AHRQ Training Leads to New Protocol at New York Health Department

Patient Safety
December 2004

As part of its overall efforts to further strengthen access to quality health care statewide, the New York State Department of Health (NYSDOH) participated in the first-ever national Patient Safety Improvement Corps (PSIC) training program sponsored jointly by AHRQ and the Department of Veterans Affairs (VA).

The PSIC-AHRQ/VA partnership seeks to improve patient safety by providing knowledge and skills to teams of state field staff and hospital partners selected by states. The program consists of three one-week sessions held over a nine-month period and includes a course-related patient safety team project during this period.

Following its training, the NYSDOH hosted nine regional PSIC educational sessions statewide in the fall of 2004, with approximately 550 health care professionals participating in the initiative. The participants included hospital administrators, vice-presidents, directors of nursing, nurse managers, pharmacists, attorneys, directors of medicine, managers of hospital quality, and risk management departments, as well as the New York Patient Occurrence Reporting and Tracking System hospital coordinators who conduct and submit root cause analyses into the department's Web-based system.

According to New York State Health Department project coordinators, Janet Mannion and Mary Dameron, the educational sessions incorporated the culture of patient safety, human factor engineering, the video presentation of the Josie King story, introduction of the root cause analysis evaluation protocol, improvement of the quality of root cause analysis, and a hands-on practicum on root cause analysis. This information was also shared with health care providers statewide.

Mannion states, "The PSIC training program helped reinforce the importance of health care providers' sharing information on policies and protocols that have worked for them in their efforts to assure high quality care for patients." In essence, the priority is to develop and implement new patient safety initiatives, ensure that health care professionals have the skills and resources they need to complete day-to-day tasks in an efficient manner, and, ultimately, continue to change the system for the better.

NYSDOH developed a root cause analysis evaluation protocol as its required PSIC project during their training. NYSDOH staff as well as hospitals will use the protocol to assure submitted reports meet standard criteria to increase consistency in interpretations across the state and enhance expectations for thorough and credible analysis.

Dameron says, "We are deeply committed to advancing effective patient safety strategies and quality assurance measures within New York State's comprehensive health care system. The PSIC training is helping New York accomplish this priority."

Impact Case Study Identifier: 
AHRQ Product(s): Patient Safety Improvement Corps (PSIC)
Topics(s): Patient Safety
Geographic Location: New York
Implementer: New York State Department of Health
Date: 12/01/2004

Patient Safety Improvement Corps: An AHRQ/VA Partnership. October 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/psimpcorps.htm

Page last reviewed October 2014