223467 Analysis of AHRQ mechanisms and resources for translating patient safety research to practice

Tuesday, November 9, 2010

Robin H. Pugh-Yi, PhD , Analytical and Technical Services Division, AFYA, Inc., Vienna, VA
Craig Dearfield, MA , Department of Sociology, Howard University, Washington, DC
Jeff Brady, MD , Patient Safety Portfolio, Agency for Healthcare Research and Quality, Rockville
James Battles, PhD , Patient Safety Portfolio, Agency for Healthcare Research and Quality, Rockville, MD
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.

Learning Areas:
Administration, management, leadership
Clinical medicine applied in public health
Conduct evaluation related to programs, research, and other areas of practice

Learning Objectives:
1. Describe AHRQ resources for patient safety research support 2. Compare the impact of support at different phases of patient safety product implementation 3. Describe estimates of return on investment for four AHRQ patient safety products

Keywords: Research, Quality of Care

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am the primary investigator for the study.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.