Patient Safety: Safety Reporting Framework 

Final Report: National Voluntary Consensus Standards for Public Reporting of Patient Safety Event Information 

The Opportunity

Public reports on healthcare quality are sponsored by many types of organizations and entities. Such reports are relatively new on the landscape; thus while they provide valuable information, when taken together they lack the common approach and standardization that could facilitate measurement, evaluation, trending and learning at a national level. To date, NQF has endorsed frameworks that address performance evaluation, quality measurement and reporting, and guidelines for consumer-focused public reporting. Each of these reports provides valuable guidance, though none have been specifically focused on healthcare-acquired conditions (HACs), which include serious reportable events.

About the Project

As part of a larger project related to HACs and patient safety measurement, NQF conducted a consensus development project to endorse a public reporting framework for HACs that will include, in addition to public reporting, recommendations for measurement and evaluation. To do so, it drew upon the literature, including related NQF-endorsed® frameworks; existing initiatives, including those at state and national levels; and the expertise of a Patient Safety Reporting Committee to develop the framework.

The project started on September 2, 2009.

Objectives 

NQF endorsed a framework for measurement, evaluation and public reporting of adverse patient safety events that includes, but is not limited to:

• Clarification of definitions, terms and strategies for measurement, evaluation, and reporting;
• Review of approaches for risk assessment methodologies regarding low-volume/high impact conditions;
• Strategies for reporting high volume “near misses”; and
• Review of the effect of these strategies on the measurement of patient safety.

Process 

NQF issued a call for frameworks to seek guidance that would inform the development of a framework which would be proffered for NQF endorsement as a national voluntary consensus standard. Agreement was developed through NQF’s Consensus Development Process (CDP, Version 1.8). This project involved the active participation of representatives from across the spectrum of healthcare stakeholders and was guided by a Steering Committee.

Project Funding 

This project was funded under NQF's contract with the Department of Health and Human Services, Consensus-based Entities Regarding Healthcare Performance Measurement.  

Contact Information 

For information, please e-mail performancemeasures@qualityforum.org.