1st Edition

Hospital Quality Implementing, Managing, and Sustaining an Effective Quality Management System

By Doug Johnson Copyright 2024
    242 Pages 135 B/W Illustrations
    by Productivity Press

    242 Pages 135 B/W Illustrations
    by Productivity Press

    242 Pages 135 B/W Illustrations
    by Productivity Press

    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.




    Chapter 1: An Introduction to Quality     

    Defining Quality               

    Examples of Quality        

    Quality Culture

    Cost of Poor Quality       



    Chapter 2: Quality Regulation and Benchmarking              


    Centers for Medicare and Medicaid Services (CMS)          

    CMS 5-Star Rankings      


    Other Benchmarking Agencies  

    Other Regulations Important to Quality Departments     

    Health Insurance Portability and Accountability Act (HIPAA)        

    Clinical Laboratory Improvement Amendments (CLIA)    



    Chapter 3: Managing Quality      

    The Original Mission      

    The ”Quality Director” as defined by Job Descriptions     

    The Paradigm of Managing Healthcare Quality   

    Quality Governance Structure   

    The Quality Committee

    The Medical Executive Committee (MEC)             

    The Governing Board    



    Chapter 4: Quality Measurement and Analytics 

    Basics of Quality Measurement

    Quality Measurement and Analytics       

    SMART Goals    

    In-Process versus Outcome Measures   

    Trending Data

    Control Charts  

    Pareto Chart      

    Cascade Measures         

    The Quality Oversight Scorecard

    Updating the Quality Oversight Scorecard            



    Chapter 5: Quality Improvement             

    Process Improvement Techniques           

    Change Management   



    Chapter 6: Quality Training          

    Role of the Quality Professional in Training          

    Employee Engagement

    Catch Ball Sessions         

    Standard Work 

    Training Within Industry              



    Chapter 7: Project Management

    Project Management in Quality 

    Action Item Tracking Tool            

    Action Item Standard Work         



    Chapter 8: Accreditation              

    Role of the Quality Professional in Accreditation

    Managing the Activities of the Accreditation Agency       

    Manage Survey Action Plans       

    Survey Readiness and Preparation           

    Example Case Study       



    Chapter 9: Sustaining Quality     

    Role of the Quality Professional in Sustaining Quality       

    Daily Operations             

    Standard Work for the Quality Professional         



    Chapter 10: The Quality Plan      

    Components of the Quality plan



    Chapter 11: External Reporting 

    National Healthcare Safety Network (NHSN)       

    Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) 

    QualityNet/HARP (CMS) Portal  

    Using Vendors for QualityNet Data          

    Updating Information In QualityNet        

    COVID-19 Reporting       



    Chapter 12: Patient Safety Organization, Quality Incidents, and Mortality Reviews             

    Patient Safety Organization (PSO)            

    Quality Incident Events 

    Quality Incident Summary           

    Mortality Reviews          



    Chapter 13: Managing Hospital Acquired Conditions (HAC) and Harms     

    Role of the Quality Professional in HACs and Harms         



    Chapter 14: Managing the Quality Team

    Developing The Quality Team    

    One-On-One Meetings 

    Huddle Meetings            

    Calendar for Reporting 

    Support, Support, Support          



    Chapter 15: Summary – Bringing it all Together 

    Quality Professional Next Steps

    Example Scenario            




    Chapter 2 Appendix: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Questions               


    Chapter 4 Appendix: Obtaining Standard Deviation in MS Excel   


    Chapter 8 Appendix: Job Descriptions for Survey Readiness         

    Committee Charter Example      


    Chapter 10 Appendix: Example Quality Improvement Plan            


    Chapter 12 Appendix: Patient Safety Organization Confidentiality Agreement     

    Quality Incident Comparison Checklist   

    Mortality Review Forms


    Glossary of Acronyms   



    Doug Johnson has been in healthcare over 30 years. He is a Registered Nurse, Certified Professional In Healthcare Quality, Lean Six Sigma Black Belt and earned his BSN with summa cum laude honors. His healthcare career began in patient transport and has progressed over numerous areas including the cardiovascular lab, health plan operations, emergency department, operating departments, nursing units, urgent care, billing processes, electronic medical records, patient-throughput, regulatory and accreditation requirements, quality, database management, data analytics and software development.

    Doug has outstanding interpretive skills in quantitative and qualitative analyses, identifying root causes of poor process control and inefficiencies. His vast experience in the multifaceted business of healthcare has equipped him to design, improve and provide sustainable solutions in all areas of healthcare operations.

    His company, DcJ Solutions (www.Innovate2Accelerate.com) offers quality management consulting and training through proven tools and techniques to allow your organization to implement, manage, and sustain a quality management program using existing and permanent staff. He developed a team of experts both in healthcare operations and information technology design. By combining the skills of healthcare operations, process improvement and technology, this team is well aligned to create meaningful solutions for healthcare organizations.

    "The moral responsibility to provide high quality care in an increasingly complex healthcare industry challenges the best healthcare organizations. Fierce competition for resources and the multidisciplinary nature of healthcare can leave organizations less focused and structured than needed to achieve their quality goals. The Hospital Quality Book is a fantastic resource for providing a practical and straightforward path to attain quality objectives. Douglas C. Johnson captures his decades of learning during his practice as a system, process, and quality professional. It is truly scalable to each organization’s current capabilities and can be used to stand up an entirely new program or as a reference to assist established programs in accelerating performance."

    Troy Greer, FACHE, MBA, MSHA
    CEO, Boone Health, Columbia, MO