Challenge Competition on the Impact of AHRQ’s Patient Safety Tools
Winner: University of Missouri - Read the impact story
University of Missouri Health Care (MU Health Care) utilized AHRQ’s Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care to decrease Patient Safety Indicator 03 (PSI-03) (reportable pressure injuries) by 92% and save an estimated $350,000 in avoidable costs. Implementation focused on MU Health Care’s 390-bed University Hospital, the only level I trauma center in central Missouri. Guided by the toolkit and implementing interventions spanning people, process, and technology, MU Health Care rose from the 87th percentile ranking of all-cause hospital-acquired pressure injury rates and PSI-03 among Vizient peers to the top decile over the course of 2 years. Their experience using this tool is summarized in “MU Health Care Uses AHRQ Toolkit to Reduce Reportable Pressure Injuries by 92%.” Award amount: $25,000
Winner: University of Chicago Medicine - Read the impact story
UChicago Medicine reduced venous thromboembolism (VTE) incidence by 30% in the perioperative patient population across their institution with the use of AHRQ’s Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement over a 12-month period. The most visible advances occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological, and specialty surgical population). Their experience using this tool is summarized in “UChicago Medicine Reduces Perioperative VTE With AHRQ’s Toolkit.” Award amount: $25,000
Winner: Chesapeake Regional Healthcare - Read the impact story
At Chesapeake Regional Healthcare, AHRQ’s Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care was instrumental in guiding the creation of an initiative entitled “Fall Free Friday” in December 2022. Initially focused on two medical-telemetry units and eventually expanding to include additional units, fall prevention compliance audits have taken place each Friday. The “Fall Free Friday” activities resulted in a 31% decrease in acute care falls from 4th quarter 2022 to 1st quarter 2023, with sustained success by not exceeding their quarter total threshold for 7 months. Their experience using this tool is summarized in “Impact of AHRQ’s Patient Safety Tools: Preventing Falls in Hospitals.” Award amount: $25,000
The Agency for Healthcare Research and Quality (AHRQ) offers many practical tools and resources to help a variety of healthcare organizations, providers, and others make patient care safer in all healthcare settings. These tools are based on research, and they are intended to help staff in hospitals, emergency departments, long-term care facilities, and ambulatory settings to prevent avoidable complications of care. Patient Safety tools can be found on the AHRQ website at Patient Safety and Quality Improvement under “Patient Safety Resources by Setting.”
AHRQ seeks to better understand how using an AHRQ patient safety tool has resulted in safer care, as evidenced by associated process and/or outcome measures. AHRQ would like to use this information as an example of the type of return on investment an organization might expect when using the tool.
The purpose of this challenge goal is to elicit new narratives and measures (process and outcome) that AHRQ is not already aware of regarding the use of specific AHRQ Patient Safety tools (listed below). Use of the tool means use in its entirety or use of a specific part. Ultimately, chosen narratives may be posted on the AHRQ website. These case studies may be used for promotion of corresponding tools.
Tools for consideration:
- Guide to Patient and Family Engagement in Hospital Quality and Safety helps hospitals work as partners with patients and families to improve quality and safety. Includes an implementation handbook and tools for patients, families, and clinicians.
- Medications at Transitions and Clinical Handoffs (MATCH) Toolkit features strategies from the field that can help hospitals improve medication reconciliation processes for patients as they move through the healthcare system.
- Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care focuses on overcoming the challenges associated with developing, implementing, and sustaining a fall prevention program. Includes an implementation guide to help put prevention strategies into practice.
- Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement outlines the latest evidence on how to lead a quality improvement effort to prevent hospital-acquired venous thromboembolism.
- Preventing Pressure Ulcers in Hospitals is a toolkit that assists hospital staff in implementing effective pressure ulcer prevention practices through an interdisciplinary approach to care.
- Community-Acquired Pneumonia Clinical Decision Support Implementation Toolkit is a resource to help clinicians and clinical informaticians in primary care and other ambulatory settings implement and adopt the community-acquired pneumonia clinical decision support alert for the management of community-acquired pneumonia.
- Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families offers four interventions and four case studies designed to improve patient safety by meaningfully engaging patients and families in their care.
- Improving Your Laboratory Testing Process: A Step-by-Step Guide for Rapid-Cycle Patient Safety and Quality Improvement can increase the reliability of the testing process in your office by helping you examine how tests are managed.
- Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings is designed to help staff actively engage patients and their care partners to prevent errors during transitions of care.
- Falls Management Program: A Quality Improvement Initiative for Nursing Facilities is an interdisciplinary quality improvement initiative to assist nursing facilities in providing individualized, person-centered care and improving their fall care processes and outcomes through educational and quality improvement tools.
- Improving Patient Safety in Long-Term Care Facilities is a training curriculum for front-line personnel in nursing home and other long-term care facilities to help them detect and communicate changes in a resident's condition and prevent and manage falls. Includes an Instructor Guide and separate student workbooks.
- Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention is a team training curriculum to help nursing homes with electronic medical records reduce the occurrence of pressure ulcers.
- Communication and Optimal Resolution (CANDOR) Toolkit enables healthcare organizations to implement an AHRQ-developed process. Like similar programs in place in other organizations, CANDOR gives hospitals and health systems the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication and timely resolution for patients and caregivers.
- Making Healthcare Safer III offers a critical analysis of existing and emerging patient safety practices reviews 47 practices that target patient safety improvements in hospitals, primary care practices, long-term care facilities, and other healthcare settings.
Timeline and Prize Amounts
June 5, 2023—Challenge launch
October 27, 2023—Submissions are due. AHRQ will complete the review of the submissions within 6 weeks of closing the announcement.
December 8, 2023—AHRQ will announce the winners.
Up to 10 winners who have described how the use of patient safety resources demonstrated measurable improvement in associated process and/or outcome measures will receive $10,000 each.
Eligibility Rules for Participating in the Challenge
To be eligible under this Challenge, an individual (whether participating singly or in a group) or entity:
- Shall have registered to participate in the Challenge.
- Shall have complied with the rules set forth in this announcement for participation in this Challenge.
- Shall be incorporated and maintain a primary place of business in the United States (in the case of a private entity), and in the case of an individual, whether participating singly or in a group, shall be a citizen or permanent resident of the United States.
- May not be a Federal entity or Federal employee acting within the scope of their employment. (All Federal employees should consult with their agency Ethics Official to determine whether the federal ethics rules will limit or prohibit the acceptance of a prize.)
- May not be an employee of AHRQ or any other company, organization, or individual involved with the design, production, execution, judging, or distribution of the Challenge, or their immediate family (spouse, parents and step-parents, siblings and step-siblings, and children and step-children), or household members (people who share the same residence at least 3 months out of the year).
- May not use Federal funds from a grant to develop Challenge applications unless consistent with the purpose of the grant award.
- May not use Federal funds from a contract to develop Challenge applications or to fund efforts in support of a Challenge submission.
- Shall not be deemed ineligible because the individual or entity used Federal facilities or consulted with Federal employees during a competition if the facilities and employees are made equitably available to all individuals and entities participating in the competition.
- Shall not be required to purchase liability insurance as a condition of participation in this competition.
Additional Rules of Participation
By participating in this Challenge, each individual (whether participating singly or in a group) or entity:
- Agrees to follow all applicable federal, state, and local laws, regulations, and policies.
- Agrees to comply with all terms and conditions of participation in this Challenge.
- Agrees that the submission will not use HHS or AHRQ logos or official seals and will not claim endorsement by HHS or AHRQ.
- Understands that all materials submitted to AHRQ as part of a submission become AHRQ records.
- Agrees that the submission must not infringe upon copyright or any other rights of any third party.
- Agrees to assume any and all risks and waive claims against the Federal Government and its related entities, except in the case of willful misconduct, for any injury, death, damage, or loss of property, revenue, or profits, whether direct, indirect, or consequential, arising from participation in this prize contest, whether the injury, death, damage, or loss arises through negligence or otherwise.
- Agrees to indemnify the Federal Government against third-party claims for damages arising from or related to Challenge activities.
- Understands that AHRQ reserves the right to cancel, suspend, and/or modify this prize contest, or any part of it, for any reason, at AHRQ’s sole discretion. AHRQ also reserves the right not to award any prizes if no entries are deemed worthy.
- Understands that AHRQ will not select a winner that is named on the Excluded Parties List System (EPLS).
Intellectual Property (IP) Rights
- Each participant retains title and full ownership in and to their submission. Participants expressly reserve all intellectual property rights not expressly granted.
- By participating in the Challenge, each participant (whether participating singly or in a group) acknowledges that he or she is the sole author or owner of, or has a right to use, any copyrightable works that the submission comprises, that the works are wholly original with the participant (or is an improved version of an existing work that the participant has sufficient rights to use and improve), and that the submission does not infringe any copyright or any other rights of any third party of which participant is aware. In addition, each participant (whether participating singly or in a group) grants to the U.S. Government a paid-up, nonexclusive, royalty-free, irrevocable worldwide license and the right to reproduce, publish, post, link to, share, display publicly (on the web or elsewhere) and prepare derivative works, including the right to authorize others to do so on behalf of the U.S. Government.
- If the submission includes any third party works (such as third party content or open source code), the participant must be able to provide, upon request, documentation of all appropriate licenses and releases for use of such third-party works. If the participant cannot provide documentation of all required licenses and releases, AHRQ reserves the right, in its sole discretion, to disqualify the submission.