Delayed Access to Health Care and Mortality

Julia C. Prentice, Steven D. Pizer
Health Services Research (2007) 42 (2), 644–662.

Abstract References Full Text HTML
Full Text PDF (141 KB) Supplementary material

Hospital Competition, Managed Care, and Mortality after Hospitalization for Medical Conditions in California

Jeannette Rogowski, Arvind K. Jain, José J. Escarce
Health Services Research 2007 42:2 682

Abstract References Full Text HTML
Full Text PDF (146 KB) Supplementary material

Integrating Incident Reporting into an Electronic Patient Record System

Guy Haller, Paul S. Myles, Johannes Stoelwinder, Mark Langley, Hugh Anderson, and John McNeil
J Am Med Inform Assoc 2007; 14: 175-181.

[Abstract] [Full Text] [PDF]

Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward.

Gao H, McDonnell A, Harrison DA, et al.
Intensive Care Med. 2007 Feb 22; [Epub ahead of print].

Pubmed

Barriers and Strategies to Influencing Physician Behavior

Kevin T. Bain
American Journal of Medical Quality 2007 22: 5-7.
[PDF] [References]

The Patient Safety and Quality Improvement Act of 2005: Provisions and Potential Opportunities

Bryan A. Liang, William Riley, William Rutherford, and William Hamman
American Journal of Medical Quality 2007 22: 8-12.
[PDF] [References]

The Role of Physicians and Certification Boards to Improve Quality

Eric S. Holmboe and Christine K. Cassel
American Journal of Medical Quality 2007 22: 18-25.
[Abstract] [PDF] [References]

Patient Safety Rounds: Description of an Inexpensive but Important Strategy to Improve the Safety Culture

Darrell A. Campbell, Jr and Maureen Thompson
American Journal of Medical Quality 2007 22: 26-33.
[Abstract] [PDF]

Emergency Departments in Crisis: Implications for Accessibility, Quality, and Safety

Carolyn M. Clancy
American Journal of Medical Quality 2007 22: 59-62.
[PDF]

Care Patterns in Medicare and Their Implications for Pay for Performance

Pham, Hoangmai H., Schrag, Deborah, O'Malley, Ann S., Wu, Beny, Bach, Peter B.
N Engl J Med 2007 356: 1130-1139
Abstract FREE Full Text PDF Supplementary Material


Editorial

Paying for Care Episodes and Care Coordination
Davis, Karen
N Engl J Med 2007 356: 1166-1168
Extract FREE Full Text PDF

Weekend versus Weekday Admission and Mortality from Myocardial Infarction

Kostis, William J., Demissie, Kitaw, Marcella, Stephen W., Shao, Yu-Hsuan, Wilson, Alan C., Moreyra, Abel E., the Myocardial Infarction Data Acquisition System (MIDAS 10) Study Group
N Engl J Med 2007 356: 1099-1109
Abstract FREE Full Text PDF Audio Interview


Editorial

Weekend Worriers
Redelmeier, Donald A., Bell, Chaim M.
N Engl J Med 2007 356: 1164-1165
Extract FREE Full Text PDF

Risk-adjusted rates for potentially avoidable reoperations were computed from routine hospital data

Halfon P, Eggli Y, Matter M, Kallay C, van Melle G, Burnand B
J Clin Epidemiol. 2007 Jan;60(1):56-67.

Abstract Full Text Full-Text PDF (219 KB)

AHRQ release Quality Indicator Version 3.1

www.qualityindicators.ahrq.gov/listserv_archive_2007.htm#Mar12

The Agency for Healthcare Research and Quality (AHRQ) announce the release of the AHRQ Quality Indicator Version 3.1 for the Prevention Quality Indicators (PQI), Inpatient Quality Indicators (IQI), Patient Safety Indicators (PSI), and Pediatric Quality Indicator (PedQI) modules.

The software and documentation are now available for download from the AHRQ QI web site at: www.qualityindicators.ahrq.gov/software.htm

Some of the features incorporated into Version 3.1 are described in the AHRQ QI newsletter at: www.qualityindicators.ahrq.gov/newsletter/2007-February-AHRQ-QI-Newsletter.htm

The Pediatric Clinics of North America - Special issue on Patient Safety

Volume 53, Issue 6, Pages 1053-1276 (December 2006)
Edited by Anne Matlow, Ronald M. Laxer

Preface
Matlow A, Laxer RM
pages xv-xvi
Full Text Full-Text PDF (114 KB)

Patient Safety: A View From the Top
Morath JM
pages 1053-1065
Full Text Full-Text PDF (375 KB)

The Incidence of Adverse Events and Medical Error in Pediatrics
Sharek PJ, Classen D
pages 1067-1077
Full Text Full-Text PDF (311 KB)

Medical Errors: Understanding the Parent's Perspective
Keatings M, Martin M, McCallum A, Lewis J
pages 1079-1089
Full Text Full-Text PDF (121 KB)

Disclosure of Medical Errors
Matlow A, Stevens P, Harrison C, Laxer RM
pages 1091-1104
Full Text Full-Text PDF (155 KB)

Human Factors Engineering and Patient Safety
Scanlon MC, Karsh BT, Densmore EM
pages 1105-1119
Full Text Full-Text PDF (348 KB)

Reliability Science and Patient Safety
Luria JW, Muething SE, Schoettker PJ, Kotagal UR
pages 1121-1133
Full Text Full-Text PDF (164 KB)

The Impact of Fatigue on Patient Safety
Parshuram CS
pages 1135-1153
Full Text Full-Text PDF (247 KB)

Medication Errors in Children
Kozer E, Berkovitch M, Koren G
pages 1155-1168
Full Text Full-Text PDF (167 KB)

Computerized Provider Order Entry and Patient Safety
Lehmann CU, Kim GR
pages 1169-1184
Full Text Full-Text PDF (190 KB)

Handoffs in Care—Can We Make Them Safer?
Streitenberger K, Breen-Reid K, Harris C
pages 1185-1195
Full Text Full-Text PDF (136 KB)

Racial/Ethnic Disparities and Patient Safety
Flores G, Ngui E
pages 1197-1215
Full Text Full-Text PDF (238 KB)

Patient Safety: A View from Down Under
Dunn KL, Moulden A, McDougall P, Bowes G
pages 1217-1230
Full Text Full-Text PDF (443 KB)

Tailoring the Institute for Health Care Improvement 100,000 Lives Campaign to Pediatric Settings: The Example of Ventilator-Associated Pneumonia
Curley MAQ, Schwalenstocker E, Deshpande JK, Ganser CC, Bertoch D, Brandon J, Kurtin P
pages 1231-1251
Full Text Full-Text PDF (345 KB)

Blueprint for Patient Safety
Stevens P, Matlow A, Laxer RM
pages 1253-1267
Full Text Full-Text PDF (264 KB)

Continuity of care and quality care outcomes for people experiencing chronic conditions: A literature review

Gwen van Servellen , Marie Fongwa , Ellen Mockus D'Errico (cand)
Nursing & Health Sciences (2006) 8 (3), 185–195.

Abstract References Full Text HTML Full Text PDF (92 KB)

Comparing health system performance assessment and management approaches in the Netherlands and Ontario, Canada

Ali R Tawfik-Shukor , Niek S Klazinga and Onyebuchi A Arah
BMC Health Services Research 2007, 7:25

Abstract Full text PDF

Identifying potentially preventable complications using a present on admission indicator.

Hughes JS, Averill RF, Goldfield NI, Gay JC, Muldoon J, McCullough E, Xiang J.
Health Care Financ Rev. 2006 Spring;27(3):63-82.

pubmed full text pdf (zip)

Surgeon information transfer and mmunication: factors affecting quality and efficiency of inpatient care.

Williams RG, Silverman R, Schwind C, Fortune JB, Sutyak J, Horvath KD, Van Eaton EG, Azzie G, Potts JR 3rd, Boehler M, Dunnington GL.
Ann Surg. 2007 Feb;245(2):159-69.

Abstract HTML PDF (388 K)


Editorials

Communication Strategies From High-reliability Organizations: Translation is Hard Work.
Emily S. Patterson
HTML PDF (118 K)


Communication, Teams, and Medical Mistakes.
Donald W. Moorman
HTML PDF (119 K)

Summarizing benchmarks in the national database of nursing quality indicators using bootstrap confidence intervals.

Byron Gajewski , Matthew Hall , Nancy Dunton
Res Nurs Health. 2007 Feb;30(1):112-9.

Abstract PDF

Designing and evaluating complex interventions to improve health care

Neil C Campbell, Elizabeth Murray, Janet Darbyshire, Jon Emery, Andrew Farmer, Frances Griffiths, Bruce Guthrie, Helen Lester, Phil Wilson, Ann Louise Kinmonth
BMJ 2007;334:455-459

[Extract] [Full text] [PDF]

Improving the Management of Chronic Disease at Community Health Centers

Landon, Bruce E., Hicks, LeRoi S., O'Malley, A. James, Lieu, Tracy A., Keegan, Thomas, McNeil, Barbara J., Guadagnoli, Edward
N Engl J Med 2007 356: 921-934

Abstract FREE Full Text PDF
PowerPoint Slide Set Supplementary Material


Editorial

Performance Measurement in Search of a Path
Hayward, Rodney A.
N Engl J Med 2007 356: 951-953

Extract Full Text PDF


AHRQ Press Release
www.ahrq.gov/news/press/pr2007/cdmqipr.htm

Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity

Sunil Kripalani; Frank LeFevre; Christopher O. Phillips; Mark V. Williams; Preetha Basaviah; David W. Baker
JAMA. 2007;297:831-841.

ABSTRACT FULL TEXT PDF

Reducing Waste in US Health Care Systems

Roger W. Bush
JAMA. 2007;297:871-874.

EXTRACT FULL TEXT PDF

Assessing the Validity of National Quality Measures for Coronary Artery Disease Using an Electronic Health Record

Stephen D. Persell; Jennifer M. Wright; Jason A. Thompson; Karen S. Kmetik; David W. Baker
Arch Intern Med. 2006;166:2272-2277.

ABSTRACT FULL TEXT PDF

Planning and Studying Improvement in Patient Care: The Use of Theoretical Perspectives

Richard P.T.M. Grol, Marije C. Bosch, Marlies E.J.L. Hulscher, Martin P. Eccles, Michel Wensing
The Milbank Quarterly (2007) 85 (1), 93–138.

Abstract Full Text HTML Full Text PDF (576 KB)

SA HealthPlus: A Controlled Trial of a Statewide Application of a Generic Model of Chronic Illness Care

Malcolm Battersby, Peter Harvey, P. David Mills, Elizabeth Kalucy, R.G. Pols, Peter A. Frith, Peter Mcdonald, Adrian Esterman, George Tsourtos, Ronald Donato, Rodney Pearce, Christopher Mcgowan
The Milbank Quarterly (2007) 85 (1), 37–67.

Abstract Full Text HTML Full Text PDF (524 KB)

RAND - Evaluation of the Use of ARHQ and Other Quality Indicators

RAND Corporation was asked to conduct a one-year evaluation to assess user experiences with the AHRQ QIs and to identify users of other quality indicators, vendors of quality measurement products using the AHRQ QIs, and developers of quality indicators comparable to the AHRQ QIs.


The results of this study are intended to inform decisions by AHRQ on future priorities for the QI program. This report has three main objectives:

1. Provide an overview of the market for the AHRQ QIs as well as indicators and quality measurement tools developed by other organizations that are similar to the AHRQ QIs or that incorporate the AHRQ QIs.
2. Provide an overview of the range of ways in which the AHRQ QIs are used by various organizations.
3. Assess the market demand for the AHRQ QIs, identify unmet needs, and discuss implications for future activities by AHRQ.

pdf

The Importance of Population-Based Performance Measures

Editorial
Joseph S. Ross M.D., M.H.S., Albert L. Siu M.D., M.S.P.H.
(2007) Health Services Research 42 (1p1), 1–6.
Summary Full Text HTML Full Text PDF (69 KB)


"Beyond Our Walls: Impact of Patient and Provider Coordination across the Continuum on Outcomes from Surgical Patients."
Weinberg, D. B., J. H. Gittell, R. W. Lusenhop, C. M. Kautz, and J. Wright.
2007. Health Services Research 42 (1, Part I): 7–24.
Abstract Full Text HTML Full Text PDF (136 KB)


"Impact of the Medicare Short Stay Transfer Policy on Patients undergoing Major Orthopedic Surgery."
Fitzgerald, J. D., W. J. Boscardin, B. H. Hahn, and S. L. Ettner.
2007. Health Services Research 42 (1, Part I): 25–44.
Abstract Full Text HTML Full Text PDF (285 KB)


"Does Ambulatory Process of Care Predict Health-Related Quality of Life Outcomes for Patients with Chronic Disease?"
Kahn, K. L., D. M. Tisnado, J. L. Adams, H. Liu, W.-P. Chen, F. A. Hu, C. M. Mangione, R. D. Hays, and C. L. Damberg.
2007. Health Services Research 42 (1, Part I): 63–83.
Abstract Full Text HTML Full Text PDF (143 KB)


"Assigning Ambulatory Patients and Their Physicians to Hospitals: A Method for Obtaining Population-Based Provider Performance Measurements."
Bynum, J. P. W., E. Bernal-Delgado, D. Gottlieb, and E. Fisher.
2007. Health Services Research 42 (1, Part I): 45–62.
Abstract Full Text HTML Full Text PDF (124 KB) Supplementary material

Pay-for-Performance: Will the Latest Payment Trend Improve Care?

Meredith B. Rosenthal; R. Adams Dudley
JAMA. 2007;297:740-744.
EXTRACT FULL TEXT PDF

Automated Review of Electronic Health Records to Assess Quality of Care for Outpatients with Heart Failure

D. W. Baker, S. D. Persell, J. A. Thompson, N. S. Soman, K. M. Burgner, D. Liss and K. S. Kmetik
Ann Intern Med 2007; 270-277.

abstract full text pdf

NHS - National electronic Library of Infection (NeLI)

www.neli.org.uk

The National electronic Library of Infection (NeLI) is a digital library from the UK NHS bringing together the best available on-line evidence-based, quality-tagged resources on the investigation, treatment, prevention and control of infectious disease.

NeLI is part of the National Library for Health (NLH) Specialist Libraries: a collections of clinical and non-clinical resources within speciality themes.

www.library.nhs.uk/specialistlibraries/

Surgeon Information Transfer and Communication: Factors Affecting Quality and Efficiency of Inpatient Care.

Williams, Reed G. ; Silverman, Ross JD; Schwind, Cathy ; Fortune, John B. ; Sutyak, John ; Horvath, Karen D. ; Van Eaton, Erik G. ; Azzie, Georges ; Potts, John R. III ; Boehler, Margaret ; Dunnington, Gary L.
Annals of Surgery. 245(2):159-169
Abstract HTML PDF


Editorials

Communication Strategies From High-reliability Organizations: Translation is Hard Work.
Patterson, Emily S.
Annals of Surgery. 245(2):170-172
HTML PDF


Communication, Teams, and Medical Mistakes.
Donald W. Moorman
Annals of Surgery. 245(2):173-175
HTML PDF

What is "quality improvement" and how can it transform healthcare?

Paul B Batalden and Frank Davidoff
Qual Saf Health Care 2007; 16: 2-3.
[Extract] [Full text] [PDF]

Quality improvement research: are randomised trials necessary?

D Neuhauser and M Diaz
Qual Saf Health Care 2007; 16: 77-80.
[Extract] [Full text] [PDF]

Assessing system failures in operating rooms and intensive care units

M van Beuzekom, S P Akerboom, and F Boer
Qual Saf Health Care 2007; 16: 45-50.
[Abstract] [Full text] [PDF]

Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and

Sisse Olsen, Graham Neale, Kat Schwab, Beth Psaila, Tejal Patel, E Jane Chapman, and Charles Vincent
Qual Saf Health Care 2007; 16: 40-44.
[Abstract] [Full text] [PDF]

Insufficient communication about medication use at the interface between hospital and primary care

Bente Glintborg, Stig Ejdrup Andersen, and Kim Dalhoff
Qual Saf Health Care 2007; 16: 34-39.
[Abstract] [Full text] [PDF]

Assessing the Accuracy of Hospital Clinical Performance Measures

Sharon-Lise T. Normand, Robert E. Wolf, John Z. Ayanian, and Barbara J. McNeil
Med Decis Making 2007 27: 9-20.
[Abstract] [PDF]

Assigning Ambulatory Patients and Their Physicians to Hospitals: A Method for Obtaining Population-Based Provider Performance Measurements

Julie P. W. Bynum, Enrique Bernal-Delgado, Daniel Gottlieb, Elliott Fisher
Health Services Research 42 (1p1), 45–62.
Abstract Full Text HTML Full Text PDF (124 KB) Supplementary material


Editorial

The Importance of Population-Based Performance Measures
Joseph S. Ross , Albert L. Siu
Health Services Research 42 (1p1), 1–6.
Summary Full Text HTML Full Text PDF (69 KB)

The AHRQ Quality Indicators in 2007 - Special issue newsletter

Selected Activities in 2007

• National Quality Forum


• Workgroup on 30-Day Mortality

Software and Documentation (Release 3.1)

• All Modules


• Prevention Quality Indicators


• Inpatient Quality Indicators


• Patient Safety Indicators/Pediatric Quality Indicators

Beyond Our Walls: Impact of Patient and Provider Coordination across the Continuum on Outcomes for Surgical Patients

Dana Beth Weinberg, Jody Hoffer Gittell, R. William Lusenhop, Cori M. Kautz, John Wright
Health Services Research 42 (1p1), 7–24.

Abstract Full Text HTML Full Text PDF (136 KB)

Comparison of Methodologies for Calculating Quality Measures Based on Administrative Data versus Clinical Data from an Electronic Health Record System

Implications for Performance Measures
Paul C. Tang, Mary Ralston, Michelle Fernandez Arrigotti, Lubna Qureshi, and Justin Graham
J. Am. Med. Inform. Assoc. 14: 10-15.
[Abstract] [Full Text] [PDF]

Improving the quality of patient care using reliability measures: A classification tree approach

Graham, PL; Kuhnert, PM; Cook, DA; Mengersen, K
STATISTICS IN MEDICINE, 26 (1): 184-196; JAN 15 2007

Abstract PDF

Performance Measurement in Healthcare:

Part I - Concepts and Trends from a State of the Science Review
Carol E. Adair, Elizabeth Simpson, Ann L. Casebeer, Judith M. Birdsell, Katharine A. Hayden, Steven Lewis
Healthcare Policy / Politiques de Santé, 1(4) 2006: 85-104

Part II - State of the Science Findings by Stage of the Performance Measurement Process
Carol E. Adair, Elizabeth Simpson, Ann L. Casebeer, Judith M. Birdsell, Katharine A. Hayden, Steven Lewis
Healthcare Policy / Politiques de Santé, 2(1) 2006: 56-78

A Systematic Review of the Literature on Multidisciplinary Rounds to Design Information Technology

Ayse P. Gurses, and Yan Xiao
J. Am. Med. Inform. Assoc. 13: 267-276.

[Abstract] [Full Text] [PDF]

National Quality-of-Care Standards in Home-Based Primary Care

K. L. Smith, T. A. Soriano and J. Boal
Ann Intern Med 2007; 188-192.

Abstract Full Text PDF Appendix Table

Medicare Payment For Selected Adverse Events: Building The Business Case For Investing In Patient Safety

Chunliu Zhan, Bernard Friedman, Andrew Mosso, and Peter Pronovost
Health Affairs, September/October 2006; 25(5): 1386-1393.

[Abstract] [Full Text] [PDF]

Closing The Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 6—Prevention of Healthcare-Associated Infections

In this report the Agency for Healthcare Research and Quality (AHRQ) systematically review the evidence supporting quality improvement strategies to reduce the incidence of key healthcare-associated infections (surgical site infections (SSI), central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and catheterassociated urinary tract infections (CAUTI)).

Evidence Report (Publication No. 04(07)-0051-6): (PDF File, 785 KB)

Public Reporting and Pay for Performance in Hospital Quality Improvement

Lindenauer, Peter K., Remus, Denise, Roman, Sheila, Rothberg, Michael B., Benjamin, Evan M., Ma, Allen, Bratzler, Dale W.
N Engl J Med 2007 356: 486-496
Abstract Full Text PDF


Editorial

Pay for Performance at the Tipping Point
A. M. Epstein
N Engl J Med 2007 356: 515-517
Extract Full Text PDF

All or none measurement: why we know so little about the comprehensiveness of care

Edward Kelley
Int J Qual Health Care 2007 19: 1-3;
[Extract] [Full Text] [PDF]

How to develop a business case for quality

Kristin L. Reiter, Kerry E. Kilpatrick, Sandra B. Greene, Kathleen N. Lohr, and Sheila Leatherman
Int J Qual Health Care 2007 19: 50-55;
[Abstract] [Full Text] [PDF]

Does the Patient's Payer Matter in Hospital Patient Safety?: A Study of Urban Hospitals.

Jan P. Clement, Richard C. Lindrooth, Askar S. Chukmaitov, Hsueh-Fen Chen
Medical Care. 45(2):131-138, February 2007.
Abstract HTML PDF

Physician Practice Revenues and Use of Information Technology in Patient Care.

Michael F. Furukawa, Jonathan D. Ketcham, Mary E. Rimsza
Medical Care. 45(2):168-176, February 2007.
Abstract HTML PDF

Did the Medicare Inpatient Rehabilitation Facility Prospective Payment System Result in Changes in Relative Patient Severity and Relative Resource Use

Susan M. Paddock, José J. Escarce, Orla Hayden, Melinda Beeuwkes Buntin
Medical Care. 45(2):123-130, February 2007
Abstract HTML PDF

The challenge of explaining why quality improvement has not done better

Robert L. Kane and Gordon Mosser
Int J Qual Health Care 2007 19: 8-10;
[Extract] [Full Text] [PDF]

The moderate success of quality of care improvement efforts: three observations on the situation

Tal Katz-Navon, Eitan Naveh, and Zvi Stern
Int J Qual Health Care 2007 19: 4-7;
[Abstract] [Full Text] [PDF]

AHRQ - Closing The Quality Gap: Asthma Care

Closing The Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 5—Asthma Care
January 2007.
Agency for Healthcare Research and Quality, Rockville, MD.
www.ahrq.gov/clinic/tp/asthmgaptp.htm

"Despite the availability of evidence-based guidelines for the management of pediatric and adult asthma, there remains a significant gap between accepted best practices for asthma care and actual care delivered to asthma patients.

The purpose of this systematic review was to evaluate the evidence that quality improvement (QI) strategies can improve the processes and outcomes of outpatient care for children and adults with asthma." (AHRQ)

Estimating the out-of-hospital mortality rate using patient discharge data.

Health Econ. 2006 Sep;15(9):983-95.
Farsi M, Ridder G.

Abstract PDF

Redesigning health systems for quality: Lessons from emerging practices.

Wang MC, Hyun JK, Harrison M, Shortell SM, Fraser I.
Jt Comm J Qual Patient Saf. 2006 Nov;32(11):599-611.

abstract

American College of Cardiology 2006 principles to guide physician pay-for-performance programs

a report of the American College of Cardiology Work Group on Pay for Performance
(A Joint Working Group of the ACC Quality Strategic Direction Committee and the ACC Advocacy Committee)

Brush JE Jr, Krumholz HM, Wright JS, Brindis RG, Cacchione JG, Drozda JP Jr, Fasules JW, Flood KB, Garson A Jr, Masoudi FA, McBride T, McKay CR, Messer JV, Mirro MJ, O'Toole MF, Peterson ED, Schaeffer JW, Valentine CM.

J Am Coll Cardiol. 2006 Dec 19;48(12):2603-9.

Full Text PDF (103 K)

AHRQ - National Healthcare Quality & Disparities Reports

National Healthcare Quality Report, 2006.
Agency for Healthcare Research and Quality, Rockville, MD.
www.ahrq.gov/qual/nhqr06/nhqr06.htm

The 2006 National Healthcare Quality Report (NHQR) is a comprehensive national overview of quality of health care in the United States.

It is organized around four dimensions of quality of care—effectiveness, patient safety, timeliness, and patient centeredness. Those dimensions cover the four stages of care from the patient perspective (staying healthy, getting better, living with illness and disability, and coping with the end of life).

Measures of access to care are covered in the companion 2006 National Healthcare Disparities Report.

What can the UK learn from the USA about improving the quality and safety of healthcare?

Tomson CR, Berwick DM.
Clin Med. 2006 Nov-Dec;6(6):551-8.

pubmed

Measuring the performance of health care services

a review of international experiences and their application to urban contexts
Garcia-Altes A, Zonco L, Borrell C, Plasencia A; Barcelona Group on the Performance of Health Care Services.

Gac Sanit. 2006 Jul-Aug;20(4):316-24.

full text pdf

Health Care Quality Improvement: Ethical and Regulatory Issues

link

alternative link

Jennings B, Baily MA, Bottrell M, Lynn J

Garrison, NY: The Hastings Center; 2007.

The Hastings Center investigate the ethical and value issues that arise in the theory and practice of QI in health care. The project, titled “The Ethics of Improving Health Care Quality and Safety,” was funded by the Agency for Healthcare Research and Quality (AHRQ). This book is one of the outcomes of that project.

A companion piece to this volume is the final project report entitled “The Ethics of Using QI Methods to Improve Health Care Quality and Safety”

(www.thehastingscenter.org/research/hchp09.asp).

Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review

Ali Baba-Akbari Sari, Trevor A Sheldon, Alison Cracknell, Alastair Turnbull
BMJ 2007;334:79,

[Abstract] [Full text] [PDF]


Editorial

Incident reporting and patient safety
Charles Vincent
BMJ 2007;334:51

[Extract] [Full text] [PDF]

Health Affairs - Quality in Cardiovascular Disease

January/February 2007 - Volume 26, Number 1

A section of Health Affairs current issue focus on Quality in Cardiovascular Disease

PROLOGUE: Improving The Quality Of Cardiovascular Disease Care
[Extract] [Full Text] [PDF]

Curbing The Cardiovascular Disease Epidemic: Aligning Industry, Government, Payers, And Academics
Robert M. Califf, Robert A. Harrington, Leanne K. Madre, Eric D. Peterson, Deborah Roth, and Kevin A. Schulman
[Abstract] [Full Text] [PDF]

Measuring Performance For Treating Heart Attacks And Heart Failure: The Case For Outcomes Measurement
Harlan M. Krumholz, Sharon-Lise T. Normand, John A. Spertus, David M. Shahian, and Elizabeth H. Bradley
[Abstract] [Full Text] [PDF]

Evidence, Appropriateness, And Technology Assessment In Cardiology: A Case Study Of Computed Tomography
Rita F. Redberg
[Abstract] [Full Text] [PDF]

Measuring Performance Directly Using the Veterans Health Administration Electronic Medical Record: A Comparison With External Peer Review.

Joseph L. Goulet, Joseph Erdos, Sue Kancir, Forrest L. Levin,Steven M. Wright, Stanlie M. Daniels, Lynnette Nilan, Amy C. Justice
Medical Care. 45(1):73-79, January 2007.

Abstract HTML PDF (480 K)

The Utility of Administrative Data for Measuring Adherence to Cancer Surveillance Care Guidelines.

Gregory S. Cooper, Lonni Schultz, Janine Simpkins, Jennifer Elston Lafata
Medical Care. 45(1):66-72, January 2007.

Abstract HTML PDF (257 K)

The Safety Organizing Scale: Development and Validation of a Behavioral Measure of Safety Culture in Hospital Nursing Units.

Timothy J. Vogus, PhD; Kathleen M. Sutcliffe, PhD
Medical Care. 45(1):46-54, January 2007.

Abstract HTML PDF (481 K)

Facility-Level Factors Influencing Chronic Heart Failure Care Process Performance in a National Integrated Health Delivery System.

Usha Subramanian, Jason Sutherland, Kimberly D. McCoy, Karl F. Welke, Thomas E. Vaughn, Bradley N. Doebbeling
Medical Care. 45(1):28-45, January 2007.

Abstract HTML PDF (8.09 M)

Multidisciplinary Primary Care Teams: Effects on the Quality of Clinician-Patient Interactions and Organizational Features of Care.

Hector P. Rodriguez, William H. Rogers, Richard E. Marshall, Dana Gelb Safran
Medical Care. 45(1):19-27, January 2007.

Abstract HTML PDF (766 K)


Editorial

Are Continuity of Care and Teamwork Incompatible?
Edward H. Wagner, Robert J. Reid
Medical Care. 45(1):6-7, January 2007.

HTML PDF (88 K)

The Effect of a Quality Improvement Initiative on the Quality of Other Aspects of Health Care: The Law of Unintended Consequences?

David A. Ganz, Neil S. Wenger, Carol P. Roth, Caren J. Kamberg, John T. Chang, Catherine H. MacLean, Roy T. Young, David H. Solomon, Takahiro Higashi, Lillian Min, David B. Reuben, Paul G. Shekelle
Medical Care. 45(1):8-18, January 2007.

Abstract HTML PDF (393 K)

Editorial

Intended and Unintended Consequences: What Should We Really Worry About?
McGlynn, Elizabeth A.
Medical Care. 45(1):3-5, January 2007.

HTML PDF (118 K)

Association Between Performance Measures and Clinical Outcomes for Patients Hospitalized With Heart Failure

Gregg C. Fonarow; William T. Abraham; Nancy M. Albert; Wendy Gattis Stough; Mihai Gheorghiade; Barry H. Greenberg; Christopher M. O'Connor; Karen Pieper; Jie Lena Sun; Clyde Yancy; James B. Young; for the OPTIMIZE-HF Investigators and Hospitals

JAMA 2007 297: 61-70

ABSTRACT | FULL TEXT | PDF

Enhancement of Claims Data to Improve Risk Adjustment of Hospital Mortality

Michael Pine; Harmon S. Jordan; Anne Elixhauser; Donald E. Fry; David C. Hoaglin; Barbara Jones; Roger Meimban; David Warner; Junius Gonzales

JAMA 2007 297: 71-76

ABSTRACT | FULL TEXT | PDF

Managing for Quality

erc.msh.org/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

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)

Editorial

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)

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]

A Systems Approach to Patient-Centered Care

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

EXTRACT FULL TEXT PDF

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

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.

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]


Comment

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


Editorial

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

[Full Text] [PDF]

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.

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

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)

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

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

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

ABSTRACT FULL TEXT PDF


Editorial

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

EXTRACT FULL TEXT PDF

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

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]

OECD - Health care: Towards quality performance

www.oecdobserver.org/news/fullstory.php/aid/1953

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

OECD - Health Data 2006 Database

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.

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

Editorial

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

Full Text PDF

A Pay-for-Population Health Performance System

David A. Kindig
JAMA. 2006;296:2611-2613.

EXTRACT FULL TEXT PDF

AHRQ - 10 Patient Safety Tips for Hospitals

www.ahrq.gov/qual/10tips.htm

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

Access to health care and hospitalization for ambulatory care sensitive conditions

Ansari, Z; Laditka, JN; Laditka, SB
Med Care Res Rev 2006 63: 719-741.

[Abstract] [PDF]