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Legal and Policy Approaches
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United States of America
United States Federal Government
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Search results for "Legal and Policy Approaches"
- Department of Health and Human Services (HHS)
- Legal and Policy Approaches
Journal Article > Review
Joseph A, Henriksen K, Malone E. Health Aff (Millwood). 2018;37:1884-1891.
The built environment influences the safety and effectiveness of care delivery. This narrative review examines how care facility design can reduce health care–associated infections, falls, and medication errors. The authors provide suggestions regarding a range of facility design strategies and discuss how accreditation, funding, and policy organizations can support design projects as improvement efforts.
Journal Article > Study
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.
Calderwood MS, Kawai AT, Jin R, Lee GM. 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.
Journal Article > Commentary
National Action Plan for Adverse Drug Event Prevention: recommendations for safer outpatient opioid use.
Ducoffe AR, York A, Hu DJ, Perfetto D, Kerns RD. Pain Med. 2016;17:2291-2304.
Agency for Healthcare Research and Quality. Priorities in Focus. March 2016.
The National Quality Strategy is part of AHRQ's ongoing efforts to enhance patient safety. This brief summarizes the results of the Partnership for Patients program and other initiatives working toward achieving the goals of the National Quality Strategy, including reducing hospital-acquired conditions, preventable readmissions, and patient harm.
Legislation/Regulation > Government Resource
Medicare and Medicaid programs; reform of requirements for long-term care facilities; proposed rule.
Federal Register. Washington, DC: US Department of Health and Human Services. Baltimore, MD: Centers for Medicare & Medicaid Services. July 16, 2015;80:42167-42269.
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.
Agency for Healthcare Research and Quality. Fed Register. September 2, 2009;74:45457-45458.
This announcement and accompanying Web site provide version 1.0 of the standardized guidelines for health care agencies to voluntarily report patient safety and health care information. Empowered by the Patient Safety and Quality Improvement Act of 2005, AHRQ-funded Patient Safety Organizations will analyze and organize the data.
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).
The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.
Web Resource > Government Resource
Agency for Healthcare Research and Quality.
In order to encourage "voluntary, provider-driven initiatives to improve the safety and quality of patient care," the Agency for Healthcare Research and Quality (AHRQ) is spearheading the certification of Patient Safety Organizations (PSOs)—public or private organizations with expertise in the analysis of patient safety and hazards in health care. This Web site provides information on the rules governing PSOs and the requirements for an organization to be listed as a PSO. Development of PSOs was authorized by the 2005 Patient Safety and Quality Improvement Act.
Rockville, MD: Agency for Healthcare Research and Quality; February 2005. AHRQ Publication Nos. 050021 (1-4).
With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine's report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.
Journal Article > Study
Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017.
Petersen EE, Davis NL, Goodman D, et al. MMWR Morb Mortal Wkly Rep. 2019;68:423-429.
Maternal safety is a critical concern in health care, and prior studies have discussed racial and ethnic disparities in patient safety. The Centers for Disease Control and Prevention examined trends in pregnancy-related deaths between 2011 and 2015. This analysis found that black women had rates of maternal mortality 3.5 times that of white women; Native American/Alaska Native women had rates 2.5 times higher than white women. About 60% of deaths were deemed preventable, and leading causes included cardiovascular events such as venous thromboembolism, infection, and hemorrhage. The study team recommends implementing interventions at health system, provider, community, and patient levels to prevent maternal mortality. A recent Annual Perspective on maternal safety touched on the persistently higher death rates among black women and discussed national initiatives to improve outcomes in maternity care.
Journal Article > Study
Studdert DM, Spittal MJ, Zhang Y, Wilkinson DS, Singh H, Mello MM. N Engl J Med. 2019;380:1247-1255.
Malpractice claims can shed light on patient safety hazards. This observational study examined how paid malpractice claims affected physicians' practice. Investigators found that a small proportion of physicians, about 10%, had one or more paid malpractice claims, consistent with prior studies. Approximately 2% of physicians accounted for nearly 40% of paid claims. Physicians with paid claims were more likely to leave clinical practice and more likely to move to smaller practice settings. The authors raise the concern that physicians who move to smaller practice settings may lack the institutional and peer support to remediate their clinical skills and behavior. A PSNet perspective explored the risk of recurring medicolegal events among providers who have received multiple malpractice claims.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.
Notice of Intent to Publish Funding Opportunity Announcement to Improve Care Transitions Through the Use of Interoperable Health Information Technology (R01).
Rockville, MD: Agency for Healthcare Research and Quality; January 28, 2019. AHRQ Publication No. NOT-HS-19-009.
The introduction of information technology has transformed health care. This notice of intent from AHRQ announces an upcoming funding opportunity to support research exploring the adoption of interoperable information technologies to improve communication during transitions. The pending funding will help to refine and develop methods to assess implementation success.
Journal Article > Government Resource
Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. MMWR Morb Mortal Wkly Rep. 2019;67:1419-1427.
This Centers for Disease Control and Prevention report provides drug and opioid overdose death figures for 2016. The rate of overdose deaths continues to rise, with the largest increase due to synthetic opioids such as fentanyl. The report calls for enhancing prevention and response measures, including the use of naloxone.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. August 2, 2018. Publication No. NOT-HS-18-015.
This announcement highlights Agency for Healthcare Research and Quality funding opportunities for health services research to assess local, state, and system-level policy to address the opioid crisis, evaluate interventions to minimize opioid misuse, and understand the rapid increase in opioid-related hospitalizations.
Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. May 21, 2018. PA-18-790; PA-18-791.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; April 10, 2018. PA-18-750.
Research on patient safety improvements has largely focused on the acute care environment. This grant will support funding for demonstration and implementation projects aimed at identifying and evaluating the application of evidence-based practices in ambulatory care and long-term care to improve patient safety. The deadline for submitting applications is September 8, 2021.
Grant > Government Resource
Patient Safety Learning Laboratories: Pursuing Safety in Diagnosis and Treatment at the Intersection of Design, Systems Engineering, and Health Services Research (R18).
Rockville, MD: Agency for Healthcare Research and Quality. RFA-HS-19-001.
Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 17-0017-EF.
This publication describes the results of demonstration projects funded by AHRQ's Patient Safety and Medical Liability Reform Initiative. Included studies examined communication and resolution programs, patient reporting of adverse events, and patient perceptions of error disclosure. An overarching theme of these studies is the gap between recommended communication practices and usual clinical care and communication. Several studies demonstrated challenges of implementing health system interventions to improve safety across a range of interventions, including error disclosure training, shared decision-making, and medication safety during transitions in care. These studies reveal the importance of measuring and improving safety culture as a foundation for patient safety efforts. Commentaries by various patient safety experts highlight the need for ongoing support for research at the intersection of patient safety and medical liability. A past PSNet perspective described how evidence-based improvements to the medical liability system could influence accountability and compensation for errors.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; July 2017. Report No. OEI-02-17-00250.