Cost-benefit analysis of a hospital pharmacy bar code solution.

Maviglia SM, Yoo JY, Franz C, Featherstone E, Churchill W, Bates DW, Gandhi TK, Poon EG.
Arch Intern Med. 2007 Apr 23;167(8):788-94.

ABSTRACT FULL TEXT PDF

The Ethics of Using Quality Improvement Methods in Health Care

J. Lynn, M. A. Baily, M. Bottrell, B. Jennings, R. J. Levine, F. Davidoff, D. Casarett, J. Corrigan, E. Fox, M. K. Wynia, G. J. Agich, M. O'Kane, T. Speroff, P. Schyve, P. Batalden, S. Tunis, N. Berlinger, L. Cronenwett, J. M. Fitzmaurice, N. N. Dubler and B. James

Ann Intern Med 2007; 666-673.
Abstract Full Text PDF


Editorial

Quality Improvement and Ethical Oversight
C. Grady
Ann Intern Med 2007; 680-681.
Full Text PDF

Introduction to risk adjustment methods in comparative evaluation of outcomes

Introduzione ai metodi di risk adjustment nella valutazione comparativa degli esiti.
[Article in Italian]
Arca M, Fusco D, Barone AP, Perucci CA.
Epidemiol Prev. 2006 Jul-Oct;30(4-5 Suppl):5-47.

pubmed

AHRQ - Hospital Survey on Patient Safety Culture

2007 Comparative Database Report

www.ahrq.gov/qual/hospsurveydb/index.html

The 2007 report contains comparative results on 108,621 hospital staff respondents from 382 participating hospitals that administered the AHRQ Hospital Survey on Patient Safety Culture.

Contents
Summary
Purpose and Use of This Report

Comparative Database Report
Chapter 1. Introduction
Chapter 2. Survey Administration Statistics
Chapter 3. Characteristics of Participating Hospitals
Chapter 4. Characteristics of Respondents
Chapter 5. Overall Results
Chapter 6. Comparing Your Results
Chapter 7. What's Next? Action Planning for Improvement
Notes: Description of Data Cleaning and Calculations
Copyright Notice
List of Tables
List of Charts

Appendixes A and B—Results by Hospital and Respondent Characteristics
Appendix A: Results by Hospital Characteristics
Appendix B: Results by Respondent Characteristics

AHRQ - Patient Safety Culture Surveys

www.ahrq.gov/qual/hospculture/index.html#toolkit

Health care organizations can use these survey assessment tools from Agency for Healthcare Research and Quality (AHRQ) to:

• Assess their patient safety culture.
• Track changes in patient safety over time.
• Evaluate the impact of patient safety interventions.

Healthcare climate: A framework for measuring and improving patient safety.

Zohar D, Livne Y, Tenne-Gazit O, Admi H, Donchin Y.
Crit Care Med. 2007 May;35(5):1312-7.

Pubmed

Use of administrative data or clinical databases as predictors of risk of death in hospital: comparison of models

Paul Aylin, Alex Bottle, Azeem Majeed
BMJ 2007:391684963, doi:10.1136/bmj.39168.496366.55

Abstract Online First PDF

Achieving the National Quality Forum's "Never Events"

prevention of wrong site, wrong procedure, and wrong patient operations
Michaels RK, Makary MA, Dahab Y, Frassica FJ, Heitmiller E, Rowen LC, Crotreau R, Brem H, Pronovost PJ.
Ann Surg. 2007 Apr;245(4):526-32.

Abstract HTML PDF (737 K)

Using medical malpractice closed claims data to reduce surgical risk and improve patient safety.

Manuel BM, Greenwald LM.
Bull Am Coll Surg. March 2007;92:27-30.

Free full text (PDF)

Staying safe: simple tools for safe surgery.

Karl RC.
Bull Am Coll Surg. April 2007;92:16-22.

Free full text (PDF)

AHRQ - Quality Indicators Mapping Tool

The AHRQ Quality Indicators Mapping Tool (QIMT) is a software program that

1. maps selected AHRQ Quality Indicators (QIs) for a State, by county
2. overlay user-defined population data, assuming the user can supply these additional datasets
3. display county-level rates and cost-reduction data in a worksheet format

The QIMT uses hospital discharge records as the basis to calculate the county level rates of each of the area-level indicators in all four of the AHRQ QI modules:

• the Prevention Quality Indicators,
• the Inpatient Quality Indicators,
• the Patient Safety Indicators, and
• the Pediatric Quality Indicators.

CMS specifications for measures included in the 2007 PQRI

Detailed specifications for the 74 measures included in the 2007 Physician Quality Reporting Initiative (PQRI) were released by the Centers for Medicare and Medicaid Services (CMS).

PQRI establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program.

2007 Physician Quality Reporting Initiative (PQRI) Quality Measures [PDF, 64KB]

2007 Physician Quality Reporting Initiative (PQRI) Measure Specifications [PDF, 838KB]

Hospital Quality Improvement: Strategies and Lessons From U.S. Hospitals

www.cmwf.org/publications/publications_show.htm?doc_id=471265
S. Silow-Carroll, T. Alteras, and J. A. Meyer
The Commonwealth Fund, April 2007



This report from the The Commonwealth Fund focuses on the dynamics of hospital performance: how hospitals achieve and sustain improvements over time.


Case studies of four hospitals that made substantial improvements reveal a pattern:


1) a trigger such as a crisis or new leader serves as a "wake-up call" that prompts the hospital to make

2) organizational and structural changes such as multidisciplinary teams, quality-related committees, and technology investments, which facilitate

3) a systematic problem-identification and problem-solving process, resulting in

4) new treatment protocols and practices, which in turn result in

5) improved outcomes.

PDF

Hospital Performance Improvement: Trends on Quality and Efficiency—A Quantitative Analysis of Performance Improvement in U.S. Hospitals

www.cmwf.org/publications/publications_show.htm?doc_id=471264

E. Kroch, M. Duan, S. Silow-Carroll et al.,

The Commonwealth Fund, April 2007

This report from The Commonwealth Fund presents results of a quantitative examination of the dynamics of hospital performance: the degree to which hospitals are improving (or deteriorating) in quality and efficiency over time.

Results indicate significant improvements across hospitals in reducing mortality and increasing efficiency over 2001–2005, with mixed results in complication and morbidity rates.

pdf

JCAHO - Improving America’s Hospitals: A Report on Quality and Safety

www.jointcommissionreport.org

This report presents how America’s accredited hospitals performed against evidence-based quality measures relating to the care of heart attacks, heart failure, and pneumonia, and to surgical infection prevention during the 2005 year.

This report updates a paper on 2002-2004 quality measures published by The Joint Commission in the New England Journal of Medicine in 2005 (NEJM, 2005;353;3; 28-37).

These measures are also utilized for the “Hospital Quality Alliance: Improving Care through Information” initiative.

This report also presents hospital performance in complying with the requirements of the Joint Commission 2005 National Patient Safety Goals.

Patient safety and quality in the pediatric intensive care unit

Pediatr Crit Care Med. 2007;8(suppl):S1-S43.

Making the pediatric intensive care unit a safe haven.
James D. Fortenberry
HTML PDF (59 K)


Determining pediatric intensive care unit quality indicators for measuring pediatric intensive care unit safety.
Matthew C. Scanlon, Kshitij P. Mistry, Howard E. Jeffries
Abstract HTML PDF (314 K)


Effect of fatigue, workload, and environment on patient safety in the pediatric intensive care unit.
Vicki L. Montgomery
Abstract HTML PDF (310 K)


Electronic medical record, error detection, and error reduction: A pediatric critical care perspective.
Brian Jacobs
Abstract HTML PDF (112 K)


Nosocomial infections in the pediatric intensive care unit: Affecting the impact on safety and outcome.
Jana Alhart Stockwell
Abstract HTML PDF (1.98 M)


Disclosure of medical error: Is it worth the risk?
John Paul Straumanis
Abstract HTML PDF (238 K)

Will Pay-For-Performance And Quality Reporting Affect Health Care Disparities?

Lawrence P. Casalino and Arthur Elster
Health Affairs Web Exclusive, April 10, 2007
[ Full Text ] [ Abstract ] [ PDF ]

American Journal of Preventive Medicine - Acute Stroke Registry Supplement

Volume 31, Issue 6, Supplement 2, S189-S260 (December 2006)

Paul Coverdell National Acute Stroke Registry Prototypes - Assessing Acute Stroke Care in the U.S. and Beyond

Edited by Darwin R. Labarthe, Joseph P. Broderick, David Atkins, Zhi-Jie Zheng and Sung Sug Yoon

link

Measuring the quality of inpatient obstetrical care.

Bailit JL
Obstet Gynecol Surv. 2007 Mar;62(3):207-13.
Abstract
HTML
PDF (262 K)

Quality Measurement in Adult Cardiac Surgery

The Annals of Thoracic Surgery Volume 83, Issue 4, Supplement 1

Quality Measurement in Adult Cardiac Surgery: Introduction
Pages S1-S2
David M. Shahian, Frederick L. Grover, Richard P. Anderson and Fred H. Edwards
Abstract Full Text + Links PDF (35 K)

Quality Measurement in Adult Cardiac Surgery: Part 1—Conceptual Framework and Measure Selection
Pages S3-S12
David M. Shahian, Fred H. Edwards, Victor A. Ferraris, Constance K. Haan, Jeffrey B. Rich, Sharon-Lise T. Normand, Elizabeth R. DeLong, Sean M. O’Brien, Cynthia M. Shewan, Rachel S. Dokholyan, et al.
Abstract Full Text + Links PDF (115 K)

Quality Measurement in Adult Cardiac Surgery: Part 2—Statistical Considerations in Composite Measure Scoring and Provider Rating
Pages S13-S26
Sean M. O’Brien, David M. Shahian, Elizabeth R. DeLong, Sharon-Lise T. Normand, Fred H. Edwards, Victor A. Ferraris, Constance K. Haan, Jeffrey B. Rich, Cynthia M. Shewan, Rachel S. Dokholyan, et al.
Abstract Full Text + Links PDF (364 K)

Towards using administrative databases to measure population-based indicators of quality of end-of-life care: testing the methodology.

Grunfeld E, Lethbridge L, Dewar R, Lawson B, Paszat LF, Johnston G, Burge F, McIntyre P, Earle CC.
Palliat Med. 2006 Dec;20(8):769-77.
link

Ambulatory care adverse events and preventable adverse events leading to a hospital admission

Donna M Woods, Eric J Thomas, Jane L Holl, Kevin B Weiss, and Troyen A Brennan
Qual Saf Health Care 2007; 16: 127-131.
[Abstract] [Full text] [PDF]

Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations

Marlene R Miller, Karen A Robinson, Lisa H Lubomski, Michael L Rinke, and Peter J PronovostQual Saf Health Care 2007; 16: 116-126.
[Abstract] [Full text] [web only appendices] [PDF]

Making use of mortality data to improve quality and safety in general practice: a review of current approaches

Richard Baker, Emma Sullivan, Janette Camosso-Stefinovic, Aly Rashid, Azhar Farooqi, Hanna Blackledge, and Justin Allen
Qual Saf Health Care 2007; 16: 84-89.
[Abstract] [Full text] [PDF]

Using trigger phrases to detect adverse drug reactions in ambulatory care notes

Michael N Cantor, Henry J Feldman, and Marc M Triola
Qual Saf Health Care 2007; 16: 132-134.
[Abstract] [Full text] [PDF]

Redefining Hospital Readmissions to Better Reflect Clinical Course of Care for Heart Failure Patients

Lin Guo, Eugene S. Chung, Donald E. Casey, JR, and Richard Snow
American Journal of Medical Quality 2007 22: 98-102.
[Abstract] [PDF] [References]

Improvement of Psychiatric Ambulatory Follow-up Care by Use of Care Coordinators

Michael J. Orlosky, Danielle Caiati, Jane Hadad, Gayle Arnold, and Jennifer Camarro
American Journal of Medical Quality 2007 22: 95-97.
[Abstract] [PDF] [References]

Measuring Children's Health Care Quality

Lisa Simpson, Denise Dougherty, David Krause, Cindy M. Ku, and James M. Perrin
American Journal of Medical Quality 2007 22: 80-84.
[PDF] [References]

Patient Safety in the Intensive Care Unit: Challenges and Opportunities.

Carolyn M. Clancy
J Patient Saf. 2007;3:6-8
HTML
PDF (56 K)

Using incident reporting to improve patient safety: a conceptual model.

Pronovost PJ, Holzmueller CG, Young J, et al.
J Patient Saf. 2007;3:27-33.
Abstract
HTML
PDF (0.99 M)

Evaluation of nurse interaction with bar code medication administration technology in the work environment.

Carayon P, Wetterneck TB, Hundt AS, et al.
J Patient Saf. 2007;3:34-42.
Abstract
HTML
PDF (374 K)

Health Affairs - Web Exclusive: Quality Of Care In A Developing World

Variations In Practice Quality In Five Low-Income Countries: A Conceptual Overview
Jishnu Das and Paul J. Gertler
[ Full Text ] [ Overview ] [ Abstract ] [ PDF ]

Variations In Prenatal Care Quality For The Rural Poor In Mexico
Sarah L. Barber, Stefano M. Bertozzi, and Paul J. Gertler
[ Full Text ] [ Supplemental Exhibit ] [ Abstract ] [ PDF ]

Variations In Doctor Effort: Evidence From Paraguay
Jishnu Das and Thomas Pave Sohnesen,
[ Full Text ] [ Supplemental Exhibit ] [ Abstract ] [ PDF ]

Location, Location, Location: Residence, Wealth, And The Quality of Medical Care In Delhi, India
Jishnu Das and Jeffrey Hammer
[ Full Text ] [ Supplemental Exhibit ] [ Abstract ] [ PDF ]

Differences In Access To High-Quality Outpatient Care In Indonesia
Sarah L. Barber, Paul J. Gertler, and Pandu Harimurti
[ Full Text ] [ Supplemental Exhibits ] [ Abstract ] [ PDF ]

The Contribution Of Human Resources For Health To The Quality Of Care In Indonesia
Sarah L. Barber, Paul J. Gertler, and Pandu Harimurti
[ Full Text ] [ Supplemental Exhibits ] [ Abstract ] [ PDF ]

Variations In The Quality Of Care Accessible To Rural Communities In Tanzania
Kenneth L. Leonard and Melkiory C. Masatu
[ Full Text ] [ Abstract ] [ PDF ]

An educational intervention, involving feedback of routinely collected computer data, to improve cardiovascular disease management in UK primary care.

de Lusignan S.
Methods Inf Med. 2007;46(1):57-62.
Pubmed

Patient performance standards: the next bold policy initiative in health care?

Buetow S, Elwyn G.
J Health Serv Res Policy. 2007 Jan;12(1):48-53.
Pubmed

Searching for a threshold, not setting one: the role of the National Institute for Health and Clinical Excellence.

Culyer A, McCabe C, Briggs A, Claxton K, Buxton M, Akehurst R, Sculpher M, Brazier J.
J Health Serv Res Policy. 2007 Jan;12(1):56-8.
Pubmed

Antibiotic dosing before primary hip and knee replacement as a pay-for-performance measure.

Bhattacharyya T, Hooper DC.
J Bone Joint Surg Am. 2007 Feb;89(2):287-91.
Pubmed

Signing on to sign out, part 2: describing the success of a web-based patient sign-out application and how it will serve as a platform for an electron

Quan S, Tsai O.
Healthc Q. 2007;10(1):120-4.
Pubmed

Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out.

Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM.
J Hosp Med. 2006 Jul;1(4):257-66.
pubmed

Enhancing patient safety: improving the patient handoff process through appreciative inquiry.

Shendell-Falik N, Feinson M, Mohr BJ.
J Nurs Adm. 2007 Feb;37(2):95-104.

Pubmed

Hospital Episodes and Physician Visits: The Concordance Between Self-Reports and Medicare Claims.

Medical Care. 45(4):300-307, April 2007.

Fredric D. Wolinsky, Thomas R. Miller, Hyonggin An, John F. Geweke, Robert B. Wallace, Kara B. Wright, Elizabeth A. Chrischilles, Li Liu, Claire B. Pavlik, Elizabeth A. Cook, Robert L. Ohsfeldt, Kelly K. Richardson, Gary E. Rosenthal

• Abstract
• HTML
• PDF (294 K)

Use of a Matching Algorithm to Evaluate Hospital Coronary Artery Bypass Grafting Performance as an Alternative to Conventional Risk Adjustment.

Laurent G. Glance, Turner M. Osler, Dana B. Mukamel, Andrew W. Dick

Medical Care. 45(4):292-299, April 2007.

• Abstract
• HTML
• PDF (764 K)

Modifying DRG-PPS to Include Only Diagnoses Present on Admission: Financial Implications and Challenges.

Medical Care. 45(4):288-291, April 2007.

Chunliu Zhan, Anne Elixhauser, Bernard Friedman, Robert Houchens, Yen-pin Chiang

• Abstract
• HTML
• PDF (162 K)

Editorial

Finally Present on Admission but Needs Attention.

Medical Care. 45(4):280, April 2007.
Lisa I. Iezzoni

• HTML
• PDF (121 K)

Failure to Rescue: Validation of an Algorithm Using Administrative Data.

Medical Care. 45(4):283-287, April 2007.

Leora I. Horwitz, Joanne F. Cuny, Julie Cerese, Harlan M. Krumholz

• Abstract
• HTML
• PDF (483 K)

Editorial

Why Rescue the Administrative Data Version of the "Failure to Rescue" Quality Indicator.
Medical Care. 45(4):277, April 2007.

Kathryn M. McDonald, Sheryl M. Davies, Jeffrey Geppert, Patrick S. Romano

• HTML
• PDF (124 K)

Communication Interventions Make A Difference in Conversations Between Physicians and Patients: A Systematic Review of the Evidence.

Medical Care. 45(4):340-349, April 2007.
Jaya K. Rao, Lynda A. Anderson, Thomas S. Inui, Richard M. Frankel

• Abstract
• HTML
• PDF (361 K)

Medical Specialists' Patient-Centered Communication and Patient-Reported Outcomes.

Medical Care. 45(4):330-339, April 2007.

Linda C. Zandbelt, Ellen M. A. Smets, Frans J. Oort, Mieke H. Godfried, Hanneke C. J. M. de Haes

• Abstract
• HTML
• PDF (503 K)

JAMA - Access To Care Theme Issue

Editorials

High-Deductible Health Plans and Emergency Department Use
Corita R. Grudzen; Robert H. Brook
JAMA. 2007;297:1126-1127.
EXTRACT FULL TEXT PDF

Access to Care as a Component of Health System Reform
Phil B. Fontanarosa; Drummond Rennie; Catherine D. DeAngelis
JAMA. 2007;297:1128-1130.
EXTRACT FULL TEXT PDF


Original Contributions

Financial Barriers to Health Care and Outcomes After Acute Myocardial Infarction
Ali R. Rahimi; John A. Spertus; Kimberly J. Reid; Susannah M. Bernheim; Harlan M. Krumholz
JAMA. 2007;297:1063-1072.
ABSTRACT FULL TEXT PDF

Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition
Jack Hadley
JAMA. 2007;297:1073-1084.
ABSTRACT FULL TEXT PDF

Trends in Emergency Medicaid Expenditures for Recent and Undocumented Immigrants
C. Annette DuBard; Mark W. Massing
JAMA. 2007;297:1085-1092.
ABSTRACT FULL TEXT PDF

Emergency Department Use and Subsequent Hospitalizations Among Members of a High-Deductible Health Plan
J. Frank Wharam; Bruce E. Landon; Alison A. Galbraith; Ken P. Kleinman; Stephen B. Soumerai; Dennis Ross-Degnan
JAMA. 2007;297:1093-1102.
ABSTRACT FULL TEXT PDF


Special Communications

How Physicians Can Change the Future of Health Care
Michael E. Porter; Elizabeth Olmsted Teisberg
JAMA. 2007;297:1103-1111.
ABSTRACT FULL TEXT PDF CME COURSE


Commentaries

State-Federal Partnerships for Access to Care: An End and a Means
Arthur Garson Jr; David Blumenthal
JAMA. 2007;297:1112-1115.
EXTRACT FULL TEXT PDF

Universal Health Care Coverage: A Potential Hybrid Solution
Harold S. Luft
JAMA. 2007;297:1115-1118.
EXTRACT FULL TEXT PDF

Health Disparities and Access to Health
Nicole Lurie; Tamara Dubowitz
JAMA. 2007;297:1118-1121.
EXTRACT FULL TEXT PDF

Structural Impairments That Limit Access to Health Care for Patients With Disabilities
Kristi L. Kirschner; Mary Lou Breslin; Lisa I. Iezzoni
JAMA. 2007;297:1121-1125.
EXTRACT FULL TEXT PDF

Adherence to Antidepressant Treatment Among Privately Insured Patients Diagnosed With Depression.

Ayse Akincigil, John R. Bowblis, Carrie Levin, James T. Walkup, Saira Jan, Stephen Crystal
Brief Report Medical Care. 45(4):363-369, April 2007.
Abstract HTML PDF (257 K)

Depression-Free Day to Utility-Weighted Score: Is it Valid?

Jeffrey M. Pyne, Shanti Tripathi, D Keith Williams, John Fortney
Medical Care. 45(4):357-362, April 2007.
Abstract HTML PDF (224 K)

Hierarchical Modeling using HCUP Data

www.hcup-us.ahrq.gov/reports/2007_01.pdf

Houchens R, Chu B, Steiner C.
HCUP Methods Series Report # 2007-01
U.S. Agency for Healthcare Research and Quality.

This report addresses the practical and statistical reasons and implications for utilizing hierarchical linear modeling (HLM) when analyzing HCUP state and national derivative
databases.

This report is intended to:

• define and explain hierarchical models,
• explore the advantages and disadvantages relative to other statistical approaches, and
• guide analysts in the application of hierarchical models to HCUP data and the interpretation of results.

The problem of engaging hospital doctors in promoting safety and quality in clinical care.

Neale G, Vincent C, Darzi SA.
J R Soc Promot Health. 2007;127:87-94.
http://psnet.ahrq.gov/resource.aspx?resourceID=5033

AHRQ - Nursing Staffing and Quality of Patient Care Evidence Report

www.ahrq.gov/clinic/tp/nursesttp.htm

Evidence Report (Publication No. 07-E005)

This new report from AHRQ assess how nurse to patient ratios and nurse work hours were associated with patient outcomes in acute care hospitals and evaluate:

• factors that influence nurse staffing policies


• nurse staffing strategies that improved patient outcomes

PDF File, 2.5 MB

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