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Web Sites for Quality-Indicator Related Information

The Premier Safety Institute Fall Prevention Web site module includes:
  • Risk factors and evidence-based interventions and sample prevention programs with policies, procedures and tools.
  • Resources for risk assessment, fall rate calculations, targeted interventions, and patient monitoring guidance.
  • Essential documents on definitions, consensus standards, classifications from national organizations and annotated references.
  • National quality improvement and benchmarking initiatives.
  • Education and training programs, including presentation templates, case studies, fact sheets, and national guidelines.
  • Equipment or products designed to reduce risk of falls and/or back injuries.
http://www.preventiveservices.ahrq.gov Agency for Healthcare Research & Quality:U.S. Preventive Services Task Force (USPSTF)
http://www.qualityindicators.ahrq.gov/ Agency for Healthcare Research & Quality
http://www.medpathways.info American Hospital Association, Health Research & Educational Trust, Institute for Safe Medication Practices: Pathways for Medication Safety
http://nursingworld.org/readroom/nurssens.htm American Nurses Association:
  • National Database of Nursing Quality Indicators (NDNQI)
  • Nursing-Sensitive Quality Indicators for Community-based Non-acute Care Indicators
http://www.guideline.gov National Guideline Clearinghouse: Agency for Healthcare Research and Quality (AHRQ, U.S. Department of Health and Human Services, in partnership with the American Medical Association and the American Association of Health Plans evidence-based clinical practice guidelines:
http://www.qualitymall.org/ This web site is maintained by the Research and Training Center on Community Living with support from the National Association of State Directors of Developmental Disabilities Services, the Human Services Research Institute and the Administration on Developmental Disabilities - U.S. Department of Health and Human Services.
  • State Performance Indicators- 12 products
    State level data used to monitor progress, assess problems, and suggest policy directions.
  • State Quality Assurance- 17 products
    Information about innovative methods for establishing quality assurance programs based on person-centered outcomes.
  • State Quality Improvement- 13 products
    Exemplary State quality improvement programs and processes.
http://www.hcbs.org/quality/toolscms.htm The Resource Network on Home and Community-Based Services is a partnership between the Assistant Secretary for Planning and Evaluation (ASPE)*, CMS - Centers for Medicare & Medicaid Services (formerly HCFA)*, state agencies that purchase and manage HCBS services, and consumers.
  • Analysis of Five State's Licensing/Certification Processes and Requirements
  • Root Cause Analysis: A Summary of Root Cause Analysis and its use in State Developmental Disabilities Agencies
  • The States' Response To The Olmstead Decision: A Work In Progress
http://www.ahrq.gov/clinic/outcomix.htm Agency for Healthcare Research & Quality:
Outcomes Research Findings for Clinicians Community-Acquired Pneumonia: Improving Treatment Decisions for Patients
Pneumonia: New Prediction Model Proves Promising
Schizophrenia: Patterns of Usual Care
Schizophrenia: PORT Treatment Recommendations
Stroke Prevention Recommendations
Sudden Cardiac Death: Treatment to Prevent
Vision Rehabilitation: Care and Benefit Plan Models
http://ps.psychiatryonline.org/cgi/content/full/53/3/281 Psychiatry Online Article Collections
  • Outcome & Process Assessment
  • Quality of Care/Practice Guidelines
Analysis of Five State's Licensing/Certification Processes and Requirements

Description: Human Services Research Institute (HSRI) conducted a study of five states that have made significant changes in their licensing requirements to be more person-centered and outcome-based. The study addressed the following questions:
  1. What outcomes and requirements were commonly incorporated in most states' licensing regulations and outcomes?
  2. What types of services did the states license/certify under these regulations and outcomes?
  3. What survey methodologies did the states use?
  4. What conclusions and recommendations can be drawn from the study?

Root Cause Analysis: A Summary of Root Cause Analysis and its use in State Developmental Disabilities Agencies
Description: Root Cause Analysis (RCA) is an analytic process designed to help identify the underlying factors that have contributed to or have directly caused a major adverse event or systems failure. The results of a RCA are typically utilized to guide and direct changes to processes, the environment, and human behavior in order to prevent or reduce the probability that the adverse event will occur in the future. This is best accomplished by embracing a systematic approach to learning from previous errors and mistakes and making changes to organizational processes not blaming individuals. Root Cause Analysis is the preferred tool for doing such and is now a required risk management procedure by the JCHO.

However, the potential of RCA has been slow to enter the developmental disabilities field, even though many of the very same issues and causes of injury and death are equally present in this service system. To date there are no known regulatory or accreditation requirements for conducting RCA in DD service and support settings, and there is very little evidence of its utilization by service providers or government agencies. Given increasing attention to consumer safety and risk it can be reasonably predicted that in the near future the use of root cause analysis will become a common practice in the DD system.

Root Cause Analysis is a process of discovery that attempts to find out exactly WHAT happened, WHY it happened, and HOW it can be prevented from happening again. Consequently, the goal of RCA is prevention. Perhaps more importantly, RCA places a focus on understanding, not on blame. It begins from the basic premise that errors and failures are the result of flaws in the system, not simply the action or inaction of people. As noted by Morey , the systems of which humans are a part call forth errors from humans, not the other way around. Thus, unlike the traditional process of investigation, RCA does not focus on finding out who made the mistake, but rather why the mistake was made. The emphasis is on identifying the environmental and system factors that directed or allowed a person or persons to make the mistake in the first place.

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