Measurement of Safety and Quality

Blood Clots Show Limits of Quality Care Penalties

Blood Clots Show Limits of Quality Care Penalties

Posted by  | Measurement of Safety and Quality, Preventing Patient Harm

In the world of medicine, blood clots during hospitalization have become synonymous with imperfect care. As many as 600,000 patients per year experience a blood clot, and more than 100,000 die as a result, accounting for between 5 and 10 percent of hospital deaths. Regulatory agencies have taken clots as signals that safety and quality(...)

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What’s Your Theory? Bringing Rigor to Local Quality Improvement Projects

What’s Your Theory? Bringing Rigor to Local Quality Improvement Projects

Posted by  | Measurement of Safety and Quality, Organizational and Cultural Change

For a moment, consider that you work at a primary care clinic, and your team needs to improve performance on annual foot exams on patients with diabetes — a critical step to prevent foot ulcers and amputations. At your monthly meeting, staff members enthusiastically suggest solutions, such as using robocalls to urge patients to schedule appointments(...)

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Can Hospitals Police Themselves to Avoid Too-Risky Surgeries?

Can Hospitals Police Themselves to Avoid Too-Risky Surgeries?

Posted by  | Measurement of Safety and Quality, Preventing Patient Harm

Imagine you were seeking major surgery, and the hospital's consent form contained this surprise statement, which you were asked to initial: "I understand that this surgeon and hospital have not performed this procedure in the last 12 months. As such, I accept the greater risk of complications and even death." It's hard to believe that(...)

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Why Health Care Performance Measures Need Their Own Grades

Why Health Care Performance Measures Need Their Own Grades

Posted by  | Measurement of Safety and Quality

Some measures of health care quality and patient safety should be taken with a grain of salt. A few need a spoonful. In April, a team of Johns Hopkins researchers published an article examining how well a state of Maryland pay-for-performance program measure for dangerous blood clots identified cases that were potentially preventable. In reviewing(...)

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To Make Hospital Quality a Priority, Take a Page from Finance

To Make Hospital Quality a Priority, Take a Page from Finance

Posted by  | Measurement of Safety and Quality, Organizational and Cultural Change

When you are a patient at a hospital, you want to know that the executives who run that facility put the safety and quality of care above all other concerns. Encouragingly, more of them are saying that safety is indeed their number-one priority—a fitting answer given that preventable patient harm may claim more than 400,000(...)

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Health Care Shouldn’t Judge Itself by Flawed Tests

Health Care Shouldn’t Judge Itself by Flawed Tests

Posted by  | Measurement of Safety and Quality, Preventing Patient Harm

As standardized exam scores increasingly define success for students, teachers and schools, parents worry about the dangers of “teaching to the test”—and of their children being judged by tests with low or unknown validity. We want our children to perform well on tests, of course, yet only if they measure something that students, patients and(...)

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A blueprint for high reliability

Posted by  | Measurement of Safety and Quality, Organizational and Cultural Change, Preventing Patient Harm

Across health care, organizations constantly struggle with the challenge of achieving patient safety and quality successes on a large scale—across a hospital or network of hospitals. Too often, they are doomed at the start, because staff don’t even know what the goals are. In other cases, staff have limited capacity to carry out improvement work(...)

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Rethinking how we think about preventing harm

Posted by  | Designing Safer Systems, Measurement of Safety and Quality, Preventing Patient Harm

Last week the Armstrong Institute, along with our partners at the World Health Organization, had the privilege of hosting more than 200 clinicians, patient advocates, health care leaders and policy makers for our inaugural Forum on Emerging Topics in Patient Safety in Baltimore. The event featured presentations by international experts in a dozen different industries,(...)

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