Friday, December 29, 2006

Managing for Quality

Health care organizations can adapt and use the materials and tools in Managing for Quality to improve quality at many different organizational levels. The following topics are addressed:

  • Problem Solving
  • Focus on the User
  • Build Teams
  • Manage the Process
  • Case Study

Thursday, December 28, 2006

Hospital volume and mortality for mechanical ventilation of medical and surgical patients: A population-based analysis using administrative data

Dale M. Needham, Susan E. Bronskill, Deanna M. Rothwell, William J. Sibbald, Peter J. Pronovost, Andreas Laupacis, Thérèse A. Stukel
Critical Care Medicine. 34(9):2349-2354.

Abstract HTML PDF (235 K)


Volume-outcome relationships: Is it the individual or the team?
Stockwell, D.C., and Slonim, A.D.
Critical Care Medicine 34(9), pp. 2495-2497.

HTML PDF (890 K)

Wednesday, December 27, 2006

Safety by design - Special Issue

Qual Saf Health Care. December 2006;15(suppl 1):i1-i90.

Quality and safety by design
J B Battles
Qual Saf Health Care 2006; 15 (Suppl 1): i1-i3.
[Abstract] [Full text] [PDF]

Design of high reliability organizations in health care
J S Carroll and J W Rudolph
Qual Saf Health Care 2006; 15 (Suppl 1): i4-i9.
[Abstract] [Full text] [PDF]

Understanding the complexity of redesigning care around the clinical microsystem
P Barach and J K Johnson
Qual Saf Health Care 2006; 15 (Suppl 1): i10-i16.
[Abstract] [Full text] [PDF]

Issues in the design of training for quality and safety
K Henriksen and E Dayton
Qual Saf Health Care 2006; 15 (Suppl 1): i17-i24.
[Abstract] [Full text] [PDF]

Improving patient safety by instructional systems design
J B Battles
Qual Saf Health Care 2006; 15 (Suppl 1): i25-i29.
[Abstract] [Full text] [PDF]

Use of assessment to reinforce patient safety as a habit
R M Galbraith, M C Holtman, and S G Clyman
Qual Saf Health Care 2006; 15 (Suppl 1): i30-i33.
[Abstract] [Full text] [PDF]

Safe design of healthcare facilities
J Reiling
Qual Saf Health Care 2006; 15 (Suppl 1): i34-i40.
[Abstract] [Full text] [PDF]

On the complexity of medical devices and systems
J W Senders
Qual Saf Health Care 2006; 15 (Suppl 1): i41-i43.
[Abstract] [Full text] [PDF]

Mistake proofing: changing designs to reduce error
J R Grout
Qual Saf Health Care 2006; 15 (Suppl 1): i44-i49.
[Abstract] [Full text] [PDF]

Work system design for patient safety: the SEIPS model
P Carayon, A Schoofs Hundt, B-T Karsh, A P Gurses, C J Alvarado, M Smith, and P Flatley Brennan
Qual Saf Health Care 2006; 15 (Suppl 1): i50-i58.
[Abstract] [Full text] [PDF]

A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional
B-T Karsh, R J Holden, S J Alper, and C K L Or
Qual Saf Health Care 2006; 15 (Suppl 1): i59-i65.
[Abstract] [Full text] [PDF]

Violations and migrations in health care: a framework for understanding and management
R Amalberti, C Vincent, Y Auroy, and G de Saint Maurice
Qual Saf Health Care 2006; 15 (Suppl 1): i66-i71.
[Abstract] [Full text] [PDF]

Accidents waiting to happen: the contribution of latent conditions to patient safety
C M Lowe
Qual Saf Health Care 2006; 15 (Suppl 1): i72-i75.
[Abstract] [Full text] [PDF]

Why did that happen? Exploring the proliferation of barely usable software in healthcare systems
C W Johnson
Qual Saf Health Care 2006; 15 (Suppl 1): i76-i81.
[Abstract] [Full text] [PDF]

An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification
W B Runciman, J A H Williamson, A Deakin, K A Benveniste, K Bannon, and P D Hibbert
Qual Saf Health Care 2006; 15 (Suppl 1): i82-i90.
[Abstract] [Full text] [PDF]

Tuesday, December 26, 2006

A Systems Approach to Patient-Centered Care

Steven C. Bergeson; John D. Dean
JAMA. 2006;296:2848-2851.


Friday, December 22, 2006

Healthcare Quarterly - Vol. 9 Special Issue

Editorial: Creating Safer Care
G. Ross Baker

Identifying and Reducing Risks

Five Years of Learning from Analysis of Clinical Occurrences in Pediatric Care Using the London Protocol
Catherine M.G. Cronin

Implementing a Good Catch Program in an Integrated Health System
Debbie Barnard, Marilyn Dumkee, Balvir Bains and Brenda Gallivan

The McGill University Health Centre Policy on Sentinel Events: Using a Standardized Framework to Manage Sentinel Events, Facilitate Learning and Improve Patient Safety
Mark Daly

Implementing System Safeguards to Prevent Error-Induced Injury with Opioids (Narcotics)
Margaret Colquhoun, Christine Koczmara and Julie Greenall

Taking Aim at Fall Injury Adverse Events: Best Practices and Organizational Change
Patricia O'Connor, Joann Creager, Sharon Mooney, Andrea Maria Laizner and Judith A. Ritchie

Enhancing Patient Safety through the Management of Clostridium difficile at Toronto East General Hospital
Arladeen Tomiczek, C. Stumpo and James F. Downey

A Multidisciplinary Approach to Reducing Outbreaks and Nosocomial MRSA in a University-Affiliated Hospital
Maryam Salaripour, Pat McKernan, Roslyn Devlin and the Infection Prevention and Control Team

Reporting for Learning and Improvement: The Manitoba and Saskatchewan Experience
Paula Beard and Linda Smyrski

A Framework for Local Accountability for Patient Safety
Rosanne Zimmerman, Emily Christoffersen, Jill Shaver and Teresa Smith

Human Factors and Work Redesign

Transfer of Accountability: Transforming Shift Handover to Enhance Patient Safety
Kim Alvarado, Ruth Lee, Emily Christoffersen, Nancy Fram, Sheryl Boblin, Nancy Poole, Janie Lucas and Shirley Forsyth

Is Your Patient Ready for Transport? Developing an ICU Patient Transport Decision Scorecard
Rosmin Esmail, Deborah Banack, Cheryl Cummings, Judy Duffett-Martin, Jonas Shultz, Teresa Thurber, Karen Rimmer and Terrance Hulme

The Role of Typography in Differentiating Look-Alike/Sound-Alike Drug Names
Sandra Gabriele

Involving Patients and Families

Patient Safety in a Pediatric Centre: Partnering with Families
Bonnie Fleming-Carroll, Anne Matlow, Siobhan Dooley, Valerie McDonald, Kimberley Meighan and Kim Streitenberger

"Your Health Care - Be Involved": The Evaluation of a Provincial Patient Safety Tips Initiative
Sudha Kutty and Sarena Weil

Using Information to Improve Safety

Cancer Care Ontario's Computerized Physician Order Entry System: A Province-wide Patient Safety Innovation
Anna Greenberg, Sarah Kramer, Vickie Welch, Emily O'Sullivan and Stephen Hall

Predicting Changes in Workflow Resulting from Healthcare Information Systems: Ensuring the Safety of Healthcare
Andre Kushniruk, Elizabeth Borycki, Shige Kuwata and Joseph Kannry

Frequency and Type of Medication Discrepancies in One Tertiary Care Hospital
Jennifer Turple, Neil J. MacKinnon and Bryan Davis

Identifying Patient Safety Risks in Non-Acute Care Settings

Broadening the Patient Safety Agenda to Include Home Care Services
Ariella Lang, Nancy Edwards, Carolyn Hoffman, Judith Shamian, Kathleen Benjamin and Marguerite Rowe

Adverse Events among Winnipeg Home Care Clients
Keir G. Johnson

Exploration of Patient Safety Phenomena in Rehabilitation and Complex Continuing Care
Carol Fancott, Karima Velji, Elaine Aimone and Lynne Sinclair

Thursday, December 21, 2006

Identification of surgical complications and deaths

an assessment of the traditional surgical morbidity and mortality conference compared with the American College of Surgeons-National Surgical Quality Improvement Program
Hutter MM, Rowell KS, Devaney LA, Sokal SM, Warshaw AL, Abbott WM, Hodin RA.

J Am Coll Surg. 2006 Nov;203(5):618-24.

Wednesday, December 20, 2006

Adverse Events Detected by Clinical Surveillance on an Obstetric Service

Alan J. Forster, Irene Fung, Sharon Caughey, Lawrence Oppenheimer, Cathy Beach, Kaveh G. Shojania, Carl van Walraven Obstet Gynecol 2006 108: 1073-1083.
[Abstract] [Full Text] [PDF]


Patient Safety in Obstetrics and Gynecology: An Agenda for the Future
Mark D. Pearlman
Obstet Gynecol 2006 108: 1266-1271.
[Abstract] [Full Text] [PDF]


Patient Safety in Obstetrics and Gynecology: The Call to Arms
William A. Grobman
Obstet Gynecol 2006 108: 1058-1059.

[Full Text] [PDF]

Tuesday, December 19, 2006

The American Surgeon - Vol. 72, No. 11. (November 2006)

A Three-Decade Perspective on Anesthesia Safety pp. 985-989 Lanier, William L.

Early Efforts with Quality at Centers for Medicare & Medicaid Services and Judicious Use of Its Powers as a Payor pp. 990-993 Grissom, Thomas L.

Safety, Quality, and the National Surgical Quality Improvement Program pp. 994-998 Khuri, Shukri F.

Surgical Quality Programs in the Veterans Health Administration pp. 999-1004(6) Author: Depalma, Ralph G

American College of Surgeons Remains Committed to Patient Safety pp. 1005-1009(5) Authors: Russell, Thomas R.; Jones, R. Scott

The Surgical Infection Prevention and Surgical Care Improvement Projects: Promises and Pitfalls pp. 1010-1016(7) Author: Bratzler, Dale w.

The Evolution of Guidelines Toward Standards of Practice pp. 1017-1020(4) Author: Polk, Hiram C

PANEL 1 pp. 1021-1030(10) Authors: Polk, Hiram C.; Bratzler, Dale; Depalma, Ralph G; Flum, David R; Grissom, Thomas L; Jones, R. Scott; Khuri, Shukri F; Lanier, William L; Loeb, Thomas M; Pugliese, Gina; Scutchfield, F. Douglas

The Hazards of Using Administrative Data to Measure Surgical Quality pp. 1031-1037(7) Authors: Fry, Donald E; Pine, Michael B; Jordan, Harmon S; Hoaglin, David C; Jones, Barbara; Meimban, Roger

The Volume-Outcome Debate Revisited pp. 1038-1042(5) Author: Finlayson, Samuel R.G

The Challenge of Small Numbers to the Contemporary Excellence of Elective Specialty Surgery pp. 1043-1045(3) Author: Polk, Hiram C

The Holy Grail of Surgical Quality Improvement: Process Measures or Risk-Adjusted Outcomes? pp. 1046-1050(5) Author: Rogers, Selwyn O

Quality and Safety Performance in Teaching Hospitals pp. 1051-1054(4) Author: Knapp, Richard M

Does Outcomes Research Impact Quality? Examples from Bariatric Surgery pp. 1055-1060(6) Author: Hutter, Matthew M.

PANEL 2 pp. 1061-1069(9) Authors: Flum, David R.; Bratzler, Dale; Finlayson, Samuel R.G.; Fry, Donald E; Hutter, Matthew M; Khuri, Shukri F; Knapp, Richard M; Rogers, Selwyn O; Russell, Thomas R; Seidenfeld, John J

An Eight-Year Analysis of Surgical Morbidity and Mortality: Data and Solutions pp. 1070-1081(12) Authors: Goldfarb, Michael A; Baker, Thomas

The Challenge of Changing Roles and Improving Surgical Care Now: Crew Resource Management Approach pp. 1082-1087(6) Authors: James, Mcgreevy; Otten, Tyler; Poggi, Michael; Robinson, Christopher; Castaneda, David; Wade, Patrick

How a System for Reporting Medical Errors Can and Cannot Improve Patient Safety pp. 1088-1091(4) Author: Clarke, John R

Maintenance of Certification: American Board of Surgery Goals pp. 1092-1096(5) Author: Lewis, Frank R

Simulation: A Strategy for Success in Quality and Safety in Pay-for-Performance Environments pp. 1097-1101(5) Author: LOYD., GARYE

Making the Operating Room of the Future Safer pp. 1102-1108(7) Authors: Greenberg, Caprice C; Roth, Emilie M; Sheridan, Thomas B; Gandhi, Tejal K; Gustafson, Michael L; Zinner, Michael J; Dierks, Meghan M

Morbidity and Mortality in Vascular Surgery: The Kentucky Experience with a Statewide Database pp. 1109-1111(3) Author: Richardson, J David

The Practicing Surgeon as a Member of the Quality-Safety Team pp. 1112-1114(3) Authors: Vallance, Steven R.; Schell, Robert H.; Robbins, Robert E.

Linking Processes and Outcomes to Improve Surgical Performance: A New Approach to Morbidity and Mortality Peer Review pp. 1115-1119(5) Authors: Pine, Michael; Fry, Donald e.

LUNCHEON DEBATE: Where Is the Captain of the Ship When You Need Her? - System Corrections Are the Right Way to Go pp. 1120-1125(6) Authors: Goldfarb, Michael A.; Flum, David R.

PANEL 3: The Unintended Consequences of Transparency pp. 1126-1132(7) Authors: Willihnganz, Shirley C.; Flum, David R.; Clarke, John R.; Galandiuk, Susan; Knapp, Richard M.; Lewis, John N.; Manassah, Edward E.; Russell, Thomas R.; Taylor, James; Ungar, Laura

PANEL 4—Closing Panel: The Future of Surgical Quality— from Micro to Macro - Would You Rather be Maitre'd (and Set the Table) or be King for a Day? pp. 1133-1148(16) Authors: Flum, David; Bratzler, Dale; Finlayson, Samuel R.G.; Fry, Donald E.; Jones, R. Scott; Lewis, Frank R.; Pine, Michael; Russell, Thomas R.; Seidenfeld, John J.; Vallance, Steven R.

An Invitational Conference on Contemporary Surgical Quality, Safety and Transparency June 5 & 6, 2006 Closing Session—Focal Points pp. 1149-1149(1) Authors: Flum, David R.; Goldfarb, Michael A.; Polk, Hiram C.

Monday, December 18, 2006

Data mining and clinical data repositories: Insights from a 667,000 patient data set

Irene M. Mullins, Mir S. Siadaty, Jason Lyman, Ken Scully, Carleton T. Garrett, W. Greg Miller, Rudy Muller, Barry Robson, Chid Apte, Sholom Weiss et al.
Comput Biol Med. 2006 Dec;36(12):1351-77.

Abstract Full Text + Links PDF (272 K) free PDF

Friday, December 15, 2006

AHRQ - Summary Statement on Comparative Hospital Public Reporting

"The Agency for Healthcare Research and Quality (AHRQ) applauds public reporting of hospital quality performance data and views public reporting as one important strategy to advance the quality improvement agenda in health care. Evidence shows that publicly reporting performance by specific hospitals is a key element that promotes enhanced patient care. AHRQ continues to be an active participant in such public reporting efforts as the Hospital Quality Alliance, the Ambulatory Care Quality Alliance and the National Quality Forum (NQF). In fact, AHRQ is submitting the Quality Indicators (QIs) to NQF to undergo the formal consensus process for endorsement for public reporting in the spring of 2006 ..."

read the full statement (pdf)

Thursday, December 14, 2006

IHI - 5 Million Lives Campaign

The 5 Million Lives Campaign is a new initiative from the Institute for Healthcare Improvement (IHI) to protect patients from five million incidents of medical harm over the next two years (December 2006 – December 2008).

Web site

Press release

Wednesday, December 13, 2006

Relationship Between Medicare’s Hospital Compare Performance Measures and Mortality Rates

Rachel M. Werner; Eric T. Bradlow
JAMA. 2006;296:2694-2702.



Performance Measures and Clinical Outcomes
Susan D. Horn
JAMA. 2006;296:2731-2732.


Tuesday, December 12, 2006

SEER-Medicare: Calculation of Comorbidity Weights

To assist investigators with the calculation of comorbidity weights, the National Cancer Institute (NCI) provids two SAS macros.

These macros will produce comorbidity weights as developed by Charlson et al (PDF) (J Clin Epidemiol 1993;46:1075-9).

SAS macros

Monday, December 11, 2006

Evaluation of a regional disease management programme for patients with asthma or chronic obstructive pulmonary disease

Lotte Steuten, Bert Vrijhoef, Frits Van Merode, Geert-Jan Wesseling, and Cor Spreeuwenberg
Int J Qual Health Care 2006 18: 429-436;

[Abstract] [Full Text] [PDF]

Friday, December 08, 2006

OECD - Health care: Towards quality performance

The OECD Observer magazine November issue presents an article on Health care systems quality performance: "The performance of health care systems is under scrutiny. The Health Care Quality Indicator Project can help identify what works and what does not. And that will help policy decisions too."

Information on the OECD Health Care Quality Indicators project

Thursday, December 07, 2006

OECD - Health Data 2006 Database


The online version of the fourteenth edition of the OECD Secretariat's electronic data base on health systems has been updated.

The 2006 edition includes new data together with an enhanced software. The standard definitions of variables and the corresponding documentation of country-specific sources and methods have been revised and expanded.

Wednesday, December 06, 2006

Do Integrated Medical Groups Provide Higher-Quality Medical Care than Individual Practice Associations?

A. Mehrotra, A. M. Epstein and M. B. Rosenthal
Ann Intern Med 2006; 826-833.

Abstract Full Text PDF


Which Type of Medical Group Provides Higher-Quality Care?
L. P. Casalino
Ann Intern Med 2006; 860-861.

Full Text PDF

Tuesday, December 05, 2006

Monday, December 04, 2006

AHRQ - 10 Patient Safety Tips for Hospitals

AHRQ Publication No. 06-P020, May 2006. Rockville, MD,

10 tips for hospitals resulted from findings resulting from studies by the Agency for Healthcare Research and Quality (AHRQ), which has funded more than 100 patient safety projects since 2001.

Press Release

Friday, December 01, 2006

Thursday, November 30, 2006

Redirecting Patients to Improve Stroke Outcomes

Implications of a Volume-Based Approach in One Urban Market.
Votruba, Mark E. ; Cebul, Randall D.
Medical Care. 44(12):1129-1136, December 2006.

Abstract HTML PDF (324 K)

Wednesday, November 29, 2006

The Effects of Patient Volume on the Quality of Diabetic Care for Medicare Beneficiaries.

Holmboe, Eric S. , Wang, Yun , Tate, Janet P. , Meehan, Thomas P.
Medical Care. 44(12):1073-1077, December 2006.

Abstract HTML PDF (195 K)

Effect of Quality Improvement Organization Activities on Outpatient Diabetes Care in Eastern New York State.

Wu, Winfred Y. , Chen, John J. , Shih, Anthony
Medical Care. 44(12):1142-1147, December 2006.

Abstract HTML PDF (434 K)

Tuesday, November 28, 2006

Can the Quality of Care in Family Practice Be Measured Using Administrative Data?

Alan Katz, Ruth-Ann Soodeen, Bogdan Bogdanovic, Carolyn De Coster, Dan Chateau
Health Services Research 2006 41:6 2238

abstract full text pdf

Monday, November 27, 2006

The 100,000 Lives Campaign: A Scientific and Policy Review

Wachter, Robert M.; Pronovost, Peter J.
Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 11, November 2006, pp. 621-627

IHI Replies to "The 100,000 Lives Campaign: A Scientific and Policy Review"
Berwick, Donald M.; Hackbarth, Andrew D.; McCannon, C. Joseph
Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 11, November 2006, pp. 628-633

Friday, November 24, 2006

CHSFR - Evaluation of Patient Safety and Nurse Staffing

This study from the Canadian Health Services Research Foundation (CHSRF) was a synthesis of the best available evidence and provision of policy recommendations in the area of nurse staffing and patient safety.

The results of the synthesis indicate a significant relationship between nurse staffing and patient safety.

Evidence also shows there are moderating factors, such as nurse characteristics and organizational factors, which influence the relationship between nurse staffing and patient safety.

The findings also demonstrate the importance of linking the implementation of good nurse staffing initiatives with effective leadership and management concepts.


see also

Thursday, November 23, 2006

Tuesday, November 21, 2006

Quality of care for hypertension in the United States

Asch SM, McGlynn EA, Hiatt L, Adams J, Hicks J, DeCristofaro A, Chen R, LaPuerta P, Kerr EA.
BMC Cardiovasc Disord. 2005 Jan 7;5(1):1.

Abstract Full text PDF

Monday, November 20, 2006

Funnel plots, performance variation and the Myocardial Infarction National Audit Project 2003-2004.

Christopher P Gale , Anthony P Roberts , Phil D Batin and Alistair S Hall
BMC Cardiovascular Disorders 2006, 6:34

Abstract Full text PDF

Friday, November 17, 2006

Potentially Inappropriate Medication Prescribing for Elderly Outpatients in Emilia Romagna, Italy

A Population-Based Cohort Study
Maio V, Yuen EJ, Novielli K, Smith KD, Louis DZ.
Drugs Aging. 2006;23(11):915-924.


Potentially inappropriate medication use in elderly patients receiving home health care

a retrospective data analysis.
Cannon KT, Choi MM, Zuniga MA.
Am J Geriatr Pharmacother. 2006 Jun;4(2):134-43.

Abstract PDF (788 K)

Thursday, November 16, 2006

World Alliance for Patient Safety: Forward Programme 2006-2007

World Health Organization 2006

table of contents

1 Global Patient Safety Challenge
2 The wisdom of patients - Patients for Patient Safety
3 Information for action - Reporting and Learning
4 More than words - Classification
5 Knowledge is the enemy of unsafe care - Research
6 Safety solutions
7 Safety in action
8 Technology for patient safety
9 International partnership for care of acutely ill patients
10 Patient Safety knowledge at your fingertips
11 Governance and programme support

full text pdf

Wednesday, November 15, 2006

Adverse outcomes in surgical patients: implementation of a nationwide reporting system

Marang-van de Mheen, PJ; Stadlander, MC; Kievit, J
Quality & Safety In Health Care, 15 (5): 320-324;

[Abstract] [Full text] [PDF]

Tuesday, November 14, 2006

Measurement in a Multi-Ethnic Society.

A special issue of Medical Care focus on measurement in a multi-ethnic society.

Medical Care November 2006, Volume 44, Issue 11 Suppl 3

issue contents

Monday, November 13, 2006

NHS - performance ratings 2005/2006

The Healthcare Commission annual health check includes an assessment of NHS trusts against 24 core standards covering areas such as safety, waiting times, cleanliness and patient focus.

Forty nine percent were assessed as having ‘fully met’ the standards. Overall, 81% of trusts met at least 90% of the standards.

Annual health check

press conference

Friday, November 10, 2006

Quality of Diagnosis and Procedure Coding in ICD-10 Administrative Data.

Henderson, Toni; Shepheard, Jennie; Sundararajan, Vijaya
Medical Care. 44(11):1011-1019, November 2006.

Abstract HTML PDF (312 K)

Thursday, November 09, 2006

NHS - State of healthcare 2006

The Healthcare Commission report independently on the state of healthcare services in England and Wales.

The report shows that patients are seeing real improvements but highlights four areas where further action is needed:

- the delivery of healthcare services that are even more focused on the needs of patients
- care for people who are least able to look after themselves
- the prevention of illness, and the reduction of
inequalities in health

- safety

full text report (pdf)

Wednesday, November 08, 2006

Experience of wrong site surgery and surgical marking practices among clinicians in the UK

Sally J Giles, Penny Rhodes, Gill Clements, Gary A Cook, Ruth Hayton, Melanie J Maxwell, Trevor A Sheldon, and John Wright
Qual Saf Health Care 2006; 15: 363-368.

[Abstract] [Full text] [PDF]

Tuesday, November 07, 2006

Validation of the Potentially Avoidable Hospital Readmission Rate as a Routine Indicator of the Quality of Hospital Care.

Patricia Halfon; Yves Eggli; Isaline Prêtre-Rohrbach; Danielle Meylan; Alfio Marazzi; Bernard Burnand
Medical Care. 44(11):972-981, November 2006.

Abstract HTML PDF (385 K)

Monday, November 06, 2006


The Department of Defense (DoD) Patient Safety Program, in collaboration with the Agency for Healthcare Research and Quality (AHRQ) developed TeamSTEPPS a Team Strategies and Tools to Enhance Performance and Patient Safety.

TeamSTEPPS is an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and other teamwork skills among healthcare professionals.

TeamSTEPPS includes a comprehensive suite of ready-to-use materials and training curricula necessary to successfully integrate teamwork principles into all areas of healthcare system.

Press Release

Friday, November 03, 2006

Internet-Based Chronic Disease Self-Management: A Randomized Trial.

Kate R. Lorig; Philip L. Ritter; Diana D. Laurent; Kathryn Plant
Medical Care. 44(11):964-971, November 2006

Abstract HTML PDF (305 K)


The Chronic Disease Self-Management Program: Extending Reach through the Internet.
Ben S. Gerber
Medical Care. 44(11):961, November 2006.

HTML PDF (121 K)

Thursday, November 02, 2006

Wednesday, November 01, 2006

Paying for Performance — Risks and Recommendations

Fisher, Elliott S.
N Engl J Med 2006 355: 1845-1847

Extract FREE Full Text PDF


Pay for Performance in Commercial HMOs

Rosenthal, Meredith B., Landon, Bruce E., Normand, Sharon-Lise T., Frank, Richard G., Epstein, Arnold M.
N Engl J Med 2006 355: 1895-1902

Abstract Full Text PDF

Press Release

Tuesday, October 31, 2006

Healthcare: The Problems Are Organizational Not Clinical.

Journal of Organizational Behavior
Volume 27, Issue 7 (November 2006)

Issue Edited by Ranga Ramanujam, Denise M. Rousseau.

This special issue looks at the organizational challenges to high quality and safe health care.

Table of contents

Organizational behavior in healthcare - the challenges are organizational, not just clinical (p 809)
Ranga Ramanujam, Denise M. Rousseau

The challenges are organizational not just clinical (p 811-827)
Ranga Ramanujam, Denise M. Rousseau

Worldviews in collision: conflict and collaboration across professional lines (p 829-849)
Andrew N. Garman, David C. Leach, Nancy Spector

Notes from a small Island: researching organisational behaviour in healthcare from a UK perspective (p 851-867)
Annabelle L. Mark

Teaching but not learning: how medical residency programs handle errors (p 869-896)
Timothy J. Hoff, Henry Pohl, Joel Bartfield

A sensemaking lens on reliability (p 897-917)
Ruth Blatt, Marlys K. Christianson, Kathleen M. Sutcliffe, Marilynn M. Rosenthal

Classifying and interpreting threats to patient safety in hospitals: insights from aviation (p 919-940)
Michal Tamuz, Eric J. Thomas

Making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams (p 941-966)
Ingrid M. Nembhard, Amy C. Edmondson

Leadership development in healthcare: a qualitative study (p 967-982)
Ann Scheck McAlearney

Reducing patient mortality in hospitals: the role of human resource management (p 983-1002)
Michael A. West, James P. Guthrie, Jeremy F. Dawson, Carol S. Borrill, Matthew Carter

Quality improvement and hospital financial performance (p 1003-1029)
Jeffrey A. Alexander, Bryan J. Weiner, John Griffith

Monday, October 30, 2006

Health Information Technology in the United States: The Information Base for Progress.

Blumenthal D, DesRoches C, Donelan K, et al.
Washington, DC: Robert Wood Johnson Foundation; 2006.

This report evaluates current information on the state of EHR adoption in the U.S. health care system.

The report reviews 36 existing data sources, including ongoing national surveys and one-time or regional studies, and recommends a coordinated, systematic national approach to measuring EHR diffusion and implementation.

Free full text (PDF)
Executive summary (PDF)

Friday, October 27, 2006

Adverse Events in the Neonatal Intensive Care Unit

Development, Testing, and Findings of an NICU-Focused Trigger Tool to Identify Harm in North American NICUs
Paul J. Sharek, Jeffrey D. Horbar, Wilbert Mason, Hema Bisarya, Cary W. Thurm, Gautham Suresh, James E. Gray, William H. Edwards, Donald Goldmann, and David Classen
Pediatrics 2006; 118: 1332-1340.

[Abstract] [Full text] [PDF]

Systematic Review of Medication Errors in Pediatric Patients

Maisoon Abdullah Ghaleb, Nick Barber, Bryony D Franklin, Vincent WS Yeung, Zahra F Khaki, and Ian CK Wong
Ann Pharmacother ; 2006 Oct;40(10):1766-76.

Abstract Full Text PDF

Thursday, October 26, 2006

Protecting the Health of the Public — Institute of Medicine Recommendations on Drug Safety

B. M. Psaty and S. P. Burke
N Engl J Med 2006 355: 1753-1755

FREE Full Text PDF


Blueprint for a Stronger Food and Drug Administration
G. D. Curfman, S. Morrissey, and J. M. Drazen
N Engl J Med 2006 355: 1821

FREE Full Text PDF

Consumer-Directed Health Care

Bloche, M. Gregg
N Engl J Med 2006 355: 1756-1759

Extract Full Text PDF

Wednesday, October 25, 2006

Disparities in the Utilization of High-Volume Hospitals for Complex Surgery

Jerome H. Liu; David S. Zingmond; Marcia L. McGory; Nelson F. SooHoo; Susan L. Ettner; Robert H. Brook; Clifford Y. Ko
JAMA. 2006;296:1973-1980.


Delivering Quality to Patients
Samuel R. G. Finlayson
JAMA. 2006;296:2026-2027.


Tuesday, October 24, 2006

Segnalare ai cittadini la qualita degli ospedali: il rischio della cattiva informazione.

[Public reporting on individual hospitals' quality: the risk of misinformation]
Di Tanna GL, Cisbani L, Grilli R.
Epidemiol Prev. 2006 May-Jun;30(3):199-204.


Do report cards influence hospital choice? The case of kidney transplantation.

Howard DH, Kaplan B.
Inquiry. 2006 Summer;43(2):150-9.


Monday, October 23, 2006

HCUP - The Case for the Present-on-Admission (POA) Indicator

This new Healthcare Cost and Utilization Project (HCUP) Report present evidence from studies that already exist, or are underway, on the case for (or against) inclusion and collection of the “Present on Admission” (POA) indicator that discriminate between comorbidities and complications in hospital administrative data.

In New York, the label was originally “Other Diagnosis Emergent Indicator,” and is now known as the “Present on Admission Indicator.” In Canada, the label is “Diagnosis Type Indicator.” Some researchers also refer to the POA as a “date stamp" or the "6th digit" of the diagnosis code. They all represent the same concept.

This report also reviews what is known about educational programs needed to implement the indicator in a way that will make the POA data element valid and reliable for improving case-mix, quality-of-care, and other measures, as well as for risk-adjustment for many comparative purposes.


Friday, October 20, 2006

Continuity of care and quality care outcomes for people experiencing chronic conditions

A literature review
Gwen van Servellen, Marie Fongwa, Ellen Mockus D'Errico
Nurs Health Sci. 2006 Sep;8(3):185-95.

abstract full text pdf

Thursday, October 19, 2006

Development and implementation of evidence-based indicators for measuring quality of acute stroke care

the Quality Indicator Board of the German Stroke Registers Study Group (ADSR)
Heuschmann PU, Biegler MK, Busse O, Elsner S, Grau A, Hasenbein U, Hermanek P, Janzen RW, Kolominisky-Rabas PL, Kraywinkel K, Lowitzsch K, Misselwitz B, Nabavi DG, Otten K, Pientka L, von Reutern GM, Ringelstein EB, Sander D, Wagner M, Berger K.
Stroke. 2006 Oct;37(10):2573-8.

abstract Full Text Full Text (PDF)

Wednesday, October 18, 2006

Graduate Medical Education and Patient Safety: A Busy—and Occasionally Hazardous—Intersection

K. G. Shojania, K. E. Fletcher and S. Saint
Ann Intern Med 2006; 592-598.

Abstract Full Text PDF


Quality Grand Rounds: The Case for Patient Safety
R. M. Wachter, K. G. Shojania, A. J. Markowitz, M. Smith and S. Saint
Ann Intern Med 2006; 629-630.

Full Text PDF

Tuesday, October 17, 2006

Monday, October 16, 2006

AHRQ - QI Composite Measure and Risk Adjustment/Hierarchical Modeling Draft


The Agency for Healthcare Research and Quality (AHRQ) has re-posted for public comment the AHRQ QI Composite Measure draft reports for the Inpatient Quality Indicators (IQIs) and the Patient Safety Indicators (PSIs):



In addition, the draft report on Risk Adjustment and Hierarchical Modeling has been posted for public comment:


Friday, October 13, 2006

The Impact Of Quality-Reporting Programs On Hospital Operations

Hoangmai H. Pham, Jennifer Coughlan, and Ann S. O’Malley
Health Affairs, September/October 2006; 25(5): 1412-1422.

[Abstract] [Full Text] [PDF]

Thursday, October 12, 2006

The Quality of Pharmacologic Care for Adults in the United States

Shrank, William H.; Asch, Steven M. ; Adams, John; Setodji, Claude; Kerr, Eve A. ; Keesey, Joan ; Malik, Shaista ; McGlynn, Elizabeth A.
Medical Care. 44(10):936-945, October 2006

Abstract HTML PDF (355 K)

RAND abstract

Wednesday, October 11, 2006

The Canadian National Outcomes Measurement Study in Schizophrenia

Acta Psychiatrica Scandinavica
May 2006 - Vol. 113 Issue s430 Page 3-39

Ashok Malla, Ross Norman

The Canadian National Outcomes Measurement Study in Schizophrenia: overview of the patient sample and methodology
G. Smith, A. Malla, R. Williams, L Kopala, L. Love, R. Balshaw

Medication decisions and clinical outcomes in the Canadian National Outcomes Measurement Study in Schizophrenia
R. Williams, L. Kopala, A. Malla, G. Smith, L. Love, R. Balshaw

Outcome on quality of life in a Canadian national sample of patients with schizophrenia and related psychotic disorders
A. Malla, R. Williams, L. Kopala, G. Smith, D. Talling, R. Balshaw

Resource utilization in a Canadian national study of people with schizophrenia and related psychotic disorders
L. Kopala, G. Smith, A. Malla, R. Williams, L. Love, D. Talling, R. Balshaw

Tuesday, October 10, 2006

Accountability sought by patients following adverse events from medical care: the New Zealand experience

Bismark, Marie, Dauer, Edward, Paterson, Ron, Studdert, David
CMAJ 2006 175: 889-894
[Abstract] [Full Text] [PDF]


Monetary and nonmonetary accountability following adverse medical events: options for Canadian patients
John E. Gray and William Beilby
CMAJ 2006 175: 903.

[Full Text] [PDF]

Monday, October 09, 2006

Assessing Patient Safety Culture: A Review and Synthesis of the Measurement Tools.

Aneesh K. Singla; Barrett T. Kitch; Joel S. Weissman; Eric G. Campbell
Abstract HTML PDF (123 K)

Impact of a Statewide Reporting System on Medication Error Reduction.

Kimberly Rask; Jonathan Hawley; Anne Davis; Dorothy 'Vi' Naylor; Kenneth Thorpe
Abstract HTML PDF (101 K)

Learning From Different Lenses: Reports of Medical Errors in Primary Care by Clinicians, Staff, and Patients:

A Project of the American Academy of Family Physicians National Research Network.
Robert L. Phillips; Susan M. Dovey; Deborah Graham; Nancy C. Elder; John M. Hickner, MD,
Abstract HTML PDF (101 K)

Friday, October 06, 2006

Adverse outcomes in Belgian acute hospitals: retrospective analysis of the national hospital discharge dataset

Koen Van den Heede , Walter Sermeus , Luwis Diya , Emmanuel Lesaffre , and Arthur Vleugels
Int J Qual Health Care 2006 18: 211-219

[Abstract] [Full Text] [PDF]

Thursday, October 05, 2006

Rapid Response Teams—Walk, Don't Run

Bradford D. Winters; Julius Pham; Peter J. Pronovost
JAMA. 2006;296:1645-1647.


AHRQ - Release of the Pediatric Quality Indicator Risk Adjustment Module (Windows)


The Agency for Healthcare Research and Quality (AHRQ) released the AHRQ Pediatric Quality Indicator (PedQI) risk adjustment module in Windows (Version 3.0b). The SAS module was released in May, 2006.



Tuesday, October 03, 2006

Assessing the reliability of standardized performance indicators

Scott C. Williams , Ann Watt , Stephen P. Schmaltz , Richard G. Koss , and Jerod M. Loeb
Int J Qual Health Care 2006 18: 246-255

[Abstract] [Full Text] [PDF]

Friday, September 29, 2006

Thursday, September 28, 2006

Public versus private institutional performance reporting: What is mandatory for quality improvement?

Veena Guru, Stephen E. Fremes, C. David Naylor, Peter C. Austin, Fiona M. Shrive, William A. Ghali, Jack V. Tu and in collaboration with the Cardiac Care Network (CCN) of Ontario
Am Heart J. 2006 Sep;152(3):573-578

Abstract Full Text + Links PDF (290 K)


Reporting for provider performance: Should we punish the bad, or try to make them all good?
T. Bruce Ferguson, Jr
Am Heart J. 2006 Sep;152(3):410-413

Abstract Full Text + Links PDF (143 K)

Implementation of a cardiac surgery report card: lessons from the Massachusetts experience.

Shahian DM, Torchiana DF, Normand SL.
Ann Thorac Surg. 2005 Sep;80(3):1146-50.

Abstract Full Text + Links PDF (70 K)


Mandatory database participation: risky business?
Grunkemeier GL, Furnary AP.
Ann Thorac Surg. 2005 Sep;80(3):799-801.

Abstract Full Text + Links PDF (68 K)

Wednesday, September 27, 2006

The Effect of Medicare Health Maintenance Organizations on Hospitalization Rates for Ambulatory Care-Sensitive Conditions.

Feng Zeng, June F. O'Leary, Elizabeth M. Sloss, Melissa Succi Lopez, Nasreen Dhanani, Glenn Melnick
Medical Care. 44(10):900-907, October 2006

Abstract HTML PDF (297 K)

Data Sources for Measuring Comorbidity: A Comparison of Hospital Records and Medicare Claims for Cancer Patients.

Carrie N. Klabunde, Linda C. Harlan, Joan L. Warren
Medical Care. 44(10):921-928, October 2006.

Abstract HTML PDF (290 K)

Tuesday, September 26, 2006

NQF - Nurses’ Educational Preparation and Patient Outcomes in Acute Care: A Case for Quality

In an effort to support the potential relationship between nursing educational preparation and quality healthcare, National Quality Forum (NQF) drafted a paper that summarizes the evidence on the significant effects of nursing education on outcomes and patient safety.


Monday, September 25, 2006

The safety attitudes questionnaire: Psychometric properties, benchmarking data, and emerging research

John B Sexton , Robert L Helmreich , Torsten B Neilands , Kathy Rowan , Keryn Vella , James Boyden , Peter R Roberts and Eric J Thomas
BMC Health Services Research 2006, 6:44

Abstract Full text PDF

Patient safety in surgery

Makary, M.A., Sexton, J.B., Freischlag, J.A., and others
Annals of Surgery (2006, May) 243(5), pp. 628-635.

Abstract HTML PDF (593 K)

Operating room teamwork among physicians and nurses

Teamwork in the eye of the beholder
Makary, M.A., Sexton, J.B., Freischlag, J.A., and others
Journal of the American College of Surgeons 202, pp. 746-752.

Abstract Full Text + Links PDF (549 K)

Friday, September 22, 2006

Are the Agency for Healthcare Research and Quality obstetric trauma indicators valid measures of hospital safety?

Grobman WA, Feinglass J, Murthy S.
Am J Obstet Gynecol. 2006;195:868-874.

Abstract Full Text + Links PDF (215 K)

Provider Attitudes toward Pay-for-Performance Programs

Development and Validation of a Measurement Instrument
Mark Meterko, Gary J. Young, Bert White, Barbara G. Bokhour, James F. Burgess Jr., Dan Berlowitz, Matthew R. Guldin, Marjorie Nealon Seibert
Health Services Research 2006 41:5 1959

abstract full-text pdf

Thursday, September 21, 2006

AHRQ QI Composite Measure Reports

The Agency for Healthcare Research and Quality (AHRQ) has posted for public comment the AHRQ QI Composite Measure draft reports for the Inpatient Quality Indicators (IQIs) and the Patient Safety Indicators (PSIs).



Wednesday, September 20, 2006

A proposed adaptation of the EFQM fundamental concepts of excellence to health care based on the PATH framework

Paula Vallejo, Rosa Maria Saura, Rosa Sunol, Vahe Kazandjian, Victoria Ureña, and Jordi Mauri
Int J Qual Health Care 2006 18: 327-335

[Abstract] [Full Text] [PDF]

Evaluating treatment process redesign by applying the EFQM Excellence Model

Udo Nabitz, Mark Schramade, and Gerard Schippers
Int J Qual Health Care 2006 18: 336-345

[Abstract] [Full Text] [PDF]

Tuesday, September 19, 2006

Direct comparison of risk-adjusted and non-risk-adjusted CUSUM analyses of coronary artery bypass surgery outcomes.

Novick RJ, Fox SA, Stitt LW, Forbes TL, Steiner S.
J Thorac Cardiovasc Surg. 2006 Aug;132(2):386-91.

Abstract Full Text + Links PDF (166 K)

Medication Dispensing Errors and Potential Adverse Drug Events before and after Implementing Bar Code Technology in the Pharmacy

E. G. Poon, J. L. Cina, W. Churchill, N. Patel, E. Featherstone, J. M. Rothschild, C. A. Keohane, A. D. Whittemore, D. W. Bates and T. K. Gandhi
Ann Intern Med 2006; 426-434.

Abstract Full Text PDF

Monday, September 18, 2006

Usefulness of the nursing home quality measures and quality indicators for assessing skilled nursing facility rehabilitation outcomes.

Silverstein B, Findley PA, Bode RK.
Arch Phys Med Rehabil. 2006 Aug;87(8):1021-5.

Abstract Full Text + Links PDF (92 K)

Identifying performance indicators for family practice

Assessing levels of consensus
Barnsley J, Berta W, Cockerill R, MacPhail J, Vayda E. Can Fam Physician. 2005 May;51:700-1.

Abstract Full Text PDF–285K

Friday, September 15, 2006

Pay-For-Performance: Too Much Of A Good Thing?

A Conversation With Martin Roland
Robert Galvin
Health Affairs, September/October 2006; 25(5): w412-w419.

Full Text (HTML)
Reprint (PDF)

Thursday, September 14, 2006

The OECD Health Care Quality Indicators Project

International Journal for Quality in Health Care
Volume 18, Issue Supplement 1: September 2006

Soeren Mattke, Arnold M. Epstein, and Sheila Leatherman
The OECD Health Care Quality Indicators Project: history and background
Int J Qual Health Care 2006 18: 1-4;
[Abstract] [Full Text] [PDF]

Onyebuchi A. Arah, Gert P. Westert, Jeremy Hurst, and Niek S. Klazinga
A conceptual framework for the OECD Health Care Quality Indicators Project
Int J Qual Health Care 2006 18: 5-13;
[Abstract] [Full Text] [PDF]

Vivienne McLoughlin, John Millar, Soeren Mattke, Margarida Franca, Pia Maria Jonsson, David Somekh, and David Bates
Selecting indicators for patient safety at the health system level in OECD countries
Int J Qual Health Care 2006 18: 14-20;
[Abstract] [Full Text] [PDF]

Martin Marshall, Niek Klazinga, Sheila Leatherman, Charlie Hardy, Eckhard Bergmann, Luis Pisco, Soeren Mattke, and Jan Mainz
OECD Health Care Quality Indicator Project. The expert panel on primary care prevention and health promotion
Int J Qual Health Care 2006 18: 21-25;
[Abstract] [Full Text] [PDF]

Antonio Nicolucci, Sheldon Greenfield, and Soeren Mattke
Selecting indicators for the quality of diabetes care at the health systems level in OECD countries
Int J Qual Health Care 2006 18: 26-30;
[Abstract] [Full Text] [PDF]

Richard C. Hermann, Soeren Mattke, David Somekh, Helena Silfverhielm, Elliot Goldner, Gyles Glover, Jane Pirkis, Jan Mainz, and Jeffrey A. Chan
Quality indicators for international benchmarking of mental health care
Int J Qual Health Care 2006 18: 31-38;
[Abstract] [Full Text] [PDF]

Ulla M. Idänpään-Heikkilä, Laura Lambie, Soeren Mattke, Vin McLaughlin, Heather Palmer, and Jack V. Tu
Selecting indicators for the quality of cardiac care at the health system level in Organization for Economic Co-operation and Development countries
Int J Qual Health Care 2006 18: 39-44;
[Abstract] [Full Text] [PDF]

Edward T. kelley, Irma Arispe, and Julia Holmes
Beyond the initial indicators: lessons from the OECD Health Care Quality Indicators Project and the US National Healthcare Quality Report
Int J Qual Health Care 2006 18: 45-51;
[Abstract] [Full Text] [PDF]

Wednesday, September 13, 2006

Cross sectional study of performance indicators for English Primary Care Trusts

testing construct validity and identifying explanatory variables
Celia Brown and Richard Lilford
BMC Health Services Research 2006, 6:81

Abstract Full text PDF

Correlates of health and healthcare performance: applying the Canadian health indicators framework at the provincial-territorial level

OA Arah and GP Westert
BMC Health Services Research 2005, 5:76

Abstract Full text PDF

Tuesday, September 12, 2006

Raising the Bar for Quality

4th Australasian Conference on Safety & Quality in Health Care

21-23 August 2006 Melbourne, Australia

Conference presentations (PDF versions) are available.

Monday, September 11, 2006

Assessment of the Medicare Quality Improvement Organization Program

W. Rollow, T. R. Lied, P. McGann, J. Poyer, L. LaVoie, R. T. Kambic, D. W. Bratzler, A. Ma, E. D. Huff and L. D. Ramunno
Ann Intern Med 2006; 342-353.

Abstract Full Text PDF


Enhancing the Potential of Quality Improvement Organizations To Improve Quality of Care
S. M. Shortell and W. A. Peck
Ann Intern Med 2006; 388-389.

Full Text PDF

Improving the Medicare Quality Improvement Organization Program

Response to the Institute of Medicine Study

U.S. Secretary of Health and Human Services Michael O. Leavitt released a report to Congress outlining his response to a March 9, 2006 study from the Institute of Medicine, which called for maximizing the potential of the Quality Improvement Organization (QIO) program.

report (pdf)

Friday, September 08, 2006

Flexible random-effects models using Bayesian semi-parametric models: applications to institutional comparisons

D. I. Ohlssen, L. D. Sharples, D. J. Spiegelhalter

Published Online: 11 Aug 2006 DOI: 10.1002
Abstract PDF (Size: 332K)