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COLLEGE OF HEALTH AND HUMAN SERVICES

California State University, Long Beach

Health Care Administration Program

HCA 450 - Quality Management/Improvement in Health Care Delivery


Semester FALL 2013


Instructor: Rus Billimoria, MD, MPH, CPHQ

E-mail: rus.billimoria@csulb.edu
Office Hours: Mondays 6 - 7 pm

(Please call for appointments)


Phone: (213) 694 1250 ext. 4274

Cell: (310) 508 1472


Class Number: Section 01, 4308 (HCA 450)

Class Location: VEC, Room-115

Class Meets: August 26 – December 10, 2013

Mondays from 7 PM to 9:45 PM


Additional Contact Information:

HCA Program Administrative Coordinator: Deby McGill, dmcgill@csulb.edu

Tel. 562/985-5694; fax 562/985-5886





Catalog Description

Prerequisites: HCA 300. (Please refer to details below) and HCA 465 (Preferred)

Basic elements of quality improvement and organizational responsibilities related to quality improvement in health care delivery. Data analysis for quality improvement, clinical practice guidelines, and future of healthcare quality improvement strategies.

Letter grade only (A-F). (Lecture)


ADA Accommodation will be provided to any student who requests such, as defined by the ADA act and CSU-LB. Please contact Dr. Billimoria or refer to your student handbook for further information.
Note: This syllabus is subject to change. Should there be any changes; students will be notified in class of the amendments.

 
COURSE PREREQUISITES:


For HCA 450 students: Prior to attending this course students are required to complete the following courses:

  • HCA 300 (Health Care System) and

  • HCA 465 (Analysis and Evaluation, preferred)

Exemptions for the prerequisites are generally not entertained. However, these may be considered on a case-by-case basis.



COURSE OBJECTIVES
The purpose of this course is to familiarize the student with the concept of Quality and the process of Quality Improvement across the Health Care continuum. This course focuses on the history and evolution of quality, its terms, principles, theories, and practices. The student is introduced to a diverse collection of methods of improving quality, including but not limited to continuous Quality Improvement and Total Quality Management, and to the guidelines for implementing quality management and the continuous quality improvement processes. Additionally , the students will be asked to review the changes that a selected number of health care systems from across America have implemented in order to achieve the Institute of Medicine’s goals to make quality health care more safe, timely, effective, equitable, efficient, and patient-centered. Students will also be exposed to new cutting edge technologies that impact the quality improvement efforts/interventions in health care delivery.

EXPECTED STUDENT LEARNING OUTCOMES

Upon completion of this course, the student will be able to:




  1. Describe the evolution of the health care systems and Quality Management/Improvement Programs and reflect on its future.




  1. Understand the reasoning and the importance of the requirements for Health Care Quality

Management/Improvement Programs.


  1. Describe the most current Quality Management/Improvement Program principles and techniques for health care in general. This includes the principles of Continuous Quality Improvement, Total Quality Management, and proactive versus reactive Quality Management programs.




  1. Understand the impact of federal and state legislation on Quality Management/Improvement Programs in Health care.




  1. Understand the need for and development of standards for accreditation of health care entities.




  1. Describe the recent impact of consumers on health care Quality Management/Improvement Programs and the development of health plan Report Cards (HEDIS etc.).




  1. Understand the use of data and statistics for an effective Quality Management/Improvement Program.




  1. Understand basic elements of provider credentialing, physician profiling and report cards, risk management and liability issues as they relate to Quality Management/Improvement Programs.




  1. Understand the effect of Patient Safety issues on Quality Management/Improvement systems.




  1. Understand the recent trends in Quality Management/Improvement and Continuous Quality and Continuity of Care issues in Assisted Living, Skilled Nursing, and Long Term Care.




  1. Health Care Report Cards, Pay For Performance and other strategies used for improving the quality of health care




  1. Demonstrate understanding of the principles in the development of a Quality Management/Improvement Program and Strategies for a health care entity via successful completion of class project.

 

REQUIRED TEXTS AND ANY OTHER REQUIRED MATERIALS AND INFORMATION.


This course now prescribes a specific text, though no single text would cover the broad scope of this course. The following books and materials are either prescribed or strongly recommended for review:



  1. Introduction to Quality Health Care Management, Patrice Spath, 2009, AUPHA, Health Administration Press, Chicago, Illinois (PRESCRIBED TEXT BOOK)




  1. Continuous Quality Improvement in Healthcare, William A. Solecito and Julie K. Johnson, 4th Edition, 2013, Jones and Bartlett Publishers, Inc. Sudbury, Massachusetts (OPTIONAL FOR REFERENCE ONLY).

Lecture notes and handout materials. All lecture notes will be posted on Beach Board. Students need to print these. Very few copies may be available for distribution by the instructor.


TYPES OF ASSIGNMENTS
I Short Essays (10% of overall class Grade for each one of 2 essays over the course of the semester. Total Percentage of overall class grade for these 2 essays is 20)

To understand the latest trends around Quality Management/Improvement Programs it is necessary to review articles related to health care quality from various sources including professional medical or health care journals. Students will be expected to write short essays on specific prescribed topics (a maximum of two, doubled spaced and typed pages). The students will be provided with a relevant topic for each essay. Students will then research and select one or more published articles pertaining to the topic and complete the short essay as follows:




  1. Introduction – Introduce the topic with a brief overview of sources used for the essay. Students must make special mention in support of selecting their articles

  2. Summary-Summarize the contents of the article(s) as they relate to the topic.

  3. Discussion-Provide your analysis and discussion pertaining the topic being discussed.

  4. Conclusions – Conclusion regarding the topic derived from the article(s).

The essays will be graded on a scale of (0 – 20 points). Grading will be based on the contents of sections addressed above.


Examples of Journals that may be used for writing your essays are as follows:


  1. Journal of the American Medical Association (JAMA) - http://jama.ama-assn.org/

  2. New England Journal of Medicine - http://content.nejm.org/

  3. Annals of Internal Medicine - http://www.annals.org/

  4. Journal of Health Politics, Policy and Law - http://www.jhppl.org/

  5. Journal of HealthCare Quality - http://www.allenpress.com/jhq/

  6. Med Bio World - Hospital & Healthcare Management Journals - http://www.medbioworld.com/

The three short essays will be due in the weeks assigned. Please see agenda on the following pages for due dates.


On the due date, submit one copy to the instructor. The essay will be returned after review and scoring.
II Class Participation (10% of Overall Class Grade)
Active classroom participation is encouraged. Each student will have adequate opportunities to participate in classroom discussions. Students will be provided the opportunity to participate in small projects and pop quizzes to assess participation. Level of participation will contribute towards the overall course grade.
III MidTerm Exam for HCA 450 (Constitutes 30% of the Overall Class Grade)
HCA 450 students will be administered a midterm exam worth 30% of the overall class grade. The exam will comprise of multiple questions. Questions will be a mix of essay type discussions based on case studies using the knowledge from topics discussed in class and the prescribed text book during the semester and a series of short case studies or notes on specific issues or topics.
For each essay question, the student will be required to use the following format:


  1. An Introduction to address the case or problem presented(20% of the question grade)

  2. Presentation of the ideas in addressing the issue or case using information from the course.(30% of the question grade)

  3. Brief Discussion of the interventions or direction suggested by the student for addressing the case or issue (40% of the question grade)

  4. Conclusion- Summary of thoughts (10% of the question grade)

Length of the written answer is left to the discretion of the student. It is important to ensure that the above four points be taken into consideration for a complete answer.



For the short notes topic the student will be expected to write a short paragraph on each of the topics.
IV PROJECT: Quality Management/Improvement Project or Program Development (30% of the overall Grade)
A major classroom project will be the development of a Quality Management/Improvement Program or Quality Improvement Project or Process/strategy pertaining to a health care entity. This project will be assigned during the course and will be completed as part of your final exam.
Students will form teams and develop a Quality Management/Improvement Program or Process for improvement of selected care and services for their assigned entity. The project will make use of quality improvement principles and information presented during the course. Each student within a team must make specific contributions to the program or project development and discussions.
The projects developed will be presented to the class by all members of each team. Each team member presents their specific contributions to the project. Please see course agenda below for day of presentation. Guest speakers may be present during presentations and will contribute to the discussions and grading.

Grading For “The Quality Management/Improvement Program Development Project": (Constitutes 30% of the overall class grade)
I In addition to the presentation, each student’s contribution towards the team project will be presented in form of a paper not less than three double-spaced type written pages. The paper shall comprise of the following elements:


  1. Introduction to the portion being contributed by the student. (10% of Final Grade)

  2. Presentation of the ideas and components the student is responsible for developing as part of the team effort (10% of Final Grade)

  3. Discussion and the importance of the student’s contribution towards the team project using the principles and theories discussed in class as well as pertinent literature reviewed by the student. (30% of Mid Term Grade)


II Class Presentation by Team (50% of the Mid Term Grade. This score achieved by the team will be applied to each team member)
III Presentation Scoring Rubric will consider the following:
All 7 Elements listed below must be covered in your Presentation


  1. Outline the research documenting need for healthcare improvement (Background)

  2. Define the system in which you are making improvements (Hospital, HMO,SNF or other entity)

  3. Identify key themes for improvement efforts (Which areas or items of the issue were selected for improvement and why)

  4. Use the improvement processes best suited for your project. (Six Sigma, Lean, PDSA etc)

  5. Develop and Describe the team meeting management skills used to accomplish your project. (Includes Team Dynamics)

  6. Describe basic steps used in managing change as you implemented your improvement plan

  7. Describe the value and context for the tools your team used and implemented in settings you used:




  • Fishbones

  • Process mapping

  • Flow charting

  • Run/control charts



The Final Exam Grade will be a combination of the individual student contribution paper and team presentation scores.
Instructor will be available to all students for guidance during development of the project.
VI QUIZZES (5 % of grade each quiz): Two Quizzes will be offered during the semester. This will be announced a week prior to each quiz giving adequate preparation time to the students.

AGENDA AND SEQUENCE OF ASSIGNMENTS (The agenda is subject to change.)
Week Objective


Week 1 – August 26 a) Introduction to the course.


b) Literature Review Guidelines.

c) Introduction to Terminologies.

d) Introduction to Health Care Systems


  1. Selection of Teams & Team Leaders for projects.



SEPTEMBER 2 LABOR DAY HOLIDAY

Week 2 – September 9 a) The evolution of Health Care Quality Management with a

historic perspective.

b) Basic Elements of Quality Improvement



Readings: Review Chapters 1 (Prescribed Text Book)

Chapters 1 & 2 Solecito (Optional for 450)

Business Case for Quality – Reading for class project


Week 3 – September 16 Essay # 1 – Topic to be announced in class

a) Basic Elements of Quality Improvement continued.

b) The Deming approach to Quality Improvement.

c) Principles of Continuous Quality Improvement (CQI) and

Total Quality Management (TQM).

d) Outcomes needed of Quality

e) Classroom Project-Business case for Quality



Readings: Chapter 2 (Prescribed ) ,

Chapter 1 (Solecito, Optional), Lecture Notes and Literature


Week 4 – September 23 Essay # 1 to be submitted in class

a) Principles in developing a Quality Improvement Program

in health care .

b) Use of Data for Quality Improvement and Health Systems

c) Data Mining



Review: Chapters 1 & 3 (Prescribed Text Book)

Chapter 11 (Solecito, Optional), Lecture Notes


Week 5 – September 30 a) Process capability and variations (Chapter 4 both books)

b) Tools for Quality- Introduction

c) Project on Quality Improvement .

d) Leadership and Quality Improvement Teams

Review: Chapter 7 (Prescribed)

Chapter 6 (Solecito Optional), Lecture Notes & Literature


Week 6 – October 7 a) Progress Report and Updates on the Quality Improvement

project by each team.

b) Tools for Quality

c) Data Analysis in Quality Management (Using more Tools)

Review: Chapters 3,4 & 5 (Prescribed Text Book) & Lecture Notes

: Chapters 4 & 5 (Solecito Optional)

Week 7 – October 14 Essay # 2 --- Topic will be announced in class

a) Six Sigma and Lean Theories


b) Using Quality Improvement Tools- Small Classroom Project

Week 8 – October 21 Health Plan Report Cards. (GUEST LECTURE)



  1. Health Employer Data Information Set -2013 (HEDIS).

  2. ORYX systems (JC)

  3. Disease Management Programs.

  4. Understanding Accreditation


Review: Chapter 3 (Prescribed)

Lecture Notes & Literature

Week 9 – October 28 a) Introduction To Government Legislation in Health Care


  1. Understanding Regulatory Requirements (Guest Lecturer)

  2. Health care Quality and Long Term care (Guest Lecturer)

Review: Chapter 8 (Prescribed Text Book), Lecture Notes
MID TERM EXAM PAPER

Week 10 – November 4 Small Classroom project- (With Guest Lecturer)

Long Term Care other Issues

Week 11 – November 12 a) Medical Management, Care Management



(TUESDAY) b) Relative Resource Use and Utilization Management

Turn in Mid Term Papers

Week 12 – November 18 GUEST LECTURE- Obama care and Quality

Week 13 – November 25 a) Leap Frog


  1. Medicare Star Program

Week 14 – December 2



  1. Health Information Technology, Information Management (Guest Lecture?)

  2. Disease Management Programs

  3. Chronic Care Improvement Programs/Care Management


Week 15 – December 9 FINAL EXAM / PRESENTATIONS


  1. Group Presentations of Quality Improvement Projects

  2. Students to submit their individual written project reports



Week 16 –December 16 FINAL EXAM / PRESENTATIONS


  1. Group Presentations of Quality Improvement Projects

  2. Students to submit their individual written project reports

a) Course Summary

b)The Future of Health Care Quality

c) Job opportunities in Quality Improvement

d) Wrap Up


BASIS FOR ASSIGNING THE COURSE GRADE
This being a double numbered course, university policy requires greater expectations, additional work and different grading scales for graduate students. Due importance will be given to student participation in projects, papers, class work and exams. Letter Grades are assigned from A-F for level of achievement in the course. For final computation of the letter grades, following weights for each course component will be used:



Component HCA 450

Percent of Grade

Short Essays:

#1


#2

10%


10%

QUIZ 1

QUIZ 2


5%

5%


Mid Term Exam Paper

30%

Final Exam

Development of a Quality Management Program Project



30%

Class Participation (Including Attendance and in class projects)

10%

TOTAL

100%


STUDENT RESPONSIBILITIES AND EVALUATION

Attendance

Students are required to attend and to be prepared for each session by reading any assigned or referenced materials. Attendance is expected at each class session. However, if there are compelling circumstances, an absence may be excused. It then becomes the responsibility of the student to bring her/himself up to date with the class material. Please notify the lecturer of any absenteeism either in advance if preplanned or after the fact if due to emergent situations. More than two absences during the semester will impact the class participation score adversely.


Drops

It is the responsibility of the student to file for a drop status if he or she desires. No drops will be signed by the instructor after the third week.
Exams

A traditional grading system is required for evaluation of student performance in this course. There will be one mid-term and one final exam. Exam formats will be developed and announced by the Instructor. No make-up exams will be offered unless the student has made specific arrangements with the instructor prior to the exam.
Student Course Evaluation
Students will have an opportunity to evaluate this course. Feedback from students is very important and is considered critical to improving this course.
ADDITIONAL INTERNET RESOURCES:


America’s Health Insurance Plans

www.ahip.org

American College of Medical Quality

www.acmq.org

American Health Information Management Association

www.ahima.org

American Health Information Management Association

http://www.ahima.org/

American Healthcare Association

www.aha.org

American Society for Healthcare Risk Management

www.ashrm.org

American Society For Healthcare Risk Management

http://www.ashrm.org/ashrm/index.jsp

Association for Quality

www.asq.org

association for quality

http://www.asq.org/

California Association for Healthcare Quality

www.cahq.org

California Code of Regulations

http://ccr.oal.ca.gov/

California Department of Corporations

www.corp.ca.gov

California Medical Association

www.cmanet.org

Joint Commission on Accreditation of Healthcare Organizations

www.jcaho.org

Medicare

www.cms.hhs.gov

National Guideline Clearinghouse

www.guideline.gov

National Library of Medicine

www.nlm.nih.gov

National Network of Libraries of Medicine

www.nnlm.gov

Quality Indicator Project

www.qiproject.org

 

CHEATING AND PLAGIARISM:



The following is excerpted from the California State University, Long Beach Policy Statement 85-19, dated December 13, 1985.

It is the policy of the faculty and administration to deal effectively with the student who practices cheating or plagiarism. These acts are fundamentally destructive of the process of education and the confident evaluation of a student's mastery over a subject. A University maintains respect and functions successfully within the larger community when its reputation is built on honesty. Similarly, each student benefits in helping to maintain the integrity of the University. This policy, therefore, provides for a variety of faculty actions including those, which may lead to the assignment of a failing grade for a course and for administrative actions, which may lead to dismissal from the University. It is the intent to support the traditional values that students are on their honor to perform their academic duties in an ethical manner.



GENERAL:
The following definitions of cheating and plagiarism shall apply to all work submitted by a student.
DEFINITION OF PLAGIARISM:
Plagiarism is defined as the act of using the ideas or work of another person or persons as if they were ones own, without giving credit to the source. Such an act is not plagiarism if it is ascertained that the ideas were arrived at through independent reasoning or logic or where the thought or idea is common knowledge.
Acknowledge of an original author or source must be made through appropriate references, i.e., quotation marks, footnotes, or commentary. Examples of plagiarism include, but are not limited to, the following: the submission of a work, either in part or in whole, completed by another; failure to give credit for ideas, statements, facts or conclusions with rightfully belong to another; in written work, failure to use quotation marks when quoting directly from another, whether it be a paragraph, a sentence, or even a part thereof; close and lengthy paraphrasing of another writing or paraphrasing should consult the instructor.
Students are cautioned that, in conducting their research, they should prepare their notes by (a) either quoting material exactly (using quotation marks) at the time they take notes from a source; or (b) departing completely from the language used in the source, putting the material into their own words. In this way, when the material is used in the paper or project, the student can avoid plagiarism resulting from verbatim use of notes. Both quoted and paraphrased materials must be given proper citations.
DEFINITION OF CHEATING:
Cheating is defined as the act of obtaining or attempting to obtain or aiding another to obtain academic credit for work by the use of any dishonest, deceptive or fraudulent means.
Examples of cheating during an examination would include, but not be limited to the following: copying, either in part or in wholes, from another test or examination; discussion of answers or ideas relating to the answers on an examination or test unless such discussion is specifically authorized by the instructor; giving or receiving copies of an exam without the permission of the instructor; using or displaying notes; "cheat sheets," or other information or devices inappropriate to the prescribed test conditions, as when the test of competence includes a test of unassisted recall of information, skill, or procedure; allowing someone other than the officially enrolled student to represent the same. Also included is plagiarism, which is defined as altering or interfering with the grading procedures.
It is often appropriate for students to study together or to work in teams on projects. However, such students should be careful to avoid use of unauthorized assistance, and to avoid any implication of cheating, by such means as sitting apart from one another in examinations, presenting the work in a manner which clearly indicates the effort of each individual, or such other method as is appropriate to the particular course.

ACADEMIC ACTION:
One or more of the following academic actions are available to the faculty member who finds a student has been cheating or plagiarizing.

  1. Review -- no action.

  2. An oral reprimand with emphasis on counseling toward prevention of further occurrences;

  3. A requirement that the work be repeated;

  4. Assignment of a score of zero (0) for the specific demonstration of competence, resulting in the proportional reduction of final course grade;

  5. Assignment of a failing final grade;

  6. Referral to the Office of Judicial Affairs for possible probation, suspension, or expulsion



COURSE BIBLIOGRAPHY



  1. Adams, Karen, Greiner, Ann C., Corrigan, Janet M., Committee on the Crossing the Quality Chasm: Next Steps Toward a New Health Care System, 2004, 176 pages.




  1. Aspden, Philip, Corrigan, Janet M., Wolcott, Julie, Erickson, Shari M., Editors, Committee on Data Standards for Patient Safety; Patient Safety: Achieving a New Standard for Care, 2004, 550 pages




  1. Berwick Donald, Payment by Capitation and the Quality of Care- Part 5 (1996) The New England Journal of Medicine, 335,16,1227-1231




  1. Blumenthal David, Quality of Care – What is it? – Part I, (1996) The New England Journal of Medicine, 335, 12, 891-894




  1. Blumenthal David, The Origins of Quality of Care Debate- Part 4 ( 1996) The New England Journal of Medicine, 335, 15, 1146-1149




  1. Brook Robert, McGlynn Elizabeth, Measuring Quality of Care – Part 2, (1996) The New England Journal of Medicine, 335, 13, 966-970




  1. Brown, RN, CPHQ, Janet A., The Healthcare Quality Handbook: A Professional Resource and Study Guide, 2004/2005 Edition (20th edition available after 7/31/05)




  1. Budetti, PP; 10 Years Beyond the Health Security Act Failure: Subsequent Developments and Persistent Problems. 2004, JAMA; 292: 2000-2006




  1. Bush, GW, Ensuring Access to Health Care: The Bush Plan. JAMA, 2004; 292: 2010-2011




  1. Chassin Mark, Improving the Quality of Care- Part 3, (1996) The New England Journal of Medicine, 335, 14, 1060-1063




  1. Chassin Mark, Hannan Edward and DeBuono Barbara , Benefits and Hazards of Reporting Medical Outcomes Publicly ( 1996) The New England Journal of Medicine, 334,6, 394-398




  1. Couch James (Editor), Health Care Quality Management/Improvement Program for the 21st Century, 1991, American College of Physician Executives and American College of Medical Quality.




  1. Davies, H. O., Washington, A. Eugene, Health Care Report Cards: Implications for vulnerable patient groups and the organizations providing them care (2002), Journal of Health Politics, Policy and Law, Vol. 27, 379- 399




  1. Dlugacz, Yosef D., Alice Greenwood, Andrea Restifo The Quality Handbook for Health Care Organizations: A Manager's Guide to Tools and Programs ISBN: 0787969214 Pub. Date: March 2004 Series: J-B AHA Press, #131




  1. Ellen Nolte and C Martin McKee, Measuring the health of nations: Updating an earlier analysis, Health Affairs, Volume 27, 58-71, 2008.




  1. Golub, Robert M, Beyond Mental Mediocrity, JAMA, 2006, 296, 1139-1140




  1. Gruen, RL, Pearson, SD, Brennan, TA, Physicians-Citizens-Public Roles and Professional Obligations. JAMA, 2004; 291: 94-98




  1. Hagland, Mark, Transformative Quality, 2009, CRC Press, ISBN: 13: 978-1-4200-8492-4




  1. Health Employer Data Information Set –HEDIS 2005/2006, Published by NCQA




  1. Hersh, W, Health Care Information Technology: Progress and Barriers. JAMA 2004; 292: 2273-2274




  1. Iezzoni Lisa, Assessing Quality Using Administrative Data, (1997) Annals of Internal Medicine , 127, 8 (Part 2), 666-674




  1. Kerry, J., Ensuring Access to Health Care: The Kerry Plan. JAMA, 2004; 292: 2010-2011




  1. Landrum, Mary Beth et al, Is spending more always wasteful? The appropriateness of care and outcomes among colorectal cancer patients. Health Affairs, Volume 27, 159-168, 2008




  1. Leach, David C, Philibert, Ingrid, High Quality Learning for High Quality Health Care-Getting it Right, JAMA, 2006, 296: 1132-1134






  1. Lighter Donald, E., Advanced Performance Improvement in Health Care-Principles and Methods, 2011, Jones and Bartlett Publishers, ISBN: 13: 978-0-7637-6449-4




  1. Mclaughlin Curtis and Kaluzny Arnold, Continuous Quality Improvement in Health Care, 3rd Edition, 2006, Aspen Publication




  1. Prevalence of Overweight and Obesity Among US Children, Adolescents and Adults, 1999-2002. JAMA, 2004; 291 2847-2850




  1. Quality First: Better Healthcare for All Americans, Advisory Commission on Consumer Protection and Quality in the Healthcare Industry (Call 800/732-8200 for your free copy)




  1. Ransom, Elizabeth, Joshi, Maulik, S., Nash, David, B., Ransom, Scott, B., The Healthcare Quality Handbook, Second Edition, 2008, ISBN: 978-1-56793-301-7




  1. Reschovsky, J, D., Hargraves, J. Lee., and Smith, A. F., Consumer beliefs and health plan performance: It’s not whether you are in an HMO but whether you think you are. ( 2002), Journal of Health Politics, Policy and Law, Vol 27, 353-377




  1. Robinson, JC, Reinvention of Health Insurance in the Consumer Era. JAMA, 2004; 291: 1880-1886




  1. Robinson, J.C., Slouching towards value based health care. Health Affairs, Volume 27, 11-12, 2008




  1. Spath , Patrice: Introduction to HealthCare Quality Management, 2009, AUPHA, Health Administration Press, Chicago, Illinois, ISBN: 978-1-56793-323-9




  1. Solecito, William A and Johnson Julie, K, 2013, McLaughlin and Kaluzny’s Continuous Quality Improvement in Healthcare, 4th Edition, Copyright 2013, Jones and Bartlett Publication, Massachusetts; ISBN 13: 978-0-7637-8154-5


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