Examining the validity of AHRQ's Patient Safety Indicators (PSIs): Is variation in PSI composite score related to Hospital organizational factors?

Medical Care Research and Review

Volumn 71, Issue 6, 2014, Pages 599-618

  Shin, Marlena H ^a   Sullivan, Jennifer L ^a,b   Rosen, Amy K ^a,c   Solomon, Jeffrey L ^d   Dunn, Edward J ^e   Shimada, Stephanie L ^b,d,f,g   Hayes, Jennifer ^a,h   Rivard, Peter E ^a,i  

^a VA BOSTON HEALTHCARE SYSTEM   (United States)

^b BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH   (United States)

^c BOSTON UNIVERSITY SCHOOL OF MEDICINE   (United States)

^d VETERANS AFFAIRS MEDICAL CENTER   (United States)

^e LEXINGTON VA MEDICAL CENTER   (United States)

^f VA EHealth Quality Enhancement Research Initiative   (United States)

^g UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL   (United States)

^h VA Office of Academic Affiliations Evaluation and Analytics   (United States)

ⁱ SUFFOLK UNIVERSITY   (United States)

Author keywords

criterion validity; hospital; organizational factors; Patient Safety Indicators; qualitative methods

Indexed keywords

ARTICLE; CLINICAL ASSESSMENT; CLINICAL INDICATOR; COORDINATION; CRITERION RELATED VALIDITY; HEALTH CARE QUALITY; HEALTH STATUS INDICATOR; HOSPITAL MANAGEMENT; HOSPITAL ORGANIZATION; HOSPITAL PERSONNEL; HUMAN; INTEGRATED HEALTH CARE SYSTEM; INTERPERSONAL COMMUNICATION; INTERVIEW; LEADERSHIP; ORGANIZATIONAL STRUCTURE; OUTCOME ASSESSMENT; PATIENT CARE; PATIENT SAFETY; PATIENT SAFETY INDICATOR; TOTAL QUALITY MANAGEMENT; VETERANS HEALTH; CROSS-SECTIONAL STUDY; GOVERNMENT; ORGANIZATION AND MANAGEMENT; PUBLIC HOSPITAL; REPRODUCIBILITY; STANDARDS; STATISTICS AND NUMERICAL DATA; UNITED STATES;

CROSS-SECTIONAL STUDIES; HOSPITALS, VETERANS; HUMANS; INTERVIEWS AS TOPIC; LEADERSHIP; PATIENT SAFETY; PERSONNEL, HOSPITAL; QUALITY INDICATORS, HEALTH CARE; REPRODUCIBILITY OF RESULTS; UNITED STATES; UNITED STATES AGENCY FOR HEALTHCARE RESEARCH AND QUALITY;

EID: 84912574220     PISSN: 10775587     EISSN: 15526801     Source Type: Journal    
DOI: 10.1177/1077558714556894     Document Type: Article

References (49)

1. Agency for Healthcare Research and Quality. (2010). AHRQ Quality Indicators: Patient Safety Indicators. Retrieved from http://www.qualityindicators.ahrq.gov
2. Bagian J. P.. Patient safety: What is really at issue?. Frontiers of Health Services Management. 2005 ; 22 (1). 3-16
3. Bergs J., Hellings J., Cleemput I., Zurel Ö., DeTroyer V., Van Hiel M.,... Vandijck D.. Systematic review and meta-analysis of the effect of the World Health Organization surgical checklist on postoperative complications. British Journal of Surgery. 2014 ; 101: 150-158
4. Borzecki A., Cowan A. J., Cevasco M., Shin M., Shwartz M., Itani K., Rosen A. K.. Is development of postoperative venous thromboembolism related to thromboprophylaxis use? A case-control study in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety. 2012 ; 38: 348-358
5. Carmeli A., Gittell J.. High-quality relationships, psychological safety, and learning from failures in work organizations. Journal of Organizational Behavior. 2009 ; 30: 709-729
6. Centers for Medicare and Medicaid Services. (2014). CMS hospital compare website. Retrieved from www.hospitalcompare.hhs.gov
7. Charns M. P., Young G. J., Daley J., Khuri S., Henderson W. The quality imperative. Kimberly J. R. Minivielle E., ed. London, England: Imperial College Press ; 2000: 49-78.
8. Chen Q., Borzecki A., Cevasco M., Shin M., Shwartz M., Itani K. M., Rosen A. K.. Examining the relationship between processes of care and selected AHRQ patient safety indicators postoperative wound dehiscence and accidental puncture or laceration using the VA electronic medical record. American Journal of Medical Quality. 2013 ; 28: 206-213
9. Curry L. A., Spatz E., Cherlin E., Thompson J. W., Berg D., Ting H.,... Bradley E.. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates?. Annals of Internal Medicine. 2011 ; 154: 384-392
10. Daley J., Forbes M. G., Young G. J., Charns M. P., Gibbs J. O., Hur K.,... Khuri S. F.. Validating risk-adjusted surgical outcomes: Site visit assessment of process and structure. National VA Surgical Risk Study. Journal of the American College of Surgeons. 1997 ; 185: 341-351
11. de Vries E. N., Prins H. A., Crolla R. M., den Outer A. J., van Andel G., van Helden S. H., Boermeester M. A.. Effect of a comprehensive surgical safety system on patient outcomes. New England Journal of Medicine. 2010 ; 363: 1928-1937
12. Donabedian A. The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press ; 1980 :
13. Eisenberg E. M., Murphy A. G., Sutcliffe K., Wears R., Schenkel S., Perry S.,... Vanderhoef M.. Communication in emergency medicine: Implications for patient safety. Communication Monographs. 2005 ; 72: 390-413
14. Frankel A., Gandhi T. K., Bates D. W.. Improving patient safety across a large integrated health care delivery system. International Journal for Quality in Health Care. 2003 ; 15: i31 - i40
15. Ginsburg L. R., Chuang Y. T., Berta W. B., Norton P. G., Ng P., Tregunno D., Richardson J.. The relationship between organizational leadership for safety and learning from patient safety events. Health Services Research. 2010 ; 45: 607-632
16. Hall R. K., Wang V., Jackson G. L., Hammill B. G., Maciejewski M. L., Yano E. M.,... Patel U. D.. Implementation of automated reporting of estimated glomerular filtration rate among Veterans Affairs laboratories: A retrospective study. BMC Medical Informatics and Decision Making. 2012 ; 12: 69
17. Hammermeister K. E., Shroyer A. L., Sethi G. K., Grover F. L.. Why it is important to demonstrate linkages between outcomes of care and processes and structures of care. Medical Care. 1995 ; 33: OS5 - OS16
18. Hartmann C. W., Meterko M., Rosen A. K., Shibei Z., Shokeen P., Singer S., Gaba D. M.. Relationship of hospital organizational culture to patient safety climate in the Veterans Health Administration. Medical Care Research and Review. 2009 ; 66: 320-338
19. Hearld L. R., Alexander J. A., Fraser I., Jiang H. J.. Review: How do hospital organizational structure and processes affect quality of care? A critical review of research methods. Medical Care Research and Review. 2008 ; 65: 259-299
20. Priority areas for national action: Transforming health care quality. K. Adams J. M. Corrigan, ed. Washington, DC: National Academies Press ; 2003:
21. The Joint Commission. (2013). Sentinel event data: Root causes by event type. Retrieved from http://www.jointcommission.org
22. Joynt K. E., Jha A. K.. Thirty-day readmissions: Truth and consequences. New England Journal of Medicine. 2012 ; 366: 1366-1369
23. Keroack M. A., Youngberg B. J., Cerese J. L., Krsek C., Prellwitz L. W., Trevelyan E. W.. Organizational factors associated with high performance in quality and safety in academic medical centers. Academic Medicine. 2007 ; 82: 1178-1186
24. Lawton R., McEachan R. R., Giles S. J., Sirriyeh R., Watt I. S., Wright J.. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: A systematic review. BMJ Quality & Safety. 2012 ; 21: 369-380
25. Longest B., Young G. Healthcare management: Organizational design and behavior. 2000 ). Coordination and communication. In ShortellS.KaluznyA. (Eds.), Healthcare management: Organizational design and behavior (4th ed., pp. 210-243). Clifton Park, NY: Delmar, Cengage Learning. Shortell S. Kaluzny A., ed. Clifton Park, NY: Delmar, Cengage Learning ; 2000: 210-243.
26. Main D. S., Cavender T. A., Nowels C. T., Henderson W. G., Fink A. S., Khuri S. F.. Relationship of processes and structures of care in general surgery to postoperative outcomes: A qualitative analysis. Journal of the American College of Surgeons. 2007 ; 204: 1147-1156
27. Marks C., Loehrer S., McCarthy D.. Hospital readmissions: Measuring for improvement, accountability, and patients. Issue Brief (Commonwealth Fund). 2013 ; 24: 1-8
28. McDonald K. M., Romano P. S., Geppert J., Davies S. M., Duncan B. W., Shojania K. G., Hansen A. Measures of patient safety based on hospital administrative data: Patient safety indicators. Rockville, MD: Agency for Healthcare Research and Quality ; 2002:
29. McFadden K. L., Henagan S. C., Gowen C. R.. The patient safety chain: Transformational leadership's effect on patient safety culture, initiatives, and outcomes. Journal of Operations Management. 2009 ; 27: 390-404
30. Miles M., Huberman A. Qualitative data analysis: An expanded sourcebook. 1994 ). Qualitative data analysis: An expanded sourcebook (2nd ed.). Thousand Oaks, CA: Sage. Thousand Oaks, CA: Sage ; 1994:
31. Mitchell P. H., Shortell S. M.. Adverse outcomes and variations in organization of care delivery. Medical Care. 1997 ; 35: NS19 - NS32
32. Mohr J. J., Abelson H. T., Barach P.. Creating effective leadership for improving patient safety. Quality Management in Health Care. 2002 ; 11 (1). 69-78
33. Mullen J., Kelloway E. K., Teed M.. Inconsistent style of leadership as a predictor of safety behaviour. Work & Stress. 2011 ; 25: 41-54
34. National Quality Forum. (2013). NQF endorsed standards. Retrieved from http://www.qualityforum.org/measures-list.aspx
35. Neily J., Mills P. D., Young-Xu Y., Carney B. T., West P., Berger D. H.,... Bagian J. P.. Association between implementation of a medical team training program and surgical mortality. Journal of the American Medical Association. 2010 ; 304: 1693-1700
36. Pronovost P. J., Lilford R.. A road map for improving the performance of performance measures. Health Affairs (Millwood). 2011 ; 30: 569-573
37. Rivard P. E., Parker V. A., Rosen A. K.. Quality improvement for patient safety: Project-level vs. program-level learning. Health Care Management Review. 2013 ; 38: 40-50
38. Rosen A. K., Itani K. M., Cevasco M., Kaafarani H. M., Hanchate A., Shin M.,... Borzecki A.. Validating the patient safety indicators in the Veterans Health Administration: Do they accurately identify true safety events?. Medical Care. 2012 ; 50: 74-85
39. Rosen A. K., Rivard P., Zhao S., Loveland S., Tsilimingras D., Christiansen C. L.,... Romano P. S.. Evaluating the patient safety indicators: How well do they perform on Veterans Health Administration data?. Medical Care. 2005 ; 43: 873-884
40. Saint S., Kowalski C. P., Banaszack-Holl J., Forman J., Damschroder L., Krein S. L.. The importance of leadership in preventing healthcare-associated infection: Results of a multisite qualitative study. Infection Control and Hospital Epidemiology. 2010 ; 31: 901-907
41. Shekelle P. G., Pronovost P. J., Wachter R. M., Taylor S. L., Dy S., Foy R.,... Walshe K.. Advancing the science of patient safety. Annals of Internal Medicine. 2011 ; 154: 693-696
42. Shojania K. G., Duncan B. W., McDonald K. M., Wachter R. M., Markowitz A. J.. Making health care safer: A critical analysis of patient safety practices. Evidence Report/Technology Assessment (Summary). 2001 ; 43: 1-668
43. Singer S. J., Falwell A., Gaba D. M., Meterko M., Rosen A., Hartmann C. W., Baker L.. Identifying organizational cultures that promote patient safety. Health Care Management Review. 2009 ; 34: 300-311
44. Ummenhofer W., Amsler F., Sutter P. M., Martina B., Martin J., Scheidegger D.. Team performance in the emergency room: Assessment of inter-disciplinary attitudes. Resuscitation. 2001 ; 49: 39-46
45. Utter G. H., Zrelak P. A., Baron R., Tancredi D. J., Sadeghi B., Geppert J. J., Romano P. S.. Detecting postoperative hemorrhage or hematoma from administrative data: The performance of the AHRQ Patient Safety Indicator. Surgery. 2013 ; 154: 1117-1125
46. Young G. J., Charns M. P., Daley J., Forbes M. G., Henderson W., Khuri S. F.. Best practices for managing surgical services: The role of coordination. Health Care Management Review. 1997 ; 22 (4). 72-81
47. Young G. J., Charns M. P., Desai K., Khuri S. F., Forbes M. G., Henderson W., Daley J.. Patterns of coordination and clinical outcomes: A study of surgical services. Health Services Research. 1998 ; 33: 1211-1236
48. Zhan C., Miller M. R.. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. Journal of the American Medical Association. 2003 ; 290: 1868-1874
49. Zrelak P. A., Romano P. S., Tancredi D. J., Geppert J. J., Utter G. H.. Validity of the AHRQ patient safety indicator for postoperative physiologic and metabolic derangement based on a national sample of medical records. Medical Care. 2013 ; 51: 806-811