Public Reporting and Pay for Performance in Hospital Quality Improvement

Lindenauer, Peter K., Remus, Denise, Roman, Sheila, Rothberg, Michael B., Benjamin, Evan M., Ma, Allen, Bratzler, Dale W.
N Engl J Med 2007 356: 486-496
Abstract Full Text PDF


Editorial

Pay for Performance at the Tipping Point
A. M. Epstein
N Engl J Med 2007 356: 515-517
Extract Full Text PDF

All or none measurement: why we know so little about the comprehensiveness of care

Edward Kelley
Int J Qual Health Care 2007 19: 1-3;
[Extract] [Full Text] [PDF]

How to develop a business case for quality

Kristin L. Reiter, Kerry E. Kilpatrick, Sandra B. Greene, Kathleen N. Lohr, and Sheila Leatherman
Int J Qual Health Care 2007 19: 50-55;
[Abstract] [Full Text] [PDF]

Does the Patient's Payer Matter in Hospital Patient Safety?: A Study of Urban Hospitals.

Jan P. Clement, Richard C. Lindrooth, Askar S. Chukmaitov, Hsueh-Fen Chen
Medical Care. 45(2):131-138, February 2007.
Abstract HTML PDF

Physician Practice Revenues and Use of Information Technology in Patient Care.

Michael F. Furukawa, Jonathan D. Ketcham, Mary E. Rimsza
Medical Care. 45(2):168-176, February 2007.
Abstract HTML PDF

Did the Medicare Inpatient Rehabilitation Facility Prospective Payment System Result in Changes in Relative Patient Severity and Relative Resource Use

Susan M. Paddock, José J. Escarce, Orla Hayden, Melinda Beeuwkes Buntin
Medical Care. 45(2):123-130, February 2007
Abstract HTML PDF

The challenge of explaining why quality improvement has not done better

Robert L. Kane and Gordon Mosser
Int J Qual Health Care 2007 19: 8-10;
[Extract] [Full Text] [PDF]

The moderate success of quality of care improvement efforts: three observations on the situation

Tal Katz-Navon, Eitan Naveh, and Zvi Stern
Int J Qual Health Care 2007 19: 4-7;
[Abstract] [Full Text] [PDF]

AHRQ - Closing The Quality Gap: Asthma Care

Closing The Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 5—Asthma Care
January 2007.
Agency for Healthcare Research and Quality, Rockville, MD.
www.ahrq.gov/clinic/tp/asthmgaptp.htm

"Despite the availability of evidence-based guidelines for the management of pediatric and adult asthma, there remains a significant gap between accepted best practices for asthma care and actual care delivered to asthma patients.

The purpose of this systematic review was to evaluate the evidence that quality improvement (QI) strategies can improve the processes and outcomes of outpatient care for children and adults with asthma." (AHRQ)

Estimating the out-of-hospital mortality rate using patient discharge data.

Health Econ. 2006 Sep;15(9):983-95.
Farsi M, Ridder G.

Abstract PDF

Redesigning health systems for quality: Lessons from emerging practices.

Wang MC, Hyun JK, Harrison M, Shortell SM, Fraser I.
Jt Comm J Qual Patient Saf. 2006 Nov;32(11):599-611.

abstract

American College of Cardiology 2006 principles to guide physician pay-for-performance programs

a report of the American College of Cardiology Work Group on Pay for Performance
(A Joint Working Group of the ACC Quality Strategic Direction Committee and the ACC Advocacy Committee)

Brush JE Jr, Krumholz HM, Wright JS, Brindis RG, Cacchione JG, Drozda JP Jr, Fasules JW, Flood KB, Garson A Jr, Masoudi FA, McBride T, McKay CR, Messer JV, Mirro MJ, O'Toole MF, Peterson ED, Schaeffer JW, Valentine CM.

J Am Coll Cardiol. 2006 Dec 19;48(12):2603-9.

Full Text PDF (103 K)

AHRQ - National Healthcare Quality & Disparities Reports

National Healthcare Quality Report, 2006.
Agency for Healthcare Research and Quality, Rockville, MD.
www.ahrq.gov/qual/nhqr06/nhqr06.htm

The 2006 National Healthcare Quality Report (NHQR) is a comprehensive national overview of quality of health care in the United States.

It is organized around four dimensions of quality of care—effectiveness, patient safety, timeliness, and patient centeredness. Those dimensions cover the four stages of care from the patient perspective (staying healthy, getting better, living with illness and disability, and coping with the end of life).

Measures of access to care are covered in the companion 2006 National Healthcare Disparities Report.

What can the UK learn from the USA about improving the quality and safety of healthcare?

Tomson CR, Berwick DM.
Clin Med. 2006 Nov-Dec;6(6):551-8.

pubmed

Measuring the performance of health care services

a review of international experiences and their application to urban contexts
Garcia-Altes A, Zonco L, Borrell C, Plasencia A; Barcelona Group on the Performance of Health Care Services.

Gac Sanit. 2006 Jul-Aug;20(4):316-24.

full text pdf

Health Care Quality Improvement: Ethical and Regulatory Issues

link

alternative link

Jennings B, Baily MA, Bottrell M, Lynn J

Garrison, NY: The Hastings Center; 2007.

The Hastings Center investigate the ethical and value issues that arise in the theory and practice of QI in health care. The project, titled “The Ethics of Improving Health Care Quality and Safety,” was funded by the Agency for Healthcare Research and Quality (AHRQ). This book is one of the outcomes of that project.

A companion piece to this volume is the final project report entitled “The Ethics of Using QI Methods to Improve Health Care Quality and Safety”

(www.thehastingscenter.org/research/hchp09.asp).

Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review

Ali Baba-Akbari Sari, Trevor A Sheldon, Alison Cracknell, Alastair Turnbull
BMJ 2007;334:79,

[Abstract] [Full text] [PDF]


Editorial

Incident reporting and patient safety
Charles Vincent
BMJ 2007;334:51

[Extract] [Full text] [PDF]

Health Affairs - Quality in Cardiovascular Disease

January/February 2007 - Volume 26, Number 1

A section of Health Affairs current issue focus on Quality in Cardiovascular Disease

PROLOGUE: Improving The Quality Of Cardiovascular Disease Care
[Extract] [Full Text] [PDF]

Curbing The Cardiovascular Disease Epidemic: Aligning Industry, Government, Payers, And Academics
Robert M. Califf, Robert A. Harrington, Leanne K. Madre, Eric D. Peterson, Deborah Roth, and Kevin A. Schulman
[Abstract] [Full Text] [PDF]

Measuring Performance For Treating Heart Attacks And Heart Failure: The Case For Outcomes Measurement
Harlan M. Krumholz, Sharon-Lise T. Normand, John A. Spertus, David M. Shahian, and Elizabeth H. Bradley
[Abstract] [Full Text] [PDF]

Evidence, Appropriateness, And Technology Assessment In Cardiology: A Case Study Of Computed Tomography
Rita F. Redberg
[Abstract] [Full Text] [PDF]

Measuring Performance Directly Using the Veterans Health Administration Electronic Medical Record: A Comparison With External Peer Review.

Joseph L. Goulet, Joseph Erdos, Sue Kancir, Forrest L. Levin,Steven M. Wright, Stanlie M. Daniels, Lynnette Nilan, Amy C. Justice
Medical Care. 45(1):73-79, January 2007.

Abstract HTML PDF (480 K)

The Utility of Administrative Data for Measuring Adherence to Cancer Surveillance Care Guidelines.

Gregory S. Cooper, Lonni Schultz, Janine Simpkins, Jennifer Elston Lafata
Medical Care. 45(1):66-72, January 2007.

Abstract HTML PDF (257 K)

The Safety Organizing Scale: Development and Validation of a Behavioral Measure of Safety Culture in Hospital Nursing Units.

Timothy J. Vogus, PhD; Kathleen M. Sutcliffe, PhD
Medical Care. 45(1):46-54, January 2007.

Abstract HTML PDF (481 K)

Facility-Level Factors Influencing Chronic Heart Failure Care Process Performance in a National Integrated Health Delivery System.

Usha Subramanian, Jason Sutherland, Kimberly D. McCoy, Karl F. Welke, Thomas E. Vaughn, Bradley N. Doebbeling
Medical Care. 45(1):28-45, January 2007.

Abstract HTML PDF (8.09 M)

Multidisciplinary Primary Care Teams: Effects on the Quality of Clinician-Patient Interactions and Organizational Features of Care.

Hector P. Rodriguez, William H. Rogers, Richard E. Marshall, Dana Gelb Safran
Medical Care. 45(1):19-27, January 2007.

Abstract HTML PDF (766 K)


Editorial

Are Continuity of Care and Teamwork Incompatible?
Edward H. Wagner, Robert J. Reid
Medical Care. 45(1):6-7, January 2007.

HTML PDF (88 K)

The Effect of a Quality Improvement Initiative on the Quality of Other Aspects of Health Care: The Law of Unintended Consequences?

David A. Ganz, Neil S. Wenger, Carol P. Roth, Caren J. Kamberg, John T. Chang, Catherine H. MacLean, Roy T. Young, David H. Solomon, Takahiro Higashi, Lillian Min, David B. Reuben, Paul G. Shekelle
Medical Care. 45(1):8-18, January 2007.

Abstract HTML PDF (393 K)

Editorial

Intended and Unintended Consequences: What Should We Really Worry About?
McGlynn, Elizabeth A.
Medical Care. 45(1):3-5, January 2007.

HTML PDF (118 K)

Association Between Performance Measures and Clinical Outcomes for Patients Hospitalized With Heart Failure

Gregg C. Fonarow; William T. Abraham; Nancy M. Albert; Wendy Gattis Stough; Mihai Gheorghiade; Barry H. Greenberg; Christopher M. O'Connor; Karen Pieper; Jie Lena Sun; Clyde Yancy; James B. Young; for the OPTIMIZE-HF Investigators and Hospitals

JAMA 2007 297: 61-70

ABSTRACT | FULL TEXT | PDF

Enhancement of Claims Data to Improve Risk Adjustment of Hospital Mortality

Michael Pine; Harmon S. Jordan; Anne Elixhauser; Donald E. Fry; David C. Hoaglin; Barbara Jones; Roger Meimban; David Warner; Junius Gonzales

JAMA 2007 297: 71-76

ABSTRACT | FULL TEXT | PDF

Managing for Quality

erc.msh.org/quality/

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:

• Problem Solving
• Focus on the User
• Build Teams
• Manage the Process
• Case Study

Hospital volume and mortality for mechanical ventilation of medical and surgical patients: A population-based analysis using administrative data

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)

Safety by design - Special Issue

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]

A Systems Approach to Patient-Centered Care

Steven C. Bergeson; John D. Dean
JAMA. 2006;296:2848-2851.

EXTRACT FULL TEXT PDF

Healthcare Quarterly - Vol. 9 Special Issue

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

Identification of surgical complications and deaths

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.

Adverse Events Detected by Clinical Surveillance on an Obstetric Service

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]

The American Surgeon - Vol. 72, No. 11. (November 2006)

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.

Data mining and clinical data repositories: Insights from a 667,000 patient data set

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

AHRQ - Summary Statement on Comparative Hospital Public Reporting

"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)

IHI - 5 Million Lives Campaign

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

Relationship Between Medicare’s Hospital Compare Performance Measures and Mortality Rates

Rachel M. Werner; Eric T. Bradlow
JAMA. 2006;296:2694-2702.

ABSTRACT FULL TEXT PDF


Editorial

Performance Measures and Clinical Outcomes
Susan D. Horn
JAMA. 2006;296:2731-2732.

EXTRACT FULL TEXT PDF

SEER-Medicare: Calculation of Comorbidity Weights

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

Evaluation of a regional disease management programme for patients with asthma or chronic obstructive pulmonary disease

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]

OECD - Health care: Towards quality performance

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

OECD - Health Data 2006 Database

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.

Do Integrated Medical Groups Provide Higher-Quality Medical Care than Individual Practice Associations?

A. Mehrotra, A. M. Epstein and M. B. Rosenthal
Ann Intern Med 2006; 826-833.

Abstract Full Text PDF

Editorial

Which Type of Medical Group Provides Higher-Quality Care?
L. P. Casalino
Ann Intern Med 2006; 860-861.

Full Text PDF

A Pay-for-Population Health Performance System

David A. Kindig
JAMA. 2006;296:2611-2613.

EXTRACT FULL TEXT PDF

AHRQ - 10 Patient Safety Tips for Hospitals

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

Access to health care and hospitalization for ambulatory care sensitive conditions

Ansari, Z; Laditka, JN; Laditka, SB
Med Care Res Rev 2006 63: 719-741.

[Abstract] [PDF]

Redirecting Patients to Improve Stroke Outcomes

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)

The Effects of Patient Volume on the Quality of Diabetic Care for Medicare Beneficiaries.

Holmboe, Eric S. , Wang, Yun , Tate, Janet P. , Meehan, Thomas P.
Medical Care. 44(12):1073-1077, December 2006.

Abstract HTML PDF (195 K)

Effect of Quality Improvement Organization Activities on Outpatient Diabetes Care in Eastern New York State.

Wu, Winfred Y. , Chen, John J. , Shih, Anthony
Medical Care. 44(12):1142-1147, December 2006.

Abstract HTML PDF (434 K)

Can the Quality of Care in Family Practice Be Measured Using Administrative Data?

Alan Katz, Ruth-Ann Soodeen, Bogdan Bogdanovic, Carolyn De Coster, Dan Chateau
Health Services Research 2006 41:6 2238

abstract full text pdf

The 100,000 Lives Campaign: A Scientific and Policy Review

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

CHSFR - Evaluation of Patient Safety and Nurse Staffing

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

Collecting data along the continuum of prevention and care: a Continuous Quality Improvement approach.

Indyk L, Indyk D.
Soc Work Health Care. 2006;42(3-4):47-60.

pubmed

Pay-for-Performance and Accountability: Related Themes in Improving Health Care

J. W. Rowe
Ann Intern Med 2006; 695-699.

Abstract Full Text PDF

Quality of care for hypertension in the United States

Asch SM, McGlynn EA, Hiatt L, Adams J, Hicks J, DeCristofaro A, Chen R, LaPuerta P, Kerr EA.
BMC Cardiovasc Disord. 2005 Jan 7;5(1):1.

Abstract Full text PDF

Funnel plots, performance variation and the Myocardial Infarction National Audit Project 2003-2004.

Christopher P Gale , Anthony P Roberts , Phil D Batin and Alistair S Hall
BMC Cardiovascular Disorders 2006, 6:34

Abstract Full text PDF

Potentially Inappropriate Medication Prescribing for Elderly Outpatients in Emilia Romagna, Italy

A Population-Based Cohort Study
Maio V, Yuen EJ, Novielli K, Smith KD, Louis DZ.
Drugs Aging. 2006;23(11):915-924.

pubmed

Potentially inappropriate medication use in elderly patients receiving home health care

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 Alliance for Patient Safety: Forward Programme 2006-2007

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

Adverse outcomes in surgical patients: implementation of a nationwide reporting system

Marang-van de Mheen, PJ; Stadlander, MC; Kievit, J
Quality & Safety In Health Care, 15 (5): 320-324;

[Abstract] [Full text] [PDF]

Measurement in a Multi-Ethnic Society.

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

NHS - performance ratings 2005/2006

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

Quality of Diagnosis and Procedure Coding in ICD-10 Administrative Data.

Henderson, Toni; Shepheard, Jennie; Sundararajan, Vijaya
Medical Care. 44(11):1011-1019, November 2006.

Abstract HTML PDF (312 K)

NHS - State of healthcare 2006

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)

Experience of wrong site surgery and surgical marking practices among clinicians in the UK

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]

Validation of the Potentially Avoidable Hospital Readmission Rate as a Routine Indicator of the Quality of Hospital Care.

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)

DoD - TeamSTEPPS

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

Internet-Based Chronic Disease Self-Management: A Randomized Trial.

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)

Public Report Cards -- Cardiac Surgery and Beyond

Steinbrook, Robert
N Engl J Med 2006 355: 1847-1849

Extract Full Text PDF

Paying for Performance — Risks and Recommendations

Fisher, Elliott S.
N Engl J Med 2006 355: 1845-1847

Extract FREE Full Text PDF

Interview

Pay for Performance in Commercial HMOs

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

Healthcare: The Problems Are Organizational Not Clinical.

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

Health Information Technology in the United States: The Information Base for Progress.

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)

Adverse Events in the Neonatal Intensive Care Unit

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]

Systematic Review of Medication Errors in Pediatric Patients

Maisoon Abdullah Ghaleb, Nick Barber, Bryony D Franklin, Vincent WS Yeung, Zahra F Khaki, and Ian CK Wong
Ann Pharmacother ; 2006 Oct;40(10):1766-76.

Abstract Full Text PDF

Protecting the Health of the Public — Institute of Medicine Recommendations on Drug Safety

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

Consumer-Directed Health Care

Bloche, M. Gregg
N Engl J Med 2006 355: 1756-1759

Extract Full Text PDF

Disparities in the Utilization of High-Volume Hospitals for Complex Surgery

Jerome H. Liu; David S. Zingmond; Marcia L. McGory; Nelson F. SooHoo; Susan L. Ettner; Robert H. Brook; Clifford Y. Ko
JAMA. 2006;296:1973-1980.
ABSTRACT FULL TEXT PDF


Editorial

Delivering Quality to Patients
Samuel R. G. Finlayson
JAMA. 2006;296:2026-2027.

EXTRACT FULL TEXT PDF

Segnalare ai cittadini la qualita degli ospedali: il rischio della cattiva informazione.

[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

Do report cards influence hospital choice? The case of kidney transplantation.

Howard DH, Kaplan B.
Inquiry. 2006 Summer;43(2):150-9.

pubmed

HCUP - The Case for the Present-on-Admission (POA) Indicator

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

Continuity of care and quality care outcomes for people experiencing chronic conditions

A literature review
Gwen van Servellen, Marie Fongwa, Ellen Mockus D'Errico
Nurs Health Sci. 2006 Sep;8(3):185-95.

abstract full text pdf

Development and implementation of evidence-based indicators for measuring quality of acute stroke care

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)

Graduate Medical Education and Patient Safety: A Busy—and Occasionally Hazardous—Intersection

K. G. Shojania, K. E. Fletcher and S. Saint
Ann Intern Med 2006; 592-598.

Abstract Full Text PDF


Editorial

Quality Grand Rounds: The Case for Patient Safety
R. M. Wachter, K. G. Shojania, A. J. Markowitz, M. Smith and S. Saint
Ann Intern Med 2006; 629-630.

Full Text PDF

Sustaining and improving hospital performance: The effects of organizational and market factors

H. Joanna Jiang; Bernard Friedman; James W. Begun
Health Care Management Review 31(3), pp. 188-196.

Abstract HTML PDF (131 K)

Physician Group Cultural Dimensions and Quality Performance Indicators: Not All Is Equal.

Amy Smalarz
Health Care Management Review. 31(3):179-187

Abstract HTML PDF (131 K)

AHRQ - QI Composite Measure and Risk Adjustment/Hierarchical Modeling Draft

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

In addition, the draft report on Risk Adjustment and Hierarchical Modeling has been posted for public comment:

QI_RAHM_Draft.doc

The Impact Of Quality-Reporting Programs On Hospital Operations

Hoangmai H. Pham, Jennifer Coughlan, and Ann S. O’Malley
Health Affairs, September/October 2006; 25(5): 1412-1422.

[Abstract] [Full Text] [PDF]

The Quality of Pharmacologic Care for Adults in the United States

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

The Canadian National Outcomes Measurement Study in Schizophrenia

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

Accountability sought by patients following adverse events from medical care: the New Zealand experience

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]

Assessing Patient Safety Culture: A Review and Synthesis of the Measurement Tools.

Aneesh K. Singla; Barrett T. Kitch; Joel S. Weissman; Eric G. Campbell
Abstract HTML PDF (123 K)

Impact of a Statewide Reporting System on Medication Error Reduction.

Kimberly Rask; Jonathan Hawley; Anne Davis; Dorothy 'Vi' Naylor; Kenneth Thorpe
Abstract HTML PDF (101 K)

Learning From Different Lenses: Reports of Medical Errors in Primary Care by Clinicians, Staff, and Patients:

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)

Adverse outcomes in Belgian acute hospitals: retrospective analysis of the national hospital discharge dataset

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]

Rapid Response Teams—Walk, Don't Run

Bradford D. Winters; Julius Pham; Peter J. Pronovost
JAMA. 2006;296:1645-1647.

EXTRACT FULL TEXT PDF

AHRQ - Release of the Pediatric Quality Indicator Risk Adjustment Module (Windows)

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

IOM - Rewarding Provider Performance: Aligning Incentives in Medicare

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)

Assessing the reliability of standardized performance indicators

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]

The Impact of Unmeasured Clinical Variables on the Accuracy of Hospital Report Cards: A Monte Carlo Study

Austin, Peter C.
Med Decis Making 2006 26: 447-466

[Abstract] [PDF] [References]