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Search results for "Health Care Executives and Administrators"

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Audiovisual > Audiovisual Presentation

The Toolkit for Using the AHRQ Quality Indicators: How To Improve Hospital Quality and Safety.

Rockville, MD: Agency for Healthcare Research and Quality; July 2016.

This toolkit provides resources to help hospitals to augment safety. The updated toolkit represents adjustments made to the AHRQ Quality Indicators to support the transition from ICD-­9 to ICD-­10, experience from testing in hospitals, and materials targeted to inform leadership of the program. The toolkit is structured around enhancing multidisciplinary teamwork by completing a series of steps such as assessing the organizational readiness for a change initiative, implementing improvements, and determining the return on investment of the programs.

Newspaper/Magazine Article

Medication administration errors in hospitals—challenges and recommendations for their measurement.

McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries; March 10, 2014.

Strategies to prevent medication errors are an ongoing focus in patient safety. This expert commentary discusses challenges associated with tracking medication administration failures and recommends regular monitoring of medication delivery practices to avoid errors.

Journal Article > Study

A closer look at associations between hospital leadership walkrounds and patient safety climate and risk reduction: a cross-sectional study.

Schwendimann R, Milne J, Frush K, Ausserhofer D, Frankel A, Sexton JB. Am J Med Qual.  2013;28:414-421.

Executive walkrounds are widely used for improving safety culture, but their effect on specific patient safety attitudes and outcomes is not well established. This retrospective study found that leadership walkrounds participation was strongly associated with positive safety climates and greater risk reductions. While the application of leadership walkrounds varies widely from institution to institution, this multicenter study used a standardized strategy that included monthly hospital executive visits and scripted, open-ended questions meant to engage staff in patient safety discussions. An AHRQ WebM&M perspective discussed the importance of involving hospital leadership with safety and quality.

Journal Article > Commentary

Leading a highly visible hospital through a serious reportable event.

Erickson JI. J Nurs Adm. 2012;42:131-133.

This commentary describes how culture, transparency, and resilience helped a chief nurse executive manage the consequences of a high-profile clinical alarm failure.

Newspaper/Magazine Article

The pursuit of perfection: hospitals take heightened actions to reduce adverse events.

May EL. Healthc Exec. 2012;27:26-28,30-33.

This article describes organizational strategies to improve patient safety, including clinician communication, disclosure, and leadership commitment.

Journal Article > Study

Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign.

Sinkowitz-Cochran RL, Garcia-Williams A, Hackbarth AD, et al. Infect Control Hosp Epidemiol. 2012;33:135-143.

The Institute for Healthcare Improvement's 100,000 Lives Campaign generated national attention for galvanizing efforts to improve patient safety. This study found that executive leadership, midlevel staff, and frontline providers reported different perceptions about the campaign at their six participating hospitals. While respondents attributed only 58% of improvements to the campaign, all felt the interventions were sustainable, particularly with effective use of performance data and necessary leadership commitment. The findings also highlight the importance of aligning such initiatives with organizational culture to balance top-down and grassroots approaches.

Book/Report

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2011.

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.

Journal Article > Commentary

A new frontier in patient safety.

McCannon J, Berwick DM. JAMA. 2011;305:2221-2222.

Highlighting goals and strategies of the Partnership for Patients program, this commentary discusses challenges to improving patient safety.

Book/Report

Hospital Reporting Program: Annual Summary.

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.

Newspaper/Magazine Article

10 years, 5 voices, 1 challenge.

Larkin H. Hosp Health Netw. October 21, 2009.

In this piece, five health care leaders briefly assess the impact of To Err Is Human and describe future directions for the patient safety community.

Book/Report

Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.

  • Classic

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.

Journal Article > Commentary

The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff.

Kerfoot KM, Rapala K, Ebright P, Rogers SM. J Nurs Adm. 2006;36:582-588.

The authors describe the development of a patient safety initiative launched by a three-hospital system, its experience over 5 years, and plans for the future that emphasize the importance of embracing a partnership model.

Tools/Toolkit > Government Resource

Prevention Quality Indicators Overview.

AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality.

The Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators use hospital admissions data to screen for potential quality lapses on conditions that generally don't require hospitalization if managed effectively at the primary care level.

Journal Article > Study

Making hospital care safer and better: the structure-process connection leading to adverse events.

El-Jardali F, Lagacé M. Healthc Q. 2005;8:40-48.

The authors propose a model for identifying factors that contribute to adverse events in hospital care. Using secondary data from a large Canadian nursing survey, the authors found that perceived understaffing, inadequate support services, and poor teamwork impacted the incidence of adverse events.

Meeting/Conference > Washington Meeting/Conference

Learning From Never Events: Aligning an Organization Around Safety.

Virginia Mason Institute. September 27-29, 2017. Virginia Mason Institute, Seattle, WA.

This workshop will discuss enhancing safety culture through the identification and review of never events and an organization's safety culture.

Meeting/Conference > Massachusetts Meeting/Conference

Patient Safety Executive Development Program.

Institute for Healthcare Improvement. September 7-13, 2017; The Charles Hotel, Cambridge, MA.

This program will educate participants about strategies and implementation plans to drive patient safety work. Featured faculty include Dr. Allen Frankel and Frank Federico.

Meeting/Conference > Maryland Meeting/Conference

CUSP Implementation Workshop.

Armstrong Institute for Patient Safety and Quality. July 18, 2017; Constellation Energy Building Conference Center, Baltimore, MD.

The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. This conference will cover how to utilize CUSP, including understanding and addressing challenges to implementation.

Meeting/Conference > Government Resource

TeamSTEPPS Master Training Course.

Agency for Healthcare Research and Quality, Health Research & Educational Trust. March-September 2017.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This series of trainings will prepare participants to guide their organizations through implementation of the TeamSTEPPS program.

Book/Report

2016–2017 Targeted Medication Safety Best Practices for Hospitals.

Horsham, PA: Institute for Safe Medication Practices; 2015.

This updated report outlines 11 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has expanded since it was first developed in 2014 to include actions related to storage and use of neuromuscular blocking agents, smart pumps, and standardized protocols for rescue agents.

Tools/Toolkit > Government Resource

CUSP Toolkit.

  • Classic

Rockville, MD: Agency for Healthcare Research and Quality; June 2015.

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.

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