Assessment of the National Patient Safety Initiative Context and Baseline

by Farley, Donna O.

• ISBN13: 9780833037879
• ISBN10: 0833037870
• Edition: 1st
• Format: Paperback
• Copyright: 2005-04-27
• Publisher: RAND CORPORATION

Summary

Assesses the context and goals that were the foundation for the Agency for Healthcare Research and Quality's patient safety initiative.

Table of Contents

Preface	iii
Table of Contents	v
Table of Figures	vii
Table of Tables	ix
Executive Summary	xi
Evaluation Framework	xi
Findings from the Context and Input Evaluations	xiii
Issues and Suggested AHRQ Actions from the Process Evaluation	xiv
Future Directions and Priorities	xviii
Acronyms	xxi
Acknowledgements	xxiii
Introduction	1	(8)
Evaluating the Patient Safety Initiative	1	(4)
Evaluation Approach and Methods	5	(1)
About This Report	6	(3)
Context Evaluation	9	(6)
Antecedents to the AHRQ Patient Safety Initiative	9	(1)
Legislative Processes for Reauthorization and Funding	10	(2)
Overview of Patient Safety Efforts	12	(1)
Pending Patient Safety Organization Legislation	13	(1)
Consequences for the AHRQ Patient Safety Initiative	14	(1)
Input Evaluation	15	(8)
The Agency for Healthcare Research and Quality	15	(1)
AHRQ Patient Safety Strategy and Goals	16	(1)
AHRQ Patient Safety Initiative	17	(2)
Current Groups of Patient Safety Projects	19	(1)
Financial Resources and Budgets	19	(1)
Issues to Consider	20	(3)
Process Evaluation: Monitoring Progress and Maintaining Vigilance	23	(10)
Policy Context	23	(2)
Availability of Patient Safety Measures	25	(1)
Standards for Patient Safety Data Systems	26	(1)
Use of Measures in Accreditation or Credentialing	27	(1)
Data Availability on Patient Safety Performance	28	(1)
Issues and Action Opportunities	29	(4)
Process Evaluation: Knowledge of Epidemiology of Patient Safety Risks	33	(8)
Policy Context	34	(1)
Measuring the Epidemiology of Patient Safety Issues	34	(1)
Current Knowledge of Patient Safety Epidemiology	35	(2)
Contributions of AHRQ-Funded Research Projects	37	(2)
Issues and Action Opportunities	39	(2)
Process Evaluation: Establishing Effective Patient Safety Practices	41	(10)
Policy Context	42	(1)
The Evidence Base for Practices to Improve Patient Safety	42	(2)
Information from Projects for Adoption of New Practices	44	(3)
Cost, Cost Effectiveness, and Return on Investment	47	(1)
Barriers and Unintended Outcomes	48	(1)
Additional Information Needed from Field Tests	48	(1)
Issues and Action Opportunities	48	(3)
Process Evaluation: Building Infrastructure for Effective Practices	51	(12)
Policy Context	52	(1)
Knowledge about Infrastructure for Patient Safety Practices	53	(2)
Infrastructure Being Built by the Patient Safety Projects	55	(2)
Infrastructure Building by AHRQ Systems Projects and Activities	57	(2)
The External Environment as Part of Infrastructure	59	(1)
Issues and Action Opportunities	59	(4)
Process Evaluation: Achieving Broader Adoption of Effective Practices	63	(10)
Policy Context	63	(1)
Interaction and Exchange of Information Among Grantees	64	(1)
Dissemination of New Knowledge and Practices	65	(3)
Technical Support for Implementation of Tested Practices	68	(2)
Issues and Action Opportunities	70	(3)
Conclusion	73	(4)
Future Directions and Priorities	73	(2)
Next Steps	75	(2)
Appendix A. Organizations and Project Groups Involved in the Patient Safety Initiative	77	(4)
Appendix B. Patient Safety Projects With Potential to Generate Patient Safety Epidemiology Information	81	(2)
Appendix C. Analysis of AHRQ Patient Safety Projects in the Context of the Evidence Report and NQF Safe Practices	83	(2)
References	85