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Quality and Population Health Management

(Updated January 19th, 2018)


Ambulatory care quality performance is measured by the Healthcare Effectiveness Data and Information Set. The National Committee for Quality Assurance establishes the Healthcare Effectiveness Data and Information Set, or HEDIS measures to address a broad range of health issues and allows consumers to compare health plans on quality measures.

HEDIS has become an integrated system that improves the accountability of the managed health care industry with the ultimate goal of improving the quality of care for care patients. Primary care providers and the primary care team can improve their HEDIS scores by:

  • Help patients stay healthy through preventive screenings, test and vaccinations
  • Manage and document all acute and chronic patient conditions
  • Ensure that services provided and diagnoses are documented in the medical record
  • Submit accurate and timely claims for every office visit
  • Use electronic registries to review and close care gaps

Population Health Management

Population health management is defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group." The goal of population health management is to keep a patient popualtion as healthy as possible minimizing the need for expensive interventions such as emergency department visits, hospitalizations, imaging, tests, and procedures.


Institute of Medicine (IOM), 2001. Crossing the quality chasm: A new health system for the 21st century. Washington , D.C.: National Press

David Kindig and Greg Stoddart, "What is Population Health?" Am J Public Health. 2003;93:380-383.


Webinars and Presentations

MiCMRC Educational Webinar

Jan 17 2018

To receive a certificate of completion Click Here


Webinar replay video

Presented by

Natalie Pirkola, Pharm D, MBA, CCM, CPHIMS, BCACP


MiPCT Educational Webinar

Apr 22 2015

To receive a certificate of completion Click Here

Webinar replay video

Patient Registry and Population Health Management Webinar Slides 2015-04-22.pdf

Part I Presentation Slides

"Patient Registry and Population Health Management" presented by Marie Beisel

UMHS Gaps In Care Process Management Webinar Slides 2015-04-22.pdf

Part II Presentation Slides

"Gaps in Care Process Management in the Primary Care Setting" presented by Jan Pund

Presented by

Marie Beisel, MSN, RN, CPHQ, Project Manager, UMHS Care Management Resource Center & Jan Pund, RN-BC, UMHS Educational Nurse Coordinator, Complex Care Navigator, Ypsilanti Health Center

MiPCT Care Management Webinar

Jun 24 2015

To receive a certificate of completion Click Here

Webinar replay video

Presented by

Tammy Minor RN, BSN, CDE

Pediatric Webinar

Aug 15 2014

To receive a certificate of completion Click Here

Webinar replay video

Presented by

Jane Turner, MD

MiPCT Webinar

Sep 4 2013

To receive a certificate of completion Click Here

Webinar replay video

Presented by

Hae Mi Choe, PharmD, Clinical Associate Professor of Pharmacy University of Michigan College of Pharmacy & Director, Innovative Ambulatory Pharmacy Practices University of Michigan Hospitals and Health Centers



IHI Quality Improvement Resources

From the Institute for Healthcare Improvement, Cambridge, MA



Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies

From Agency for Healthcare Research and Quality. Vol 7: Care Coordination Shojania KG, McDonald KM, Wachter RM, Owens DK, editors. Technical Review 9 (Prepared by Stanford-UCSF Evidence-Based Practice Center under contract No. 290-02-0017). AHRQ Publication No. 04(07)-0051-7. Rockville, MD: Agency for Healthcare Research and Quality. June 2007

This paper develops a working definition of care coordination, applies it to a review of systematic reviews, and identifies theoretical frameworks that might predict or explain how care coordination mechanisms are influenced by factors in the health care setting and how they relate to patient outcomes and health care costs.


Reduced Readmissions - Reform’s Low-Hanging Fruit

From Institute for Healthcare Improvement via Health Insight. Boutwell, A. Reduced Readmissions - Reform’s Low-Hanging Fruit: How can we be sure it’s within our grasp? Healthcare Executive March/April 2011


Guides and Policies

Quality Improvement Strategy

From the Safety Net Medical Home Initiative


QI Strategy Implementation Guide Part I: Choosing and Using a QI Framework

Part 1 of the QI Strategy Implementation Guide Series includes an overview of QI methods and provides detailed information and case studies. August 2011


QI Strategy Implementation Guide Part 2: Optimizing Health Information Technology for Patient-Centered Medical Homes

This guide describes how clinics can optimize health information technology to power medical home workflows. It also includes tips for clinics without electronic health records. March 2011



Lean for Clinical Redesign Clinical Quality Initiative

Web site provides Lean background, tools, videos, websites, and highlights Michigan Practices Lean Collaboratives.


Improving Chronic Illness Care

Website focused on chronic care model and includes tools, literature, resources


Health Care Informatics - Care Management

Provides various articles related to Care Management