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THE HEALTHCARE
QUALITY BOOK
Vision, Strategy,
and Tools

AUPHA
HAP Editorial Board
Frederick J. Wenzel
University of St. Thomas, Minneapolis, MN
G. Ross Baker, Ph.D.
University of Toronto
Sharon B. Buchbinder, R.N., Ph.D.
Towson University, Towson, MD
Caryl Carpenter, Ph.D.
Widener University, Chester, PA
Leonard Friedman, Ph.D.
Oregon State University, Corvallis
William C. McCaughrin, Ph.D.
Trinity University, San Antonio, TX
Thomas McIlwain, Ph.D.

Medical University of South Carolina, Charleston
Janet E. Porter, Ph.D.
University of North Carolina at Chapel Hill
Lydia Reed
AUPHA, Arlington, VA
Louis Rubino, Ph.D., FACHE
California State University–Northridge
Dennis G. Shea, Ph.D.
Pennsylvania State University, University Park
Dean G. Smith, Ph.D.
University of Michigan, Ann Arbor
Mary E. Stefl, Ph.D.
Trinity University, San Antonio, TX
Linda E. Swayne, Ph.D.
University of North Carolina–Charlotte
Douglas S. Wakefield, Ph.D.
University of Iowa, Iowa City
Scott B. Ransom
Maulik S. Joshi
David B. Nash
Health Administration Press, Chicago, Illinois
AUPHA Press, Washington, D.C.
AUPHA
HAP
THE HEALTHCARE
QUALITY BOOK
Vision, Strategy,
and Tools

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The statements and opinions contained in this book are strictly those of
the author(s) and do not represent the official positions of the American
College of Healthcare Executives, of the Foundation of the American
College of Healthcare Executives, or of the Association of University
Programs in Health Administration.
Copyright © 2005 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.
09 08 07 06 05 5 4 3 21
Library of Congress Cataloging-in-Publication Data
The healthcare quality book : vision, strategy, and tools / [edited by
Scott B. Ransom, Maulik Joshi, David Nash.
p. cm.
Includes bibliographical references and index.
ISBN 1-56793-224-X (alk. paper)
1. Medical care—United States—Quality control. 2. Health
services administration—United States—Quality control. 3. Total
quality mangement—United States. I. Ransom, Scott B. II. Joshi,
Maulik. III. Nash, David B.
RA399.A3H433 2004
362.11'068—dc22
2004052331

The paper used in this publication meets the minimum requirements of
American National Standard for Information Sciences—Permanence of
Paper for Printed Library Materials, ANSI Z39.48-1984. ∞
Acquisitions editor: Audrey Kaufman; Project manager: Joyce Sherman;
Cover designer: Megan Avery
Health Administration Press Association of University Programs
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of the American College of 2000 N. 14th Street
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Some images in the original version of this book are not
available for inclusion in the eBook.
CONTENTS IN BRIEF
Academic Foreword, Stephen M. Shortell xix
Executive Foreword, Gail Warden xxi
Preface xxiii
Acknowledgments xxvii
Part I Science and Knowledge Foundation
1 Healthcare Quality and the Patient, Donald Berwick and
Maulik S. Joshi 3
2 Basic Concepts of Healthcare Quality, Leon Wyszewianski 25
3 Variation in Medical Practice and Implications for Quality,
David J. Ballard, Robert S. Hopkins III, and
David Nicewander 43
4 Quality Improvement Systems, Theories, and Tools,
Mike Stoecklein 63
Part II Organization and Microsystem

5 The Search for a Few Good Indicators, Robert C. Lloyd 89
6 Data Collection, John J. Byrnes 117
7 Statistical Tools for Quality Improvement, Kwan Y. Lee,
Linda S. Hanold, Rick G. Koss, and Jerod M. Loeb 145
8 Physician and Provider Profiling, David B. Nash and
Adam Evans 167
v
9 Measuring and Improving Patient Experiences of Care,
Susan Edgman-Levitan 183
10 Dashboards and Scorecards: Tools for Creating Alignment,
Michael D. Pugh 213
11 Patient Safety and Medical Errors, Frances A. Griffin and
Carol Haraden 241
12 Information Technology Applications for Improved Quality,
Richard E. Ward 267
13 Leadership for Quality, James L. Reinertsen 309
14 Organizational Quality Infrastructure: How Does an
Organization Staff Quality? A. Al-Assaf 329
15 Implementing Quality as the Core Organizational Strategy,
Scott B. Ransom, Narendra Kini, Michael L. Jones, and
Elizabeth R. Ransom 349
16 Implementing Healthcare Quality Improvement:
Changing Clinician Behavior, Valerie Weber and
John Bulger 371
Part III Environment
17 Medical Malpractice and Medicolegal Implications of
Quality, Troyen A. Brennan, Ann Louise Puopolo,
John L. McCarthy, Robert Hanscom, and Luke Sato 399
18 Accreditation: Its Role in Driving Accountability in
Healthcare, Greg Pawlson and Paul Schyve 411

19 How Purchasers Select and Pay for Quality,
Francois de Brantes 435
Appendix 1. Control Chart Formulas 453
Appendix 2. Comparison Chart Formulas 459
Appendix 3. Case Studies 465
Index 475
About the Authors 491
Contents in Brief
vi
DETAILED CONTENTS
Academic Foreword, Stephen M. Shortell xix
Executive Foreword, Gail Warden xxi
Preface xxiii
Acknowledgments xxvii
Part I Science and Knowledge Foundation
1
Healthcare Quality and the Patient, Donald Berwick and
Maulik S. Joshi 3
Important Reports 4
A Focus on the Patient 6
Lessons Learned in Quality Improvement 7
Case Study 17
Conclusion 22
Study Questions 23
References 24
2 Basic Concepts of Healthcare Quality, Leon Wyszewianski 25
Definition-Related Concepts 26
Measurement-Related Concepts 32
Conclusion 39
Study Questions 40

References 40
3 Variation in Medical Practice and Implications for Quality,
David J. Ballard, Robert S. Hopkins III, and
David Nicewander 43
Background and Terminology 43
Scope and Use of Variation in Healthcare 47
Clinical and Operational Issues 48
vii
Keys to Successful Implementation and Lessons
Learned from Failures 50
Case Study 52
Conclusion 54
Study Questions 57
References 58
4 Quality Improvement Systems, Theories, and Tools,
Mike Stoecklein 63
Theories, Paradigms, and Assumptions: Foundation of the
Iceberg Model 63
Systems and Processes: Middle of the Iceberg Model 67
Tools, Methods, and Procedures: Tip of the Iceberg Model 75
Application of Quality Improvement Science in Healthcare 80
The First and Second Curves of Healthcare Quality
Improvement 82
Case Study: A Second Curve Example 82
Conclusion 84
Study Questions 85
References 85
Part II Organization and Microsystem
5 The Search for a Few Good Indicators, Robert C. Lloyd 89
National Indicator Initiatives 90

The Measurement Challenge 94
Milestones Along the Quality Measurement Journey 95
Conclusion 113
Study Questions 113
References 115
6 Data Collection, John J. Byrnes 117
Categories of Data: Case Example 117
Considerations in Data Collection 119
Sources of Data 121
Case Study in Clinical Reporting 133
Conclusion 139
Study Questions 140
References 142
7 Statistical Tools for Quality Improvement, Kwan Y. Lee,
Linda S. Hanold, Rick G. Koss, and Jerod M. Loeb 145
Fundamentals of Performance Measurement 145
Detailed Contents
viii
Detailed Contents
ix
Control Chart Analysis 152
Comparison Chart Analysis 157
Using Data for Performance Improvement 162
Study Questions 165
References 165
8 Physician and Provider Profiling, David B. Nash and
Adam Evans 167
Background and Terminology 167
Scope and Use of Profiling in Healthcare 169
Keys to Successful Implementation and Lessons Learned 175

Case Study 178
Study Questions 180
References 180
9 Measuring and Improving Patient Experiences of Care,
Susan Edgman-Levitan 183
Regulatory and Federal Patient Survey Initiatives 184
Using Patient Feedback for Quality Improvement 186
Scope and Use of Patient Experiences in Healthcare 193
Keys to Successful Implementation and Lessons Learned 200
Lessons Learned, or “The Roads Not to Take” 203
Case Study 207
Conclusion 209
Study Questions 209
References 210
10 Dashboards and Scorecards: Tools for Creating Alignment,
Michael D. Pugh 213
Background and Terminology 213
Scope and Use of Dashboards and Scorecards in Healthcare 215
Clinical and Operational Issues 222
Keys to Successful Implementation and Lessons Learned 227
Case Study: St. Joseph Hospital 233
Conclusion 235
Study Questions 236
References 240
11 Patient Safety and Medical Errors, Frances A. Griffin and
Carol Haraden 241
Background and Terminology 241
Scope and Use of Patient Safety Considerations in Healthcare 245
Clinical and Operational Issues 257

Case Study: OSF Health System 259
Conclusion 264
Study Questions 264
References 265
12 Information Technology Applications for Improved Quality,
Richard E. Ward 267
Background and Terminology 267
Taking a Lesson from Other Industries 270
The Emerging Field of Medical Informatics 272
Two Tiers of Clinical IT 272
Technologies for Different Types of Clinical Care Management
Initiatives 276
Requirements and Architecture Framework for Clinical IT 278
Workflow Automation Technology Applied to Clinical Processes 283
Other Clinical IT Components 285
Case Examples 289
Overall Return on Investment of Clinical Information Systems 293
Key Strategy Debates 300
The Challenge 305
Study Questions 307
References 307
13 Leadership for Quality, James L. Reinertsen 309
Background and Overview 309
Scope and Use of Leadership Concepts in Healthcare 314
Clinical and Operational Issues 318
Keys to Successful Quality Leadership and Lessons Learned 319
Case Study of Leadership: Interview with William Rupp, M.D. 321
Study Questions 326
References 327
14 Organizational Quality Infrastructure: How Does an

Organization Staff Quality? A. Al-Assaf 329
Management Commitment 330
Allocation of Resources 333
Organizational Structure 334
Increasing Awareness of Healthcare Quality 336
Mapping Quality Improvement Interventions 337
Challenges, Opportunities, and Lessons Learned 342
Study Questions 347
References 347
Detailed Contents
x
Detailed Contents
xi
15 Implementing Quality as the Core Organizational Strategy,
Scott B. Ransom, Narendra Kini, Michael L. Jones, and
Elizabeth R. Ransom 349
Implementing Quality in Healthcare Organizations 351
Case Study: Entering the Digital Era 364
Study Questions 369
References 369
16 Implementing Healthcare Quality Improvement:
Changing Clinician Behavior, Valerie Weber and
John Bulger 371
Understanding Change Management in Healthcare 371
Active Implementation Strategies 379
Addressing the Cost of Implementation 384
Keys to Successful Implementation and Lessons Learned 386
Case Studies 388
Conclusion 393
Study Questions 393

References 393
Part III Environment
17
Medical Malpractice and Medicolegal Implications of
Quality, Troyen A. Brennan, Ann Louise Puopolo,
John L. McCarthy, Robert Hanscom, and Luke Sato 399
Background and Terminology 399
Scope and Use of Medicolegal Implications of Quality in
Healthcare
401
Clinical and Operational Issues 403
Keys to Success and Understanding Failure 407
Study Questions 409
References 410
18 Accreditation: Its Role in Driving Accountability in
Healthcare, Greg Pawlson and Paul Schyve 411
Background and Terminology 411
Scope and Use of Accreditation in Healthcare:
Successes and Failures
415
The Future of Accreditation: Challenges and Changes 421
Conclusion 429
Study Questions 430
References 431
19 How Purchasers Select and Pay for Quality,
Francois de Brantes 435
Background and Terminology 436
Bridges to Excellence 438
Defining the Program Specifications—The “What” 442
Designing the Program Implementation—The “How” 450

Conclusion 450
Study Questions 451
References 451
Appendix 1. Control Chart Formulas 453
Appendix 2. Comparison Chart Formulas 459
Appendix 3. Case Studies 465
Index 475
About the Authors 491
Detailed Contents
xii
LIST OF FIGURES
Preface Figure 1: The Healthcare Quality Book Overview . . . . . . . . xxiv
Figure 1.1: Four Levels of the Healthcare System . . . . . . . . . . . . . . . 7
Figure 1.2: Improving Critical Care Processes: Mortality Rates
and Average Ventilator Days. . . . . . . . . . . . . . . . . . . . . . . 9
Figure 1.3: Improving Effectiveness: Asthma Symptom-Free
Days and Average HbA1c Levels . . . . . . . . . . . . . . . . . . 13
Figure 1.4: Improving Patient Safety: Percent of Medication
Lists on All Charts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Figure 1.5: Improving Patient Centeredness: Percent of
Patients’ Self-Management Goals Met . . . . . . . . . . . . . . 15
Figure 1.6: Improving Efficiency: Average Minutes Spent with
Clinician in an Office Visit . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 1.7: Improving Timeliness: Days to Third Next Available
Appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 1.8: Improving Equity: Disparity by Race for Key
Effectiveness Measures . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure 1.9: Improving Vitality: Percent of Office Team
Reporting a Stressful Work Environment. . . . . . . . . . . . 18
Figure 3.1: Percent of Medicare Enrollees Admitted to

Intensive Care During the Last Six Months of Life
(by Hospital Referral Region, 1995–96) . . . . . . . . . . . . 44
Figure 3.2: Pneumococcal Vaccine Screening and Administration
for Patients Hospitalized with Community-Acquired
Pneumonia: Irving Hospital, Baylor Health Care
System, Dallas, Texas, January 1999–June 2003 . . . . . . 55
Figure 3.3: Pneumococcal Vaccine Screening and Administration
for Patients Hospitalized with Community-Acquired
Pneumonia: Irving Hospital, Baylor Health Care
System (BHCS; Excluding Irving), Dallas, Texas,
June 2002–June 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . 56
xiii
Figure 3.4: Process Control Chart for Pneumococcal Vaccine
Screening and Administration for Patients
Hospitalized with Community-Acquired Pneumonia:
Baylor Health Care System (BHCS), Dallas, Texas,
July 2001–June 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Figure 4.1: Framework for Viewing Quality Improvement Tools
and Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Figure 4.2: API Improvement Model . . . . . . . . . . . . . . . . . . . . . . . . 68
Figure 4.3: IHI Breakthrough Series Model. . . . . . . . . . . . . . . . . . . 70
Figure 4.4: Three Histories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Figure 4.5: Two Curves of Healthcare Quality Improvement . . . . . 83
Figure 4.6: First Curve Process: Breast Diagnosis,
1920s–Now . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Figure 4.7: Second Curve Process: Breast Diagnosis,
Park-Nicollet 1995–Now . . . . . . . . . . . . . . . . . . . . . . . . 84
Figure 5.1: Relationship Between a Concept and Specific
Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Figure 5.2: Probability and Nonprobability Sampling

Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Figure 5.3: Discussion Questions for Developing an
Analysis Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Figure 6.1: Diabetes Provider Support Report . . . . . . . . . . . . . . . . 130
Figure 6.2: Patient Registry Collection and Management
Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Figure 6.3: Executive Dashboard on Lower Joint
Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Figure 6.4: Clinical Outcome Report: Example of Trended
Data Over Six Quarters . . . . . . . . . . . . . . . . . . . . . . . . 138
Figure 6.5: Surveillance Report Showing Measures Outside
the Severity Adjusted Expected . . . . . . . . . . . . . . . . . . 139
Figure 7.1: Process that Generates a Product or Service
Simultaneously Generates Data that Can Be Used
to Improve the Process Itself . . . . . . . . . . . . . . . . . . . . 153
Figure 7.2: Control Chart: C-Section Rate (1998–2000) . . . . . . . 155
Figure 7.3: Tests for Special Causes . . . . . . . . . . . . . . . . . . . . . . . . 155
Figure 7.4: Determination of Outlier Status Based on
p-Value . . . 161
Figure 7.5: Determination of Outlier Status Based on
Expected Range: C-Section Rate (July–Sept.) . . . . . . . 161
Figure 7.6: Control Chart: C-Section Rate Demonstrates
Special-Cause Variation . . . . . . . . . . . . . . . . . . . . . . . . 164
Figure 8.1: Example of a Physician Profile . . . . . . . . . . . . . . . . . . . 176
List of Figures
xiv
List of Figures
Figure 8.2: Touchpoint Health Plan: Comparison of
Diabetes HbA1c Levels Across Providers. . . . . . . . . . . 179
Figure 9.1: Relationship Between Patient/Member Satisfaction

and Retention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Figure 10.1: Balanced Scorecard Central to the Strategic
Leadership System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Figure 10.2: Different Sets of Measures for Different Purposes . . . . 220
Figure 10.3: Critical Dimensions of Healthcare Organizational
Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Figure 10.4: 2003 Baldrige National Quality Program Category
7 Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Figure 10.5: Leadership Functions . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Figure 10.6: Different Measurement Sets Support Different
Leadership Functions . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Figure 10.7: Creating Organizational Alignment Around a
Critical Project: Cardiac Mortality . . . . . . . . . . . . . . . . 227
Figure 10.8: St. Joseph Health System (SJHS) Performance
Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Figure 10.9: St. Joseph Hospital (SJH) Strategy Map: Vital Few . . . . 236
Figure 10.10: Strategic Dashboard Used to Drive Progress on
Oncology Strategy at St. Joseph Hospital (SJH) . . . . . 237
Figure 12.1: Two Core Processes Involving Patients and Clinicians . . . 274
Figure 12.2: Care Management Process . . . . . . . . . . . . . . . . . . . . . . 275
Figure 12.3: Different Types of Care Management Initiatives
Call for Different Methods and Technologies . . . . . . . 277
Figure 12.4: Architecture Framework for Clinical Information
Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Figure 12.5: Template Charting Tradeoff: Quantity Versus
Quality of Structured Data. . . . . . . . . . . . . . . . . . . . . . 282
Figure 12.6: Results of Randomized Trial of Alternative
Reminders for Adult Influenza Immunization . . . . . . . 291
Figure 12.7: Screen Shot of Performance Graph in Diabetes
Care Management System . . . . . . . . . . . . . . . . . . . . . . 292

Figure 12.8: Capital Requirement for Hypothetical Institution . . . . 295
Figure 12.9: Assumed Gradual Deployment of Components
of Clinical Information Systems for a
Hypothetical Institution. . . . . . . . . . . . . . . . . . . . . . . . 296
Figure 12.10: Net Income Effect of Different Clinical Information
System Investments for Different Thresholds for
Required Strength of Evidence . . . . . . . . . . . . . . . . . . 298
xv
Figure 12.11: ROI for Clinical Information Systems Investments
in Hypothetical Institution Varies Based on Standard
of Evidence and Degree of Optimism of Estimating
Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
Figure 12.12: Model for Balancing Organizational and Clinician
Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Figure 12.13: Debate About Optimal Pathway for Clinical IT
Investments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
Figure 12.14: “Ice Versus Spikes” Debate Regarding Enterprise
Versus Departmental Clinical IT Solutions . . . . . . . . . 305
Figure 13.1: Leadership System for Transformation. . . . . . . . . . . . . 312
Figure 14.1: Quality Management Cycle . . . . . . . . . . . . . . . . . . . . . 330
Figure 14.2: Quality Program Document. . . . . . . . . . . . . . . . . . . . . 339
Figure 15.1: Quality Measurement Journey . . . . . . . . . . . . . . . . . . . 359
Figure 15.2: Comparison to Other Industries . . . . . . . . . . . . . . . . . 360
Figure 16.1: Rogers’s Adopter Categories Based on Degree of
Innovativeness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Figure 16.2: Kotter’s Stages of Creating Major Change. . . . . . . . . . 378
Figure 16.3: Barriers to Guideline Adherence . . . . . . . . . . . . . . . . . 380
Figure 16.4: Intervention Strategies for Influencing Clinician
Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
Figure 16.5: Evaluating Cost Effectiveness. . . . . . . . . . . . . . . . . . . . 386

Figure 16.6: Common Implementation Pitfalls . . . . . . . . . . . . . . . . 389
Figure 18.1: Potential Sources of Data for Use in Accreditation. . . . . 414
Figure 19.1: Design for Six Sigma (DFSS) Process . . . . . . . . . . . . . 441
Figure 19.2: Quality Functional Deployment . . . . . . . . . . . . . . . . . . 444
Figure 19.3: Process Groupings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Figure 19.4: Summary of Physician Office Link Measures . . . . . . . . 446
Figure 19.5: Physician Report Card Prototype . . . . . . . . . . . . . . . . . 449
List of Figures
xvi
LIST OF TABLES
Table 2.1: Importance of Selected Aspects of Care in Key
Participants’ Definitions of Quality . . . . . . . . . . . . . . . . 27
Table 2.2: Illustrative Examples of Criteria and Standards . . . . . . . 37
Table 5.1: Quality Measurement Journey Milestones and Their
Related Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Table 5.2: Self-Assessment for Making Quality Improvement a
Reality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Table 6.1: Orthopedic Patient Registry Data Elements . . . . . . . . 134
Table 12.1: Examples of Problems in Healthcare Delivery . . . . . . . 268
Table 12.2: Clinical IT Benefit Categories and Associated
Functional Areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Table 12.3: Net Income Effects of Clinical IT Investments in a
Hypothetical Healthcare Organization, Assuming
Lowest Threshold of Evidence . . . . . . . . . . . . . . . . . . . 297
Table 13.1: Individual Leadership: Being and Doing . . . . . . . . . . . 310
Table 15.1: Healthcare Quality Measures . . . . . . . . . . . . . . . . . . . . 350
Table 15.2: Recruiting Process and Timetable . . . . . . . . . . . . . . . . 355
Table 17.1: Emergency Department Claims by Loss Year. . . . . . . . 406
Table 17.2: Breast Cancer Claims by Loss Year. . . . . . . . . . . . . . . . 408
Table 19.1: Pay-for-Quality Initiatives . . . . . . . . . . . . . . . . . . . . . . 440

Table 19.2: Provider Critical-to-Quality (CTQ) Factors. . . . . . . . . 443
xvii
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ACADEMIC FOREWORD
Stephen M. Shortell
The U.S. healthcare system can be likened to a shoddily constructed build-
ing located in the pathway of an impending natural disaster. The system
has been constructed by thousands of different architects, engineers, masons,
and carpenters working from wildly different blueprints. For the most part,
it has been built to the codes of the nineteenth century. Three major Institute
of Medicine reports—the National Roundtable on Healthcare Quality’s
“The Urgent Need to Improve Health Care Quality,”
To Err is Human,
and Crossing the Quality Chasm
—highlighted the deficiencies in the design
of the U.S. healthcare system. These reports have pointed out the inade-
quacies of the system for dealing with today’s problems. But an even greater
challenge lies in meeting the storms of the future. These include an aging
population and the frequently associated increase in chronic illness; wide
and growing disparities by ethnicity and income in access to care, provision
of care, and outcomes of care; continued technological advances; and work-
force challenges. On the chronic illness front, 125 million Americans already
suffer from at least one chronic illness, and of these, approximately 50 per-
cent suffer from two or more chronic illnesses at a cost of hundreds of bil-
lions of dollars. As our society becomes more diverse, the currently
documented differences in access to care, delivery of care, and outcomes
of care by ethnicity and income will grow. These disparities will further
exacerbate the problems and costs associated with chronic illness. In the
meantime, new diagnostic, treatment, and preventive technologies are accel-
erating at a pace that is overwhelming the ability of the delivery system to

use them and the financing and payment systems to reimburse for them.
The growth of chronic illness, existence of disparities, and advance of new
technologies also have important implications for the healthcare workforce
in regard to size, composition, and the nature of the work to be performed.
The major question facing us is whether the current edifice of the
U.S. health system can be retrofitted and brought “up to code” through a
xix
systematic program of quality improvement reengineering and value enhance-
ment or whether it needs to be destroyed altogether and built again from
the ground up. It is the hope of most and the thesis of this book that the
former is possible, namely, that the system can be retrofitted to meet the
twenty-first century forces that are emerging.
Successfully meeting these challenges will require a new generation
of healthcare leaders: people with the vision, strategies, and tools to make
the continuous improvement of patient care quality the number one and
ongoing commitment of the organizations that they lead. This must involve
a marked change in the education of health professionals in which techni-
cal knowledge is married to improvement knowledge and change man-
agement knowledge centered on improving patient and community
experience with the system. The Healthcare Quality Book by Ransom, Joshi,
and Nash is an exemplary step in that direction. The book is appropriate
as a graduate text for all of the health professions and focuses on improved
quality for patients within the context of microsystems of care, the larger
organization, and the external environment. The book provides an excel-
lent balance of content between techniques and tools for quality improve-
ment on the one hand and the leadership and change-management skills
needed for implementation on the other hand. It also discusses the impor-
tance of environmental factors, including regulatory and accreditation
processes, legal issues, and payment. The editors have done a superb job
of assembling authors who have conceptual command of their subject com-

bined with practical experience. A broad range of examples and illustra-
tions of quality improvement applications are provided, ranging from the
intensive care unit to the physician’s office to the patient’s home. All of
the relevant topics are covered. The book will yield its greatest value when
used in its entirety, but the individual chapters are strong enough to stand
alone for selective use. It is hoped that future editions will incorporate the
progress made by current readers in their efforts to use the knowledge and
insights of this book to bring the U.S. healthcare system up to code.
Stephen M. Shortell, Ph.D.,
Blue Cross of California
Distinguished Professor of
Health Policy and Management and
Dean of the School of Public Health at the
University of California, Berkeley
Academic Foreword
xx
EXECUTIVE FOREWORD
Gail L. Warden
The second and final report of the Institute of Medicine’s (IOM) Committee
on Health Care Quality in America, entitled Cr
ossing the Quality Chasm:
A New Health System for the 21st Century
, published in 2001, calls for fun-
damental change in the healthcare system. Simply put, it says, “The cur-
rent system cannot do the job, trying harder will not work, changing systems
will.” The report challenges the nation to undertake a major redesign of
the delivery system and the policy environment that shapes it. Meeting
those challenges requires the introduction of radical new ways of health-
care delivery, more sophisticated assessments of quality, and a commitment
to continually improve it.

In the last decade the introduction of a quality philosophy in health-
care similar to other industries has stimulated extensive discussion about
quality and how to improve it. However, the work of IOM, Rand Health,
the Institute for Healthcare Improvement, the National Quality Forum,
and the Agency for Healthcare Research and Quality has now clearly estab-
lished the magnitude of the nation’s problems in healthcare quality and
what needs to be done about it.
Leaders in today’s healthcare organizations are beginning to be
very thoughtful about strategies to improve quality. They have learned
that every organization must have a vision on what quality should be, a
willingness to reject the status quo, and a will to improve quality that per-
vades the organization. They also understand that change does not hap-
pen without good leadership, transparency, and the ability to execute
changes in the organization.
The editors of
The Healthcare Quality Book: Vision, Strategy, and
Tools
provides a guide for quality improvement and a facilitator for dialog
about quality. The chapters define quality in depth and put it into context
for healthcare organizations and professionals desiring to “cross the qual-
ity chasm.” They recognize the importance of quality measurement as well
xxi
as reporting and analysis in relationship to clinical and operational effec-
tiveness. Their emphasis on quality leadership will provide guidance to
organizations as they take steps to bring their internal and external con-
stituencies to an active involvement in quality improvement.
The editors acknowledge that all health constituencies, including
policymakers, public and private purchasers, consumer advocates, health
professionals, provider organizations, and health plans, influence both the
practice and quality outcomes. A thoughtful set of study questions is pro-

vided in the book that will facilitate the right dialog in both the academic
and practice settings.
The Healthcare Quality Book: Vision, Strategy, and Tools is an impor-
tant contribution that will benefit all constituencies and take quality to
another level. This was the aim of not only IOM but the editors as well.
Gail L. Warden
President Emeritus
Henry Ford Health System
Detroit, Michigan
E xecutive Foreword
xxii
PREFACE
Why do we need a textbook on healthcare quality? The question is ironic
indeed. Healthcare, one of the largest industries in the United States, rep-
resenting nearly 14 percent of the gross domestic product, ought to serve
as a model for a consumer- or patient-focused market. Instead, as the reader
will soon learn, we are faced with the realities of fragmentation, waste,
deadly mistakes, and a prevailing sense of dread that little can be done to
fix this mess. Virtually every adult American can retell a personal story
detailing aspects of the lack of patient centeredness in our current health-
care system.
This textbook, then, seeks to provide a framework, context, and
strategies and tactics enabling us to understand the complexities in the
healthcare system. Most important, this book will provide an opportunity
for all healthcare stakeholders to take charge and lead the way in improv-
ing health and healthcare, with a special focus on patient centeredness.
It is the editors’ responsibility to articulate the purpose, audience,
and scope of any assembled work. No doubt, the chapters could have been
arranged differently. Some opinions are unorthodox, perhaps even irrever-
ent. Readers will be challenged to rethink their assumptions individually

and collectively. The editors have assembled a nationally prominent group
of contributors to provide the best available current thinking in each of
their respective disciplines. How did we organize such a broad field, and
what was the overarching conceptual framework used?
Building on recent work from the Institute of Medicine (IOM), the
editors chose to put the patient at the center of a discussion on improving
healthcare quality. Chapter 1 (by Donald Berwick and Maulik Joshi) pro-
vides the foundation for understanding the patient with respect to the
healthcare system. Chapters 2 through 4 provide an overview of the sci-
ence and knowledge base of quality by discussing global topics of key qual-
ity theories and concepts (Chapter 2, by Leon Wysziewianski), the critical
topic of variation in medical practice (Chapter 3, by David J. Ballard, Robert
S. Hopkins III, and David Nicewander), and methods and tools for qual-
ity improvement (Chapter 4, by Mike Stoecklein).
xxiii