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Meeting/Conference > Meeting/Conference Proceedings
Hammons T, Piland NF, Small SD, Hatlie MJ, Burstin HR. Englewood, CO: Medical Group Management Association Center for Research; 2001.
This summarizes a multidisciplinary conference (November 30 and December 1, 2000) dedicated to developing a research agenda in ambulatory patient safety. It reviews current knowledge about patient safety and contains information from presentations and discussions of conference participants. Eleven consensus recommendations are provided. The project was supported by grant number R13 HS10106 from the Agency for Healthcare Research and Quality (AHRQ).
Journal Article > Study
Relationship between performance measurement and accreditation: implications for quality of care and patient safety.
Miller MR, Pronovost P, Donithan M, et al. Am J Med Qual. 2005;20:239-252.
This AHRQ-supported study discovered few existing relationships between the Joint Commission on Accreditation of Healthcare Organizations accreditation scores and AHRQ's Inpatient Quality and Patient Safety Indicators (IQIs/PSIs). Given the increasing focus on public reporting of such information to guide consumers in making health care choices, the investigators sought to determine if current reports of accreditation scores reflect more recent and evidence-based IQIs/PSIs. Discussion includes detailed analyses illustrating the relationships, or lack thereof, between the different systems. While many argue that accreditation and performance measurement capture different aspects of quality and safety, this study suggests a need for greater vigilance in defining how and what to measure if the goal is to provide an accurate representation of quality and safety to the public.
VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements is Poor.
Washington, DC: United States Government Accountability Office; May 2006. Publication GAO-06-544.
This investigation determined that the U.S. Veterans Administration has taken steps to improve the reliability of their practitioner licensure and certification screening processes for employees and new hires but found that some weaknesses still exist.
VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement.
Washington, DC: United States Government Accountability Office; May 2006. Publication GAO-06-648.
This report reviews findings from a federal inspection indicating that Veterans Affairs (VA) facilities, while complying with basic credentialing policies, are not routinely submitting malpractice data as required to be used by the VA to inform privileging determinations.
Callender AN, Hastings DA, Hemsley MC, Morris L, Peregrine MW. Washington, DC: US Department of Health and Human Services Office of the Inspector General; June 29, 2007.
This report outlines the fiduciary and corporate responsibilities of board members to support quality and safety in hospitals and provides questions to help them examine the scope of these efforts in their organizations.
Journal Article > Government Resource
Acute Hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic—Nevada, 2007.
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2008;57:513-517.
This report further discusses the investigation of a Hepatitis C outbreak that resulted from unsafe injection practices at an endoscopy clinic.
Journal Article > Commentary
Clancy CM. Am J Med Qual. 2008;23:318-321.
This article explains how AHRQ's Patient Safety Organization (PSO) initiative will help dismantle barriers to sharing data on errors.
Legislation/Regulation > Government Resource
US Department of Health and Human Services; Agency for Healthcare Research and Quality; Federal Register. November 21, 2008;73:70731-70814.
This final rule outlines how to become a Patient Safety Organization (PSO), and supports AHRQ action to receive applications from qualified entities that wish to become PSOs. The interim guidance will remain in effect until January 19, 2009, the official activation date for the final rule.
Web Resource > Government Resource
Agency for Healthcare Research and Quality.
This Web site supports AHRQ implementation of the Patient Safety and Quality Improvement Act of 2005 by providing technical assistance and educational materials to Patient Safety Organizations. The site includes updates on the latest definitions and common formats.
VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events.
Draper D. Washington, DC: United States Government Accountability Office; December 3, 2013. Publication GAO-14-55.
Evaluation of provider behavior can identify problems that affect patient safety. This report analyzed data and expert interviews from four Veterans Affairs medical centers to identify weaknesses in peer review processes. Investigators found inconsistent adherence to peer review policy elements, such as timely review performance and peer review trigger development, and make recommendations to drive actions that address these issues.
Legislation/Regulation > Government Resource
Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care; Proposed Rule.
Centers for Medicare & Medicaid Services. Fed Regist. 2016;81:39447-39480.
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.
Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.
Washington, DC: United States Government Accountability Office; February 2019. Publication GAO-19-6.
Gaps in responding to concerns about clinician competence can result in care failures. This report examined Veterans Health Administration (VHA) actions associated with National Practitioner Data Bank records and found variation in how organizations responded to that information including some instances where VHA facilities inappropriately hired providers. The Government Accountability Office makes seven recommendations to address this problem.