System Design: AHRQ Resources

The health care system in the United States has been the subject of much debate as experts try to determine the best way to deliver high-quality care. In Crossing the Quality Chasm,1 the Institute of Medicine (IOM) called for the redesign of health care delivery systems and their external environments to promote care that is safe, effective, patient-centered, timely, efficient, and equitable. Below are examples of research, resources, and tools on system design developed with support from the Agency for Healthcare Research and Quality (AHRQ).


   Efficiency and Value
   System Change and Quality Improvement
   Organization and Delivery of Care
   Organizational Culture, Work Force, and Working Environment
   External Catalysts for System Design and Performance: Regulation, Payment, and Reporting
Tools and Guidance
   Efficiency and Value
   Systemwide Transformation
   Innovation and Performance Improvement in Care Delivery
   Process Redesign
   Enhancing Minority Health, Cultural Competency, and Health Literacy
   Implementing Information Technology and Other Health Technologies
Useful Links
For More Information


Health care delivery systems are complex sociotechnical systems, characterized by dynamic interchanges with their environments (e.g., markets, payers, regulators, and consumers) and interactions among internal system components. These components include people, physical settings, technologies, care processes, and organization (e.g., rules, structure, information systems, communication, rewards, work flow, culture).2 Systems design research examines interactions among system components and their possible impact on quality and cost. Systems design resources and tools provide guides to changes in system design (also known as redesign) that can improve care value and its safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity of care.

Care value may be enhanced by improving quality while reducing or maintaining cost. Value is also increased when systems reduce waste and inefficiency while maintaining or improving quality. To foster sustainable value improvements, design initiatives often bundle changes in several mutually reinforcing system components (e.g., information technology, process redesign, and training programs).3

Below are examples of research, resources, and tools on system design developed with support from AHRQ. AHRQ's research and tools on system design complement and build on many other AHRQ programs. Many of the items listed below were funded under AHRQ's Patient Safety and Health Information Technology (IT) portfolios. Below is just a small sampling of recent and valuable studies and tools. Special attention is given to contributions by AHRQ staff and to helpful redesign resources and tools.

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Efficiency and Value

Fraser I, Encinosa W, Glied S. Improving efficiency and value in health care. Health Serv Res 2008 Oct;43(5 Pt 2):1781-6.

This theme issue includes an introduction and seven state-of-the-art research studies on improving efficiency and value in health care.

James B, Bayley KB. Cost of poor quality or waste in integrated delivery system settings. Final report. Rockville, MD: Agency for Healthcare Research and Quality; September 2008. AHRQ Publication No. 08-0096-EF.

The authors examine existing approaches for capturing the costs of waste/poor quality and present specific examples of these estimates. Drawing on available constructs from the literature, the authors identify a model for estimating waste at the population, episode, and patient levels.

Wallace C, Savitz L. Estimating waste in frontline health care worker activities. J Eval Clin Pract 2008;14(1):178-80.

This publication reports on part of the above study of waste (James and Baley, 2008). The authors found that hospital workers encounter substantial waste as they perform their duties.

Mutter RL, Rosko MD, et al. Translating frontiers into practice: Taking the next steps toward improving hospital efficiency. Med Care Res Rev 2011 Feb;68(1 Suppl):3S-19S. Epub 2010 Nov 11.

The articles in this special issue focus on the application of Frontier techniques, including data envelopment analysis (DEA) and stochastic frontier analysis (SFA) to hospitals with the hope of making these techniques more accurate and accessible to end users.

Rosko MD, Mutter RL. What have we learned from the application of stochastic frontier analysis to U.S. hospitals? Med Care Res Rev 2011 Feb;68 (1 Suppl):75S-100S.

This article focuses on lessons learned about hospital efficiency and market pressures and about relationships between inefficiency and hospital behavior and hospital performance.

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System Change and Quality Improvement

Aagaard EM, Gonzales R, Camargo CA Jr, et al. Physician champions are key to improving antibiotic prescribing quality. Jt Comm J Qual Patient Saf 2010 Mar;36(3):109-16.

Success or failure in appropriate antibiotic prescribing for acute respiratory tract infections (ARIs) depended on a physician champion, a previous history of implementing quality improvement initiatives, and an institution's attitude toward patient satisfaction.

Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med 2011 May-Jun;24(3):229-39.

Patient-centered care, observed during videotaped office visits was associated with significantly fewer annual visits for specialty care, less frequent hospitalizations, fewer diagnostic tests, and a 35-percent reduction in annual per-patient charges.

Blake SC, McMorris K, Jacobson KL. A qualitative evaluation of a health literacy intervention to improve medication adherence for underserved pharmacy patients. J Health Care Poor Underserved 2010 May;21(2):559-67.

Reminder telephone calls and patient education materials, coupled with verbal counseling, are well-received by pharmacists and patients.

Braithwaite SA, Pines JM, Asplin BR, Epstein SK. Enhancing systems to improve the management of acute, unscheduled care. Acad Emerg Med 2011 Jun;18(6):e39-44.

The authors propose a research agenda to explore the advantages and disadvantages of treating unscheduled care in primary vs. acute settings and offer guidance to policymakers in determining optimum settings for acute, unscheduled care.

Brokel J, Harrison M. Redesigning care processes using an electronic health record: A system's experience. Jt Comm J Qual Patient Saf 2009 Feb;35(2):82-92.

Crandall DK, Brokel JM, Schwichtenberg T, et al. Redesigning care delivery through health IT implementation. Exploring Trinity Health's IT model. J Healthc Inf Manag. 2007 Fall;21(4):41-48.

These papers describe how Trinity Health, a major integrated delivery system, successfully leveraged implementation of a systemwide electronic health record to promote process redesign and continuous quality improvement.

Fifield J, McQuillan J, Martin-Peele M., et al. Improving pediatric asthma control among minority children participating in Medicaid: Providing practice redesign support to deliver a chronic care model. J Asthma 2010 Sep;47(7):718-27.

This study assessed the effectiveness of practice redesign and computerized provider feedback in improving provider adherence to professional guidelines and improving outcomes in four federally qualified health centers.

Filardo G, Nicewander D, Herrin J, et al. A hospital-randomized controlled trial of a formal quality improvement educational program in rural and small community Texas hospitals: One year results. Int J Qual Health Care 2009;21(4):225-32.

Participating hospitals were randomized to either a formal quality improvement educational program or to usual quality management. No pneumonia or heart failure care benefit was observed in the intervention hospitals.

Foy R, Ovretveit J, Shekelle PG, et al. The role of theory in research to develop and evaluate the implementation of patient safety practices. BMJ Qual Saf 2011 May;20(5):453-9.

Ovretveit JC, Shekelle PG, Dy SM, et al. How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals. BMJ Qual Saf 2011 Jul;20(7):604-10.

Shekelle PG, Pronovost PJ, Wachter RM, et al. Advancing the science of patient safety. Ann Intern Med 2011 May 17;154(10):693-6.

Taylor SL, Dy S, Foy R, et al. What context features might be important determinants of the effectiveness of patient safety practice interventions? BMJ Qual Saf2011 Jul;20(7):611-7.

These articles provide expert recommendations for criteria to improve the design, evaluation, and reporting of practice research in patient safety. For the original report, go to

Greenwald J, Denham C, Jack B. The hospital discharge: A review of a high risk care transition with highlights of a reengineered discharge process. J Patient Saf 2007 June;3(2):97-106.

This article reviews findings from Project RED, which identified modifiable components of the hospital discharge process that may increase or reduce the risk of adverse events and rehospitalizations. See below (Tools & Guidance/Process Redesign: Preventing Avoidable Readmissions) for a toolkit substantially derived from Project RED.

Harrison M, Kimani J. Building capacity for a transformation initiative: System redesign at Denver Health. Health Care Manage Rev 2009 Jan-Mar;34(1):42-53.

This paper presents a case study of the first 2 years of a system design initiative at Denver Health and an analysis of developments during the preceding decade that created positive antecedents for the transformation initiative. See below (Tools and Guidance/Systemwide Transformation: Gabow) for a toolkit based on Denver Health's experience.

Hicks LS, O'Malley J, Lieu TA, et al. Impact of health disparities collaboratives on racial/ethnic and insurance disparities in U.S. community health centers. Arch Intern Med 2010 Feb;170(3):279-86.

The Health Resources and Services Administration Health Disparities Collaboratives (HDCs) improve overall care quality at community health centers, but have little impact on care disparities.

Holden RJ. Lean thinking in emergency departments: A critical review. Ann Emerg Med 2011 Mar;57(3):265-78.

The article reviews 18 papers describing the implementation of Lean in 15 EDs in the United States, Australia, and Canada, most of which reported improved patient care.

Jiang HJ. Enhancing quality oversight. Healthc Exec 2010 Mar-Apr;25(2):80-3. 

The Governance Institute's 2009 survey provides updates on the extent to which boards have adopted the 13 recommended quality oversight practices. Better quality performance was significantly associated with the existence of a board quality committee and the adoption of six particular governance practices.

Kritchevsky SB, Braun BI, Bush AJ, et. Al. The effect of a quality improvement collaborative to improve antimicrobial prophylaxis in surgical patients. A randomized trial. Ann Intern Med 2008 Oct;149(7):472-80.

This study reports that there was no demonstrated benefit to hospitals participating in a quality improvement collaborative in improving infection prevention in surgical patients compared to nonparticipating control hospitals. Performance feedback and new reporting requirements may have motivated hospitals in both groups to give more attention to infection prevention.

Lakshminarayab K, Borbos C, McLaughlin B, et al. A cluster-randomized trial to improve stroke care in hospitals. Neurology May 2010; 74(20):1634-42.

The study found no significant difference in 10 quality measures between hospitals randomly assigned to the quality-improvement intervention and nonintervention hospitals.

Leff B, Reider L, Frick K, et al. Guided Care and the cost of complex healthcare: A preliminary report. Am J Manag Care 2009 Aug;15(8):555-9.

Boult C, Reider L, Leff B, et al. The effect of Guided Care teams on the use of health services: Results from a cluster-randomized controlled trial. Arch Intern Med 2011;171(5):460-6.

A Guided Care Nurse in a primary care office works with patients, families, and community agencies to improve quality of life and enhance efficiency of health service use. The articles cited above are among several reporting results of this initiative that are available at

Lipitz-Snyderman A, Steinwachs D, Needham DM, et al. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ 2011 Jan 28;342:d219.

Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter-related bloodstream infections in Michigan intensive care units: Observational study. BMJ 2010 Feb 4;340:c309.

These papers provide recent findings from the Michigan Keystone ICU project, a comprehensive statewide quality improvement initiative program called the Comprehensive Unit-based Safety Program (CUSP), which successfully reduced central line-associated blood stream infections in intensive care units. CUSP involves the redesign of work processes and the application of teamwork principles within the unit. For a fact sheet on this initiative, go to

McDonald KM, Sundaram V, Bravata, DM, et al. Closing the quality gap: a critical analysis of quality improvement strategies: Vol. 7, Care coordination. Technical Review 9. (Prepared by the Stanford University-UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Rockville, MD: Agency for Healthcare Research and Quality; June 2007. AHRQ Publication No. 04(07)-0051-7.

This report develops a working definition of care coordination, provides a research review, and identifies frameworks for analyzing factors influencing coordination and examining coordination's effects on outcomes and costs.

Pines JM, Asplin BR. Conference proceedings—improving the quality and efficiency of emergency care across the continuum: A systems approach. (AHRQ grant HS18114). Acad Emerg Med 2011 Jun;18(6):61.

This article describes a 2009 conference held by the American College of Emergency Physicians that included panels on systems and workflow redesign to improve health care, and care coordination for high-cost patients.

Raab SS, Andrew-Jaja C, Grzybicki DM, et al. Dissemination of Lean methods to improve Pap testing quality and patient safety. J Low Genit Tract Dis 2008 Apr;12(2):103-10.

This paper documents how Lean-based process redesign among a group of clinicians improved Pap test quality and accuracy.

Savitz L, ed. AHRQ's Partnerships for Quality Program: Advancing quality together. Jt Comm J Qual Patient Saf 2007 Dec;33 (12, Supplement).

This supplement contains papers examining ways that partnerships among institutions implementing quality improvement can contribute to improvement and to dissemination of successful interventions

Thomas EJ, Lucke JF, Wueste L, et al. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA 2009 Dec 23;302(24):2671-8.

There was an improved survival rate in sicker patients cared for under the tele-ICU intervention, but no improvement or worse outcomes in less sick patients. Hospital or ICU length of stays did not significantly change.

Valdez RS, Ramly E, Brennan PF. Industrial and systems engineering and health care: critical areas of research. Rockville, MD: Agency for Healthcare Research and Quality; May 2010. AHRQ Publication No. 10-0079. AndSystemsEngineeringAndHealthCare

This report explores critical areas of research at the intersection of industrial and systems engineering (ISyE)E and health care, with a special emphasis on the supportive role of health information technology (IT).

Wang M, Hyun J, Shortell M, et al. Redesigning health systems for quality: Lessons from emerging practices. Jt Comm J Qual Patient Saf 2006 Nov;32:599-611.

The authors develop an integrated systems approach to redesign, which reflects success factors observed in a scan of redesign activities among leading delivery systems.

Yawn BP, Pace W, Dietrich A, et al. Practice benefit from participating in a practice-based research network study of post-partum depression: A National Research Network (NRN) report. J Am Board Fam Med 2010 Jul-Aug;23(4):455-64.

Participants in a study conducted by a practice-based research network (PBRN) reported adoption of system changes and practices beyond those targeted in the study's objectives and content.

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Organization and Delivery of Care

Allareddy V, Ward MM, Allareddy V, et al. Effect of meeting Leapfrog volume thresholds on complication rates following complex surgical procedures. Ann Surg 2010 Feb; 251(2):377-83.

Lower mortality rates in high-volume hospitals can be partly, though not completely, attributed to lower complication rates.

Alper SJ, Karsh B-T. A systematic review of safety violations in industry. Accid Anal Prev 2009 Jul;41(4):739-54.

The studies tested 57 variables potentially associated with violations of safety procedures and norms in health care and other industries.

Arora V, Prochaska M, Farnan JM, et al. Problems after discharge and understanding of communication with their primary care physicians among hospitalized seniors: A mixed methods study. J Hosp Med 2010 Sep; 5(7):385-91.

This study documents problems among discharged patients stemming from poor communication between hospitalists and primary care practitioners.

Butler M, Kane RL, McAlpine D, et al. Integration of mental health/substance abuse and primary care. (Prepared by the Minnesota Evidence-based Practice Center.) Rockville, MD: Agency for Healthcare Research and Quality; October 2008. AHRQ Publication No. 09-E003.

In general, integrated care achieved positive outcomes. The evidence is particularly strong for depression. However, it is not possible to distinguish the effects of specific strategies; correlation is lacking between measures of processes of integration of care and outcomes.

Carey K, Burgess JF Jr, Young GY. Single specialty hospitals and service competition. Inquiry 2009;46:162-71.

Specialty hospitals owned by physicians, which are one of the fastest growing segments in health care, focus on one area of care, such as cardiac, orthopedic, or general surgical services. Acute care hospitals are stepping up their own offerings in these areas in direct response to serious competition from single specialty hospitals.

Castle NG, Hanlon JT, Handler SM. Results of a longitudinal analysis of national data to examine relationships between organizational and market characteristics and changes in antipsychotic prescribing in U.S. nursing homes from 1996-2006. Am J Geriatr Pharmacother2009 Jun;7(3):143-50.

For-profit nursing homes used more antipsychotic drugs than others. Chain membership, increased Medicaid reimbursement, and increased market competition were associated with lower rates of antipsychotic use.

Chen MA, Hollenberg JP, Michelen W, et al. Patient care outside of office visits: A primary care physician time study. J Gen Int Med 2011 Jan;26(1):58-63.

The study documents extensive out-of-visit time use, including work that could be done by nonphysicians.

Coleman K, Austin B, Brach C, et al. Evidence on the chronic care model in the new millennium. Health Aff (Milwood) 2009;Jan-Feb;28(1):75-85.

Accumulated evidence since 2000 appears to support the Chronic Care Model (CCM) as an integrated framework to guide practice redesign. These studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes. Work remains to be done in areas such as cost-effectiveness.

Concannon TW, Kent DM, Normand SL, et al. Comparative effectiveness of ST-segment elevation myocardial infarction regionalization strategies. Circ Cardiovasc Qual Outcomes 2010 Sep;3(5):506-13.

To improve access to percutaneous coronary intervention capable hospitals, an enhanced emergency medical services strategy of transporting all ST-segment elevation myocardial infarction patients to existing facilities would be less costly and more effective than a hospital expansion strategy.

Curry l, Spatz E, Cherlin E, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Ann Intern Med 2011 Mar 15;154(6):384-90.

This article describes cultural, management, and organizational features that distinguish high- and low-performing hospitals.

Fieldston ES, Hall M, Sills MR, et al. Children's hospitals do not acutely respond to high occupancy. Pediatrics 2010 May;125(5):974-81.

Despite very high occupancy levels, only a handful of the children's hospitals took active steps to reduce crowding through admissions cutoffs or transfers out.

Glickman SW, Kit Delgado M, Hirshon JM, et al. Defining and measuring successful emergency care networks: A research agenda. Acad Emerg Med 2010 Dec;17(12):1297-305.

This article explores the concept of integrated emergency care delivery and prioritizes a research agenda for how to best define and measure successful networks of emergency care.

Hsia R, Asch S, et al. Hospital determinants of emergency department left without being seen rates. Ann Emerg Med 2011 Jul;58(1):24-32.

Research in California shows rates of left without being seen (LWBS) as high as 20 percent and reveals that EDs serving low-income communities and communities with a high proportion of poorly insured patients had higher LWBS rates.

Jiang J, Friedman B, Begun J. Factors associated with quality/low-cost hospital performance. J Health Care Finance 2006 Spring; 32:39-52.

Jiang H, et al. Board oversight of quality: Any differences in process of care and mortality? J Healthc Manag 2009 Jan-Feb;54(1):15-29; discussion 29-30.

Jiang J, Friedman B, Begun J. Sustaining and improving hospital performance: The effects of organizational and market factors. Health Care Manage Rev 2006;31(3):188-96.

These three studies explore organizational and market characteristics associated with superior hospital performance with regard to both quality and cost of care.

Kaissi AA, Parchman M. Organizational factors associated with self-management behaviors in diabetes primary care clinics. Diabetes Educator 2009 Sep/Oct; 35(5):843-50.

Organizational aspects of the Chronic Care Model (CCM) affect the self-management behaviors of patients with type 2 diabetes; however, some primary care organizational features had a positive impact, while others had a negative impact.

Karsh B-T, Brown R. Macroergonomics and patient safety: The impact of levels on theory, measurement, analysis, and intervention in patient safety research. (AHRQ grant HS13610). Appl Ergon 2010 Sep;41(5):674-81.

Medication errors may be the result of nurse behavior, leadership decisions, group dynamics, poor workflow, safety culture, the lack of use of health information technology, or some combination of all of these factors.

Khare RK, Powell ES, Reinhardt G, et al. Adding more beds to the emergency department or reducing admitted patient boarding times: Which has a more significant influence on emergency department congestion? Ann Emerg Med 2009 May;53(5):575-85.

A computer simulation using institutional data and augmented by expert estimates shows that improving the rate at which admitted patients depart the ED produces an improvement in overall ED length of stay, whereas increasing the number of ED beds does not.

Koppel R, Wetterneck T, Telles JL, et al. Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc 2008 Jul-Aug;15(4):408-23.

This study examined reasons for workarounds of bar-coded medication administration systems. The most common causes were organizational, in which workflow policies were incompatible with safety. Most workarounds resulted from poor process design.

Owens PL, Barrett ML, et al. Emergency department care in the United States: A profile of national data sources. Ann Emerg Med 2010 Aug;56(2):150-65.

This article provides a comparison of data sources that can be used to examine utilization and quality of care in the ED nationally.

Popescu I, Werner RM, Vaughan-Sarrazin MS, Cram P. Characteristics and outcomes of America's lowest-performing hospitals: An analysis of acute myocardial infarction hospital care in the United States. Circ Cardiovasc Qual Outcomes 2009 May;2(3):221-7.

Hospitals that have poor compliance with five measures of care quality for treating heart attacks tend to have lower bed numbers, lower staffing ratios, lower patient volumes, and worse mortality rates than hospitals that comply better with the five care measures.

Stratton TP, Worley MM, Schmidt M, et al. Implementing after-hours pharmacy coverage for critical access hospitals in northeast Minnesota. Am J Health Syst Pharm 2008 Sep;15;65(18):1727-34.

A round-the-clock hub pharmacy serving a network of rural hospitals enhanced the timeliness, availability, and safety of pharmacy services.

Thomas JC, Carter C, Torrone E, et al. Pulling together: Interagency coordination and HIV/STD prevention. J Public Health Manag Pract 2008 Jan-Feb;14(1):E1-E6.

This study found a relationship between interagency coordination and prevention of HIV and STDs.

Tucker AL, Singer SJ, et al. Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems. Health Serv Res 2008 Oct;43(5 Pt 2):1807-29.

Based on field observations, the authors explore systemic gaps in efforts to improve patient safety and efficiency; they recommend giving priority to improvements in work systems, rather than targeting specific clinical conditions.

Van Dyke KJ, McHugh M, Yonek J, Moss D. Facilitators and barriers to the implementation of patient flow improvement strategies. Qual Manag Health Care 2011 Jul-Sep;20(3):223-33.

McHugh M, Van Dyke KJ, et al. Changes in Patient flow among five hospitals participating in a learning collaborative. J Healthc Qual 2011 Sep 13.

These two articles describe the experiences and impacts at six hospitals that participated in a learning collaborative to improve patient flow and reduce ED crowding. Five of the participating hospitals implemented a total of seven innovative improvement strategies—including several that involved redesigned processes. The evaluation of these efforts showed that the impacts on ED LOS and "Left Without Being Seen" were modest, at best.

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Organizational Culture, Work Force, and Working Environment

Castle NG, Engberg J. Further examination of the influence of caregiver staffing levels on nursing home quality. Gerontologist 2008 Aug;48(4):464-76.

Alexander GL. An analysis of nursing home quality measures and staffing. Qual Manag Health Care 2008 Jul-Sep;17(3):242-51.

These two papers show that staffing mix (e.g., percentage temporary, ratio of RNs to other caregivers) and turnover affect nursing home quality, whereas overall staffing levels have only weak associations with quality measures.

Garman AN, McAlearney AS, Harrison MI, et al. High-performance work systems in health care management, part 1: Development of an evidence-informed model. Health Care Manage Rev 2011 Jul-Sep;36(3):201-13.

McAlearney AS, Garman AN, Song PH, et al. High-performance work systems in health care management, part 2: Qualitative evidence from five case studies. Health Care Manage Rev 2011 Jul-Sep;36(3):214-26.

High-performance work practices (HPWPs) are defined as a set of organizational and management practices that enhance outcomes by improving employee performance. Through case studies in five high-performing organizations, the authors examine the potential of HPWPs to support these objectives in health care settings.

Go JT, Vaughn-Sarrazin M, Auerbach A, et al. Do hospitalists affect clinical outcomes and efficiency for patients with acute upper gastrointestinal hemorrhage (UGIH)? J Hosp Med 2010 Mar;5(3):133-39.

Differences in adverse outcomes between providers (hospitalists vs. nonhospitalists) were not seen after multivariable adjustments.

Hanlon JT, Handler SM, Castle NG. Antidepressant prescribing in U.S. nursing homes between 1996 and 2006 and its relationship to staffing patterns and use of other psychotropic medications. J Am Med Dir Assoc 2010 Jun;11(5):320-4.

Prescribing of antidepressants among older nursing home residents has risen dramatically. This increase was associated with staffing patterns and coprescribing of other psychotropic medications.

Harrison M, ed. Improving the health care work environment to promote quality and safety. Jt Comm J Qual Patient Saf 2007 November;33 (Suppl). Available as AHRQ Publication OM 08-0007.

This AHRQ-sponsored journal supplement reviews evidence on the effects of working conditions on the quality of health care. The papers examine persistent threats to patient safety in hospital work environments and present options for improvement. The supplement contains six papers, five of them written by AHRQ-funded researchers or staff members, along with an introduction and afterword.

Hoff T. How work context shapes physician approach to safety and error. Qual Manag Health Care 2007 Apr-Jun;17(2):140-53.

This article examines how the work environment (e.g., workload, relationships among physicians) affects patient safety behaviors in the surgery, medical intensive care unit (ICU), and emergency departments of an academic medical center. The author found that the medical ICU had the highest potential capacity for dealing with patient safety and quality of care. The article also discusses interventions most likely to improve patient safety in each setting.

Hoff T. Managing the negatives of experience in physician teams. Health Care Manage Rev 2010 Jan-Mar;35(1):65-76.

Physicians used three experience-based schemas to structure social relations and perform work. Each schema had the potential for undermining learning, participation, and entrepreneurship in the group.

Kane R, Shamliyan T, Mueller C, et al. Nurse Staffing and Quality of Patient Care. Evidence Report/Technology Assessment Number 151 (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-02-0009). Rockville, MD: Agency for Healthcare Research and Quality, March 2007. AHRQ Publication No. 07-E005.

This evidence report documents the effects of nurse staffing on quality.

Lanham HJ, McDaniel RR, Crabtree BF, et al. How improving practice relationships among clinicians and nonclinicians can improve quality in primary care. Jt Comm J Qual Patient Saf 2009 Sep;35(9):457-66.

Seven characteristics identified as important in practice improvement were trust, mindfulness, heedfulness, respectful interaction, diversity, social/task relatedness, and rich/lean communication. A model depicts the relationship between these characteristics and other factors such as reflection, sensemaking and learning, and practice outcomes.

Mardon RE, Khanna K, Sorra J, et al. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf 2010 Dec; 6(4):226-32.

Higher patient safety scores on AHRQ's Hospital Survey of Patient Safety Culture were associated with fewer adverse events at the hospitals. Select Tools and Guidance/Innovation & Performance Improvement: Surveys on Patient Safety Culture for the tools.

Mark BA, Harless DW. Nurse staffing and post-surgical complications using the present on admission indicator. Res Nurs Health 2010 Feb; 33(1):35-47.

Using present-on-admission data, the study found that upping the number of registered nurses (RNs) did not significantly affect postsurgical complication rates.

Mazotti LA, Vidyarthi AR, Wachter RM, et al. Impact on duty-hour restriction on resident inpatient teaching. J Hosp Med 2009 Oct;4(8):476-80.

The amount of time residents spend teaching has declined as a result of recent work- hour restrictions. However, residents report feeling less exhausted and more satisfied with the level of care they deliver.

McHugh MD. Hospital nurse staffing and public health emergency preparedness: Implications for policy. Public Health Nurs 2010 Sep-Oct;27(5):442-9.

This review outline challenges facing hospitals in establishing surge capacity for public health emergencies in the context of a nursing shortage; the paper identifies policy approaches to developing a robust nursing workforce.

Menchik D, Meltzer D. The cultivation of esteem and retrieval of scientific knowledge in physician networks. J Health Soc Behav 2010:51(2):137-52.

The investigators found two very different routes for cultivating esteem in low- and high-prestige hospitals.

Mukamel DB, Spector WD, Limcangco R, et al. The costs of turnover in nursing homes. Med Care 2009 Oct;47(10):1039-45.

Nursing homes in California with higher turnover experience lower costs. This finding helps explain the persistence of staffing practices that encourage high turnover and points to the need for policy initiatives to reduce the financial incentives for turnover.

Nelson C, West T, Goodman C. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? (Prepared by The Lewin Group under Contract No. 290-04-0011). Rockville, MD: Agency for Healthcare Research and Quality, August 2005. AHRQ Publication No. 06-0106-EF.

This report summarizes evidence to date about relationships between the built environment in hospitals (i.e., its physical features) and patient outcomes, safety, and satisfaction, as well as hospital staff safety and satisfaction. The report discusses research needs and implications for current practice.

Reinertsen J, Clancy C. Keeping our promises: Research, practice, and policy issues in health care reliability. Health Serv Res 2006 August;41 (4, part II):1535-38.

This supplement contains articles on factors that contribute to high reliability in health care delivery systems and explores lessons about reliability from other industries.

Rivera-Rodriguez AJ, Karsh B-T. Interruptions and distractions in healthcare: Review and reappraisal. Qual Saf Health Care 2010 Aug;19(4):304-312.

Some interruptions may be harmful, but many just reflect a need for constant communication and coordination. A complex sociotechnical systems approach will guide more comprehensive studies that take into account the complexity of interruptions and their contexts.

Rutledge T, Stucky E, Dollarhide A, et al. A real-time assessment of work stress in physicians and nurses. Health Psychol 2009;28(2):194-200.

This study shows that doctors and nurses in teaching hospitals report widespread sleep deprivation and job stress, despite growing awareness of the consequences of these conditions and attempts to mandate shorter hours for residents.

Stone P, Harrison MI, Feldman P, et al. Organizational climate of staff working conditions and safety—an integrative model. In: Henriksen K, Battles J, Marks E, et al., eds. Advances in patient safety: from research to implementation. Vol. 2, Concepts and methodology. Rockville, MD: Agency for Healthcare Research and Quality; 2005.

This paper compares measures of organizational climate in ongoing patient safety studies and develops a model of climate domains that are hypothesized to affect outcomes across settings. It also tests aspects of the model with data from six separate AHRQ-funded studies.

Singer SJ, Falwell A, Gaba DM, et al. Identifying organizational cultures that promote patient safety. Health Care Manage Rev 2009 Oct-Dec; 34(4):300-11.

Using a typology of cultures, the study found that a higher level of group culture correlated with a higher level of safety climate, but a more "hierarchical" culture was associated with a lower safety climate.

Singer SJ, Gaba DM, Falwell A, et al. Patient safety climate in 92 US hospitals: Differences by work area and discipline. Med Care 2009 Jan;47(1):23-31.

Singer SJ. Falwell A, Gaba DM. et al. Patient safety climate in U.S. hospitals: Variation by management level and clinical disciplines. Med Care 2008 Nov; 46(11):1149-56.

Many studies of culture and climate in hospitals overlook divergence among ranks, work areas, and occupational disciplines. The differences in patient safety climate within and between organizations documented in these papers point to the need for better communication between senior management and frontline workers. Moreover, safety and quality interventions need to be tailored for rank, work areas, and disciplines.

Shamliyan TA, Kane RL, Mueller C, et al. Cost savings associated with increased RN staffing in acute care hospitals: Simulation exercise. Nurs Econ 2009; 27(5):302-31.

This simulation study shows that increased registered nurse (RN) staffing was associated with lower hospital-related mortality and adverse patient events. This approach can result in societal net savings, depending on the area of the hospital.

Tjia J, Mazor KM, Field T, et al. Nurse-physician communication in the long-term care setting: Perceived barriers and impact on patient safety. J Patient Saf 2009; 5(3):145-52.

The study identified several communication barriers in nursing homes, particularly related to telephone communication between nurses and physicians, which have important implications for patient safety.

Tsai CL, Sullivan AF, Ginde AA, et al. Quality of emergency care provided by physician assistants and nurse practitioners in acute asthma. Am J Emerg Med 2010 May; 28(4):485-91.

Unsupervised physician assistants and nurse practitioners (midlevel providers, or MLPs) provided poorer quality of emergency department (ED) care to patients with acute asthma than did physicians.

Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, National Research Council. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Washington, DC: National Academies Press; 2008. Available at:

This IOM committee report recommends: protected sleep periods, limits on work hours for residents, redesigned schedules, increased resident training on better communication during handovers, and more involvement of residents in patient safety activities and adverse event reporting.

Vailovskis E, Knebel R, Dudley R, et al. Cross-sectional analysis of hospitalist prevalence and quality of care in California. J Hosp Med 2010 Apr; 5(4):200-07.

Use of hospitalists was associated with modest improvements in performance on publicly-reported care process measures for heart attack, congestive heart failure (CHF), and pneumonia. The question of causality remains a subject for future study.

Vasilevskis EE, Knebel RJ, Wachter RM, Auerbach AD. California hospital leaders' views of hospitalists: Meeting needs of the present and future. J Hosp Med 2009 Nov/Dec;4(9):528-34.

The study examines the prevalence of hospitalist groups in California hospitals as well as the scope of clinical and nonclinical practice of hospitalists.

Vasilevskis EE, Meltzer DM, Schnipper J, et al. Quality of care for decompensated heart failure: comparable performance between academic hospitalists and nonhospitalists. J Gen Intern Med 2008 Sep;23(9):1399-1406.

Hospitalists and general internists provide similar quality of care for patients with congestive heart failure; however, hospitalists' patients were nearly twice as likely to have a 30-day posthospitalization followup.

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External Catalysts for System Design and Performance: Regulation, Payment, and Reporting

Burns ME. Medicaid managed care and cost containment in the adult disabled population. Med Care 2009;47(10):1069-76.

The cost of monthly Medicaid expenditures for adult Medicaid patients did not differ between counties with fee-for-service (FFS) or mandatory managed care organizations (MCO). Voluntary MCOs were much more costly. Beneficiaries in mandatory MCO counties had a lower probability of emergency room use than those in FFS plans.

Burns ME. Medicaid managed care and health care access for adult beneficiaries with disabilities. Health Serv Res2009;44(5 Part I):1521-41.

The study found little or no benefit from voluntary or mandatory enrollment of adult Medicaid patients with disabilities in managed care organizations (MCOs). Patients in mandatory Medicaid MCOs were more likely to experience delays in care than similar patients enrolled in Medicaid fee-for-service (FFS) or voluntary MCO programs.

Friedman B, Jiang HJ. Do Medicare Advantage enrollees tend to be admitted to hospitals with better or worse outcomes compared with fee-for-service enrollees? Int J Health Care Finance Econ 2010 Jun;10(2):171-85.

The study found that Medicare Advantage enrollees are more likely than Medicare fee-for-service enrollees to receive care at hospitals with higher mortality rates but with fewer patient safety problems.

Hellinger FJ. The effect of certificate-of-need laws on hospital beds and healthcare expenditures: An empirical analysis. Am J Manag Care 2009 Oct;15(10):737-44.

Certificate-of-need programs are intended to curtail the construction of unnecessary hospitals and limit the acquisition of costly medical equipment by compelling health care entities to acquire prior approval from a government agency. Certificate-of-need laws reduced the number of hospital beds by about 10 percent and health care spending at the State level by nearly 2 percent.

Mukamel DB, Spector WD, Zinn J, et al. Changes in clinical and hotel expenditures following publication of the Nursing Home Compare report card. Med Care 2010 Oct; 48(10):869-74.

When the Nursing Home Compare Web site began publishing report cards based on the less-observable clinical services, nursing homes increased funding for these services to attract future residents.

Mukamel DB, Ladd H, Weimer DL, et al. Is there evidence of cream skimming among nursing homes following the publication of the nursing home compare report card? Gerontologist Dec 2009;49(6):793-802.

The study found little evidence of adverse selection of patients with pain and memory limitations. Although anticipated, there was no evidence of cream skimming among high-occupancy facilities.

Palsbo SE, Diao G. The business case for adult disability care coordination. Arch Phys Med Rehabil 2010;91(2):178-83.

A capitated Medicaid care-coordination program led to reductions in medical costs that more than paid for the additional cost of coordination. However, savings may not be sustainable beyond a few years.

Park J, Konetzka RT, Werner RM. Performing well on nursing home report cards: Does it pay off? Health Serv Res 2011 Apr;46(2):531-54.

Facilities that improved on publicly reported performance had increased revenues and higher profit margins after public reporting, mainly through increased Medicare admissions.

Fraser I, Encinosa W, Baker L. Payment Reform. Introduction. Health Serv Res 2010 Dec;45(6 Pt 2):1847-53.

This theme issue focuses on four major challenges to payment reform: (1) structuring payment bundles that reduce regional variation without hurting quality; (2) selecting performance measures that really measure performance; (3) fine-tuning pay-for-performance models; and (4) factoring in external market factors.

Reiter K, Harless D, Pink GH, et al. The effect on minimum nurse staffing legislation on uncompensated care provided by California hospitals. Med Care Res Rev 2011 Jun;68(3):332-51.

Mandated minimum nurse staffing requirements raised hospital operating costs; there was no a broad reduction in uncompensated care as hospitals responded to the rise in their costs, but county and for-profit hospitals apparently did reduce uncompensated care.

Rosko MD, Mutter RL. Inefficiency differences between critical access hospitals and prospectively paid rural hospitals. J Health Polit Policy Law 2010 Feb;35(1):95-126.

This article compares the cost inefficiency of CAHs with that of nonconverting rural hospitals to contrast the performance of hospitals operating under the Medicare Rural Hospital Flexibility Program (Flex Program) of 1997 with hospitals paid under Medicare regulations that apply to most other hospitals.

Werner R, Kostad J, Stuart EA, et al. The effect of pay-for-performance in hospitals: Lessons for quality Improvement. Health Aff (Millwood) 2011 Apr;30(4):690-8.

Hospitals in a Centers for Medicare & Medicaid Services pay-for-performance demonstration project showed early gains in performance. However, nonparticipating also improved their scores over time so that the scores for both groups were nearly identical by the fourth and fifth years of the demonstration.

Werner E, Polsky D. Public reporting drove quality gains at nursing homes. Health Aff (Millwood) Sep 2010;29(9):1706-13.

Research on postacute stays for the 12 months before and after the introduction of Nursing Home Compare found that public reporting drove modest gains in nursing home care quality.

Werner RM, Konetzka RT, Stuart EA, et al. Impact of public reporting on quality of postacute care. Health Serv Res 2009;44(4):1169-87.

The launch in 2002 of the Nursing Home Compare Web site, which publicly rates the performance of nursing homes, was associated with improvement in two of the three posthospitalization care performance measures: no pain and improved walking. However, it was not linked to fewer potentially preventable rehospitalizations, a broader measure of nursing home postacute care quality.

Zinn JS, Spector WD, Weimer DL, et al. Strategic orientation and nursing home response to public reporting of quality measures: An application of the Miles and Snow typology. Health Serv Res 2008 Apr;43(2):598-615.

This article reports an association between whether/how a facility responded to the Nursing Home Compare report and the facility's strategic orientation.

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Tools and Guidance

Efficiency and Value

McGlynn E. Identifying, categorizing, and evaluating healthcare efficiency measures. PowerPoint® presentation. AHRQ 2007 Annual Conference: Improving Healthcare, Improving Lives; 2007 Sept 26-28; Bethesda, MD.

This presentation summarizes an AHRQ-commissioned report titled Identifying, Categorizing, and Evaluating Health Care Efficiency Measures. It identifies and describes existing measures of health care efficiency, organizes them into a typology, and evaluates them according to broad criteria.

Romano P, Hussey P, Ritley D. Selecting quality and resource use measures: A decision guide for community quality collaboratives. Rockville, MD: Agency for Healthcare Research and Quality; May 2010. AHRQ Publication No. 09(10)-0073.

The guide summarizes available empirical evidence and incorporates expert advice, best practices, and real-life case examples to illustrate the breadth of considerations and implementation options.

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Systemwide Transformation

Gabow P, Eisert S, Karkhanis A, et al. A toolkit for redesign in health care. (Prepared by Denver Health under Contract No. 290-00-0014-7). Rockville, MD: Agency for Healthcare Research and Quality, September 2005. AHRQ Publication No. 05-0108-EF.

Managing and evaluating rapid-cycle process improvements as vehicles for hospital system redesign. (Prepared by Denver Health under Contract No. 290-00-0014). Rockville, MD: Agency for Healthcare Research and Quality, September 2007. AHRQ Publication No. 07-0074-EF.

Melinkovitch P. Adoption of rapid cycle improvement process from Toyota increases efficiency and productivity at community health clinics. adoption-rapid-cycle-improvement-process-toyota-increases-efficiency-and-productivity.

Denver Health initiated a systemwide change initiative that sought to transform its physical environment, culture, reward system, staffing, and processes. To drive process redesign, it applied Toyota Production Systems/Lean methods throughout its delivery system. This effort is documented in the above three documents. These documents contain detailed descriptions of improvements in efficiency, access, and quality, along with lessons learned and recommendations for providers. The Toolkit for Redesign contains advice on planning, executing, and assessing a system redesign.

Getting Lean: health care's challenge. A "Lean" training and health care system redesign conference. 2005 Oct 19-21; Denver. Denver: Denver Health; 2005.

These are proceedings from a conference on applying Toyota Production Systems/Lean to improve quality and efficiency.

Hines S, Luna K, Lofthus J, et al. Becoming a high reliability organization: operational advice for hospital leaders. (Prepared by The Lewin Group under Contract No. 290-04-0011.) Rockville, MD: Agency for Healthcare Research and Quality; February 2008. AHRQ Publication No. 08-0022.

This publication discusses five key characteristics of high reliability organizations (HROs) and their application to hospitals: the document reflects the experiences and insights of leaders from 19 health care systems who participated in an AHRQ Learning Network on HROs.

Integrating chronic care and business strategies in the safety net: a toolkit for primary care practices and clinics. Rockville, MD: Agency for Healthcare Research and Quality; August 2008. AHRQ Publication No. 08-0104-EF.

This toolkit is designed to help safety net organizations implement the Chronic Care Model (CCM) effectively and sustainably. The toolkit provides tools and a step-by-step approach to redesigning safety net systems of care while attending to financial realities.

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Process Redesign

American Institutes for Research, Urban Institute, & Mayo Clinic. Improving Care Delivery Through Lean: Implementation Case Studies: Contract Report. November 2014.

This report presents an introduction to the application of Lean principles in health care settings to improve quality of care, increase efficiency, lower costs, and provide better patient outcomes. Lean is an organizational redesign approach focused on elimination of waste, which is defined as any activity that consumes resources (e.g., staff, time, money, space) without adding value to those being served by the process. In addition to background information and the results of a literature review, the report presents six case studies from five organizations that implemented Lean principles in different types of health care settings. Recommendations are provided for similar organizations wishing to implement Lean in their facilities.

Battles JB, ed. Safety by design. Qual Saf Health Care 2006;15 (Suppl 1):i1-i3.

Is it possible to actually "design-in" quality and "design-out" failure? This journal supplement approaches quality and safety as challenges for design, rather than quality improvement. The 15 papers discuss methods and approaches for design of health care facilities, organizations, clinical microsystems, clinical work processes, and information technology systems. Go to for a detailed table of contents and abstracts.

Burdick T, Cochran JK. Door-to-doc patient safety toolkit.

This toolkit includes implementation tools for redesigning the flow of patients in the emergency room in order to reduce waiting time and enhance capacity.

Carayon P. Human factors in patient safety as an innovation. Appl Ergon Sep 2010:41(5): 657-65.

A review of characteristics that can facilitate the adoption and long-term sustainability of human factors engineering.

Carayon P, Schoofs Hundt A, Karsh B-T, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care 2006;15 (Suppl 1):i50-i58.

This article describes the Systems Engineering Initiative for Patient Safety (SEIPS) model.The model describes the system components that can contribute to causes and control of medical errors and explores how design of the components and interactions between them can result in acceptable or unacceptable processes.

Fairbanks RJ. The emergency department pharmacist as a safety measure in emergency medicine.

This toolkit is designed to facilitate the implementation of an emergency department pharmacist program to improve medication safety.

Fieldston E, Hall M, et al. Addressing inpatient crowding by smoothing occupancy at children's hospitals. J Hosp Med 2011 Oct;6(8):462-8.

Retrospective analysis of occupancy data shows how rescheduling elective (prescheduled) admissions can reduce inpatient admissions rates and thereby reduce high occupancy rates.

Harrison M and Moss D. Reducing waste and inefficiency in health care through Lean process redesign.

This literature review explores possible adaptations of Lean/TPS to health care settings.

Jack B, Paasche-Orlow M, Mitchell S, Forsythe S, Martin J. Re-Engineered Discharge (RED) Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; 2013. AHRQ Publication No. 12(13)-0084.

A variety of forces are pushing hospitals to improve their discharge processes to reduce readmissions. Researchers at the Boston University Medical Center (BUMC) developed and tested the Re-Engineered Discharge (RED). Research showed that the RED was effective at reducing readmissions and posthospital emergency department (ED) visits. The Agency for Healthcare Research and Quality contracted with BUMC to develop this toolkit to assist hospitals, particularly those that serve diverse populations, to replicate the RED.

Preventing Avoidable Readmissions: Improving the Hospital Discharge Process

This toolkit provides resources for redesigning the process of discharging patients to reduce post discharge adverse events and avoidable readmissions. Many of the items in the toolkit derive from project RED.

Linking Clinical Practices and the Community for Prevention.

This special page of the AHRQ Health Care Innovations Exchange focuses on integration of the delivery of clinical care, community-based prevention, and health promotion interventions. Among the innovations accessible from this page are several that were presented at the 2008 AHRQ Linking Clinical Practice and the Community for Health Promotion Summit.

Page A, ed. Keeping patients safe: Transforming the work environment of nurses. Institute of Medicine. Washington, DC: National Academies Press; 2004.

This report calls for substantial changes in nurses' work environment, including staffing levels and work hours, to protect patients from health care errors.

Sharkey S, Hudak S, Horn SD, et al. Leveraging certified nursing assistant documentation and knowledge to improve clinical decision making: The on-time quality improvement program to prevent pressure ulcers. Adv Skin Wound Care 2011 Apr;24(4):182-8; quiz 188-90.

The paper describes the main components of the On-Time Quality Improvement for Long-term Care Program (On-Time). The program embeds health information technology into quality improvement at the frontline of care and incorporates culture change, workflow redesign principles, and current best clinical practices for preventing pressure ulcers.

TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) Tools and Materials.

TeamSTEPPS® (Team Strategy and Tools to Enhance Performance and Patient Safety) is an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and other teamwork skills. This multimedia resource kit helps organizations plan, conduct, and evaluate its team training program.

Transforming Hospitals: Designing for Safety and Quality. Rockville, MD: Agency for Healthcare Research and Quality; 2007.

This video reviews the case for evidence-based hospital design. See also "The Hospital Built Environment: What Role Might Funders of Health Services Research Play?"

Triggers and Targeted Injury Detection Systems (TIDS). Expert Panel Meeting. Conference summary report. Rockville, MD: Agency for Healthcare Research and Quality; 2009. AHRQ Publication No. 09-0003.

Clinical triggers are data flags identifying patients who may be at risk of harm or clinical situations that have the potential for harm. This meeting reviewed progress on trigger/TIDS development and explored options for future work.

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Innovation and Performance Improvement in Care Delivery

Berlowitz, D, VanDeusen Lukas, C, et. al. Preventing pressure ulcers in hospitals: a toolkit for improving quality of care. Rockville, MD: Agency for Healthcare Research and Quality; April 2011. AHRQ Publication No. 11-0053-EF.

This toolkit is designed to assist hospital staff in implementing effective pressure ulcer prevention practices.

Advances in Patient Safety: New Directions and Alternative Approaches. Volumes 1-4, July 2008. Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication Nos. 08-0034 (1-4).

This publication includes 115 papers on safety culture, human factors, teamwork, communication, organizational issues, system redesign, information technology, and medication safety. The compendium includes articles that provide advice on implementation as well as tools and products that can be used to improve patient safety.

Brach C, Lenfestey N, Roussel A, et al. Will it work here? A decisionmaker's guide to adopting innovations. Rockville, MD: Agency for Healthcare Research and Quality; September 2008. AHRQ Publication No. 08-0051.

This guide provides guidance about the range of considerations for selecting appropriate health care delivery innovations and planning for their adoption. Individual sections address tasks such as assessing the suitability of innovations and an organization's readiness, and planning and executing implementation.

Committee on the Role of Human Factors in Home Health Care; National Research Council. Health Care Comes Home: The Human Factors. Washington, DC: National Academy of Sciences, 2011.

Committee on the Role of Human Factors in Home Health Care; National Research Council. Consumer Health Information Technology in the Home: A Guide for Human Factors Design Considerations.

The first of these two reports (Health Care Comes Home) outlines the impact of technology, environment, policy and human factors on the growing field of home health care. The second (Consumer Health Information Technology) provides guidance on issues to consider for health IT systems to be used in the home.

Denham CR, Angood P, Berwick D, et al. The chasing zero department: Making idealized design a reality; Chasing zero: Can reality meet the rhetoric? J Patient Saf 2009;5(4):211-15, 216-22.

Leaders from the quality, purchasing, and certifying sectors of health care at a national leadership meeting address the issue of hospital-acquired infections (HAIs). The objective was to determine if zero HAIs should be the improvement target for hospitals and what a Chasing Zero Department (CZD) should be like.

Dougherty D, Conway PH. The "3T's" road map to transform US health care: The "how" of high-quality care. JAMA 2008;299(19):2319-21.

The authors present a model characterizing the conditions for accelerating spread and implementation of evidence-based clinical innovations.

Gibbons MC, Casale C, eds. Reducing disparities in health care quality in under-resourced settings using health IT and quality improvement strategies. Med Care Res Rev 2010 Oct;67(5 Suppl):155S-162S.

This issue includes 6 articles addressing ways to reduce care disparities through health information technology and quality improvement.

Halladay JR, Stearns SC, Wroth T, et al. Cost to primary care practices of responding to payer requests for quality and performance data. Ann Fam Med 2009 Nov/Dec; 7(6):495-503.

Participation in quality reporting programs can be costly, and programs seeking to engage primary care physicians should choose measures with great care. Both financial and nonfinancial incentives may help improve physician acceptance.

Halpern M, Roussel A, et al. Designing consumer reporting systems for patient safety events. Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-0060-EF.

This report summarizes recommended specifications for designing a consumer reporting system that emerged from a series of technical expert panel meetings, consumer focus groups, interviews with key stakeholders, and an environment scan and literature review.

Hughes R, ed. Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0043.

This comprehensive handbook provides research, techniques, and interventions that nurses can use to enhance patient and organizational outcomes.

Margolis P, Halfon N. Innovation networks: A strategy to transform primary health care. JAMA 2009;302(13):1461-2.

Collaborative networks of primary care practices can enhance the capability of individual practices, as well as the capacity of local primary care systems, to improve health outcomes. User-led innovation networks, linked by technology and common purpose, are becoming a widespread means of sharing the work of innovation while improving large complex systems.

Meltzer D, Chung J, Khalili P, et al. Exploring the use of social network methods in designing healthcare quality improvement teams. (AHRQ grant HS16967). Soc Sci Med 2010;71:1119-30.

Social network analysis (SNA) provides actionable insights into design of quality improvement teams.

Rundall TG, Martelli PF, Arroyo L, et al. The informed decisions toolbox: Tools for knowledge transfer and performance improvement. J Healthc Manag 2007 Sep-Oct;52(5):325-41; discussion 341-2.

The Informed Decisions Toolbox describes six steps to assist health care decisionmakers in acquiring the best available evidence when making management decisions.

Schmittdiel JA, Grumbach K, Selby JV. System-based participatory research in health care: An approach for sustainable translational research and quality improvement. Ann Fam Med 2010 May/Jun; 8(3):256-9.

The model and methods of community-based participatory research (CBPR) may help transitional research produce sustainable interventions.

Surveys on Patient Safety Culture.

These widely-used patient safety culture assessment tools for hospitals, nursing homes, and ambulatory outpatient medical offices can be applied to raise staff awareness, assess current status of patient safety culture, identify strengths and areas for improvement, track changes in safety culture over time, make comparisons within and between organizations, and evaluate the effects of interventions on patient safety culture.

Tapp H, Dulin M. The science of primary health-care improvement: Potential use of community-based participatory research by practice-based research networks for translation of research into practice. Exp Biol Med (Maywood) 2010; 235:290-99.

The authors describe the background and development of community-based participatory research (CBPR) and practice-based research networks (PBRNs) and the ways in which they currently function and are envisaged to blend in the future.

Werner RM, Konetzka RT. Advancing nursing home quality through quality improvement itself. Health Aff (Millwood) 2010 Jan-Feb;29(1):81-6.

Instead of being tied simply to quality levels, with little guidance on how to improve performance, incentives should also be tied to efforts to improve quality. This involves collecting and reviewing data on quality of care, assembling multidisciplinary teams to review data and identify areas for improvement, and empowering all employees to both identify quality problems and identify and implement solutions to address them.

Yu H, Greenberg MD, Haviland AM, Farley DO. "Canary measures" among the AHRQ patient safety indicators. Am J Med Qual 2009 Nov/Dec; 24(6):465-73.

Among the 19 Patient Safety Indicators (PSIs), PSI #7 (selected infections due to medical care) may serve as a barometer of broad trends and thereby offer a way for hospital staff to detect general trends in safety by examining fewer safety measures.

Zane R, Biddinger P, et al. Hospital evacuation decision guide. Rockville, MD: Agency for Healthcare Research and Quality; May 2010. AHRQ Publication No. 10-0009.

Zane R, Biddinger P, et al. Hospital assessment and recovery guide. Rockville, MD: Agency for Healthcare Research and Quality; May 2010. AHRQ Publication No. 10-0081.

These two guides examine how hospital personnel have coped under emergency situations in the past to better understand what factors should be considered when making evacuation, shelter-in-place, and reoccupation decisions.

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Enhancing Minority Health, Cultural Competency, and Health Literacy

Beach M, Cooper L, Robinson K, et al. Strategies for improving minority healthcare quality. (Summary Evidence Report/Technology Assessment: Number 90.) Rockville, MD: Agency for Healthcare Research and Quality; January 2004. AHRQ Publication No. 04-E008-1.

This report synthesizes research on strategies that can help health care providers or organizations enhance cultural competency and improve minority health care quality.

Community Care Coordination Learning Network. Connecting those at risk to care: A guide to building a community "HUB" to promote a system of collaboration, accountability, and improved outcomes. Rockville, MD: Agency for Healthcare Research and Quality; September 2010. AHRQ Publication No. 09(10)-0088. connecting-those-risk-care-guide-building-community-hub-promote-system-collaboration

This guide outlines a step-by-step process for community-based organizations and health care services to work together to improve the quality and coordination of medical care and social services for the most vulnerable groups, including blacks, Hispanics, women, and older adults.

DeWalt DA, Broucksou KA, Hawk V, et al. Developing and testing the health literacy universal precautions toolkit. Nurs Outlook 2011 Mar-Apr;59(2):85-94.

Health Literacy Universal Precautions Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; April 2010. AHRQ Publication No. 10-0046-EF.

Research suggests that clear communication practices and removing literacy-related barriers will improve care for all patients, regardless of their level of health literacy. Hence the Universal Precautions Toolkit was developed to help primary care practices organize and deliver their care as if every patient had limited health literacy.

Also visit the AHRQ Pharmacy Health Literacy Center:

Improving Access to Language Services in Health Care: A Look at National and State Efforts.

Andrulis D, Brach C. Integrating literacy, culture, and language to improve health care quality for diverse populations. Am J Health Behav 2007;31(Suppl 1):S122-S133.

To improve care for diverse patients with limited health literacy, health care organizations must make changes in their delivery systems. Leadership and senior management must be willing to invest in training, staffing, and physical plants. The authors present a vision for an integrated approach to health literacy and cultural and linguistic competence that illustrates the important roles that both clinicians and health care organizations play.

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Implementing Information Technology and Other Health Technologies

Carayon P, Karsh B-T, Cartmill RS, et al. Incorporating health information technology into workflow redesign—summary report. (Prepared by the Center for Quality and Productivity Improvement, University of Wisconsin-Madison, under Contract No. HHSA 290-2008-10036C). Rockville, MD: Agency for Healthcare Research and Quality; October 2010. AHRQ Publication No. 10-0098-EF.

Workflow Assessment for Health IT Toolkit.

A key to successful implementation, use and improvement of health information technology (health IT) is to recognize its impact on both clinical and administrative workflow. This summary report and accompanying toolkit are designed for people and organizations interested or involved in the planning, design, implementation, and use of health IT in ambulatory care.

Gibbons MC, Casale CR, eds. Reducing disparities in health care quality in underresourced settings using HIT and other quality improvement strategies. Med Care Res Rev 2010 Oct:67(5 Suppl.) 155S-162S.

Includes six articles on upgrading the use of health information technology and with reducing inconsistencies in health care delivery.

Henriksen K, Joseph A, Zayas-Caban T. Human factors of home health care: A conceptual model for examining safety and quality concerns. J Patient Saf 2009;5:229-36.

This paper uses a sociotechnical systems model to examine potential threats to safety and quality in home health care and possible responses to them.

Jones SS, Koppel R, Ridgely MS, et al. Guide to reducing unintended consequences of electronic health records. (Prepared by RAND Corporation under Contract No. HHSA290200600017I, Task Order #5). Agency for Healthcare Research and Quality. Rockville, MD; August 2011. AHRQ Publication No. 11-0105-EF.

The Guide to Reducing Unintended Consequences of Electronic Health Records is an online resource designed to help implementers of health IT anticipate, avoid, and address problems that can occur when implementing and using an electronic health record.

Karsh B. Beyond usability for patient safety: Designing effective technology implementation systems. Qual Saf Health Care 2004;13(5):388-94.

This paper examines organizational, job, individual, and technological factors affecting adoption of technologies capable of promoting safety and quality. It derives a set of organizational design guidelines for implementing new technologies.

Karsh B-T, Weinger MB, Abbott PA, Weaver RL. Health information technology: Fallacies and sober realities. J Am Med Inform Assoc 2010:17:617-23.

Discusses 12 misguided beliefs about health IT and their implications for design and implementation.

Langley J, Beasley C. Health information technology for improving quality of care in primary care settings. (Prepared by the Institute for Healthcare Improvement for the National Opinion Research Center under contract No. 290-04-0016.) Rockville, MD: Agency for Healthcare Research and Quality; July 2007. AHRQ Publication No. 07-0079-EF. PTARGS_0_1248_661809_0_0_18/AHRQ_HIT_Primary_Care_July07.pdf

The authors identify effective change ideas for implementing and spreading health IT to large numbers of primary care practices. The guide shows how to use IT to support system improvements, as well as to improve efficiency.

Pervez MA, Silva G, Masrur S, et al. Remote supervision of IV-tPA for acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe. Stroke 2010 January; 41:e18-e24.

Intravenous tissue plasminogen activator (IV tPA) can be given safely and effectively at outlying hospitals when a neurologist supervises the procedure using telemedicine or telephone guidance. The patient can then be moved to a regional stroke center.

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Useful Links

AHRQ Health Care Innovations Exchange
The Health Care Innovations Exchange (HCIE) is a searchable Web site designed to support health care professionals in sharing and adopting innovations that improve the delivery of care to patients. The Web site contains descriptions of a wide range of innovations, their impact, and how the innovations were developed and implemented. Among the many strategies and quality-related tools reported on the HCIE Web site are redesign innovations for enhancing access to care, reducing hospitalizations, and reducing costs through improved information technology-supported workflow.

AHRQ National Resource Center Health Information Technology (NRC) ahrq_national_resource_center_for_health_it/650
Through this Web-based resource, AHRQ makes available research findings, best practices, and lessons learned from over an investment of over $300 million. More than 10,000 documents, presentations, articles, and tools are freely available on the NRC.

AHRQ PSNet Patient Safety Network
This is a national Web-based resource featuring the latest news and essential resources on patient safety.

Linking Clinical Practices and Community Organizations for Prevention building-relationships-between-clinical-practices-and-community-improve-care
This special Innovations Exchange page facilitates collaborative work of participants in two summits on linking practices and community organizations for prevention and provides case studies and tools on this theme.

Patient Centered Medical Home Resource Center
This site provides policymakers and researchers with access to evidence-based resources about the medical home and its potential to transform primary care and improve the quality, safety, efficiency, and effectiveness of U.S. health care.

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For More Information

For more information, contact:

Michael I. Harrison, Ph.D.
Senior Research Scientist—Organizations and Systems
Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
5600 Fishers Lane
Mailstop 7W25B
Rockville, MD 20857
Phone: (301) 427-1434

For more information on system design for quality and safety, go to:

For more information on use of health information technology in system design, go to:

For further information on system design innovations, go to:

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1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001.
2. Harrison K, Henriksen R, Hughes RG. Improving the health care work environment: a sociotechnical systems approach. Jt Comm J Qual Patient Saf 2007 Nov;33(11 Suppl):3-6.
3. Wang M, Hyun J, Harrison M, et al. redesigning health systems for quality: lessons from emerging practices. Jt Comm J Qual Patient Saf 2006 Nov;32(11):599-611.

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Page last reviewed June 2019
Page originally created February 2012
Internet Citation: System Design: AHRQ Resources. Content last reviewed June 2019. Agency for Healthcare Research and Quality, Rockville, MD.
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