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Search results for "Health Care Executives and Administrators"
- Health Care Executives and Administrators
Famolaro T, Yount ND, Hare R, Thornton S, Sorra J. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0028-EF.
For more than a decade, the Hospital Survey on Patient Safety Culture has been used in hospitals to evaluate aspects of local organizational culture that affect patient safety. Improved patient safety culture scores have been associated with reduced adverse events and better patient outcomes. The Medical Office Survey on Patient Safety Culture expands this widely used tool for application in the medical office setting. The 2016 User Comparative Database includes data from more than 25,000 respondents across 1,528 medical offices that completed the survey between 2013 and 2015. As with similar databases for hospitals and pharmacies, this resource serves as a tool for benchmarking performance and identifying potential areas for improvement. Teamwork and patient care tracking received the strongest positive scores, whereas work pressure and pace was identified as the area with the most potential for improvement. A prior PSNet perspective discussed establishing a safety culture.
Boston, MA: National Patient Safety Foundation; 2015.
This report provides an objective assessment of the state of the safety field 15 years after the release of the Institute of Medicine's To Err Is Human. Acknowledging that progress has been slower than anticipated, the report makes eight recommendations for achieving total system safety, including creating a common set of safety metrics that reflect meaningful outcomes, establishing and sustaining a culture of safety, centralizing oversight of patient safety at the national level, improving the safety of information technology, and supporting patients, families, and the health care workforce. The report also highlights the need for greater investment in patient safety, particularly in the outpatient and long-term care areas. Dr. Tejal Gandhi, President and CEO of the National Patient Safety Foundation (NPSF), discussed the evolving responsibilities of NPSF in a 2014 PSNet interview.
Rockville, MD: Agency for Healthcare Research and Quality; December 2015. AHRQ Publication No. 16-0009-EF.
The Partnership for Patients initiative has led efforts to reduce hospital-acquired conditions (HACs), such as health care–associated infections and other never events. Since 2010, AHRQ has been tracking rates of HACs including adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, pressure ulcers, and surgical site infections. This interim update demonstrates that HACs were reduced by 17% in 2014, indicating that the previously reported decline has been sustained. With this decrease in HACs, the analysis estimates that 87,000 fewer hospital patients died and $19.8 billion in health care costs were saved from 2011 to 2014. Although HACs persist despite incentives and strategies to eliminate them, these reductions indicate that hospitals have made substantial progress in improving safety.
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-0006-EF.
Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.
Influencing the Quality, Risk and Safety Movement in Healthcare: In Conversation with International Leaders.
Sears K, Stockley D, Broderick B, eds. Aldershot, UK: Ashgate Publishing; 2015. ISBN: 9781472449276.
Blumenthal D, Malphrus E, McGinnis JM, eds. Committee on Core Metrics for Better Health at Lower Cost, Institute of Medicine. Washington, DC: National Academies Press; 2015. ISBN: 9780309324939.
Measures to assess health care often add burden for overwhelmed hospital workers, and lack of consistency limits the usability of data to inform improvement. This publication reviews findings of a committee convened to discuss core measures for health care and outlines a set of 15 standardized measures to optimize performance assessment and develop data that drives progress.
Hanlon C, Sheedy K, Kniffin T, Rosenthal J. Portland, ME: National Academy for State Health Policy; 2015.
State reporting systems were advocated early in the patient safety movement as a way to enable learning from errors. This analysis of 27 state-level reporting programs highlights that while adverse event reporting has become more sophisticated since the previous survey, only one new program has launched since then. The authors emphasize the value of partnership, collaboration, and transparency in the work of the participating states. An AHRQ WebM&M perspective spotlights state reporting programs as mechanisms to augment patient safety.
Waterson P, ed. London, UK: Ashgate; 2014. ISBN: 9781409448143.
Zipperer L, ed. London, UK: Gower Publishing; 2014. ISBN: 9781409438571.
Levit L, Balogh E, Nass S, Ganz PA, eds. Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population, Institute of Medicine. Washington, DC: National Academies Press; 2013. ISBN: 9780309293099.
Cancer patients are particularly vulnerable to preventable errors in both inpatient and outpatient settings, as their care involves exposure to high-risk medications and requires closely coordinated care. Seen in that light, this Institute of Medicine report, which bluntly concludes that the current system of cancer care is untenable, is particularly concerning. The report highlights numerous deficiencies in the current system, such as insufficient compliance with evidence-based guidelines, high rates of medication errors, and failure to incorporate patient preferences into advanced care planning. To reshape how cancer care is delivered, the report recommends leveraging information technology to augment care coordination and real-time analysis of treatment data, better end-of-life planning, and improving communication with patients and families around prognosis and the risks and benefits of treatments. Multiple AHRQ WebM&M commentaries discuss safety issues in oncology patients, including a case of a chemotherapy medication error detected by the patient himself and a near-fatal error ascribed in part to poorly coordinated care.
Partnering with Patients to Drive Shared Decisions, Better Value, and Care Improvement—Workshop Proceedings.
Roundtable on Value and Science Driven Healthcare; Institute of Medicine. Washington, DC: National Academies Press; 2013. ISBN: 9780309288965.
This publication reports on a workshop that explored methods to engage patients and families in safety improvement efforts, including shared decision making and providing information to consumers about costs.
Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Committee on the Learning Health Care System in America, Institute of Medicine. Washington, DC: National Academies Press; 2012. ISBN: 9780309260732.
This Institute of Medicine (IOM) report presents evidence of poor quality care and significant waste (to the tune of an estimated $750 billion per year) in the American health care system. It emphasizes the importance of continuous learning—not only from high performing health care systems but also from industries such as manufacturing, banking, and aviation—and highlights the role of mobile technologies and electronic health records in continuously improving health care.
Patankar MS, Brown JP, Sabin EJ, Bigda-Peyton TG. Burlington, VT: Ashgate; 2012. ISBN: 9780754672371.
This book presents a safety culture model as a tactic to assess and improve safety in health care.
Oakbrook Terrace, IL: The Joint Commission; September 2011.
This report emphasizes performance on Hospitals in the United States have made significant improvements in quality of care over the past several years, according to the sixth annual Joint Commission report. This report emphasizes performance on accountability measures—quality metrics that are closely tied to patient outcomes—and cites exemplar hospitals across the country that have demonstrated outstanding performance on these metrics for patients undergoing surgery, and for patients hospitalized with myocardial infarctions, pneumonia, and asthma (in children). Beginning in 2012, The Joint Commission began to integrate performance expectations on accountability measures into their annual accreditation surveys, meaning that for the first time, hospitals must demonstrate high-quality performance in order to retain accreditation.
Parush A, Campbell C, Hunter A, et al. Ottawa, Ontario: The Royal College of Physicians and Surgeons of Canada; 2011. ISBN: 9781926588100.
This publication provides training to improve situational awareness and patient safety.
Portland, OR: Oregon Patient Safety Commission.
This annual publication provides data and analysis of adverse events voluntarily reported to the Oregon Patient Safety Commission. The review of 2015 data discussed the 704 events submitted from the 4 types health care settings involved and found that medication errors, invasive procedure incidents, care delays, and falls were the most frequent problems.
Antonsen S. Burlington, VT: Ashgate; 2009. ISBN: 9780754676959.
Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. Washington, DC: The National Academies Press; 2008. ISBN: 9780309127721.
The 2003 regulations limiting housestaff work hours have had a profound impact on residency training. Although clinical outcomes appear to be unaffected, faculty and residents have expressed concern that education has been harmed, and the regulations' effect on patient safety remains unclear. The Institute of Medicine's report bases its recommendations on the growing body of research linking clinician fatigue and error, and recommends eliminating extended-duration shifts (defined as more than 16 hours), increasing days off, and improving sleep hygiene by reducing night duty and providing more scheduled sleep breaks. The report estimates that approximately $1.7 billion would be required to hire additional staff to allow residency programs to adhere to these recommendations. A related editorial discusses the balance between patient safety, resident safety, and resident education that was central to the development of these recommendations.
Spath P, ed. Chicago, IL: AHA Press; 2008. ISBN: 9781556483530.
This book discusses strategies for health care professionals to improve patient-provider relationships and to involve patients in ensuring safety. The editor provides narratives from patients to illustrate the struggles they encounter when trying to effectively partner for their care.
Nemeth CP, ed. Burlington, VT: Ashgate Publishing; 2008. ISBN: 9780754670254.
This book provides analysis from experts in high-risk industries regarding how cognition affects information sharing and team communication.