Form 2 Appendix B: Organizational Self-Assessment

1. Appendix B –Organizational Self-Assessment (From Measure Dx)

Form Approved
OMB No. xxxx-xxxx
Exp. Date xx/xx/20xx

Appendix B – Organizational Self-Assessment (From Measure Dx)

Organizational Self-Assessment

General Organizational Readiness Checklist

Before selecting specific diagnostic safety measurement strategies, ensure that sufficient resources and supportive mechanisms are available not only to collect information about diagnostic safety but also to respond effectively when learning opportunities are discovered. Check the following items as you develop your plan for measurement:

Clear objectives

The diagnostic safety team has identified specific motivations and expected outcomes of measurement activities that foster nonpunitive learning and improvement.

Leadership engagement

Leaders at the appropriate level of the organization have committed support to learning from diagnostic safety events.

Human resources

One or more team members are able and willing to commit time and effort to lead a diagnostic safety measurement and improvement program.

Team members have support from others at your organization who are also willing to learn in pursuit of diagnostic excellence. These could include physicians/clinicians, nursing staff, risk management/legal staff, representatives of diagnostic specialties (if available), and information technology and informatics staff (if available).

Safety culture

Your organization demonstrates commitment to safety culture (e.g., by conducting periodic surveys of safety culture,¹¹ reviewing and learning from the findings, and implementing strategies to address findings).

Your organization has a mechanism to share learning from case review/analysis.

Quality and safety resources and infrastructure

Patient safety and quality infrastructure is available to support your efforts. This could include basic safety measurement and reporting infrastructure or resources that support more advanced data gathering and analysis.

RESULTS

None to few items checked: Start small. Consider using one strategy in a limited capacity (e.g., pilot test on a single unit).

Several items checked: Consider using one or more of the strategies below, or focus on broad implementation of a single measurement strategy.

Most/all items checked: You seem well positioned

to use multiple measurement strategies from the list below

Selecting a Measurement Strategy

Assuming leadership support and sufficient commitment of time and effort, most HCOs will at least be able to use a strategy based on learning from cases that have already been identified by risk management, quality and safety, or another entity in the organization (Strategy A). However, some teams will opt to solicit information about diagnostic safety directly from clinicians (Strategy B) or use information provided by patients (Strategy C). Others will leverage the capabilities of EHRs (Strategy D) to identify previously undetected diagnostic safety events. Although a robust measurement program incorporates multiple strategies, most organizations new to this work should begin with only one and expand their portfolio of strategies over time.

Question	Response	If YES, then consider...
Does your HCO collect patient safety data for quality improvement purposes?	Yes No	Strategy A
Does your HCO perform root cause analyses or other forms of case reviews for specific safety events or adverse outcomes (e.g., mortality, sepsis, trauma)?	Yes No
Does your HCO have an event reporting system for receiving input from frontline clinicians that includes (or could be modified to include) a dedicated category for diagnostic safety?	Yes No	Strategy B
Does your HCO collect and aggregate any patient experience data through routine surveys, a hotline, or another mechanism?	Yes No	Strategy C
Does your HCO have an EHR data warehouse or equivalent system for EHR queries?	Yes No	Strategy D
Is there a person who can access the data warehouse and can support the team with EHR queries?	Yes No
Is there a team member who understands clinical data quality/validation?	Yes No
Does the HCO have a coordinated process for requesting EHR data, running queries, and generating reports?	Yes No

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)].  Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 30 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.