The QA to QI Contribution

My 3 national studies of peer review practices have shown that the many hospitals do not effectively track and manage to measures of program process and outcomes. Considering the potential for healthy peer review to contribute to quality and safety, this situation cannot continue. Our Normative Peer Review Database Project has defined a simple set of measures see Data Definitions appropriate to most settings. The measure set incorporates the AHRQ Common Formats Harm Scale.

In 2010, I predicted that self-reporting of cases for peer review, catalyzed by the protections of the Patient Safety and Quality Improvement Act of 2005, will be the next major advancement in peer review process. If so, then the work of defining best-practices could be accelerated as greater numbers of organizations begin to report case-level peer review data to PSOs in a standardized manner. There is now evidence that self-reporting is being adopted in healthcare with the same benefit that was realized in high-reliability industries such as aviation.

Frequently Asked Questions and Answers from the AHRQ

What are Common Formats?

Almost all US hospitals have some type of system for reporting adverse events. However, organizations can differ in the way they collect data, which makes it difficult to track patient safety trends accurately. A set of common definitions and reporting formats, known as Common Formats, specify the clinical definitions and technical requirements that allow healthcare providers to exchange data with Patient Safety Organizations (PSOs) and the Network of Patient Safety Databases in an interoperable and standardized manner. Common Formats optimize the opportunity for the public and private sectors to learn more about trends and patterns in patient safety, with the purpose of improving healthcare quality for all Americans.

Who Can Use Common Formats?

Patient safety, quality, and risk managers, clinicians, and others can use Common Formats to collect patient safety event information in a standard way—using common language, definitions, technical requirements, and reporting specifications. The Agency for Healthcare Research and Quality (AHRQ) anticipates that most initial users of the Common Formats will be based in hospital settings.

Why do Patient Safety Organizations Use Common Formats?

PSOs use AHRQ’s Common Formats to ensure consistency in reporting patient safety event information. PSOs:

  • Aggregate data for pattern analysis, learning, and trending, as required by the Patient Safety and Quality Improvement Act of 2005.
  • Provide analysis of patient safety event information and give feedback to healthcare providers.
  • Facilitate a learning environment that reduces future risk to patients.

Which Common Formats Are Available?

AHRQ has released initial and revised sets of Common Formats for hospitals and beta versions for hospital readmissions and skilled nursing facilities. The Hospital set of Common Formats may be used to collect data for all types of adverse events, near misses, and unsafe conditions. Common Formats are available for initial reporting of patient safety events. Future development plans include Common Formats for reporting root cause analysis, improvement actions, and effectiveness of improvement actions. In addition, AHRQ plans to expand the scope to include ambulatory surgery centers.

Where Are Common Formats Located?

Common Formats and information for users are accessible online: AHRQ Common Formats.