Core Curriculum for Medical Quality Management, by Arthur L. Pelberg et al, Sudbury, Mass: American College of Medical Quality, Jones & Bartlett Publishers, 2005. 213 pages, softcover, $61.95.
Eighteen years ago, this reviewer surveyed the deans of the member institutions of the Association of American Medical Colleges, asking 3 or 4 questions about their course offerings in the assessment and improvement of the quality of medical care. The response rate was around 30%, pretty good considering that the survey was not sponsored by some prestigious organization. About one fifth of the respondents reported that they did offer some training in the assessment of quality. The most common offering reported was a 2-hour lecture during the first or second year. None of the respondents had designated any form of quality management study as a requirement. The most common comment by the respondents was that the curriculum was so crammed with required courses that it was impossible to fit quality management in. When the survey was repeated in 1993, the results were about the same. Apparently, nothing had changed. Incidentally, the authors of a study published in this issue of the Quality Management in Health Care (QMHC) report that 54% of their study sample of medical residents indicated that their training had not included content on medical errors. 1
As Dr George C. Martin, president of the American College of Medical Quality, states in the Foreword to this book,
The objectives of ACMQ's educational programs in medical quality management and clinical quality improvement are to develop and disseminate a core body of knowledge, provide a forum for health care professionals, government agencies, and other regulatory bodies, take a leadership role in creating, sustaining and applying a scientifically based infrastructure for the specialty, elevate the standards of medical schools and post-graduate education in quality management and sponsor on-going research and evaluation. 2
Given the history, that is a tall order. In 1986, Donabedian listed the core areas of knowledge that would be required of physicians working in the field of health care quality management. 3 In addition to the expected attributes such as clinical competence and experience within the health care system, Donabedian cited the need for competence in nonmedical areas such as performance review methodology; information systems; epidemiology; organizational theory; adult education; health care law; risk and safety; and health care economics. Rodriguez points out the failures of leadership on the part of government, organized medicine, the medical educational system, and the regulatory agencies to address the requirements of effective quality management in the field of health care.
In his discussion of the purpose and philosophy of quality management, Pelberg addresses the broad focus of quality management as we see it today-combining both clinical and organizational aspects of the concept. He contrasts it with the narrow focus, limited to clinical behavior, which characterized the field 20 years ago. There is one little problem here, though. A lot of work still has to be done to disseminate this broad approach. It is by no means universally understood in the provider world.
Pelberg's discussions of benchmarking, the use of statistical tools, and outcomes assessment are clear and helpful. This 68-page chapter on methods and procedures of quality management, with its figures, tables, lists, and exhibits, is a whole-quality management curriculum in itself.
In their chapter on utilization management, Silfen and Rosenblum explain the role of predetermined criteria of care in evaluating the appropriateness of, and necessity for, medical treatment. They list the basic concepts underlying their discussion of utilization review as the background purpose of utilization review; developmental milestones in utilization management; utilization methods and procedures; outcomes and benefits of utilization management; and the roles of accreditation and regulatory organizations in utilization management. The authors provide examples of the implementation of the principles of utilization review. The chapter winds up with a list of accreditation and oversight organizations: the Utilization Review Accreditation Organization; the Joint Commission on Accreditation of Healthcare Organizations; and the National Commission on Quality Assurance, with the areas addressed in their respective standards.
To its credit, the College recognizes the relationship between the design of the health care organization and the quality of its service performance. This relationship is explored and analyzed in the chapter "Organization Design and Management," written by James T. Ziegenfuss, Jr. He begins by asking why the field has moved beyond clinical quality assurance; what systems thinking contributes to quality management; what the leader's critical responsibilities and competencies are; and what the quality leader's roles and skills are. In the rest of the chapter, the author answers these questions. The figures and the organization and management summary are well done.
Donald Fetterolf and Joseph L. Braun have contributed an excellent chapter on the roles of economics, finance, and government in health care quality management. Their discussion is long on useful facts and practical examples of the concepts they address. They start out with a lengthy, comprehensive orientation section, providing a valuable historical perspective. Their case studies and study lists would be invaluable to any serious student of the relationships among economics, finance, government, and health care quality management.
The information infrastructure needed to support quality measurement and improvement is the subject of Louis H. Diamond's chapter on medical informatics. The author provides insightful discussions of recent health care information history, the purpose and philosophy of a health care information infrastructure, and of the components and functions of a health care information system. Particularly interesting is the short section dealing with barriers to the development of a health information infrastructure. An illustrative case study ends this chapter.
Mislove and Zale contribute a thoughtful chapter addressing legal and ethical issues in medical quality management. To anyone who might ask why the management of quality is such a compelling issue in the health care industry, the authors respond with insightful discussions of the applicable institutional accreditation requirements, risk management incentives, and the legal responsibility for conducting health care quality management activities. The authors divide their chapter into 2 sections: legal issues and ethical issues. While legal protections for those who conduct peer review and quality review have not been widely challenged in the United States and Canada for a number of years, the authors supply an informative refresher course on the confidentiality and immunity protections that apply. Their discussion of data bank reporting under Health Insurance Portability and Accountability Act is timely and relevant.
Mislove and Zale open their second section, on medical ethics, by asking what medical ethics is and why it is important. Then they proceed to a classic structure-and-function explanation of the field and history of medical ethics, its theories and principles, decision-making practices, and operating structures. They conclude the section with a case study involving the right to die.
The core curriculum set forth in this book would be an ideal component in a graduate program in health systems management. Aside from that, the book pulls together the many different, but complementary, subjects that make up an authentic health care quality assessment and improvement program. Too often, such programs are splintered or isolated, reflecting little understanding of the interrelationships among the different operating units, organizational groups, and professional disciplines that function in a health care organization. The College, in developing and promulgating the core curriculum in quality management that is set forth in this book, is making a major contribution toward combining the knowledge and skills of several disciplines in the interest of improving patient care outcomes. Besides its virtues in terms of erudition and authority, the book is a very easy read. The many study lists and case studies are outstanding.
Jean Gayton Carroll, PhD, Editor
Quality Management in Health Care, Chicago, Ill
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