Analysis of AHRQ mechanisms and resources for translating patient safety research to practice

The Agency for Health Care Research and Quality's (AHRQ) patient safety portfolio's congressionally mandated mission is to identify risks and hazards that lead to medical errors and find ways to prevent patient injury associated with delivery of health care. AHRQ accomplishes this by operating core business areas: knowledge creation, knowledge synthesis, dissemination, and support for implementation in the field. Patient safety products develop by progressing through these core business areas. This study summarizes the processes and resources that led to current work on four selected patient safety products: 1) Comprehensive Unit-based Safety Practices (CUSP) to prevent central line-associated blood stream infections (CLABSI), which AHRQ is implementing nationally, 2) Partnerships in Implementing Patient Safety products to prevent hospital associated venous thromboembolism, 3) TeamStepps teamwork system, and 4) the Hospital Survey Of Patient Safety . Findings about how work is initiated, how progress is sustained, and the projected impact or continued efforts will inform future decisions about supporting research and implementation, such as determining funding priorities, and leveraging support from other stakeholders. The current study describes the progress of four projects from initiation to their current status. This report also presents initial analyses of return on investment. Analysts interviewed key AHRQ personnel, reviewed AHRQ funding announcements, project reports, and dissemination plans, and reviewed peer-reviewed publications to assess project evolution and results. Initial estimates of the impact and potential impact of AHRQ-funded research in the field suggest high returns on investment. Over the course of six years' investment in research AHRQ has begun support for national implementation of CUSP, which may result in reducing CLABSI rates by well over 50 percent, with a return on investment rate of over 200:1. Initial estimates show the effects of variation in investment intensity. The analytic approach provides insight into how systems change can impact public health.