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The Opportunity
Americans are exposed to more preventable medical errors than patients in other industrialized nations. Each year, 1.7 million infections occur in U.S. hospitals, accounting for nearly 99,000 associated deaths. It’s estimated that preventable errors cost the United States $17-$29 billion per year in healthcare expenses, lost worker productivity, and disability. As healthcare expenditures grow at more than seven percent each year, patient safety is improving by only one percent.
In November 2008, the National Priority Partnership (NPP) deemed Patient Safety as one of the six national priorities, with specific focus on reduction of hospital-level mortality rates, serious adverse events, and healthcare associated infections. Among the NQF inventory of 550 endorsed measures, approximately 100 measures relate to patient safety. In addition, NQF has endorsed 34 safe practices in the 2009 update of the Safe Practices for Better Healthcare and 28 Serious Reportable Events (SRE). The Safe Practices, SREs, and NQF-endorsed patient safety measures are important tools for tracking and improving patient safety performance in American healthcare. However, significant gaps remain in the measurement of patient safety. There is also a recognized need to expand available patient safety measures beyond the hospital setting and harmonize safety measures across sites and settings of care. In order to fill these gaps and to develop a more robust set of safety measures, NQF will be soliciting patient safety measures to fill gap areas and to address environment-specific issues with highest potential leverage for improvement (e.g., healthcare associated infections (e.g., MRSA), culture of safety, and hospital standardized mortality rates).
About the Project
NQF will convene a Patient Safety Measures Steering Committee to review submitted measures. An intent to call for patient safety-related measures was issued on November 23, 2009, the responses to which will help determine the expertise required for the Steering Committee and related technical panels. A full Call for Measures and a Call for Nominations for Steering Committee members was issued on January 4, 2009.
Through the Call for Measures, NQF will solicit safety measures to fill gap areas and to address environment-specific issues with highest potential leverage for improvement. NQF is particularly interested in measures focused on healthcare associated infections (HAI), including MRSA.
Process
Candidate practices and measures will be considered for NQF endorsement as national voluntary consensus standards. Agreement will be developed through NQF’s Consensus Development Process (CDP, version 1.8). This project will involve the active participation of representatives from across the spectrum of healthcare stakeholders and will be guided by a steering committee.
Funding
This project is funded under NQF's contract with the Department of Health and Human Services, Consensus-based Entities Regarding Healthcare Performance Measurement.
Related NQF Work
Contact Information
For further information, contact Andrew Lyzenga, MPP or Elisa Munthali, MPH at 202-783-1300 or via email at patientsafety@qualityforum.org.
NQF is seeking endorsement of measures for patient safety. Under this project, NQF will identify and endorse cross-cutting patient safety measures across conditions, populations, and settings of care.
NQF issued a Call for Intent to submit candidate standards for Patient Safety Measures. Notices of intent closed on December 7, 2009. For additional information, see the full Call for Intent document.
The Call for Nominations closed on February 2, 2010. A Steering Committee will be formed to guide the endorsement process and assess candidate standards. For information on the Steering Committee formation process, please refer to the Call for Nominations document.
Call for Nominations (PDF)
The 14-day review period for the proposed Healthcare-Associated Infections (HAI) Technical Advisory Panel (TAP) roster closed on June 7, 2010.
Final HAI TAP Roster (PDF)
HAI TAP Bios (PDF)
The 10-day Call for Nominations for the Patient Safety Measures Steering Committee closed on July 6, 2010.
Call for Nominations (PDF)
The Steering Committee and Technical Advisory Panels (TAPs) will meet in person and by phone to review the submitted measures.
The Healthcare Associated Infections (HAI) TAP met via conference call on August 2-3, 2010.
The Medication Safety TAP met via conference call on August 10, 2010.
The Perinatal TAP met via conference call August 11, 2010.
The Medication Safety TAP met via conference call on August 17, 2010.
The Patient Safety Measures Steering Committee met via conference call on August 30, 2010 to review five submitted HAI measures.
Agenda (PDF)
Measures (Review by HAI TAP)
PSM-001-10 - National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome Measure
PSM-002-10 - ACS-CDC Harmonized SSI Outcome Measure
PSM-003-10 - National Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection (CAUTI) Outcome Measure
PSM-006-10 - Risk Adjusted Surgical Site Infection Outcome Measure
PSM-007-10 - Risk Adjusted Urinary Tract Infection Outcome Measure
Measures (Reviewed by Medication Safety TAP)
PSM-010-10 - Querying and Counseling about Anti-Epileptic Drug (AED) Side-Effects
PSM-017-10 - Patient(s) with rheumatoid arthritis taking methotrexate, sulfasalazine, or leflunomide that had serum ALT or AST test in last 3 reported months.
PSM-018-10 - Patient(s) with rheumatoid arthritis taking methotrexate or sulfasalazine that had a serum creatinine in last 6 reported months.
PSM-019-10 - Patient(s) with rheumatoid arthritis taking methotrexate, sulfasalazine, gold, or leflunomide that had a CBC in last 3 reported months.
PSM-020-10 - Patient(s) with inflammatory bowel disease taking methotrexate, azathioprine or mercaptopurine that had serum ALT or AST test in last 6 reported months.
PSM-021-10 - Adult patient(s) with multiple sclerosis taking interferon that had a serum ALT/AST test in last 12 reported months.
PSM-022-10 - Adult patient(s) with multiple sclerosis taking interferon that had a CBC in last 12 reported months.
PSM-023-10 - Patient(s) with hepatitis C infection taking interferon that had periodic serum ALT monitoring.
PSM-024-10 - Patient(s) with hepatitis C infection taking interferon that had periodic CBC with differential monitoring.
PSM-025-10 - Patient(s) with HIV infection taking antiretroviral medications that had a had serum ALT or AST test in last 6 reported months.
PSM-026-10 - Patient(s) with HIV infection taking antiretroviral medications that had a CBC in last 6 reported months.
PSM-027-10 - Adult patient(s) with atrial fibrillation taking amiodarone that had serum ALT or AST test in last 12 reported months.
PSM-028-10 - Adult patient(s) taking a statin-containing medication or nicotinic acid that had an annual serum ALT or AST test.
PSM-029-10 - Adult patient(s) taking warfarin that had three or more prothrombin time tests in last 6 reported months.
PSM-030-10 - Patient(s) with inflammatory bowel disease taking methotrexate, sulfasalazine, mercaptopurine, or azathioprine that had a CBC in last 3 reported months.
PSM-031-10 - Patient(s) with inflammatory bowel disease taking methotrexate that had a serum creatinine in last 6 reported months.
The Patient Safety Measures Steering Committee met in person on October 28-29, 2010.
Agenda (PDF)
Meeting Transcripts (PDF)
October 28 | October 29
Meeting Recording (MP3)
Oct. 28 | Oct. 29
Medication Safety and Additional Patient Safety Measures Under Review
PSM-011-10 - Counseling about Epilepsy Specific Issues
PSM-012-10 - Querying about Falls (Parkinson's Disease Patients)
PSM-013-10 - Parkinson's Disease Related Safety Issues Counseling
PSM-014-10 - Colonoscope Processing Personnal Instruction
PSM-015-10 - Colonoscope Processing Currency
PSM-016-10 - Colonoscope Processing Competency
PSM-043-10 - Participation in a Systematic National Dose Index Registry
PSM-044-10 - Radiation Dose Computed Tomography (CT)
The Steering Committee is meeting on August 15, 2011 via conference call. This meeting is open to members and the public.
Please note that voting on the first report was postponed temporarily in order to accommodate measure harmonization issues related to this project. For this reason, voting on the second report occurred before voting on the first report.
Member voting for the second draft report closed on May 5, 2011. The first draft report was available for Member Voting on October 13, 2011. Members had 15 days to submit their vote.
The first draft report has been revised based on the comments received during the Public and Member Comment and in consultation with the Steering Committee. Member voting closed on October 27, 2011.
The second draft report has been revised based on the comments received during the Public and Member Comment and in consultation with the Steering Committee. Member voting closed on May 5, 2011.
First Report: The CSAC met on November 2-3, 2011. In this meeting CSAC considered endorsement of Patient Safety SSI measures.
Second Report: The CSAC met on June 13, 2011. In this meeting CSAC considered endorsement of medication safety, querying and counseling on side-effects, radiation dosing and additional patient safety measures.
The CSAC met on November 2-3, 2011. In this meeting, the CSAC considered endorsement of Patient Safety SSI measures.
Post-meeting documents:
For more meeting information, including meeting transcripts, please go to CSAC Meetings.
The CSAC met on June 13, 2011. In this meeting, the CSAC considered endorsement of medication safety, querying and counseling on side-effects, radiation dosing and additional patient safety measures.
Patient Safety Measures Memo (PDF)
The NQF Board of Directors chose to ratify one of the endorsements for Patient Safety Measures - 2nd Report. Note: The rest of the measures are still under review and may be ratified in the 1st report.
Announcement of Board Endorsement
There was one other measure that was recently ratified by the NQF Board from the second report.
Announcement of Board Endorsement
The appeals period closed on February 15, 2012. No appeals were filed during this time.
First Measure Appeals Period:
August 15, 2011 - September 13, 2011
The public has 30 days to appeal the final decision to endorse the first measure. The appeals period closed on September 13, 2011. Two appeals were received.
Second Measure Appeals Period:
September 19, 2011 - October 18, 2011
The public had 30 days to appeal the final decision made to endorse the second measure. The appeals process closed on October 18, 2011. No appeals were received.
