Read the Patient Safety and Quality Improvement Act of 2005 (FOUND BELOW) and review the information on the Measures (FOUND BELOW)
web page of The Joint Commission website. Pick one of the core measures
from the list on the right-hand side of this web page. For this
assignment, create a PowerPoint presentation in which you explain how a
hospital would typically put policies and procedures into place to
ensure that it is following your selected core measure.
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In your presentation,
- Describe the core measure you chose.
- Analyze how your hospital will follow the requirements in the chosen core measure.
- Examine the penalties that will occur if this policy/procedure is not followed.
You are basically creating the policy/procedure and presenting it on the PowerPoint as if you were presenting to an audience.
Create a PowerPoint presentation using the guidelines below. Your
presentation must utilize at least two scholarly sources from the last
five to seven years, in addition to the textbook, that contain research
regarding how your policy and/or procedure would be put into place in a
The Core Measures PowerPoint presentation assignment
- Must be five to seven slides (excluding the title slide and
reference slides) and be formatted according to APA style.
- Must use speakers notes as follows: (GIRL VOICE PLEASE)
- Speaker notes are the typed notes that appear below the slide that
complement the presentation slides. Whereas the slides will have short
bulleted items, the speaker notes will be more detailed. They are
essentially what the presenter would say during the presentation to
explain each of the bulleted points on the slide. Therefore, it is
important that the speaker notes are concise and detailed when
explaining the bullet points.
- It is recommended that PowerPoint Slides contain no more than five
bullet points and should not contain more than seven to 10 words each.
Do not type paragraphs or long sentences on the slide. The information
that explains each bullet point is conveyed via speaker notes or by
recording your voice to each slide.
The Patient Safety and Quality Improvement Act of 2005
Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41),
signed into law on July 29, 2005, was enacted in response to growing
concern about patient safety in the United States and the Institute of
Medicine’s 1999 report, To Err is Human: Building a Safer Health System.
The goal of the Act is to improve patient safety by encouraging
voluntary and confidential reporting of events that adversely affect
patients.The Patient Safety and Quality Improvement Act signifies the Federal Government’s commitment to fostering a culture of patient safety. It creates Patient Safety Organizations
(PSOs) to collect, aggregate, and analyze confidential information
reported by health care providers. Currently, patient safety improvement
efforts are hampered by the fear of discovery of peer deliberations,
resulting in under-reporting of events and an inability to aggregate
sufficient patient safety event data for analysis. By analyzing patient
safety event information, PSOs will be able to identify patterns of
failures and propose measures to eliminate patient safety risks and
Many providers fear that patient safety event reports could be used
against them in medical malpractice cases or in disciplinary
proceedings. The Act addresses these fears by providing Federal legal
privilege and confidentiality protections to information that is
assembled and reported by providers to a PSO or developed by a PSO
(“patient safety work product”) for the conduct of patient safety
activities. The Act also significantly limits the use of this
information in criminal, civil, and administrative proceedings. The Act
includes provisions for monetary penalties for violations of
confidentiality or privilege protections.
Additionally, the Act specifies the role of PSOs and defines “patient
safety work product” and “patient safety evaluation systems,” which
focus on how patient safety event information is collected, developed,
analyzed, and maintained. In addition, the Act has specific requirements
for PSOs, such as:
- PSOs are required to work with more than one provider.
- Eligible organizations include public or private entities, profit or
not-for-profit entities, provider entities, such as hospital chains,
and other entities that establish special components.
- Ineligible organizations include insurance companies or their affiliates.
Finally, the Act calls for the establishment of a Network of Patient
Safety Databases (NPSD) to provide an interactive, evidence-based
management resource for providers, PSOs, and other entities. It will be
used to analyze national and regional statistics, including trends and
patterns of patient safety events. The NPSD will employ common formats
(definitions, data elements, and so on) and will promote
interoperability among reporting systems. The Department of Health and
Human Services will provide technical assistance to PSOs.
For Additional Information
To contact PSO Office staff, go to the PSO site at http://www.pso.ahrq.gov/contact/contact.htm.Page last reviewed October 2014
Page originally created June 2008Internet Citation: The Patient Safety and Quality Improvement Act of
2005. Content last reviewed October 2014. Agency for Healthcare Research
and Quality, Rockville, MD.
In early 1999, The Joint Commission solicited input from a wide variety
of stakeholders (e.g., clinical professionals, health care provider
organizations, state hospital associations, health care consumers) and
convened a Cardiovascular Conditions Clinical Advisory Panel about the
potential focus areas for core measures for hospitals. In May 2001, the
Joint Commission announced four initial core measurement areas for
hospitals, which included acute myocardial infarction (AMI) and heart
Simultaneously, The Joint Commission worked with the Centers for
Medicare & Medicaid Services (CMS) on the AMI, and HF sets that were
common to both organizations. CMS and the Joint Commission worked to
align the measure specifications for use in the 7th Scope of Work and
for Joint Commission accredited hospitals. Hospitals began collecting
AMI measures for patient discharges beginning July 1, 2002.
In November of 2003, CMS and The Joint Commission began to work to
precisely and completely align these common measures so that they are
identical. This resulted in the creation of one common set of measure
specifications documentation known as the Specifications Manual for
National Hospital Inpatient Quality Measures to be used by both
organizations. The Manual contains common (i.e., identical) data
dictionary, measure information forms, algorithms, etc. The goal is to
minimize data collection efforts for these common measures and focus
efforts on the use of data to improve the health care delivery process.