National Voluntary Consensus Standards for Serious Reportable Events in Healthcare
Access the Final Report: Serious Reportable Events In Healthcare—2011 Update
The Opportunity
As a portion of its contract with the Department of Health and Human Services (Contract #HHSM-500-2009-00010C), the National Quality Forum (NQF) is seeking nominations for members of three Technical Advisory Panels (TAPs). These panels will provide expertise and guidance to the Steering Committee for Serious Reportable Events (SREs) in Healthcare. This committee is updating the existing list of NQF SREs and developing an expanded listing of SREs which will be relevant for environments of patient care beyond inpatient hospital settings.
About The Project
In 2002, NQF published an initial report, Serious Reportable Events in Healthcare, which identified 27 adverse events occurring in hospitals that are serious, largely preventable and of concern to both the public and healthcare providers. The objective of the report and project was to establish consensus among consumers, providers, purchasers, researchers, and other healthcare stakeholders about those preventable adverse events that should never occur and to define them in a way that, should they occur, it would be clear what had to be reported. This report was updated in 2006, with one additional event being added. In addition, the 2006 update summarized the progress made by implementing the list and provided guidance to those engaged in implementing such reporting systems. This program is now due for review and maintenance with possible updates and additions to the listing of SREs that will be published in early 2011.
The Department of Health and Human Services (HHS) has recently recognized the importance of identifying SREs that are not specific Hospital Acquired Conditions relating to payment or reimbursement practices. There is also recognition that the SREs should be expanded into other environments of care beyond hospital settings, and that they should be relevant and applicable for these non-hospital settings. As such, the SREs will delineate the conditions or complications that are acquired by patients throughout the processes of care for a given illness, which may be managed in several different healthcare environments. The following environments of healthcare will be prioritized for the 2009 update and expansion of the SREs:
- Ambulatory & Office-Based Surgery Centers
- Long-Term Care Settings (including Skilled Nursing Facilities)
- Ambulatory Non-Hospital Practice Settings (Physician Offices)
Objectives
Development and maintenance of the respective listings will include:
- Expanding the listing of SREs to be relevant and applicable in hospital settings as well as the varied non-hospital environments of patient care.
- Bridging overlaps and complementarities of the listings with the NQF-endorsed Safe Practices and other national healthcare priorities.
- Recommendations related to enhancing implementation of the listings at the facility, state, and national level.
- Recommendations related to the need for additional specifications for the existing SREs.
- Recommendations of potentially new SREs for endorsement.
Process
This process involves the active participation of representatives from across the spectrum of healthcare stakeholders. The project will be guided by the Steering Committee for Healthcare Acquired Conditions and Serious Reportable Events, which will evaluate the practices and make recommendations to refresh the currently endorsed set. Four technical advisory panels will be formed with expertise in the occurrence of unforeseen conditions and complications in the various environments of healthcare. These panels will ensure that NQF and the Steering Committee receive relevant industry and public input and that resulting policies and standards are developed in alignment with NQF's role as a national voluntary consensus standards-setting organization. Agreement around the recommendations will be developed through NQF’s formal Consensus Development Process.
Project Funding
This project is funded under NQF’s contract with the Department of Health and Human Services.
Related NQF Work
Serious Reportable Events in Healthcare - 2006 Update
Contact Information
For more information, contact Melinda Murphy, RN, MS, NE-BC, at 202-783-1300 or patientsafety@qualityforum.org.
NQF seeks to further define healthcare acquired conditions (HACs), develop an expanded list of HACs relevant to non-hospital settings, and review and update the NQF-endorsed® Serious Reportable Events.
NQF opened a Call for Nominations for Steering Committee members representing a full range of stakeholder perspectives.
NQF will also be seeking nominations for members of four Technical Advisory Panels (TAPs). These panels will provide expertise and guidance to the Steering Committee for Healthcare Acquired Conditions (HACs) and Serious Reportable Events (SREs).
The Call for Nominations closed on October 15, 2009.
For additional information on the Steering Committee formation process, please refer to the Call for Nominations document.
NQF sought members for three (of four) TAPs with expertise/experience in the occurrence of conditions and complications during patient care management in the following healthcare environments:
1. outpatient and office-based surgery centers;
2. nursing homes, specifically skilled nursing facilities; and
3. ambulatory practice settings, specifically physician offices.
The Call for Nominations closed on June 16, 2010. For additional information on the TAP formation process, please refer to the Call for Nominations documentation.
The Call for Candidate Standards closed on June 16, 2010.
The Call for Events closed on June 16, 2010. NQF received over 80 events to review for potential endorsement as national voluntary consensus standards.
Call for Events (PDF)
Event Submissions Form (PDF)
The Steering Committee first met on November 18, 2009. The Committee will meet through 2010 to evaluate SREs and prepare the draft report.
The Patient Safety: Healthcare Associated Conditions and Serious Reportable Events Meeting was open to NQF members and the public. It was held at the Park Hyatt Washington Hotel in Washington, DC.
The Skilled Nursing Facilities Technical Advisory Panel met via conference call on August 10, 2010.
The Physician Offices Technical Advisory Panel met via conference call on August 11, 2010.
The Ambulatory and Office-based Surgery Centers Technical Advisory Panel met via conference call on August 12, 2010.
The Steering Committee met via conference call on August 31, 2010.
The Steering Committee met via conference call on September 8, 2010.
The Steering Committee met via conference call on September 14, 2010.
The Steering Committee met via conference call on September 29, 2010.
The Steering Committee met via conference call on October 20, 2010.
The voting draft has been revised based on the comments received during the review period and consultation with the Steering Committee. Member voting closed on March 18, 2011 at 6:00 pm ET.
The CSAC met on April 15, 2011. In this meeting, the CSAC recommended the events put forth in the project, Patient Safety: Serious Reportable Events in Healthcare for endorsement.
CSAC Memo (PDF)
The public had 30 days to appeal the final decision made to endorse this voluntary consensus standard. The appeals process closed on July 12, 2011. There were three appeals filed during this time.
Appeals Letters (PDF)
