Are Patients With Coexisting Mental Disorders More Likely to Receive CABG Surgery From Low-Quality Cardiac Surgeons?: The Experience in New York State

Yue Li, Laurent G. Glance, Xueya Cai, Dana B. Mukamel
Medical Care. 45(7):587-593, July 2007.
Abstract HTML PDF (268 K)


Editorial

Selecting the Ideal Cardiovascular Surgeon: Is it Possible With Public Dissemination of Clinical Outcomes?
John G. Canto
Medical Care. 45(7):585, July 2007.
HTML PDF (89 K)

Current Concepts: Disclosing Harmful Medical Errors to Patients

Gallagher, Thomas H., Studdert, David, Levinson, Wendy
N Engl J Med 2007 356: 2713-2719

Extract Full Text PDF

Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study

Ruth McDonald, Stephen Harrison, Kath Checkland, Stephen M Campbell, and Martin Roland
BMJ 2007 334: 1357.
[Abstract] [Full Text]


Editorials

The side effects of "P4P"
Douglas Kamerow
BMJ 2007;334, doi:10.1136/bmj.39260.443970.3A
[Extract] [Full text]

Performance measurement and equity
Arlene S Bierman, Jocalyn P Clark
BMJ 2007;334:1333-1334
[Extract] [Full text] [PDF]

Ethics of collecting and using healthcare data

Derick Wade
BMJ 2007;334:1330-1331

[Extract] [Full text] [PDF]

Implementing the NHS information technology programme: qualitative study of progress in acute trusts

Jane Hendy, Naomi Fulop, Barnaby C Reeves, Andrew Hutchings, and Simon Collin
BMJ 2007;334:1360, doi:10.1136
[Abstract] [Full text] [PDF]


Views

How to avoid an e-headache
Joan S Ash
BMJ 2007;334:1373, doi:10.1136/bmj.39252.490880.80
[Extract] [Full text] [PDF]

Pay-for-Performance in Pediatrics: Proceed With Caution

Chien, Alyna T., Dudley, R. Adams
Pediatrics 2007 120: 186-188

[Extract] [Full text] [PDF]

The Evidence Base for Telemedicine: Current Status and Approaches for Improvement

Journal of Telemedicine and Telecare
Supplement 2, September 2006

The evidence base of telemedicine: overview of the supplement
pp. 1-2(2) Authors: Hersh, William R.; Hickam, David H.; Erlichman, Martin

Diagnosis, access and outcomes: update of a systematic review of telemedicine services
pp. 3-31(29) Authors: Hersh, William R.; Hickam, David H.; Severance, Susan M.; Dana, Tracy L.; Pyle Krages, Kathryn; Helfand, Mark

State Medicaid and private payer reimbursement for telemedicine: an overview
pp. 32-39(8) Author: Brown, Nancy A.

What lessons can be learned from telemedicine programmes in other countries?
pp. 40-44(5) Author: Ohinmaa, Arto

The role of telemedicine in fostering health-care innovations to address problems of access, specialty shortages and changing patient care needs
pp. 45-50(6) Author: Rheuban, Karen S.

The diffusion of a medical innovation: where teleradiology is and where it is going
pp. 51-58(8) Authors: Dimmick, Susan L.; Ignatova, Kunka D.

Telehealth and the national health information technology strategic framework
pp. 59-64(6) Authors: Speedie, Stuart M.; Davies, Diane

Will we see data repositories for telehealth activity in the near future?
pp. 65-71(7) Author: Whitten, Pamela

Standards for data collection and monitoring in a telemedicine research network
pp. 72-76(5) Authors: Yellowlees, Peter W.; Harry, David

Alternatives to randomized controlled trials in telemedicine
pp. 77-84(8) Authors: Grigsby, Jim; Bennett, Rachael E.

Health delivery system changes required when integrating telemedicine into existing treatment flows of information and patients
pp. 85-90(6) Author: Shea, Steven

Performance measures for pneumonia: are they valuable, and are process measures adequate?

Bratzler DW, Nsa W, Houck PM.
Curr Opin Infect Dis. 2007 Apr;20(2):182-9.
pubmed

Can the Incidence of Unplanned Reoperations Be Used as an Indicator of Quality of Care in Surgery?

Hidde M. Kroon, Paul J. Breslau, and Jan Willem H. P. Lardenoye
American Journal of Medical Quality 2007 22: 198-202.

[Abstract] [PDF] [References]

Determining Hospital Performance Based on Rank Ordering: Is It Appropriate?

Judy Anderson, Mark Hackman, Jeff Burnich, and Thomas R. Gurgiolo
American Journal of Medical Quality 2007 22: 177-185.

[Abstract] [PDF] [References]

TeamSTEPPS: Assuring Optimal Teamwork in Clinical Settings

Carolyn M. Clancy and David N. Tornberg
American Journal of Medical Quality 2007 22: 214-217.

[PDF] [References]

Accuracy of administrative databases in identifying patients with hypertension

Karen Tu, Norman RC Campbell, Xhong-Liang Chen, Karen J Cauch-Dudek, Finlay A McAlister
Open Medicine Vol 1, No 1 (2007) : 18-26

Abstract HTML PDF

Healthcare climate: A framework for measuring and improving patient safety

Critical Care Medicine. 35(5):1312-1317, May 2007.
Zohar, Dov PhD; Livne, Yael MSc; Tenne-Gazit, Orly MSc; Admi, Hanna PhD; Donchin, Yoel MD
Abstract HTML PDF (424 K)

Editorial

Safety culture: easy to advocate, difficult to create.
O'Connor MF
Crit Care Med. 2007 May;35(5):1429
HTML PDF (1.32 M)

Defining and Measuring Quality Outcomes in Long-Term Care

J Am Med Dir Assoc. 2007 Mar;8(3 Suppl 2):e129-37

Vincent Mor
Abstract Full Text + Links PDF (126 K)

Conflicting measures of hospital quality: Ratings from Hospital Compare versus Best Hospitals

Lakshmi K. Halasyamani, Matthew M. Davis
Journal of Hospital Medicine Volume 2, Issue 3, 2007. (p 128-134)
Abstract References HTML PDF


Editorial

Hospital quality measurement - Perplexing for professionals, let alone for patients
Kevin J. O'Leary, Cynthia Barnard, Gary A. Noskin
Journal of Hospital Medicine Volume 2, Issue 3, 2007. (p 119-122)
HTML PDF

Relationship between Number of Medical Conditions and Quality of Care

Higashi, Takahiro, Wenger, Neil S., Adams, John L., Fung, Constance, Roland, Martin, McGlynn, Elizabeth A., Reeves, David, Asch, Steven M., Kerr, Eve A., Shekelle, Paul G.
N Engl J Med 2007 356: 2496-2504
Abstract Full Text PDF

Information Technology Comes to Medicine

Blumenthal, David, Glaser, John P.
N Engl J Med 2007 356: 2527-2534
Extract Full Text PDF

In the Dark -- The Case for Electronic Health Records

Litvin, Cara B.
N Engl J Med 2007 356: 2454-2455
Extract Full Text PDF

NHQRnet: National Healthcare Quality & Disparities Report Data Query Tool

NHQRnet is an online query system from Agency for Healthcare Research and Quality (AHRQ) to access U.S. data on the quality and access to health care.

NHQRnet: National Healthcare Quality Report Data Query Tool

NHDRnet: National Healthcare Disparities Report Data Query Tool

2006 State Snapshots: Quality Information and Comparisons

Case Volume and Mortality in Pediatric Cardiac Surgery Patients in California, 1998–2003

Lianna G. Bazzani and James P. Marcin
Circulation 2007 115: 2652 - 2659;
[Abstract] [Full Text] [PDF] [Clinical Perspective]



Editorial

Reevaluation of the Volume-Outcome Relationship for Pediatric Cardiac Surgery
Kimberlee Gauvreau

Circulation 2007 115: 2599 - 2601

[Full Text] [PDF]

The MINDFUL Database

The MINDFUL mental health indicator database comprises a set of 35 mental health indicators for all the 25 EU Member States. The database contains two elements of indicator data: numerical data and metadata.

The metadata contains information about the indicators' descriptions, definitions, availability and data sources.

Overview
Indicators
Glossary

AHRQs National Healthcare Quality and Disparities Reports: An Ever-Expanding Road Map for Improvement

Jeffrey Brady, Karen Ho, Edward Kelley, Carolyn M. Clancy
Health Services Research 42 (3p1), xi–xxi.

References Full Text HTML Full Text PDF (69 KB)

NAHDO - Health care data collection use and public reporting

NAHDO 21st Annual Meeting

Slides from the National Association of Health Data Organizations (NAHDO) Annual Meeting dedicated to health care data collection use and public reporting are now available.

Meeting Topics & Highlights:

• Quality Measurement and Reporting


• Enhancing Administrative Data for Quality Reporting


• Healthcare-Acquired Infection Reporting Standards and Practices


• Translating Data into Action


• CMS DRG Modifications


• Health information Technology


• Web-based Data Query Systems

Adding Clinical Data Elements to Administrative Data for

Barbara A. Rudolph, Denise Love
National Association of Health Data Organizations
Agency for Health Care Research and Quality
February 2007

This synthesis provides a brief summary of a new study evaluating how the addition of a “Present on Admission” indicator for secondary diagnoses and a limited number of electronic laboratory values can enhance the capacity of administrative data for public reporting on mortality and other hospitalization-related complications.

PDF File

Pay for Performance, Quality of Care, and Outcomes in Acute Myocardial Infarction

Seth W. Glickman; Fang-Shu Ou; Elizabeth R. DeLong; Matthew T. Roe; Barbara L. Lytle; Jyotsna Mulgund; John S. Rumsfeld; W. Brian Gibler; E. Magnus Ohman; Kevin A. Schulman; Eric D. Peterson
JAMA. 2007;297:2373-2380.

ABSTRACT FULL TEXT PDF

Comparison of clinical and administrative data sources for hospital coronary artery bypass graft surgery report cards.

Shahian DM, Silverstein T, Lovett AF, Wolf RE, Normand SL.
Circulation. 2007 Mar 27;115(12):1518-27.
[Abstract] [Full Text] [PDF]


Editorial

To understand cardiac surgical report cards: look both ways.
Circulation. 2007 Mar 27;115(12):1508-10.
Ryan TJ.
[Full Text] [PDF]

Quality indicators for cardiovascular primary care.

Burge FI, Bower K, Putnam W, Cox JL.
Can J Cardiol. 2007 Apr;23(5):383-8.
pubmed

Coordination Between Formal Providers and Informal Caregivers

D. B. Weinberg, R. W. Lusenhop, and J. Hoffer Gittell, Ph.D. et al.,
Health Care Management Review, April–June 2007 32(2):1–10
Abstract HTML PDF (166 K)

Multimorbidity is Associated With Better Quality of Care Among Vulnerable Elders.

Lillian C. Min, MD, MSHS; Neil S. Wenger, MD; Constance Fung, MD, MSHS; John T. Chang, MD, MPH; David A. Ganz, MD, MPH; Takahiro Higashi, MD, PhD; Caren J. Kamberg, MSPH; Catherine H. MacLean, MD, PhD; Carol P. Roth, RN, MPH; David H. Solomon, MD; Roy T. Young, MD; David B. Reuben, MD

Medical Care. 45(6):480-488, June 2007.
Abstract HTML PDF (361 K)

Editorial

Health Care Quality and Multimorbidity: The Jury is Still Out.

Christine Ritchie, MD, MSPH
HTML PDF (120 K)

Potentially Avoidable Hospitalizations for COPD and Pneumonia: The Role of Physician and Practice Characteristics.

Ann S. O'Malley, MD, MPH; Hoangmai H. Pham, MD, MPH; Deborah Schrag, MD, MPH; Beny Wu, MS; Peter B. Bach, MD, MAPP
Medical Care. 45(6):562-570, June 2007.
Abstract HTML PDF (739 K)

Nurse Working Conditions and Patient Safety Outcomes.

Patricia W. Stone, PhD; Cathy Mooney-Kane, MPH; Elaine L. Larson, PhD; Teresa Horan, MPH; Laurent G. Glance, MD; Jack Zwanziger, PhD; Andrew W. Dick, PhD
Medical Care. 45(6):571-578, June 2007.
Abstract HTML PDF (410 K)

AHRQ - Health Care Report Card Compendium

http://www.talkingquality.gov/compendium/

The Health Care Report Card Compendium from Agency for Healthcare Research and Quality (AHRQ) is a searchable directory of over 200 samples of report cards produced by a variety of organizations.

The samples show formats and approaches for providing comparative information on the quality of health plans, hospitals, medical groups, individual physicians, nursing homes, and other providers of care.

press release

Combining Multiple Indicators of Clinical Quality: An Evaluation of Different Analytic Approaches.

David Reeves, PhD; Stephen M. Campbell, PhD; John Adams, PhD; Paul G. Shekelle, MD, PhD; Evan Kontopantelis, PhD; Martin O. Roland, DM
Medical Care. 45(6):489-496, June 2007.
Abstract HTML PDF (287 K)

Quality of Care in Hospitals with a High Percent of Medicaid Patients.

L Elizabeth Goldman, MD, MCR; Eric Vittinghoff, PhD; R Adams Dudley, MD, MBA
Medical Care. 45(6):480-488, June 2007.
Abstract HTML PDF (397 K)

AHRQ - Registries for Evaluating Patient Outcomes: A User's Guide

Gliklich RE, Dreyer NA, eds.

Prepared by Outcome DEcIDE Center

The purpose of this handbook co-funded by AHRQ and HHS' Centers for Medicare & Medicaid Services (CMS) is to serve as a reference for establishing, maintaining, and evaluating the success of registries created to collect data about patient outcomes. This book is divided into three sections: Creating, Operating, and Evaluating Registries.

"A patient registry is a database of confidential patient information that can be analyzed to understand and compare the outcomes and safety of health care.

The data may originate from multiple sources, including hospitals, pharmacy systems, physician practices, and insurance companies. Some registries include patients who have the same disease. Others are comprised of patients who have undergone a common surgical procedure or received a newly approved medication. " Press release

Registry Report home page

View the full HTML report

Open the Final Research Report (4M)

Open the summary version (1.1MB)

HCUP - Adverse Drug Events in US Hospitals, 2004.

Elixhauser A, Owens P.
HCUP Statistical Brief #29.
Rockville, MD: Agency for Healthcare Research and Quality;
April 2007.

pdf

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;334:1044
[Abstract] [Full text] [PDF]

Editorial

The value of administrative databases
Mohammed A Mohammed, Andrew Stevens
BMJ 2007;334:1014-1015,
[Extract] [Full text] [PDF]

Improving Quality Assessment through Multilevel Modeling: The Case of Nursing Home Compare

Greg Arling, Teresa Lewis, Robert L. Kane, Christine Mueller, Shannon Flood
Health Services Research 42 (2007) (3p1), 1177–1199.

Abstract References Full Text HTML Full Text PDF (194 KB)

Using hierarchical models to attribute sources of variation in consumer assessments of health care

Alan M. Zaslavsky
Statistics in Medicine Volume 26, Issue 8 , Pages 1885 - 1900

Abstract References PDF

Webcast of the International Forum on Quality and Safety in Health Care

http://barcelona.bmj.com/

This site allows you to watch the plenary sessions and discussions of the International Forum on Quality and Safety in Health Care. Barcelona - April 18th, 19th & 20th 2007

Forum Introduction Video

Can healthcare ever be safe?

Plenary 1: Donald Berwick Panel Discussion 1

What the quality movement can learn from other social movements

Plenary 2: Richard Smith Panel Discussion 2

When things go wrong: communicating about adverse events

Plenary 3: Lucian Leape, Linda Kenney Panel Discussion 3

WHO - Nine Patient Safety Solutions

The complete Patient Safety Solutions

The World Health Organization (WHO) launched nine patient safety solutions to reduce the toll of health care-related harm affecting patients worldwide.

Patient Safety Solutions are defined as: "Any system design or intervention that has demonstrated the abilityto prevent or mitigate patient harm stemming from the processes of health care."

Patient Safety Solutions Preamble (PDF)

1. Look-Alike, Sound-Alike Medication Names (PDF)

2. Patient Identification (PDF)

3. Communication During Patient Hand-Overs (PDF)

4. Performance of Correct Procedure at Correct Body Site (PDF)

5. Control of Concentrated Electrolyte Solutions (PDF)

6. Assuring Medication Accuracy at Transitions in Care (PDF)

7. Avoiding Catheter and Tubing Mis-Connections (PDF)

8. Single Use of Injection Devices (PDF)

9. Improved Hand Hygiene to Prevent Health Care-Associated Infection (HAI) (PDF)

View All Patient Safety Solutions Preamble and Nine Solutions (PDF)

Media:
News Release: Announcing WHO Collaborating Centre for Patient Safety Releases Nine Life-Saving Patient Safety Solutions

News Release Audio Recording: Nine Life-Saving Patient Safety Solutions


WHO: Patient safety

Webstream download link

AHRQs National Healthcare Quality and Disparities Reports: An Ever-Expanding Road Map for Improvement

Jeffrey Brady, Karen Ho, Edward Kelley, Carolyn M. Clancy
Health Services Research 42 (2007) (3p1), xi–xxi.

Summary References Full Text HTML Full Text PDF (69 KB)

Hospital Workload and Adverse Events.

Joel S. Weissman, PhD; Jeffrey M. Rothschild, MD, MPH; Eran Bendavid, MD; Peter Sprivulis, MBBS, PhD, Facem, FACHI; E Francis Cook, ScD; R Scott Evans, PhD; Yevgenia Kaganova, PhD; Melissa Bender, MD; JoAnn David-Kasdan, RN, MS; Peter Haug, MD; Jim Lloyd, BS; Leslie G. Selbovitz, MD; Harvey J. Murff, MD, MPH; David W. Bates, MD, MSc

Medical Care. 45(5):448-455, May 2007
Abstract HTML PDF (293 K)

The evaluation of health care outcomes and hospital performance indicators

[Article in French]
Chouaid C, Hejblum G, Guidet B, Valleron AJ.
Rev Mal Respir. 2006 Sep;23(4 Suppl):13S87-98.

Pubmed

Risk adjustment for inter-hospital comparison of primary cesarean section rates: need, validity and parsimony.

Fantini MP, Stivanello E, Frammartino B, Barone AP, Fusco D, Dallolio L, Cacciari P, Perucci CA.

BMC Health Serv Res. 2006 Aug 15;6:100.

[Abstract] [Full text] [PDF] [PubMed] [Related articles]

J Manag Care Pharm - Pay for Performance: Where’s the Return?

Volume 13 Issue 2 CE Supplement B March (pdf)

Smith AL.
Merging P4P and disease management: how do you know which one is working?
J Manag Care Pharm. 2007 Mar;13(2 Suppl B):S7-10.
Pubmed

O'Kane ME.
Performance-based measures: the early results are in.
J Manag Care Pharm. 2007 Mar;13(2 Suppl B):S3-6.
Pubmed

Properties of analysis methods that account for clustering in volume-outcome studies when the primary predictor is cluster size

Katherine S. Panageas, Deborah Schrag, A. Russell Localio, E. S. Venkatraman, Colin B. Begg
Statistics in Medicine Volume 26, Issue 9 , Pages 2017 - 2035

Abstract References PDF

How important is continuity of care?

Sudhakar-Krishnan, Vidya, Rudolf, Mary C J
Arch Dis Child 2007 92: 381-383

[Extract] [Full text] [PDF]

Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis

Robyn A Clark, Sally C Inglis, Finlay A McAlister, John G F Cleland, Simon Stewart
BMJ 2007;334:942, doi:10.1136/bmj.39156.536968.55
[Abstract] [Abridged PDF] [Full text] [PDF] [extra: References]

Editorial

Telephone interventions for disease management in heart failure
Hugo O Grancelli, Daniel C Ferrante
BMJ 2007;334:910-911, doi:10.1136/bmj.39197.577442.80
[Extract] [Full text] [PDF]

The American College of Surgeons’ Closed Claims Study: New Insights for Improving Care

Griffen FD, Stephens LS, Alexander JB, Bailey HR, Maizel SE, Sutton BH, Posner KL
Journal of the American College of Surgeons Volume 204, Issue 4, (April 2007) pages 561-569
Abstract Full Text Full-Text PDF (112 KB)

Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients

Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, Gawande AA

Journal of the American College of Surgeons- 2007 04 (Vol. 204, Issue 4) pages 533-540

Abstract Full Text Full-Text PDF (122 KB)

Expanded Surgical Time Out: A Key to Real-Time Data Collection and Quality Improvement

Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk Jr HC
Journal of the American College of Surgeons- 2007 04 (Vol. 204, Issue 4) pages 527-532
Abstract Full Text Full-Text PDF (92 KB)

Patient-Reported Outcomes Measurement Information System (PROMIS)

Medical Care May 2007, Volume 45, Issue 5 Suppl 1

Developing the Patient-Reported Outcomes Measurement Information System (PROMIS).
Deborah N. Ader, PhD
HTML PDF (86 K)

The Patient-Reported Outcomes Measurement Information System (PROMIS): Progress of an NIH Roadmap Cooperative Group During its First Two Years.
David Cella, PhD; Susan Yount, PhD; Nan Rothrock, PhD; Richard Gershon, PhD; Karon Cook, PhD; Bryce Reeve, PhD; Deborah Ader, PhD; James F. Fries, MD; Bonnie Bruce, DrPH, MPH, RD; Mattias Rose, MD; on behalf of the PROMIS Cooperative Group
Abstract HTML PDF (515 K)

Evaluation of Item Candidates: The PROMIS Qualitative Item Review.
Darren A. DeWalt, MD, MPH; Nan Rothrock, PhD; Susan Yount, PhD; Arthur A. Stone, PhD; on behalf of the PROMIS Cooperative Group
Abstract HTML PDF (352 K)

Psychometric Evaluation and Calibration of Health-Related Quality of Life Item Banks: Plans for the Patient-Reported Outcomes Measurement Information System (PROMIS).
Bryce B. Reeve; Ron D. Hays; Jakob B. Bjorner; Karon F. Cook; Paul K. Crane; Jeanne A. Teresi; David Thissen; Dennis A. Revicki; David J. Weiss; Ronald K. Hambleton; Honghu Liu; Richard Gershon; Steven P. Reise; Jin-shei Lai; David Cella; on behalf of the PROMIS Cooperative Group
Abstract HTML PDF (392 K)

Item Response Theory Analyses of Physical Functioning Items in the Medical Outcomes Study.
Ron D. Hays, PhD; Honghu Liu, PhD; Karen Spritzer, BS; David Cella, PhD
Abstract HTML PDF (908 K)

Practical Issues in the Application of Item Response Theory: A Demonstration Using Items From the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales.
Cheryl D. Hill, PhD; Michael C. Edwards, PhD; David Thissen, PhD; Michelle M. Langer, MA; R J. Wirth, MA; Tasha M. Burwinkle, PhD; James W. Varni, PhD
Abstract HTML PDF (516 K)

Considerations for Developing Interfaces for Collecting Patient-Reported Outcomes That Allow the Inclusion of Individuals With Disabilities.
Mark Harniss, PhD; Dagmar Amtmann, PhD; Debbie Cook, BS; Kurt Johnson, PhD
Abstract HTML PDF (257 K)

Enhancing Compliance With Medicare Guidelines for Surgical Infection Prevention

Experience With a Cross-disciplinary Quality Improvement Team
Laurence E. McCahill; John W. Ahern; Linda A. Gruppi; James Limanek; Gail A. Dion; Jessica A. Sussman; Christina B. McCaffrey; Diane B. Leary; Margaret B. Lesage; Richard M. Single
Arch Surg. 2007;142:355-361.

ABSTRACT FULL TEXT PDF

Quality Assessment in High-Acuity Surgery: Volume and Mortality Are Not Enough

Charles M. Vollmer, Jr; Wande Pratt; Tsafrir Vanounou; Shishir K. Maithel; Mark P. Callery
Arch Surg 2007 142: 371-380

ABSTRACT FULL TEXT PDF

Mistake-Proofing the Design of Health Care Processes.

www.ahrq.gov/qual/mistakeproof/

Grout JR. AHRQ Publication No. 07-P0020, May 2007.

This new report from Agency for Healthcare Research and Quality (AHRQ) is a synthesis of practical examples from the real world of health care on the use of process or design features to prevent medical errors or the negative impact of errors.

It contains over 150 examples of mistake-proofing that can be applied in health care—and in many cases relatively inexpensively.

PDF File (1.6 MB).

Improving emergency department efficiency by patient streaming to outcomes-based teams.

Kelly AM, Bryant M, Cox L, Jolley D.
Aust Health Rev. 2007 Feb;31(1):16-21.

Pubmed

A synthesis of the secondary literature on effectiveness of hospital avoidance and discharge programs.

Kumar S, Grimmer-Somers K.
Aust Health Rev. 2007 Feb;31(1):34-48.

Pubmed

Implementing Pay-for-Performance in the Neonatal Intensive Care Unit

Profit, Jochen, Zupancic, John A. F., Gould, Jeffrey B., Petersen, Laura A.
Pediatrics 2007 119: 975-982
[Abstract] [Full text] [PDF]

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)