The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 14 of 14 Results

Hospital Compare.

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Centers for Medicare & Medicaid Services.

The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.

Care Compare.

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Centers for Medicare and Medicaid Services.

The Centers for Medicare & Medicaid Services (CMS) support transparency through the provision of publicly available information on the quality of health care service in the United States. This portal enables access to comparative quality and safety data from doctors & clinicians, hospital, nursing home, home health, hospice, inpatient rehabilitation facilities, long-term care hospitals, and dialysis facilities to support informed consumer health care provider selection activities.

Hospital-Acquired Condition (HAC) Reduction Program.

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QualityNet. Centers for Medicare and Medicaid Services.

Eliminating hospital-acquired harm requires policy, organizational, and individual approaches to motivate the necessary changes. This website provides information and data collected from a Centers for Medicare and Medicaid Services financial incentive program reducing reimbursements to hospitals with elevated rates of hospital-acquired conditions.

Centers for Medicare and Medicaid Services hospital-acquired conditions policy for central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement.

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Calderwood MS, Kawai AT, Jin R, et al. Infect Control Hosp Epidemiol. 2018;39:897-901.

The Centers for Medicare and Medicaid Services (CMS) nonpayment policy for health care–associated infections is widely viewed as a catalyst for infection prevention initiatives. This analysis of Medicare fee-for-service claims data shows that following nonpayment policy implementation, there was a substantial increase in claims in which central line–associated bloodstream infections and catheter-associated urinary tract infections were reported to be present on arrival to the hospital. According to this analysis, because CMS continued to reimburse hospitals for conditions present on arrival, the nonpayment policy did not have significant financial impact. The authors conclude that the nonpayment policy for health care–associated infections did not have its intended effect. A past PSNet interview discussed the potential benefits and limitations of insurers not paying for preventable complications.

Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care; Proposed Rule.

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Centers for Medicare & Medicaid Services; CMS.

This proposed rule suggests updates to the government requirements hospitals must comply with to participate in Medicare and Medicaid. Changes include emphasis on the role of leadership engagement and safety culture as ways to generate improvements in areas such as reducing hospital-acquired infections and readmissions. Comments on the proposed rule are due August 15, 2016.

Association between the Centers for Medicare and Medicaid Services hospital star rating and patient outcomes.

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Wang DE, Tsugawa Y, Figueroa JF, et al. JAMA Intern Med. 2016;176:848-50.

Centers for Medicare and Medicaid Services star ratings are based on patient experience surveys, and the relationship between such ratings and patient outcomes has not been well-established. This secondary data analysis found that hospitals with higher star ratings had lower 30-day mortality and readmission rates. The authors suggest that these ratings may lead patients to higher-performing hospitals.

Medicare and Medicaid programs; reform of requirements for long-term care facilities; proposed rule.

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US Department of Health and Human Services; Centers for Medicare & Medicaid Services.

Poor safety culture and lack of available resources to provide high-quality care can hinder safety in long-term care facilities. This set of regulations will revise requirements for long-term care facilities in areas such as clinical practice standards, service delivery, patient-centeredness, and infection control. The deadline for officially submitting comments on the proposed rule was September 14, 2015.

Variation in Patient Safety Outcomes and the Importance of Being Informed.

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Golden, CO: Healthgrades; 2013.

This analysis of Medicare hospitalization data from 2009–2011 highlights hospital efforts to drive safety improvement but notes that more than 280,000 preventable patient safety events occurred. The report also recognizes 379 hospitals with a Patient Safety Excellence Award for 2013.

Effect of nonpayment for preventable infections in U.S. hospitals.

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Lee GM, Kleinman K, Soumerai SB, et al. N Engl J Med. 2012;367:1428-37.

In 2008, the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for certain preventable errors and hospital-acquired infections. This landmark policy aimed to align financial disincentives with adverse events, an increasingly utilized strategy. However, this AHRQ-funded study found that the "no pay for errors" policy had no measurable effect on rates of catheter–associated bloodstream infections and catheter–associated urinary tract infections in hospitals in the United States. No subgroup of hospitals or patients identified in this national evaluation seemed to clearly benefit from this policy change. The benefits and limitations of the CMS policy are discussed in an AHRQ WebM&M interview with Dr. Robert Wachter.

Medicaid program; payment adjustment for provider-preventable conditions including health care–acquired conditions.

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Centers for Medicare & Medicaid Services. 42 CFR Parts 434, 438, and 447: June 1, 2011.

This final rule prohibits federal reimbursements to states for costs associated with health care–acquired conditions. The regulations are effective as of July 1, 2011.

Medicare proposes new hospital value-based purchasing program.

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Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; January 07, 2011.

This fact sheet highlights key points of a government effort to link performance on quality with select AHRQ patient safety indicators to raise Medicare reimbursement. The opportunity for submitting comments has passed.

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

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Centers for Medicare and Medicaid Services; CMS

This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.

Quality Improvement Organizations.

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Medicare Quality Improvement Community; MedQIC

This Web site features resources to support the Medicare Quality Improvement Program and Medicare Quality Improvement Organizations (QIOs) in delivering quality care.

Nursing Home Compare.

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Centers for Medicare and Medicaid Services.

This website provides consumers with detailed information about the past performance of every Medicare- and Medicaid-certified nursing home in the country. Additional resources available at the site help with other nursing home selection issues. Information is provided in English and Spanish. In 2020, the website was renamed Care Compare, with links to compare hospitals, hospice, and other care providers.

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