Introduction to Health Care Quality: Theory, Methods, and Tools 1st Edition

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CONTENTS
List of Figures and Tables xvii
Preface xxi
Acknowledgments xxv
About the Author xxvii
Introduction xxix
PART I: QUALITY MANAGEMENT FUNDAMENTALS 1
1 Foundations of Health Care Quality 3
Deﬁning Quality 4
Contributions of Quality Theorists—Nothing New under the Sun 5
Florence Nightingale • Ernest A. Codman • William Andrew Shewhart
• William Edwards Deming • Avedis Donabedian • Joseph M. Juran
• Philip Crosby
Quality Management Methodologies 14
Total Quality Management • Continuous Quality Improvement
vii

viii Contents
Organizations Making an Impact on Quality and Safety Standards 16
Institute of Medicine • The Joint Commission
Centers for Medicare and Medicaid Services 21
Hospital Compare • Patient Education • Pay for Performance • Never Events
Institute for Healthcare Improvement 24
Agency for Health Research and Quality 25
National Quality Forum 27
The Leapfrog Group 27
Data: The Foundation of Quality Management 28
Case Example: Falls • Quality Indicator • Barriers to Using Quality
Data to Assess Care • Case Example: Cardiac Surgery Mortality
Summary 32
Key Terms 33
Quality Concepts in Action 33
References 33
Suggestions for Further Reading 34
Useful Websites 35
2 Understanding the Impact of Health Care Reform 37
The Affordable Care Act 38
Accountable Care Organizations • Health Insurance Exchanges
New Models of Payment 42
Bundled Payment • Pioneer and Advance Payment Accountable Care
Organization • Comprehensive Primary Care Improvement • Value-Based
Purchasing • Pay for Performance • Case Example: Communicating with Clinicians
through P4P Data
New Models of Providing Care 47
Patient-Centered Medical Homes • Community Health Centers • Prevention and
Wellness • Local Prevention Efforts • Case Example: Inﬂuenza Vaccination
New Models for Collecting Data 53
Background • Advantages of Electronic Health Records • Challenges to Effective
Use of Electronic Health Records • International Classiﬁcation of Diseases Codes
Improving Interpersonal Communication 56
Narrative Medicine • Improving Documentation • Looking Ahead

Contents ix
Summary 60
Key Terms 60
References 61
Useful Websites 63
3 Making the Case for Change 65
What Is Involved in Change? 66
New Models of Care • Case Example: Advanced Illness Screening
• Improving Quality
Managing and Measuring Quality in the Reform Environment 69
Measuring Quality Performance • Measuring Care in the Community
Who Is Involved in Change? 71
Leaders • Managers • Governance • Case Example: Developing a Quality
Structure for Change • Administrators and Clinicians • Monitoring
Quality • Quality Managers
Changing Communication 77
Breaking Down Silos • Educating Patients • Case Example: Confronting
Choices • Health Literacy • Communicating across Institutions and
Organizations • Organizing Information • Communicating Information
The Role of Data in Promoting Change 86
Tables of Measures • Quality Measures • Performance Improvement
Summary 89
Key Terms 90
References 91
Suggestion for Further Reading 92
Useful Websites 92
4 New Challenges for Health Care Professionals 93
Meeting Statistical Expectations for Standards of Care 94
The Evolution of Quality • Measures of Quality • Case Example:
Heart Failure Readmission

x Contents
Meeting Patient Expectations 97
HCAHPS • Case Example: Cleveland Clinic
Role of Dashboards 100
Leadership Reports
Role of Data Analysis 104
Case Example: Assessing High-Risk Pregnancy • Data for Performance Improvement
Understanding Different Kinds of Data 105
Challenges with Health Information Technology • Different Data Sources and Clinical
Research • Data and Quality
Managing Care for Chronic Illness across the Continuum 109
The Medicare Chronic Conditions Dashboard • Quality Measures
• Case Example: Readmission
Managing Aggregated Patient Care Issues 112
Population-Based Measures • Case Example: Aspirin
Administration • Microsystems/Macrosystems • Microsystems and Lean
• Case Example: Total Joint Replacement
Improving Communication 121
Teamwork • Case Example: Improving Cardiac Mortality
Summary 127
Key Terms 127
References 128
Useful Websites 130
5 Improving Patient Safety 133
Understanding Medical Errors and Adverse Events 134
Reporting Patient Safety Issues • Systems Errors • Institutionalizing
Error Prevention • The Necessity of Culture Change
High-Reliability Organizations 139
Guiding Principles • Becoming a High-Reliability Organization
The Role of Quality Management in Promoting a Safety Culture 142
Using Quality Data to Promote Safety • Case Example: Monitoring Falls
• Monitoring with Measures • Case Example: APACHE

Contents xi
Prioritizing Improvements 147
Using Data to Define Priorities • Case Example: Understanding Suicide
• Defining Priorities Locally • Case Example: Implementing Prioritization
Expanding Data Sources: Partnerships to Develop Best Practice 154
Case Example: Collaborations to Promote Patient Safety
Leading Organizational Improvements 155
Supporting Quality Data • Business Intelligence
The Role of Nursing Leaders in Promoting Safety 158
Communication Strategies • Integrating New Responsibilities • Transformational
Leadership • Case Example: Monitoring Patient Safety
The Role of the Medical Staff in Promoting Safety 162
Providing Education to New Physicians • Case Example: Resident Education Program
Promoting Safety through Effective Communication 165
Breaking Down Silos • Case Example: Reducing Length of Stay for Stroke Patients
Summary 169
Key Terms 169
References 170
Useful Websites 171
PART II: APPLYING QUALITY TOOLS AND TECHNIQUES 173
6 Working with Quality Tools and Methods 175
Identifying a Problem 176
Cause-and-Effect Diagram • Flowchart • Checklist • Run Chart • Histogram
Describing Information 183
Mean • Median • Mode
Variability 185
Range • Standard Deviation • Bell Curve
Making Use of Data 188
Significance

xii Contents
Using Quality Tools and Techniques to Improve Safety 189
Root Cause Analysis • Case Example: Sepsis Mortality • Failure Mode
and Effects Analysis • Case Example: Blood Transfusion
Clinical Pathways or Care Maps 195
Care Map Characteristics • Variance • Improving Efﬁciency • Case Example:
Creating Guidelines
Improving Performance: Plan-Do-Study-Act 201
Plan • Do • Study • Act • Case Example: Workplace Violence
Summary 206
Key Terms 206
Useful Websites 207
7 Working with Quality Data 209
Working with Measurements 210
Compliance • Case Example: Using Data to Change Practice • Performance
Improvement • Case Example: Pressure Injury Performance Improvement Initiative
Understanding Issues in Data Collection 214
Case Example: Standardizing Data • Moving from Manual to Electronic
Records • Extracting Accurate Data from Electronic Health Records
Using Data to Understand Appropriateness of Care 218
Case Example: Analyzing Mortality • Analyzing End-of-Life Care • Case Example:
Understanding Mortality
The Value of Aggregated Data in Performance Improvement 222
Case Example: Improving Transplant Mortality
The Role of Data in Managing Chronic Disease 225
Understanding Readmission • Case Example: Heart Failure Readmissions
Using Data to Monitor Variability 230
Control Chart • Variance Analysis
Publicly Reported Data 234
Hospital Compare
Interpreting and Making Use of Data 237
Administrative Concerns • Data Analytics in the Future
Quality Management in the Future 239

Contents xiii
Summary 240
Key Terms 241
References 241
Useful Websites 242
8 Working with Quality and Safety Measures 245
Commitment to Quality 246
The Future of Quality
Using Measures to Understand Care 247
For the Consumer • For the Administrator • For the Physician
Defining the Measure 250
Define the Numerator and the Denominator • Measuring for Improvement
Process Measures 253
Case Example: Medication Measures • Complying with Process Measures
• Case Example: Mammography Rate • Understanding Variables • Making
Compliance Meaningful • Case Example: Reducing Central Line Infections
Pay for Performance 263
P4P Measures
Patient Satisfaction Measures 264
Interpreting Patient Satisfaction Scores • Understand the Process
• Refine the Process • Define Expectations
Monitoring Measures 268
Dashboards in the Past • Dashboards Today • Performance Details
Safety and Environment of Care Measures 273
Case Example: Monitoring Safety • Linking Environmental and Clinical Variables
Summary 277
Key Terms 277
References 278
Useful Websites 279

xiv Contents
9 Translating Information into Action 281
Maximizing Efﬁciency 282
Throughput • Bottlenecks • Theory of Constraints • Queueing
Theory • Case Example: Managing Throughput
Determining Appropriate Levels of Care 288
End-of-Life Care/Advanced Illness 289
The Reform Mandate
Understanding Mortality 291
Financial Implications • Mortality Data
Improving ICU Care 295
Case Example: Introducing APACHE
Analyzing Readmission 298
Case Example: Readmission
Using Data for Improvements 299
Case Example: Joint Replacement Surgery • Case Example: Bariatric Surgery
Patient-Centered Care 303
SF-36 • Case Example: Quality of Life
Delivering the Message 305
Data and Nursing Staff • Data and Medical Directors
• Multidisciplinary Teams • Working with Measures
Summary 308
Key Terms 308
References 309
Useful Websites 311
10 Preparing for the Future 313
The New Quality Management 314
The New Role of Administrators
The Business of Health Care 315
Improve the Product • Measures of Success • Transparency • Case Example:
Improving a Hospital in Trouble

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Contents xv
Measurements Are the Nuts and Bolts of Quality 319
Know What the Data Mean • Make the Data Useful • Measures Reﬂect Values
Getting Everyone on Board 322
Case Example: Improving Transplant Services • Changing Behavior
• Case Example: Understanding Complex Processes
Challenges for the Future 324
New Strategies • Break Down the Silos
Summary 326
Key Terms 327
Useful Websites 328
Index 329

LIST OF FIGURES AND TABLES
Figures
1.1 Causes of Patient Mortality Pie Chart 6
1.2 Causes of Patient Mortality Histogram 6
1.3 Medication Error Rate Pareto Chart, January 2011–June 2011 12
1.4 Hospital Compare Webpage for Unplanned Readmissions 22
1.5 Hospital Compare for Waiting Times 23
1.6 Quality Indicator 31
2.1 Value-Based Performance at a Community Hospital 46
2.2 Value-Based Performance at a Tertiary Hospital 46
3.1 Screening Tool to Identify Advanced Illness 67
3.2 Dimensions of Care 83
3.3 Lines of Communication 84
3.4 JCPAC Communication 85
4.1 Inpatient Likelihood to Recommend 99
4.2 Quality and Safety Vector of Measures Dashboard 102
4.3 Hospital Comparison Dashboard 103
4.4 Raw Heart Failure Readmission Rate 112
4.5 Tactics and Team Responsibilities 118
4.6 Patient Friendly Care Map for Hip Replacement Surgery 119
4.7 Preoperative Continuum of Care 120
xvii

xviii List of Figures and Tables
4.8 Postoperative Continuum of Care 120
5.1 Falls with Injury 144
5.2 Analytics and Interpretation 145
5.3 Monthly Emergency Department Data 149
5.4 Raw Sepsis and Severe Sepsis/Septic Shock Mortality Rate,
January 2008–September 2014 150
5.5 Discharge Follow-Up Information Heart Failure 152
5.6 Prioritization Matrix 153
5.7 Serum Lactate Order to Result within 90 Minutes for Severe
Sepsis/Septic Shock in the Emergency Department 155
5.8 Integrating Data/Generating Reports 158
5.9 Patient Outcome Monitoring Tool 162
5.10 Communication across the Care Continuum 168
6.1 Falls Cause-and-Effect Diagram 178
6.2 Flowchart 179
6.3 Time-Out Checklist 180
6.4 Newborn Deliveries Run Chart 182
6.5 Waiting Time for Emergency Department Triage 182
6.6 Standard Deviation Formula 186
6.7 Blood Pressure Bell Curve 187
6.8 Comparing RCA and FMEA 193
6.9 Transfusion Flowchart 194
6.10 Hip Replacement Care Map 196
6.11 Variance Analysis: CAP Chart 198
6.12 Variance Analysis: CAP Outcome Bar Chart 198
6.13 Quality Improvement through Care Pathways 200
6.14 Improved Efficiency and Throughput 201
6.15 Clinical Guidelines Creation Methodology 202
6.16 PDSA Cycle 203
7.1 Hospital-Acquired Pressure Injury Index 213
7.2 Mortality Surveillance Tool Summary Report 219
7.3 Kidney Transplant Data Input 223
7.4 Wound Infection Rate 224
7.5 30-Day Observed Readmission Rate for Heart Failure Analysis 227
7.6 Heart Failure Readmissions by Age 227
7.7 Heart Failure Readmission Analysis: HF Discharges by Discharge
Disposition 228
7.8 Know Your Heart Failure Zones 229
7.9 Control Chart of Clostridium difficile 233
7.10 Hospital Compare Benchmark Report: Inpatient Clinical
Measures—Inpatient Surgical Infection Prevention 235
7.11 Timely Heart Attack Care 236
8.1 Hospital Medication Administration Process 254

List of Figures and Tables xix
8.2 Medication Error Measures 255
8.3 Executive Summary Medication Measures 256
8.4 Medication Safety Alert 257
8.5 Mammography Rate 260
8.6 Independent Variables 261
8.7 Non-ICU Central Line–Associated BSI Control Chart 263
8.8 Public Reporting Scores 269
8.9 Executive Summary 270
8.10 Risk-Adjusted Mortality Index 271
8.11 Non-ICU Central Line–Associated BSI Index 272
8.12 Non-ICU Central Line–Associated BSI Index Pivot View 273
8.13 Safety Services Quarterly Report 275
9.1 Throughput 284
9.2 Ambulatory Surgery Log Tracking 288
9.3 Advanced Illness 291
9.4 APACHE Reports 296
9.5 Bariatric Preoperative Checklist 302
9.6 SF-36 Physical and Mental Health Component
Analysis by Time Point 304
10.1 Data Overload 320
Tables
3.1 Inpatient Quality Indicators 87
3.2 Table of Measures for Ambulatory Services 88
7.1 Kidney Transplant Table of Measures 224
9.1 Bariatric Table of Measures 303

PREFACE
When I began to think about revising the outdated Quality Handbook
for Health Care Organizations: A Manager’s Guide to Tools and Programs
(Jossey-Bass, 2004), my goal was to introduce and explore the many changes
that have made an impact on health care in the last decade. I quickly real-
ized that I couldn’t simply revise the book for a second edition; too much had
changed. An entirely new book introducing quality management was needed
if I wanted it to be of value to health care professionals and students. This
Introduction to Health Care Quality: Theory, Methods, and Tools seemed necessary.
Even the change in titles is revealing. Quality is no longer the sole purview
of managers. To the contrary, now everyone—clinicians, administrators, exec-
utives, patients—involved in health care services needs to work within a qual-
ity framework and be familiar with quality management processes. Students
who hope to work in health care, whether in the clinical, administrative, or
policy-making roles, need to know the fundamentals of quality management
to succeed. Physicians, nurses, pharmacists, and public health policy makers all
need to involve themselves in performance improvement activities and under-
stand how to transform data into useful information in order to take action.
Administrators and executives have to meet the goals of specific quality mea-
sures set by government agencies in order to be reimbursed for the delivery of
care and medical services.
My books are designed to be of practical use to students and professionals
and are based on my experience working in the field of quality management
xxi

xxii Preface
for decades and teaching fundamentals of quality all over the world. I have the
good fortune of being part of a vast health care system that encompasses the
entire spectrum of health care services—21 hospitals, the Feinstein Institute
for Medical Research, the Krasnoff Quality Management Institute, the Cen-
ter for Learning and Innovation, rehabilitation and skilled nursing facilities, a
home care network, a hospice network, and progressive care centers—offering
a range of outpatient services; ambulatory facilities; psychiatric care; long-term
nursing care; and children’s organizations. Thus I have direct and immediate
access to the issues that most concern administrators and executives, floor and
unit managers, clinicians, policy makers, IT professionals, and others. Writing
from personal experience gives me the opportunity to share practical issues
of quality in action and relay the direct application of quality management
theory, methods, and tools.
I have always been a champion of quality and I like to think an advocate
for patients’ rights and patient safety. I have worked diligently to ferret out
gaps in care and potential gaps in safety to improve performance, and further
communication and accountability across the hospital and the continuum of
care. I followed this path because I believe in the tenets of quality management;
I believe in the objectivity of data to make a case for good or poor care. I believe
in numbers, in measurements, in tracking improvements and interventions
over time using reliable and valid data.
But it was not until I myself became a patient that my theoretical exper-
tise quickly became of immediate and practical concern. As a patient, I found
myself vulnerable to issues of safety and communication failures that I had writ-
ten about and spoken about but had never directly experienced. Although I
had always understood the importance of patient identification, for example,
until I was receiving chemotherapy and the nurses made absolutely sure that I
was getting the correct dose of the correct medications in the correct manner,
and asked me multiple times to confirm my name, I didn’t realize how reas-
suring it was to know that the procedures developed to ensure proper patient
identification were in place and being followed. When I needed my MRI results
to be transmitted to my oncologist in a timely fashion, I didn’t want any fail-
ures of communication to take place. Ensuring quality care became deeply
personal.
And although I am probably better educated than most about dealing with
health care data, I found that when I was confronted with three very different
plans of care from three very highly regarded physicians, I needed to under-
stand mortality rates and complications from treatment, numbers, variation,
and evidence in a new way. How many patients with my particular very rare
cancer had each doctor treated and with what outcome? I realized how valu-
able my experience as a quality professional was. I knew what questions to
ask. Quality care is, of course, a goal for organizations to strive for, but it is
also for everyone. I realized that everyone—health care professionals, patients,

Preface xxiii
and potential patients—should be quality managers. This book, then, is for
everyone.
New models of health care are so-called patient-centered, making patients
central to the care plan and treatment process. Again, to me, this is no longer
theory. It is in fact critical that patients understand what is happening to them,
why they are having the treatment they are having, what the predicted out-
comes will be, and what complications might occur. All these issues, basic to
quality management, were now basic to me. All patients should indeed be
treated holistically. We are not defined by our disease or our illness; we are
people with psychosocial experiences and needs, some of us more capable
than others or simply luckier than others in being able to take good care of
ourselves.
Everyone should be a quality manager. Everyone will have occasion to
interact with a health care delivery system of one kind or another, either for
themselves or for family and loved ones. Everyone needs to be schooled about
quality, how to assess care, what to look for, what is expected, what should not
be tolerated. Everyone should be an advocate for quality care. I hope this book
will be useful to professionals and nonprofessionals alike.

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epistyliorum. quo
altius
enim scandit oculi species,
non facile | persecat
aeris 25 (20)
crebritatem. dilapsa itaque
altitudinis spatio et
viribus exsucta
incertam modulorum
renuntiat sensibus
quantitatem.

1 capitulorumque HS (·quę
G).
2 reliqua x.
7 latitudine: altitudine x. |
suae (suę S, sue Gc)
partis Hc S(Gc): repartis
HG.
11 deinde columnarum (sic)
x (om. ratione vel pro
ratione). cf. p. 123, 12.
14 respondeat sy(i
G)mmetria aepystiliorum
(epystiliorū G, epistylioꝝ
S). Epystiliorum
(Epistyliorū GS) ratio … x
(cum rubr.).
16 dimidia x.
17 si om. x.
18 demetiatur x.
20 episty(i G)lium (-iū GS) x.
23 si altiores (vel si quae
supra altiores fuerint cf.
p. 74, 22. 79, 21) om. x.
| ratā partē (-tem H) x.
25 candit ante corr H

25 candit ante corr. H.
26 exsucta (ut p. 47, 8 cf.
137, 22. 47, 2):
extructam H, exstructā
S, exstructa G.
Plain text

10
quare semper adiciendum
est rationis
supplementum in
symmetriarum membris, ut
cum fuerint aut
altio|ribus 81
locis opera aut etiam ipsa
colossicotera,
habeant
magnitudinum
rationem. epistylii latitudo
in imo quod supra
capitulum erit quanta
crassitudo summae
columnae sub 5
capitulo erit tanta fiat,
summum quantum
imus scapus.
cy|matium epistylii septima
parte suae
altitudinis est
faciendum, (5)
et in proiectura tantundem.
reliqua pars praeter
cymatium dividenda est in
partes xii et earum
trium ima
fascia est facienda,

11
secunda iiii, summa
v. item zophorus 10
supra epistylium quarta
parte minor quam
epistylium, sin
autem | sigilla designari
oportuerit, quarta
parte altior (10)
quam epistylium, uti
auctoritatem
habeant scalpturae.
cymatium
suae altitudinis partis
septimae, proiectura
cymatii
quantum crassitudo. supra
zophorum denticulus
est faciendus 15
tam altus quam epistylii
media fascia,
proiectura eius
quantum altitudo. |
intersectio, quae
graece μετοπη
dicitur, (15)
sic est dividenda uti
denticulus altitudinis
suae dimidiam
partem habeat in fronte,

12
cavum autem
intersectionis huius
frontis e tribus duas partes,
huius cymatium
altitudinis 20
eius sextam partem.
corona cum suo
cymatio, praeter
simam, quantum media
fascia | epistylii,
proiectura coronae
(20)
cum denticulo facienda est
quantum erit
altitudo a zophoro
ad summum coronae
cymatium, et
omnino omnes
ecphorae
venustiorem habent
speciem quae
quantum altitudinis
tantundem 25
habeant proiecturae.
tympani autem quod
est in
fastigio altitudo sic est
facienda | uti frons
coronae ab 82

coronae ab 82
extremis cymatiis tota
dimetiatur in partes
novem et ex

1 rationis G: rationi HS. |
sublementū G.
2 ut cum fuerint aut: cum
fuerint ut aut x.
3 colossi(| H)cae(ę S)tera
HS, colosi. ce(ę Gc)tera
G.
7 cymatiū epistilii Sc: cimatiū
epistiliū G, cymatii epy(i
S)stilii HS.
9 ima: iam x.
11 minus x.
12 altiorem (-ē GS) x.
14 proiecturae cymatium H,
proiecturę cy(i G)matiū
GS.
15 quantum: quam (quā GS)
x.
16 fascia: fastigia x.
17 metoce HS, meta(o
Gc)che G.
19 cavus x. | intersectionis
G: -nes HS.
20 &tribus S, et tribus G

,
(ettribus Gc).
22 fasci≣a H.
25 habeant x. | altitudinis
GSc: -nes HS.
27 uti HG: ut S.
Plain text

13
eis una pars in medio
cacumine tympani
constituatur,
dum contra epistylia
columnarumque
hypotrachelia ad
perpendiculum
respondeat. coronaeque
supra | aequaliter
imis (5)
praeter simas sunt
conlocandae.
insuper coronas
simae,
quas Graeci επαιετὶδαϲ
dicunt, faciendae
sunt altiores 5
octava parte coronarum
altitudinis. acroteria
angularia
tam alta quantum est
tympanum medium,
mediana altiora
octava parte quam
angularia.
| Membra omnia quae
supra capitula
columnarum sunt

columnarum sunt
(10)
futura id est epistylia
zophoroe coronae
tympana fastigia 10
acroteria inclinanda sunt in
fronte suae cuiusque
altitudinis
parte xii, ideo quod cum
steterimus contra
frontes, ab
oculo lineae duae si
extensae fuerint et
una tetigerit
imam | operis partem,
altera summam,
quae summam
tetigerit (15)
longior fiet. ita quo longior
visus linea in
superiorem 15
partem procedit,
resupinatam facit
eius speciem. cum
autem, uti supra scriptum
est, in fronte
inclinata fuerint,
tunc in aspectu videbuntur
esse ad
d l

14
15
perpendiculum et
normam.
columnarum | striae
faciendae sunt xxiiii
ita excavatae (20)
uti norma in cavo striae
cum fuerit coniecta,
20
circumacta anconibus
striarum dextra ac
sinistra ＜angulos＞
tangat cacumenque
normae circum
rotundationem
tangendo
pervagari possit.
crassitudines
striarum faciendae
sunt
quantum adiectio in media
columna ex |
descriptione
invenietur. (25)
in simis quae supra
coronam in lateribus
sunt 25
aedium, capita leonina sunt
scalpenda, disposita
| ita uti 83

contra columnas singulas
primum sint
designata, cetera
aequali modo disposita uti
singula singulis
mediis tegulis
respondeant. haec autem
quae erunt contra
columnas

2 epi(y H)sty(i G)lii x.
3 respondeant x. |
coronae(ę) quae (quę G,
q̄ S) x.
6 epi(y S)tidas x.
10 zophora x. | corona & ty(i
G)mpana x.
11 fronte S(G?): frontis HGc
(fronte＜s＞ ante ips.
corr. G).
12 c
v
om H.
14 alterā S et ante ras. H.
15 lineae (-eę) x.
16 procedit HSGc: -det G. |
resopinatam S et ante
corr. H.
17 fuerit x.
21 angulos om. x.
22 acumen quae (quę G, q̄
S) x (cac. Ussing ex p.
92, 10). | ro(u ante corr.
H)tundatione x.
23 crassitudinis H (-nes GS).

26 ita om. x.
29 autem om. S.
Plain text

perterebrata sint ad
canalem qui excipit
e tegulis aquam
| caelestem, mediana
autem sint solida,
uti quae cadit vis (5)
aquae per tegulas in
canalem ne deiciatur
per intercolumnia
neque transeuntes
perfundat, sed quae
sunt contra
columnas
videantur emittere
vomentia ructus
aquaram ex ore. 5
Aedium ionicarum quam
apertissime potui
dispositiones
| hoc volumine scripsi,
doricarum autem et
corinthiarum (10)
quae sint proportiones
insequenti libro
explicabo.
LIBER

1
LIBER
QUARTUS.
Cum animadvertissem,
imperator, plures de
architectura 10
praecepta voluminaque
commentariorum
non ordinata sed
| incepta uti particulas
errabundas
reliquisse, dignam et
(15)
utilissimam rem putavi
tantae disciplinae
corpus ad perfectam
ordinationem perducere et
praescriptas in
singulis
voluminibus singulorum
generum qualitates
explicare. itaque, 15
Caesar, primo volumine tibi
de officio eius et
quibus
eruditum | esse rebus
architectum
oporteat exposui.
secundo (20)

2
secundo (20)
de copiis materiae, e
quibus aedificia
constituuntur,
disputavi.
tertio autem de aedium
sacrarum
dispositionibus et
de earum generum
varietate quasque et
quot habeant 20
species earumque quae
sint in singulis
generibus
distributiones,
ex tribus ge|neribus, quae
subtilissimas
haberent (25)
proportionibus modulorum
quantitates, ionici
generis moribus
docui. nunc hoc volumine
de dorici
corinthiique
constitutis
rationibus dicam eorumque
discrimina et
proprietates 25
explicabo.

1 perterebrata HS: ꝑteri
brate G (-tæ Sc, sed -t
a
ẹ
Gc).
4 perfundant x.
12 errabundos x.
13 tantae: antea x.
19 disputationibus S.
20 quot GS: quod H (qui sic
semper).
21 sunt (ſ̄ S) x.
24 doricis corinthiisque
constitutis & omnibus x.
25 proprietatis ante corr. H.
Plain text

I
2
| Columnae corinthiae
praeter capitula
omnes symmetrias
84
habent uti ionicae, sed
capitulorum
altitudines efficiunt
eas pro rata excelsiores et
graciliores, quod
ionici capituli
altitudo tertia pars est
crassitudinis
columnae, corinthii
tota | crassitudo scapi.
igitur quod duae
partes e crassitudine
5
＜in altitudine＞
corinthiorum
adiciuntur, efficiunt
excelsitate speciem earum
graciliorem. cetera
membra
quae supra columnas
inponuntur aut e
doricis symmetriis
aut ionicis moribus in
corinthiis columnis

3
conlocantur,
quod ipsum co|rinthium
genus propriam
coronarum
reliquorumque 10
ornamentorum non
habuerat
institutionem, sed
aut e triglyphorum
rationibus mutuli in
coronis et in
epistyliis guttae dorico
more disponuntur,
aut ex ionicis
institutis zophoroe
scalpturis ornati cum
denticulis et coronis
distribuuntur. ita e
ge|neribus duobus
capitulo interposito
15
tertium genus in operibus
est procreatum. e
columnarum
enim formationibus trium
generum factae sunt
nominationes, dorica,
ionica, corinthia, e
quibus prima et

4
antiquitus dorica est nata.
Namque Achaia
Peloponnesoque
tota Dorus Hellenos
20
et | Pthias nymphae filius
regnavit, isque Argis
vetusta (20)
civitate Iunonis templo
aedificavit eius
generis fortuito
formae fanum, deinde
isdem generibus in
ceteris Achaiae
civitatibus, cum etiamnum
non esset
symmetriarum ratio
nata. postea autem quam
Athenienses ex
responsis Apollinis
25
Del|phici, communi consilio
totius Hellados, xiii
colonias (25)
uno tempore in Asiam
deduxerunt
ducesque in
singulis coloniis |

constituerunt et
summam imperii
potestatem 85

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