Health Serv Res - Physician Visits, Hospitalizations, and Socioeconomic Status

Ambulatory Care Sensitive Conditions in a Canadian Setting
Leslie L. Roos, Randy Walld, Julia Uhanova, Ruth Bond
Health Serv Res. 2005 Aug;40(4):1167-8
Pubmed

Editorial
The persistent challenge of avoidable hospitalizations.
Clancy CM
Health Serv Res. 2005 Aug;40(4):953-6
Pubmed

AHRQ - Chronic Condition Indicator

The Chronic Condition Indicator is one in a family of databases and software tools developed as part of the Healthcare Cost and Utilization Project (HCUP), it provides an easy way for users to categorize ICD-9-CM diagnosis codes as either "chronic" or "not chronic."

The Chronic Condition Indicator is created to facilitate health services research on diagnoses using administrative data. This classification system allows researchers to readily determine if a diagnosis is a chronic condition. In addition, the tool groups all diagnoses into body systems so that users can create indicators listing which specific body systems are affected by a chronic condition.

Chronic Condition Indicator

Am J Med Qual - Relationship between performance measurement and accreditation

implications for quality of care and patient safety
Miller MR, Pronovost P, Donithan M, Zeger S, Zhan C, Morlock L, Meyer GS Am J Med Qual. 2005 Sep-Oct;20(5):239-52.
[Abstract] [PDF] [References]

Am J Med Qual -Training Health Care Professionals for Patient Safety

American Journal of Medical Quality 2005 20: 277-279.
Carolyn M. Clancy
[PDF] [References]

Ann Intern Med - Hospital at Home

Feasibility and Outcomes of a Program To Provide Hospital-Level Care at Home for Acutely Ill Older Patients
Bruce Leff, Lynda Burton, Scott L. Mader, Bruce Naughton, Jeffrey Burl, Sharon K. Inouye, William B. Greenough, III, Susan Guido, Christopher Langston, Kevin D. Frick, Donald Steinwachs, and John R. Burton
Ann Intern Med. 2005 Dec 6;143(11):798-808
Abstract Full Text PDF

Editorial
Hospital at Home: The Evidence Is Not Compelling
Sasha Shepperd
Ann Intern Med. 2005 Dec 6;143(11):840-1
Full Text PDF

NASHP - Maximizing the Use of State Adverse Event Data to Improve Patient Safety

During the nearly six years since the Institute of Medicine released its first report on medical errors, there has been growing recognition of the size and scope of the problem.
Many US states have responded by creating or improving reporting systems for collecting hospital-based adverse events. As of September 2005, twenty-four states had passed legislation or regulation related to hospital reporting of adverse events.

In May 2005, National Academy for State Health Policy (NASHP) convened a meeting of data collectors, analysts, and users to identify mechanisms to improve reporting, tools used for event report analysis and dissemination, and opportunities for improvement.
This report reviews key findings from the meeting to assist states in improving their reporting systems and to encourage providers to improve the quality of the required reports so that data are credible and useful in shaping patient safety improvement interventions.

Full text

saferhealthcare - Out of the Shadows

Raising the Profile of healthcare associated infections (HCAI)
saferhealthcare.org.uk - 14 December 2005
Brian Duerden
Read

Int J Qual Health Care - Economic modeling of methods to stimulate quality improvement

Karen Eggleston
Int J Qual Health Care 2005 17: 521-531
[Abstract] [Full Text] [PDF]

Qual Saf Health Care - Narrative methods in quality improvement research

T Greenhalgh, J Russell and D Swinglehurst
Qual Saf Health Care 2005; 14: 443-449
[Abstract] [Full text] [PDF]

Int J Qual Health Care - Policymaker use of quality of care information

Jacqueline J. Fickel and Carol R. Thrush
Int J Qual Health Care 2005 17: 497-504
[Abstract] [Full Text] [PDF]

Pediatrics - Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system

Han YY, Carcillo JA, Venkataraman ST, et al.
Pediatrics. 2005;116:1506-1512.
Pubmed

Int J Qual Health Care - A performance assessment framework for hospitals

the WHO regional office for Europe PATH project
J. Veillard, F. Champagne, N. Klazinga, V. Kazandjian, O. A. Arah, and A.-L. Guisset
Int J Qual Health Care 2005 17: 487-496
[Abstract] [Full Text] [PDF]

BMJ - Scottish health service is ordered to release data on surgeons’ performance

Bryan Christie
BMJ 2005;331:1424
[Extract] [Abridged PDF] [Full text]

Anesthesiology - Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients

Haller G, Myles PS, Wolfe R, Weeks AM, Stoelwinder J, McNeil J.
Anesthesiology. 2005;103:1121-1129.
PubMed

Qual Saf Health Care - Control, compare and communicate

designing control charts to summarise efficiently data from multiple quality indicators
B Guthrie, T Love, T Fahey, A Morris, and F Sullivan
Qual Saf Health Care 2005; 14: 450-454
[Abstract] [Full text] [Web-only figures] [PDF]

Int J Qual Health Care - Patient perspectives of patient–provider communication after adverse events

Christine W. Duclos, Mary Eichler, Leslie Taylor, Javan Quintela, Deborah S. Main, Wilson Pace, and Elizabeth W. Staton
Int J Qual Health Care 2005 17: 479-486
[Abstract] [Full Text] [PDF]

Health Affairs - Blind faith and choice

Edwards RT
Health Affairs, Vol 24, Issue 6, 1624-1628
full text

J Gen Intern Med - What can hospitalized patients tell us about adverse events?

Learning from patient-reported incidents.
Weingart SN, Pagovich O, Sands DZ, et al.
J Gen Intern Med 2005 Sep; 20(9):830-836.
Pubmed

ACSQ - Australian Council for Safety and Quality in Health Care Annual Report 2005

This sixth report is the last formal report to Health Ministers as the Australian Council for Safety and Quality in Health Care’s (Council) agreed extended term will finish in June 2006. It is set against a background of the Ministerial Review of future governance arrangements for safety and quality in health care.

This report builds on all five previous reports to Australian Health Ministers, provides a summary of achievements since Council’s inception in 2000 and identifies the foundation for future directions in safety and quality in Australia that has been built with the active support of many stakeholders.

final report

Australian Health Ministers Agree on New Safety and Quality Measures

Ministers agreed that the Australian Council for Safety and Quality in Health Care, which was established in January 2000, will be succeeded by a national body called the Australian Commission on Safety and Quality in Health Care which will report to Health Ministers and be closely linked to health departments and other government and non-government health bodies.

Ministers agreed with the Review finding (see previous news) that it was crucial that the state of safety and quality in the Australian health care system be regularly measured and reported publicly, and a new Australian Commission on Safety and Quality in Health Care would be charged with publishing a national report every two years.

read more

JAMA - The Long Road to Patient Safety

A Status Report on Patient Safety Systems
Daniel R. Longo; John E. Hewett; Bin Ge; Shari Schubert
JAMA. 2005;294:2858-2865.
ABSTRACT FULL TEXT PDF


Editorial
Creating a Safer Health Care System: Finding the Constraint
Stephen G. Pauker; Ellen M. Zane; Deeb N. Salem
JAMA. 2005;294:2906-2908.
EXTRACT FULL TEXT PDF

IOM - Performance Measurement: Accelerating Improvement

This is the first report in the Institute of Medicine (IOM) Pathways to Quality Health Care series, each report will be focused on a specific policy approach to improving the quality of health care.

This report focuses on the selection of measures to support the quality improvement efforts of a diverse set of stakeholders, and on the creation of a common infrastructure for guiding and managing aconsistent set of such measures nationally and regionally.

www.iom.edu/report.asp?id=31310

WHO - Draft Guidelines for Adverse Event Reporting and Learning Systems

World Health Organisation - World Alliance for Patient Safety is launching the new Draft Guidelines for Adverse Event Reporting and Learning Systems. The guidelines are being made available worldwide to facilitate the development of new and improved reporting systems for patient safety .

The primary importance of reporting systems is to learn from experience and mistakes, and to use these results as a basis for implementing preventive action in the future. The Alliance efforts in this area facilitate the compilation and interpretation of international data on adverse events for early detection of potential problems and sharing of results to ensure that solutions are developed.

The draft guidelines aim to support countries to select, adapt or modify the recommendations to improve their reporting. The guidelines will undergo modification over time as experiences accumulate.

More information [pdf 1.20Mb]

Department of Health - Surveillance of surgical site infection in orthopaedic surgery

Surveillance of surgical site infection following orthopaedic surgery has been included in the mandatory healthcare-associated infection surveillance system in England since April 2004.

The surveillance is managed by the Health Protection Agency on behalf of the Department of Health. Data is collected as part of the Surgical Site Infection Surveillance Service (SSISS), which has supported voluntary surveillance in several categories of surgical procedure since 1997.

Surgical Site Infection Surveillance Service (SSISS) has recently published the first annual report:

Mandatory surveillance of surgical site infection in orthopaedic surgery, report of data collected between April 2004 and March 2005

JAMA - Clinical Decision Support and Appropriateness of Antimicrobial Prescribing

A Randomized Trial
Matthew H. Samore, Kim Bateman, Stephen C. Alder, Elizabeth Hannah, Sharon Donnelly, Gregory J. Stoddard, Bassam Haddadin, Michael A. Rubin, Jacquelyn Williamson, Barry Stults, Randall Rupper, and Kurt Stevenson
JAMA. 2005;294:2305-2314.
ABSTRACT FULL TEXT

-----------------------------------------------------

The Institute of Healthcare Improvement has partnered with JAMA, with the help of The Robert Wood Johnson Foundation, to facilitate the transition of science into practice through the series “Author in the Room."

In this series, the author of a study published in JAMA with the potential to change clinical practice will talk with clinicians during a conference call, facilitated by clinical experts in implementing changes in practice.

Read the editorial (DeAngelis, C., MD, MPH, Berwick, D., MP, MPP. JAMA. 2005;293:1004.)

Wednesday, December 21, 2005 Author in the Room teleconference deal with Matthew H. Samore, MD, author of "Clinical Decision Support and Appropriateness of Antimicrobial Prescribing."
Author in the RoomSM

NQF - Voluntary Consensus Standards for Diabetes Quality Improvement

The National Quality Forum (NQF) has announced the endorsement of 29 national voluntary consensus standards for diabetes care for internal quality improvement (QI) and community-level monitoring.

The purpose of these NQF-endorsed™ measures is to improve the care of adults who have diabetes mellitus. The standards are derived from a larger set of measures advocated by the National Diabetes Quality Improvement Alliance or measures developed by the Agency for Healthcare Research and Quality.

www.qualityforum.org....pdf

Medical Care - How Robust Are Hospital Ranks Based on Composite Performance Measures?

Rowena Jacobs, Maria Goddard, Peter C. Smith
Medical Care. 43(12):1177-1184
Abstract HTML PDF (343 K)

AHRQ - QI Workgroup on Composite Measures

Call for Nominations

The Agency for Healthcare Research and Quality (AHRQ) is seeking nominations for members of the AHRQ Quality Indicators Workgroup on Composite Measures for the Prevention Quality Indicators (PQIs).

The AHRQ QI Workgroup is being formed as part of a structured approach for developing composite measures at the national and state level.

The Workgroups will evaluate appropriate technical and feasible methodological approaches currently available.

Their role will be to discuss and suggest strategies as to what composite measure methodology would best fit the AHRQ QI user needs.

news

WHO/Europe – Do current discharge arrangements from inpatient hospital care

for the elderly reduce readmission rates, the length of inpatient stay or mortality, or improve health status?

For many older people, admission to an acute hospital is associated with a decline in physical functioning, which is not always recovered at the time of discharge, or even soon.

Iatrogenic deterioration is not uncommon and, with extended stays, both informal and formal patterns of support at home may be disrupted and make a return to independent living extremely difficult.

Thus, hospital discharge arrangements are a key issue in ensuring the safe and effective transfer of older people between inpatient hospital care, and community-based home care.

A Health Evidence Network (HEN) evidence report shows that it is possible to reduce the rate of hospital readmission of elderly people.

Report

PBGH - Reports on Physician Performance Measurement and Incentives

The Pacific Business Group on Health (PBGH), a business coalition of 50 purchasers, recently released two reports:

" Using Administrative Data to Assess Physician Quality and Efficiency " outlines quality measures that address structure, process, and outcome metrics currently in use. Commercially available cost efficiency software measures relative use of resources after defining episodes of care, considering attribution, and adjusting for risk. The report describes an array of national initiatives engaged in the development, endorsement, or deployment of standardized measurement.

"Aligning Physician Incentives" documents agreement by a diverse group of stakeholders to endorse performance-based payment of physicians.

BMJ - Why doctors' outcomes should be published in the press

Ben Bridgewater
BMJ 2005;331:1210
[Extract] [Full text]

see also:

Dying to Know: Public Release of Information About Quality of Health Care
Martin N. Marshall, Paul G. Shekelle, Robert H. Brook, Sheila Leatherman
2000 - The Nuffield Trust – RAND Health
www.rand.org/publications/MR/MR1255/

Milbank Quarterly - Improving the Quality of Long-Term Care with Better Information

Vincent Mor
Milbank Quarterly September 2005 83 (3): 333–64

click here for full text

JAMA - Quality, Innovation, and Value for Money

NICE and the British National Health Service
Steven D. Pearson; Michael D. Rawlins
JAMA. 2005;294:2618-2622.
ABSTRACT FULL TEXT PDF

WHO/Europe – What are the advantages and limitations of different quality and safety tools for health care?

The term "quality tools" is used in many different ways to refer to a method used by an individual, a team, an organization or a health system. It is most often used in a narrow sense in American texts to refer to a set of simple "continuous quality improvement" methods (CQI tools).

More broadly, it includes many other safety and quality methods, frameworks, programmes or systems. Some are diagnostic methods to help decision-making, some are for intervention and change only, and some include both methods for diagnosis and intervention.

What are the advantages and limitations of different quality and safety tools for health care?

A Health Evidence Network (HEN) analysis of the effectiveness of different tools for improving quality of care in hospitals and communities.

Report

CMS - National Implementation of Hospital Consumer Assessment of Health Providers and Systems (HCAHPS)

The Centers for Medicare & Medicaid Services (CMS) recently released the final Hospital CAHPS (HCAHPS) survey instrument.

The intent of the HCAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care.

HCAHPS can be viewed as a core set of questions that can be
combined with a broader, customized set of hospital-specific items.

Once HCAHPS is fully implemented its results will be publicly reported on the Hospital Compare website

• CMS10102-SS.pdf 332KB Supporting Statement and Instrument_Survey
• CMS10102-Response.pdf 283 KB Response to Comments Dated 10-27-05
• CMS10102-Instructions.pdf 23 KB Instructions for Completing the 83-I
• CMS – HCAHPS
• AHRQ - Fact Sheet HCAHPS®

The Sorry Works! Coalition

The Sorry Works! Coalition is a new, nationwide organization of doctors, lawyers, insurers, and patient advocates dedicated to promoting full-disclosure and apologies for medical errors as a “middle ground solution” to the medical liability crisis.

The coalition advocates that after every bad outcome or adverse event hospitals and doctors perform root cause analyses to determine if the standard of care was met.

If a root cause analysis showed that the standard of care was not met (i.e, a medical error, negligence), the hospital staff and doctors apologize to the patient/family, provide an explanation of what happened and how the hospital will fix the procedures so the error is not repeated, and make a fair offer of upfront compensation. The hospital attorney and plaintiffs’ attorney will usually negotiate the compensation and the case will be closed in a short period of time.

If, however, the standard of care was met (no errors), the hospital still meets with the patient/family and their attorney(s) and explains what happened, provides medical charts, and answers all questions. Hospitals and doctors show compassion, prove their innocence, and avoid any appearance of a cover up.

www.sorryworks.net

IOM - Improving the Quality of Health Care for Mental and Substance-Use Conditions

Quality Chasm Series


This new report Institute of Medicine (IOM)examines the difference between overall health care and health care for mental and substance-use conditions and finds that the framework set forth in the 2001 report, Crossing the Quality Chasm, can be applied to health care for mental and substance-use conditions.

The report then describes a multifaceted and comprehensive strategy to do so.
www.iom.edu/report.asp?id=30836

The AMA - "Making Strides in Safety"

www.ama-assn.org/ama/pub/category/15010.html

The AMA is working as a strategic partner with the Institute for Healthcare Improvement (IHI) in the 100,000 Lives Campaign, which aims to educate physicians on ways to enhance patient safety in the hospital setting.

Hospitals can implement any or all of the programs, including:

• Deployment of "Rapid Response Teams"
• Assurance of optimal care for patients with acute myocardial infarction
• Prevention of ventilator-associated pneumonia
• Prevention of surgical-site infections
• Prevention of adverse drug events
• Prevention of central line infections

The AMA has developed educational materials to help you get hospital involved in this campaign.

Download a participation toolkit (PDF, 310KB), which provides step-by-step instructions on how to get started or an implementation toolkit (PDF, 372KB), which assists involvement in the campaign.

CMS - Requires Hospitals to submit data on Implantable Cardioverter Defibrillator (ICD)

ICD Registry™

In accordance with the ICD National Coverage Determination (NCD), hospitals must submit data on all ICD implantations that were performed for primary prevention and occurred on or after January 2005.

Medicare intends to purchase the minimum data necessary to ensure that the appropriate beneficiaries are receiving ICDs as required by the NCD.

In addition, CMS plans to use data from the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR®) ICD Registry™ in order to equip the public with the ability to compare quality metrics for facilities that implant ICDs for the primary prevention of sudden cardiac death.

CMS also hopes to answer several key questions about ICD implantation, including: whether complications vary by device manufacturer or device type; whether patient outcomes (i.e., morbidity and mortality) differ among patients based on clinical characteristics, device characteristics, the facility and/or physician who implants the device, etc.

As it becomes available, this aggregate information will be posted to the CMS Coverage web site at www.cms.hhs.gov/coverage.

Health Affairs - Rethinking Health Reform

November/December 2005 - Volume 24, Number 6

• The Struggle That Never Ends: Reforming U.S. Health Care - John K. Iglehart
• Health Care Reform: Why? What? When? - Victor R. Fuchs and Ezekiel J. Emanuel
• Whence And Whither Health Insurance? A Revisionist History - Donald W. Moran
• The Political Divide In Health Care: A Liberal Perspective -Thomas Bodenheimer
• The Rise In Health Care Spending And What To Do About It - Kenneth E. Thorpe
• Making Markets Work: Five Steps To A Better Health Care System - John F. Cogan, R. Glenn Hubbard, and Daniel P. Kessler
• Federalism And Health Policy - Richard P. Nathan
• Health Insurance In Mexico: Achieving Universal Coverage Through Structural Reform - Felicia Marie Knaul and Julio Frenk
• Managed Consumerism In Health Care - James C. Robinson
• Reviving Managed Care With Health Savings Accounts - Mark A. Hall and Clark C. Havighurst
• Coordinated Agency Versus Autonomous Consumers In Health Services Markets - Bryan E. Dowd
• Competition In Health Care: Its Evolution Over The Past Decade - Paul B. Ginsburg
• Competition And New Technology - Mark V. Pauly
• Which Way For Competition? None Of The Above - Robert A. Berenson
• The Delivery System Matters - Francis J. Crosson
• Why Employers Need To Rethink How They Buy Health Care - Robert S. Galvin and Suzanne Delbanco
• Consumer-Driven Health Care: Just A Tweak Or A Revolution? - Greg Scandlen
• The 100,000 Lives Campaign: Crystallizing Standards Of Care For Hospitals - Alice G. Gosfield and James L. Reinertsen
• Reporting Clinical Trial Results To Inform Providers, Payers, And Consumers - Rodney A. Hayward, David M. Kent, Sandeep Vijan, and Timothy P. Hofer

AHRQ - National Resource Center Health IT Teleconference Series

Making Health IT Work

Three state-of-the art teleconferences sponsored by the Agency for Healthcare Research and Quality's (AHRQ) National Resource Center for Health Information Technology will walk through the steps of three challenging enterprises: external collaboration, EHR readiness assessment, and health IT implementation.

• Community-Based Health IT Initiatives: How Do You Make Them Work?
• Are You Ready for EHRs? How to Make that Assessment
• Getting Started with Health IT Implementation

All three national conferences are free and open to the public.
event registration website

AMA - Opposes Physician Voluntary Reporting Program

The American Medical Association (AMA) is urging the Centers for Medicare and Medicaid Services (CMS) not to implement the Physician Voluntary Reporting Program (PVRP) that would measure quality of care from physician offices starting in January 2006.

In a letter to CMS the AMA said:




AMA letter

CMS/Premier - Hospital Quality Incentive Demonstration (HQID)

Data from the first year

“Pay-for-performance” can increase clinical quality and save lives, according to the first year of official data from a national project involving more than 260 hospitals. The Centers for Medicare and Medicaid Services (CMS) will pay $8.85 million in incentives to the top-performing hospitals in the project, which is managed by Premier Inc.

Data from the first year of CMS/Premier Hospital Quality Incentive Demonstration (HQID), validated by CMS and reported publicly, demonstrate a significant improvement in the quality of care across five clinical focus areas as measured by 33 nationally standardized and widely accepted quality indicators.

Year 1 Results release

CMS/Premier Hospital Quality Incentive Demonstration

CMS - Physician Voluntary Reporting Program

As part of its overall quality improvement efforts, CMS is launching the Physician Voluntary Reporting Program (PVRP).

This new program builds on Medicare’s comprehensive efforts to substantially improve the health and function of beneficiaries by preventing chronic disease complications, avoiding preventable hospitalizations, and improving the quality of care delivered. Under the voluntary reporting program, physicians will be asked to help capture data about the quality of care provided to Medicare beneficiaries.

Voluntary reporting of quality data through the PVRP will begin in January 2006.

The PVRP will begin with 36 evidence-based quality performance measures (these clinically valid measures have been part of the guidelines endorsed by physicians and the medical specialty societies and are the result of extensive input and feedback from physicians and other quality care experts).

Additional quality measures are under development now and could be phased-in for reporting later in 2006.

• Overview
• PVRP Background and General Instructions
• G-Code Specifications and Instruction for Clinical Measures
• Medlearn Matters article
• Change Request

AHRQ - CERTs Annual Report: Year 5

The Centers for Education & Research on Therapeutics (CERTs) program was created to investigate and research specific areas of therapeutics, and to use this knowledge to educate consumers, health care providers, and policymakers about the risks and benefits of such therapies.

The CERTs were established in 1999 by the Agency for Healthcare Research and Quality (AHRQ) in consultation with the U.S. Food and Drug Administration (FDA).

The CERTs consist of a network of research centers, a coordinating center, a steering committee, and numerous partnerships with public and private organizations dedicated to improving the quality and safety of therapeutics.

This report highlights a number of CERTs research and educational projects completed in the past year. It also includes some of the projects currently in progress and in the planning stages.

CERTs Annual Report: Year 5 (PDF File, 3.8 MB)

Overview: Fact Sheet

IOM - 35th Annual Meeting to Focus on Pharmaceuticals

As part of its 35th annual meeting, the Institute of Medicine host an all-day public symposium, "Pharmaceuticals in the 21st Century"

Agenda and Slide Presentations

A specific presentation pointed to Drug Safety:

Improving Drug Safety: A Systems Approach
Brian L. Strom, M.D., M.P.H., Professor and Chair, Department of Biostatistics and Epidemiology and Director, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine
View Slides

AHRQ - launched its first audio newscast

This audio podcast features current news and information from the U.S. Agency for Healthcare Research and Quality (AHRQ) Features include:

• A look at this week's AHRQ’s News & Numbers.
• AHRQ’s patient safety research found that physician groups are slow to adopt electronic health records.
• "Learning from Errors" segment reports on two studies, one examining the impact of nurse fatigue and the other on ICU patients.
• AHRQ releases a New Publication to help consumers understand and get quality health care called the: Guide to Health Care Quality: How to know it when you see it.
• Finally, a look at the first podcast produced by the U.S. Department of Health and Human Services.

listen to the audio newscast

Medical Care - Hospital Level of Care and Neonatal Mortality in Low- and High-Risk Deliveries

Reassessing the Question in Sweden by Multilevel Analysis
Medical Care. 43(11):1092-1100, November 2005.
Merlo Juan; Gerdtham Ulf-G; Eckerlund Ingemar; Hakansson Stefan; Otterblad-Olausson Petra; Pakkanen Milla; Lindqvist Pelle-G

Abstract
HTML
PDF

Medical Care - Effects of New Zealand's Health Reengineering on Nursing and Patient Outcomes

Medical Care. 43(11):1140-1146, November 2005.
McCloskey, Barbara A. ; Diers, Donna K.

Abstract
HTML
PDF (361 K)

AHRQ - Health Information Technology, Quality of Care, and Evidence-based Medicine

An Interlinked Triad
Remarks by Carolyn Clancy, M.D., Director of the Agency for Healthcare Research and Quality
Annual Symposium, American Medical Informatics Association
Washington, D.C., October 25, 2005

Introduction
Momentum for Health IT
The Coming Revolution
Quality and Health IT
Effective Health Care
What's Next

Medical Care - Comorbidity

Comorbidity Indices to Predict Mortality From Medicare Data: Results From the National Registry of Atrial Fibrillation.
Yan Yan, Elena Birman-Deych, Martha J. Radford, David S. Nilasena, Brian F. Gage.
Medical Care. 43(11):1073-1077, November 2005

Abstract
HTML
PDF (194 K)


Coding Algorithms for Defining Comorbidities in ICD-9-CM and ICD-10 Administrative Data.
Hude Quan; Vijaya Sundararajan; Patricia Halfon; Andrew Fong; Bernard Burnand; Jean-Christophe Luthi; L Duncan Saunders; Cynthia A. Beck; Thomas E. Feasby; William A. Ghali.

Abstract
HTML
PDF (351 K)

CMWF - Taking the Pulse of Health Care Systems

Experiences of Patients with Health Problems in Six Countries
Cathy Schoen, Robin Osborn, Phuong Trang Huynh, Michelle Doty, Kinga Zapert, Jordon Peugh, Karen Davis
Health Affairs Web Exclusive, November 3, 2005, W5-509–W5-525

A new Commonwealth Fund international survey report on health care access, safety, and care coordination in Australia, Canada, Germany, New Zealand, the U.K., and the U.S.

The survey found no one nation best or worst overall on the measures studied. But the U.S. stood out for high error rates, inefficient care coordination, and high out-of-pocket costs that serve as barriers to access.

• More than one of four patients in each country (28% to 32%) said risks were not completely explained during their hospital stay.
• In all countries, sizable majorities of patients said physicians had not always reviewed all their medications during the past year, and one-third or more reported infrequent reviews.
• Across countries, one-sixth to one-fourth of patients said physicians only sometimes, rarely, or never make goals of care and treatment clear or give them clear instructions.
• Relative to the U.S. and Canada, the four countries reporting comparatively rapid access to physicians— Australia, Germany, New Zealand, and the U.K.—also had significantly lower rates of emergency room use.

Chartpack pdf[download] ppt [download]

Topline Results [download]

In the Literature [download]

Commonwealth Fund publication details

Press release

Kaiser Family Foundation - Conversations on Health

Hosted by former ABC News Correspondent and current Kaiser Family Foundation Vice President and Senior Advisor for Communications Jackie Judd, Kaiser Conversations on Health is a series of live interviews with leading newsmakers discussing major health issues.

• October 20, 2005 -- Aetna CEO Dr. John W. "Jack" Rowe
• June 14, 2005 -- NIH Director Dr. Elias A. Zerhouni
• April 14, 2005 -- Virginia Governor Mark Warner
• March 24, 2005 -- Former Health and Human Services (HHS) Secretary Tommy Thompson
• September 29, 2004 -- Centers for Medicare & Medicaid Services (CMS) Administrator Mark McClellan
• March 3, 2004 -- AARP CEO Bill Novelli
• December 3, 2003 -- Irish rock star Bono, founder of the debt, AIDS and trade advocacy group DATA
  
  

Qual Saf Health Care - Effectiveness of routine reporting

to identify minor and serious adverse outcomes in surgical patients
P J Marang-van de Mheen, N van Hanegem, and J Kievit
Qual Saf Health Care 2005; 14: 378-382.
[Abstract] [Full text] [PDF]

Qual Saf Health Care - Measuring patient safety climate

a review of surveys
J B Colla, A C Bracken, L M Kinney, and W B Weeks
Qual Saf Health Care 2005; 14: 364-366.
[Abstract] [Full text] [PDF]

J Clin Epidemiol - A review of uses of health care utilization databases for epidemiologic research on therapeutics

Schneeweiss S, Avorn J.
J Clin Epidemiol. 2005 Apr;58(4):323-37
Pubmed

NICE/HDA - Annual Report 2004-2005

The National Institute for Health and Clinical Excellence (NICE) was formed on 1 April 2005, when the National Institute for Clinical Excellence took on the functions of the Health Development Agency to create a single excellence-in-practice organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

Currently NICE produces guidance in three areas of health:

• Technology appraisals - guidance on the use of new and existing medicines and treatments within the NHS in England and Wales.
• Clinical guidelines - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS in England and Wales.
• Interventional procedures - guidance on whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use in England, Wales and Scotland.
  

The annual report and its accompanying accounts cover the activities of both NICE and the Health Development Agency (HDA) during 2004/5.

NICE/HDA Annual Report 2004-2005 (pdf 3.4 MB)

Am Heart Hosp J - Electronic health record systems

The vehicle for implementing performance measures
O'Toole, M., Kmetik, K., Bossley, H., and others.
American Heart Hospital Journal 3, pp. 88-93
Pubmed

Cancer - Clinical impact and frequency of anatomic pathology errors in cancer diagnoses

Raab SS, Grzybicki DM, Janosky JE, Zarbo RJ, Meier FA, Jensen C, Geyer SJ.
Cancer. 2005 Published Online: 10 Oct 2005
pubmed

Qual Saf Health Care - Toward stronger evidence on quality improvement

Draft publication guidelines: the beginning of a consensus project
F Davidoff and P Batalden
Qual Saf Health Care 2005; 14: 319-325.
[Abstract] [Full text] [PDF]

Editorial

Why new guidelines for reporting improvement research? And why now?
D P Stevens
Qual Saf Health Care 2005;
[Extract] [Full text] [PDF]

Commentaries

Broadening the view of evidence-based medicine
D M Berwick
Qual Saf Health Care 2005; 14: 315-316.
[Extract] [Full text] [PDF]

Consensus publication guidelines: the next step in the science of quality improvement?
R G Thomson
Qual Saf Health Care 2005; 14: 317-318.
[Extract] [Full text] [PDF]

AHA - Forward Momentum

Hospital Use of Information Technology
American Hospital Association - October 2005

While 9 out of 10 hospitals are using or considering adopting health information technology (IT) for clinical uses, most hospitals, especially small or rural hospitals, cite cost as a considerable barrier to broader implementation, according to a new study released by the American Hospital Association (AHA).

The results from more than 900 hospitals show that IT use falls along a broad spectrum, ranging from hospitals just getting started to hospitals using sophisticated IT systems.

While most are still in the beginning stages, the survey shows hospitals are making investments in IT, in large part, to make gains in the safety and quality of patient care. Some of the technologies and systems hospitals are using include bar coding devices, computerized physician order entry and electronic health records (EHR).

Press Release

report

RAND - Research on Health Information Technology

RAND researchers have estimated the potential costs and benefits of widespread adoption of Health Information Technology (HIT). The team also has identified the actions needed to turn potential benefits into actual benefits.

a selection of RAND Health's recent research on HIT

NCQA - State of Health Care Quality report 2005

Health care quality improved markedly in many key areas in 2004, but only about 21.5% of the industry now reports publicly on its performance, according to National Committee for Quality Assurance (NCQA)’s annual State of Health Care Quality report.

Report
Quick Facts
Charts
Webcast (Windows Media)
NCQA News

U.S. News and World Report used the NCQA study as the basis of a new magazine feature called "America's Best Health Plans"

The U.S. News feature is available online
U.S. News and World Report/NCQA Ranking methodology

David A. Winston Health Policy Lecture - Health Care Quality

From Theory to Practice

The Seventh Annual David A. Winston Health Policy Lecture sponsored by the Federation of American Hospitals provides an overview of various efforts to improve patient safety and healthcare quality, and discusses the importance of unifying these efforts to achieve standardized mechanisms for measurement, accountability and consumer reporting.

A webcast of this event is available from kaisernetwork.org

Presentation Slides (.pdf)

NQMC - Features Patient Safety-Related Measures

More than 40 of the approximately 700 quality measures included in the National Quality Measures Clearinghouse (NQMC) have been categorized in the Institute of Medicine's domain of "safety".

The NQMC team classifies a measure as patient safety-related when safety applies to the measure's primary clinical component.

To find these safety-related evidence-based measures, use the detailed search feature at (scroll approximately two-thirds down, select "safety" in the IOM Domain field box, scroll to the bottom of page, and select Search).

WHO - Clean Care is Safer Care

Health care-associated infection is a major issue in patient safety as it affects millions of people worldwide and complicates the delivery of patient care. Infections contribute to patient deaths and disability, promote resistance to antibiotics and generate additional expenditure to those already incurred by the patients' underlying disease.

The World Alliance for Patient Safety addresses the problem of health care-associated infection through the Global Patient Safety Challenge programme with the theme "Clean Care is Safer Care".

Hand hygiene, a very simple action, remains the primary measure to reduce health careassociated infection and the spread of antimicrobial resistance, enhancing safety of care across all settings, from advanced health care establishments to community health posts across countries.

The new World Health Organization (WHO) Guidelines on Hand Hygiene in Health Care are being developed in collaboration with experts from research and academic institutions worldwideand technical experts from WHO.

documents


Clean Care is Safer Care: a worldwide priority
Pittet D, Donaldson L
The Lancet, Volume 366, Number 9493, 8 October 2005 pages 1246-1247
Full Text

AHA - The Costs of Caring

Sources of Growth in Spending for Hospital Care
American Hospital Association - August 2005

Greater demand for hospital care, more complex treatments and the continued workforce shortage are major factors behind the growth in spending on hospital care from 1998 to 2003, according to a new report released by the American Hospital Association (AHA).

Of the increase in spending on hospital care from 1998 to 2003:

• 52 percent is due to rising costs for the goods and services hospitals purchase to provide care. Rising wages and salaries account for three quarters of this increase as hospitals face a growing workforce shortage.

• 43 percent is due to higher demand for care. The population is growing and aging and on average, each person is using more hospital services.

• 5 percent is due to increased intensity of care provided. Hospital care is more complex due to both changes in demographics (older, frailer patients) and changes in technology (more sophisticated treatment options).

Press Release

report

Chartpack

AAFP - Pay-For-Performance statement

"...Both public and private health insurers, as well as employers, have come to recognize the importance of experimentation with physician payment methodologies that incentivize medical practices to expand the provision of preventive services, improve clinical outcomes and enhance patient safety and satisfaction with the care they receive.

These incentive programs, known collectively as “pay for performance” programs, have the potential to increase physician use of electronic health information technology, evidence-based clinical guidelines, administrative and clinical “best practices” and access to appropriate and timely care.

The American Academy of Family Physicians (AAFP) will use its influence to support and encourage pay for performance experimentation using the following guidelines "

JAMA - Early Experience with Pay-for-Performance

From Concept to Practice
Meredith B. Rosenthal; Richard G. Frank; Zhonghe Li; Arnold M. Epstein
JAMA. 2005;294:1788-1793.
ABSTRACT FULL TEXT PDF

Editorial
Pay-for-Performance Research: How to Learn What Clinicians and Policy Makers Need to Know
R. Adams Dudley
JAMA. 2005;294:1821-1823.
EXTRACT FULL TEXT PDF

Related Commonwealth Fund press release

AHRQ - Quality Indicators User Meeting

September 26-27, 2005
AHRQ Conference Center – Rockville Maryland

The two-day User Meeting was intended both for active users of the AHRQ Quality Indicators (AHRQ QI) and for those interested in how the AHRQ QI might be used in their organizations.

The sessions focused on lessons learned from actual applications on these topics:

• New Pediatric Indicator Module
• Applying the AHRQ QI to improve population health
• Using the AHRQ QI as a catalyst for quality improvement
• Implications of ICD-9-CM coding practices
• Use of the AHRQ QI in the National Healthcare Quality Reports
• Methods for creating aggregate performance indices
• Considerations in using the AHRQ QI for comparative reporting and pay-for-performance

presentations are now available

CMAJ - Improving patient safety

moving beyond the "hype" of medical errors
Alan J. Forster, Kaveh G. Shojania, and Carl van Walraven
CMAJ 2005 173: 893-894
[Full Text] [PDF]

Lancet - Personal digital assistants in health care

experienced clinicians in the palm of your hand?
Daniel C Baumgart
The Lancet 2005; 366:1210-1222
Summary Full Text

NEJM - Cost-Effectiveness in a Flat World

Can ICDs Help the United States Get Rhythm?
L. Goldman
N Engl J Med 2005 353: 1513-1515
Extract Full Text PDF


Medicare and Cost-Effectiveness Analysis
P. J. Neumann, A. B. Rosen, and M. C. Weinstein
N Engl J Med 2005 353: 1516-1522
Extract Full Text PDF


Cost-Effectiveness of Implantable Cardioverter–Defibrillators
G. D. Sanders, M. A. Hlatky, and D. K. Owens
N Engl J Med 2005 353: 1471-1480
Abstract Full Text PDF

IHI - Leadership Guide to Patient Safety

Resources and Tools for Establishing and Maintaining Patient Safety

Institute for Healthcare Improvement; 2005

Leadership is the critical element in a successful patient safety program. The unique role of leadership is to establish the value system in the organization, set strategic goals for activities to be undertaken, align efforts within the organization to achieve those goals, provide resources for the creation of effective systems, remove obstacles for clinicians and staff, and require adherence to known practices that will promote patient safety.

Eight steps to achieving patient safety and high reliability are presented in this guide.
View guide

Ministero della Salute - protocollo per il monitoraggio degli "eventi sentinella"

Il Ministero della Salute ha elaborato, in via sperimentale, un Protocollo per il monitoraggio degli eventi sentinella, con l’obiettivo di fornire alle Regioni e alle Aziende sanitarie una modalità univoca di sorveglianza e gestione di tali eventi.

CMWF - A Need to Transform the U.S. Health Care System

Improving Access, Quality, and Efficiency
Anne Gauthier and Michelle Serber
The Commonwealth Fund, October 2005

Despite spending more per capita on health care than any other country, the U.S. health system is fraught with waste and inefficiency, according to a new chartbook released by the Commonwealth Fund Commission on a High Performance Health System.

Overview

Chartbook PDF (386K) [download]
Chartbook PowerPoint (1647K) [download]

webcast provided by kaisernetwork.org

Commentary: "A Tale of Two Health Systems"
James J. Mongan, M.D.,
The Commonwealth Fund, October 2005

HCUP - Procedure Classes

Procedure Classes is one in a family of databases and software tools developed as part of the Healthcare Cost and Utilization Project (HCUP). The Procedure Classes provide users an easy way to categorize procedure codes into one of four broad categories: Minor Diagnostic, Minor Therapeutic, Major Diagnostic, and Major Therapeutic. Procedure codes for this tool are based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Fifth Edition.

The Procedure Classes are created to facilitate health services research on hospital procedures using administrative data. This classification system allows the researcher to readily determine if (a) a procedure is diagnostic or therapeutic, and (b) a procedure is minor or major in terms of invasiveness and/or resource use.

downloadable software

AHRQ – Effective Health Care Program

www.ahrq.gov/news/press/pr2005/effectivepr.htm

HHS’ Agency for Healthcare Research and Quality launched its new Effective Health Care Program to help clinicians and patients determine which drugs and other medical treatments work best for certain health conditions.

The new program includes three components:

Comparative Effectiveness Reports—The 13 existing Evidence-based Practice Centers (EPCs) will focus especially on comparing the relative effectiveness of different treatments.

Network of Research Centers—A new network of 13 Developing Evidence to Inform Decisions about Effectiveness research centers (referred to as DEcIDE) will carry out accelerated studies.

Making Findings Clear for Different Audiences—A new Clinical Decisions and Communications Science Center (Eisenberg Center) will translate findings in ways appropriate for the needs of the different stakeholders, including consumers, clinicians, payers, and health care policy makers

A new Web site for the program, www.effectivehealthcare.ahrq.gov, was also announced.

Qual Saf Health Care - Handling over-dispersion of performance indicators

D J Spiegelhalter

Qual Saf Health Care 2005; 14: 347-351.
[Abstract] [Full text] [Web-only appendix] [PDF]

AHRQ - September 2005 QI Newsletter

View as Web Page
Download PDF

In this issue:

· AHRQ QI User Meeting
· AHRQ Developing New Pediatric QI Module
· USER STORY: Colorado and Oregon Publish IQI Reports
· AHRQ QI TIPS: ICD-9-CM Coding Issues

HCUP - Tool for Classifying Mental Health and Substance Abuse Diagnoses

Healthcare Cost and Utilization Project (HCUP) announced the availability of a new tool for researchers working in the fields of mental health and substance abuse.

The Clinical Classification Software for Mental Health and Substance Abuse (CCS-MHSA) assigns variables that identify mental health and substance abuse-related diagnoses in hospital discharge records using the diagnosis coding of ICD-9-CM (International Classification of Diseases, Ninth Edition, Clinical Modification).

CCS-MHSA can be used with any data that include ICD-9-CM diagnosis information and can be adapted to work with the particular software a researcher is using.

This original software provides a method for classifying diagnoses or procedures into clinically meaningful categories that help to facilitate aggregate statistical reporting.

Like all HCUP tools and software, the CCS-MHSA is free and can be downloaded from the HCUP-US Website.

NEJM - Accidental Deaths, Saved Lives, and Improved Quality

T. A. Brennan, A. Gawande, E. Thomas, and D. Studdert
N Engl J Med 2005 353: 1405-1409
Extract Full Text PDF

NQF/CMWF - Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy

http://www.cmwf.org/General/General_show.htm?doc_id=296964

With Commonwealth Fund support, NQF has published a new report, Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy, that focuses on what has been learned from providers who adopted a method known as "teach back," which involves asking patients to recount information to demonstrate their level of understanding.
The report, is now available online on the NQF Web site.

Jt Comm J Qual Patient Saf - Advising Patients About Patient Safety

Current Initiatives Risk Shifting Responsibility
V. A. Entwistle, M. M. Mello, and T. A. Brennan
Joint Commission Journal on Quality and Patient Safety 31 (September 2005): 483–94.
[download] full text

AHRQ - Guide to Health Care Quality: How To Know It When You See It

http://www.ahrq.gov/consumer/guidetoq/

Agency for Healthcare Research and Quality released a new publication, Guide to Health Care Quality: How To Know It When You See It, to help consumers identify high-quality health care. This booklet is part of AHRQ's new consumer education campaign to help people take a more active role in their own health care.

The Guide to Health Care Quality includes steps that consumers can take to improve their quality of care. It explains the difference between clinical measures and consumer ratings.

Print Document (PDF)
Press Release

NPSA - Medical error

The NPSA, the Medical Defence Union and Medical Protection Society


A compendium of case studies citing senior doctors giving examples of mistakes they have made and what they learnt from them.

The handbook provides practical advice on how to reduce risk, and highlights the importance of reporting and the need to change systems to protect doctors from error.

Medical error part 1

• A message from the Chief Medical Officer
• Speaking up for safety - the work of the NPSA with junior doctors and other healthcare providers
• My mistake - 14 personal accounts of mistakes made by the nation's leading doctors

Medical error part 2

• Case studies - 6 accounts of medical error followed by expert advice
• Reporting your mistakes - advice on reporting errors

Medical error was produced as part of Engaging clinicians - A resource pack to help promote patient safety and the reporting of incidents amongst clinicians-in-training.

AHRQ - Podcast on Understanding Health Care Quality

This audio podcast features Agency for Healthcare Research and Quality (AHRQ) Director Dr. Carolyn Clancy answering questions about health care quality.


In the podcast, Dr. Clancy discusses preventive care, medical errors, and what people can do to make sure they get quality health care.

AHRQ Audio Podcast

Int J Qual Health Care - Improving the evidence base for promoting quality and equity of surgical care

using population-based linkage of administrative health records
Sonja E. Hall, C. D’Arcy, J. Holman, Judith Finn, and James B. Semmens
Int J Qual Health Care 2005 17: 415-420
[Abstract] [Full Text] [PDF]

BMJ - Developing clinical guidelines

a challenge to current methods
Rosalind Raine, Colin Sanderson, Nick Black
BMJ 2005:631-633
[Extract] [Full text] [PDF]

J Gen Intern Med - What can hospitalized patients tell us about adverse events?

Learning from patient-reported incidents.
Weingart SN, Pagovich O, Sands DZ, Li JM, Aronson MD, Davis RB, Bates DW, Phillips RS.
J Gen Intern Med. 2005 Sep;20(9):830-6.
Abstract PDF

WHO - Collaborating Centre on Patient Safety Solutions

newsalert

Recognizing that health care errors seriously harm one in every 10 patients around the world, the World Health Organization (WHO) is designating the Joint Commission on Accreditation of Healthcare Organizations and Joint Commission International (JCI) as the world’s first WHO Collaborating Centre dedicated solely to patient safety.

WHO - patient safety
WHO - World Alliance for Patient Safety

Lancet - Patient safety alliance to tackle hand washing worldwide

Bristol N
The Lancet 2005; 366:973-974
Full Text

Medical Care - Hospital Variation in Mortality After First Acute Myocardial Infarction in Denmark From 1995 to 2002

Lower Short-Term and 1-Year Mortality in High-Volume and Specialized Hospitals.
Søren Rasmussen, Ann-Dorthe O. Zwisler, Steen Z. Abildstrom, Jan K. Madsen, Mette Madsen
Medical Care. 43(10):970-978, October 2005.

Abstract HTML PDF (561 K)

Medical Care - Indiana Chronic Disease Management Program Risk Stratification Analysis

Jingjin Li, Ann M. Holmes, Marc B. Rosenman, Barry P. Katz, Stephen M. Downs, Michael D. Murray, Ronald T. Ackermann, Thomas S. Inui
Medical Care. 43(10):979-984, October 2005.
Abstract HTML PDF (221 K)

Health Affairs - Health Information Technology

September/October 2005 - Volume 24, Number 5
http://content.healthaffairs.org/content/vol24/issue5/

The new issue of Health Affairs focuses entirely on health information technology, including studies on electronic health records and other health IT efforts

Ann Intern Med - Quality of Care Is Associated with Survival in Vulnerable Older Patients

Higashi T, Shekelle PG, Adams JL, Kamberg CJ, Roth CP, Solomon DH, Reuben DB, Chiang L, MacLean CH, Chang JT, Young RT, Saliba DM, Wenger NS.
Ann Intern Med. 2005 Aug 16;143(4):274-81
Abstract Full Text PDF Summary for Patients Appendix Table

Editorial
Improving Patient Care Can Set Your Brain on Fire
Williams SV.
Ann Intern Med. 2005 Aug 16;143(4):305-6
Full Text PDF

Delmarva/JCAHO - The state of the art of online hospital public reporting

Delmarva Foundation and the Joint Commission on Accreditation of Healthcare Organizations published the results of a one year study that analyzed the effectiveness and constitution of more than 50 publicly available and subscription based online hospital performance websites.

The study found that an increasing number of consumers utilize online hospital performance websites to make health care decisions.

Press Release
download full report (3.45 MB)

J Health Polit Policy Law - The who, what, and why of risk adjustment

a technology on the cusp of adoption
Blumenthal D, Weissman JS, Wachterman M, Weil E, Stafford RS, Perrin JM, Ferris TG, Kuhlthau K, Kaushal R, Iezzoni LI.
J Health Polit Policy Law. 2005 Jun;30(3):453-73.
Entrez PubMed

Med Care Res Rev - An empirical assessment of high-performing medical groups

results from a national study
Shortell SM, Schmittdiel J, Wang MC, Li R, Gillies RR, Casalino LP, Bodenheimer T, Rundall TG.
Med Care Res Rev. 2005 Aug;62(4):407-34.
[Abstract] [PDF]

AHRQ - Quality Indicators Windows Application

www.qualityindicators.ahrq.gov/winqi_download.htm

The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Windows Application is a tool to assist quality improvement efforts in acute care hospital settings.

Using hospital discharge data from your organization, the application facilitates the review of individual cases flagged by the AHRQ Quality Indicators and calculates basic rates for comparison with peers.

The single application includes all of the AHRQ QI modules: Prevention Quality Indicators, Patient Safety Indicators, and Inpatient Quality Indicators.

The AHRQ Quality Indicators Windows Application is intended as a tool for individual hospitals that do not have access to the statistical software packages required by the currently available SAS and SPSS syntax.

The AHRQ QI Windows Application Version 1.0 requires Microsoft Windows 2000 or Microsoft Windows XP, with the Microsoft.NET platform and an available Microsoft SQL Server database. A public-use version of Microsoft .NET and the SQL Server database are included with the software.

APAC - Guiding Principles to Achieve Continuity in Medication Management

Australian Pharmaceutical Advisory Council
July 2005

Evidence from research into medication safety indicates that significant patient harm and sub-optimal use of medicines frequently result from the discontinuity that occurs when consumers move between different health care settings and health care providers. There is also good evidence that continuity in medication management can improve with a systems approach.

These Guiding Principles have been developed to address this problem by achieving the continuity of quality use of medicines in medication management as consumers move from one episode of health care to another.

Free full text (PDF)

CMAJ - Frequency, type and clinical importance of medication history errors at admission to hospital

a systematic review
Vincent C. Tam, Sandra R. Knowles, Patricia L. Cornish, Nowell Fine, Romina Marchesano, and Edward E. Etchells
CMAJ 2005 173: 510-515
[Abstract] [Full Text] [PDF]

Jt Comm J Qual Patient Saf - Using the AHRQ Quality Indicators to Improve Health Care Quality

Elixhauser A, Pancholi M, Clancy CM.
Jt Comm J Qual Patient Saf. 2005;31:533-538.
full text options

American College of Surgeons - Surgical M+M and Patient Safety

www.facs.org/education/surgical-m-and-m/index.html

The Division of Education of the American College of Surgeons has developed this online educational resource focusing on the Morbidity and Mortality (M&M) conference for today's practicing surgeon.

article of the month:

Morbidity and Mortality Conference: Both Ahead of its Time and Behind the Times
David W. Roberson, Ajit Sachdeva, Gerald B. Healy.

RAND - Evaluation of a Patient Safety Training Program

Christopher Nelson
This report evaluates a pilot fellowship program on patient safety. It evaluates the program curriculum’s design and content, program implementation, and training outcomes.

Full Document: PDF
Summary Only: PDF

Ann Intern Med - Electronic health records and the national health information network

The Costs of a National Health Information Network
Kaushal R, Blumenthal D, Poon EG, Jha AK, Franz C, Middleton B, Glaser J, Kuperman G, Christino M, Fernandopulle R, Newhouse JP, Bates DW; Cost of National Health Information Network Working Group.
Ann Intern Med. 2005 Aug 2;143(3):165-73
Abstract Full Text PDF


Perspectives
Electronic Health Records: Just around the Corner? Or over the Cliff?
Baron RJ, Fabens EL, Schiffman M, Wolf E.
Ann Intern Med. 2005 Aug 2;143(3):222-6
Abstract Full Text PDF


Editorial
Electronic health records and the national health information network: affordable, adoptable, and ready for prime time?
Basch P.
Ann Intern Med. 2005 Aug 2;143(3):227-8
Full Text PDF

Medical Care - Evaluating the Patient Safety Indicators

How Well Do They Perform on Veterans Health Administration Data?
Amy K. Rosen; Peter Rivard; Shibei Zhao; Susan Loveland; Dennis Tsilimingras; Cindy L. Christiansen; Anne Elixhauser; Patrick S. Romano
Medical Care. 43(9):873-884, September 2005

Abstract HTML PDF (413 K)

NEJM - Linking Compensation to Quality

Medicare Payments to Physicians
J. K. Iglehart
N Engl J Med. 2005 Sep 1;353(9):870-2.
Extract Full Text PDF

IOM - Building a Better Delivery System

A New Engineering/Health Care Partnership
www.iom.edu/report.asp?id=28393

This report from the National Academy of Engineering (NAE) and the Institute of Medicine (IOM) provides a framework and action plan for a systems approach to health care delivery based on a partnership between engineers and health care professionals.

The report describes the opportunities and challenges to harnessing the power of systems-engineering tools, information technologies, and complementary knowledge in social sciences, cognitive sciences, and business/management to advance the six IOM quality aims (health care should be: safe, effective, timely, patient-centered, efficient, and equitable)

Summary

USA - Patient Safety and Quality Improvement Act

http://www.govtrack.us/congress/bill.xpd?tab=main&bill=s109-544

The new law creates a new confidential “patient safety work product” that is to be used only for analysis and review to improve health outcomes.

Full Text: Text or PDF

The new law “Amends the Public Health Service Act to make patient safety work product privileged information.

• Defines "patient safety work product" as a record concerning patient information either reported to a patient safety organization by a health care provider (doctor, hospital, etc.) or created by a patient safety organization.
• Defines a "patient safety organization" as an organization, certified under this Act, that collects such information with the goal of improving patient safety and the quality of health care delivery.
• Prohibits patient safety work product: (1) from being subject to a civil or administrative subpoena or order; (2) from being required to be admitted as evidence in any State or Federal civil or administrative proceeding…”

(read complete summary from the American Association Of Clinical Endocrinologists)

NPSA - Patient Safety analysis

The National Patient Safety Agency (NPSA) has published its first analysis of patient safety data in England and Wales and the first issue of the new Patient Safety Bulletin – a review of learning from reported incidents.

The new report, Building a memory: preventing harm, reducing risks and improving patient safety, offers a unique overview of what is going wrong and describes the role of the Patient Safety Observatory in supporting improvements in patient safety at a national level.

The Patient Safety Bulletin is a new way of providing feedback to the NHS to help organisations identify and address the patient safety problems or risks that they may face locally.

Patient Safety Observatory

BMJ - Best practices for safe handling of products containing concentrated potassium

Michelle Tubman, Sumit R Majumdar, Daniel Lee, Carol Friesen and Terry P Klassen
BMJ 2005;331;274-277
[Extract] [Full text] [PDF]

Arch Intern Med - Adherence to Heart Failure Quality-of-Care Indicators in US Hospitals

Analysis of the ADHERE Registry
Gregg C. Fonarow, Clyde W. Yancy, J. Thomas Heywood, and for the ADHERE Scientific Advisory Committee, Study Group, and Investigators
Arch Intern Med. 2005;165:1469-1477.
ABSTRACT FULL TEXT

Editorial

Quality: The Need for Intelligent Efforts
Lawrence Baruch; Robert A. Phillips
Arch Intern Med. 2005;165:1455-1456.
EXTRACT FULL TEXT PDF

CMS - Quality Improvement Roadmap

http://www.cms.hhs.gov/quality/quality%20roadmap.pdf

the CMS quality roadmap features five main strategies to achieve the goal of high-quality care:

1. Work through partnerships – within CMS, with Federal and State agencies, and especially with non-governmental partners – to achieve specific quality goals.
2. Develop and provide quality measures and information, as a basis for supporting more effective quality improvement efforts.
3. Pay in a way that reinforces our commitment to quality, and that helps providers and patients take steps to improve health and avoid unnecessary costs.
4. Assist practitioners and providers in making care more effective, particularly including the use of effective electronic health systems.
5. Bring effective new treatments to patients more rapidly and help develop better evidence so that doctors and patients can use medical technologies more effectively.