule 236

Facilitated Health Care Fraud and Abuse Investigation and Reporting 236

The Security Rule 237

The Enforcement Rule 237

HITECH Act 237

Medical Errors and Transparency 237

Basics of Malpractice 239

Facility-Organizational Risk Management Issues 243

Antitrust in Medicine 243

Future 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 11

Ethics and Quality Improvement 249

Executive Summary 249

Ethics in Healthcare: Basic Concepts 250

Major Historical Milestones 251

Ten Standards of the Nuremberg Code 251

Clinical Frameworks for Ethical Analysis: 252

Organizational Frameworks for Ethics 262

Human Subjects in Research and Quality Improvement 264

Characteristics of QI Initiatives 264

Characteristics of Research Initiatives 265

Institutional Review Boards 266

QI Initiatives and IRB oversight 267

Guidelines for Submitting QI Initiatives for IRB Review 268

Determination of Research Component within a Quality Improvement Initiative 270

Checklists to guide the IRB Review of QI Initiatives 270

Institutional Approaches to Quality Improvement Initiatives 273

Future 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. 

Authors

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.

O autorze

On behalf of the American College of Medical Quality, the following three editors will produce the book:

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. 

Blurb

This comprehensive medical textbook is a compendium of the latest information on healthcare quality. The text provides knowledge about the theory and practical applications for each of the core areas that comprise the field of medical quality management as well as insight and essential briefings on the impact of new healthcare technologies and innovations on medical quality and improvement. The third edition provides significant new content related to medical quality management and quality improvement, a user-friendly format, case studies, and updated learning objectives. This textbook also serves as source material for the American Board of Medical Quality in the development of its core curriculum and certification examinations.

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.