Quality of Care for Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Peter K. Lindenauer, Penelope Pekow, Shan Gao, Allison S. Crawford, Benjamin Gutierrez, and Evan M. Benjamin
Ann Intern Med 2006;144 894-903

Abstract Full Text PDF

National survey of surgical morbidity and mortality conferences.

Gore DC
Am J Surg. 2006 May;191(5):708-14.
PDF (222 K)

Understanding diagnostic errors in medicine: a lesson from aviation

H Singh, L A Petersen, and E J Thomas
Qual Saf Health Care 2006; 15: 159-164.
[Abstract] [Full text] [PDF]

Local clinical quality monitoring for detection of excess operative deaths.

Arrowsmith JE, Powell SJ, Nashef SA.
Anaesthesia. 2006 May;61(5):423-6.
html pdf

Linking community pharmacy dispensing data to prescribing data of general practitioners.

Florentinus SR, Souverein PC, Griens FA, Groenewegen PP, Leufkens HG, Heerdink ER.
BMC Med Inform Decis Mak. 2006 Apr 3;6:18.
pdf

Are there better ways to determine wait times?

Schaafsma, Joseph
CMAJ 2006 174: 1551-1552

[Full Text] [PDF]

Persistence of unsafe practice in everyday work

an exploration of organizational and psychological factors constraining safety in the operating room
S Espin, L Lingard, G R Baker, and G Regehr
Qual Saf Health Care 2006; 15: 165-170.
[Abstract] [Full text] [PDF]

The Care of Patients with Severe Chronic Illness: An Online Report on the Medicare Program

A new study by the Dartmouth Atlas Project at the Center for the Evaluative Clinical Sciences (CECS) at Dartmouth Medical School report that:

• The care of people with chronic illness accounts for more than 75% of all u.s. health care expenditures, but Medicare spends much more per enrollee in some states and regions than it does elsewhere.

• The differences in spending provide important insights into the causes of waste in the health care system – and the opportunities to improve both the quality and the efficiency of care.
  

Report: The Care of Patients with Severe Chronic Illness:An Online Report on the Medicare Program

Executive Summary

Interactive data tools and hospital performance reports by state

Printable copy of press release

What Do We Know about Health Care Team Effectiveness? A Review of the Literature

Louise Lemieux-Charles and Wendy L. McGuire
Med Care Res Rev 2006 63: 263-300.
[Abstract] [PDF]

Computer based medication error reporting: insights and implications

M R Miller, J S Clark, and C U Lehmann
Qual Saf Health Care 2006; 15: 208-213.
[Abstract] [Full text] [PDF]

Procedures in U.S. Hospitals, 2003: HCUP Fact Book No. 7

www.ahrq.gov/data/hcup/factbk7/

Merrill CT, Elixhauser A.
AHRQ Publication No. 06-0039, May 2006.
Agency for Healthcare Research and Quality, Rockville, MD.

The report highlights statistics for 2003 on:

• Number and types of procedures performed during a hospital stay.
• Age and gender variation in receipt of procedures.
• Sources of payment (i.e., who is billed) for various procedures.
• Procedures associated with the:
• Longest lengths of stay.
• Highest charges.
• Highest inpatient mortality.

In addition, information is presented on the share of the Nation's hospitals that were high-volume providers for specific procedures as well as on how various patient safety indicators changed between 1997 and 2003.

PDF File (9.7 KB)

The "To Err is Human" report and the patient safety literature

H T Stelfox, S Palmisani, C Scurlock, E J Orav, and D W Bates
Qual Saf Health Care 2006; 15: 174-178.
[Abstract] [Full text] [PDF]

CMWF - Mirror, Mirror on the Wall

An Update on the Quality of American Health Care Through the Patient's Lens
K. Davis, C. Schoen, S. C. Schoenbaum, A.-M. J. Audet, M. M. Doty, A. L. Holmgren, and J. L. Kriss.
The Commonwealth Fund, April 2006.

Overview

report (pdf)

Active surveillance using electronic triggers to detect adverse events in hospitalized patients

Szekendi, M K, Sullivan, C, Bobb, A, Feinglass, J, Rooney, D, Barnard, C, Noskin, G A
Qual Saf Health Care 2006 15: 184-190
[Abstract] [Full text] [PDF]


Editorial

Automated surveillance for adverse events in hospitalized patients: back to the future
Kilbridge, P M, Classen, D C
Qual Saf Health Care 2006 15: 148-149
[Extract] [Full text] [PDF]

AHRQ - Release of the Pediatric Quality Indicator Risk Adjustment Module

www.qualityindicators.ahrq.gov/pdi_download.htm

The Agency for Healthcare Research and Quality (AHRQ) announce the release of the AHRQ Pediatric Quality Indicator (PedQI) risk adjustment module in SAS (Version 3.0b)

Physician reactions to quantitative individual performance reports

Beckman, H; Suchman, AL; Curtin, K; Greene, RA
AMERICAN JOURNAL OF MEDICAL QUALITY, 21 (3): 192-199; MAY-JUN 2006
[Abstract] [PDF]

AHRQ - Cancer Care Quality Measures

Cancer Care Quality Measures: Diagnosis and Treatment of Colorectal CancerEvidence Report
(Publication No. 06-E002)
(PDF file, 1.6 MB)

This evidence report from Agency for Healthcare Research and Quality (AHRQ) identify measures that are currently available to assess the quality of care provided to patients with colorectal cancer (CRC), and assess the extent to which these measures have been developed and tested.


Cancer Care Quality Measures: Symptoms and End of Life CareEvidence Report
(Publication No. 06-E001)
(PDF file, 1.7 MB)

This evidence report from Agency for Healthcare Research and Quality (AHRQ) identify quality measures and the evidence for them to support quality assessment and improvement in the palliative care of patients with cancer in the areas of pain, dyspnea, depression, and advance care planning (ACP), and identify important gaps in related research.

BMJ - NICE work

Review of NICE's recommendations, 1999-2005
James Raftery
BMJ 2006;332:1266-1268
[Full text] [PDF] [extra: Classification of the recommendations]

Resource allocation: NICE work
BMJ 2006;332:1266
[Full text]

How NICE may be outflanked
R E Ferner, Sarah E McDowell
BMJ 2006;332:1268-1271
[Full text] [PDF] [extra: References w1 - w36]

CMWF - Committed to Safety: Ten Case Studies on Reducing Harm to Patients

This report from The Commonwealth Fund presents 10 case studies of health care organizations, clinical teams, and learning collaborations that have designed innovations in five areas that hold great promise for improving patient safety:

• promoting an organizational culture of safety,
• improving teamwork and communication,
• enhancing rapid response to prevent heart attacks and other crises in the hospital,
• preventing health care–associated infections in the intensive care unit, and
  preventing adverse drug events throughout the hospital.

report pdf

Executive Summary

Development and Validation of a Psychiatric Case-Mix System

Kevin L. Sloan, Maria E. Montez-Rath, Avron Spiro III, Cindy L. Christiansen, Susan Loveland, Priti Shokeen, Lawrence Herz, Susan Eisen, James N. Breckenridge, Amy K. Rosen
Medical Care. 44(6):568-580, June 2006.
Abstract HTML PDF (711 K)

Indices for Continuity of Care: A Systematic Review of the Literature

Sandra H. Jee and Michael D. Cabana
Med Care Res Rev 2006 63: 158-188.
[Abstract] [PDF]

HCUP Statistical Briefs

www.hcup-us.ahrq.gov/reports/statbriefs.jsp

The Agency for Healthcare Research and Quality (AHRQ) has launched a new series of Web-based publications, the HCUP Statistical Briefs containing information from its Healthcare Cost and Utilization Project (HCUP).

These publications will provide concise, easy-to-read information on hospital care, costs, quality, utilization, and access.

MJA - The safety and quality of health care: where are we now?

Key achievements of the Australian Council for Safety and Quality in Health Care
Med J Aust 2006; 184 (10): S37.
HTML PDF

The safety and quality of health care: from Council to Commission
Richard A Smallwood
Med J Aust 2006; 184 (10): S39-S40.
HTML PDF

Shared meanings: preferred terms and definitions for safety and quality concepts
William B Runciman
Med J Aust 2006; 184 (10): S41-S43.
HTML PDF

Sea change: public reporting and the safety and quality of the Australian health care system
Clifford F Hughes and Patricia Mackay
Med J Aust 2006; 184 (10): S44-S47.
HTML PDF

Health care safety and quality: where have we been and where are we going?
Bruce H Barraclough and Jim Birch
Med J Aust 2006; 184 (10): S48-S50.
HTML PDF

Measurement of the safety and quality of health care
Sarah Scobie, Richard Thomson, John J McNeil and Paddy A Phillips
Med J Aust 2006; 184 (10): S51-S55.
HTML PDF

Designing safer health care through responsive regulation
Judith Healy and John Braithwaite
Med J Aust 2006; 184 (10): S56-S59.
HTML PDF

Improving safety and quality: how can education help?
Merrilyn M Walton and Susan L Elliott
Med J Aust 2006; 184 (10): S60-S64.
HTML PDF

The development of the National Reporting and Learning System in England and Wales, 2001–2005
Susan K Williams and Sue S Osborn
Med J Aust 2006; 184 (10): S65-S68.
HTML PDF

The WHO World Alliance for Patient Safety: towards the years of living less dangerously
Liam J Donaldson and Martin G Fletcher
Med J Aust 2006; 184 (10): S69-S72.
HTML PDF

AARP - Home Care Quality: Emerging State Strategies to Deliver Person-Centered Services

assets.aarp.org/rgcenter/il/2006_07_hcc.pdf

Folkemer, Donna, and Barbara Coleman.
PPI Issue Paper #2006-07. February 2006

This paper reviews the quality improvement initiatives of three states (Wisconsin, Washington, and South Carolina) to ensure faster consumer access to services and supports, to guarantee that consumers receive prompt and competent assistance from care managers and providers, and to assess how well consumers are being served through feedback from the consumers.

Qual Manag Health Care - Why We Love Quality but Hate to Measure It

Quality Management in Health Care. 15(2):116-120, April/June 2006.
Peabody, John
Abstract HTML PDF (73 K)

Am J Med Qual - Consumer Assessment of Health Providers and Systems (CAHPS)

Evolving to Meet Stakeholder Needs
Charles Darby, Christine Crofton, and Carolyn M. Clancy
American Journal of Medical Quality 2006 21: 144-147.
[PDF]

What Is the Empirical Basis for Paying for Quality in Health Care?

Meredith B. Rosenthal and Richard G. Frank
Med Care Res Rev 2006 63: 135-157.
[Abstract] [PDF]

Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care

B. Chaudhry, J. Wang, S. Wu, M. Maglione, W. Mojica, E. Roth, S. C. Morton and P. G. Shekelle
Ann Intern Med 2006; 742-752.
Abstract Full Text PDF

Leapfrog Group - Designing incentives to improve care tools

Tools

The Leapfrog Group offer tools to design, implement, and evaluat financial and nonfinancial incentives to reward hospitals for providing high-quality care.

These tools include:

• profiles of insurers, purchasers, and employers that have implemented incentive programs
• models of potential incentives
• strategies for determining the business case for such programs
• how to communicate benefits
• other practical materials

BMA - Reporting Adverse Drug Reactions

A guide for healthcare professionals
British Medical Association
May 2006

The BMA believes that effective reporting of adverse drug reactions (ADRs) is an important mechanism for post-marketing surveillance of medicines and is vital for maintaining drug safety.

This report includes significant changes to the Yellow Card Scheme through which suspected ADRs can be reported spontaneously.

Also in the report are recommendations about ways in which healthcare professionals can help improve reporting of ADRs.

Download the report in PDF format (493K)

NEJM - Medical Malpractice Litigation

Claims, Errors, and Compensation Payments in Medical Malpractice Litigation
D. M. Studdert and Others
N Engl J Med 2006 354: 2024-2033
Abstract Full Text PDF

The Patient's Right to Safety — Improving the Quality of Care through Litigation against Hospitals
G. J. Annas
N Engl J Med 2006 354: 2063-2066
Extract Full Text PDF

Arch Surg - Incidence, Patterns, and Prevention of Wrong-Site Surgery

Mary R. Kwaan; David M. Studdert; Michael J. Zinner; Atul A. Gawande
Arch Surg 2006 141: 353-358
ABSTRACT FULL TEXT PDF

Qual Manag Health Care - Readmission Data for Outcomes Measurement

Identifying and Strengthening the Empirical Base
Quality Management in Health Care. 15(2):83-95, April/June 2006.
Landrum, Laurie ; Weinrich, Sally.
Abstract HTML PDF (100 K)

Health Econ - Cost inefficiency and mortality rates in Florida hospitals

Deily, ME; McKay, NL
Health Economics, 15 (4): 419-431; APR 2006
Abstract PDF

Pharmacy Quality Alliance (PQA)

www.pqaalliance.org

Centers for Medicare & Medicaid Services (CMS) announces the formation of the Pharmacy Quality Alliance (PQA).

The Mission of the PQA is to improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the pharmacy and pharmacist-levels; collecting data in the least burdensome way; and reporting meaningful information to consumers, pharmacists, employers, health insurance plans, and other healthcare decision-makers to help make informed choices, improve outcomes and stimulate the development of new payment models.

Ann Intern Med - Patients' Global Ratings of Their Health Care Are Not Associated with the Technical Quality of Their Care

John T. Chang, Ron D. Hays, Paul G. Shekelle, Catherine H. MacLean, David H. Solomon, David B. Reuben, Carol P. Roth, Caren J. Kamberg, John Adams, Roy T. Young, and Neil S. Wenger
Ann Intern Med. 2006 May 2;144(9):665-72.
Abstract Full Text PDF

NHS - Website on cardiac care

heartsurgery.healthcarecommission.org.uk

The Healthcare Commission has worked with the Society of Cardiothoracic Surgeons of Great Britain and Ireland to develop a website on cardiac care.

The website provides detailed information to help patients who need cardiac surgery to make informed decisions about their care and treatment.

Patients are able to see the performance of cardiac units and in many cases of their individual surgeons.

AHRQ - Patient Safety Tools and Resources

www.ahrq.gov/qual/pstools.htm
April 2006.
Agency for Healthcare Research and Quality, Rockville, MD.

The information here summarizes AHRQ patient safety tools and resources designed for health systems, providers, and consumers.

JAMA - How the US Drug Safety System Should Be Changed

Brian L. Strom
JAMA. 2006;295:2072-2075.
EXTRACT FULL TEXT PDF

AHRQ - Pay for Performance: A Decision Guide for Purchasers

This Guide from Agency for Healthcare Research and Quality (AHRQ) is intended to be used by public and private purchasers of health care services who are considering sponsorship of a pay-for-performance (P4P) initiative.

Twenty questions are presented for consideration along with options and any available evidence for each.

The questions are grouped into four phases: contemplation, design, implementation, and evaluation.

PDF File, 320 KB

Am J Med Qual - National Quality Forum 30 safe practices

priority and progress in Iowa hospitals
Ward MM, Evans TC, Spies AJ, Roberts LL, Wakefield DS.
Am J Med Qual. 2006;21:101-108.
[Abstract] [PDF]

Qual Manag Health Care - A Mathematical Theory for Identifying and Measuring Severity of Episodes of Care

Alemi, Farrokh; Walters, Samuel R.
Quality Management in Health Care. 15(2):72-82, April/June 2006.
Abstract HTML PDF (95 K)

Milbank Quarterly - Stories from the Sharp End

Case Studies in Safety Improvement
D. McCarthy and D. Blumenthal
Milbank Quarterly, March 2006 84(1):165–200
abstract full text pdf

JAMA - Association Between Hospital Process Performance and Outcomes Among Patients With Acute Coronary Syndromes

Eric D. Peterson; Matthew T. Roe; Jyotsna Mulgund; Elizabeth R. DeLong; Barbara L. Lytle; Ralph G. Brindis; Sidney C. Smith Jr; Charles V. Pollack Jr; L. Kristin Newby; Robert A. Harrington; W. Brian Gibler; E. Magnus Ohman
JAMA. 2006;295:1912-1920.

ABSTRACT FULL TEXT PDF

NICE - new website

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:

• public health
• health technologies
• clinical practice

Key features of the site include:

• An improved “guidance search” facility
• The ability to search for NICE guidance by type and topic

How States Are Working with Physicians to Improve the Quality of Children's Health Care

H. Pelletier
National Academy for State Health Policy and The Commonwealth Fund
April 2006

summary

full report (pdf)

AHRQ – Prevention Quality Indicators (PQI) Composite Measure Workgroup

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.

Measuring the quality of cancer care

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]

JAMA - Will Physician-Level Measures of Clinical Performance Be Used in Medical Malpractice Litigation?

Aaron S. Kesselheim; Timothy G. Ferris; David M. Studdert
JAMA. 2006;295:1831-1834.
EXTRACT FULL TEXT PDF

AHRQ - Costs and Benefits of Health Information Technology

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

Physician Exec - Special Report: Patient Trust and Safety

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)

J Nurs Care Qual - A Nurse-driven System for Improving Patient Quality Outcomes

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)

Ann Intern Med - Computerization can create safety hazards

a bar-coding near miss
McDonald CJ.
Ann Intern Med. 2006 Apr 4;144(7):510-6.
Abstract Full Text PDF

HealthcarePapers - Performance Reports

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

Health Affairs - Nurse Staffing in Hosptials

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

Premier - Culture : Patient Safety

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.

J Biomed Inform - Using software agents to preserve individual health data confidentiality in micro-scale geographical analyses

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)

JAMIA - A Context-sensitive Approach to Anonymizing Spatial Surveillance Data

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]

Arch Intern Med - Role of pharmacist counseling in preventing adverse drug events after hospitalization

Schnipper JL, Kirwin JL, Cotugno MC, et al.
Arch Intern Med. 2006;166:565-571.
pubmed

Nursing - Preventing adverse drug events

Manno MS.
Nursing. 2006 Mar;36:56-61.
Abstract HTML PDF (926 K)

Harvard Hospitals - When Things Go Wrong

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)

HSR - Quality Improvement Implementation and Hospital Performance on Quality Indicators

Bryan J. Weiner, Jeffrey A. Alexander, Stephen M. Shortell, Laurence C. Baker, Mark Becker, Jeffrey J. Geppert
Health Services Research 2006 41:2 307
abstract html pdf

J Clin Epidemiol - Specific comorbidity risk adjustment was a better predictor

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)

J Clin Epidemiol - Charlson scores based on ICD-10 administrative data were valid in assessing comorbidity

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)

Medical Care - Impact of Changing the Statistical Methodology on Hospital and Surgeon Ranking

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)

Medical care - Risk-Adjusted Mortality as an Indicator of Outcomes

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)

AHRQ - Consumer Assessment of Healthcare Providers and Systems

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/

JCAHO - Implementation Guide for the National Quality Forum (NQF) Endorsed Nursing-Sensitive Care Performance Measures

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

Medical Care Research and Review - Pay-for-Performance supplement

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]

Milbank Quarterly - The Indiana Chronic Disease Management Program

Rosenman, MB; Holmes, AM; Ackermann, RT; Murray, MD; Doebbeling, CC; Katz, B; Li, JJ; Zillich, A; Prescott, VM; Downs, SM; Inui, TS
MILBANK QUARTERLY, 84 (1): 135-163; 2006
abstract full text pdf

Milbank Quarterly - Stories from the sharp end

Case studies in safety improvement
McCarthy, D; Blumenthal, D
MILBANK QUARTERLY, 84 (1): 165-200; 2006
abstract full text pdf

AHRQ - 2005 State Snapshots

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

ASSR - Gli Indicatori per la qualità: strumenti, metodi, risultati

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

• Presentazione di Laura Pellegrini e Leonardo La Pietra
• I componenti del gruppo di ricerca
• Introduzione alla ricerca e obiettivi
• Metodologia e risultati
• Rassegna della letteratura e delle esperienze
• Allegati

Parte 2: Identificazione, sperimentazione e validazione di alcuni indicatori di qualità delle attività sanitarie e socio sanitarie del territorio Rapporto preliminare

• Il nuovo progetto sugli indicatori per le attività territoriali
• I componenti del gruppo di ricerca
• Rassegna della letteratura

Parte 3: Allegati aggiuntivi non pubblicati nel Supplemento

Criteri di transcodifica e trasformazione delle variabili nel tracciato record SDO

Quesiti dei rilevatori dati e risposte dei clinici

Distribuzione delle covariate per sesso

Distribuzione delle covariate per classe di età

Distribuzione delle covariate per classe di gravità (rischio di morte)

Distribuzione delle covariate e copertura degli indicatori di mortalità per regione

La qualità della documentazione clinica

OECD - Health Care Quality Indicators Project Initial Indicators Report

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.

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IOM - Medicare's Quality Improvement Organization Program

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.

• Webcast Archive
• Powerpoint Presentation
• The report available at National Academies Press

NEJM - Who Is at Greatest Risk for Receiving Poor-Quality Health Care?

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

International Journal of Evidence-based Healthcare - Systematic review

Strategies to reduce medication errors with reference to older adults.
Hodgkinson, Brent, Koch, Susan, Nay, Rhonda & Nichols, Kim
International Journal of Evidence-based Healthcare (2006) 4 (1), 2-41.
abstract full text pdf

OECD - Health Care Quality Indicators Project Conceptual Framework Paper

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.

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BMJ - Information technology

Will Connecting for Health deliver its promises?
Michael Cross
BMJ 2006;332:599-601
[Full text] [PDF]

Psychiatr Serv - Transforming mental health care at the interface with general medicine

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]

BMJ - Kaiser Permanente's experience of implementing an electronic medical record

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]

JAMA - All-or-None Measurement Raises the Bar on Performance

Thomas Nolan; Donald M. Berwick
JAMA. 2006;295:1168-1170.
EXTRACT FULL TEXT PDF

NACH - Briggs® National Quality Improvement and Hospitalization Reduction Study

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.

Health Affairs - Medical Technology

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]

J Am Coll Surg - Developing Quality Indicators for Elderly Patients Undergoing Abdominal Operations

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)

J Clin Oncol - Results of the National Initiative for Cancer Care Quality

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]

Supportive Care in Cancer - Understanding Cancer Patients Experience and Outcomes

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.

HFMA - Overcoming Barriers to Electronic Health Record Adoption

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)

Medical Care - Exposure to Automated Drug Alerts Over Time

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)

Medical Care - Clinical Information Technology Capabilities in Four U.S. Hospitals

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)

JAMA - Credentialing and Public Accountability

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

Ann Intern Med - Volume, Quality of Care, and Outcome in Pneumonia

Peter K. Lindenauer, Raj Behal, Cynthia K. Murray, Wato Nsa, Peter M. Houck, and Dale W. Bratzler
Ann Intern Med.2006; 144: 262-269.
Abstract Full Text PDF

NQF - Standardizing a Patient Safety Taxonomy

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)

NEJM - Strategies for Improving Surgical Quality

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

Ann Intern Med - Better Ways To Question Patients about Adverse Medical Events

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

AHRQ - Quality Indicator Version 3.0

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

BMJ - Determinants of primary medical care quality measured under the new UK contract

cross sectional study
Matt Sutton, Gary McLean
BMJ 2006;332:389-390
[Abstract] [Full text] [PDF] [extra: Results]

BMJ - Have targets improved performance in the English NHS?

Gwyn Bevan, Christopher Hood
BMJ 2006;332:419-422
[Full text] [PDF] [extra: Additional references]

Health Care Manage Rev - Comparing high- and low-performing hospitals using risk-adjusted excess mortality and cost inefficiency.

McKay NL, Deily ME.
Health Care Manage Rev. 2005 Oct-Dec;30(4):347-60.
Abstract HTML PDF (280 K)

IHI - A Guide to Idealized Design

Moen R.
Cambridge, Massachusetts: Institute for Healthcare Improvement; 2002.

The Institute for Healthcare Improvement created Idealized Design to bring together organizations committed to comprehensive system redesign.
more...

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