Patient Safety First Campaign

www.patientsafetyfirst.nhs.uk

To implement the World Health Organization’s campaign to reduce the incidence of avoidable harm and death improving patient safety, the Patient Safety First Campaign seeks to provide NHS staff with the knowledge and support to take simple steps to improve the safety of patients in their care.

Measurement of Quality and Assurance of Safety in the Critically Ill

Peter J. Pronovost, J. Bryan Sexton, Julius Cuong Pham, Christine A. Goeschel, Bradford D. Winters, Marlene R. Miller

Clinics in Chest MedicineVolume 30, Issue 1, March 2009, Pages 169-179
Abstract Full Text Full-Text PDF (272 KB)

A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial

B. W. Jack, V. K. Chetty, D. Anthony, J. L. Greenwald, G. M. Sanchez, A. E. Johnson, S. R. Forsythe, J. K. O'Donnell, M. K. Paasche-Orlow, C. Manasseh, S. Martin and L. Culpepper
Ann Intern Med 2009; 178-187.
Abstract Full Text PDF

A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

Haynes, Alex B., Weiser, Thomas G., Berry, William R., Lipsitz, Stuart R., Breizat, Abdel-Hadi S., Dellinger, E. Patchen, Herbosa, Teodoro, Joseph, Sudhir, Kibatala, Pascience L., Lapitan, Marie Carmela M., Merry, Alan F., Moorthy, Krishna, Reznick, Richard K., Taylor, Bryce, Gawande, Atul A., the Safe Surgery Saves Lives Study Group
N Engl J Med 2009 360: 491-499

Abstract FREE Full Text PDF Supplementary Material

Principles for allocation of scarce medical interventions

Govind Persad, Alan Wertheimer, Ezekiel J Emanuel
The Lancet, Volume 373, Issue 9661, Pages 423-431
Preview Summary Full Text PDF

How good is your doctor? Click here to find out

Editorial
The Lancet Volume 373, Issue 9658, Page 96
Preview Full Text PDF

National Health Service website

Changes Over Time and Disparities in Schizophrenia Treatment Quality.

Busch, Alisa B., Lehman, Anthony F., Goldman, Howard; Frank, Richard G.
Medical Care Volume 47(2) February 2009 pp 199-207
Abstract HTML PDF (324 K)

Using Electronic Health Records to Measure Physician Performance for Acute Conditions in Primary Care

Empirical Evaluation of the Community-Acquired Pneumonia Clinical Quality Measure Set.
Jeffrey A. Linder; Erin O. Kaleba; Karen S. Kmetik
Medical Care Volume 47(2) February 2009 pp 208-216
Abstract HTML PDF (469 K)

Empirically Derived Composite Measures of Surgical Performance.

Douglas O. Staiger; Justin B. Dimick; Onur Baser; Zhaohui Fan; John D. Birkmeyer
Medical Care Volume 47(2) February 2009 pp 226-233
Abstract HTML PDF (313 K)

Identifying Potentially Avoidable Hospital Admissions From Canadian Long-Term Care Facilities.

Jennifer D. Walker; Gary F. Teare; David B. Hogan; Steven Lewis; Colleen J. Maxwell
Medical Care Volume 47(2) February 2009 pp 250-254
Abstract HTML PDF (420 K)

Assessing the effectiveness of quality improvement strategies in Europe: the MARQuIS project

Quality and Safety in Health Care 2009;18 (Suppl 1)

This supplement is focused on the methods, results and recommendations from the research project "Methods of Assessing Response to Quality Improvement Strategies" (MARQuIS). MARQuIS was funded by the Scientific Support to Policies component of the European Union Sixth Framework Research Programme (Contract SP21-CT-2004-513712), and it lasted from January 2004 to June 2008.

Improving the Quality of Health Care: Who Is Responsible for What?

J. Frank Wharam; Daniel Sulmasy
JAMA. 2009;301(2):215-217.
EXTRACT FULL TEXT PDF

Evaluating service delivery interventions to enhance patient safety

Celia Brown, Richard Lilford
BMJ 2008;337:a2764
[Extract] [Full text][PDF]

Comorbidity and repeat admission to hospital for adverse drug reactions in older adults: retrospective cohort study

Min Zhang, C D'Arcy J Holman, Sylvie D Price, Frank M Sanfilippo, David B Preen, Max K Bulsara
BMJ 2009;338:a2752
[Abstract] [Full text] [PDF]

Editorial


Readmissions as a result of adverse drug reactions in older people
Susan Morgan
BMJ 2009;338:a2436
[Extract] [Full text]

What's the Risk? A Simple Approach for Estimating Adjusted Risk Measures from Nonlinear Models Including Logistic Regression

Lawrence C. Kleinman, Edward C. Norton
Health Services Research Volume 44 Issue 1 p 288-302
Abstract References Full Text: HTML, PDF

Advancing Measurement of Patient Safety Culture

Liane Ginsburg, Debra Gilin, Deborah Tregunno, Peter G. Norton, Ward Flemons, Mark Fleming
Health Services Research Volume 44 Issue 1 p 205-224
Abstract References Full Text: HTML, PDF

Validity of Selected AHRQ Patient Safety Indicators Based on VA National Surgical Quality Improvement Program Data

Patrick S. Romano, Hillary J. Mull, Peter E. Rivard, Shibei Zhao, William G. Henderson, Susan Loveland, Dennis Tsilimingras, Cindy L. Christiansen, Amy K. Rosen
Health Services Research Volume 44 Issue 1 p 182-204
Abstract References Full Text: HTML, PDF

Building the Path to High-Quality Care

Carolyn Clancy
Health Services Research Volume 44 Issue 1 p 1-4
Abstract References Full Text: HTML, PDF (Size: 39K)

Comparison of Two VA Laboratory Data Repositories Indicates That Missing Data Vary Despite Originating From the Same Source.

Kathleen A. McGinnis; Melissa Skanderson; Forrest L. Levin; Cynthia Brandt; Joseph Erdos; Amy C. Justice

Medical Care Volume 47(1) January 2009 pp 121-124

Abstract HTML PDF (163 K)

Identification and Validation of Vertebral Compression Fractures Using Administrative Claims Data.

Jeffrey R. Curtis; Amy S. Mudano; Daniel H. Solomon; Juan Xi; Mary Elkins Melton; Kenneth G. Saag
Medical Care Volume 47(1) January 2009 pp 69-72
Abstract HTML PDF (163 K)

Patient Safety Climate in 92 US Hospitals: Differences by Work Area and Discipline.

Sara J. Singer; David M. Gaba; Alyson Falwell; Shoutzu Lin; Jennifer Hayes; Laurence Baker
Medical Care Volume 47(1) January 2009 pp 23-31
Abstract HTML PDF (363 K)

Public Reporting in Health Care: How Do Consumers Use Quality-of-Care Information?: A Systematic Review.

Marjan Faber; Marije Bosch; Hub Wollersheim; Sheila Leatherman; Richard Grol
Medical Care Volume 47(1) January 2009 pp 1-8
Abstract HTML PDF (292 K)

Do report cards tell consumers anything they don't know already? The case of Medicare HMOs.

Dafny L, Dranove D.
Rand J Econ. 2008 Autumn;39(3):790-821.
pubmed PDF

National Registry of Myocardial Infarction

Trends in presenting characteristics and hospital mortality among patients with ST elevation and non-ST elevation myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006
William J. Rogers, Paul D. Frederick, Edna Stoehr, John G. Canto, Joseph P. Ornato, C. Michael Gibson, Charles V. Pollack, Joel M. Gore, Nisha Chandra-Strobos, Eric D. Peterson, William J. French, for the National Registry of Myocardial Infarction Investigators
American Heart Journal, Volume 156, Issue 6, pages 1026-1034
Abstract Full Text Full-Text PDF (799 KB)

Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006
C. Michael Gibson, Yuri B. Pride, Paul D. Frederick, Charles V. Pollack, John G. Canto, Alan J. Tiefenbrunn, W. Douglas Weaver, Costas T. Lambrew, William J. French, Eric D. Peterson, William J. Rogers, for the NRMI Investigators
American Heart Journal, Volume 156, Issue 6, pages 1035-1044
Abstract Full Text Full-Text PDF (855 KB)


Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006
Eric D. Peterson, Bimal R. Shah, Lori Parsons, Charles V. Pollack, William J. French, John G. Canto, C. Michael Gibson, William J. Rogers, for the NRMI Investigators
American Heart Journal, Volume 156, Issue 6, pages 1045-1055
Abstract Full Text Full-Text PDF (1132 KB)

Interruptions in Medicaid Coverage and Risk for Hospitalization for Ambulatory Care–Sensitive Conditions

A. B. Bindman, A. Chattopadhyay and G. M. Auerback
Ann Intern Med 2008; 854-860.

Abstract Full Text PDF

Measuring Hospital Inefficiency: The Effects of Controlling for Quality and Patient Burden of Illness

Ryan L. Mutter, Michael D. Rosko, Herbert S. Wong
Health Services Research Volume 43 Issue 6 (December 2008): p 1992-2013
Abstract References Full Text: HTML, PDF

Physician Autonomy and Informed Decision Making: Finding the Balance for Patient Safety and Quality

Simon C. Mathews; Peter J. Pronovost
JAMA. 2008;300(24):2913-2915.
EXTRACT FULL TEXT PDF

Planning a patient’s discharge from hospital

Srinivasa Vittal Katikireddi, Geoffrey Christopher Cloud
BMJ 2008;337:a2694, doi: 10.1136/bmj.a2694
Extract Full text

Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008.

http://www.jointcommissionreport.org/

An analysis of National Patient Safety Goal compliance and hospital quality measures related to heart attacks, heart failure, pneumonia, or surgical conditions, provides scientific evidence of improved patient care according to data gathered by the Joint Commission from nearly 1,500 institutions.

Finding order in heterogeneity: types of quality-improvement intervention publications

L V Rubenstein, S Hempel, M M Farmer, S M Asch, E M Yano, D Dougherty, and P W Shekelle
Qual Saf Health Care 2008; 17: 403-408.
[Abstract] [Full text] [PDF]

Falls in English and Welsh hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports

F Healey, S Scobie, D Oliver, A Pryce, R Thomson, and B Glampson
Qual Saf Health Care 2008; 17: 424-430.
[Abstract] [Full text] [PDF]

Do falls and falls-injuries in hospital indicate negligent care—and how big is the risk?

A retrospective analysis of the NHS Litigation Authority Database of clinical negligence claims, resulting from falls in hospitals in England 1995 to 2006
D Oliver, S Killick, T Even, and M Willmott
Qual Saf Health Care 2008; 17: 431-436.
[Abstract] [Full text] [PDF]

A model to evaluate quality and effectiveness of disease management

K M M Lemmens, A P Nieboer, C P van Schayck, J D Asin, and R Huijsman
Qual Saf Health Care 2008; 17: 447-453.
[Abstract] [Full text] [PDF]

Assessment of the implementation of a national patient safety alert to reduce wrong site surgery

P Rhodes, S J Giles, G A Cook, A Grange, R Hayton, M J Maxwell, T A Sheldon, and J Wright
Qual Saf Health Care 2008; 17: 409-415.
[Abstract] [Full text] [PDF]


Editorial

The egocentric surgeon or the roots of wrong side surgery
John W Senders and Regine Kanzki
Qual Saf Health Care 2008; 17: 396-400.
[Extract] [Full text] [PDF]

Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback

P Garnerin, M Arès, A Huchet, and F Clergue
Qual Saf Health Care 2008; 17: 454-458.
[Abstract] [Full text] [PDF]

Adverse-event-reporting practices by US hospitals: results of a national survey

D O Farley, A Haviland, S Champagne, A K Jain, J B Battles, W B Munier, and J M Loeb
Qual Saf Health Care 2008; 17: 416-423.
[Abstract] [Full text] [PDF]

Editorial

The frustrating case of incident-reporting systems
Kaveh G Shojania
Qual Saf Health Care 2008; 17: 400-402.
[Extract] [Full text] [PDF]

Medical Acceptance of Quality Assurance in Health Care: The French Experience

Alexandra Giraud-Roufast; Jean Michel Chabot
JAMA. 2008;300(22):2663-2665.
EXTRACT FULL TEXT PDF

Do specialty cardiac hospitals have greater adherence to acute myocardial infarction and heart failure process measures?

An empirical assessment using Medicare quality measures: Quality of care in cardiac specialty hospitals
Ioana Popescu, M.D., M.P.H., Brahmajee K. Nallamothu, M.D., M.P.H., Mary S. Vaughan-Sarrazin, Ph.D., and Peter Cram, M.D., M.B.A.,
2008 American Heart Journal 156(1), pp. 155–160.
Abstract Full Text Full-Text PDF (184 KB)

How Many Nurses per Patient? Measurements of Nurse Staffing in Health Services Research

Joanne Spetz, Nancy Donaldson, Carolyn Aydin, Diane S. Brown
Health Services Research Volume 43 Issue 5p1 : p 1674-1692
Abstract References Full Text: HTML, PDF

Hospital Quality, Efficiency, and Input Slack Differentials

Vivian G. Valdmanis, Michael D. Rosko, Ryan L. Mutter

2008 Health Services Research 43 (5, Part 2): p 1830-1848
Abstract References Full Text: HTML, PDF

Examining quality improvement programs: The case of Minnesota hospitals

Olson, J.R., Belohlav, J.A., Cook, L.S., and Hays, J.M.
2008 Health Services Research 43 (5, Part 2): pp.1787-1806.
Abstract References Full Text: HTML, PDF

Doctors, Dollars & Quality: A Health Affairs Web Exclusive Package

A package of papers and perspectives published on the Health Affairs Web site explore the relationships among the supply of doctors, the composition of the physician workforce, the quality of health care and overall health spending.

http://content.healthaffairs.org/cgi/content/full/hlthaff.28.1.w87/DC2

Choosing The Best Hospital: The Limitations Of Public Quality Reporting

Michael B. Rothberg, Elizabeth Morsi, Evan M. Benjamin, Penelope S. Pekow, and Peter K. Lindenauer
Health Affairs, November/December 2008; 27(6): 1680-1687.
[Abstract] [Full Text] [Figures Only] [PDF] [Online Appendix]

Focusing Measures for Performance-Based Privileging of Physicians on Improvement

Myers, Sarah S.; Clark, Marta D.; Russell, Jennifer A.; Graham, Camille C.; Stultz, Michelle B.; Reidy, Kevin M.
Joint Commission Journal on Quality and Patient Safety Volume 34, Number 12, December 2008 , pp. 724-733(10)
abstract

IOM - Resident Duty Hours: Enhancing Sleep, Supervision, and Safety

This report from the Institute of Medicine (IOM), asserts that revisions to medical residents’ workloads and duty hours are necessary to better protect patients against fatigue-related errors and to enhance the learning environment for doctors in training.

link

Revisiting Duty-Hour Limits -- IOM Recommendations for Patient Safety and Resident Education

Iglehart, John K.
N Engl J Med 2008 0: NEJMp0808736
full text PDF

Hospital-wide Code Rates and Mortality Before and After Implementation of a Rapid Response

TeamPaul S. Chan; Adnan Khalid; Lance S. Longmore; Robert A. Berg; Mikhail Kosiborod; John A. Spertus
JAMA. 2008;300(21):2506-2513.
ABSTRACT FULL TEXT PDF

Information exchange among physicians caring for the same patient in the community

Carl van Walraven, MD MSc, Monica Taljaard, PhD, Chaim M. Bell, MD PhD, Edward Etchells, MD MSc, Kelly B. Zarnke, MD, Ian G. Stiell, MD MSc, and Alan J. Forster, MD MSc
CMAJ 2008 179: 1013-1018.
[Abstract] [Full Text] [PDF]

Commentary

Strengthening primary care with better transfer of information
Robert J. Reid and Edward H. Wagner
CMAJ 2008 179: 987-988.
[Full Text] [PDF]

Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events.

J M Aranaz-Andrés, C Aibar-Remón, J Vitaller-Murillo, P Ruiz-López, R Limón-Ramírez, E Terol-García, and the ENEAS work group
J Epidemiol Community Health 2008; 62: 1022-1029.
[Abstract] [Full text] [PDF]

AHRQ - Nursing Home Survey on Patient Safety Culture

Sorra J, Franklin M, Streagle S.
Agency for Healthcare Research and Quality

• Survey Forms (PDF File, 75 KB; Word® File, 170 KB).
• Items and Dimensions (PDF File, 22 KB; Word® File, 60 KB).
• User's Guide (PDF File, 290 KB).

How a simple checklist can dramatically reduce medical errors.

Pronovost PJ.
On Call. IHI Open School for Health Professionals. November 2008.
link

IHI Open School’s On Call audio conference series

Active Bed Management by Hospitalists and Emergency Department Throughput

E. Howell, E. Bessman, S. Kravet, K. Kolodner, R. Marshall and S. Wright
Ann Intern Med 2008; 804-810.
Abstract Full Text PDF

Patient-safety reforms inhibited by systemic impediments

Silversides, Ann
CMAJ 2008 179: 1253-1255
[Full Text] [PDF]

The Canadian Healthcare Safety Symposium 8
visit the speakers page to download individual documents

Pediatric Aspects of Inpatient Health Information Technology Systems

Council on Clinical Information Technology
Pediatrics 2008; 122: e1287-e1296.
[Abstract] [Full text] [PDF]

Quality of Care for Common Pediatric Respiratory Illnesses in United States Emergency Departments

Analysis of 2005 National Hospital Ambulatory Medical Care Survey Data
Jane F. Knapp, Stephen D. Simon, and Vidya Sharma
Pediatrics 2008; 122: 1165-1170.
[Abstract] [Full text] [PDF]

Quality of Inpatient Care for Asthma: Challenges and Opportunities
Meyer KattanPediatrics 2008; 122: 1369-1370.
[Extract] [Full text] [PDF]

IHI Open School for Health Professions

Case studies, podcasts, videos, featured articles — and a bounty of other free online resources from the Institute for Healthcare Improvement

• Overview
• Courses
• Audio
• Video

HHS - Quality Measure Inventory

The Department of Health and Human Services (HHS) released the first-ever inventory of quality measures that are used for reporting, payment, or quality improvement by its agencies and operating divisions.

The HHS measure inventory is available on the National Quality Measures Clearinghouse, a Web site of the Agency for Healthcare Research and Quality (AHRQ) link

HHS Measures is available for download in Excel

The Lessons of Success — Revisiting the Medicare Story

D. Blumenthal and J. Morone
N Engl J Med 2008 359: 2384-2389
Extract FREE Full Text PDF

Is health care getting safer?

Charles Vincent, Paul Aylin, Bryony Dean Franklin, Alison Holmes, Sandra Iskander, Ann Jacklin, Krishna Moorthy
BMJ 2008;337:a2426
extract Full text PDF

Medical mistakes, when things are left behind.

Freed T. KSEE 24 News. November 11, 2008.
video

Complex Surgical Site Infections and the Devilish Details of Risk Adjustment: Important Implications for Public Reporting

Deverick J. Anderson, Luke F. Chen, Daniel J. Sexton, Keith S. Kaye
Infection Control and Hospital Epidemiology 2008 29:10, 941-946
Abstract-Full Text-PDF Version (291 kB)

Risk adjustment performance of Charlson and Elixhauser comorbidities in ICD-9 and ICD-10 administrative databases

Bing Li, Dewey Evans, Peter Faris, Stafford Dean, Hude Quan
BMC Health Services Research 2008, 8:12 (14 January 2008)
[Abstract] [Full text] [PDF] [PubMed] [Related articles]

Electronic Health Record Components and the Quality of Care.

Salomeh Keyhani, MD; Paul L. Hebert, PhD; Joseph S. Ross, MD, MHS; Alex Federman, MD, MPH; Carolyn W. Zhu, PhD; Albert L. Siu, MD, MSPH
Medical Care. 46(12):1267-1272, December 2008.
Abstract HTML PDF (228 K)

Blueprint for a New American College of Surgeons: National Surgical Quality Improvement Program .

J . Birkmeyer , D . Shahian , J . Dimick , S . Finlayson , D . Flum , C . Ko , B . Hall
Journal of the American College of Surgeons , Volume 207 , Issue 5 , Pages 777 - 782
Full Text Full-Text PDF (106 KB)

Mental Illness and Hospitalization for Ambulatory Care Sensitive Medical Conditions.

Yue Li, PhD; Laurent G. Glance, MD; Xueya Cai, PhD; Dana B. Mukamel, PhD
Medical Care. 46(12):1249-1256, December 2008.
Abstract HTML PDF (325 K)

Does interhospital transfer improve outcome of acute myocardial infarction? A propensity score analysis from the Cardiovascular Cooperative Project

John M Westfall, Catarina I Kiefe, Norman W Weissman, Anthony Goudie, Robert M Centor, O Dale Williams, Jeroan J Allison
BMC Cardiovascular Disorders 2008, 8:22
[Abstract] [Full text] [PDF] [PubMed] [Related articles]

Role of routines in collaborative work in healthcare organisations

Trisha Greenhalgh
BMJ 2008;337:a2448, doi: 10.1136/bmj.a2448
extract Full text PDF of print issue

Quality improvement scheme hopes to save authority £17m in first year

Zosia Kmietowicz
BMJ 2008;337:a1884
[Extract] [Full text]

SQUIRE: Standards for QUality Improvement Reporting Excellence

SQUIRE arrives—with a plan for its own improvement
David P Stevens and Richard Thomson
Qual Saf Health Care 2008; 17 (Suppl 1): i1-i2.
[Extract] [Full text] [PDF]

Publication guidelines for quality improvement in health care: evolution of the SQUIRE project
F Davidoff, P Batalden, D Stevens, G Ogrinc, S Mooney for the SQUIRE development group
Qual Saf Health Care 2008; 17 (Suppl 1): i3-i9.
[Abstract] [Full text] [PDF]

QIR and SQUIRE: continuum of reporting guidelines for scholarly reports in healthcare improvement
R G Thomson and F M Moss
Qual Saf Health Care 2008; 17 (Suppl 1): i10-i12.
[Extract] [Full text] [PDF]

The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration
G Ogrinc, S E Mooney, C Estrada, T Foster, D Goldmann, L W Hall, M M Huizinga, S K Liu, P Mills, J Neily, W Nelson, P J Pronovost, L Provost, L V Rubenstein, T Speroff, M Splaine, R Thomson, A M Tomolo, and B Watts
Qual Saf Health Care 2008; 17 (Suppl 1): i13-i32.
[Abstract] [Full text] [PDF]

When things go wrong.

Institute for Healthcare Improvement. Campaign Live. August 18, 2008.
PSNet link

Early Readmissions to the Department of Medicine as a Screening Tool for Monitoring Quality of Care Problems.

Uri Balla, Stephen Malnick, Ami Schattner
Medicine. 87(5):294-300, September 2008.
Abstract HTML PDF (89 K)

Joint Commission Journal on Quality and Patient Safety, Volume 34, Number 10, October 2008

Handoffs Causing Patient Harm: A Survey of Medical and Surgical House Staff pp. 563-570D(8)
Kitch, Barrett T.; Cooper, Jeffrey B.; Zapol, Warren M.; Marder, Jessica E.; Karson, Andrew; Hutter, Matt; Campbell, Eric G.

Adverse Events During Hospitalization: Results of a Patient Survey
pp. 583-590(8)
Fowler, Floyd J.; Epstein, Arnold; Weingart, Saul N.; Annas, Catherine L.; Bolcic-Jankovic, Dragana; Clarridge, Brian; Schneider, Eric C.; Weissman, Joel S.

Developing Process-Support Tools for Patient Safety: Finding the Balance Between Validity and Feasibility
pp. 604-607(4)
Marsteller, Jill A.; Holzmueller, Christine G.; Makary, Martin; Sexton, J. Bryan; Thompson, David A.; Lubomski, Lisa H.; Pronovost, Peter J.

The Daily Goals Communication Sheet: A Simple and Novel Tool for Improved Communication and Care
pp. 608-613(6)
Schwartz, Jamie M.; Nelson, Kristen L.; Saliski, Mary; Hunt, Elizabeth A.; Pronovost, Peter J.

The Team Checkup Tool: Evaluating QI Team Activities and Giving Feedback to Senior Leaders
pp. 619-623(5)
Lubomski, Lisa H.; Marsteller, Jill A.; Hsu, Yea-Jen; Goeschel, Christine A.; Holzmueller, Christine G.; Pronovost, Peter J.

Nosocomial Infection, the Deficit Reduction Act, and Incentives for Hospitals

Nicholas Graves; John E. McGowan Jr
JAMA. 2008;300(13):1577-1579.
EXTRACT FULL TEXT PDF

Getting Real Performance Out of Pay-for-Performance

SEAN NICHOLSON, MARK V. PAULY, ANITA YA JUNG WU, JAMES F. MURRAY, STEVEN M. TEUTSCH, MARC L. BERGER
Milbank Quarterly Volume 86 Issue 3, Pages 435 - 457
Abstract References Full Text: HTML, PDF

Modifying ICD-9-CM Coding of Secondary Diagnoses to Improve Risk-Adjustment of Inpatient Mortality Rates

Pine, Michael, Jordan, Harmon S., Elixhauser, Anne, Fry, Donald E., Hoaglin, David C., Jones, Barbara, Meimban, Roger, Warner, David, Gonzales, Junius
Med Decis Making 2008 0: 0272989X08323297
Abstract

Benchmarking Physical Therapy Clinic Performance: Statistical Methods to Enhance Internal Validity When Using Observational Data

Resnik, Linda, Liu, Dawei, Hart, Dennis L, Mor, Vince
PHYS THER 2008 88: 1078-1087
[Abstract] [Full Text] [PDF]

AHRQ Annual Meeting and AHRQ Quality Indicators User Meeting

www.qualityindicators.ahrq.gov/presentations.htm

The Quality Indicators Support Team hosted the 2008 QI Users Meeting in conjunction with the AHRQ Annual Meeting.
This meeting included presentations on:

• Patient Safety Indicator validation efforts
• tiering of the QIs
• public reporting of the QIs

Impact of date stamping on patient safety measurement in patients undergoing CABG: Experience with the AHRQ Patient Safety Indicators

Laurent G Glance, Yue Li, Turner M Osler, Dana B Mukamel, Andrew W Dick
BMC Health Services Research 2008, 8:176 (13 August 2008)
[Abstract] [Full text] [PDF]

AHRQ - Quality Indicators Learning Institute

www.ahrq.gov/QILearningInstitute/

The intent of the AHRQ Quality Indicators Learning Institute is to promote open discussions and interactions among program leaders, policymakers, researchers, and other experts involved in developing public reporting systems.

The "Introduction to the AHRQ QI Learning Institute" Webinar was held on July 30, 2008. Select to access the slide presentation (PowerPoint® presentation [950 KB]; Web version) and the Webinar transcript.

The Webinar "AHRQ Quality Indicators 101: Background and Introduction to the AHRQ QIs" was held on September 17, 2008. Select to access the slide presentation (PowerPoint® presentation [1.8 MB]; Web version) and the Webinar transcript).

The Tipping Point: The Relationship Between Volume and Patient Harm

Alberta T. Pedroja
American Journal of Medical Quality 2008 23: 336-341.
[Abstract] [PDF]

An Innovative Method to Assess Negotiation Skills Necessary for Quality Improvement

Prathibha Varkey, Priyanka Gupta, and Kevin E. Bennet
American Journal of Medical Quality 2008 23: 350-355.
[Abstract] [PDF]

Transition from pediatric to adult services: are we getting it right?.

Andrew Kennedy; Susan Sawyer
Current Opinion in Pediatrics. 20(4):403-409, August 2008.
Abstract HTML PDF (111 K)

The Quality and Disparities Reports: Why Is Progress So Slow?

Jeffrey Brady, Karen Ho, and Carolyn M. Clancy
American Journal of Medical Quality 2008 23: 396-398.
[PDF]

Ranking Hospitals on Surgical Quality: Does Risk-Adjustment Always Matter?

J . Dimick , J . Birkmeyer
Journal of the American College of Surgeons , Volume 207 , Issue 3 , Pages 347 - 351
Abstract Full Text Full-Text PDF (145 KB)

AHRQ - Common Formats for event reporting to Patient Safety Organizations

www.pso.ahrq.gov/formats/commonfmt.htm

The Agency for Healthcare Research and Quality (AHRQ) coordinates the development of Common Formats for event reporting to Patient Safety Organizations (PSOs). This activity is authorized by the Patient Safety and Quality Improvement Act of 2005 (the Patient Safety Act).

The Common Formats optimize the opportunity for the public and private sectors to learn more about trends and patterns in patient safety, with the purpose of improving health care quality.

How Many Nurses per Patient? Measurements of Nurse Staffing in Health Services Research

Joanne Spetz, Nancy Donaldson, Carolyn Aydin, Diane S. Brown

Health Services ResearchVolume 43 Issue 5p1 (October 2008): p 1674-1692
Abstract HTML PDF Supporting information

FDA Patient Safety News

www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/index.cfm

A Video News Show for Health Professionals from Food and Drug Administration (FDA) that offers information on common types of medical errors.

Does Hospital Performance on Process Measures Directly Measure High Quality Care or Is It a Marker of Unmeasured Care?

Rachel M. Werner, Eric T. Bradlow, David A. Asch
Health Services ResearchVolume 43 Issue 5p1 (October 2008): 1464-1484
Abstract HTML PDF Supporting information


Editorial
Reflections on Improving Hospital Performance
Ann Barry Flood, Marie-Claire Rosenberg
Health Services ResearchVolume 43 Issue 5p1 (October 2008): 1457-1463
Abstract HTML, PDF

Development and Evaluation of the Institute for Healthcare Improvement Global Trigger Tool.

David C. Classen; Robert C. Lloyd; Lloyd Provost; Frances A. Griffin; Roger Resar
Journal of Patient Safety. 4(3):169-177, September 2008.
Abstract HTML PDF (681 K)

Questionable hospital chart documentation practices by physicians.

Sharma R, Kostis WJ, Wilson AC, et al.
J Gen Intern Med. 2008 Aug 27; [Epub ahead of print].
Pubmed

Testing the hospital value proposition: An empirical analysis of efficiency and quality.

Huerta, Timothy R.; Ford, Eric W.; Peterson, Lori T.; Brigham, Keith H.
Features Health Care Management Review. 33(4):341-349, October/December 2008.
Abstract Fulltext PDF (107 K)

The Potential Effects Of HEDIS Performance Measures On The Quality Of Care

David M. Eddy, L. Gregory Pawlson, David Schaaf, Barbara Peskin, Andrei Shcheprov, Julia Dziuba, Jill Bowman, and Benjamin Eng
Health Affairs, September/October 2008; 27(5): 1429-1441.
[Abstract] [Full Text] [Figures Only] [PDF]

Pay for Performance -- Emerging Models of provider-Payment Reform

Rosenthal, Meredith B.Beyond
N Engl J Med 2008 359: 1197-1200
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Care Platforms: A Basic Building Block For Care Delivery

Richard M.J. Bohmer and David M. Lawrence
Health Affairs, September/October 2008; 27(5): 1336-1340.
[Abstract] [Full Text] [PDF]

A Survey of Hospital Quality Improvement Activities

Alan B. Cohen, Joseph D. Restuccia, Michael Shwartz, Jennifer E. Drake, RayKang, Peter Kralovec, Sally K. Holmes, Frances Margolin, and Deborah Bohr
Med Care Res Rev 2008;65 571-595
[Abstract] [PDF] [References]

Hospitalists And Care Transitions: The Divorce Of Inpatient And Outpatient Care

Hoangmai H. Pham, Joy M. Grossman, Genna Cohen, and Thomas Bodenheimer
Health Affairs, September/October 2008; 27(5): 1315-1327.
[Abstract] [Full Text] [PDF] [Online Supplement]

Statistical modeling of the volume-outcome effect for carotid endarterectomy for 10 years of a statewide database

Susanna M. Nazarian, Gayane Yenokyan, Richard E. Thompson, Michael E. Griswold, David C. Chang, Bruce A. Perler
J Vasc Surg. 2008 Aug;48(2):343-50
Abstract Full Text Full-Text PDF (367 KB)

Discussion
ageJ Vasc Surg. 2008 Aug;48(2): 360-361
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Self reported receipt of care consistent with 32 quality indicators

national population survey of adults aged 50 or more in England
Nicholas Steel, Max Bachmann, Susan Maisey, Paul Shekelle, Elizabeth Breeze, Michael Marmot, David Melzer
BMJ 2008;337:a957
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Bridging From the Picker Hospital Survey to the CAHPS(R) Hospital Survey.

Denise D. Quigley, PhD; Marc N. Elliott, PhD; Ron D. Hays, PhD; David J. Klein, MS; Donna O. Farley, PhD
Medical Care. 46(7):654-661, July 2008.
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AHRQ - Informed Decisions Toolbox

Finding and Using Management Research Evidence

To promote evidence-based management in health care, the Agency for Healthcare Research and Quality (AHRQ) funded development of tools to help decisionmakers find and interpret evidence related to decisions.

http://www.ahrq.gov/research/decisiontoolbx.htm#top