Assessment of the AHRQ Patient Safety Initiative

Assessment of the AHRQ Patient Safety Initiative: Focus on Implementation and Dissemination Evaluation Report III (2004–2005)

Donna O. Farley
Cheryl L. Damberg
M. Susan Ridgely
Melony E. Sorbero
Michael D. Greenberg
Amelia Haviland
Robin C. Meili
Stephanie S. Teleki
Lily Bradley
Jacob W. Dembosky
Allen Fremont
Teryl K. Nuckols
Rebecca Shaw
Stephanie L. Taylor
Hao Yu
Copyright Date: 2007
Edition: 1
Published by: RAND Corporation
Pages: 128
https://www.jstor.org/stable/10.7249/tr508ahrq
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  • Book Info
    Assessment of the AHRQ Patient Safety Initiative
    Book Description:

    Updates the policy context of the Agency for Healthcare Research and Quality (AHRQ) patient safety initiative; documents the current priorities and activities undertaken; and assesses contributions of health information technology projects and dissemination actions to support adoption of evidence-based safe practices. Discusses implications for future AHRQ policy, programming, and research; suggests ways to strengthen AHRQ activities.

    eISBN: 978-0-8330-4444-0
    Subjects: Health Sciences, Management & Organizational Behavior, Technology, Political Science

Table of Contents

  1. Front Matter
    (pp. i-ii)
  2. PREFACE
    (pp. iii-iv)
  3. Table of Contents
    (pp. v-vi)
  4. FIGURES
    (pp. vii-viii)
  5. TABLES
    (pp. ix-x)
  6. EXECUTIVE SUMMARY
    (pp. xi-xxii)
  7. ACKNOWLEDGMENTS
    (pp. xxiii-xxiv)
  8. ACRONYMS
    (pp. xxv-xxvi)
  9. CHAPTER 1. INTRODUCTION
    (pp. 1-6)

    As of October 2005, it has been four years since the U.S. Congress funded the Agency for Healthcare Research and Quality (AHRQ) to establish the national patient safety research and implementation initiative. With these funds, AHRQ has committed to improving patient safety in the U.S. health care system by developing a comprehensive strategy for supporting expansion of knowledge about patient safety epidemiology and effective practices and by identifying and disseminating the most effective practices. AHRQ contracted with RAND Corporation in September 2002 to serve as the evaluation center for its patient safety initiative. The evaluation center is responsible for performing...

  10. CHAPTER 2. CONTEXT AND INPUT EVALUATIONS
    (pp. 7-16)

    This chapter updates the information presented inEvaluation Reports IandIIregarding the policy context that frames the AHRQ patient safety initiative (context evaluation), as well as the priorities and activities being pursued by AHRQ as it implements the initiative (input evaluation).

    The historical context that led to formation and funding of the AHRQ patient safety initiative may be summarized as follows:

    The science of patient safety was relatively immature as this initiative began, including limited knowledge of the epidemiology of safety in health care, an inadequate body of published research to establish evidence regarding the effectiveness of practices...

  11. CHAPTER 3. PROCESS: MONITORING PROGRESS AND MAINTAINING VIGILANCE
    (pp. 17-24)

    This chapter focuses on the first of five system components of an effective patient safety system, as depicted in Figure 1.1 of this report. This component is monitoring progress and maintaining vigilance, as defined in the box above.

    The ability to assess performance on established patient safety measures is vital to the health care community for reducing risk of harm to patients and the consequences of such harm. This performance information will also enable AHRQ to report to Congress on the results of its investment in patient safety research and dissemination so that appropriate adjustments can be made to the...

  12. CHAPTER 4. PROCESS EVALUATION: KNOWLEDGE OF EPIDEMIOLOGY AND DEVELOPMENT OF EFFECTIVE PRACTICES
    (pp. 25-44)

    This chapter focuses on the second and third of the five system components of an effective patient safety system, as depicted in Figure 1.1. These two components contribute to development of knowledge regarding patient safety epidemiology and effective practices and tools, as defined in the box above.

    InEvaluation Report I, separate chapters addressed the two components encompassed in theKnowledge Developmentportion of the patient safety system defined in Figure 1.1: (1) the epidemiology of patient safety risks and hazards and (2) establishment of effective patient safety practices and tools. We combined these two components into one chapter in...

  13. CHAPTER 5. PROCESS: BUILDING INFRASTRUCTURE FOR EFFECTIVE PRACTICES
    (pp. 45-54)

    This chapter focuses on the fourth of five system components of an effective patient safety system, as depicted in Figure 1.1. This component is building infrastructure for effective practices, as defined in the box above.

    As noted in our previous reports, building a supportive infrastructure is critical for successful adoption of improved patient safety practices throughout the United States. InEvaluation Report I, we delineated a number of infrastructure elements, including patient safety culture, information systems, adverse-event-reporting systems, interdisciplinary teams, multiinstitutional collaborations, and quality-improvement systems and measures. We also highlighted how the FY 2000–FY 2001 patient safety projects were...

  14. CHAPTER 6. PROCESS: ACHIEVING BROADER ADOPTION OF EFFECTIVE PRACTICES
    (pp. 55-70)

    This chapter focuses on the last of five system components of an effective patient safety system, as depicted in Figure 1.1. This component is achieving broader adoption of effective practices, as defined in the box above.

    AHRQ’s current challenge in achieving broader adoption of effective patient safety practices is to ensure that the wealth of information emerging from the projects it has funded gets into the hands of end users, along with appropriate tools and assistance to facilitate their efforts. InEvaluation Report I, we established baseline information on dissemination activities and published output from patient safety grantees, and we...

  15. CHAPTER 7. PATIENT SAFETY OUTCOMES
    (pp. 71-88)

    A key component of this evaluation is the identification and tracking of measures for assessing the effects of the AHRQ patient safety initiative. We begin this chapter with a reference to the earlier work we have done on this topic, as well as a review of the framework used for the product evaluation (the final component of the CIPP model; see Chapter 1). We follow this review with an assessment of the availability and limitations of data on patient safety effects. We then present baseline trends for selected patient-outcome measures related to safety, including measures for which data already are...

  16. CHAPTER 8. CONCLUSION
    (pp. 89-92)

    The evaluation results presented inEvaluation Report IIIhave focused on the process and product evaluations in 2004–2005. Some highlights from this phase of the evaluation are assessments of the potential contributions of the health IT projects to patient safety knowledge and practices and AHRQ’s progress in activities to disseminate proven patient safety practices for broad adoption by health care providers. We also developed baseline trends for selected measures to assess effects of the initiative on patient outcomes and other stakeholders. In addition, the activities of field-based initiatives (e.g., 5 Million Lives Campaign; see Chapter 6) have become subjects...

  17. APPENDIX SUGGESTIONS FOR AHRQ ACTION: EVALUATION REPORTS I AND II
    (pp. 93-96)
  18. REFERENCES
    (pp. 97-102)