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Journal Article > Study
How improving practice relationships among clinicians and nonclinicians can improve quality in primary care.
Lanham HJ, McDaniel RR, Crabtree BF, et al. Jt Comm J Qual Patient Saf. 2009;35:457-466.
This study used organizational theory approaches to analyze work relationships in primary care practices and to identify relationship factors that influenced the quality of care.
Case study: sustaining a culture of safety in the U.S. Department of Veterans Affairs Health Care System.
Chase D, McCarthy D. Quality Matters. April/May 2010.
Special or Theme Issue
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 23, 2010.
This issue features successful patient safety innovations pertaining to disclosure, multidisciplinary patient safety conferences, and proactive reporting.
Journal Article > Study
West P, Sculli G, Fore A, et al. J Nurs Adm. 2012;42:15-20.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in several landmark patient safety initiatives. The CUSP approach emphasizes improving safety culture by through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Most recently, an AHRQ-funded project using the CUSP model achieved a 40% reduction of central line–associated bloodstream infections in intensive care units nationwide. This toolkit includes modules on how to build the CUSP team, identify recurring safety concerns, and improve teamwork and communication.
Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals.
Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 12-0041.
Web Resource > Government Resource
Washington, DC: US Department of Health and Human Services.
Launched in 2011, the Partnership for Patients plans to invest approximately $1 billion total in an effort to decrease preventable harm in United States hospitals. Its emphasis on partnerships (between government, provider organizations, payers, and patients) echoes certain Institute for Healthcare Improvement (IHI) campaigns, developed by Medicare director Dr. Donald Berwick while he led IHI. The Partnership focuses on skill building, demonstration projects, and collaboratives. Through 2019, the Hospital Improvement and Innovation Networks will work to achieve a 20% decrease in overall patient harm and a 12% reduction in 30-day hospital readmissions as a population-based measure from the 2014 baseline. In September 2015, the program awarded $110 million to 17 national, regional, or state hospital associations and health system organizations. CMS estimates that 2.1 million fewer patients were harmed and nearly $20 in health care costs were saved from 2010 to 2014. Medicare hopes these recent monetary awards will continue to drive this momentum on improving patient safety.