In healthcare, quality management refers to the administration of systems design, policies, and processes that minimize, if not eliminate, harm while optimizing patient care and outcomes. Whether you are a hospital with 1,000 beds or 25, the fact remain that every hospital must navigate and manage the many complexities associated with a quality management system.
Why is quality management important in healthcare? There are numerous reasons why it is important to improve quality of healthcare, including enhancing the accountability of health practitioners and managers, resource efficiency, identifying, and minimizing medical errors while maximizing the use of effective care and improving outcomes, and aligning care to what users and patients want in addition to what they need.
Hospital Quality: Implementing, Managing, and Sustaining an Effective Quality Management System demonstrates a practical approach to managing and improving quality. Whether you agree with the premise that these activities are complex, this book will outline a standardized approach that any organization can adopt to meet their needs while accommodating the foundational concepts of quality improvement by accreditation agencies. It also outlines how to set-up and manage a quality management program as a part of continuous process improvement initiative, as well as the purpose and managing of a patient safety organization.
The purpose of this book is twofold. If you’re a senior healthcare manager or director tasked with setting up a quality management system, this book will provide tools and techniques you can immediately apply. If you’re a healthcare professional preparing for the CPHQ certification exam, this book will take you beyond study guides by explaining what you need to know and the why behind each concept.
Author(s): Doug Johnson
Edition: 1
Publisher: Routledge
Year: 2024
Language: English
Commentary: Medicine//Healthcare
Pages: xiii; 227
City: Abingdon
Tags: Health and Social Care; Healthcare Administration and Management; Healthcare Process Improvement; Healthcare Management; Healthcare Financial Management & Leadership; Business, Management and Marketing; Economics, Finance, Business & Industry; Public Health Policy and Practice; Public & Nonprofit Management; Quality & Patient Safety; Organizational Studies; Organizational Change; Process Improvement; Leadership;
Cover
Endorsements
Half Title
Title
Copyright
Contents
Acknowledgments
About the Author
Introduction
1 An Introduction to Quality
1.1 Defining Quality
1.2 Examples of Quality
1.3 Quality Culture
1.4 Cost of Poor Quality
1.5 Summary
1.5.1 Key Concepts
1.5.2 Areas You Can Geek Out On
2 Quality Regulation and Benchmarking
2.1 Regulation
2.2 Centers for Medicare and Medicaid Services (CMS)
2.3 CMS Five-Star Rankings
2.4 QualityNet/HARP
2.5 Other Benchmarking Agencies
2.6 Other Regulations Important to Quality Departments
2.7 Health Insurance Portability and Accountability Act (HIPAA)
2.8 Clinical Laboratory Improvement Amendments (CLIA)
2.9 Summary
2.9.1 Key Concepts
2.9.2 Areas You Can Geek Out On
3 Managing Quality
3.1 The Original Mission
3.2 The “Quality Director” as Defined by Job Descriptions
3.3 The Paradigm of Managing Healthcare Quality
3.4 Quality Governance Structure
3.5 The Quality Committee
3.5.1 The Quality Committee Structure
3.6 The Medical Executive Committee (MEC)
3.7 The Governing Board
3.8 Summary
3.8.1 Key Concepts
3.8.2 Areas You Can Geek Out On
4 Quality Measurement and Analytics
4.1 Basics of Quality Measurement
4.2 Quality Measurement and Analytics
4.2.1 Exercise
4.3 SMART Goals
4.3.1 Exercise
4.3.2 SMART Goals for Individual Tasks
4.4 In-Process versus Outcome Measures
4.5 Trending Data
4.6 Control Charts
4.7 Pareto Chart
4.8 Cascading Measures
4.9 The Quality Oversight Scorecard
4.10 Updating the Quality Oversight Scorecard
4.11 Summary
4.11.1 Key Concepts
4.11.2 Areas You Can Geek Out On
5 Quality Improvement
5.1 Process Improvement Techniques
5.1.1 Lean
5.1.2 Six Sigma
5.1.3 ISO 9001
5.1.4 Plan-Do-Study-Act (PDSA)
5.1.5 Root-Cause Analysis
5.2 Change Management
5.3 Summary
5.3.1 Key Concepts
5.3.2 Areas You Can Geek Out On
6 Quality Training
6.1 Role of the Quality Professional in Training
6.2 Employee Engagement
6.2.1 Motivation
6.2.2 Assessing the Current State of Employee Engagement
6.3 Catch-Ball Sessions
6.4 Standard Work
6.5 Training within Industry
6.6 Summary
6.6.1 Key Concepts
6.6.2 Areas You Can Geek Out On
7 Project Management
7.1 Project Management in Quality
7.2 Action Item Tracking Tool
7.3 Action Item Standard Work
7.4 Summary
7.4.1 Key Concepts
7.4.2 Areas You Can Geek Out On
8 Accreditation
8.1 Role of the Quality Professional in Accreditation
8.2 Managing the Activities of the Accreditation Agency
8.3 Manage Survey Action Plans
8.4 Survey Readiness and Preparation
8.4.1 Leadership Commitment
8.4.2 Manager Accountability
8.4.3 Survey Readiness Oversight
8.4.4 Requirements Oversight
8.4.5 Organizational Assessment
8.4.6 Staff Education
8.4.7 Survey Audits
8.5 Sample Case Study
8.5.1 Pre-Survey Activities
8.5.2 Post-Survey Activities
8.5.3 Staff Recognition
8.6 Summary
8.6.1 Key Concepts
8.6.2 Areas You Can Geek Out On
9 Sustaining Quality
9.1 Role of the Quality Professional in Sustaining Quality
9.2 Daily Operations
9.3 Standard Work for the Quality Professional
9.4 Summary
9.4.1 Key Concepts
9.4.2 Areas You Can Geek Out On
10 The Quality Plan
10.1 Components of the Quality Plan
10.2 Summary
10.2.1 Key Concepts
10.2.2 Areas You Can Geek Out On
11 External Reporting
11.1 National Healthcare Safety Network (NHSN)
11.2 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
11.3 QualityNet/HARP (CMS) Portal
11.4 Using Vendors for QualityNet Data
11.5 Updating Information in QualityNet
11.6 COVID-19 Reporting
11.7 Summary
11.7.1 Key Concepts
11.7.2 Areas You Can Geek Out On
12 Patient Safety Organization, Quality Incidents, and Mortality Reviews
12.1 Patient Safety Organization (PSO)
12.2 Quality Incident Events
12.2.1 Serious Reportable Events (SRE)
12.2.2 Sentinel Events (SE)
12.2.3 Never Events (NE)
12.2.4 Patient Safety Indicators (PSI)
12.2.5 Hospital-Acquired Infections (HAI)
12.3 Quality Incident Summary
12.4 Mortality Reviews
12.5 Summary
12.5.1 Key Concepts
12.5.2 Areas You Can Geek Out On
13 Managing Hospital-Acquired Conditions (HAC) and Harms
13.1 Role of the Quality Professional in HACs and Harms
13.2 Summary
13.2.1 Key Concepts
13.2.2 Areas You Can Geek Out On
14 Managing the Quality Team
14.1 Developing the Quality Team
14.1.1 Interviews
14.1.2 Summarize the Findings
14.1.3 Prioritize Your Key Themes
14.1.4 Present Your Findings to the Group
14.1.5 Provide a Plan
14.1.6 Personality Assessment
14.1.7 Outline the Work of the Department
14.1.8 Assign Primary and Secondary Owners
14.2 One-on-One Meetings
14.3 Huddle Meetings
14.4 Calendar for Reporting
14.5 Support, Support, Support
14.6 Summary
14.6.1 Key Concepts
14.6.2 Areas You Can Geek Out On
15 Summary: Bringing It All Together
15.1 Quality Professional Next Steps
15.2 Sample Scenario
15.3 Summary
Appendix
Chapter 2 Appendix
Chapter 4 Appendix
Chapter 8 Appendix
Chapter 10 Appendix
Chapter 12 Appendix
Glossary of Acronyms
Index
