Advancing Healthcare Quality and Safety

Foreword
Preface

Chapter 1. Quality and Safety in Health Care: History and Core Concepts

• Introduction
• Basic Concepts and Definitions
• Safety Defined
• Health Care Benefit and Value
• Basic Elements of Quality
• Quality Improvement Aims
• Other Key Terms
• A Focused History of Quality and Safety in Healthcare
• Early Leaders in Quality Improvement
• Contemporary Leaders in Healthcare Quality and Safety
• Organizations Important in Current Quality and Safety Efforts
• Stories of Actual Cases that Changed Health Care
• Conclusion
• Exercises
• References

Chapter 2. The Science, Process and Tools of Quality Improvement

• Introduction
• The Science of Quality Improvement
• Relationship to Research
• Lessons from Other Industries
• Quality Improvement Process
• Data Monitoring and Observation
• Health Information Technology and Improvement Science
• Conclusion
• Exercises
• References
• Appendix 2.1

Chapter 3. Safety Monitoring and Improvement

• Introduction and Definitions
• The How, Whys and Wherefores of Errors
• Factors Contributing to Human Error in Healthcare
• From Error to Harm/Adverse Events
• Lack of Attention Designing Safe System
• Conclusion
• Exercises
• References

Chapter 4. Preventing Errors and Reducing Harm

• Introduction
• Recognizing and Reporting Errors
• Investigation of Errors
• Error Prevention
• A Detour on the Road to Error Prevention: Malpractice
• Conclusion
• Exercises
• References

Chapter 5. Measures: Finding the Right Yardstick

• Introduction
• The Structure of Measures
• Basics of Measurement
• A Brief Overview of Major Players in Quality Measure Development and Use
• Types of Measures in Healthcare
• Areas of Quality to Measure
• CMS Meaningful Measures Initiative
• Conclusion
• Exercises
• References

Chapter 6. Data and Measurement

• Introduction
• Other Data Issues
• Levels of Health Care and Measurement
• Measurement Basics
• Measurement Challenges
• Electronic Health Records: A Growing Role in Measurement
• Professional and Cultural Responses to Measurement
• Potential Harm From Measurement
• Conclusion
• Exercises
• References

Chapter 7. Controversies and Challenges in Measurement

• Introduction
• Questions Concerning Controversies in Measurement
• Public Reporting: Pitfalls and Opportunities
• Pay-for-performance: Panacea or Curse?
• Conclusion
• Exercises
• References

Chapter 8. Leadership and Building a Culture of Quality and Safety

• Introduction
• What is a Culture of Quality and Safety?
• Quality is Everyone’s Responsibility Always
• Leading Culture Change
• Building Your Team
• Resources to Build and Assess Teams
• Leaders Making the Case for Quality
• Creating Culture Change
• Conclusion
• Exercises
• References

Chapter 9. Professional, Legal and Regulatory Impacts

• Introduction
• Professionalism
• Use of Regulation and Incentives to Advance Quality and Safety
• Direct Legal Influences on Quality and Safety
• Ethics, Quality and Safety
• Ethics of Research and Quality Improvement
• Conclusion
• Exercises
• References

Chapter 10. Quality and Safety Landscape

• Introduction
• Non-government Organizations
• Governmental Organizations
• Organizations Providing Certification in Quality and Safety
• Health Professional Clinical Organizations
• Health Professions Educational Organizations
• Insurers and Health Systems
• Consumer/Patient Safety and Quality Advocacy Groups
• Foundations
• Conclusion
• Exercises
• References

Chapter 11. The Future of Quality and Safety Improvement

• Introduction
• Challenges to Future Progress in Quality and Safety
• Paucity of Research Demonstrating Benefits of Quality and Safety Improvement
• Opportunities
• Conclusion and After Thoughts
• Exercises
• References

Index