AHRQ Patient Safety Chartbook

Angie Szumlinski
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August 20, 2020
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The Agency for HealthCare Research and Quality recently published the “ChartBook on Patient Safety.” This document is part of a family of documents and tools that support the National Healthcare Quality and Disparities Report (QDR) which is an annual report to Congress mandated in the Healthcare Research and Quality Act of 1999. The QDR provides a comprehensive overview of the quality of healthcare received by the general U.S. population and disparities in care experienced by different racial and socioeconomic groups. The purpose of the report is to assess the performance of our healthcare system and to identify areas of strengths and weaknesses in the healthcare system along three main axes: access to healthcare, quality of healthcare and QDR priorities.

Of special interest to us as post-acute care providers is the section on Nursing Homes (beginning on page 61). As nursing homes aim to improve their performance, there is growing recognition of the importance of establishing a culture of patient safety by looking at patient safety culture areas where they are most positive and where they are perceived most negative by nursing home staff.

The good news: overall perceptions of resident safety was scored at 85% and communication about incidents was also scored at 85% and had the highest average percent positive responses.

The bad news: staffing was at 34% negative and non-punitive response to mistakes was rated at 19% negative and had the highest percent of negative responses.

Can we do better? Sure we can! Notice that staffing and non-punitive responses to mistakes are the lowest scoring areas. Do you think they are connected? Maybe? We talk a lot about staff appreciation, fairness, avoiding blaming staff for errors, etc. It might be time to take a step back and determine if we can affect change in these areas for the next report by being good listeners, coaches and mentors. Worth a try!


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