National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Events (4)
- Cancer (2)
- Central Line-Associated Bloodstream Infections (CLABSI) (2)
- Communication (1)
- Consumer Assessment of Healthcare Providers and Systems (CAHPS) (1)
- Disparities (1)
- Education: Continuing Medical Education (3)
- Evidence-Based Practice (3)
- Guidelines (2)
- Healthcare-Associated Infections (HAIs) (2)
- Healthcare Cost and Utilization Project (HCUP) (1)
- Healthcare Delivery (1)
- Health Services Research (HSR) (1)
- Labor and Delivery (1)
- Medical Errors (3)
- Medical Liability (1)
- Mortality (1)
- Newborns/Infants (1)
- Nursing (1)
- Outcomes (1)
- Palliative Care (1)
- Patient-Centered Outcomes Research (2)
- Patient Experience (1)
- (-) Patient Safety (18)
- Pregnancy (1)
- Prevention (2)
- Primary Care (1)
- Provider (1)
- Provider: Health Personnel (1)
- Provider Performance (1)
- Quality Improvement (1)
- Quality Indicators (QIs) (3)
- Quality Measures (3)
- (-) Quality of Care (18)
- Risk (1)
- Surgery (2)
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 18 of 18 Research Studies DisplayedPhillips R, Kennedy J, Jaén C
Transforming physician certification to support physician self-motivation and capacity to improve quality and safety.
The American Board of Family Medicine (ABFM) is making strategic investments in the next major evolution of continuous certification. The ABFM is the first certifying board to launch a registry that is designed to support physician capacity for quality assessment, improvement, data-reporting requirements, and population management. The ABFM aims to help physicians maintain the privilege of self-governance by helping them continuously earn it.
AHRQ-funded; HS022583.
Citation: Phillips R, Kennedy J, Jaén C .
Transforming physician certification to support physician self-motivation and capacity to improve quality and safety.
Journal of Enterprise Transformation 2016 Dec 14;6(3-4):162-69. doi: 10.1080/19488289.2016.1216020.
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Keywords: Education: Continuing Medical Education, Quality of Care, Patient Safety, Provider
Burstein PD, Zalenski DM, Edwards JL
Changing labor and delivery practice: focus on achieving practice and documentation standardization with the goal of improving neonatal outcomes.
The researchers established a multifactorial shoulder dystocia response and management protocol to promote sustainable practice change. In the first year, there was a threefold increase in shoulder dystocia reporting, which continued in years 2 and 3. In the first year, 96 percent of clinicians completed all training elements. Overall teams reached a 99 percent adoption rate of the shoulder dystocia protocol.
AHRQ-funded; HS019608.
Citation: Burstein PD, Zalenski DM, Edwards JL .
Changing labor and delivery practice: focus on achieving practice and documentation standardization with the goal of improving neonatal outcomes.
Health Serv Res 2016 Dec;51 Suppl 3:2472-86. doi: 10.1111/1475-6773.12589.
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Keywords: Labor and Delivery, Newborns/Infants, Adverse Events, Quality Improvement, Quality of Care, Patient Safety, Patient-Centered Outcomes Research, Outcomes, Guidelines, Evidence-Based Practice, Pregnancy, Teams
Gallagher TH, Farrell ML, Karson H
Collaboration with regulators to support quality and accountability following medical errors: The Communication and Resolution Program Certification Pilot.
The Medical Quality Assurance Commission (MQAC, board of medicine) in Washington State has collaborated with the Foundation for Health Care Quality (FHCQ) on the CRP Certification pilot. A panel of physicians, risk managers, and patient advocates at FHCQ will review cases for use of the CRP key elements. After describing the process, the authors concluded that the CRP Certification program is a promising example of collaboration among institutions, insurers, and regulators to promote patient-centered accountability and learning following adverse events.
AHRQ-funded; HS019531.
Citation: Gallagher TH, Farrell ML, Karson H .
Collaboration with regulators to support quality and accountability following medical errors: The Communication and Resolution Program Certification Pilot.
Health Serv Res 2016 Dec;51 Suppl 3:2569-82. doi: 10.1111/1475-6773.12557.
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Keywords: Adverse Events, Communication, Medical Errors, Medical Liability, Patient Safety, Quality of Care
Rajaram R, Saddat L, Chung J
Impact of the 2011 ACGME resident duty hour reform on hospital patient experience and processes-of-care.
The investigators evaluated the association between resident duty hour reform and measures of processes-of-care and patient experience. They concluded that the 2011 Accreditation Council for Graduate Medical Education duty hour reform was not associated with improvements in process-of-care and patient experience measures.
AHRQ-funded; HS000078.
Citation: Rajaram R, Saddat L, Chung J .
Impact of the 2011 ACGME resident duty hour reform on hospital patient experience and processes-of-care.
BMJ Qual Saf 2016 Dec;25(12):962-70. doi: 10.1136/bmjqs-2015-004794.
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Keywords: Consumer Assessment of Healthcare Providers and Systems (CAHPS), Education: Continuing Medical Education, Quality of Care, Patient Experience, Patient Safety
Musuuza JS, Hundt AS, Zimbric M
Standardizing direct observation for assessing compliance to a daily chlorhexidine bathing protocol among hospitalized patients.
This paper describes the authors' experience training observers to conduct chlorhexidine gluconate bathing observations, and they present findings from pilot observations.
AHRQ-funded; HS024039.
Citation: Musuuza JS, Hundt AS, Zimbric M .
Standardizing direct observation for assessing compliance to a daily chlorhexidine bathing protocol among hospitalized patients.
Infect Control Hosp Epidemiol 2016 Dec;37(12):1516-18. doi: 10.1017/ice.2016.214.
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Keywords: Guidelines, Quality of Care, Healthcare-Associated Infections (HAIs), Patient Safety, Prevention
Pogorzelska-Maziarz M, Nembhard IM, Schnall R
Psychometric evaluation of an instrument for measuring organizational climate for quality: evidence from a national sample of infection preventionists.
This study tested the psychometric properties of the Leading a Culture of Quality for Infection Prevention (LCQ-IP) instrument measuring the infection prevention climate in a sample of 972 infection preventionists from acute care hospitals. An exploratory principal component analysis showed that the instrument had structural validity and captured 4 factors related to the climate for infection prevention: Psychological Safety, Prioritization of Quality, Supportive Work Environment, and Improvement Orientation.
AHRQ-funded; HS018987.
Citation: Pogorzelska-Maziarz M, Nembhard IM, Schnall R .
Psychometric evaluation of an instrument for measuring organizational climate for quality: evidence from a national sample of infection preventionists.
Am J Med Qual 2016 Sep;31(5):441-7. doi: 10.1177/1062860615587322.
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Keywords: Quality of Care, Healthcare-Associated Infections (HAIs), Patient Safety, Prevention
Wong SL, Revels SL, Yin H
Variation in hospital mortality rates with inpatient cancer surgery.
The purpose of this national study was to elucidate clinical mechanisms underlying variation in hospital mortality with major cancer surgery. It found that case-fatality rates among patients with complications at high-mortality hospitals were approximately twice as high as at low-mortality hospitals. This study implicates failure to rescue as the major reason for differences in hospital mortality rates with major cancer surgery.
AHRQ-funded; HS020937.
Citation: Wong SL, Revels SL, Yin H .
Variation in hospital mortality rates with inpatient cancer surgery.
Ann Surg 2015 Apr;261(4):632-6. doi: 10.1097/sla.0000000000000690..
Keywords: Mortality, Surgery, Cancer, Patient Safety, Quality of Care
Pronovost PJ, Cleeman JI, Wright D
AHRQ Author: Cleeman JI
Fifteen years after to Err is Human: a success story to learn from.
This paper provides a historical profile of the central line-associated bloodstream infection (CLABSI) success story, comparing infection rates before and 15 years after the IOM report. It discusses the five elements essential to the national success in reducing CLABSI rates: a reliable and valid measurement system, evidence-based care practices, investment in implementation sciences, local ownership and peer learning communities, and coordination and alignment of CLABSI reduction efforts.
AHRQ-authored.
Citation: Pronovost PJ, Cleeman JI, Wright D .
Fifteen years after to Err is Human: a success story to learn from.
BMJ Qual Saf 2016 Jun;25(6):396-9. doi: 10.1136/bmjqs-2015-004720.
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Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Patient Safety, Medical Errors, Evidence-Based Practice, Quality of Care
Hernandez-Boussard TM, McDonald KM, Morrison DE
Risks of adverse events in colorectal patients: population-based study.
The authors sought to assess adverse events in colorectal surgical patients. They found important differential rates of adverse events by diagnostic category, with the highest odds ratio occurring in patients undergoing surgery for ischemic colitis.
AHRQ-funded; HS018558.
Citation: Hernandez-Boussard TM, McDonald KM, Morrison DE .
Risks of adverse events in colorectal patients: population-based study.
J Surg Res 2016 May 15;202(2):328-34. doi: 10.1016/j.jss.2016.01.013.
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Keywords: Healthcare Cost and Utilization Project (HCUP), Adverse Events, Surgery, Patient Safety, Risk, Quality Indicators (QIs), Quality of Care, Quality Measures
Yang D, Wooten HO, Green O
A software tool to automatically assure and report daily treatment deliveries by a Cobalt-60 radiation therapy device.
The researchers developed a method for verification of treatment delivery after each treatment fraction in order to detect and correct errors, and they developed a comprehensive daily report. The end result has been integrated into a commercial version of the treatment delivery system, and it has been in clinical use for over one year.
AHRQ-funded; HS022888.
Citation: Yang D, Wooten HO, Green O .
A software tool to automatically assure and report daily treatment deliveries by a Cobalt-60 radiation therapy device.
J Appl Clin Med Phys 2016 May 8;17(3):6001.
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Keywords: Treatments, Cancer, Quality of Care, Patient Safety
Kamal AH, Bull J, Ritchie CS
Adherence to measuring what matters measures using point-of-care data collection across diverse clinical settings.
The purpose of this paper was to evaluate the implementation of Measuring What Matters (MWM) measures by exploring documentation of quality measure adherence across six diverse clinical settings inherent to palliative care practice. The authors found that the lowest adherence involved comprehensive assessments during the first visit in hospitalized patients in the intensive care unit and that the highest adherence across all settings involved documentation of management of moderate to severe pain. They recommended additional studies for better understanding of benchmarks and acceptable ranges for adherence tailored to various clinical settings.
AHRQ-funded; HS023681; HS022763.
Citation: Kamal AH, Bull J, Ritchie CS .
Adherence to measuring what matters measures using point-of-care data collection across diverse clinical settings.
J Pain Symptom Manage 2016 Mar;51(3):497-503. doi: 10.1016/j.jpainsymman.2015.12.313.
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Keywords: Quality Measures, Palliative Care, Patient-Centered Outcomes Research, Quality of Care, Patient Safety
Kronick R
AHRQ Author: Kronick R
AHRQ's role in improving quality, safety, and health system performance.
The author, director of AHRQ, focuses on several topics including investing in research and evidence to understand how to improve the safety and quality of health care, and generating measures and data used to track and improve performance and evaluate progress of the U.S. health-care system. He concludes by discussing AHRQ’s continuing exploration of ways to expand its efforts in patient safety into nonhospital settings.
AHRQ-authored.
Citation: Kronick R .
AHRQ's role in improving quality, safety, and health system performance.
Public Health Rep 2016 Mar-Apr;131(2):229-32.
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Keywords: Patient Safety, Quality of Care, Evidence-Based Practice, Health Services Research (HSR)
Calaman S, Hepps JH, Bismilla Z
The creation of standard-setting videos to support faculty observations of learner performance and entrustment decisions.
The authors report their experience developing videos that represent five levels of performance for an entrustable professional activities (EPA) for patient handoffs. They describe a process that begins with mapping the EPA to the critical competencies needed to make an entrustment decision. Each competency is then defined by five milestones (behavioral descriptors of performance at five advancing levels).
AHRQ-funded; HS019456.
Citation: Calaman S, Hepps JH, Bismilla Z .
The creation of standard-setting videos to support faculty observations of learner performance and entrustment decisions.
Acad Med 2016 Feb;91(2):204-9. doi: 10.1097/acm.0000000000000853..
Keywords: Education: Continuing Medical Education, Provider Performance, Patient Safety, Quality of Care
Southern DA, Pincus HA, Romano PS
Enhanced capture of healthcare-related harms and injuries in the 11th revision of the International Classification of Diseases (ICD-11).
The authors presented recommendations made to the World Health Organization (WHO) by the ICD revision's Quality and Safety Topic Advisory Group (Q&S TAG) for a new conceptual approach to capturing healthcare-related harms and injuries in ICD-coded data. They concluded that this new framework for coding healthcare-related harm has great potential to improve the clinical detail of adverse event descriptions and the overall quality of coded health data.
AHRQ-funded; HS020543.
Citation: Southern DA, Pincus HA, Romano PS .
Enhanced capture of healthcare-related harms and injuries in the 11th revision of the International Classification of Diseases (ICD-11).
Int J Qual Health Care 2016 Feb;28(1):136-42. doi: 10.1093/intqhc/mzv099.
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Keywords: Adverse Events, Quality of Care, Patient Safety, Quality Indicators (QIs)
Southern DA, Hall M, White DE
Opportunities and challenges for quality and safety applications in ICD-11: an international survey of users of coded health data.
The authors identified opportunities and challenges in improving the utility of ICD-11 for quality and safety applications. The 246 online survey respondents specified desires for the ICD revision: more code content for adverse events/complications; a desire for code clustering mechanisms; the need for diagnosis timing information; and the addition of better code definitions to reference materials. The authors concluded that the World Health Organization's ICD revision process is addressing each of these desires.
AHRQ-funded; HS020543.
Citation: Southern DA, Hall M, White DE .
Opportunities and challenges for quality and safety applications in ICD-11: an international survey of users of coded health data.
Int J Qual Health Care 2016 Feb;28(1):129-35. doi: 10.1093/intqhc/mzv096.
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Keywords: Quality of Care, Patient Safety, Quality Indicators (QIs)
Ricciardi R, Moy E, Wilson NJ
AHRQ Author: Ricciardi R and Moy E
Finding the true north: lessons from the National Healthcare Quality and Disparities Report.
The authors delineate important features and findings of the 2014 report. For example, it shows that one measure of patient safety improved quickly. The rate of central line–associated bloodstream infection per 1000 medical and surgical discharges (age 18+ years or obstetric admissions) improved at an annual rate of change of more than 10 percent. This success reflects the direct impact that nurses can have in making care safer for their patients.
AHRQ authors Ricciardi and Moy
Citation: Ricciardi R, Moy E, Wilson NJ .
Finding the true north: lessons from the National Healthcare Quality and Disparities Report.
J Nurs Care Qual 2016 Jan-Mar;31(1):9-12. doi: 10.1097/ncq.0000000000000164..
Keywords: Quality of Care, Disparities, Patient Safety, Nursing, Central Line-Associated Bloodstream Infections (CLABSI)
Yanes AF, McElroy LM, Abecassis ZA
Observation for assessment of clinician performance: a narrative review.
The authors summarized studies utilizing video recorded or in-person observations for assessing clinician performance in medicine and surgery. They found that observations are useful for the improvement of healthcare delivery through the identification of clinician lapses and weaknesses that affect quality and safety. Further, limitations of observations included the Hawthorne effect and the necessity of trained observers to capture and analyze the notes or videos.
AHRQ-funded; HS000078.
Citation: Yanes AF, McElroy LM, Abecassis ZA .
Observation for assessment of clinician performance: a narrative review.
BMJ Qual Saf 2016 Jan;25(1):46-55. doi: 10.1136/bmjqs-2015-004171.
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Keywords: Healthcare Delivery, Quality of Care, Patient Safety, Quality Measures
Rabatin J, Williams E, Baier Manwell L
Predictors and outcomes of burnout in primary care physicians.
This study assessed relationships between primary care work conditions, physician burnout, quality of care, and medical errors. It found that burnout is highly associated with adverse work conditions and a greater intention to leave the practice, but not with adverse patient outcomes. Care quality thus appears to be preserved at great personal cost to primary care physicians.
AHRQ-funded; HS011955.
Citation: Rabatin J, Williams E, Baier Manwell L .
Predictors and outcomes of burnout in primary care physicians.
J Prim Care Community Health 2016 Jan;7(1):41-3. doi: 10.1177/2150131915607799.
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Keywords: Provider: Health Personnel, Primary Care, Medical Errors, Patient Safety, Quality of Care