AHRQ - Hospital Survey on Patient Safety Culture

2007 Comparative Database Report

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

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

Contents
Summary
Purpose and Use of This Report

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

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

AHRQ - Patient Safety Culture Surveys

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

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

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

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

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

Pubmed

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

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

Abstract Online First PDF

Achieving the National Quality Forum's "Never Events"

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

Abstract HTML PDF (737 K)

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

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

Free full text (PDF)

Staying safe: simple tools for safe surgery.

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

Free full text (PDF)

AHRQ - Quality Indicators Mapping Tool

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

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

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

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

CMS specifications for measures included in the 2007 PQRI

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

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

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

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

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

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



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


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


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

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

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

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

5) improved outcomes.

PDF

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

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

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

The Commonwealth Fund, April 2007

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

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

pdf

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

www.jointcommissionreport.org

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

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

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

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

Patient safety and quality in the pediatric intensive care unit

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

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


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


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


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


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


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

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

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

American Journal of Preventive Medicine - Acute Stroke Registry Supplement

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

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

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

link

Measuring the quality of inpatient obstetrical care.

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

Quality Measurement in Adult Cardiac Surgery

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Measuring Children's Health Care Quality

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Pubmed

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

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

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

• Abstract
• HTML
• PDF (294 K)

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

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

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

• Abstract
• HTML
• PDF (764 K)