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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.

Book/Report

Medical Office Survey on Patient Safety Culture: 2016 User Comparative Database Report.

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.

Book/Report

Saving Lives and Saving Money: Hospital-Acquired Conditions Update.

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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.

Journal Article > Study

Differing perceptions of safety culture across job roles in the ambulatory setting: analysis of the AHRQ Medical Office Survey on Patient Safety Culture.

Hickner J, Smith SA, Yount N, Sorra J. BMJ Qual Saf. 2016;25:588-594.

Studies of safety culture have consistently found that management has more positive perceptions of safety than frontline workers. This analysis of data from the AHRQ Medical Office Survey on Patient Safety Culture explored this finding in greater depth. The study examines the specific areas where perceptions of safety diverged between medical office management, physicians, and staff from more than 800 clinics. The investigators found that staff (including physicians and nurses) had markedly lower perceptions of the quality of staff training in patient safety and the openness of communication around safety issues compared with management. Consistent with other studies, management also had a much higher perception of overall safety than staff. As high reliability organizations rely on shared goals and open communication to ensure situational awareness, variations in perceptions of safety culture across professional roles will impair an organization's ability to address safety issues.

Book/Report

2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.

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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.

Web Resource > Course Material/Curriculum

TeamSTEPPS 2.0 Core Curriculum.

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

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This curriculum offers training for participants to implement TeamSTEPPS in their organizations. The course includes evidence reviews, trainer guidance, measurement tools, and a pocket guide for frontline staff.

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.

Tools/Toolkit > Government Resource

Pediatric Quality Indicators Overview.

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

The Agency for Healthcare Research and Quality's (AHRQ) Quality Indicators (QIs) represent quality measures that make use of a hospital's available administrative data. The Pediatric Quality Indicators focus on quality of care inside hospitals and identify potentially avoidable hospitalizations among children.

Book/Report

Advances in Patient Safety: New Directions and Alternative Approaches.

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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.

Newspaper/Magazine Article

Is the measurement mandate diverting the patient safety revolution?

Wachter RM. National Quality Measures Clearinghouse: Expert Commentaries; March 3, 2008.

This commentary describes how the focus on measurement in health care has affected both quality and safety initiatives.

Tools/Toolkit > Government Resource

Surveys on Patient Safety Culture.

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

The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools and user guides. Hospitals can also use the AHRQ database to compare their Patient Safety Culture Survey results. In addition, an annual report summarizes the benchmarking data across more than 1000 hospitals nationwide. Poor staff perception of safety culture has been linked to increased error rates in hospitals. Culture has also been described as a key to establishing high reliability organizations. An AHRQ WebM&M perspective discussed how to establish a safety culture.

Press Release/Announcement

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.

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.

Book/Report

Advances in Patient Safety: From Research to Implementation.

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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.

Tools/Toolkit > Government Resource

Patient Safety Indicators Overview.

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

The AHRQ Patient Safety Indicators (PSIs) represent quality measures that make use of a hospital's available administrative data. The PSIs reflect the quality of inpatient care but also focus on preventable complications and iatrogenic events. Investigators have found PSIs to be a useful tool for understanding adverse events and identifying possible areas of improvement within health care delivery systems. Although relying on administrative data has clear limitations, select PSIs have been shown to accurately identify certain accidental inpatient injuries. The AHRQ Web site offers publicly available comparative data, along with resources and tools. Patient safety measurement methods are discussed in an AHRQ WebM&M perspective.

Meeting/Conference > Maryland Meeting/Conference

TeamSTEPPS Master Training Course.

Johns Hopkins Armstrong Institute for Patient Safety and Quality. October 31-November 1, 2017; Constellation Energy Building, Baltimore, MD.

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model. 

Web Resource > Government Resource

National Healthcare Safety Network.

Centers for Disease Control and Prevention.

Health care–associated infection is a persistent patient safety problem. This website provides resources related to a national health care–associated infection and blood safety error monitoring program that allows organizations to identify areas of weakness and track the impact of improvements.

Audiovisual > Audiovisual Presentation

Presenting TeamSTEPPS in the Perioperative Setting.

TeamSTEPPS Webinar Series. Agency for Healthcare Research and Quality. May 10, 2017; 1:00–2:00 PM (Eastern).

TeamSTEPPS is a process to enhance communication and teamwork in health care. This webinar will offer insights on implementing TeamSTEPPS in a large health system to improve perioperative practice. The session will highlight developing leadership as program champions, creating learning materials, and monitoring as tactics for sustaining improvements. This is part of a monthly series of educational modules on TeamSTEPPS.

Audiovisual > Audiovisual Presentation

Progress at the Intersection of Patient Safety and Medical Liability.

Health Services Research and the Health Research and Educational Trust. March 2, 2017.

Communication-and-resolution programs emphasize transparency and respect in discussions with patients and families following an adverse event. This webinar highlighted AHRQ-funded research and programs that explored the impact of communication-and-resolution programs and other strategies that focus on improving patient safety and reducing liability. Researchers from a recent special issue devoted to this work were featured speakers.

Press Release/Announcement

Implantable infusion pumps in the magnetic resonance (MR) environment: FDA safety communication—important safety precautions.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2017.

Hazards in the magnetic resonance imaging environment can result in patient harm. This announcement raises awareness of inaccuracies and disruptions that may affect the safety of patients with implantable infusion devices who undergo an MRI exam. The statement recommends that patients inform their care team and carry an implant card with information about the implanted device to prevent these problems.

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