Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 2
- Education and Training 2
- Error Reporting and Analysis 7
- Human Factors Engineering 1
Legal and Policy Approaches
- Credentialing, Licensure, and Discipline
- Quality Improvement Strategies 8
- Specialization of Care 1
- Technologic Approaches 1
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 3
- Identification Errors 2
- Medical Complications 3
- Medication Safety 3
- Psychological and Social Complications 1
- Surgical Complications 1
Search results for "Credentialing, Licensure, and Discipline"
- Credentialing, Licensure, and Discipline
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.
Oakbrook Terrace, IL: The Joint Commission; November 2015.
The annual report from The Joint Commission, which accredits hospitals in the United States, serves as a snapshot for quality reporting. This year's report reflects an expansion in the number of quality measures used. About one-third of participating hospitals performed at 95% or above for all accountability measures. The report also found that quality of care has improved over time for myocardial infarction, pneumonia, surgery, pediatric asthma, venous thromboembolism, stroke, immunization, perinatal care, and inpatient psychiatry. New measurements of tobacco and substance abuse care reveal potential for improvement. This report underscores both the power of performance measurement and reporting to drive progress. It also demonstrates that patient safety issues such as medication safety and diagnosis remain under-emphasized in the accreditation and performance measurement sphere.
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.
Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2008. ISBN: 9780980346275.
This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.
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.
Marx D. New York, NY: Columbia University; 2001.
Accountability is a concept that many wrestle with as they steer their organizations and patients toward understanding and accepting the idea of a blameless culture within the context of medical injury. Marx presents the concept from the legal perspective but does so for the non-barrister. Written prior to the acceptance of open disclosure or general policy support of it, the primer thoughtfully outlines the complex nature of deciding how best to hold individuals accountable for mistakes. Four key behavior concepts serve as the structure for the paper: human error, negligence, reckless conduct, and knowing violations. How they are applied to various situations in health care and how the individuals involved should be disciplined provide thoughtful reading.
Chicago, IL: American Board of Medical Specialties; 2016.
In response to the 2015 Improving Diagnosis in Health Care report, the National Patient Safety Foundation and American Board of Medical Specialties convened a multidisciplinary panel of patient safety experts to determine safety challenges in the diagnostic process as a way to inform recommendations for improving diagnosis. Their consensus focused on educational, assessment, and cultural aspects of the process.
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.
Jewell K, McGiffert L. Austin, TX: Consumers Union; 2009.
The 10 years since the release of the Institute of Medicine's To Err Is Human report have yielded some improvements in patient safety, but this Consumers Union report reminds clinicians and consumers alike that much work remains to be done. As the report notes, preventable safety problems such as medication errors and health care–associated infections still cause significant morbidity and mortality, despite the existence of effective preventive strategies. The report advocates for standardized measurement and public reporting of errors and calls for tighter accreditation standards for health care professionals.
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.
Thompson WC Jr. New York, NY: Office of the New York City Comptroller, Office of Policy Management; 2009.
This report assesses the New York State Department of Health's New York Patient Occurrence and Tracking System (NYPORTS). It observes trends of adverse event reporting, finds that New York City hospitals report dramatically fewer events per discharge, explores reasons for underreporting, and discusses the impact on safety improvement efforts.
Oakbrook Terrace, IL: The Joint Commission; November 2007.
Building on its inaugural publication, this report summarizes the quality and safety of care delivered to hospitalized patients between 2002 and 2006. The report suggests that hospital performance consistently improved from year to year as measured by adherence to evidence-based treatments for heart attacks, heart failure, and pneumonia, as well as more recent measures of surgical care. While similar improvements were noted in compliance with National Patient Safety Goals, significant room for improvement remains on additional quality measures, and noted variability exists in performance by hospital and by state. The report emphasizes the Joint Commission's efforts to improve performance measurement and reporting requirements in future years to adequately reflect the organization's goal of improved health outcomes. A past AHRQ WebM&M commentary discussed the unintended consequences of the public reporting of hospital quality.
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.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.
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.