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Quality Improvement and Population Management in Adult Primary Care

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Quality Measures


Initial efforts to define quality metrics in the ambulatory setting were hampered by the lack of tools for population management. With the advent of electronic health records, standardized data capture, and clinical decision support, the tools for measuring and tracking quality metrics have made quality improvement and population management feasible. The patient-centered medical home provides an organizational model to conduct population management, utilizing the whole team, including nursing, medical assistants, frontline staff, information technologists, and administrators to achieve quality goals, and unburdening the primary care provider from administrative tasks.

There has been an explosion of ambulatory quality metrics, with each insurer, both public and private, developing their own list of metrics and goals. We present the strategy of one practice to address these ballooning metrics by a process of selecting a targeted number of population management goals and metrics that meet the Quadruple Aim of (1) improved healthcare quality, (2) lower cost, (3) patient, and (4) provider satisfaction. The processes to conduct effective outpatient quality improvement include a multidisciplinary Change Team to define goals, conduct PDSA cycles, and build provider buy-in, informational technology to provide accurate and actionable reports, and specific work flow processes to engage each team member in activities appropriate to their level of training. We provide three examples of quality improvement projects developed to address diabetes, hypertension, and chronic opioid management, with descriptions of performance improvement cycles to address implementation of work flows to improve patient care.

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Correspondence to Deborah Blazey-Martin .

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Tishler, J., Huang, K.T., Blazey-Martin, D. (2020). Quality Improvement and Population Management in Adult Primary Care. In: Salem, D. (eds) Quality Measures. Springer, Cham.

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  • Print ISBN: 978-3-030-37144-9

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