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Patient Safety and Health Information Technology E-Newsletter

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November 21, 2008, Issue No. 49

Quote of the Month

"I expect the final rule and the creation of Patient Safety Organizations to greatly improve the quality of health care for all Americans. By making it easier for clinicians and health care organizations to report and learn from adverse events without fear of new legal liability, we will be able to improve our Nation's health care systems and minimize factors that can contribute to mistakes." (For more information on final rule for Patient Safety Organizations, go to item no.1.)

—HHS Secretary Mike Leavitt

Today's Headlines:

  1. Final rule for Patient Safety Organizations issued
  2. New AHRQ report shows factors that drive or prevent certain consumers from using health IT
  3. AHRQ releases survey to assess nursing home safety culture
  4. AHRQ director participates in scientific session at recent medical informatics symposium
  5. Web conference on implementing teambuilding tools in nursing homes and assisted living facilities set for December 10
  6. New inventory of HHS quality measures released
  7. AHRQ announces new risk-informed intervention patient safety grants
  8. AHRQ director speaks at electronic health record safety conference
  9. Health IT adoption toolbox now available through AHRQ's Health IT Web site
  10. AHRQ podcast on using health IT to connect patients and doctors in Hawaii
  11. Meeting for users of AHRQ CAHPS® and Patient Safety Culture Surveys on December 3-5
  12. Latest issue of WebM&M is available online
  13. 2009 brings new Adobe-based forms for electronic submission of grant applications

1. Final Rule for Patient Safety Organizations Issued

HHS issued a final rule for Patient Safety Organizations (PSOs), which is now available on the AHRQ PSO Web site. The rule becomes effective on January 19, 2009, and provides final requirements and procedures for PSOs—new entities with which clinicians and health care providers can work to collect, aggregate and analyze data, within a legally secure environment of privilege and confidentiality protections, to identify and reduce patient care risks and hazards. As outlined in the Patient Safety Act, AHRQ administers provisions governing PSO operations, and HHS' Office for Civil Rights enforces the confidentiality provisions of the Act. Under interim guidance issued on October 8, AHRQ listed 15 PSOs that will maintain their status as PSOs during the remainder of the interim period and be required to comply with the final rule once it takes effect. Select to access AHRQ's press release and the November 21 Federal Register notice.

2.  New AHRQ Report Shows Factors that Drive or Prevent Certain Consumers from Using Health IT

A new AHRQ evidence report shows that there are distinct factors that influence the use and usability of interactive consumer health information technology (health IT) by the elderly, chronically ill, and underserved populations. Researchers found that health IT systems that allow physicians to assess their patients' current health status, treatment plan and goals, and provide new or adjusted treatment advice are most successfully used. These systems are effective regardless of the type of illness the patient has, their education or income status, location, or type of technology used. Barriers to adoption of health IT systems can occur when patients do not see the benefit of using computer or other interactive technologies for self-managing their health problems. Other barriers include time constraints for the patient, lack of trust in the information received, technical problems, and physician unresponsiveness to questions. Select to read Barriers and Drivers of Health Information Technology Use for the Elderly, Chronically Ill, and Underserved, conducted for AHRQ by the Oregon Health & Science University Evidence-Based Practice Center.

3.  AHRQ Releases Survey to Assess Nursing Home Safety Culture

AHRQ has released the Nursing Home Survey on Patient Safety Culture to help nursing homes assess safety culture, track changes in resident safety over time, and evaluate the impact of safety interventions. The new evidence-based survey assesses nursing home staff opinions of patient safety culture in the nursing home. The survey is part of a toolkit that includes a user's guide that explains the survey process, and the survey materials. The survey measures 12 important dimensions related to resident safety culture, including communication openness, compliance with procedures, feedback and communication about incidents, handoffs, and nonpunitive response to mistakes. It is important to note that the survey was developed for use in nursing home facilities; it is not intended for use in assisted living, rehabilitation, community care, or independent living facilities. Select to access the survey and other toolkit materials. Free technical assistance for survey administration is available by sending an E-mail to

4. AHRQ Director Participates in Scientific Session at Recent Medical Informatics Symposium

AHRQ Director Carolyn M. Clancy, M.D., participated in a scientific session, titled "New Perspectives and Progress from the American Health Information Community," at the American Medical Informatics Association Symposium last week in Washington, D.C. Dr. Clancy was joined by Jonathan Teich, M.D., Ph.D., Harvard University, Boston, MA; Charles P. Friedman, Ph.D., Office of the National Coordinator, HHS; and John Glaser, Vice President and Chief Information Officer, Partners Healthcare, Boston, MA. They discussed the progress, effectiveness, and future of the American Health Information Community (AHIC), a federal advisory committee established in 2005 to offer recommendations to HHS Secretary Mike Leavitt to accelerate the adoption of health IT. Select to access the HHS press release to learn more about the accomplishments resulting from AHIC's recommendations.

5.  Web Conference on Implementing Teambuilding Tools in Nursing Homes and Assisted Living Facilities Set for December 10

AHRQ and the Department of Defense are hosting a series of free, 90-minute Web conferences on various topics related to patient safety culture and team training as part of a project to implement the TeamSTEPPS™ training program nationwide. The next Web conference, "Using TeamSTEPPS™ and Nursing Homes and Assisted Living Facilities" is scheduled for December 10 from 12:00 p.m.-1:30 p.m., EST. Participants will learn how TeamSTEPPS™ can be implemented in federally funded health care facilities, including nursing homes and assisted living facilities. Facilitators will review data regarding preventable medical errors common to these facilities and how staff can address errors by using TeamSTEPPS™ tools and strategies.

Future Web conferences are planned for 2009 that will cover a range of topics. To register for the December 10 Web conference, send an E-mail to

6.  New Inventory of HHS Quality Measures Released

HHS recently released the first-ever inventory of quality measures that are used for reporting, payment, or quality improvement by its agencies and operating divisions. The HHS measure inventory, which is available on AHRQ's National Quality Measures Clearinghouse (NQMC), is designed to advance collaboration within the quality measurement community and to synchronize measurement. The inventory is available on the NQMC Web site. Measures for this inventory were contributed by the: Administration on Aging, AHRQ, Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services, Health Resources and Services Administration, Indian Health Service, Office of Public Health and Science, National Institutes of Health, Substance Abuse and Mental Health Services Administration, and Office of the National Coordinator for Health Information Technology. The measures currently can be sorted by agency or operating division and can be downloaded in their entirety. The inventory will be enhanced in the next several months so that measures can be sorted by condition, setting, or domain.

7.  NAHRQ Announces New Risk-informed Intervention Patient Safety Grants

AHRQ has announced over $3.7 million in awards for patient safety grants focusing on risk-informed interventions. The objectives of these 3-year projects are to identify, develop, test, and implement safe practice interventions in ambulatory care settings. Findings and lessons learned about the challenges and barriers to developing and implementing these interventions through toolkits will be shared so that they may be adapted and/or adopted by other health care organizations. Select for more information.

8. AHRQ Director Speaks at Electronic Health Record Safety Conference

AHRQ and the Electronic Health Record (EHR) Safety Institute at Geisinger Health System sponsored a conference focused on implementing and using EHRs in ways that reliably increase patient safety on October 22-23 in Washington, DC. This conference brought together health care leaders, researchers, and EHR implementers to discuss the factors that lead to the safe and successful use of EHRs as well as the potential for EHRs to contribute to adverse effects across the spectrum of health care. AHRQ Director Carolyn Clancy, M.D., presented opening remarks. "There is substantial evidence that well-implemented EHRs improve the quality of care—in areas including safety," Dr. Clancy said. "This conference is an opportunity to learn how others are using EHRs to increase health care quality and safety, and determine how their experiences can help us refine our efforts."

9.  Health IT Adoption Toolbox Now Available Through AHRQ's Health IT Web Site

A new health IT adoption toolbox is accessible through the AHRQ National Resource Center for Health Information Technology. Developed by the Health Resources and Services Administration's (HRSA) Office of Health Information Technology, the adoption toolbox is a compilation of planning, implementation, and evaluation resources to help community health centers and other safety net providers implement health IT applications in their facilities. It includes resources that are useful for users with different levels of knowledge and at various stages of health IT implementation.

10. AHRQ Podcast on Using Health IT to Connect Patients and Doctors in Hawaii

AHRQ's recent Healthcare 411 podcast features health IT grantee Christine Sakuda, Information Officer at the Hawaii Primary Care Association, Honolulu, HI, discussing her experiences using health IT to connect patients and doctors on Hawaii's six major islands. Ms. Sakuda and researchers launched a 4-year initiative, called the Holomua Project to Improve Transitional Care in Hawaii, to help community health centers and hospitals improve care for their shared patients. The project uses data from the Master Visit Registry, a record locator system developed by the Hawaii Primary Care Association designed to help doctors locate a patient's history of visits, show what type of care they received and who provided that care. This lets the provider know which facility the patient visited, the type of visit and something about their diagnosis. Users can access the registry from their workstation within the clinic or the hospital. Select to listen to the podcast or select to read the transcript.

To access any of AHRQ's podcasts and special reports or to sign up for a free subscription to the series and receive notice of all future AHRQ podcasts, visit our Healthcare 411 series main page.

11.  Meeting for Users of AHRQ CAHPS® and Patient Safety Culture Surveys on December 3-5

Register now to attend AHRQ's joint meeting for users of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) family of surveys and of the AHRQ patient safety culture surveys for hospitals, nursing homes, and medical offices on December 3-5. Registration is free and the meeting will be held at the Doubletree Paradise Valley Resort in Scottsdale, AZ. The main meeting will be December 4-5 and the CAHPS® College will be on December 3. The CAHPS® program develops standardized surveys of patients' experiences with health plans, medical groups, hospitals, nursing homes, individual clinicians, and other providers. The program also offers guidance on how to use the survey results to improve quality of care and report useful information to consumers. The patient safety culture surveys are tools that staff in hospitals, nursing homes, and medical offices can use to assess their patient safety culture, track changes in patient safety culture over time, and evaluate the impact of patient safety interventions. AHRQ released the hospital patient safety culture survey in 2004 and plans to issue the surveys for nursing homes and medical offices this fall. Select for more information and to register. Exit Disclaimer

12.  Latest Issue of WebM&M Is Available Online

The November issue of AHRQ WebM&M is now available online. The Perspectives on Safety section covers how research on preventing urinary tract infections (UTIs) offers broader lessons for patient safety. The section includes an interview with Sanjay Saint, M.D., of the University of Michigan, Ann Arbor, MI, about his research on reducing health care-associated infections and how this relates to preventing catheter-related UTIs. In an accompanying perspective piece, Lindsay Nicolle, M.D., of University of Manitoba, Winnipeg, Canada, discusses the problem of health care-acquired UTI along with potential solutions. The Spotlight Case features a story on how the lack of communication during a shift change lead to an infant developing respiratory distress. As always, a Spotlight slide presentation is available for download. Physicians and nurses can receive free medical education (CME), continuing education units (CEU), or trainee certification by taking the Spotlight Quiz. You can share AHRQ WebM&M cases by using the "Email a colleague" feature.

13.  2009 Brings New Adobe-based Forms for Electronic Submission of Grant Applications

Most electronic grant submissions to AHRQ on or after January 1, 2009, must use Adobe® application forms (go to NIH Guide Notice NOT-OD-08-117). As AHRQ/NIH wait to incorporate the latest updates to the Adobe forms by December, there are two critical points applicants need be aware of:

  • New Funding Opportunity Announcements (FOAs) released after September 1, will not have Adobe application forms for downloading until December At that time, it will be necessary for you to go back to your chosen FOA to download the Adobe®-based application packages. Existing FOAs that were released prior to September 1 will have PureEdge application forms that will remain active and available until they are replaced by Adobe forms in December. Do not wait for the Adobe® forms to become available—develop your research plan components and required application attachments now!

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Current as of November 2008


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