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Institutional quality and patient safety programs: An overview for the healthcare epidemiologist

Published online by Cambridge University Press:  04 September 2020

Pranavi V. Sreeramoju Open the ORCID record for Pranavi V. Sreeramoju [Opens in a new window] ,
Tara N. Palmore ,
Grace M. Lee ,
Michael B. Edmond ,
Jan E. Patterson ,
Kent A. Sepkowitz ,
Donald A. Goldmann ,
David K. Henderson  and
Keith S. Kaye
Pranavi V. Sreeramoju*
Affiliation:
Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
Tara N. Palmore
Affiliation:
Clinical Center, National Institutes of Health, Bethesda, Maryland
Grace M. Lee
Affiliation:
Division of Infectious Diseases, Lucile Salter Packard Children’s Hospital, Stanford University Stanford Children’s Health, Stanford, California
Michael B. Edmond
Affiliation:
Carver College of Medicine, University of Iowa, Iowa City, Iowa University of Iowa Health Care, Iowa City, Iowa
Jan E. Patterson
Affiliation:
Division of Infectious Diseases, University of Texas Health Science Center, San Antonio, Texas
Kent A. Sepkowitz
Affiliation:
Memorial Sloan Kettering Cancer Center, New York, New York
Donald A. Goldmann
Affiliation:
Department of Immunology and Infectious Diseases and Epidemiology, Harvard School of Public Health, Boston, Massachusetts Harvard Medical School, Boston, Massachusetts Institute for Healthcare Improvement, Boston, Massachusetts
David K. Henderson
Affiliation:
Clinical Center, National Institutes of Health, Bethesda, Maryland
Keith S. Kaye
Affiliation:
Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan
*
Author for correspondence: Pranavi V. Sreeramoju, E-mail: [email protected]
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Abstract

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Type
SHEA White Paper
Information
Infection Control & Hospital Epidemiology , Volume 42 , Issue 1 , January 2021 , pp. 6 - 17
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© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.

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Footnotes

a

First authors of equal contribution.

References

Kadar, N. Rediscovering Ignaz Philipp Semmelweis (1818–1865). Am J Obstet Gynecol 2019;220:26–39.CrossRefGoogle Scholar
Larson, E. A retrospective on infection control. Part 2: Twentieth century—the flame burns. Am J Infect Control 1997;25:340–349.CrossRefGoogle ScholarPubMed
Smith, PW, Watkins, K, Hewlett, A. Infection control through the ages. Am J Infect Control 2012;40:35–42.CrossRefGoogle ScholarPubMed
McDonald, L. Florence Nightingale, statistics and the Crimean War. J Roy Statist Soc A 2014;177:569–586.CrossRefGoogle Scholar
Donabedian, A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966;44 suppl 3:166–206.CrossRefGoogle Scholar
Codman, EA. The classic: a study in hospital efficiency: as demonstrated by the case report of first five years of private hospital. Clin Orthop Relat Res 2013;471:1778–1783.CrossRefGoogle ScholarPubMed
Neuhauser, D. Ernest Amory Codman MD. Qual Saf Health Care 2002;11:104–105.CrossRefGoogle Scholar
Berwick, DM. Controlling variation in health care: a consultation from Walter Shewhart. Med Care 1991;29:1212–1225.CrossRefGoogle ScholarPubMed
Best, M, Neuhauser, D. W Edwards Deming: father of quality management, patient and composer. Qual Saf Health Care 2005;14:310–312.CrossRefGoogle Scholar
Best, M, Neuhauser, D. Joseph Juran: overcoming resistance to organisational change. Qual Saf Health Care 2006;15:380–382.CrossRefGoogle ScholarPubMed
Haley, RW, Culver, DH, White, JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985;121:182–205.CrossRefGoogle ScholarPubMed
Haley, RW, Culver, DH, Emori, TG, Hooton, TM, White, JW. Progress report on the evaluation of the efficacy of infection surveillance and control programs. Am J Med 1981;70:971–975.CrossRefGoogle ScholarPubMed
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press 2001.Google Scholar
Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: The National Academies Press; 2000.Google Scholar
Pronovost, P, Needham, D, Berenholtz, S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725–2732.CrossRefGoogle ScholarPubMed
Pronovost, PJ, Watson, SR, Goeschel, CA, Hyzy, RC, Berenholtz, SM. Sustaining reductions in central-line–associated bloodstream infections in Michigan intensive care units: a 10-year analysis. Am J Med Qual 2016;31:197–202.CrossRefGoogle ScholarPubMed
Institute for Healthcare Improvement webstie. http://www.ihi.org/about/Documents/IHI_Timeline_2018.pdf. Published May 4, 2018. Accessed February 25, 2019.Google Scholar
Berwick, DM, Nolan, TW, Whittington, J. The triple aim: care, health, and cost. Health Aff (Millwood) 2008;27:759–769.CrossRefGoogle ScholarPubMed
Bodenheimer, T, Sinsky, C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014;12:573–576.CrossRefGoogle ScholarPubMed
Mery, G, Majumder, S, Brown, A, Dobrow, MJ. What do we mean when we talk about the Triple Aim? A systematic review of evolving definitions and adaptations of the framework at the health system level. Health Policy 2017;121:629–636.CrossRefGoogle Scholar
Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html. Updated January 2020. Accessed August 7, 2020.Google Scholar
Centers for Medicare & Medicaid Services website. https://innovation.cms.gov/initiatives/bundled-payments/. Acccessed September 5, 2019.Google Scholar
Marx, D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives. New York, NY: Trustees of Columbia University; 2001.Google Scholar
Sreeramoju, P. Reducing infections “together”: a review of socioadaptive approaches. Open Forum Infect Dis 2019;6(2):ofy348.CrossRefGoogle ScholarPubMed
Hollnagel, E, Wears, R, Braithwaite, J. From Safety-I to Safety-II: A White Paper. Middelfart, Denmark; University of Denmark; 2015.Google Scholar
Gandhi, T. Leadership and vision for a culture of safety. NEJM Catalyst 2018.Google Scholar
Knobloch, MJ, Chewning, B, Musuuza, J, et al. Leadership rounds to reduce healthcare-associated infections. Am J Infect Control 2018;46:303–310.CrossRefGoogle Scholar
Chassin, MR, Loeb, JM. High-reliability health care: getting there from here. Milbank Q 2013;91:459–490.CrossRefGoogle Scholar
Chassin, MR, Loeb, JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood) 2011;30:559–568.CrossRefGoogle ScholarPubMed
Stalter, AM, Phillips, JM, Ruggiero, JS, et al. A concept analysis of systems thinking. Nurs Forum 2017;52:323–330.CrossRefGoogle ScholarPubMed
National Institute for Occupational Safety and Health (NIOSH) website. https://www.cdc.gov/niosh/topics/hierarchy/default.html. Published 2015. Accessed February 25, 2019.Google Scholar
Reason, J. Understanding adverse events: human factors. Qual Health Care 1995;4:80–89.CrossRefGoogle ScholarPubMed
Reason, J. Human error: models and management. West J Med 2000;172:393–396.CrossRefGoogle ScholarPubMed
Charles, R, Hood, B, Derosier, JM, et al. How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient Saf Surg 2016;10:20.CrossRefGoogle ScholarPubMed
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2016.Google Scholar
Ashley, L, Armitage, G, Neary, M, Hollingsworth, G. A practical guide to failure mode and effects analysis in health care: making the most of the team and its meetings. Jt Comm J Qual Patient Saf 2010;36:351–358.Google Scholar
Diller, T, Helmrich, G, Dunning, S, Cox, S, Buchanan, A, Shappell, S. The Human Factors Analysis Classification System (HFACS) applied to health care. Am J Med Qual 2014;29:181–190.CrossRefGoogle ScholarPubMed
Langley, G, Moen, R, Nolan, K, Nolan, T, Norman, C, Provost, L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed. San Francisco: Jossey-Bass; 2009.Google Scholar
Agency for Healthcare Research and Quality website. https://innovations.ahrq.gov/qualitytools/plan-do-study-act-pdsa-cycle. Accessed February 25, 2019.Google Scholar
Agency for Healthcare Research and Quality website. https://www.ahrq.gov/talkingquality/measures/types.html. Accessed February 25, 2019.Google Scholar
Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Hospital-Value-Based-Purchasing-.html./ Published 2017. Accessed February 25, 2019.Google Scholar
Hospital value-based purchasing. Centers for Medicare & Medicaid Services website. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdfIn: Published 2017. Accessed August 7, 2020.Google Scholar
Healthcare Consumer Assessent of Healthcare Providers and Systems website. https://www.hcahpsonline.org/. Accessed February 28, 2019.Google Scholar
Mannon, M. Lean healthcare and quality management: the experience of ThedaCare. Qual Manage J 2014;21:7–10.CrossRefGoogle Scholar
Swensen, S, Pugh, M, McMullan, C, Kabcenell, A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013.Google Scholar
Kaye, KS, Anderson, DJ, Cook, E, et al. Guidance for infection prevention and healthcare epidemiology programs: healthcare epidemiologist skills and competencies. Infect Control Hosp Epidemiol 2015;36:369–380.CrossRefGoogle ScholarPubMed
Gittell, JH, Beswick, J, Goldmann, D, Wallack, SS. Teamwork methods for accountable care: relational coordination and team STEPPS. Health Care Manage Rev 2015;40:116–125.CrossRefGoogle Scholar
Valentine, MA, Nembhard, IM, Edmondson, AC. Measuring teamwork in health care settings: a review of survey instruments. Med Care 2015;53:e16–e30.CrossRefGoogle ScholarPubMed
Rau, J. Medicare eases readmission penalties against safety-net hospitals. Kaiser Health News, September 26, 2018.Google Scholar
Institute for Healthcare Improvement website. http://www.ihi.org/. Accessed January 2, 2019.Google Scholar
Agency for Healthcare Research and Quality website. https://www.ahrq.gov/. Accessed January 2, 2019.Google Scholar
National Quality Forum website. http://www.qualityforum.org/Home.aspx. Accessed January 2, 2019.Google Scholar
Centers for Medicare & Medicaid Services website. https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitalacqcond/hospital-acquired_conditions.html. Accessed January 2, 2019.Google Scholar
The Joint Commission website. https://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx. Published 2019. Accessed August 7, 2020.Google Scholar
The Leapfrog Group website. http://www.leapfroggroup.org/. Accessed January 2, 2019.Google Scholar
Association for Professionals in Infection Control and Epidemiology webiste. https://apic.org/Professional-Practice/Infection_preventionist_IP_competency_model. Accessed February 25, 2019.Google Scholar
Scoville, R, Little, K. Comparing Lean and Quality Improvement. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2014.Google Scholar
Perla, RJ, Provost, LP, Parry, GJ. Seven propositions of the science of improvement: exploring foundations. Qual Manag Health Care 2013;22:170–186.CrossRefGoogle ScholarPubMed
Goyal, S, Law, E. An introduction to Kaizen in health care. Br J Hosp Med (Lond) 2019;80:168–169.CrossRefGoogle ScholarPubMed
Varkey, P, Reller, MK, Resar, RK. Basics of quality improvement in health care. Mayo Clin Proc 2007;82:735–739.CrossRefGoogle ScholarPubMed
Saint, S, Greene, MT, Krein, SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med 2016;374:2111–2119.CrossRefGoogle ScholarPubMed
Agency for Healthcare Research and Quality website. https://www.ahrq.gov/professionals/quality-patient-safety/hais/cauti-tools/guides/sustainability-guide.html. Published 2015. Accessed February 25, 2019.Google Scholar
Healthcare Leadership Alliance website. http://www.healthcareleadershipalliance.org/. Published 2017. Accesssed September 26, 2019.Google Scholar
American Society for Quality website. https://asq.org/programs/emerging-quality-leaders/schedule. Accessed September 26, 2019.Google Scholar
Agency for Healthcare Research and Quality website. https://psnet.ahrq.gov/perspectives/perspective/98/The-University-of-Texas-System-Clinical-Safety-and-Effectiveness-Course. Published 2011. Accessed February 25, 2019.Google Scholar
American College of Medical Quality website. https://acmq.org/page/Certification. Published 2019. Accessed February 25, 2019.Google Scholar
Nash, DB, Joshi, M, Ransom, ER, Ransom, SB. The Healthcare Quality Book: Vision, Strategy, and Tools, fourth edition. Washington, DC: Health Administration Press; 2019.Google Scholar
Ogrinc, GS, Headrick, LA, Barton, AJ, Dolansky, MA, Madigosky, WS, Miltner, RS. Fundamentals of Health Care Improvement: A Guide to Improving Your Patients’ Care. 3rd editon. Oakbrook, IL: Joint Commission Resources; 2018.Google Scholar
Langley, GJ, Moen, RD, Nolan, KM, Nolan, TW, Norman, CL, Provost, LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd edition. San Francisco, CA: Jossey-Bass; 2009.Google Scholar
Wachter, RM. The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. New York: McGraw-Hill Education; 2017.Google Scholar
Vincent, C. Patient Safety. Edinburgh; New York: Churchill Livingstone; 2006.Google ScholarPubMed
Reason, JT. A Life in Error: From Little Slips to Big Disasters. Surrey, England: Ashgate; 2013.Google Scholar
Ogrinc, G, Davies, L, Goodman, D, Batalden, P, Davidoff, F, Stevens, D. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. BMJ Qual Saf 2016;25:986–992.CrossRefGoogle ScholarPubMed
Gottlieb, AS, Travis, EL. Rationale and models for career advancement sponsorship in academic medicine: the time is here; the time is now. Acad Med 2018;93:1620–1623.CrossRefGoogle ScholarPubMed
Krackhardt, D, Hanson, JR. Informal networks: the company behind the chart. Harv Bus Rev 1993;71:104–411.Google Scholar
Ibarra, H, Hunter, M. How leaders create and use networks. Harv Bus Rev 2007;85:40–47, 124.Google Scholar
Cross, R, Thomas, R. A smarter way to network. Harv Bus Rev 2011;89:149–153, 167.Google Scholar