Health care organizations can adapt and use the materials and tools in Managing for Quality to improve quality at many different organizational levels. The following topics are addressed:
Dale M. Needham, Susan E. Bronskill, Deanna M. Rothwell, William J. Sibbald, Peter J. Pronovost, Andreas Laupacis, Thérèse A. Stukel
Critical Care Medicine. 34(9):2349-2354.
Abstract HTML PDF (235 K)
Editorial
Volume-outcome relationships: Is it the individual or the team?
Stockwell, D.C., and Slonim, A.D.
Critical Care Medicine 34(9), pp. 2495-2497.
HTML PDF (890 K)
Qual Saf Health Care. December 2006;15(suppl 1):i1-i90.
Quality and safety by design
J B Battles
Qual Saf Health Care 2006; 15 (Suppl 1): i1-i3.
[Abstract] [Full text] [PDF]
Design of high reliability organizations in health care
J S Carroll and J W Rudolph
Qual Saf Health Care 2006; 15 (Suppl 1): i4-i9.
[Abstract] [Full text] [PDF]
Understanding the complexity of redesigning care around the clinical microsystem
P Barach and J K Johnson
Qual Saf Health Care 2006; 15 (Suppl 1): i10-i16.
[Abstract] [Full text] [PDF]
Issues in the design of training for quality and safety
K Henriksen and E Dayton
Qual Saf Health Care 2006; 15 (Suppl 1): i17-i24.
[Abstract] [Full text] [PDF]
Improving patient safety by instructional systems design
J B Battles
Qual Saf Health Care 2006; 15 (Suppl 1): i25-i29.
[Abstract] [Full text] [PDF]
Use of assessment to reinforce patient safety as a habit
R M Galbraith, M C Holtman, and S G Clyman
Qual Saf Health Care 2006; 15 (Suppl 1): i30-i33.
[Abstract] [Full text] [PDF]
Safe design of healthcare facilities
J Reiling
Qual Saf Health Care 2006; 15 (Suppl 1): i34-i40.
[Abstract] [Full text] [PDF]
On the complexity of medical devices and systems
J W Senders
Qual Saf Health Care 2006; 15 (Suppl 1): i41-i43.
[Abstract] [Full text] [PDF]
Mistake proofing: changing designs to reduce error
J R Grout
Qual Saf Health Care 2006; 15 (Suppl 1): i44-i49.
[Abstract] [Full text] [PDF]
Work system design for patient safety: the SEIPS model
P Carayon, A Schoofs Hundt, B-T Karsh, A P Gurses, C J Alvarado, M Smith, and P Flatley Brennan
Qual Saf Health Care 2006; 15 (Suppl 1): i50-i58.
[Abstract] [Full text] [PDF]
A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional
B-T Karsh, R J Holden, S J Alper, and C K L Or
Qual Saf Health Care 2006; 15 (Suppl 1): i59-i65.
[Abstract] [Full text] [PDF]
Violations and migrations in health care: a framework for understanding and management
R Amalberti, C Vincent, Y Auroy, and G de Saint Maurice
Qual Saf Health Care 2006; 15 (Suppl 1): i66-i71.
[Abstract] [Full text] [PDF]
Accidents waiting to happen: the contribution of latent conditions to patient safety
C M Lowe
Qual Saf Health Care 2006; 15 (Suppl 1): i72-i75.
[Abstract] [Full text] [PDF]
Why did that happen? Exploring the proliferation of barely usable software in healthcare systems
C W Johnson
Qual Saf Health Care 2006; 15 (Suppl 1): i76-i81.
[Abstract] [Full text] [PDF]
An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification
W B Runciman, J A H Williamson, A Deakin, K A Benveniste, K Bannon, and P D Hibbert
Qual Saf Health Care 2006; 15 (Suppl 1): i82-i90.
[Abstract] [Full text] [PDF]
Editorial: Creating Safer Care
G. Ross Baker
Identifying and Reducing Risks
Five Years of Learning from Analysis of Clinical Occurrences in Pediatric Care Using the London Protocol
Catherine M.G. Cronin
Implementing a Good Catch Program in an Integrated Health System
Debbie Barnard, Marilyn Dumkee, Balvir Bains and Brenda Gallivan
The McGill University Health Centre Policy on Sentinel Events: Using a Standardized Framework to Manage Sentinel Events, Facilitate Learning and Improve Patient Safety
Mark Daly
Implementing System Safeguards to Prevent Error-Induced Injury with Opioids (Narcotics)
Margaret Colquhoun, Christine Koczmara and Julie Greenall
Taking Aim at Fall Injury Adverse Events: Best Practices and Organizational Change
Patricia O'Connor, Joann Creager, Sharon Mooney, Andrea Maria Laizner and Judith A. Ritchie
Enhancing Patient Safety through the Management of Clostridium difficile at Toronto East General Hospital
Arladeen Tomiczek, C. Stumpo and James F. Downey
A Multidisciplinary Approach to Reducing Outbreaks and Nosocomial MRSA in a University-Affiliated Hospital
Maryam Salaripour, Pat McKernan, Roslyn Devlin and the Infection Prevention and Control Team
Reporting for Learning and Improvement: The Manitoba and Saskatchewan Experience
Paula Beard and Linda Smyrski
A Framework for Local Accountability for Patient Safety
Rosanne Zimmerman, Emily Christoffersen, Jill Shaver and Teresa Smith
Human Factors and Work Redesign
Transfer of Accountability: Transforming Shift Handover to Enhance Patient Safety
Kim Alvarado, Ruth Lee, Emily Christoffersen, Nancy Fram, Sheryl Boblin, Nancy Poole, Janie Lucas and Shirley Forsyth
Is Your Patient Ready for Transport? Developing an ICU Patient Transport Decision Scorecard
Rosmin Esmail, Deborah Banack, Cheryl Cummings, Judy Duffett-Martin, Jonas Shultz, Teresa Thurber, Karen Rimmer and Terrance Hulme
The Role of Typography in Differentiating Look-Alike/Sound-Alike Drug Names
Sandra Gabriele
Involving Patients and Families
Patient Safety in a Pediatric Centre: Partnering with Families
Bonnie Fleming-Carroll, Anne Matlow, Siobhan Dooley, Valerie McDonald, Kimberley Meighan and Kim Streitenberger
"Your Health Care - Be Involved": The Evaluation of a Provincial Patient Safety Tips Initiative
Sudha Kutty and Sarena Weil
Using Information to Improve Safety
Cancer Care Ontario's Computerized Physician Order Entry System: A Province-wide Patient Safety Innovation
Anna Greenberg, Sarah Kramer, Vickie Welch, Emily O'Sullivan and Stephen Hall
Predicting Changes in Workflow Resulting from Healthcare Information Systems: Ensuring the Safety of Healthcare
Andre Kushniruk, Elizabeth Borycki, Shige Kuwata and Joseph Kannry
Frequency and Type of Medication Discrepancies in One Tertiary Care Hospital
Jennifer Turple, Neil J. MacKinnon and Bryan Davis
Identifying Patient Safety Risks in Non-Acute Care Settings
Broadening the Patient Safety Agenda to Include Home Care Services
Ariella Lang, Nancy Edwards, Carolyn Hoffman, Judith Shamian, Kathleen Benjamin and Marguerite Rowe
Adverse Events among Winnipeg Home Care Clients
Keir G. Johnson
Exploration of Patient Safety Phenomena in Rehabilitation and Complex Continuing Care
Carol Fancott, Karima Velji, Elaine Aimone and Lynne Sinclair
an assessment of the traditional surgical morbidity and mortality conference compared with the American College of Surgeons-National Surgical Quality Improvement Program
Hutter MM, Rowell KS, Devaney LA, Sokal SM, Warshaw AL, Abbott WM, Hodin RA.
J Am Coll Surg. 2006 Nov;203(5):618-24.
Alan J. Forster, Irene Fung, Sharon Caughey, Lawrence Oppenheimer, Cathy Beach, Kaveh G. Shojania, Carl van Walraven Obstet Gynecol 2006 108: 1073-1083.
[Abstract] [Full Text] [PDF]
Comment
Patient Safety in Obstetrics and Gynecology: An Agenda for the Future
Mark D. Pearlman
Obstet Gynecol 2006 108: 1266-1271.
[Abstract] [Full Text] [PDF]
Editorial
Patient Safety in Obstetrics and Gynecology: The Call to Arms
William A. Grobman
Obstet Gynecol 2006 108: 1058-1059.
[Full Text] [PDF]
A Three-Decade Perspective on Anesthesia Safety pp. 985-989 Lanier, William L.
Early Efforts with Quality at Centers for Medicare & Medicaid Services and Judicious Use of Its Powers as a Payor pp. 990-993 Grissom, Thomas L.
Safety, Quality, and the National Surgical Quality Improvement Program pp. 994-998 Khuri, Shukri F.
Surgical Quality Programs in the Veterans Health Administration pp. 999-1004(6) Author: Depalma, Ralph G
American College of Surgeons Remains Committed to Patient Safety pp. 1005-1009(5) Authors: Russell, Thomas R.; Jones, R. Scott
The Surgical Infection Prevention and Surgical Care Improvement Projects: Promises and Pitfalls pp. 1010-1016(7) Author: Bratzler, Dale w.
The Evolution of Guidelines Toward Standards of Practice pp. 1017-1020(4) Author: Polk, Hiram C
PANEL 1 pp. 1021-1030(10) Authors: Polk, Hiram C.; Bratzler, Dale; Depalma, Ralph G; Flum, David R; Grissom, Thomas L; Jones, R. Scott; Khuri, Shukri F; Lanier, William L; Loeb, Thomas M; Pugliese, Gina; Scutchfield, F. Douglas
The Hazards of Using Administrative Data to Measure Surgical Quality pp. 1031-1037(7) Authors: Fry, Donald E; Pine, Michael B; Jordan, Harmon S; Hoaglin, David C; Jones, Barbara; Meimban, Roger
The Volume-Outcome Debate Revisited pp. 1038-1042(5) Author: Finlayson, Samuel R.G
The Challenge of Small Numbers to the Contemporary Excellence of Elective Specialty Surgery pp. 1043-1045(3) Author: Polk, Hiram C
The Holy Grail of Surgical Quality Improvement: Process Measures or Risk-Adjusted Outcomes? pp. 1046-1050(5) Author: Rogers, Selwyn O
Quality and Safety Performance in Teaching Hospitals pp. 1051-1054(4) Author: Knapp, Richard M
Does Outcomes Research Impact Quality? Examples from Bariatric Surgery pp. 1055-1060(6) Author: Hutter, Matthew M.
PANEL 2 pp. 1061-1069(9) Authors: Flum, David R.; Bratzler, Dale; Finlayson, Samuel R.G.; Fry, Donald E; Hutter, Matthew M; Khuri, Shukri F; Knapp, Richard M; Rogers, Selwyn O; Russell, Thomas R; Seidenfeld, John J
An Eight-Year Analysis of Surgical Morbidity and Mortality: Data and Solutions pp. 1070-1081(12) Authors: Goldfarb, Michael A; Baker, Thomas
The Challenge of Changing Roles and Improving Surgical Care Now: Crew Resource Management Approach pp. 1082-1087(6) Authors: James, Mcgreevy; Otten, Tyler; Poggi, Michael; Robinson, Christopher; Castaneda, David; Wade, Patrick
How a System for Reporting Medical Errors Can and Cannot Improve Patient Safety pp. 1088-1091(4) Author: Clarke, John R
Maintenance of Certification: American Board of Surgery Goals pp. 1092-1096(5) Author: Lewis, Frank R
Simulation: A Strategy for Success in Quality and Safety in Pay-for-Performance Environments pp. 1097-1101(5) Author: LOYD., GARYE
Making the Operating Room of the Future Safer pp. 1102-1108(7) Authors: Greenberg, Caprice C; Roth, Emilie M; Sheridan, Thomas B; Gandhi, Tejal K; Gustafson, Michael L; Zinner, Michael J; Dierks, Meghan M
Morbidity and Mortality in Vascular Surgery: The Kentucky Experience with a Statewide Database pp. 1109-1111(3) Author: Richardson, J David
The Practicing Surgeon as a Member of the Quality-Safety Team pp. 1112-1114(3) Authors: Vallance, Steven R.; Schell, Robert H.; Robbins, Robert E.
Linking Processes and Outcomes to Improve Surgical Performance: A New Approach to Morbidity and Mortality Peer Review pp. 1115-1119(5) Authors: Pine, Michael; Fry, Donald e.
LUNCHEON DEBATE: Where Is the Captain of the Ship When You Need Her? - System Corrections Are the Right Way to Go pp. 1120-1125(6) Authors: Goldfarb, Michael A.; Flum, David R.
PANEL 3: The Unintended Consequences of Transparency pp. 1126-1132(7) Authors: Willihnganz, Shirley C.; Flum, David R.; Clarke, John R.; Galandiuk, Susan; Knapp, Richard M.; Lewis, John N.; Manassah, Edward E.; Russell, Thomas R.; Taylor, James; Ungar, Laura
PANEL 4—Closing Panel: The Future of Surgical Quality— from Micro to Macro - Would You Rather be Maitre'd (and Set the Table) or be King for a Day? pp. 1133-1148(16) Authors: Flum, David; Bratzler, Dale; Finlayson, Samuel R.G.; Fry, Donald E.; Jones, R. Scott; Lewis, Frank R.; Pine, Michael; Russell, Thomas R.; Seidenfeld, John J.; Vallance, Steven R.
An Invitational Conference on Contemporary Surgical Quality, Safety and Transparency June 5 & 6, 2006 Closing Session—Focal Points pp. 1149-1149(1) Authors: Flum, David R.; Goldfarb, Michael A.; Polk, Hiram C.
Irene M. Mullins, Mir S. Siadaty, Jason Lyman, Ken Scully, Carleton T. Garrett, W. Greg Miller, Rudy Muller, Barry Robson, Chid Apte, Sholom Weiss et al.
Comput Biol Med. 2006 Dec;36(12):1351-77.
Abstract Full Text + Links PDF (272 K) free PDF
"The Agency for Healthcare Research and Quality (AHRQ) applauds public reporting of hospital quality performance data and views public reporting as one important strategy to advance the quality improvement agenda in health care. Evidence shows that publicly reporting performance by specific hospitals is a key element that promotes enhanced patient care. AHRQ continues to be an active participant in such public reporting efforts as the Hospital Quality Alliance, the Ambulatory Care Quality Alliance and the National Quality Forum (NQF). In fact, AHRQ is submitting the Quality Indicators (QIs) to NQF to undergo the formal consensus process for endorsement for public reporting in the spring of 2006 ..."
read the full statement (pdf)
The 5 Million Lives Campaign is a new initiative from the Institute for Healthcare Improvement (IHI) to protect patients from five million incidents of medical harm over the next two years (December 2006 – December 2008).
Web site
Press release
To assist investigators with the calculation of comorbidity weights, the National Cancer Institute (NCI) provids two SAS macros.
These macros will produce comorbidity weights as developed by Charlson et al (PDF) (J Clin Epidemiol 1993;46:1075-9).
SAS macros
Lotte Steuten, Bert Vrijhoef, Frits Van Merode, Geert-Jan Wesseling, and Cor Spreeuwenberg
Int J Qual Health Care 2006 18: 429-436;
[Abstract] [Full Text] [PDF]
www.oecdobserver.org/news/fullstory.php/aid/1953
The OECD Observer magazine November issue presents an article on Health care systems quality performance: "The performance of health care systems is under scrutiny. The Health Care Quality Indicator Project can help identify what works and what does not. And that will help policy decisions too."
Information on the OECD Health Care Quality Indicators project
database
The online version of the fourteenth edition of the OECD Secretariat's electronic data base on health systems has been updated.
The 2006 edition includes new data together with an enhanced software. The standard definitions of variables and the corresponding documentation of country-specific sources and methods have been revised and expanded.
www.ahrq.gov/qual/10tips.htm
AHRQ Publication No. 06-P020, May 2006. Rockville, MD,
10 tips for hospitals resulted from findings resulting from studies by the Agency for Healthcare Research and Quality (AHRQ), which has funded more than 100 patient safety projects since 2001.
Press Release
Ansari, Z; Laditka, JN; Laditka, SB
Med Care Res Rev 2006 63: 719-741.
[Abstract] [PDF]
Implications of a Volume-Based Approach in One Urban Market.
Votruba, Mark E. ; Cebul, Randall D.
Medical Care. 44(12):1129-1136, December 2006.
Abstract HTML PDF (324 K)
Holmboe, Eric S. , Wang, Yun , Tate, Janet P. , Meehan, Thomas P.
Medical Care. 44(12):1073-1077, December 2006.
Abstract HTML PDF (195 K)
Wu, Winfred Y. , Chen, John J. , Shih, Anthony
Medical Care. 44(12):1142-1147, December 2006.
Abstract HTML PDF (434 K)
Wachter, Robert M.; Pronovost, Peter J.
Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 11, November 2006, pp. 621-627
IHI Replies to "The 100,000 Lives Campaign: A Scientific and Policy Review"
Berwick, Donald M.; Hackbarth, Andrew D.; McCannon, C. Joseph
Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 11, November 2006, pp. 628-633
psnet.ahrq.gov/resource.aspx?resourceID=4478
This study from the Canadian Health Services Research Foundation (CHSRF) was a synthesis of the best available evidence and provision of policy recommendations in the area of nurse staffing and patient safety.
The results of the synthesis indicate a significant relationship between nurse staffing and patient safety.
Evidence also shows there are moderating factors, such as nurse characteristics and organizational factors, which influence the relationship between nurse staffing and patient safety.
The findings also demonstrate the importance of linking the implementation of good nurse staffing initiatives with effective leadership and management concepts.
pdf
see also
Indyk L, Indyk D.
Soc Work Health Care. 2006;42(3-4):47-60.
pubmed
A Population-Based Cohort Study
Maio V, Yuen EJ, Novielli K, Smith KD, Louis DZ.
Drugs Aging. 2006;23(11):915-924.
pubmed
a retrospective data analysis.
Cannon KT, Choi MM, Zuniga MA.
Am J Geriatr Pharmacother. 2006 Jun;4(2):134-43.
Abstract PDF (788 K)
World Health Organization 2006
table of contents
Introduction
1 Global Patient Safety Challenge
2 The wisdom of patients - Patients for Patient Safety
3 Information for action - Reporting and Learning
4 More than words - Classification
5 Knowledge is the enemy of unsafe care - Research
6 Safety solutions
7 Safety in action
8 Technology for patient safety
9 International partnership for care of acutely ill patients
10 Patient Safety knowledge at your fingertips
11 Governance and programme support
full text pdf
Marang-van de Mheen, PJ; Stadlander, MC; Kievit, J
Quality & Safety In Health Care, 15 (5): 320-324;
[Abstract] [Full text] [PDF]
A special issue of Medical Care focus on measurement in a multi-ethnic society.
Medical Care November 2006, Volume 44, Issue 11 Suppl 3
issue contents
The Healthcare Commission annual health check includes an assessment of NHS trusts against 24 core standards covering areas such as safety, waiting times, cleanliness and patient focus.
Forty nine percent were assessed as having ‘fully met’ the standards. Overall, 81% of trusts met at least 90% of the standards.
Annual health check
press conference
Henderson, Toni; Shepheard, Jennie; Sundararajan, Vijaya
Medical Care. 44(11):1011-1019, November 2006.
Abstract HTML PDF (312 K)
The Healthcare Commission report independently on the state of healthcare services in England and Wales.
The report shows that patients are seeing real improvements but highlights four areas where further action is needed:
- the delivery of healthcare services that are even more focused on the needs of patients
- care for people who are least able to look after themselves
- the prevention of illness, and the reduction of
inequalities in health
- safety
full text report (pdf)Sally J Giles, Penny Rhodes, Gill Clements, Gary A Cook, Ruth Hayton, Melanie J Maxwell, Trevor A Sheldon, and John Wright
Qual Saf Health Care 2006; 15: 363-368.
[Abstract] [Full text] [PDF]
Patricia Halfon; Yves Eggli; Isaline Prêtre-Rohrbach; Danielle Meylan; Alfio Marazzi; Bernard Burnand
Medical Care. 44(11):972-981, November 2006.
Abstract HTML PDF (385 K)
The Department of Defense (DoD) Patient Safety Program, in collaboration with the Agency for Healthcare Research and Quality (AHRQ) developed TeamSTEPPS a Team Strategies and Tools to Enhance Performance and Patient Safety.
TeamSTEPPS is an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and other teamwork skills among healthcare professionals.
TeamSTEPPS includes a comprehensive suite of ready-to-use materials and training curricula necessary to successfully integrate teamwork principles into all areas of healthcare system.
www.usuhs.mil/cerps/teamstepps.html
www.ahrq.gov/qual/teamstepps/
Press Release
Kate R. Lorig; Philip L. Ritter; Diana D. Laurent; Kathryn Plant
Medical Care. 44(11):964-971, November 2006
Abstract HTML PDF (305 K)
Editorial
The Chronic Disease Self-Management Program: Extending Reach through the Internet.
Ben S. Gerber
Medical Care. 44(11):961, November 2006.
HTML PDF (121 K)
Fisher, Elliott S.
N Engl J Med 2006 355: 1845-1847
Extract FREE Full Text PDF
Interview
Rosenthal, Meredith B., Landon, Bruce E., Normand, Sharon-Lise T., Frank, Richard G., Epstein, Arnold M.
N Engl J Med 2006 355: 1895-1902
Abstract Full Text PDF
Press Release
Journal of Organizational Behavior
Volume 27, Issue 7 (November 2006)
Issue Edited by Ranga Ramanujam, Denise M. Rousseau.
This special issue looks at the organizational challenges to high quality and safe health care.
Table of contents
Organizational behavior in healthcare - the challenges are organizational, not just clinical (p 809)
Ranga Ramanujam, Denise M. Rousseau
The challenges are organizational not just clinical (p 811-827)
Ranga Ramanujam, Denise M. Rousseau
Worldviews in collision: conflict and collaboration across professional lines (p 829-849)
Andrew N. Garman, David C. Leach, Nancy Spector
Notes from a small Island: researching organisational behaviour in healthcare from a UK perspective (p 851-867)
Annabelle L. Mark
Teaching but not learning: how medical residency programs handle errors (p 869-896)
Timothy J. Hoff, Henry Pohl, Joel Bartfield
A sensemaking lens on reliability (p 897-917)
Ruth Blatt, Marlys K. Christianson, Kathleen M. Sutcliffe, Marilynn M. Rosenthal
Classifying and interpreting threats to patient safety in hospitals: insights from aviation (p 919-940)
Michal Tamuz, Eric J. Thomas
Making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams (p 941-966)
Ingrid M. Nembhard, Amy C. Edmondson
Leadership development in healthcare: a qualitative study (p 967-982)
Ann Scheck McAlearney
Reducing patient mortality in hospitals: the role of human resource management (p 983-1002)
Michael A. West, James P. Guthrie, Jeremy F. Dawson, Carol S. Borrill, Matthew Carter
Quality improvement and hospital financial performance (p 1003-1029)
Jeffrey A. Alexander, Bryan J. Weiner, John Griffith
Blumenthal D, DesRoches C, Donelan K, et al.
Washington, DC: Robert Wood Johnson Foundation; 2006.
This report evaluates current information on the state of EHR adoption in the U.S. health care system.
The report reviews 36 existing data sources, including ongoing national surveys and one-time or regional studies, and recommends a coordinated, systematic national approach to measuring EHR diffusion and implementation.
Free full text (PDF)
Executive summary (PDF)
Development, Testing, and Findings of an NICU-Focused Trigger Tool to Identify Harm in North American NICUs
Paul J. Sharek, Jeffrey D. Horbar, Wilbert Mason, Hema Bisarya, Cary W. Thurm, Gautham Suresh, James E. Gray, William H. Edwards, Donald Goldmann, and David Classen
Pediatrics 2006; 118: 1332-1340.
[Abstract] [Full text] [PDF]
B. M. Psaty and S. P. Burke
N Engl J Med 2006 355: 1753-1755
FREE Full Text PDF
Editorial
Blueprint for a Stronger Food and Drug Administration
G. D. Curfman, S. Morrissey, and J. M. Drazen
N Engl J Med 2006 355: 1821
FREE Full Text PDF
[Public reporting on individual hospitals' quality: the risk of misinformation]
Di Tanna GL, Cisbani L, Grilli R.
Epidemiol Prev. 2006 May-Jun;30(3):199-204.
pubmed
Howard DH, Kaplan B.
Inquiry. 2006 Summer;43(2):150-9.
pubmed
This new Healthcare Cost and Utilization Project (HCUP) Report present evidence from studies that already exist, or are underway, on the case for (or against) inclusion and collection of the “Present on Admission” (POA) indicator that discriminate between comorbidities and complications in hospital administrative data.
In New York, the label was originally “Other Diagnosis Emergent Indicator,” and is now known as the “Present on Admission Indicator.” In Canada, the label is “Diagnosis Type Indicator.” Some researchers also refer to the POA as a “date stamp" or the "6th digit" of the diagnosis code. They all represent the same concept.
This report also reviews what is known about educational programs needed to implement the indicator in a way that will make the POA data element valid and reliable for improving case-mix, quality-of-care, and other measures, as well as for risk-adjustment for many comparative purposes.
Report
the Quality Indicator Board of the German Stroke Registers Study Group (ADSR)
Heuschmann PU, Biegler MK, Busse O, Elsner S, Grau A, Hasenbein U, Hermanek P, Janzen RW, Kolominisky-Rabas PL, Kraywinkel K, Lowitzsch K, Misselwitz B, Nabavi DG, Otten K, Pientka L, von Reutern GM, Ringelstein EB, Sander D, Wagner M, Berger K.
Stroke. 2006 Oct;37(10):2573-8.
abstract Full Text Full Text (PDF)
H. Joanna Jiang; Bernard Friedman; James W. Begun
Health Care Management Review 31(3), pp. 188-196.
Abstract HTML PDF (131 K)
Amy Smalarz
Health Care Management Review. 31(3):179-187
Abstract HTML PDF (131 K)
listserv_archive_2006.htm#Oct13
The Agency for Healthcare Research and Quality (AHRQ) has re-posted for public comment the AHRQ QI Composite Measure draft reports for the Inpatient Quality Indicators (IQIs) and the Patient Safety Indicators (PSIs):
IQI_Composite_Draft.pdf
PSI_Composite_Draft.pdf
Hoangmai H. Pham, Jennifer Coughlan, and Ann S. O’Malley
Health Affairs, September/October 2006; 25(5): 1412-1422.
[Abstract] [Full Text] [PDF]
Shrank, William H.; Asch, Steven M. ; Adams, John; Setodji, Claude; Kerr, Eve A. ; Keesey, Joan ; Malik, Shaista ; McGlynn, Elizabeth A.
Medical Care. 44(10):936-945, October 2006
Abstract HTML PDF (355 K)
RAND abstract
Acta Psychiatrica Scandinavica
May 2006 - Vol. 113 Issue s430 Page 3-39
www.blackwell-synergy.com/toc/acp/113/s430
Preface
Ashok Malla, Ross Norman
The Canadian National Outcomes Measurement Study in Schizophrenia: overview of the patient sample and methodology
G. Smith, A. Malla, R. Williams, L Kopala, L. Love, R. Balshaw
Medication decisions and clinical outcomes in the Canadian National Outcomes Measurement Study in Schizophrenia
R. Williams, L. Kopala, A. Malla, G. Smith, L. Love, R. Balshaw
Outcome on quality of life in a Canadian national sample of patients with schizophrenia and related psychotic disorders
A. Malla, R. Williams, L. Kopala, G. Smith, D. Talling, R. Balshaw
Resource utilization in a Canadian national study of people with schizophrenia and related psychotic disorders
L. Kopala, G. Smith, A. Malla, R. Williams, L. Love, D. Talling, R. Balshaw
Bismark, Marie, Dauer, Edward, Paterson, Ron, Studdert, David
CMAJ 2006 175: 889-894
[Abstract] [Full Text] [PDF]
Commentary
Monetary and nonmonetary accountability following adverse medical events: options for Canadian patients
John E. Gray and William Beilby
CMAJ 2006 175: 903.
[Full Text] [PDF]
Aneesh K. Singla; Barrett T. Kitch; Joel S. Weissman; Eric G. Campbell
Abstract HTML PDF (123 K)
Kimberly Rask; Jonathan Hawley; Anne Davis; Dorothy 'Vi' Naylor; Kenneth Thorpe
Abstract HTML PDF (101 K)
A Project of the American Academy of Family Physicians National Research Network.
Robert L. Phillips; Susan M. Dovey; Deborah Graham; Nancy C. Elder; John M. Hickner, MD,
Abstract HTML PDF (101 K)
Koen Van den Heede , Walter Sermeus , Luwis Diya , Emmanuel Lesaffre , and Arthur Vleugels
Int J Qual Health Care 2006 18: 211-219
[Abstract] [Full Text] [PDF]
listserv_archive_2006.htm#Sept29
The Agency for Healthcare Research and Quality (AHRQ) released the AHRQ Pediatric Quality Indicator (PedQI) risk adjustment module in Windows (Version 3.0b). The SAS module was released in May, 2006.
pdi_download.htm
pdi_measures_v30b.pdf
www.nap.edu/catalog/11723.html
This new report from Institute of Medicine analyzes the promise and risks of instituting a pay-for-performance program within Medicare to encourage a more effective health care system.
Front Matter
Summary
1 Introduction
2 The Promise of Pay for Performance
3 Alternative Funding Sources
4 Distribution of Rewards
5 Implementation
6 Research and Evaluation
Appendix A: Selected Medicare Prospective Payment Systems
Appendix B: Review of the Evidence
Appendix C: Comparison of Various Professional Groups' Pay-for-Performance Position Statements
Appendix D: MEDPAC Data Runs
Appendix E: Pay for Performance in Various Care Settings
Appendix F: Acronyms
Appendix G: Biographies
Report Brief.
Fact Sheet.
Slides.
News Release.
The New England Journal of Medicine Audio Interview
Pay for Performance — Recommendations of the Institute of Medicine
Elliott Fisher, M.D., M.P.H., and Karen Davis, Ph.D.
View Transcript of Interview (PDF)
Download Interview MP3 (08:54, 4.1 MB)
Scott C. Williams , Ann Watt , Stephen P. Schmaltz , Richard G. Koss , and Jerod M. Loeb
Int J Qual Health Care 2006 18: 246-255
[Abstract] [Full Text] [PDF]
Austin, Peter C.
Med Decis Making 2006 26: 447-466
[Abstract] [PDF] [References]
Simpson CR, Hannaford PC, Lefevre K, Williams D.
Stroke. 2006 Sep;37(9):2354-60.
[Abstract] [Full Text] [PDF]
Veena Guru, Stephen E. Fremes, C. David Naylor, Peter C. Austin, Fiona M. Shrive, William A. Ghali, Jack V. Tu and in collaboration with the Cardiac Care Network (CCN) of Ontario
Am Heart J. 2006 Sep;152(3):573-578
Abstract Full Text + Links PDF (290 K)
Editorial
Reporting for provider performance: Should we punish the bad, or try to make them all good?
T. Bruce Ferguson, Jr
Am Heart J. 2006 Sep;152(3):410-413
Abstract Full Text + Links PDF (143 K)
Shahian DM, Torchiana DF, Normand SL.
Ann Thorac Surg. 2005 Sep;80(3):1146-50.
Abstract Full Text + Links PDF (70 K)
Editorial
Mandatory database participation: risky business?
Grunkemeier GL, Furnary AP.
Ann Thorac Surg. 2005 Sep;80(3):799-801.
Abstract Full Text + Links PDF (68 K)
Feng Zeng, June F. O'Leary, Elizabeth M. Sloss, Melissa Succi Lopez, Nasreen Dhanani, Glenn Melnick
Medical Care. 44(10):900-907, October 2006
Abstract HTML PDF (297 K)
Carrie N. Klabunde, Linda C. Harlan, Joan L. Warren
Medical Care. 44(10):921-928, October 2006.
Abstract HTML PDF (290 K)
In an effort to support the potential relationship between nursing educational preparation and quality healthcare, National Quality Forum (NQF) drafted a paper that summarizes the evidence on the significant effects of nursing education on outcomes and patient safety.
pdf
Makary, M.A., Sexton, J.B., Freischlag, J.A., and others
Annals of Surgery (2006, May) 243(5), pp. 628-635.
Abstract HTML PDF (593 K)
Teamwork in the eye of the beholder
Makary, M.A., Sexton, J.B., Freischlag, J.A., and others
Journal of the American College of Surgeons 202, pp. 746-752.
Abstract Full Text + Links PDF (549 K)
Grobman WA, Feinglass J, Murthy S.
Am J Obstet Gynecol. 2006;195:868-874.
Abstract Full Text + Links PDF (215 K)
The Agency for Healthcare Research and Quality (AHRQ) has posted for public comment the AHRQ QI Composite Measure draft reports for the Inpatient Quality Indicators (IQIs) and the Patient Safety Indicators (PSIs).
AHRQ_IQI_Composite_Draft.pdf
AHRQ_PSI_Composite_Draft.pdf
Paula Vallejo, Rosa Maria Saura, Rosa Sunol, Vahe Kazandjian, Victoria Ureña, and Jordi Mauri
Int J Qual Health Care 2006 18: 327-335
[Abstract] [Full Text] [PDF]
Udo Nabitz, Mark Schramade, and Gerard Schippers
Int J Qual Health Care 2006 18: 336-345
[Abstract] [Full Text] [PDF]
Novick RJ, Fox SA, Stitt LW, Forbes TL, Steiner S.
J Thorac Cardiovasc Surg. 2006 Aug;132(2):386-91.
Abstract Full Text + Links PDF (166 K)
Silverstein B, Findley PA, Bode RK.
Arch Phys Med Rehabil. 2006 Aug;87(8):1021-5.
Abstract Full Text + Links PDF (92 K)
A Conversation With Martin Roland
Robert Galvin
Health Affairs, September/October 2006; 25(5): w412-w419.
Full Text (HTML)
Reprint (PDF)
International Journal for Quality in Health Care
Volume 18, Issue Supplement 1: September 2006
Soeren Mattke, Arnold M. Epstein, and Sheila Leatherman
The OECD Health Care Quality Indicators Project: history and background
Int J Qual Health Care 2006 18: 1-4;
[Abstract] [Full Text] [PDF]
Onyebuchi A. Arah, Gert P. Westert, Jeremy Hurst, and Niek S. Klazinga
A conceptual framework for the OECD Health Care Quality Indicators Project
Int J Qual Health Care 2006 18: 5-13;
[Abstract] [Full Text] [PDF]
Vivienne McLoughlin, John Millar, Soeren Mattke, Margarida Franca, Pia Maria Jonsson, David Somekh, and David Bates
Selecting indicators for patient safety at the health system level in OECD countries
Int J Qual Health Care 2006 18: 14-20;
[Abstract] [Full Text] [PDF]
Martin Marshall, Niek Klazinga, Sheila Leatherman, Charlie Hardy, Eckhard Bergmann, Luis Pisco, Soeren Mattke, and Jan Mainz
OECD Health Care Quality Indicator Project. The expert panel on primary care prevention and health promotion
Int J Qual Health Care 2006 18: 21-25;
[Abstract] [Full Text] [PDF]
Antonio Nicolucci, Sheldon Greenfield, and Soeren Mattke
Selecting indicators for the quality of diabetes care at the health systems level in OECD countries
Int J Qual Health Care 2006 18: 26-30;
[Abstract] [Full Text] [PDF]
Richard C. Hermann, Soeren Mattke, David Somekh, Helena Silfverhielm, Elliot Goldner, Gyles Glover, Jane Pirkis, Jan Mainz, and Jeffrey A. Chan
Quality indicators for international benchmarking of mental health care
Int J Qual Health Care 2006 18: 31-38;
[Abstract] [Full Text] [PDF]
Ulla M. Idänpään-Heikkilä, Laura Lambie, Soeren Mattke, Vin McLaughlin, Heather Palmer, and Jack V. Tu
Selecting indicators for the quality of cardiac care at the health system level in Organization for Economic Co-operation and Development countries
Int J Qual Health Care 2006 18: 39-44;
[Abstract] [Full Text] [PDF]
Edward T. kelley, Irma Arispe, and Julia Holmes
Beyond the initial indicators: lessons from the OECD Health Care Quality Indicators Project and the US National Healthcare Quality Report
Int J Qual Health Care 2006 18: 45-51;
[Abstract] [Full Text] [PDF]
4th Australasian Conference on Safety & Quality in Health Care
www.aaqhc.org.au/resources_conf2006.asp
21-23 August 2006 Melbourne, Australia
Conference presentations (PDF versions) are available.
W. Rollow, T. R. Lied, P. McGann, J. Poyer, L. LaVoie, R. T. Kambic, D. W. Bratzler, A. Ma, E. D. Huff and L. D. Ramunno
Ann Intern Med 2006; 342-353.
Abstract Full Text PDF
Editorial
Enhancing the Potential of Quality Improvement Organizations To Improve Quality of Care
S. M. Shortell and W. A. Peck
Ann Intern Med 2006; 388-389.
Full Text PDF
Response to the Institute of Medicine Study
U.S. Secretary of Health and Human Services Michael O. Leavitt released a report to Congress outlining his response to a March 9, 2006 study from the Institute of Medicine, which called for maximizing the potential of the Quality Improvement Organization (QIO) program.
report (pdf)
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