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]