The effect of a novel Housestaff Quality Council on Quality and patient safety

Joint Commission Journal on Quality and Patient Safety

Volumn 38, Issue 7, 2012, Pages 311-317

  Fleischut, Peter M ^a   Faggiani, Susan L ^a   Evans, Adam S ^b   Brenner, Samantha ^c   Liebowitz, Richard S ^d,e   Forese, Laura ^a   Kerr, Gregory E ^c,f   Lazar, Eliot J ^a,f  

^a WEILL CORNELL MEDICAL CENTER   (United States)

^b JOHNS HOPKINS HOSPITAL   (United States)

^c Department of Public Health   (United States)

^d NewYork Presbyterian Hospital   (United States)

^e NYP   (United States)

^f Department of Anesthesiology ^*  (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ACCREDITATION; ADVISORY COMMITTEE; ARTICLE; AWARDS AND PRIZES; CATHETER INFECTION; ELECTRONIC MEDICAL RECORD; HAND WASHING; HEALTH CARE QUALITY; HOSPITAL PERSONNEL; HUMAN; LEADERSHIP; ORGANIZATION; ORGANIZATION AND MANAGEMENT; PATIENT CARE; PATIENT SAFETY; SAFETY; TEACHING HOSPITAL; UNITED STATES;

ADVISORY COMMITTEES; AWARDS AND PRIZES; CATHETER-RELATED INFECTIONS; CONTINUITY OF PATIENT CARE; ELECTRONIC HEALTH RECORDS; HANDWASHING; HOSPITALS, TEACHING; HUMANS; JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS; LEADERSHIP; ORGANIZATIONAL INNOVATION; PATIENT SAFETY; PERSONNEL, HOSPITAL; QUALITY OF HEALTH CARE; SAFETY MANAGEMENT; UNITED STATES;

EID: 84863108268     PISSN: 15537250     EISSN: None     Source Type: Journal    
DOI: 10.1016/S1553-7250(12)38041-0     Document Type: Article

References (49)

1. Bohmer RM, et al. Restructuring within an academic health center to support quality and safety: The development of the Center for Quality and Safety at the Massachusetts General Hospital. Acad Med. 2009;84(12):1663-1671.
2. Abramson E, et al. Implementing a patient safety and quality program across two merged pediatric institutions. Jt Comm J Qual Patient Saf. 2009;35(1):43-48.
3. Birnbaum M. A conversation with Donald Berwick on implementing national health reform. J Health Polit Policy Law. 2012 Mar. 30. [Epub ahead of print.]
4. McGlynn EA, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003 Jun. 26;348(26):2635-2645. (Pubitemid 36741592)
5. Brennan T, et al. Accidental deaths, saved lives, and improved quality. N Engl J Med. 2005 Sep. 29;353(13):1405-1409. (Pubitemid 41362712)
6. Bloomrosen M, et al. Anticipating and addressing the unintended consequences of health IT and policy: A report from the AMIA 2009 Health Policy Meeting. J Am Med Inform Assoc. 2011;18(1):82-90.
7. Ash JS, et al. Categorizing the unintended sociotechnical consequences of computerized provider order entry. Int J Med Inform. 2007;76 Suppl 1:S21-S27.
8. Weiner JP, et al. "e-Iatrogenesis": The most critical unintended consequence of CPOE and other HIT. J Am Med Inform Assoc. 2007;14(3):387-388. (Pubitemid 46636347)
9. Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11(2):104-112. (Pubitemid 38327498)
10. Campbell EM, et al. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13(5):547-556. (Pubitemid 44292018)
11. Health Management Technology. A look at unintended consequences of EHRs. Weidemann L. Feb. 2012. Accessed May 30, 2012. http://www.healthmgttech. com/index.php/solutions/electronic-medical-records/a-look-at- unintendedconsequences-of-ehrs.html. Accessed Apr. 19, 2012.
12. Huckvale C, et al. Information technology for patient safety. Qual Saf Health Care. 2010;19 Suppl 2:i25-i33.
13. Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care - An interactive sociotechnical analysis. J Am Med Inform Assoc. 2007;14(5):542-549. (Pubitemid 47379560)
14. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000.
15. Leape LL, Berwick DM. Five years after To Err Is Human: What have we learned? JAMA. 2005 May 18;293(19):2384-2390. (Pubitemid 40676761)
16. Wachter RM. The end of the beginning: Patient safety five years after "To Err Is Human. " Quality of Care. 2004 November 30.
17. Wachter RM. Patient safety at ten: Unmistakable progress, troubling gaps. Health Aff (Millwood). 2010;29(1):165-173.
18. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.
19. Altman DE, Clancy C, Blendon RJ. Improving patient safety - Five years after the IOM report. N Engl J Med. 2004 Nov. 11;351(20):2041-2043. (Pubitemid 39482495)
20. The Joint Commission. Hospital:2012 National Patient Safety Goals. Dec. 27, 2011. Accessed May 22, 2012. http://www.jointcommission.org/standards- information/npsgs.aspx.
21. Kennerly D, et al. Journey to no preventable risk: The Baylor Health Care System patient safety experience. Am J Med Qual. 2011;26(1):43-52.
22. Wakefield DS, Ward MM, Wakefield BJ. A 10-Rights framework for patient care quality and safety. Am J Med Qual. 2007;22(2):103-111.
23. Pronovost P, et al. Medication reconciliation: A practical to reduce the risk of medication errors. J Crit Care. 2003;18(4);201-205. (Pubitemid 38036900)
24. Allegranzi B, et al. The First Global Patient Safety Challenge "Clean Care Is Safer Care": From launch to current progress and achievements. J Hosp Infect. 2007;65 Suppl 2:115-123.
25. Blake SC, et al. Facilitators and barriers to 10 National Quality Forum safe practices. Am J Med Qual. 2006;21(5):323-334. (Pubitemid 44342869)
26. Pittet D, et al. Hand hygiene among physicians: Performance, beliefs, and perceptions. Ann Intern Med. 2004 Jul. 6;141(1):1-8.
27. Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol. 2000;21(6):381-386.
28. Lankford MG, et al. Influence of role models and hospital design on hand hygiene of healthcare workers. Emerg Infect Dis. 2003;9(2):217-223. (Pubitemid 36231793)
29. Baker DP, Day R, Salas E. Teamwork as an essential component of highreliability organizations. Health Serv Res. 2006;41(4 Pt 2):1576-1598. (Pubitemid 44114583)
30. Accreditation Council for Graduate Medical Education. Accreditation Council for Graduate Medical Education and Institute for Healthcare Improvement 90-Day Project: Involving Residents in Quality Improvement: Contrasting "Top-Down" and "Bottom-Up" Approaches. Philibert I. Aug. 2008. Accessed May 30, 2012. http://www.acgme.org/acWebsite/ci/ 90DayProjectReportDFA-PA-09-15-08.pdf.
31. Nash DB, Goldfarb NI. Point with pride, view with alarm, end with hope. Acad Med. 2009;84(12):1641-1642.
32. Ramsey PG, Miller ED. A single mission for academic medicine: Improving health. JAMA. 2009 Apr. 8;301(14):1475-1476.
33. Batalden P, Davidoff F. Teaching quality improvement: The devil is in the details. JAMA. 2007 Sep. 5;298(9):1059-1061. (Pubitemid 47360820)
34. Shojania KG, Levinson W. Clinicians in quality improvement: A new career pathway in academic medicine. JAMA. 2009 Feb. 18;301(7):766-768.
35. Patel K, Nash DB. The scholarship of quality. Health Policy Newsletter. 2008;21(2):1-2.
36. Jefferson School of Population Health. Master of Science in Healthcare Quality and Safety (MS-HQS): Online Program. Accessed May 30, 2012. http://www.jefferson. edu/population-health/academic-programs/quality-safety. html
37. Northwestern University School of Continuing Studies. Master of Science in Quality Assurance and Regulatory Science. Accessed May 30, 2012. http://www.scs.northwestern. edu/grad/mqars/.
38. Tess AV, et al. Combining clinical microsystems and an experiential quality improvement curriculum to improve residency education in internal medicine. Acad Med. 2009;84(3):326-334.
39. Fleischut PM, et al. Ten years after the IOM report: Engaging residents in quality and patient safety by creating a House Staff Quality Council. Am J Med Qual. 2011:26(2):89-94.
40. Fleischut PM, et al. Perspective: Call to action: It is time for academic institutions to appoint a resident quality and patient safety officer. Acad Med. 2011;86(7):826-828.
41. Fleischut PM, et al. An anesthesiology department leads culture change at a hospital system level to improve quality and patient safety. Anesthesiol Clin. 2011;29(1):153-167.
42. Evans AS, et al. The role of housestaff in implementing medication reconciliation on admission at an academic medical center. Am J Med Qual. 2011;26(1):39-42.
43. Kerr G, et al. Anesthesiology department creates innovative council to promote patient safety at its hospital. ASA Newsletter. 2009;73(9):32-33.
44. Association of American Medical Colleges. House Staff Involvement Is Key to Quality Efforts. Wing of Zock blog entry by Fleischut P. Jan 12, 2012. Acessed May 30, 2012. http://www.wingofzock.org/2012/01/12/house-staff- involvement-is-key-to-quality-efforts/.
45. Fernandes O, Shojania KG. Medication reconciliation in the hospital: What, why, where, when, who and how? Healthc Q. 2012; (15): 42-49.
46. The Joint Commission. 2012 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oak Brook, IL: Joint Commission Re - sources, 2011.
47. Frey K, et al. The "Collaborative Care" curriculum: An educational model addressing key ACGME core competencies in primary care residency training. Med Educ. 2003;37(9):786-789. (Pubitemid 37083000)
48. Singh R, et al. A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies. Med Educ. 2005;39(12):1195-1204. (Pubitemid 41752334)
49. Patow CA, et al. Residents' engagement in quality improvement: A systematic review of the literature. Acad Med. 2009;84(12):1757-1764.