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CONTEXT: Information is needed on the performance of hospitals' adverse-event reporting systems and the effects of national patient-safety initiatives, including the Patient Safety and Quality Improvement Act (PSQIA) of 2005. Results are presented of a 2009 survey of a sample of non-federal US hospitals and changes between 2005 and 2009 are examined. METHODS: The Adverse Event Reporting System survey was fielded in 2005 and 2009 using a mixed-mode design with stratified random samples of non-federal US hospitals; risk managers were respondents. Response rates were 81% in 2005 and 79% in 2009. RESULTS: Virtually all hospitals reported they had centralised adverse-event-reporting systems. However, scores on four performance indexes suggested that hospitals have not effectively implemented key components of reporting systems. Average index scores improved somewhat between 2005 and 2009 for supportive environment (0.7 increase; p<0.05) and types of staff reporting (0.08 increase; p<0.001). Average scores did not change for timely distribution of event reports or discussion with key departments and committees. Some within-hospital inconsistencies in responses between 2005 and 2009 were found. These self-reported responses may be optimistic assessments of hospital performance. CONCLUSIONS: The 2009 survey confirmed improvement needs identified by the 2005 survey for hospitals' event reporting processes, while finding signs of progress. Optimising the use of surveys to assess the effects of national patient-safety initiatives such as PSQIA will require decreasing within-hospital variations in reporting rates. [ABSTRACT FROM AUTHOR]

Despite the fact that the Agency for Healthcare Research and Quality patient safety indicators (PSIs) are useful for evaluating adverse events in hospitals, the 20 PSIs make it difficult to summarize broad trends across indicators. This study aims to identify 1 or more measures among the PSIs best suited for a quick index of general patient safety status. The 1997-2002 Nationwide Inpatient Sample was used to calculate the hospital-level risk-adjusted rates of the PSIs. Both pairwise correlation analyses and multivariate analyses showed that PSI #7 (Selected infections due to medical care) is significantly correlated with most of the other PSIs. The results are robust even when (1) the pairwise and multivariate analyses are rerun on a reduced data set that excludes admissions with multiple patient safety events, and (2) Bonferroni-adjusted P values are calculated. The study concludes that PSI #7 appears to be a candidate for a quick index of patient safety status. [ABSTRACT FROM AUTHOR]

Research on prosocial behaviors in primates often relies on the two-choice paradigm. Motoric lateralization is a surprisingly big problem in this field of research research, as it may influence which lever will ultimately be chosen by the actor. The results of lateralization studies on primates do not form a clear picture of that phenomenon, which makes it difficult to address the problem during research. The authors discuss possible ways of managing this confounding variable.

Objectives: Ventilator-associated events are associated with increased mortality, prolonged mechanical ventilation, and longer ICU stay. Given strong national interest in improving ventilated patient care, the National Institute of Health and Agency for Healthcare Research and Quality funded a two-state collaborative to reduce ventilator-associated events. We describe the collaborative's impact on ventilator-associated event rates in 56 ICUs., Design: Longitudinal quasi-experimental study., Setting: Fifty-six ICUs at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015., Interventions: We organized a multifaceted intervention to improve adherence with evidence-based practices, unit teamwork, and safety culture. Evidence-based interventions promoted by the collaborative included head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials. Each unit established a multidisciplinary quality improvement team. We coached teams to establish comprehensive unit-based safety programs through monthly teleconferences. Data were collected on rounds using a common tool and entered into a Web-based portal., Measurements and Results: ICUs reported 69,417 ventilated patient-days of intervention compliance observations and 1,022 unit-months of ventilator-associated event data. Compliance with all evidence-based interventions improved over the course of the collaborative. The quarterly mean ventilator-associated event rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation (p = 0.007). During the same time period, infection-related ventilator-associated complication and possible and probable ventilator-associated pneumonia rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1,000 ventilator-days (p = 0.018, p = 0.012), respectively., Conclusions: A multifaceted intervention was associated with improved compliance with evidence-based interventions and decreases in ventilator-associated event, infection-related ventilator-associated complication, and probable ventilator-associated pneumonia. Our study is the largest to date affirming that best practices can prevent ventilator-associated events.

Objective: Little smoking research in the past 20years includes persons 50 and older; herein we describe patterns of clinician cessation advice to US seniors, including variation by Medicare beneficiary characteristics., Method: In 2012-4, we analyzed 2010 Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data from Medicare beneficiaries over age 64 (n=346,674). We estimated smoking rates and the proportion of smokers whose clinicians encouraged cessation., Results: 12% of male and 8% of female respondents aged 65 and older smoke. The rate decreases with age (14% of 65-69, 3% of 85+) and education (12-15% with no high school degree, 5-6% with BA+). Rates are highest among American Indian/Alaskan Native (16%), multiracial (14%), and African-American (13%) seniors, and in the Southeast (14%). Only 51% of smokers say they receive cessation advice "always" or "usually" at doctor visits, with advice more often given to the young, those in low-smoking regions, Asians, and women. For all results cited p<0.05., Conclusions: Smoking cessation advice to seniors is variable. Providers may focus on groups or areas in which smoking is less common or when they are most comfortable giving advice. More consistent interventions are needed, including cessation advice from clinicians., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To develop and field test an implementation assessment tool for assessing progress of hospital units in implementing improvements for the prevention of ventilator-associated pneumonia (VAP) in a two-state collaborative, including data on actions implemented by participating teams and contextual factors that may influence their efforts. Using the data collected, learn how implementation actions can be improved and analyze effects of implementation progress on outcome measures., Design: We developed the tool as an interview protocol that included quantitative and qualitative items addressing actions on the Comprehensive Unit-based Safety Program (CUSP) and clinical interventions for use in guiding data collection via telephone interviews., Setting: We conducted interviews with leaders of improvement teams from units participating in the two-state VAP prevention initiative., Methods: We collected data from 43 hospital units as they implemented actions for the VAP initiative and performed descriptive analyzes of the data with comparisons across the 2 states., Results: Early in the VAP prevention initiative, most units had made only moderate progress overall in using many of the CUSP actions known to support their improvement processes. For contextual factors, a relatively small number of barriers were found to have important negative effects on implementation progress (in particular, barriers related to workload and time issues). We modified coaching provided to the unit teams to reinforce training in weak spots that the interviews identified., Conclusion: These assessments provided important new knowledge regarding the implementation science of quality improvement projects, including feedback during implementation, and give a better understanding of which factors most affect implementation.

Background: Effective doctor communication is critical to positive doctor-patient relationships and predicts better health outcomes. Doctor communication is the strongest predictor of patient ratings of doctors, but the most important aspects of communication may vary by specialty., Objective: To determine the importance of five aspects of doctor communication to overall physician ratings by specialty., Design: For each of 28 specialties, we calculated partial correlations of five communication items with a 0-10 overall physician rating, controlling for patient demographics., Patients: Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CG-CAHPS®) 12-month Survey data collected 2005-2009 from 58,251 adults at a 534-physician medical group., Main Measures: CG-CAHPS includes a 0 ("Worst physician possible") to 10 ("Best physician possible") overall physician rating. Five doctor communication items assess how often the physician: explains things; listens carefully; gives easy-to-understand instructions; shows respect; and spends enough time., Key Results: Physician showing respect was the most important aspect of communication for 23/28 specialties, with a mean partial correlation (0.27, ranging from 0.07 to 0.44 across specialties) that accounted for more than four times as much variance in the overall physician rating as any other communication item. Three of five communication items varied significantly across specialties in their associations with the overall rating (p < 0.05)., Conclusions: All patients valued respectful treatment; the importance of other aspects of communication varied significantly by specialty. Quality improvement efforts by all specialties should emphasize physicians showing respect to patients, and each specialty should also target other aspects of communication that matter most to their patients. The results have implications for improving provider quality improvement and incentive programs and the reporting of CAHPS data to patients. Specialists make important contributions to coordinated patient care, and thus customized approaches to measurement, reporting, and quality improvement efforts are important.

This study evaluated how the Perfecting Patient Care (PPC) University, a quality improvement (QI) training program for health care leaders and clinicians, affected the ability of organizations to improve the health care they provide. This training program teaches improvement methods based on Lean concepts and principles of the Toyota Production System and is offered in several formats. A retrospective evaluation was performed that gathered data on training, other process factors, and outcomes after staff completed the PPC training. A majority of respondents reported gaining QI competencies and cultural achievements from the training. Organizations had high average scores for the success measures of "outcomes improved" and "sustainable monitoring" but lower scores for diffusion of QI efforts. Total training dosage was significantly associated with the measures of QI success. This evaluation provides evidence that organizations gained the PPC competencies and cultural achievements and that training dosage is a driver of QI success.

The Center for Medicare and Medicaid Innovation within the Centers for Medicare & Medicaid Services (CMS) has funded 108 Health Care Innovation Awards, funded through the Affordable Care Act, for applicants who proposed compelling new models of service delivery or payment improvements that promise to deliver better health, better health care, and lower costs through improved quality of care for Medicare, Medicaid, and Children's Health Insurance Program enrollees. CMS is also interested in learning how new models would affect subpopulations of beneficiaries (e.g., those eligible for Medicare and Medicaid and complex patients) who have unique characteristics or health care needs that could be related to poor outcomes. In addition, the initiative seeks to identify new models of workforce development and deployment, as well as models that can be rapidly deployed and have the promise of sustainability. This article describes a strategy for evaluating the results. The goal for the evaluation design process is to create standardized approaches for answering key questions that can be customized to similar groups of awardees and that allow for rapid and comparable assessment across awardees. The evaluation plan envisions that data collection and analysis will be carried out on three levels: at the level of the individual awardee, at the level of the awardee grouping, and as a summary evaluation that includes all awardees. Key dimensions for the evaluation framework include implementation effectiveness, program effectiveness, workforce issues, impact on priority populations, and context. The ultimate goal is to identify strategies that can be employed widely to lower cost while improving care.

Objectives: To compare reports about care experiences of individuals who died within 1 year of survey with reports of those who did not., Design: Medicare Advantage (MA) Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys asked about care experiences. Survey completion dates were linked to Social Security Administration death records to identify enrollees dying within 1 year of survey completion. Propensity-score weighting combined with regression-based case-mix adjustment was used to compare these individuals' experiences with experiences of those who were alive 1 year later., Setting: Nationally representative sample of MA enrollees., Participants: Four hundred two thousand five hundred ninety-three MA enrollees responding to 2008 and 2009 CAHPS Surveys., Measurements: Outcomes were five care ratings (plan, prescription drug coverage, doctor, specialists, care) and five composite measures of care (getting needed care, getting care quickly, doctor communication, getting drugs, getting drug information). Analyses were adjusted for age, sex, race and ethnicity, education, Medicaid status, geographic region, and several health status measures., Results: Twelve thousand one hundred two enrollees (3%) died within 1 year of survey completion (near-end-of-life group). Those enrollees reported slightly better experiences than other enrollees with respect to getting care quickly (+2%, P < .001) and gave slightly higher ratings for their plans (+1%, P = .02) and prescription drug coverage (+1%, P < .001). There were no measures of participant experience for which the near-end-of-life group reported worse experiences than other enrollees., Conclusion: Contrary to analyses based on retrospective reports from surviving relatives after an individual's death, MA enrollees' reports about care within 1 year of death were as good as or better than reports of other MA enrollees. Future research might investigate whether results are similar in other Medicare populations., (© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.)

Background: Patients with end-stage renal disease (ESRD) have special health needs; little is known about their care experiences., Study Design: Secondary analysis of 2009-2010 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) data, using representative random samples of Medicare beneficiaries. Description of Medicare beneficiaries with ESRD and investigation of differences in patient experiences by sociodemographic characteristics and coverage type., Setting & Participants: Data were collected from 823,564 Medicare beneficiaries (3,794 with ESRD) as part of the Medicare CAHPS survey, administered by mail with telephone follow-up of nonrespondents., Predictor: ESRD status, age, education, self-reported general and mental health status, race/ethnicity, sex, Medicare coverage type, state of residence, and other demographic measures., Outcomes: 6 composite measures of patient experience in 4 care domains (access to care, physician communication, customer service, and access to prescription drugs and drug information) and 4 ratings (overall care, personal physician, specialist physician, and prescription drug plan)., Results: Patients with ESRD reported better care experiences than non-ESRD beneficiaries for 7 of 10 measures (P < 0.05) after adjustment for patient characteristics, geography, and coverage type, although to only a small extent (adjusted mean difference, <3 points [scale, 0-100]). Black patients with ESRD and less educated patients were more likely than other patients with ESRD to report poor experiences., Limitations: Inability to distinguish patient experiences of care for different treatment modalities., Conclusions: On average, beneficiaries with ESRD report patient experiences that are at least as positive as non-ESRD beneficiaries. However, black and less educated patients with ESRD reported worse experiences than other ESRD patients. Stratified reporting of patient experience by race/ethnicity or education in patients with ESRD can be used to monitor this disparity. Physician choice and confidence and trust in physicians may be particularly important for patients with ESRD., (Copyright © 2013 National Kidney Foundation, Inc. All rights reserved.)

The objective was to examine co-occurrence of iatrogenic events in US hospitals. Using Agency for Healthcare Research and Quality patient safety indicators (PSIs), the authors defined multiple patient safety events (MPSEs) as the occurrence of multiple PSIs during a single hospitalization. The National Inpatient Sample was analyzed to estimate the national prevalence of MPSEs, risk factors for MPSEs, and the average length of stay and average hospital charges associated with MPSEs. MPSEs occurred in approximately 1 in every 1000 hospitalizations, affecting more than 30 000 patients in 2004. Significant risk factors for MPSEs include age, black race, Medicare coverage, and treatment at urban teaching hospitals. Compared with all admissions, the average length of stay for MPSE admissions was 4 times longer, and the average charge for MPSE admissions was 8 times greater. Despite the low prevalence, MPSEs affect large numbers of hospital patients in America. MPSEs have distinct characteristics and are far more resource intensive than hospital admissions generally.

Objectives: To compare health care experiences of Medicare beneficiaries with and without symptoms of depression and investigate the role of patient confidence in shaping these experiences., Data Sources: Data came from the 2009 CAHPS Medicare 4.0 Fee-for-Service (FFS) Survey, which was fielded to a national probability sample of 298,492 FFS Medicare beneficiaries., Study Design: Linear regression was used to model associations of depression with four global ratings and three composite measures of health care and to test whether beneficiaries' confidence in their ability to recognize the need for care mediates these associations., Principal Findings: Beneficiaries with depressive symptoms reported worse experiences with care across the full range of patient experience covered by the CAHPS survey. Depressive symptoms were associated with decreased patient confidence and decreased confidence was in turn associated with poorer reports of care., Conclusions: Our study highlights depressive symptoms as a risk factor for poorer experiences of health care and highlights depressed patients' confidence in recognizing their need for care and for designing programs to improve the health care of this population., (© Health Research and Educational Trust.)

Objective: To understand reasons why California has lower Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores than the rest of the country, including differing patterns of CAHPS scores between Medicare Advantage (MA) and fee-for-service, effects of additional demographic characteristics of beneficiaries, and variation across MA plans within California., Study Design/data Collection: Using 2008 CAHPS survey data for fee-for-service Medicare beneficiaries and MA members, we compared mean case mix adjusted Medicare CAHPS scores for California and the remainder of the nation., Principal Findings: California fee-for-service Medicare had lower scores than non-California fee-for-service on 11 of 14 CAHPS measures; California MA had lower scores only for physician services measures and higher scores for other measures. Adding race/ethnicity and urbanity to risk adjustment improved California standing for all measures in both MA and fee-for-service. Within the MA plans, one large plan accounted for the positive performance in California MA; other California plans performed below national averages., Conclusions: This study shows that the mix of fee-for-service and MA enrollees, demographic characteristics of populations, and plan-specific factors can all play a role in observed regional variations. Anticipating value-based payments, further study of successful MA plans could generate lessons for enhancing patient experience for the Medicare population., (© Health Research and Educational Trust.)

Despite a decade's worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.

Background: The American Medical Association led a collaborative initiative to explore opportunities for improving the quality of outpatient chronic care through the use of nationally endorsed clinical performance measures and tools. The measures and tools focused on adult diabetes, major depressive disorder, chronic stable coronary artery disease, heart failure, hypertension, and asthma., Methods: The RAND Corporation conducted an independent, formative assessment of the initiative's four pilot activities using the Context-Input-Process-Product evaluation model., Results: Pilots 1 and 2 demonstrated the feasibility and value of implementing performance measures and tools in practices with electronic health information systems, while highlighting the difficulty of using them in practices with paper-based systems and in community-based models, where multiple stakeholders are expected to share patient data. Pilot 3 illustrated the usefulness of validating performance measures before their use for internal quality improvement or external reporting. Pilot 4 documented the challenges involved in exporting clinical performance data from a physician practice to external entities for multiple potential uses., Discussion: Improving the quality of chronic care through clinical performance measurement, data aggregation, and reporting will require expanded use of clinical performance measures for both internal quality improvement and pay-for-performance; integrating electronic health records (EHRs) or electronic-based registries into more physician offices; more accurate measurement and documentation of diagnoses and care procedures; EHR products that make it easier to capture certain types of information; and simplified, standardized processes for performance data extraction and exporting.

Objective: Evaluate short-term effects of the Patient Safety Improvement Corps (PSIC), an Agency for Healthcare Research and Quality–sponsored program to train state teams in patient safety skills/tools, to assess its contribution to building a national infrastructure supporting effective patient safety practices., Data Source: Self-reported information gathered from (1) group interviews at the end of each year; (2) individual telephone interviews 1 year later; (3) faxed information forms 2 years later., Study Design: Program evaluation of immediate and short-term process and impact (use of skills/tools, information sharing, changes in practice)., Data Collection: Semistructured interviews; faxed forms., Principal Findings: One year after training, approximately half of Year 1 and 2 state agency representatives reported they had initiated or modified legislation to strengthen safe practices, and modified adverse event oversight procedures. Approximately three-quarters of hospital representatives said training contributed to modifications to adverse event oversight procedures and promotion of patient safety culture. Two years posttraining, approximately three-quarters of Year 1 trainees said they continued to use many skills/tools., Conclusions: The PSIC contributed to building a national infrastructure supporting effective patient safety practices. Expanded training is needed to reach a larger fraction of the population for which this training is important.

Objectives: To document and assess the experiences of 104 Agency for Healthcare Research and Quality (AHRQ)-funded health information technology (health IT) grantees in planning and implementing health IT systems., Data Source: Grant proposals and interviews with the AHRQ health IT grantees., Data Collection Method: Extracted descriptive data from the health IT grant proposals; conducted telephone interviews with principal investigators., Principal Findings: AHRQ funding of the health IT projects provided important support for health IT development work in various health care settings. Successful implementation required commitment from top management, dedicated staff and financial resources, an open process to encourage buy-in and enthusiasm by end users, and sheer persistence. Technologies required tailoring to the specific organization's needs. Grantees felt their projects could be replicated by others, if organizations had ample IT expertise and resources. Evaluating the value of health IT was hampered by the absence of validated instruments and measures, organizational demands that competed with data collection, and lack of evaluation expertise among health IT implementers., Conclusions: Experiences of the health IT grantees provide rich information for use by health care providers, AHRQ, and other policy makers to help strengthen future health IT development efforts, including the need to improve evaluation design and standards to assess impact.

Objective: To prepare Agency for Healthcare Research and Quality (AHRQ) for monitoring the impact of its own patient safety initiative, by exploring available outcomes data, assessing usability of measures, and estimating national trends in patient outcomes., Data Sources: Annual summary data on incidence of Joint Commission Sentinel Events, MEDMARX medication error events, and MDS measures of falls and pressure ulcers in nursing home residents. HCUP National Inpatient Sample (NIS) administrative claims data., Methods: Description and assessment of published summary data on selected safety measures. Analysis of selected Patient Safety Indicators (PSIs) and Utah–Missouri adverse event measures using HCUP NIS claims data (1994–2003)., Principal Findings: Interpretation of safety outcome trends requires close attention to the characteristics of underlying data sources and measures. Encounter-based measures have been affected by changes in definitions and ICD-9 coding, as well as by changes in the structure of administrative datasets like HCUP NIS. Historical trends are mixed for the safety outcome measures reviewed, with some measures showing improvement, others deterioration, and still others remaining fairly stable., Conclusions: Constructing national trends of safety outcomes is difficult because of limitations in available data sources and measures. Tracking growth in the adoption of safe practices could offer an important strategy for complementing existing safety measurement capabilities.

Objective: Describe the evaluation performed of the patient safety initiative operated by the Agency for Healthcare Research and Quality (AHRQ). AHRQ PATIENT SAFETY INITIATIVE When patient safety became a national priority in 2000, Congress charged and funded AHRQ to improve health care safety. Over the next 6 years, AHRQ funded more than 300 research projects and other activities, addressing diverse patient safety issues and practices., The Patient Safety Evaluation: AHRQ contracted with RAND in 2002 to perform a 4-year evaluation of the initiative, which was completed in 2006. This formative evaluation used the CIPP program evaluation model, which emphasizes multiple stakeholders' interests (e.g., patients, providers, funded researchers). We monitored the progress of the patient safety initiative and provided AHRQ annual feedback that assessed each year's activities, identifying issues and offering suggestions for actions by AHRQ. Given the size and complexity of the initiative, the evaluation needed to examine key individual components and synthesize results across them, and it also had to be responsive to changes in the initiative over time. We used a conceptual framework to bring together the disparate pieces to synthesize overall findings. The remaining articles in this issue describe selected results from this evaluation.

Objective: To characterize the activities of projects funded in Agency for Healthcare Research and Quality (AHRQ)'s patient safety portfolio and assess their aggregate potential to contribute to knowledge development., Data Sources: Information abstracted from proposals for projects funded in AHRQ's patient safety portfolio, information on safety practices from the AHRQ Evidence Report on Patient Safety Practices, and products produced by the projects., Study Design: This represented one part of the process evaluation conducted as part of a longitudinal evaluation based on the Context–Input–Process–Product model., Principal Findings: The 234 projects funded through AHRQ's patient safety portfolio examined a wide variety of patient safety issues and extended their work beyond the hospital setting to less studied parts of the health care system. Many of the projects implemented and tested practices for which the patient safety evidence report identified a need for additional evidence. The funded projects also generated a substantial body of new patient safety knowledge through a growing number of journal articles and other products., Conclusions: The projects funded in AHRQ's patient safety portfolio have the potential to make substantial contributions to the knowledge base on patient safety. The full value of this new knowledge remains to be confirmed through the synthesis of results

Objectives: To document the numbers and types of interorganizational partnerships within the national patient safety domain, changes over time in these networks, and their potential for disseminating patient safety knowledge and practices., Data Sources: Self-reported information gathered from representatives of national-level organizations active in promoting patient safety., Study Design: Social network analysis was used to examine the structure and composition of partnership networks and changes between 2004 and 2006., Data Collection: Two rounds of structured telephone interviews (n=35 organizations in 2004 and 55 in 2006)., Principal Findings: Patient safety partnerships expanded between 2004 and 2006. The average number of partnerships per interviewed organization increased 40 percent and activities per reported partnership increased over 50 percent. Partnerships increased in all activity domains, particularly dissemination and tools development. Fragmentation of the overall partnership network decreased and potential for information flow increased. Yet network centralization increased, suggesting vulnerability to partnership failure if key participants disengage., Conclusions: Growth in partnerships signifies growing strength in the capacity to disseminate and implement patient safety advancements in the U.S. health care system. The centrality of AHRQ in these networks of partnerships bodes well for its leadership role in disseminating information, tools, and practices generated by patient safety research projects.

Objective: To present overall findings from the 4-year evaluation of the national patient safety initiative operated by the Agency for Healthcare Research and Quality (AHRQ)., Data Sources: Interviews with AHRQ staff, grantees, and other patient safety stakeholders; published materials; and internal AHRQ documents., Study Design: The evaluation was structured to address a system framework of five components involved in improving safety. The initiative's contributions to improving each system component were assessed qualitatively, comparing results from three separate analyses—AHRQ's achievement of its patient safety goals, our own assessment of the initiative's activities, and independent stakeholder ratings of AHRQ's contributions., Findings and Conclusions: AHRQ has faced a daunting challenge for improving patient safety, given the complex problems of the U.S. health care system and the limited resources AHRQ has had to address them. The patient safety initiative achieved strongest progress for its contributions to knowledge of patient safety epidemiology and effective practices, where AHRQ has considerable experience, and to strengthening infrastructure to support adoption of safe practices. Progress was slower in establishing a national monitoring capability and dissemination of safe practices for adoption. AHRQ needs to expand efforts to apply new knowledge for stimulating use of safe practices in the field.

Objectives: To synthesize lessons learned from the experiences of Agency for Healthcare Research and Quality-funded patient safety projects in implementing safe practices., Data Sources: Self-reported data from individual and group interviews with Original, Challenge, and Partnerships in Implementing Patient Safety (PIPS) grantees, from 2003 to 2006., Study Design: Interviews with three grantee groups (n=60 total) implementing safe practice projects, with comparisons on factors influencing project implementation and sustainability., Data Collection: Semi-structured protocols contained open-ended questions on lessons learned and more structured questions on factors associated with project implementation and sustainability., Principal Findings: The grantees shared common experiences, frequently identifying lessons learned regarding structural components needing to be in place before implementation, components of the implementation process, components of interventions' results needed for sustainability, changes in timelines or activities, unanticipated issues, and staff acceptance/adoption. Also, fewer Original grants had many of the factors related project to implementation/sustainability than the PIPS or Challenge grantees had., Conclusions: Although much of what was reported seemed like common sense, surprisingly few projects actually planned for or expected many of the barriers or facilitators they experienced during their project implementation. Others implementing practice improvements likely will share the experiences and issues identified by these implementation projects and can learn from their lessons.

Context: Little is known about hospitals' adverse-event-reporting systems, or how they use reported data to improve practices. This information is needed to assess effects of national patient-safety initiatives, including implementation of the Patient Safety and Quality Improvement Act of 2005 (PSQIA). This survey generated baseline information on the characteristics of hospital adverse-event-reporting systems and processes, for use in assessing progress in improvements to reporting., Methods: The Adverse Event Reporting Survey, developed by Westat, was administered in September 2005 through January 2006, using a mixed-mode (mail/telephone) survey with a stratified random sample of 2050 non-federal US hospitals. Risk managers were the respondents. An 81% response rate was obtained, for a sample of 1652 completed surveys., Results: Virtually all hospitals reported they have centralised adverse-event-reporting systems, although characteristics varied. Scores on four performance indexes suggest that only 32% of hospitals have established environments that support reporting, only 13% have broad staff involvement in reporting adverse events, and 20-21% fully distribute and consider summary reports on identified events. Because survey responses are self-reported by risk managers, these may be optimistic assessments of hospital performance., Conclusions: Survey findings document the current status of hospital adverse-event-reporting systems and point to needed improvements in reporting processes. PSQIA liability protections for hospitals reporting data to patient-safety organisations should also help stimulate improvements in hospitals' internal reporting processes. Other mechanisms that encourage hospitals to strengthen their reporting systems, for example, strong patient-safety programmes, also would be useful.

Objective: Illustrate an accessible method of bridging data from earlier surveys to the CAHPS Hospital Survey to support hospitals' internal quality improvement efforts., Data Sources/study Setting: Survey of patients with more than 300,000 annual hospitalizations in a large urban hospital. STUDY DESIGN AND DATA: Six pairs of parallel items from the CAHPS and Picker Hospital Surveys were administered to the same 734 patients. We assessed item comparability and applied bridging adjustments to convert old items to predicted scores on the new CAHPS items., Principle Findings: Differences in wording, response options, and cut points for "problem scores" yielded large differences in problem score rates between the Picker and CAHPS Hospital Surveys, requiring bridging formulas. Tetrachoric correlations for 5 of 6 pairs indicated high correspondence (r = 0.71-0.97, P < 0.001) in the underlying constructs assessed by the 2 surveys, validating the use of bridging. Bridged scores contain less information per observation than directly measured new scores, but with sufficient sample sizes they can be used to detect trends across the transition., Conclusions: Hospitals can use the methodology described here to trend their scores from a previous survey to the CAHPS Hospital Survey with sufficient precision to support ongoing quality improvement efforts. Hospitals should administer an instrument containing pairs of old and new items to enough patients to yield at least 625 completes to measure bridging parameters precisely. Where correspondence is high, old items can and should be replaced by CAHPS items. Important old items with weaker associations with new items may be retained.

This study examines trends in Medicare spending for basic payments and bonus payments for physician services provided to beneficiaries residing in nonmetropolitan counties. For our analysis, we used Medicare Part B physician/supplier claims data for 1992, 1994, 1996, and 1998. Payments under the congressionally mandated bonus payment program acccounted for less than 1 percent of expenditures for physician services in nonmetropolitan, underserved counties. Physician payments increased from 1992 to 1998, while bonus payments increased through 1996 but then declined by 13 percent by 1998. The share of bonus payments to primary care physicians declined throughout the decade, but the share for primary care services increased.

This evaluation tested if Consumer Assessment of Health Plans Study (CAHPS) information on plan performance affected health plan choices by new beneficiaries in Iowa Medicaid. New cases entering Medicaid in selected counties during February through May 2000 were assigned randomly to experimental or control groups. The control group received standard Medicaid enrollment materials, and the experimental group received these materials plus a CAHPS report. We found that CAHPS information did not affect health plan choices by Iowa Medicaid beneficiaries, similar to previously reported findings for New Jersey Medicaid. However, it did affect plan choice in an earlier laboratory experiment. The value of this information may be limited to a subset of receptive consumers who actively study information received, even then only when (1) ratings of available plans differ greatly, (2) ratings differ from prior beliefs about plan quality, and (3) reports are easy to understand.

Objective: To assess the effects of CAHPS health plan performance information on plan choices and decision processes by New Jersey Medicaid beneficiaries., Data Sources/study Setting: The study sample was a statewide sample of all new Medicaid cases that chose Medicaid health plans during April 1998. The study used state data on health maintenance organization (HMO) enrollments and survey data for a subset of these cases., Study Design: An experimental design was used, with new Medicaid cases randomly assigned to experimental or control groups. The experimental group received a CAHPS report along with the standard enrollment materials, and the control group did not., Data Collection: The HMO enrollment data were obtained from the state in June 1998, and evaluation survey data were collected from July to October 1998., Principal Findings: No effects of CAHPS information on HMO choices were found for the total sample. Further examination revealed that only about half the Medicaid cases said they received and read the plan report and there was an HMO with dominant Medicaid market share but low CAHPS performance scores. The subset of cases who read the report and did not choose this dominant HMO chose HMOs with higher CAHPS scores, on average, than did those in an equivalent control group., Conclusions: Health plan performance information can influence plan choices by Medicaid beneficiaries, but will do so only if they actually read it. These findings suggest a need for enhancing dissemination of the information as well as further education to encourage informed choices.

This article evaluates the usefulness of the Consumer Assessment of Health Plan Study (CAHPS) surveys and reports in a demonstration and evaluation with three health care purchasers in Iowa. The CAHPS survey detected significant differences between health plans in several domains of health care. Both paper- and Web-based consumer reports were developed and distributed to consumers and stakeholders. There was some agreement on the value of these reports, but areas for improvement were noted.

Objective: To learn whether consumer reports of health plan quality can affect health plan selection., Data Sources: A sample of 311 privately insured adults from Los Angeles County., Study Design: The design was a fractional factorial experiment. Consumers reviewed materials on four hypothetical health plans and selected one. The health plans varied as to cost, coverage, type of plan, ability to keep one's doctor, and quality, as measured by the Consumer Assessment of Health Plans Study (CAHPS) survey., Data Analysis: We used multinomial logistic regression to model each consumer's choice among health plans., Principal Findings: In the absence of CAHPS information, 86 percent of consumers preferred plans that covered more services, even though they cost more. When CAHPS information was provided, consumers shifted to less expensive plans covering fewer services if CAHPS ratings identified those plans as higher quality (59 percent of consumers preferred plans covering more services). Consumer choices were unaffected when CAHPS ratings identified the more expensive plans covering more services as higher quality (89 percent of consumers preferred plans covering more services)., Conclusions: This study establishes that, under certain realistic conditions, CAHPS ratings could affect consumer selection of health plans and ultimately contain costs. Other studies are needed to learn how to enhance exposure and use of CAHPS information in the real world as well as to identify other conditions in which CAHPS ratings could make a difference.

Objectives: The Consumer Assessment of Health Plans Study (CAHPS) was developed to provide an integrated set of tested, standardized surveys to obtain meaningful information from health plan enrollees and their experiences. Many organizations began to implement CAHPS in 1997. Formal evaluations of the experiences of three demonstration sites with implementing CAHPS (ie, process evaluations) and the impact of CAHPS on consumer's choices (ie, outcome evaluations) were conducted. This article reports on the early findings and feedback from our process evaluations about the sites' experiences with using CAHPS. Results are presented from the first round demonstration sites, including the lessons learned during the demonstrations. Our plans for future demonstrations and evaluations are included., Methods: A similar evaluation design and instruments were used across demonstration sites. The process evaluation to monitor program intervention included on-site interviews, off-site review of documents, and focus groups with consumers., Results: There are 4 early results from the CAHPS demonstrations: (1) the CAHPS survey covers topics of importance to sponsors, is of reasonable length, and can be administered quickly; (2) the report templates are being used effectively, but sponsors vary widely in their preferences for summarizing and presenting CAHPS ratings; (3) standardized or off-the-shelf products are aspects of CAHPS that sponsors value highly, while emphasizing need for further development; and (4) because surveys like CAHPS require multiple within-plan samples to make plan comparisons, they require a substantial investment and may be affordable only for large sponsors., Conclusion: The first round CAHPS demonstrations highlighted the strengths of the integrated surveys and the areas for improving the products and the implementation process.

Objectives: The authors describe the process used to develop and test survey items targeted to Medicaid consumers for the Consumer Assessment of Health Plans Study (CAHPS). In addition, the authors highlight the special challenges in locating and surveying Medicaid recipients and provide recommendations for increasing response rates., Methods: The RAND CAHPS team reviewed the literature and existing questionnaires to identify health care issues and concepts important to Medicaid consumers. Three focus groups and 66 one-on-one cognitive interviews were conducted to test the relevance of our concepts and items and to identify additional concepts important to Medicaid consumers. After the cognitive interviews, the CAHPS Medicaid consumer survey was field tested using a sample of 930 adults and children receiving both Medicaid and Aid to Families with Dependent Children in Los Angeles County and Oklahoma. To determine if one particular mode were preferable for surveying a Medicaid population, our field test sample was divided randomly into a telephone-mode sample, a mixed-mode sample, and a second telephone-mode sample with enhanced locating procedures. Before finalizing the CAHPS 1.0 surveys, the full CAHPS item set was subjected to a formal literacy review., Results: The results of the focus groups and cognitive testing informed iterative versions of the list of concepts addressed by the Medicaid-targeted items. Concepts that were not relevant to Medicaid consumers or that consumers were unable to accurately attribute to a health plan were discarded. New concepts addressing important aspects of health care and the health care experience of Medicaid consumers were identified and added. Item wording and format were revised and refined based on the findings from focus groups, cognitive testing, the field test, and the formal literacy review. In the field test, the mixed-mode method achieved the best results with a 56% completion rate., Conclusions: The testing and formatting efforts described in this article, in combination with a formal literacy review, led to the development of a Medicaid questionnaire that measures the important health care experiences of Medicaid consumers in a format that is "respondent-friendly." Our recommendations for surveying Medicaid recipients can benefit any survey of a Medicaid population.

Objective: To describe the innovative programs of three health maintenance organizations (HMOs) for providing primary care for long-stay nursing home (NH) residents and to compare this care with that of fee-for-service (FFS) residents at the same NHs., Design: Cross-sectional interviews and case-studies, including retrospective chart reviews for 1 year., Setting: The programs were based in 20 community-based nursing homes in three regions (East, West, Far West)., Participants: Administrative and professional staff of HMOs in three regions and 20 NHs; 215 HMO and 187 FFS residents at these homes were studied., Main Outcome Measures: Emergency department (ED) and hospital utilization., Results: All HMO programs utilized nurse practitioner/physician's assistants (NP/PA), but the structural configuration of physicians' (MD) practices differed substantially. At nursing homes within each region, all three HMO programs provided more total (MD plus NP/PA) visits per month than did FFS care (2.0 vs 1.1, 1.3 vs .6, and 1.4 vs .8 visits per month; all P < .05). The HMO that provided the most total visits had a significantly lower percentage of residents transferred to EDs (6% vs 16%, P = .048), fewer ED visits per resident (0.1 vs .4 per year, P = .027), and fewer hospitalizations per resident (0.1 vs .5 per year, P = .038) than FFS residents; these differences remained significant in multivariate analyses. However, the other two programs did not achieve the same benefits on healthcare utilization., Conclusions: HMO programs for NH residents provide more primary care and have the potential to reduce ED and hospital use compared with FFS care. However, not all programs have been associated with decreased ED and hospital utilization, perhaps because of differences in structure or implementation problems.

Objective: To characterize the use of formal primary care programs by health maintenance organizations (HMOs) for their members who are long-stay residents of nursing homes., Design: Using mail survey techniques, 34 Medicare risk-contracting HMOs with the largest Medicare beneficiary enrollments were asked to complete a written questionnaire. HMOs were asked how they evaluate care in nursing home settings and whether they operate a formal primary care program for members who are long-stay nursing home residents. Those reporting they had programs were asked about the program features, participation in the program, roles performed by clinical practitioners, and clinical caseloads. Surveys were completed by 21 (61.8%) of the HMOs., Participants: HMO management personnel who know the primary care programs the HMOs operate in affiliated nursing homes., Measurements: Descriptive summaries of the HMOs' responses to the survey questions were generated. For HMOs with primary care programs, caseloads of physicians and nurse practitioners were estimated using survey data reported by the HMOs., Results: Eight (38.1%) of the responding HMOs operate formal primary care programs in affiliated nursing homes. HMOs with programs consider more factors than non-program HMOs in evaluating care for nursing home residents. Reasons cited most frequently for not having a program are costs and too few nursing home residents. The most common primary care program features are designated physicians and use of physician extenders., Conclusions: Survey findings point to the potential importance of formal HMO primary care programs for long-term nursing home residents, which may expand with growth in the older population and Medicare-managed care. Program adoption, however, may depend on sufficient resident participation to be financially feasible.

This study developed a modified capitation payment method for the Medicare end stage renal disease (ESRD) program designed to support appropriate treatment choices and protect health plans from undue financial risk. The payment method consists of risk-adjusted monthly capitated payments for individuals on dialysis or with functioning kidney grafts, lump sum event payments for expected incremental costs of kidney transplantations or graft failures, and outlier payments for expensive patients. The methodology explained 25 percent of variation in annual payments per patient. Risk adjustment captured substantial variations across patient groups. Outlier payments reduced health plan risk by up to 15 percent.

Estimation of infant mortality rates for racial and ethnic subgroups has been plagued by uncertainties. Yet policymakers need accurate estimates to allocate resources toward the goal of reducing infant mortality. The authors compared hospital discharge records and death certificate information to birth certificate information from the California Birth Cohort (years 1985-1987) and 1986 Annual Hospital Discharge Abstract. They found discrepancies in infant mortality rates between reporting methods and underreporting of some non-White groups. Infant mortality rates based on death certificates underestimated non-White mortality, particularly for Native Americans and East Asians. Compared to infants who died soon after birth, larger discrepancies in reported race and ethnicity between birth certificates and death certificates for infants who died later also indicated possible errors in hospital reporting methods. These findings extend prior research that documents that standard methods of reporting infant mortality underestimate non-White mortality rates.

The Medicare end-stage renal disease (ESRD) program has offered financial access to needed health care for ESRD patients, and it has given ESRD providers a reliable source of payment for their services. Total Medicare ESRD expenditures have increased since the inception of the program, due mainly to increased enrollment and changing patient mix. As a result, cost control is a dominant theme of payment policy. This article describes the history of Medicare ESRD financing policy and identifies related service delivery issues including treatment technology, service resources, treatment processes, and patient selection. It also discusses several options available to Medicare for managing the growth of ESRD program costs, including capitation payment methods, control of ESRD enrollment, and payment for erythropoietin treatment. Possible future changes in financing ESRD are identified. With a goal to control costs. Medicare probably will use payment methods to change service mix and reduce use by influencing provider incentives and marketplace competition. Health system reform also may affect ESRD benefits and payments, if the ESRD program is folded into a new financing system. ESRD patients and providers face a challenge of uncertainty during this period of change.

In fiscal year (FY) 1989, Medicare changed its rules for paying for extremely long or expensive hospital stays called "outliers." We compared outlier payments in FYs 1989 and 1988, after adjusting for other simultaneous policy changes. We found that the new policy succeeded in targeting more outlier payments to the most expensive cases and to the hospitals suffering larger prospective payment system (PPS) losses and in reducing hospital financial risk. Using time-series analyses, we show that the policy change had no measurable effect on the timing of discharges or on the concentration of expensive cases in urban government-owned hospitals.

The diagnosis-related group weights that determine prices for Medicare hospital stays are recalibrated annually using charge data. Using data from fiscal years 1985 through 1987, the authors show that differences between these charge-based weights and cost-based weights are increasing only slightly. Charge-based weights are available in a more timely manner and, based on temporal changes in the weights, we show that this is an important consideration. Charge-based weights provide higher payments than cost-based weights to hospitals with higher case-mix indexes, but have little effect on hospitals with low cost-to-charge ratios, high capital costs, or high teaching costs.