Online Performance Appendix: Performance Detail, Patient Safety

Budget Estimates for Appropriations Committees, Fiscal Year 2011

This appendix provides more detailed performance information for all HHS measures related to the Agency for Healthcare Research and Quality's budget.

Historically, the Patient Safety Program's goal has been to prevent, mitigate, and decrease the number of medical errors, patient safety risks and hazards, and quality gaps associated with health care and their harmful impact on patients. The program funds grants, contracts, and interagency agreements (IAAs) to support projects that identify the threats to patient safety and identify and evaluate effective safe practices. Projects within the program seek to educate multiple stakeholders including health care organizations, providers, policymakers, researchers, patients and others; disseminate information and implement initiatives to enhance patient safety and quality; and maintain vigilance to prevent patient harm.

The Patient Safety Program comprises two key components: (1) coordination of support for the creation, synthesis, dissemination, implementation, and use of knowledge about patient safety threats and medical errors and (2) operation of a program to establish Patient Safety Organizations (PSOs), which are a fundamental element of the Patient Safety and Quality Improvement Act (Patient Safety Act) of 2005.

The Patient Safety Program, which formally commenced in FY 2001, began with AHRQ awarding $50 million for 94 new projects aimed at reducing medical errors and improving patient safety. Throughout the past 10 years, AHRQ has funded many additional projects and initiatives in a number of areas of patient safety and health care quality. Additionally, the Agency is working collaboratively with other HHS components to design and implement initiatives to reduce healthcare associated infections (HAIs). As a result, a large body of research continues to emerge, and numerous surveys, reporting and decision support systems, training and technical assistance opportunities, taxonomies, publications, guides, tools, and presentations are available for general use. AHRQ continues to work to address these patient safety issues independently and in collaboration with federal partners and public and private sector organizations, and does so by utilizing the various grant and contract mechanisms. The following section highlights some specific examples of projects that make up the Patient Safety Program.

Research Grants

  • AHRQ continues to draw from the work of 17 Partnerships in Implementing Patient Safety (PIPS) two-year grants awarded to assist health care institutions in implementing safe practice interventions that show evidence of eliminating or reducing medical errors, risks, hazards, and harms associated with the process of care. The majority of these grants are completed and the resultant tool kits are being made available to the public and/or further tested in different environments to identify what easily works and what challenges are faced by providers in implementing these safe practice intervention tool kits. In FY 2010, AHRQ has issued a second funding opportunity announcement (PIPS II), which will build on the successful past effort.
  • In September 2008, AHRQ awarded $3,708,799 for 13 risk-informed intervention grants. These 3-year projects are ongoing, and build on previously funded risk assessment projects funded by AHRQ and support risk-informed development and implementation of safe practice interventions that have the potential of eliminating or reducing medical errors, risks, hazards, and harms associated with the process of care in the ambulatory setting. The objectives of the projects are to: (1) identify, develop, test, and implement safe practice interventions in ambulatory care settings, and (2) share the findings and lessons learned about the challenges and barriers to developing and implementing these interventions through toolkits. (Source:
  • During FY 2010, AHRQ plans to award $9 million in new research and career-development grants that target the prevention of healthcare-associated infections (HAIs). The addition of AHRQ-funded grants on the topic of HAIs, which will continue in FY 2011, will further augment a growing Department-wide effort in this area. For more information about AHRQ's HAI research, please see the Contracts section below.
  • In September 2009, President Obama announced to a joint session of Congress his intention to invest in new ways to resolve medical liability claims. In FY 2010, AHRQ will award $25 million to study ways to put patient safety first while letting doctors focus on practicing medicine: $23 million in grants to undertake multi-year demonstration and planning projects on the topic of Patient Safety and Medical Liability Reform, as well as $2 million in contract funds for an evaluation of these demonstrations.

Research Contracts:


  • AHRQ Patient Safety Network (AHRQ PSNet). AHRQ PSNet is a national Web-based resource featuring the latest news and essential resources on patient safety. The site offers weekly updates of patient safety literature, news, tools, and meetings ("What's New"), and a vast set of carefully annotated links to important research and other information on patient safety ("The Collection"). Supported by a robust patient safety taxonomy and Web architecture, AHRQ PSNet provides powerful searching and browsing capabilities, as well as the ability for diverse users to customize the site around their interests (My PSNet). In addition, AHRQ funds the WebM&M (Morbidity and Mortality Rounds on the Web). WebM&M is an online journal and forum on patient safety and health care quality. This site features expert analysis of medical errors reported anonymously by readers, interactive learning modules on patient safety ("Spotlight Cases"), Perspectives on Safety, and forums for online discussion. Use of these sites has steadily increased over the past 4 years, with web sessions totaling more than 140,000 in July 2009.
  • Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™). In their 1999 report on medical errors, the Institute of Medicine (IOM) suggested that systemic failures were important underlying factors in medical error and that better teamwork and coordination could prevent harm to patients. The IOM recommended that health care organizations establish team training programs for personnel in critical care areas such as emergency departments, intensive care units, and operating rooms. As a follow up, AHRQ, in partnership with the Department of Defense, developed a teamwork training program -TeamSTEPPS™. It is an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and other teamwork skills among health care professionals. It includes a comprehensive set of ready-to-use materials and training curricula necessary to integrate teamwork principles successfully into an organization's health care system. TeamSTEPPS™ is presented in a multimedia format, with tools to help a health care organization plan, conduct, and evaluate its own team training program. It includes five components: (1) an instructor guide; (2) a multimedia resource kit including a CD-ROM and DVD with 9 video vignettes about how failures in teamwork and communication can place patients in jeopardy, and how successful teams can work to improve patient outcomes; (3) a spiral-bound pocket guide; (4) PowerPoint® presentations; and (5) a poster that tells staff that the organization is adopting TeamSTEPPS™. In addition, AHRQ has a technical assistance contract in place to support those interested in implementing TeamSTEPPS™. TeamSTEPPS National Implementation continues to grow and expand. As of the end of FY 2008, the project has trained or registered 651 individuals for TeamSTEPPS Master Trainers representing 147 different organizations across the United States. TeamSTEPPS is now part of the 9th Scope of Work for Quality Improvement Organizations (QIOs). All QIOs have received initial Master Team Training. To date, Master Trainers reported that they have trained 4,780 individuals from 119 organizations. In 2009, a new module, Rapid Response Systems, was added to the TeamSTEPPS™ set of tools. The module includes PowerPoint presentations, teaching modules, and video vignettes that can be used to train hospital staff. The focus of the module is to use groups of clinicians to bring critical care expertise to patients requiring immediate treatment. In 2010, the focus will be on additional training and dissemination of TeamSTEPPS.

AHRQ Healthcare-Associated Infections (HAIs) Activities

Due to increased Congressional interest in the prevention of healthcare-associated infections, the Agency has been awarded increasing amounts of funding to reduce HAIs, including methicillin-resistant Staphylococcus aureus (MRSA) infections. The following are brief descriptions of some HAI projects and initiatives.

MRSA Collaborative Research Initiatives

In FY 2008, Congress appropriated $5,000,000 to AHRQ to identify and to help suppress the spread of MRSA and related HAIs. Until then, the only large scale study that had produced evidence on how to reduce serious HAIs and maintain that reduction was supported by AHRQ and carried out in 127 Michigan hospitals from 2003 - 2006. The FY 2008 efforts to reduce MRSA built on the Michigan initiative, known as the Keystone Project. Working in close collaboration with the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS), projects were designed that would use electronic and administrative data, surveillance and implementation strategies to:

  • Reduce the burden of MRSA infections via novel interventions aimed at critical control points in a community/region.
  • Determine scope, risk factors, and control measures for hospital-acquired, community-onset MRSA infections.
  • Test methods to reduce hospitalization from community-acquired MRSA.
  • Understand the role of inter-facility MRSA transmission on overall infection rates.
  • Understand the role of nursing home transmission on overall rates and delineate interventions that are effective in reducing such transmission.

A list of specific projects follows:

  • Reduction of Clostridium difficile Infections in a Regional Collaborative of In-patient Health Care Settings.
  • Reducing the Overuse of Antibiotics by Primary Care Clinicians Treating Patients in Ambulatory and Long-term Care Settings.
  • Improving the Measurement of Surgical Site Infection (SSI) Risk Stratification and Outcome Detection.
  • Produce Rapid National, Regional and State-level Estimates of HAIs to Evaluate the Impact of Inter-Agency HAI Initiatives.
  • Reduction of Infections Caused by Carbapenem Resistant Enterobacteriaceae (KPC producing organisms) through Application of Recently Developed CDC/HICPAC Recommendations.

In FY 2009, Congress more than doubled their appropriation to AHRQ with a total of $17,304,000 in funding - $8 million specifically for MRSA and other infections and $9 million for Comprehensive Unit-based Patient Safety Program (CUSP)/Central line-associated Blood Stream Infections (CLABSI). The CLABSI project is the nationwide implementation of the project successfully undertaken in Michigan - the Michigan Keystone Project. Using the same collaborative planning approach, the Agency worked in very close collaboration with CDC and CMS to identify and design appropriate projects that were funded through existing AHRQ contract mechanisms. Additionally, the planning teams used the DHHS Office of the Secretary's HAI National Action Plan to guide the selection of projects. Specifically, the $8 million MRSA funds were allocated among the following targeted projects:

  • Reduction of Clostridium difficile in Regional Collaborative of Inpatient Healthcare Settings through Implementation of Anti-microbial Stewardship ($2 M).
  • Reduction of the Overuse of Antibiotics by Primary Care Clinicians Treating Patients in Ambulatory and Long-term Care Settings ($2 M).
  • REDUCE MRSA: Randomized Evaluation Decolonization vs. Universal Clearance to Eliminate MRSA ($1.5 M).
  • Improve the Measurement of SSI Risk Stratification and Outcome Detection ($500,000).
  • Produce Rapid, national, Regional and State-level Estimates of HAIs to Evaluate the Impact of Inter-Agency HAI Initiatives ($500,000).
  • Reduce Infections Caused by KPC-Producing Organisms ($500,000).
  • SAUL: Standardizing Antibiotic Use in Long-term Care Settings ($1 M).

The FY 2009 CUSP/CLABSI funds in the amount of $9 million dollars were allocated accordingly:

  • Expanded the CUSP/CLABSI initiative to include all states in the US, Puerto Rico, and the District of Columbia, additional hospitals in each of the States, and in healthcare settings outside of the intensive care unit ($6 M).
  • CUSP model with Catheter-associated Urinary Tract Infections ($1 M).
  • Prevention of Surgical Site Infections implemented through the CMS Quality Improvement Organization ($1 M).
  • Prevention of Blood Stream Infections for Patients Undergoing Hemodialysis ($1 M).

In FY 2010, with funding of $34 million allocated for HAIs, AHRQ is poised to continue this work in close collaboration with our HHS partners from the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services. Approximately $9 million of the FY 2010 budget will be utilized to fund a variety of grants related to HAI prevention. Detailed planning for specific projects to be accomplished via contracts is ongoing. To date, the following project topics have been identified for further development through the use of research contracts:

  • Identifying Claims-based Surrogate Markers of HAIs Originating in Ambulatory Surgical Centers (ASC).
  • Optimizing Oral Decontamination Strategies for the Prevention of ventilator-associated pneumonia (VAP).
  • Utility of Algorithm-based Antimicrobial Prescribing for Ventilator-associated Pneumonia (VAP) to Reduce Unnecessary Antimicrobial use in ICUs.
  • Nursing Home Antibiograms to Improve Antibiotic Prescribing for Patients Transferred to Emergency Departments.
  • Optimizing Pre-Operative Surgical Antibiotic Prophylaxis for the 21st Century.
  • Stopping Staphylococcus aureus Surgical Site Infections Before They Start.
  • Effect of the use of universal glove and gown on HAI rates and antibiotic-resistant bacteria.
  • Assessment of Novel Strategies for Preventing blood stream infections (BSI) in Patients Undergoing Hemodialysis.
  • Identifying modifiable human/organizational factors that are associated with successful implementation of an HAI Prevention Program.
  • A Regional Approach to HAI Infection Reduction in Dialysis Population.
  • Developing and Testing Best-Practices for the Detection and Diagnosis of Clostridium difficile in Hospitalized Patients.

Other Patient Safety Contracts

AHRQ's Patient Safety portfolio also supports other dissemination, translation and rapid cycle research activities. These contracts include rapid cycle projects awarded through AHRQ's Accelerating Change and Transformation in Organizations and Networks (ACTION), Primary Care Practice-Based Research Networks (PBRNs), and the Planning, Evaluation and Analysis Task Order Contract (PEATOC) mechanisms. These projects address relevant issues such as quantifying the scope, magnitude, and impact of patient safety events, including risks and harms; identifying, developing, disseminating, and implementing safe practices; understanding and preventing healthcare-associated infections in a variety of healthcare settings.

Patient Safety Organizations (PSOs)

The Patient Safety and Quality Improvement Act (PSQIA) of 2005 amended the Public Health Service Act to foster a culture of safety in health care organizations. To encourage health care providers to work with PSOs, the Act (and implementing regulations) provides Federal confidentiality and privilege protections to deliberations carried out under the aegis of patient safety organizations. This legal protection of information voluntarily reported to PSOs will promote increased reporting and analysis of patient safety events and subsequent improvements in care. The Act prohibits the use of these analyses in civil, administrative, or disciplinary proceedings and limits their use in criminal proceedings. AHRQ administers the provisions of the Patient Safety Act dealing with PSO operations. The Department of Health and Human Services (HHS) has issued regulations to implement the Patient Safety Act, which authorizes the creation of PSOs. The Agency's goals are to help advance the methodologies that identify the most important causes of threats to patient safety, identify best practices for addressing those threats, and share the lessons learned as widely as possible. Specific work to carry out the Act includes:

  1. Promulgating regulations to implement the Act.
  2. Developing systems to allow application by organizations to become PSOs.
  3. Listing successful applicant organizations as PSOs.
  4. Where appropriate, re-listing and de-listing PSOs.
  5. Maintaining a database of PSO administrative information.
  6. Providing technical assistance to PSOs; and
  7. Holding an annual meeting of PSOs.

AHRQ, in conjunction with the Office of the Secretary and the Office of Civil Rights, has made significant progress in implementing the Patient Safety Act. On November 21, 2008, regulations to implement the Act were published, and the regulations became effective January 19, 2009. AHRQ has currently listed 75 PSOs in 28 states and the District of Columbia.

In addition, AHRQ has continued development of common definitions and reporting formats (Common Formats) to describe patient safety events. Promulgation of these Common Formats, which will allow aggregation and analysis of events collected by Patient Safety Organizations and national reporting annually on patient safety, was authorized by the Act. Based upon feedback and comments received on Version 0.1 beta of the Common Formats, AHRQ announced the availability of Common Formats, v 1.0, in a Federal Register notice on September 2, 2009. AHRQ anticipates that the PSO Database will be operational in February, 2011.

Program Assessment and Looking Forward

Historically, the Patient Safety Program has concentrated most of its resources on evidence generation. While that activity continues to be important for AHRQ, increasingly, program support is moving more toward data development/reporting and dissemination/implementation as the Agency focuses on making demonstrable improvements in patient safety. This reporting and implementation focus has the advantage of providing a natural feedback loop that can highlight areas in which new evidence is most needed to address real quality and safety problems encountered by providers and patients. At the same time, the Patient Safety Program appreciates a clear need to balance investments in data development/reporting and dissemination and implementation with funding for more fundamental research in patient safety. This balance will support ongoing knowledge creation and a continuous cycle of improvement that encompasses both the discovery and application of safe healthcare practices.

Most of the measures for the patient safety program have been modified to better reflect goals. The new measures, effective in FY 2008, are provided in the Performance Table below. The new measures better reflect an emphasis on implementation of evidence-based practices and reporting on their impact. Two of the measures also enable capture of information on two major new Agency initiatives (i.e., PSOs and HAIs).

Currently, two Patient Safety measure have updated data to report for FY 2009.

  • For measure 1.3.41, "Increase the number of tools that will be available in AHRQ's inventory of evidence-based tools to improve patient safety and reduce the risk of patient harm," a total of 81 tools are included in the inventory. The FY 2009 target was 76 tools.
  • For measure 1.3.40, "Patient Safety Organizations (PSOs) listed by DHHS Secretary," AHRQ has currently listed 75 PSOs in 28 states and the District of Columbia. The baseline for this measure was established in FY 2009. AHRQ's FY 2011 target is 100 PSOs.

The Program had already taken the following actions in 2008 to improve performance:

  • Measuring the number of PSOs that become certified based on Patient Safety and Quality Improvement Act legislation. The list of certified PSOs is available on an ongoing basis as PSOs become listed. (Please see
  • Establishing annual targets around the Patient Safety and Quality Improvement Act.
  • Updating performance measures and targets. Patient Safety continues efforts to develop a data source to capture the use of AHRQ-supported tools.

The Patient Safety program underwent a program assessment in 2003, and was found to be performing adequately. The review cited improvements in the safety and quality of care as a strong attribute of the program. As a result of the program assessment, the program continued to take actions to prevent, mitigate and decrease the number of medical errors, patient safety risks and hazards associated with health care and their harmful impact on patients. The Patient Safety Program has also benefited from a robust effort aimed at evaluating the impact of projects that have been funded under this portion of AHRQ's budget. In April 2009, summaries of the findings were published in a special issue of the journal Health Services Research (available at The contents include a description of the evaluation framework and approach, along with other articles that address AHRQ Contributions to patient safety knowledge, experiences with implementation research, the Patient Safety Improvement Corps, and trends and challenges in measuring safety outcomes.

Performance Trends: The program exceeded the FY 2009 goal for listing PSOs as it reached 75 PSOs. This higher than expected number of listed PSOs within the first year is believed to be due in part to high interest in the rule.

The program also exceeded the FY 2009 goal for the number of tools available in AHRQ's inventory of evidence-based tools to improve patient safety and reduce the risk of patient harm. At the end of FY 2009, 81 such tools were available. This number mostly likely resulted in part from adequate funding across the Patient Safety Program that enabled project leaders to effectively translate the results of research into practical, user-friendly tools.

Long-Term Objective: Within five years, providers that implement evidence-based tools, interventions, and best practices will progressively improve their patient safety scores on standard measures (e.g., HCAPS, HSOPS, PSIs, and the Medical Office Survey on Patient Safety Culture).

1.3.37: Increase the percentage of hospitals in the U.S. using computer-based patient safety event reporting systems (PSERS) (Long-term Outcome)201144%Oct 31, 2011
201034%Oct 31, 2010
200924%Oct 31, 2009
1.3.38: Increase the number of U.S. health care organizations per year using AHRQ-supported tools to improve patient safety from the 2007 baseline (new portfolio measure) (Output)2011640 hospitalsDec 31, 2012
2010580 hospitalsDec 31, 2011
2009500 hospitalsDec 31, 2010
2008450 hospitalsDec 31, 2009
2007Baseline382 hospitals
1.3.39: Increase the number of patient safety events (e.g., medical errors) reported to the Network of Patient Safety Databases (NPSD) from baseline. (Output)2011NPSD Operational Establish BaselineSep 30, 2011
2010Publication of technical specification for Common Format (V1.1)Sep 30, 2010
2009BaselinePublication of Common Formats 1.0
1.3.5: Annual percentage reduction in the cost per capita of treating hospital-acquired infections per year (Baseline actual in 2003:$4,437.28 per capita) (Efficiency)2011-2%Oct 31, 2013
2010-2%Oct 31, 2012
2009-2%Oct 31, 2011
2008-2%Oct 31, 2010
2007-2%Sep 30, 2009
1.3.40: Number of Patient Safety Organizations (PSOs) listed by HHS Secretary (Outcome)2011100 listed PSOsOct 31, 2011
201085 listed PSOsOct 31, 2010
2009PSOs listed by Secretary75 listed PSOs
2008Final Regulation publishedPSO Final Regulation Issued (Target Met)
1.3.41: Increase the number of tools available in AHRQ's inventory of evidence-based tools to improve patient safety and reduce the risk of patient harm (Output)201192Oct 31, 2011
201086Oct 31, 2010
20097681 (Target Exceeded)
20086873 (Target Exceeded)


MeasureData SourceData Validation
1.3.37Survey to be completed every 3 years (contract TBD)Survey contractor will develop methods to validate survey data
1.3.38Surveys/Case studiesAHRQ staff (OCKT) and evaluation contractor (TBD) to develop methods to validate survey data and conduct case studies
1.3.39PSOs (and the Privacy Protection Center and contractor that builds the NSPD)The privacy center contractor monitors the number of reports in the NPSD that is submitted through the PSOs
1.3.5HCUP/PSIsOngoing HCUP/PSI validation activities (HCUP and QI Project Officers use established methodology to check data).
1.3.40AHRQ PSO Web siteAHRQ PSO Web site is updated weekly to reflect total number of PSOs
1.3.41AHRQ FOAs, grant awards, and contract recordsAHRQ staff (i.e., project officers, portfolio leads, grants management and contracts staff) monitor project completion and dissemination of results

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Current as of February 2010
Internet Citation: Online Performance Appendix: Performance Detail, Patient Safety: Budget Estimates for Appropriations Committees, Fiscal Year 2011. February 2010. Agency for Healthcare Research and Quality, Rockville, MD.