The Healthcare Quality Book: Vision, Strategy, and Tools, Fifth Edition

By AUPHA/HAP Book

The Healthcare Quality Book provides a framework, methodology, and practical approaches to assist healthcare professionals in championing improvement efforts. The book is divided into three sections that cover the fundamentals of healthcare quality, critical quality topics, and key strategies for effectively leading quality.

The extensively revised fifth edition of this definitive text brings together healthcare thought leaders with a wide range of subject matter expertise. Chapter contributors explore the foundation of healthcare quality, share their perspectives on essential and cutting-edge topics, and offer strategies for learning the skills to lead a culture of quality.

New content includes chapters on health equity and disparities in care and expanded content on quality improvement tools, the patient experience and digital technologies.

The book concludes with three well-developed case studies of quality improvement in action that incorporate the lessons learned in the preceding chapters.

The Healthcare Quality Book will assist leaders at all levels in developing a solid foundation of quality leadership knowledge, skills, and tools.

• Language: English
• Publisher: AUPHA/HAP Book
• Release date: Oct 3, 2022
• ISBN: 9781640553538

Book preview

Front Cover: The Healthcare Quality Book: Vision, Strategy, and Tools, Fifth Edition, Maulik S. Joshi, Scott B. Ranson, Elizabeth R. Ransom, David B. Nash Editors

HAP/AUPHA Editorial Board for Graduate Studies

Olena Mazurenko, MD, PhD, Chair

Indiana University

Julie Agris, PhD, FACHE

SUNY at Stony Brook

Ellen Averett, PhD

University of Kansas School of Medicine

Robert I. Bonar, DHA

George Washington University

Lynn T. Downs, PhD, FACHE

University of the Incarnate Word

Laura Erskine, PhD

UCLA Fielding School of Public Health

Cheryl J. Holden, DHS

University of Arkansas

Diane M. Howard, PhD, FACHE

Rush University

Ning Lu, PhD

Governors State University

Kourtney Nieves, PhD, MSHS

University of Central Florida

Martha C. Riddell, DrPH

University of Kentucky

Gwyndolan L. Swain, DHA

Belmont Abbey College

Mary Ellen Wells, FACHE

C-Suite Resources

Asa B. Wilson, PhD

Southeast Missouri State University

The Healthcare Quality Book: Vision, Strategy, and Tools Fifth Edition Maulik S. Joshi | Scott B. Ransom | Elizabeth R. Ransom David B. Nash, Editors Health Administration Press, Chicago, Illinois Association of University Programs in Health Administration, Washington, DC

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This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The statements and opinions contained in this book are strictly those of the authors and do not represent the official positions of the American College of Healthcare Executives or the Foundation of the American College of Healthcare Executives.

Copyright © 2023 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher.

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ISBN: 978-1-64055-357-6

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BRIEF CONTENTS

Foreword

Maureen Bisognano

Preface

Maulik S. Joshi, Scott B. Ransom, Elizabeth R. Ransom, and David B. Nash

Part I Introduction

Zach Goldberg and David Nash

Chapter 1. Overview of Healthcare Quality

Maulik S. Joshi and Marianthi N. Hatzigeorgiou

Chapter 2. Quality Improvement Models and Frameworks for Excellence

Cathy E. Duquette

Chapter 3. Variation in Medical Practice and Implications for Quality

Briget da Graca, David Nicewander, Brett D. Stauffer, and David J. Ballard

Chapter 4. Statistical Tools for Quality Improvement

Davis Balestracci

Part II Essential Quality Topics

Elizabeth R. Ransom

Chapter 5. Safety Science and High Reliability Organizing

Craig Clapper and Tami Strong

Chapter 6. Health Equity and Diversity

Deneen Richmond

Chapter 7. Population Health

Deneen Richmond

Chapter 8. Quality Measurement: Measuring What Matters

Thomas H. Lee and Deirdre E. Mylod

Chapter 9. Value-Based Purchasing

Lucy Liu, Rachel Zeldin, Julia Goldner, and Scott B. Ransom

Part III Leading Quality

Scott B. Ransom

Chapter 10. Health System Transformation

Dan Shellenbarger, Bryce Bach, Hector Nelson, and Scott B. Ransom

Chapter 11. Quality and Leadership: Utilizing Measures to Create Alignment

Michael D. Pugh

Chapter 12. Governance for Quality

Kathryn C. Peisert

Chapter 13. The Digitization of Healthcare

Saad Chaudhry

Chapter 14. Putting It All Together: Three Quality Improvement Case Studies

Edited by Kedar Mate and Dan Schummers

Index

About the Editors

About the Contributors

DETAILED CONTENTS

Foreword

Maureen Bisognano

Preface

Maulik S. Joshi, Scott B. Ransom, Elizabeth R. Ransom, and David B. Nash

Part I Introduction

Zach Goldberg and David Nash

Chapter 1. Overview of Healthcare Quality

Maulik S. Joshi and Marianthi N. Hatzigeorgiou

The Focus on Quality

Frameworks, Models, and Measurement

Quality Improvement Models

Measurement

Quality Improvement Tools

Conclusion

Case Study: Mr. Roberts and the US Healthcare System

Case Study: Stopping Catheter-Related Bloodstream Line Infections at Johns Hopkins University Medical Center and Hospitals Across the United States

Study Questions

References

Chapter 2. Quality Improvement Models and Frameworks for Excellence

Cathy E. Duquette

Quality Improvement Models

Frameworks for Excellence

Quality Improvement Tools

Conclusion

Case Study: Using Lean Tools to Identify and Eliminate Waste

Study Questions

References

Chapter 3. Variation in Medical Practice and Implications for Quality

Briget da Graca, David Nicewander, Brett D. Stauffer, and David J. Ballard

Variation in Medical Practice

Analyzing Variation

Using Variation Data to Drive Healthcare Quality Initiatives

Case Study: Baylor Scott & White Health

Case Study: Opioid Prescribing in the Anne Arundel Health System

Conclusion

Study Questions

References

Chapter 4. Statistical Tools for Quality Improvement

Davis Balestracci

Introduction

Process-Oriented Thinking: The Context for Improvement Statistics

Variation: The Framework of This Chapter

Plotting Data over Time: The Run Chart

Common Causes Versus Special Causes of Variation

The Control Chart: A Very Powerful Tool

Analysis: The I-Chart Is Your Swiss Army Knife

An Important Expansion of the Concepts of Perfectly Designed, Common Cause, and Special Cause

Summary

Study Questions

References

Additional Resources

Part II Essential Quality Topics

Elizabeth R. Ransom

Chapter 5. Safety Science and High Reliability Organizing

Craig Clapper and Tami Strong

Safety and Reliability

History of the Modern Safety Movement

Reliability as an Emergent Property

Descriptive Theories of High Reliability Organizations

Why Should We Care?

Creating Safety and High Reliability in Practice

Case Study: A Journey to High Reliability

Important Topics in Safety and High Reliability

Sustaining Cultures of Safety and High Reliability

Summary

Study Questions

References

Chapter 6. Health Equity and Diversity

Deneen Richmond

Introduction

Health Equity and Health Disparities Defined

The Impact of Racism and Discrimination

Conscious and Unconscious Bias

Equality Versus Equity

A Look at the Data: The Persistent State of Health Disparities

Data on Disparities at the National, Local, and State Levels

The Urgency to Achieve Health Equity

Workforce Diversity

Taking Action

Case Study: Reducing COVID-19 Vaccination Disparities

Case Study: Luminis Health’s Approach to Achieving Health Equity

Conclusion

Study Questions

References

Chapter 7. Population Health

Deneen Richmond

Population Health Defined

Factors Influencing the Health of a Population

The Health of Our Communities

Improving the Health of Our Communities

Defining the Population of Focus

A Framework for Healthcare Organizations to Drive a Population Health Focus

Measuring Social Determinants of Health

Case Study: A COVID-19 Community Prevention Program

Conclusion

Study Questions

References

Chapter 8. Quality Measurement: Measuring What Matters

Thomas H. Lee and Deirdre E. Mylod

Introduction

Safe

Timely

Effective

Efficient

Equitable

Patient Centered

Creating a Data Strategy for Quality Metrics: The Foundation

Data Integration

Deep Diagnosis of Barriers and Opportunities

Who Needs What Data?

Conclusion

Study Questions

References

Chapter 9. Value-Based Purchasing

Lucy Liu, Rachel Zeldin, Julia Goldner, and Scott B. Ransom

Introduction

Overview of Value-Based Financial Models

The Evolution of Value-Based Purchasing

Strategies and Capabilities to Succeed in Value

Key Learnings in the Evolution Toward Value-Based Care

Conclusion

Study Questions

References

Part III Leading Quality

Scott B. Ransom

Chapter 10. Health System Transformation

Dan Shellenbarger, Bryce Bach, Hector Nelson, and Scott B. Ransom

A Foundation for Realizing Transformational Goals

Kotter’s Eight-Step Change Process

An Unconventional Leadership Approach to Transformation

Reducing Cost While Improving Patient Quality

Transforming Quality and the Consumer Experience

Active Implementation Strategies

Making Change Stick: Workforce Culture and Behaviors

Conclusion

Study Questions

References

Chapter 11. Quality and Leadership: Utilizing Measures to Create Alignment

Michael D. Pugh

Introduction

Quality Measures and Metrics

Quality Assurance, Quality Control, and Quality Improvement

Leadership, Measurement, and Improvement

Case Study: Governance of Quality

Conclusion

Notes

Study Questions

References

Chapter 12. Governance for Quality

Kathryn C. Peisert

Background: Why Is Quality the Board’s Responsibility?

What Are the Board’s Quality Oversight Duties?

The Board-Level Quality Committee

Building a Culture of Quality and Safety

Conclusion

Notes

Study Questions

References

Chapter 13. The Digitization of Healthcare

Saad Chaudhry

Introduction

Technology

The Digital Scope

Case Study: Digital Transformation

Study Questions

References

Chapter 14. Putting It All Together: Three Quality Improvement Case Studies

Edited by Kedar Mate and Dan Schummers

Introduction

Case Study 1: Value Management at Lenox Hill Hospital of Northwell Health

Case Study 2: Implementation of an Age-Friendly Health System at the VA Boston Healthcare System Geriatrics Clinic

Case Study 3: Reducing Cesarean Section Rates in Brazilian Hospitals

Putting It All Together

Study Questions

References

Index

About the Editors

About the Contributors

FOREWORD

In the years since the Institute for Healthcare Improvement introduced a new way to look at quality, called the Triple Aim—better health for our populations, better experience of care, and lower per capita costs (Berwick, Nolan, and Whittington 2008)—we have seen improvements in many areas worldwide. The COVID-19 pandemic, however, has created an urgent need to improve in many more ways and to diffuse new measures and models quickly. The tools that we all need to make these changes are discussed in this book, and they support our work to uphold our moral duty to get the best care to every person, every time.

When I visit healthcare sites around the world, I begin by asking four questions:

Do you know how good you are?

Do you know where your variation is?

Do you know where you stand relative to the best?

Do you know your rate of improvement over time?

In these conversations, I aim to learn what matters to leaders, what tools they have built for change, and how they learn. Often, these conversations lead them to want to improve more widely and more quickly, to spread best practices, and to innovate to build new care models.

Healthcare leaders are clear on what they hope to improve by looking at quality in a new way. The challenge is how. Building a dosing formula of skills needed at every level of the organization sheds light on paths for building vibrant and effective skill sets across all levels. The science of improvement and the methods for change are here in each of the chapters in this book and pave the way for the how.

As we look at quality through the lens of the Triple Aim amid the ongoing COVID-19 pandemic, the urgency to innovate and improve is clearer than ever before. We are seeing new ways to work across traditional siloes in organizations and between healthcare and community groups. The voice of the patient is driving change to new levels, and we are seeing the vital necessity of coproducing health and care (IcoHN 2022).

COVID-19 is redefining care, with a strong focus on technical and medical expertise to encompass caring for the whole person. Though many feared that the stress of caring in COVID-19 times would move healthcare to a more tactical approach, we are seeing quality improvement methods effectively eliminating what is wasteful or ineffective to allow the humanity in care to thrive. Across the world, healthcare teams are exnovating—eliminating unnecessary and ineffective ways of working—to give the needed time and energy to innovating for new models and better outcomes. The power of exnovation, innovation, and quality improvement lies in improving care, but also supporting the joy in work that is so vital in these challenging times.

The new ways of seeing that are shared in this book will give all of us in healthcare the skill, time, and space to care in new ways. We are seeing global momentum for a movement that asks patients not only What is the matter? but also What matters to you? (Barry and Edgman-Levitan 2012; see also https://wmty.world). This shift in the way we think about what matters most and the way we use the science of quality improvement is creating new and fulfilling work for staff, enhancing clinical and experience outcomes for patients, and driving down wasteful costs—the Triple Aim for us all. It is my hope that every student in a healthcare professional program and every clinician and leader will read this book and make the changes we need!

Maureen Bisognano

President Emerita and Senior Fellow, Institute for Healthcare Improvement

Member, National Academy of Medicine

References

Barry, M. J., and S. Edgman-Levitan. 2012. Shared Decision Making: The Pinnacle of Patient-Centered Care. New England Journal of Medicine 366 (9): 780–81.

Berwick, D. M., T. W. Nolan, and J. Whittington. 2008. The Triple Aim: Care, Health, and Cost. Health Affairs 27 (3): 759–69.

International Coproduction Health Network (IcoHN). 2022. The Power of Coproduction (podcast). Accessed March 24. https://icohn.org/center/icohn/podcasts.html.

PREFACE

Much of the dramatic change over the last few years can be categorized by one label—COVID-19. Without any overstatement, the COVID-19 pandemic has fundamentally changed our lives, and nowhere more profound than in healthcare. The disruption caused by this global health crisis has altered the way we communicate with communities, how we care for patients (both physically and virtually), and how public health, population health, and medical care intersect. To no one’s surprise, there has been one constant, and that is quality.

The pandemic has heightened the importance of quality. Against the backdrop of this global infection, we have shined a brighter light on disparities in outcomes, we have shown how to meaningfully address population health, we have gotten better at measuring quality efficiently, and we have sharpened our focus on accelerating the pace of improvement. Because of the severity of the situation we have been in, quality is essential to ensure that everyone gets the best care and service possible, to achieve the highest health status. Quality is the compass pointing us to better healthcare and health.

This textbook provides a framework, strategies, and practical tactics to help all healthcare leaders learn, teach, and lead improvement efforts. This fifth edition of The Healthcare Quality Book has undergone a significant update, but once again, it boasts an all-star list of contributors with incredible expertise and breadth of experience. Like the healthcare field, this edition has been improved, reimagined, and redesigned. Organized into three sections, the book focuses on the foundation of healthcare quality (four chapters in part I), essential quality topics (five chapters in part II), and, finally, key strategies to effectively lead quality (five chapters in part III). Individually, and in the aggregate, this book is designed to be both an instructional guide and a conversation starter among all students of healthcare quality—that is, all current and future healthcare professionals.

Part I contains four chapters that together provide a foundation for understanding healthcare quality. In chapter 1, Maulik S. Joshi and Marianthi Hatzigeorgiou provide an overview of the major reports and findings of seminal quality work, including the six aims of quality: care that is safe, timely, effective, efficient, equitable, and patient centered. Cathy E. Duquette in chapter 2 dives deeper into important quality improvement tools and quality-oriented models that are essential for assessing and improving quality at the micro and macro levels. In chapter 3, Briget de Graca, David Nicewander, Brent D. Stauffer, and David J. Ballard examine one of the most pervasive and significant issues in healthcare quality—clinical variation. They explain the concept, distinguish between warranted and unwarranted variation, and discuss quality improvement tools that can help manage and reduce unwarranted variation in medical practice. Davis Balestracci in chapter 4 discusses the true underpinning of quality—the ability to apply and understand the application of statistical analyses with data. At the end of this chapter, you will have a newfound appreciation of run charts as your friend.

Part II builds on this foundation and dives into a variety of integral quality topics with a greater degree of granularity. It starts with chapter 5, in which Craig Clapper and Tami Strong wonderfully articulate the key aspects of defining and implementing a culture of safety and high reliability, because, as we often hear, culture eats strategy for lunch. Deneen Richmond in chapters 6 and 7 provide the theories and practical actions to address health equity and population health, with a focus on social determinants of health. Her chapters are intentionally presented in this order as these topics complement each other in the goal of providing the best care, tailored for all people. Thomas H. Lee and Deirdre E. Mylod in chapter 8 are experts in discussing the salient issues of quality measurement, with a keen emphasis on patient experience. Finally, part II ends with another essential quality topic: value-based purchasing. In chapter 9, Lucy Liu, Rachel Zeldin, Julia Goldner, and Scott Ransom discuss how measurement and improvement can align with payment.

The chapters in part III put it all together for you as you lead quality improvement efforts. The foundation and the essential topics are only as good as their application; part III is all about how to lead, engage, and drive a culture of quality. To begin this section, Dan Schellenbarger, Bryce Bach, Hector Nelson, and Scott Ransom summarize the two most important elements of quality transformation—people and culture—in chapter 10. Chapter 11, by Michael D. Pugh, exquisitely details the why and how of dashboards and scorecards as critical leadership system tools for improvement and accountability. Chapter 12, written by Kathryn C. Peisert, describes the fiduciary responsibility of the board of directors and delineates its central role in quality. The board bears the ultimate responsibility for everything in the healthcare organization, including quality and safety. Saad Chaudhry in chapter 13 talks about the role of information technology, not just an influential tool, but also an enabling strategy for better outcomes. In Chapter 14, Kedar Mate and Dan Schummers bring the entire textbook together by providing three well-developed case studies of quality improvement in action, using all the building blocks from the foundation section and the essential topics.

We have learned a lot in healthcare quality in the last few years. The people we serve expect and demand that quality be improved, and faster. We owe it to our patients and to our communities to make that happen. That will only happen if you, as a leader, develop a solid base of the knowledge, skills, and tools required to lead quality. Thank you for taking on this challenge and obligation.

In addition to being the editors of this book, we also use it extensively, whether for teaching in our own courses, as reference material, or for research. The most important use, however, is for leading improvement within our organizations. We greatly appreciate all the feedback we have received thus far, and we have used it to improve this textbook so that we can all be better leaders and healthcare providers.

Please contact us at [e-mail] with your feedback on this edition. Your teaching, learning, and leadership are what will ultimately transform healthcare.

Maulik S. Joshi

Scott B. Ransom

Elizabeth R. Ransom

David B. Nash

Instructor Resources

This book’s instructor resources include a test bank, PowerPoint summaries, and teaching aids for each chapter, including answers to the end-of-chapter study questions.

For the most up-to-date information about this book and its instructor resources, go to ache.org/HAP and search for the book’s order code (2463I).

This book’s instructor resources are available to instructors who adopt this book for use in their course. For access information, please email [e-mail].

PART

I

INTRODUCTION

Zach Goldberg and David Nash

Much has changed since the fourth edition of The Healthcare Quality Book was published in April 2019. Chief among these changes has been the society-altering COVID-19 pandemic, which has infected half a billion people globally and left more than six million dead. As courageous healthcare workers labored tirelessly to heal as many of the sick as possible, other priorities fell by the wayside to attend to more immediate concerns. Healthcare quality was one of those priorities that took a back seat during the pandemic. Despite a temporary waning focus on healthcare quality, the relevance and continued importance of quality improvement in the post-pandemic environment cannot be understated. Quality is essential for the transformation of American healthcare into a more efficient and equitable system.

Every aspect of quality must be considered as we seek to change the way care is provided and paid for. This includes:

Identifying key components of the US healthcare system that have ignited the charge toward quality improvement

Utilizing relevant data, models, and frameworks to drive quality improvement and make healthcare excellent

Understanding variation and gaps in care, especially when and how they must be managed to achieve a standard of practice

Implementing processes-oriented thinking through statistical analysis to visualize and correct variation that hinders quality

The four chapters in part I of this book introduce the reader to quality, present a variety of models and frameworks for quality improvement, discuss variation in care and its management, and explain how statistical processes can be used to understand variation. This part provides a foundation for transforming healthcare quality and offers strategies to help accomplish this critical goal.

Maulik S. Joshi and Marianthi N. Hatzigeorgiou begin chapter 1 by highlighting several major reports that have identified key areas of the American healthcare system in need of systematic quality improvement. Two of these reports continue to stand out today, more than 20 years after their publication. To Err is Human (2000) and Crossing the Quality Chasm (2001) were the first publications to define our current understanding of healthcare quality and provide preliminary assessments of its current state.

Chapter 1 also establishes quality as an essential component of the two core frameworks for healthcare improvement: the Triple Aim and the Quadruple Aim. Both focus on improving the experience of care, enhancing population health outcomes, and reducing the per capita cost of care. However, the Quadruple Aim takes the Triple Aim a step further to include improvement of work life for clinicians and healthcare staff, an essential goal that has taken center stage during the COVID-19 pandemic. True healthcare improvement will only be realized when all components of the Quadruple Aim are addressed.

Chapter 1 concludes by reviewing the work of Avedis Donabedian, who notes that all quality evaluations can be viewed according to measures of structure, process, or outcome. Structure involves the individuals who provide care and the settings where care is delivered. Process is the series of events that occur throughout care delivery. Outcome is a determination of whether the patient’s healthcare goals were achieved. Taken together, these three components offer meaningful insights into quality, but outcomes are the ultimate measure. Finally, the two case studies at the end of the chapter introduce opportunities to improve care that will be discussed further throughout the remainder of the book.

In chapter 2, Cathy E. Duquette presents several models and frameworks that drive quality improvement. Although all of them are unique, they follow a common structure that involves identifying a problem, analyzing elements of current performance that contribute to the problem, developing an intervention, measuring the intervention, and continuously modifying the intervention after its initial implementation. Models and frameworks from healthcare pioneers such as Walter Shewhart and W. Edwards Deming (Plan-Do-Study-Act), as well as more modern approaches (Lean, Six Sigma, Malcolm Baldrige Performance Excellence Framework, Magnet Model) are discussed in detail.

Duquette continues chapter 2 by distinguishing quality models and frameworks from quality improvement tools. The former design a concept, while the latter give physical structure to the design. The seven categories of quality improvement tools are presented, with examples, to illustrate that the approach to improving healthcare quality is multifaceted. Together, quality models, frameworks, and tools provide an opportunity to overcome consistent barriers in healthcare that have impeded quality improvement for decades. The case study at the end of the chapter illustrates how several frameworks and tools can be applied to drive quality improvement in practice.

In chapter 3, Briget da Graca and colleagues seek to demystify the complex phenomenon of variation in healthcare. They discuss the multitude of factors that contribute to variation, especially those that go beyond inconsistencies in quality of care. Variation has been an area of interest since the late 1930s, when a study by J. Allison Glover identified geographic variation strictly on the basis of medical opinion. This work opened the door to more complicated and nuanced evaluations of variation over subsequent decades. The authors note that it is not only necessary to identify variation, it is also essential to determine its value as warranted or, less desirably, unwarranted variation. This describes the work of John Wennberg and the Dartmouth Atlas of Health Care, which identified three categories of care and the unique implications of unwarranted variation in each category.

After presenting several strategies to decrease unwarranted variation in care in each of the Atlas’s three categories, the authors continue chapter 3 by presenting several tools that make each strategy possible. These include league tables, forest plots, funnel plots, and statistical process control. These strategies and tools have already been put to use in different healthcare settings. The Centers for Medicare & Medicaid Services and several healthcare systems have used variation data to drive successful healthcare quality initiatives. More recently, variation data have been applied to population health. Together, this work indicates that management of variation, rather than complete elimination of it, can serve as a guiding force to achieve greater value.

Finally, in chapter 4, Davis Balestracci builds on the discussion of variation to explain the role of statistics in quality improvement. Rather than describe an overcomplicated tool set, he emphasizes a statistical mindset and utilization of several effective strategies. To ameliorate unintended or unwarranted variation, the strategy of process-oriented thinking must be implemented. Process-oriented thinking employs three different kinds of statistics: descriptive statistics (e.g., a specific patient), enumerative statistics (e.g., a specific patient group), and analytic statistics (processes that produce descriptive and enumerative statistics). To visualize process-oriented thinking, the run chart is most effective. Secondary analyses that quantify the amount of process variation apply data from the run chart toward a control chart. Utilizing these tools helps us understand the two principal types of variation: common cause (systemic) and special cause (unique). We as humans have a natural tendency to treat all variation as special, when in reality, there is plenty of common cause variation that is improperly labeled as special. By considering healthcare quality as series of processes, it is easier to realize that the common cause variation in each process is actually an aggregation of special causes of variation.

Chapter 4 continues by explaining how strategies that address common cause variation help expose special causes and enable change. Implementation of a strategy requires an intimate understanding of the problem at hand, because a poor understanding of the problem will yield an equally poor result. To make this as simple as possible, data should be used according to the Pareto principle: identify the 20 percent of the process that is causing 80 percent of the problem. It is also important to remember that setting and striving to reach an arbitrary numerical goal does not always lead to actual quality improvement, nor does it reduce unwarranted variation. This problem is exacerbated by poor displays of data that may falsely show improvement or improperly treat deviations as a special cause.

Quality cannot be improved to reform healthcare without a fundamental understanding of its past shortcomings. Despite growing interest in quality in recent decades, work in the field has been ongoing for over a century. Reports that confirm the need to address certain domains of quality gave rise to models and frameworks to fill the void. However, variation and gaps in care remain, and they must be identified and managed using effective strategies rooted in statistics that drive legitimate change. The post-pandemic future provides us once again with the opportunity to improve quality on the road to better care.

CHAPTER

1

OVERVIEW OF HEALTHCARE QUALITY

Maulik S. Joshi and Marianthi N. Hatzigeorgiou

The Focus on Quality

Comparative health dimensions were created to measure the journey to better health outcomes. Health status, health risk factors, healthcare resources, and access to care are some of the established health dimensions that delve into the upstream determinants and resultant outcomes of health. Another such dimension, quality of care, encourages health systems and hospitals to compare the effectiveness of interventions aimed at improving the quality of patient care regionally, nationally, and globally. Despite the United States’ significant financial investment in health, metrics continue to highlight that quality outcomes trail those of other countries. The mismatch between health spending and quality outcomes signals the need for substantial reform to ensure high-quality care for all individuals (OECD 2019).

For several decades, health researchers and practitioners have worked to improve the quality of healthcare delivered and the patient outcomes, while also lowering healthcare spending. These efforts stemmed from several reports highlighting the shortcomings of the US healthcare system. Among the major reports driving the imperative for quality improvement, the following stand out:

The Urgent Need to Improve Health Care Quality published by the Institute of Medicine (IOM), renamed National Academy of Medicine in 2015, National Roundtable on Health Care Quality (Chassin and Galvin 1998)

The IOM’s To Err Is Human: Building a Safer Health System (Kohn, Corrigan, and Donaldson 2000)

The IOM’s Crossing the Quality Chasm: A New Health System for the 21st Century (2001)

The National Healthcare Quality Report, published annually by the Agency for Healthcare Research and Quality (AHRQ) since 2003 (the report has since been renamed the National Healthcare Quality and Disparities Report)

The National Academies of Sciences, Engineering, and Medicine’s Improving Diagnosis in Health Care (National Academies 2015)

Decades after their initial publication, these reports continue to create ripples throughout the healthcare industry and serve as tremendous, vital statements on the current quality condition. They call for action, draw attention to gaps in care, and identify opportunities to significantly improve the quality of healthcare in the United States. It is up to stakeholders to hold themselves and others accountable and ensure that better quality is achieved.

The Urgent Need to Improve Health Care Quality

Published in 1998, the IOM’s National Roundtable report The Urgent Need to Improve Health Care Quality first defined healthcare quality and pointed out the United States’ failure in healthcare outcomes. In addition, the report made two notable contributions to the quality movement. The first was an assessment of the state of quality at the time: Serious and widespread quality problems exist throughout American medicine. These problems occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care. Very large numbers of Americans are harmed (Chassin and Galvin 1998, 1000). The second contribution was the categorization of quality issues into three broad types: underuse, overuse, and misuse. This classification scheme has become a standard for quality defects, and it can be summarized as follows:

Underuse occurs when scientifically sound practices are not used as often as they should be. For example, only 72 percent of women between the ages of 50 and 74 reported having a mammogram within the past two years (White et al. 2015). In other words, nearly one in four women does not receive treatment consistent with evidence-based guidelines.

Overuse occurs when treatments and practices are used to a greater extent than evidence deems appropriate. Examples of overuse include imaging studies for the diagnosis of acute low-back pain and the prescription of antibiotics for acute bronchitis.

Misuse occurs when clinical care processes are not executed appropriately—for example, when the wrong drug is prescribed, or the correct drug is prescribed but incorrectly administered.

Each of these schemas, as these studies and others indicate, has led to inordinate healthcare costs for several stakeholders, despite contributing little to the positive improvement of patient outcomes and often creating waste and inefficiencies as a result.

To Err Is Human: Building a Safer Health System

Although the disconnect between efforts and quality outcomes was not a novel insight when the IOM published To Err Is Human in 2000, the report carried significant weight throughout the industry and beyond. Underscoring that reform and improvement are both complex and multifaceted, this thorough report exposed the severity and prevalence of quality problems in a way that captured the attention of a large variety of key stakeholders for the first time. The executive summary of To Err Is Human (Kohn, Corrigan, and Donaldson 2000, 1–2) begins with the following headlines:

The knowledgeable health reporter for the Boston Globe, Betsy Lehman, died from an overdose during chemotherapy. . . .

Ben Kolb was eight years old when he died during minor surgery due to a drug mix-up. . . .

[A]t least 44,000 Americans die each year as a result of medical errors. . . . [T]he number may be as high as 98,000. . . .

Total national costs . . . of preventable adverse events . . . are estimated to be between $17 billion and $29 billion, of which healthcare costs represent over one-half.

Although many individuals and organizations had called for the improvement of healthcare in the past, this report focused specifically on patient harm and medical errors in an unprecedented way, presenting them as the most urgent forms of quality defects. To Err Is Human framed the quality problem in a manner that was accessible to the general public, and it demonstrated that the status quo was unacceptable. For the first time, patient safety became a unifying cause for policymakers, regulators, providers, administrators, and consumers.

Crossing the Quality Chasm: A New Health System for the 21st Century

Closely following the publication of To Err Is Human, the IOM released Crossing the Quality Chasm in March 2001. This comprehensive report offered a new framework for a redesigned US healthcare system. Crossing the Quality Chasm provided a blueprint for the future, classifying and unifying the components of quality through six pillar aims for improvement. These aims— commonly viewed as the six dimensions of quality—provide healthcare professionals and policymakers with simple rules for redesigning healthcare. These six dimensions of quality are safe, timely, effective, efficient, equitable, and patient centered, known collectively by the acronym STEEEP (Berwick 2002).

Improving the quality of healthcare in the STEEEP focus areas requires that change occur at four levels, as shown in exhibit 1.1. Level A is the patient’s experience, as well as the experience of their affected family or community during the healthcare encounter. Level B is the microsystem in which care is delivered by small provider teams. Level C is the organizational level—the macrosystem or aggregation of microsystems and all supporting functions. Level D is the external environment, which includes payment mechanisms, policy, and regulatory factors. The environment affects how organizations operate, the macrosystem is influenced by operations and workflows that influence each microsystem housed within organizations, and microsystems, in turn, affect the individual patient. True north lies at level A, in the experience of patients, their loved ones, and the communities where they live (Berwick 2002).

EXHIBIT 1.1 The Four Levels of the Healthcare System

An illustration shows four levels of the healthcare system. It shows the four levels in ovals placed inside one after the next as follows: first or innermost: patient, level A; microsystem, level B; organization, level C; environment, level D.

An illustration shows four levels of the healthcare system. It shows the four levels in ovals placed inside one after the next as follows: first or innermost: patient, level A; microsystem, level B; organization, level C; environment, level D.

Source: Ferlie and Shortell (2001). Used with permission.

National Healthcare Quality Report

Mandated by the US Congress to focus on national trends in the quality of health care provided to the American people (42 USC § 299b-2(b)(2)), the AHRQ’s annual National Healthcare Quality Report highlighted progress and identified opportunities for improvement. Recognizing that the alleviation of healthcare disparities is integral to achieving quality goals, Congress further mandated that a second report, the National Healthcare Disparities Report, focus on prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations (42 USC § 299a-1(a)(6)). AHRQ’s priority populations included women, children, people with disabilities, low-income individuals, and the elderly. Together, these two reports are fundamental to ensuring that improvement efforts simultaneously advance the quality of care and work toward eliminating inequities in healthcare outcomes.

These reports use national quality measures to track the state of healthcare and address three questions:

What is the status of healthcare quality and disparities in the United States?

How have healthcare quality and disparities changed over time?

Where is the need to improve healthcare quality and reduce disparities greatest?

In its 2019 National Healthcare Quality and Disparities Report (the new combined report), the AHRQ (2019) noted several improvements that had been achieved, including improved access to healthcare, better care coordination, and improvement in patient-centered care. Despite these improvements, many challenges and disparities remain with regard to income, ethnicity, race, gender, and insurance status.

Improving Diagnosis in Health Care

The National Academies of Sciences, Engineering, and Medicine’s 2015 report on Improving Diagnosis in Health Care claims that most people will experience at least one diagnostic error—defined as either a missed or delayed diagnosis—in their lifetime. Diagnostic errors are thought to account for up to 17 percent of hospital-related adverse events. Likewise, up to 5 percent of patients in outpatient settings may experience a diagnostic error.

Previous reports had steered clear of discussing diagnostic errors, perhaps fearing that the topic assigned blame to clinicians on a personal level. This report, however, proposed an organizational structure for the diagnostic process, allowing for analysis of where healthcare may be failing and what might be done about it. The report recommended that healthcare organizations involve patients and families in the diagnostic process, develop health information technologies to support the diagnostic process, establish a culture that embraces change implementation, and promote research opportunities on diagnostic errors (National Academies 2015). In doing so, it becomes acceptable to highlight where diagnostic errors are occurring as a means to prevent them.

How Far Has Healthcare Quality Come?

More than two decades after the prevalence of medical errors was brought to light in To Err Is Human, healthcare in the United States has seen a call to arms for the improvement of quality and safety. But has anything really changed? A 2016 analysis published by the British Medical Journal suggests not. The article, titled Medical Error—The Third Leading Cause of Death in the US, delivered a startling picture of the scope of medical error in healthcare following extensive changes and initiatives. Using death certificate records

along with national hospital admission data, the report’s authors, Makary and Daniel (2016), concluded that if medical errors are tracked in the same way as diseases, they account for more than 250,000 deaths annually in the United States—outranked only by heart disease and cancer.

Marking the 20-year anniversary of the publication of To Err Is Human, Dzau and Shine (2020) evaluated the degree to which the United States has advanced in its quest for quality improvement. Echoing the disappointment expressed in Makary and Daniel’s work, the authors also concluded that quality had not improved noticeably even after years of investing in change processes, methodologies, and initiatives.

Even though there is work yet to be done, To Err Is Human and Crossing the Quality Chasm were catalysts for change in healthcare, and they led to increased recognition and reporting of medical errors and improved accountability measures set by governing bodies. Nonetheless, additional work and diligence is needed to shrink the quality gap still present in US healthcare. The remainder of this chapter will focus on existing frameworks that have led quality improvement efforts while examining measurement concepts and useful models.

Frameworks, Models, and Measurement

The Triple Aim

Though it was introduced after several of these foundational quality-of-care reports, the Triple Aim has served as a framework for healthcare improvement efforts since its publication in 2008. According to the Triple Aim framework, developed by Berwick, Nolan, and Whittington (2008), it is not enough to focus on improving care. True improvement instead relies on interdependent efforts toward three goals, or aims: (1) improving the experience of care; (2) improving the health of (identified) populations; and (3) reducing the per capita cost of healthcare. Focusing on only one of these aims is insufficient. Although focusing on quality of care has led to some improvement efforts, those initiatives remain isolated to a single site of care, rather than following patients through the care continuum. As a result, such efforts can be difficult to replicate.

Healthcare spending and costs of care in the United States remain disproportionately higher than national quality rankings, despite the many resources available to hospitals and systems. The Triple Aim provides a framework for addressing the gaps in care to create long-lasting change. Creating change is not without challenges, however. Since the goals of the Triple Aim are interdependent, substantial time after the implementation of efforts is required to see a return on investment or a significant impact.

The Quadruple Aim

The Triple Aim was not a novel theory upon its publication, but rather the articulation of several ideas and concepts that had been attempted by healthcare researchers. It set out to create a better healthcare system but failed to incorporate the perspective of providers and healthcare staff. The Quadruple Aim, introduced in 2014 by Thomas Bodenheimer and Christine Sinsky, corrects this oversight by adding a fourth aim: improving the work life of clinicians and staff. In order for the healthcare system to be optimized, achieving lower costs and improved healthcare quality outcomes, providers and staff need to be engaged, energized, and positively enforced. True change, Bodenheimer and Sinsky claim, happens at the intersection of the four aims.

The Triple and now Quadruple Aim serve as a true north for the healthcare industry. Efforts to create long-lasting change require time, investment, and careful coordination between stakeholders. Additional frameworks support these efforts and outline quality measurement.

The STEEEP Framework

The six STEEEP aims (Berwick 2002), as presented in the IOM’s Crossing the Quality Chasm, provide a valuable framework that can be used to describe quality at any of the four levels of the healthcare system (see exhibit 1.1). The many stakeholders involved in healthcare—including clinicians, patients, health insurers, administrators, and the general public—attach varying levels of importance to particular aims and, as a result, define quality of care differently (Bodenheimer and Grumbach 2009; Harteloh 2004).

Safety

Safety refers to the technical performance of care but also includes other aspects of the STEEEP framework. Technical performance can be assessed based on the success with which current scientific medical knowledge and technology are applied in each situation. Assessments typically focus on the accuracy of diagnoses, the clinical appropriateness of therapies, the skill with which procedures and other medical interventions are performed, and the absence of accidental injuries (Donabedian 1988a, 1980).

Timeliness

Timeliness refers to the speed with which patients receive care or services. It inherently relates to the degree to which individuals and groups are able to obtain needed services (IOM 1993, 4) or their ability to access care. Poor access leads to delays in diagnosis and treatment. Timeliness can also manifest as wait times in the patient experience—either the wait in the medical facility or the delay from scheduling an appointment to the actual visit. Timeliness is often a balance between quality of care and speed of care.

Effectiveness

Effectiveness refers to standards of care and how well they are implemented. Perceptions of the effectiveness of healthcare have evolved over the years to increasingly emphasize value. The cost-effectiveness of a given healthcare intervention is determined by comparing the potential for benefit, typically measured in terms of improvement in individual health status, with the intervention’s cost (Drummond et al. 2005; Gold et al. 1996). As the amount spent on healthcare services increases, each unit of expenditure yields ever-smaller benefits until no further benefit accrues from additional expenditures on care (Donabedian, Wheeler, and Wyszewianski 1982). Within the microsystem, the effectiveness of care can relate to the ability of an intervention to cure or treat ailments and maladies.

Efficiency

Efficiency refers to how well resources are used to achieve a given result. Efficiency improves whenever fewer, more appropriate resources are used to produce an output. Because inefficient care uses more resources than necessary, it is considered wasteful care, and care that involves waste is deficient—and therefore of lower quality and value—no matter how good it may be in other respects. Wasteful care is either directly harmful to health or is harmful by displacing more useful care (Donabedian 1988b, 1745).

Equity

Findings that the amount, type, or quality of healthcare provided can relate systematically to an individual’s characteristics—particularly race and ethnicity—rather than to the individual’s need for care or healthcare preferences have heightened concerns about equity in health services delivery (IOM 2002; Wyszewianski and Donabedian 1981). Many decades ago, Lee and Jones (1933, 10) asserted that good medical care implies the application of all the necessary services of modern, scientific medicine to the needs of all the people. . . . No matter what the perfection of technique in the treatment of one individual case, medicine does not fulfill its function adequately until the same perfection is within the reach of all individuals. Despite the several initiatives and years of research, global problems such as the COVID-19 pandemic reflected the United States’ shortcomings in equitable care outcomes (Dzau and Shine 2020).

Patient Centeredness

The concept of patient centeredness, originally formulated by Gerteis and colleagues (1993), is characterized in Crossing the Quality Chasm as encompassing qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient and rooted in the idea that healthcare should cure, when possible, but always help to relieve suffering (IOM 2001, 50). The report states that the goal of patient centeredness is to modify the care to respond to the person, not the person to the care (IOM 2001, 51). Initiatives such as precision medicine aim to incorporate individualized approaches to healthcare to improve outcomes. Recent efforts have targeted specific diagnoses with the hope of expanding to all of healthcare. In addition, it is suggested that patient-centered care can improve the overall patient experience and increase patient satisfaction scores. The patient’s perception of their quality of care often correlates with their understanding and experience of the STEEEP aims during an encounter. Therefore, patients tend to make decisions about their care based on their assessments of the factors they are best able to evaluate—patient centeredness, amenities, wait times, and reputation (Cleary and McNeil 1988; Sofaer and Firminger 2005).

Quality Improvement Models

Several models exist to guide the process of quality improvement. These quality improvement models address the complexities involved in the process and structure the approach to health system improvement. All the quality improvement models were initially developed for industries outside of healthcare and later applied to the industry. Their adaptation to the field of healthcare quality improvement demonstrates the field’s ability to learn from the success of other industries, but it also reflects the recentness of the quality movement in the healthcare arena. The quality improvement models have different names, but they share several core commonalities. Most follow the same basic format:

Identify the problem

Measure current performance

Perform a cause analysis

Develop and implement an improvement strategy

Measure the effect of the intervention

Modify, maintain, or spread the intervention

The idea that form follows function, a concept rooted in the field of architecture, stresses the importance of understanding what you are trying to accomplish before you determine how you are going to do it. Applied to healthcare quality improvement, this phrase highlights the need to understand the purpose behind the effort—the goal—at the individual, departmental, and organizational levels before deciding which improvement process or approach to adopt. The following approaches, though not an exhaustive list, are most commonly applied:

The Plan-Do-Study-Act cycle

Model for Improvement

Lean, or the Toyota Production System

Six Sigma

Human-centered design

These models are discussed in detail in chapter 2.

Measurement

Frameworks, stakeholders, and models are useful for advancing our understanding of quality of care, but they rely heavily on measurement, particularly with respect to quality improvement initiatives. Without appropriate measurement metrics and benchmarks, there is little clarity for those performing quality improvement work. Measurement must be an organic part of any quality improvement model or framework.

Donabedian Model: Structure, Process, and Outcome

As Avedis Donabedian (1966) first noted, all evaluations of the quality of care can be classified in terms of one of three measures: structure, process, or outcome.

Structure

In the context of measuring the quality of care, structure refers to characteristics of the individuals who provide care and of the settings where care is delivered. These characteristics include the education, training, and certification of professionals who provide care and the adequacy of the facility’s staffing, equipment, and overall organization.

Evaluations of quality based on structural elements assume that well-qualified people working in well-appointed and well-organized settings provide high-quality care. However, although good structure makes good quality more likely, it does not guarantee it (Donabedian 2003). Licensing and accrediting bodies rely heavily on structural measures of quality because they are relatively stable, and thus easier to capture and compare, and because they reliably identify providers or practices lacking the means to deliver high-quality care. The Quadruple Aim takes a more direct approach to incorporating and considering providers and clinical staff, highlighting the structural elements that are necessary for healthcare quality improvement.

Process

Process—the series of events that take place during the delivery of care—can also be a basis for evaluating the quality of care. The quality of the process can vary on three aspects: (1) appropriateness—whether the right actions were taken; (2) skill—the proficiency with which actions were carried out; and (3) the timeliness of the care.

Ordering the correct diagnostic procedure for a patient is an example of an appropriate action. However, to fully evaluate the process in which this particular action is embedded, we also need to know how promptly the procedure was ordered and how skillfully it was carried out. Similarly, successful completion of a surgical operation and a good recovery are not enough evidence to conclude that the process of care was of high quality; they only indicate that the procedure was performed skillfully. For the entire process of care to be judged as high quality, one also must ascertain that the operation was appropriate for the patient and that it was carried out in time. Finally, as is the case for structural measures, the use of process measures for assessing the quality of care rests on a key assumption—that if the right things are done and they are done right, good results (i.e., good outcomes of care) are more likely to be achieved.

Outcome

Outcome measures capture whether healthcare goals were achieved. The goals of care can be defined broadly, so these outcome measures often include the costs of care as well as patients’ satisfaction with their care (Iezzoni 2013). In many instances, the outcomes focus on indicators of health status, such as whether a patient’s pain subsided or condition cleared up, or whether the patient regained full function (Donabedian 1980).

Clinicians tend to have an ambivalent view of outcome measures. Clinicians are aware that many of the factors that determine clinical outcomes—including genetic and environmental factors—are not under their control. At best, they control the process, and a good process only increases the likelihood of good outcomes; it does not guarantee them. Some patients do not improve despite the best treatment that medicine can offer, whereas other patients regain full health even though they receive inappropriate care. Despite this complexity, clinicians view improved outcomes as the ultimate goal of quality initiatives. Clinicians are unlikely to value the effort involved in fixing a process-oriented gap in care if it is unlikely to result in an improvement in outcomes.

Which Is Best?

Of structure, process, and outcome, which is the best measure of the quality of care? The answer is that none is inherently better, and