www.nice.org.uk
The National Institute for Health and Clinical Excellence (NICE) has re-launched its website.
Following on from the merger between NICE and the Health Development Agency, the new site integrates clinical and public health content on one site.
NICE produces guidance in three areas of health:
Key features of the site include:
H. Pelletier
National Academy for State Health Policy and The Commonwealth Fund
April 2006
summary
full report (pdf)
Final Report - April 7, 2006
This report summarizes the work of the PQI Composite Measure Workgroup, which was convened to assist Agency for Healthcare Research and Quality (AHRQ) in developing a composite measure based on the Prevention Quality Indicators for use in the National Healthcare Quality Report and National Healthcare Disparities Report.
The intended use of the PQI composite is to provide national estimates that can be tracked over time, and to provide state estimates than can be compared with the national estimate and to each other.
Outcomes research at the National Cancer Institute: Measuring, understanding and improving the outcomes of cancer care.
Lipscomb J, Davidson M
Clin Ther 25:699-712, 2003
Abstract Abstract + References PDF (875 K)
A process for measuring the quality of cancer care: The Quality Oncology Practice Initiative.
Neuss MN, Desch CE, McNiff KK, et al
J Clin Oncol 23:6233-6239, 2005
[Abstract/Free Full Text]
Medicare demonstration projects acknowledge evidence-based medicine in cancer care.
Twombly R
J Natl Cancer Inst 97:6-7, 2005
[Free Full Text]
Developing a system to assess the quality of cancer care: ASCO's national initiative on cancer care quality.
Schneider EC, Epstein AM, Malin JL, et al
J Clin Oncol 22:2985-2991, 2004
[Free Full Text]
The report from Agency for Healthcare Research and Quality (AHRQ) is a synthesis of studies that have examined the quality impact of health IT as well as the costs and organizational changes needed to implement health IT systems.
report pdf
press release
An article summarizing the report is available on Annals of Internal Medicine
Full disclosure and apology—an idea whose time has come.
Leape LL.
Physician Exec. 2006 Mar-Apr;32:16-18.
Free full text (PDF)
Who’s sorry now?
Weber DO.
Physician Exec. 2006 Mar-Apr;32:6,11-14.
Free full text (PDF)
Kathie Johnson; David Hallsey; Rita L. Meredith; Elizabeth Warden
Journal of Nursing Care Quality. 21(2):168-175, April/June 2006.
Abstract HTML PDF (112 K)
HealthcarePapers Vol. 6 No. 2 2005
Editorial
Notes from the Editor-in-Chief
Peggy Leatt
Invited Essay
Making Performance Reports Work
Adalsteinn D. Brown, Hamida Bhimani and Hugh MacLeod
Commentary
Back to Basics on Report Cards
Albert J. Schumacher
Extreme Makeover: Can We Achieve Rapid Improvement in Canada's Healthcare System?
Nandita Chaudhuri, Bonnie Brossart, Steven Lewis, Gill White
Why Performance Indicators Have a Place in Health Policy
Terri Jackson
Target and Tailor the Data
Brian T. Collopy
Making Performance Reports Work: It's a Matter of Common Sense
Bruce A. Boissonnault
Performance Reporting: Alignment with Accreditation
Wendy Nicklin, Paula Greco, Christopher Dean
Public Reporting Makes Accountability Possible
Robert Y. McMurtry
About Context and Systems
Niek Klazinga
The Authors Respond
The Importance of Context and Attention
Adalsteinn D. Brown, Hamida Bhimani, and Hugh MacLeod
Is there a Business Case for Quality?
J. Needleman et al.
Health Affairs, Jan./Feb. 2006 25(1):204–11.
html Reprint (PDF) Technical Appendix
www.premierinc.com/all/safety/culture/
The Agency for Healthcare Research and Quality (AHRQ) in partnership with Premier Inc., the Department of Defense and the American Hospital Association announced a new survey tool to assess the safety culture of a hospital as a whole, or specific units within hospitals, as well as to track changes in patient safety over time and evaluate the impact of patient safety interventions.
Many other resources are available at the web site to assess organizational safety culture.
Maged N. Kamel Boulos, Qiang Cai, Julian A. Padget and Gerard Rushton
Journal of Biomedical Informatics, Volume 39, Issue 2, April 2006, Pages 160-170
Abstract Full Text + Links PDF (464 K)
Impact on Outbreak Detection
Cassa CA, Grannis SJ, Overhage JM, Mandl KD.
Journal of Nursing Care Quality. 21(2):168-175, April/June 2006.
[Abstract] [Full Text] [PDF]
Schnipper JL, Kirwin JL, Cotugno MC, et al.
Arch Intern Med. 2006;166:565-571.
pubmed
Manno MS.
Nursing. 2006 Mar;36:56-61.
Abstract HTML PDF (926 K)
Responding to Adverse Events
A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
This consensus statement of the Harvard-affiliated hospitals examines the potential benefits and risks of an institutional response quite different from what most hospitals choose today.
It focuses on rapid and open disclosure and emotional support to patients and families who experience serious incidents.
It also addresses ways to support and educate clinicians involved in such incidents and outlines the administrative components of a comprehensive institutional policy.
Free full text (PDF)
of 5-year acute myocardial infarction mortality than general methods
Grunau, GL; Sheps, S; Goldner, EM; Ratner, PA
JOURNAL OF CLINICAL EPIDEMIOLOGY, 59 (3): 274-280; MAR 2006
Abstract Full Text + Links PDF (116 K)
in patients undergoing urological cancer surgery
Nuttall, M; van der Meulen, J; Emberton, M
JOURNAL OF CLINICAL EPIDEMIOLOGY, 59 (3): 265-273; MAR 2006
Abstract Full Text + Links PDF (148 K)
The Case of the New York State Cardiac Surgery Report Card.
Laurent G. Glance, Andrew Dick, Turner M. Osler, Yue Li, Dana B. Mukamel.
Medical Care. 44(4):311-319, April 2006.
Abstract HTML PDF (469 K)
Comparison of the Medicare Advantage Program With the Veterans' Health Administration.
Alfredo J. Selim, Lewis E. Kazis, William Rogers, Shirley Qian, James A. Rothendler, Austin Lee, Xinhua S. Ren, Samuel C. Haffer, Russ Mardon, PhD; Donald Miller, Avron Spiro III, Bernardo J. Selim, Benjamin G. Fincke.
Medical Care. 44(4):359-365, April 2006.
Abstract HTML PDF (268 K)
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program develops and supports the use of a comprehensive and evolving family of standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care.
CAHPS originally stood for the Consumer Assessment of Health Plans Study, but as the products have evolved beyond health plans, the name has evolved as well to capture the full range of survey products and tools.
The CAHPS program is funded and administered by the U.S. Agency for Healthcare Research and Quality (AHRQ), which works closely with a consortium of public and private organizations.
http://www.cahps.ahrq.gov/
The guide provides detailed specifications for the 15 national voluntary consensus standards for nursing-sensitive care endorsed by the
National Quality Forum (NQF).
The project to develop this guide was undertaken by The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) through funding provided by the Robert Wood Johnson Foundation (RWJF), with the guidance of an advisory panel which included the measure developers.
full text
Peggy McNamara
Foreword: Payment Matters? The Next Chapter
Med Care Res Rev 2006 63: 5S-10S.
[PDF] [References]
Dan Berlowitz, James F. Burgess, Jr., and Gary J. Young
Introduction
Med Care Res Rev 2006 63: 11S-13S.
[PDF]
Jeffrey Levin-Scherz, Nicole DeVita, and Justin Timbie
Impact of Pay-for-Performance Contracts and Network Registry on Diabetes and Asthma HEDIS®Measures in an Integrated Delivery Network
Med Care Res Rev 2006 63: 14S-28S.
[Abstract] [PDF] [References]
Stephen R. Grossbart
What's the Return? Assessing the Effect of "Pay-for-Performance" Initiatives on the Quality of Care Delivery
Med Care Res Rev 2006 63: 29S-48S.
[Abstract] [PDF] [References]
Tammie A. Nahra, Kristin L. Reiter, Richard A. Hirth, Janet E. Shermer, and John R. C. Wheeler Cost-Effectiveness of Hospital Pay-for-Performance Incentives
Med Care Res Rev 2006 63: 49S-72S.
[Abstract] [PDF] [References]
Barbara G. Bokhour, James F. Burgess, Jr., Julie M. Hook, Bert White, Dan Berlowitz, Matthew R. Guldin, Mark Meterko, and Gary J. Young
Incentive Implementation in Physician Practices: A Qualitative Study of Practice Executive Perspectives on Pay for Performance
Med Care Res Rev 2006 63: 73S-95S.
[Abstract] [PDF] [References]
Jeff Beich, Dennis P. Scanlon, Jan Ulbrecht, Eric W. Ford, and Ibrahim A. Ibrahim
The Role of Disease Management in Pay-for-Performance Programs for Improving the Care of Chronically Ill Patients
Med Care Res Rev 2006 63: 96S-116S.
[Abstract] [PDF] [References]
Glenn Hackbarth
Commentary
Med Care Res Rev 2006 63: 117S-121S.
[PDF]
Mark R. Chassin
Does Paying for Performance Improve the Quality of Health Care?
Med Care Res Rev 2006 63: 122S-125S.
[PDF]
Robert S. Galvin
Evaluating the Performance of Pay for Performance
Med Care Res Rev 2006 63: 126S-130S.
[PDF] [References]
Agency for Healthcare Research and Quality released a new interactive Web-based tool for States to use in measuring health care quality.
The new State Snapshot Web tool is based on the 2005 National Healthcare Quality Report (NHQR) and the 2005 National Healthcare Disparities Report (NHDR) and provides quick and easy access to the many measures and tables of the NHQR from each State’s perspective.
State Snapshot tool
Supplemento al n. 15 di Monitor PDF
Agenzia per i Servizi Sanitari Regionali (ASSR)
Parte 1: Identificazione sperimentazione e validazione di alcuni indicatori di processo ed esito della qualità delle attività sanitarie
Parte 2: Identificazione, sperimentazione e validazione di alcuni indicatori di qualità delle attività sanitarie e socio sanitarie del territorio Rapporto preliminare
Parte 3: Allegati aggiuntivi non pubblicati nel Supplemento
OECD HEALTH WORKING PAPERS NO. 22
Soeren Mattke, Edward Kelley, Peter Scherer,
Jeremy Hurst, Maria Luisa Gil Lapetra
and the HCQI Expert Group Members
09-Mar-2006
The Health Care Quality Indicators Project has been divided into two phases. The initial phase, for which this report serves as the summary report, concentrated on 17 important and readily available indicators of effectiveness of care.
Future indicators to be considered in the second phase of work will consider a broader set of clinical conditions and other dimensions of health care quality.
pdf
Maximizing Potential
Series: Pathways to Quality Health Care - Institute of Medicine
This report examines the Quality Improvement Organization program in detail and proposes a major restructuring of it so that it can become an important national resource integral to strategies of performance measurement, public reporting, and payment incentives.
The QIO program should focus on offering, through its infrastructure in each state, technical assistance to providers and practitioners aimed at building their capacity for quality improvement.
Asch, Steven M., Kerr, Eve A., Keesey, Joan, Adams, John L., Setodji, Claude M., Malik, Shaista, McGlynn, Elizabeth A.
N Engl J Med 2006 354: 1147-1156
Abstract FREE Full Text PDF Supplementary Material
RAND News Release
OECD HEALTH WORKING PAPERS NO. 23
Edward Kelley and Jeremy Hurst
09-Mar-2006
This paper represents an attempt to set out a conceptual framework for the OECD's Health Care Quality Indicator (HCQI) Project.
Two main issues are tackled: what concepts, or dimensions, of quality of health care should be measured and how, in principle, should they be measured.
pdf
Will Connecting for Health deliver its promises?
Michael Cross
BMJ 2006;332:599-601
[Full text] [PDF]
report for the presidents commission
Unutzer J, Schoenbaum M, Druss BG, Katon WJ.
Psychiatr Serv. 2006 Jan;57(1):37-47.
[Abstract] [Full Text] [PDF]
a qualitative study
J Tim Scott, Thomas G Rundall, Thomas M Vogt, John Hsu
BMJ 2005;331:1313-1316
[Abstract] [Full text] [PDF] [extra: Interview prompt sheet]
Commentary
Trouble in paradise—learning from Hawaii
Sheila Teasdale
BMJ 2005;331:1316
[Full text] [PDF]
The final Briggs National Quality Improvement/ Hospitalization Reduction Study has been completed and the full report is now available.
The study, which was launched to determine the best practices used by home health agencies to reduce patient re-hospitalizations, was sponsored by the Briggs Corp. and cosponsored by National Association for Home Care (NAHC) and Fazzi Associates.
Is Technological Change In Medicine Always Worth It? The Case Of Acute Myocardial Infarction
Jonathan S. Skinner, Douglas O. Staiger, and Elliott S. Fisher
Health Affairs, 25, no. 2 (2006): w34-w47
[Abstract] [Full Text] [Figures Only] [PDF]
Making Sense Of Medical Technology
David M. Cutler
Health Affairs, 25, no. 2 (2006): w48-w50
[Abstract] [Full Text] [PDF]
To Use Technology Better
Alan M. Garber
Health Affairs, 25, no. 2 (2006): w51-w53
[Abstract] [Full Text] [PDF]
McGory ML, Shekelle PG, Rubenstein LZ, Fink A, Ko CY.
Journal of the American College of Surgeons, Vol. 201, No. 6, Dec 2005, pp. 870-883.
Abstract Full Text + Links PDF (141 K)
How Can We Improve the Quality of Cancer Care in the United States?
Jennifer L. Malin, Eric C. Schneider, Arnold M. Epstein, John Adams, Ezekiel J. Emanuel, Katherine L. Kahn
Journal of Clinical Oncology, Vol 24, No 4 (February 1), 2006: pp. 626-634
[Abstract] [Full Text] [PDF]
Development and Pilot Study of the Cancer Care Outcomes Research and Surveillance Patient Survey
Malin JL, Ko C, Ayanian JZ, Harrington D, Nerenz DR, Kahn KL, Ganther-Urmie J, Catalano PJ, Zaslavsky AM, Wallace RB, Guadagnoli E, Arora NK, Roudier MD, Ganz PA.
Supportive Care in Cancer , Vol. 44, No. 2, Feb 2006, pp. 141-148.
Results of Survey and Roundtable Discussions Conducted by the Healthcare Financial Management Association
The Healthcare Financial Management Association (HFMA) released a report that identifies the top barriers to electronic health record implementation and recommends strategies for government to help providers overcome those barriers.
Report (pdf)
Effects On Clinicians' Knowledge And Perceptions.
Medical Care. 44(3):250-256, March 2006.
Peter A. Glassman; Pamela Belperio; Barbara Simon; Andrew Lanto; Martin Lee
Abstract HTML PDF (264 K)
Testing a New Structural Performance Measure.
Medical Care. 44(3):216-224, March 2006.
Ruben Amarasingham; Marie Diener-West; Michael Weiner; Harold Lehmann; Jerome E. Herbers; Neil R. Powe
Abstract HTML PDF (635 K)
A Central Role for Board Certification
Christine K. Cassel and Eric S. Holmboe
JAMA. 2006;295:939-940.
EXTRACT FULL TEXT
Use of Board Certification and Recertification of Pediatricians in Health Plan Credentialing Policies
Gary L. Freed, Dianne Singer, Indu Lakhani, John R. C. Wheeler, James A. Stockman, III, and for the Research Advisory Committee of the American Board of Pediatrics
JAMA. 2006;295:913-918.
ABSTRACT FULL TEXT
Policies and Practices Related to the Role of Board Certification and Recertification of Pediatricians in Hospital Privileging
Gary L. Freed, Rebecca L. Uren, Ericka J. Hudson, Indu Lakhani, John R. C. Wheeler, James A. Stockman, III, and for the Research Advisory Committee of the American Board of Pediatrics
JAMA. 2006;295:905-912.
ABSTRACT FULL TEXT
The lack of a framework on how to define and classify patient safety events, healthcare errors, and systems failures is a major barrier to the systematic understanding of where and how such problems occur.
This National Quality Forum (NQF) report presents a set of four voluntary consensus standards around a specific patient safety taxonomy—the Patient Safety Event Taxonomy (PSET).
Executive summary (PDF)
Should Payers Reward Excellence or Effort?
N. J.O. Birkmeyer and J. D. Birkmeyer
N Engl J Med 2006 354: 864-870
Extract Full Text PDF
A Randomized, Controlled Trial
Stephen Bent, Amy Padula, and Andrew L. Avins
Ann Intern Med.2006; 144: 257-261.
Abstract Full Text PDF
Editorial
Adverse Events: The More You Search, the More You Find
John P.A. Ioannidis, Cynthia D. Mulrow, and Steven N. Goodman
Ann Intern Med.2006; 144: 298-300.
Full Text PDF
The Agency for Healthcare Research and Quality (AHRQ) announced the release of the AHRQ Quality Indicator Version 3.0 for the Inpatient Quality Indicators (IQI) and Patient Safety Indicators (PSI), and the new Pediatric Quality Indicator (PedQI) module.
The software (developed in SAS and Windows) and documentation are available for download from the AHRQ QI web site:
www.qualityindicators.ahrq.gov
cross sectional study
Matt Sutton, Gary McLean
BMJ 2006;332:389-390
[Abstract] [Full text] [PDF] [extra: Results]
Gwyn Bevan, Christopher Hood
BMJ 2006;332:419-422
[Full text] [PDF] [extra: Additional references]
McKay NL, Deily ME.
Health Care Manage Rev. 2005 Oct-Dec;30(4):347-60.
Abstract HTML PDF (280 K)
an indicator of access to prenatal and primary care during pregnancy
Laditka SB, Laditka JN, Mastanduno MP, Lauria MR, Foster TC.
Women Health. 2005;41(3):1-26.
Pubmed
McGory ML, Shekelle PG, Rubenstein LZ, Fink A, Ko CY.
J Am Coll Surg. 2005 Dec;201(6):870-83.
Abstract Full Text + Links PDF (141 K)
the case for cardiac rehabilitation.
Thomas RJ, Witt BJ, Lopez-Jimenez F, King ML, Squires RW.
J Cardiopulm Rehabil. 2005 Sep-Oct;25(5):249-56.
HTML PDF (139 K)
Agency for Healthcare Research and Quality (AHRQ) launched a new suite of "learning resources" designed to help health care providers adopt health information technologies quickly and effectively.
The resource center site provides emerging lessons from the field; a knowledge library with links to more than 5,000 health IT information resources; an evaluation toolkit to help those implementing health IT projects; a summary of key topics; plus other resources pointing to current health IT activities, funding opportunities, and other information.
http://www.healthit.ahrq.gov
Volume 24, Supplement 1, 2005 (pdf)
Introduction
Verena H. Menec
Trends in the Health Status of Older Manitobans, 1985 to 1999
Verena H. Menec, Lisa Lix, and Leonard MacWilliam
Trends in the Utilization of Specific Health Care Services among Older Manitobans: 1985 to 2000
Marcia Finlayson, Lisa Lix, Gregory S. Finlayson, and Terry Fong
Use ofPhysician Services by Older Adults: 1991/1992 to 2000/2001
Diane E. Watson, Petra Heppner, Robert Reid, Bogdan Bogdanovic, and Noralou Roos
Growing Old Together: The Influence of Population and Workforce Aging on Supply and Use of Family Physicians
Diane E. Watson, Robert Reid, Noralou Roos, and Petra Heppner
Non-Clinical Factors Associated with Variation in Cataract Surgery Waiting Times in Manitoba
Carolyn De Coster
Patterns in Home Care Use in Manitoba
Lori Mitchell, Noralou P. Roos, and Evelyn Shapiro
Regional Variation in Home Care Use in Manitoba
Sandra Peterson, Evelyn Shapiro, and Noralou P. Roos
Pharmaceutical Use among Older Adults: Using Administrative Data to Examine Medication-Related Issues
Colleen Metge, Ruby Grymonpre, Matthew Dahl, and Marina Yogendran
Use of Acute Care Hospitals by Long-Stay Patients: Who, How Much, and Why?
Carolyn De Coster, Sharon Bruce, and Anita Kozyrskyj
Discharge Outcomes in Seniors Hospitalized for More than 30 Days
Anita Kozyrskyj, Charlyn Black, Dan Chateau, and Carmen Steinbach
Exploring Reasons for Bed Pressures in Winnipeg Acute Care Hospitals
Verena H. Menec, Sharon Bruce, and Leonard MacWilliam
Anticipating Change: How Many Acute Care Hospital Beds Will Manitoba Regions Need in 2020?
Gregory S. Finlayson, David Stewart, Robert B. Tate, Leonard MacWilliam,and Noralou Roos
A Methodology for Estimating Hospital Bed Need in Manitoba in 2020
Robert B. Tate, Leonard MacWilliam, and Gregory S. Finlayson
Data Quality in an Information-Rich Environment: Canada as an Example
Leslie L. Roos, Sumit Gupta, Ruth-Ann Soodeen, and Laurel Jebamani
Commentary
Betty Havens
Yoon Kong Loke, Deirdre Price, Sheena Derry, and Jeffrey K Aronson
BMJ 2006 332: 335-339.
[Abstract] [Full Text] [PDF] [extra: References]
Factors affecting the use of patient survey data in quality improvement
E Davies and P D Cleary
Qual Saf Health Care 2005; 14: 428-432.
[Abstract] [Full text] [PDF]
Report from the Second Consensus Conference on Population Health Indicators
The second Consensus Conference on Population Health Indicators was convened in order to achieve agreement on the measures used by the Canadian Institute for Health Information (CIHI) and Statistics Canada reflecting the health of Canadians, factors that affect our health and the performance of the health care system. This report summarizes the results of the conference, and includes a list of confirmed health indicators as well as directions for future development
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=GR_1326_E
A tool for identifying and addressing the root causes of critical incidents in healthcare
The Canadian Root Cause Analysis Framework is designed as a quality improvement tool to help individuals and healthcare organizations determine all of the root causes/contributing factors that led to an event.
Authors: Canadian Patient Safety Institute (CPSI), Institute For Safe Medication Practices Canada and Saskatchewan Health
Root Cause Analysis Framework (PDF)
Paul F. M. Krabbe
Med Decis Making 2006;26 30-37
[Abstract] [PDF] [References]
Failure, success and improvisation
R. Heeks
International Journal of Medical Informatics
Volume 75, Issue 2 , February 2006, Pages 125-137
Abstract Full Text + Links PDF (160 K)
Weiner BJ, Alexander JA, Baker LC, Shortell SM, Becker M.
Med Care Res Rev. 2006;63:29-57.
[Abstract] [PDF] [References]
Cina JL, Gandhi TK, Churchill W, et al.
Jt Comm J Qual Patient Safety. 2006;32:73-80.
Abstract
Unnecessary prescribing of antibiotics is a major problem in the US and worldwide, contributing to the problem of antimicrobial resistance (AMR). This review examines the effects of quality improvement strategies on reducing inappropriate prescribing of antibiotics, targeting both prescribing of antibiotics for non-bacterial illnesses ("the antibiotic treatment decision") and prescribing of broad-spectrum antibiotics when narrow-spectrum agents are indicated ("the antibiotic selection decision").
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 4—Antibiotic Prescribing BehaviorEvidence
Report (Publication No. 04(06)-0051-4)
(PDF file, 790 KB)
View or download Summary/Report
This report from the Institute of Medicine (IOM) reviews and makes recommendations for using integrated measures of morbidity and mortality (such as quality-adjusted life years, or QALYs); reporting cost-effectiveness ratios; and data and research needs to improve regulatory cost-effectiveness analysis.
It also considers the ethical implications of using cost-effectiveness analysis, and integrated measures of health impact, in regulatory policy development.
www.iom.edu/CMS/3809/19739/32029.aspx
Didier Pittet and Liam Donaldson
International Journal for Quality in Health Care 2006 18(1):4-8
[Abstract] [Full Text] [PDF]
editorial
A research agenda for patient safety
Thomas V. Perneger
Int J Qual Health Care 2006 18: 1-3
[Extract] [Full Text] [PDF]
Selim AJ, Berlowitz D, Fincke G, Rogers W, Qian S, Lee A, Cong Z, Selim BJ, Ren XS, Rosen AK, Kazis LE.
International Journal for Quality in Health Care . 2006 Feb;18(1):43-50.
[Abstract] [Full Text] [PDF]
Organizations working to develop or improve a culture of safety need a reliable measure to monitor the success of their initiatives.
The Institute for Healthcare Improvement (IHI) in collaboration with The Center of Excellence for Patient Safety Research & Practice at the University of Texas develop this survey tool to gain information about the perceptions of front-line clinical staff about safety in their clinical area.
Safety Climate Survey 2005 (IHI Tool)
Safety Climate Survey 2005 Benchmarking Data
Safety Climate Survey Calculation Spreadsheet 2005 (IHI Tool)
The Incident Decision Tree is a key component of the National Patient Safety Agency’s (NPSA) drive to help the NHS move away from asking “Who was to blame?” to “Why did the individual act in this way?” when things go wrong.
The Incident Decision Tree has been created to help NHS managers and senior clinicians decide whether they need to suspend (exclude) staff involved in a serious patient safety incident and to identify appropriate management action.
The aim is to promote fair and consistent staff treatment within and between healthcare organisations.
The Incident Decision Tree complements the NPSA’s Root Cause Analysis toolkit and the two can be used in parallel.
Setting a Goal and a Deadline for Improving Health Care Quality
Donald M. Berwick, MD, MPP, FRCP; David R. Calkins, MD, MPP; C. Joseph McCannon, BA; Andrew D. Hackbarth, BA
JAMA. 2006;295:324-327
PDF
when medical advances are less important than improving the fidelity with which they are delivered
Woolf SH, Johnson RE.
Ann Fam Med. 2005 Nov-Dec;3(6):545-52
[Full Text] [PDF] [Supplemental data: Figure]
What Role Might Funders of Health Services Research Play?
AHRQ Publication No. 05-0106-EF, October 2005.
http://www.ahrq.gov/qual/hospbuilt/
A literature review and interviews with architects, designers, academics, and health care executives were conducted between February and May of 2005, in an attempt to determine if associations exist between hospital building design elements and patient and staff safety, health outcomes, and patient and staff satisfaction levels.
The findings were used to bring focus to the challenges of evidence-based hospital design and the roles that funders might play in the development and transfer of knowledge related to the constructed hospital environment.
pdf
Health and the future: promise or peril?
Jeremy C Wyatt and Frank Sullivane
BMJ, Dec 2005; 331: 1391 - 1393
Full text PDF
Communication and navigation around the healthcare system
Jeremy C Wyatt and Frank Sullivan
BMJ, Dec 2005; 331: 1325 - 1327
Full text PDF
Improving services with informatics tools
Frank Sullivan and Jeremy C Wyatt
BMJ, Nov 2005; 331: 1190 - 1192
Full text PDF
Keeping up: learning in the workplace
Jeremy C Wyatt and Frank Sullivan
BMJ, Nov 2005; 331: 1129 - 1132
Full text PDF
Referral or follow-up?
Frank Sullivan and Jeremy C Wyatt
BMJ, Nov 2005; 331: 1072 - 1074
Full text PDF
How computers help make efficient use of consultations
Frank Sullivan and Jeremy C Wyatt
BMJ, Oct 2005; 331: 1010 - 1012
Full text PDF
How informatics tools help deal with patients' problems
Frank Sullivan and Jeremy C Wyatt
BMJ, Oct 2005; 331: 955 - 957
Full text PDF
How computers can help to share understanding with patients
Frank Sullivan and Jeremy C Wyatt
BMJ, Oct 2005; 331: 892 - 894
Full text PDF
How decision support tools help define clinical problems
Frank Sullivan and Jeremy C Wyatt
BMJ, Oct 2005; 331: 831 - 833
Full text PDF
Why is this patient here today?
Frank Sullivan and Jeremy C Wyatt
BMJ, Sep 2005; 331: 678 - 680
Full text PDF
Is a consultation needed?
Frank Sullivan and Jeremy C Wyatt
BMJ, Sep 2005; 331: 625 - 627
Full text PDF
What is health information?
Jeremy C Wyatt and Frank Sullivan
BMJ, Sep 2005; 331: 566 - 568
Full text PDF
January/February 2006 - Volume 25, Number 1
The new issue of Health Affairs focuses entirely on hospitals, including studies on quality, reporting, pay-for-performance and other new technology.
This document provides a synopsis of the major findings from the 2005 Patient Safety and Health IT Conference as well as lists of various tools and products developed.
For greater detail, including power point presentations and video recordings of select presentations go to: healthit.ahrq.gov/.../materials.html.
Download the conference proceedings (MS-Word, 536KB)
Agency for Healthcare Research and Quality
www.ahrq.gov/qual/toolkit/
This toolkit presents strategies for comprehensively redesigning and transforming processes of care in a hospital.
It includes a discussion of the forces that compel health care systems to embark on redesign or system transformation; a series of steps to be taken in planning for such as redesign or system transformation; and strategies for translating information gathered into proposed projects for implementation.
This toolkit was prepared for the Agency for Healthcare Research and Quality (AHRQ) by Denver Health, a partner in AHRQ's Integrated Delivery System Research Network.
Select for print version (PDF File, 350 KB).
Press Release, January 9, 2006.
Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/press/pr2005/nhqrdrpr.htm
These reports, issued annually, measure quality and disparities in four key areas of health care in U.S.: effectiveness, patient safety, timeliness, and patient centeredness.
The 2005 National Healthcare Quality Report finds that overall quality of care for all Americans improved at a rate of 2.8 percent, the same increase shown in last year's report. However, the report notes there has been much more rapid improvement in some measures, especially where there have been focused efforts to improve care.
The 2005 National Healthcare Disparities Report finds that many of the largest disparities in measures of quality and access are observed for low-income people regardless of race or ethnicity, with some signs of improvement.
are there implications for risk adjustment and quality assessment?
Rosen AK, Gardner J, Montez M, Loveland S, Hendricks A.
Am J Med Qual. 2005 Jul-Aug;20(4):182-94
Pubmed
This special issue of Health Services Research focuses on Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey
December 2005 - Vol. 40 Issue 6p2 Page 1973-2181
Measuring Hospital Care from the Patients' Perspective: An Overview of the CAHPS® Hospital Survey Development Process
Goldstein, Elizabeth; Farquhar, Marybeth; Crofton, Christine; Darby, Charles; Garfinkel, Steven
Review of the Literature on Survey Instruments Used to Collect Data on Hospital Patients' Perceptions of Care
Castle, Nicholas G.; Brown, Julie; Hepner, Kimberly A.; Hays, Ron D.
What Do Consumers Want to Know about the Quality of Care in Hospitals?
Sofaer, Shoshanna; Crofton, Christine; Goldstein, Elizabeth; Hoy, Elizabeth; Crabb, Jenny
Role of Cognitive Testing in the Development of the CAHPS® Hospital Survey
Levine, Roger E.; Fowler, Floyd J.; Brown, Julie A.
Methods Used to Streamline the CAHPS® Hospital Survey
Keller, San; O'Malley, A. James; Hays, Ron D.; Matthew, Rebecca A.; Zaslavsky, Alan M.; Hepner, Kimberly A.; Cleary, Paul D.
Exploratory Factor Analyses of the CAHPS® Hospital Pilot Survey Responses across and within Medical, Surgical, and Obstetric Services
O'Malley, A. James; Zaslavsky, Alan M.; Hays, Ron D.; Hepner, Kimberly A.; Keller, San; Cleary, Paul D.
Patterns of Unit and Item Nonresponse in the CAHPS® Hospital Survey
Elliott, Marc N.; Edwards, Carol; Angeles, January; Hambarsoomians, Katrin; Hays, Ron D.
Equivalence of Mail and Telephone Responses to the CAHPS® Hospital Survey
Vries, Han; Elliott, Marc N.; Hepner, Kimberly A.; Keller, San D.; Hays, Ron D.
Assessment of the Equivalence of the Spanish and English Versions of the CAHPS® Hospital Survey on the Quality of Inpatient Care
Hurtado, Margarita P.; Angeles, January; Blahut, Steven A.; Hays, Ron D.
Case-Mix Adjustment of the CAHPS® Hospital Survey
O'Malley, A. James; Zaslavsky, Alan M.; Elliott, Marc N.; Zaborski, Lawrence; Cleary, Paul D.
March 2005, Volume 105, Issue 3 supplement
Making Medication Administration Safe: Report challenges nurses to lead the way
Kathleen G. Burke, Diana J. Mason
Discussion & Recommendations: Safe Medication Administration: An invitational symposium recommends ways of addressing obstacles
Errors from the Consumer’s Perspective: Tragedy motivated one woman to take action
Ilene Corina
Executive Summary: The State of the Science on Safe Medication Administration symposium
Kathleen G. Burke
How We Think About Medication Errors: A model and a charge for nurses
Victoria L. Rich
Medication Errors: Why they happen, and how they can be prevented
Ronda G. Hughes, Eduardo Ortiz
Medication Reconciliation: Transfer of medication information across settings—keeping it free from error
Jane H. Barnsteiner
Technology and Safe Medication Administration
Mark Crawford, Janet Mullan, et al.
Toward Safer IV Medication Administration: The narrow safety margins of many IV medications make this route particularly dangerous
Patrice K. Nicholas, Christine R. Agius
An Analysis of Administrative Data Found that Proximate Clinical Event Ratios Provided a Systematic Approach to Identifying Possible Iatrogenic Risk Factors or Complications.
Organisations and safety in healthcare
Quality and Safety in Health Care 2004 Dec; 13 (Suppl 2) : 1-56.
Patient safety methodology
Quality and Safety in Health Care 2003 Dec; 12 (Suppl 2) : 1-72.
This special issue of Health Services Research focuses on measurement issues in health services research and on the potential contributions of measurement toward quality improvement efforts.
October 2005 - Vol. 40 Issue 5p2 Page 1571-1711
Health Services Research: Critical Measurement Issues
Shirley Meehan, PhD, MBA
Measurement in Veterans Affairs Health Services Research: Veterans as a Special Population
Robert O. Morgan, PhD et al.
Validity of Measures Is No Simple Matter
Lee Sechrest, PhD
Integrating Validity Theory with Use of Measurement Instruments in Clinical Settings
P. Adam Kelly, PhD, MBA et al.
Measuring Diagnoses: ICD Code Accuracy
Kimberly J. O'Malley, PhD et al.
Measurement Issues in Health Disparities Research
Mildred Ramirez, PhD et al.
Conceptualizing and Categorizing Race and Ethnicity in Health Services Research
Marvella E. Ford, PhD et al.
Proxies and Other External Raters: Methodological Considerations
A. Lynn Snow, PhD et al.
Dynamic Assessment of Health Outcomes: Time to Let the CAT Out of the Bag?
Karon F. Cook, PhD et al.
The Evidence-based Relation
This paper present evidence to support the relation between team training and patient safety. It extends earlier work by Pizzi and colleagues who argue that Crew Resource Management (CRM) training has a great deal of potential as a safe patient practice.
Training medical professionals to operate as a well-coordinated team should enhance patient safety and lead to a reduction in medical errors.
http://www.ahrq.gov/qual/medteam/
PDF File
Posts
All Comments
