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For additional support, we have researched and accumulated useful web links and listed them below. We have also included two important white papers which are listed up front. Full descriptions of each resource can be found by selecting the resource link or by scrolling downward.

RESOURCE SUMMARY

Agency for Healthcare Research and Quality
The American Health Care Association (AHCA)
American Hospital Association
American Society of Health Risk Managers
Anesthesia Patient Safety Foundation
American Society of Health-System Pharmacists
Consumers Advancing Patient Safety (CAPS)
The Centers for Disease Control and Prevention (CDC)
The Commonwealth Fund
The Institute for Healthcare Improvement
The Institute of Medicine
The Institute for Safe Medication Practices
The Joint Commission on Accreditation of Healthcare Organization
Just Culture Community
The Federation of State Physician Health Programs
The Leapfrog Group
National Institute of Health (NIH)
National Patient Safety Foundation (NPSF)
The National Quality Forum (NQF)
New Agreements in Healthcare
Partnership for Healthcare Excellence
Partnership for Patient Safety
The Picker Institute
Planetree
Risk Management Foundation
TheKenneth B. Schwartz Center
VA National Center for Patient Safety
The World Health Organization (WHO)

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Disclosure and Apology: What's Missing? Advancing Programs that Support Clinicians

A report based on an invitational forum held on March 13, 2009, sponsored by MITSS, the Massachusetts Medical Society, CRICO/RMF, and Promutual Group.

Click here to download a free PDF version.

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When Things Go Wrong: Responding to Adverse Events
A Consensus Statement of the Harvard Hospitals

Prepared by physicians, nurses, risk managers, and patients from the Harvard teaching hospitals, the document attempts to summarize the current thinking about the best practices to follow when a patient suffers injury from medical treatment. Its objectives are to provide a deeper understanding of the issues involved to help hospitals and caregivers develop more effective policies for managing patients and caregivers following injury. The concepts and principles are supported by the Harvard teaching hospitals.

Click here to download a free PDF version
Published with permission


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Agency for Healthcare Research and Quality
AHRQ's mission to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.  This website provides downloadable patient safety tool kits on various topics.
http://www.ahrq.gov

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The American Health Care Association (AHCA)
The American Health Care Association (AHCA) is a non-profit federation of affiliated state health organizations, together representing more than 10,000 non-profit and for-profit assisted living, nursing facility, developmentally-disabled, and subacute care providers that care for more than 1.5 million elderly and disabled individuals nationally.
www.ahca.org

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American Hospital Association
The AHA’s vision is a society of healthy communities, where all individuals reach their highest potential for health.  The mission is to advance the health of individuals and communities.  The AHA leads, represents and serves hospital, health systems and other related organizations that are accountable to the community and committed to health improvement.
www.aha.org

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American Society of Health Risk Managers
The American Society for Healthcare Risk Management is a personal membership group of the American Hospital Association with more than 5,000 members representing health care, insurance, law and other related professions.

ASHRM promotes effective and innovative risk management strategies and professional leadership through education, recognition, advocacy, publications, networking and interactions with leading health care organizations and government agencies.  ASHRM initiatives focus on developing and implementing safe and effective patient care practices, the preservation of financial resources and the maintenance of safe working environments.
http://www.ashrm.org

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Anesthesia Patient Safety Foundation
The mission of the Anesthesia Patient Safety Foundation is to ensure that no patient shall be harmed by anesthesia. The purposes of APSF are to: foster investigations that will provide a better understanding of preventable anesthetic injuries; encourage programs that will reduce the number of anesthetic injuries; and promote national and international communication of information and ideas about the causes and prevention of anesthetic morbidity and mortality. http://www.apsf.org

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American Society of Health-System Pharmacists
http://www.ashp.org/

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Consumers Advancing Patient Safety (CAPS)
CAPS mission is to be a champion for patient safety in a new healthcare culture, to be a voice for individuals, families and healers who wish to prevent harm in healthcare encounters through partnerships and collaboration and to teach the healthcare community what consumers and providers need to know whenever they interact within healthcare systems.
www.patientsafety.org

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The Centers for Disease Control and Prevention (CDC)
The Centers for Disease Control and Prevention (CDC) is one of the 13 major operating components of the Department of Health and Human Services (HHS), which is the principal agency in the United States government for protecting the health and safety of all Americans and for providing essential human services, especially for those people who are least able to help themselves. http://www.cdc.gov

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The Commonwealth Fund
The Commonwealth Fund is a private foundation that aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.

The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries.
http://www.cmwf.org

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The Institute for Healthcare Improvement
The Institute for Healthcare Improvement (IHI) is a non-for-profit organization leading the improvement of health care throughout the world.  IHI was founded in 1991 and is based in Cambridge, Massachusetts. IHI is a reliable source of energy, knowledge, and support for a never-ending campaign to improve health care worldwide.  The Institute helps accelerate change in health care by cultivating promising concepts for improving patient care and turning those ideas into action.
http://www.ihi.org/ihi

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The Institute of Medicine
The Institute of Medicine serves as adviser to the nation to improve health.  Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. www.iom.edu

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The Institute for Safe Medication Practices
The Institute for Safe Medication Practices (ISMP), based in suburban Philadelphia, is the nation’s only 501c (3) nonprofit organization devoted entirely to medication error prevention and safe medication use. ISMP represents over 30 years of experience in helping healthcare practitioners keep patients safe, and continues to lead efforts to improve the medication use process. The organization is known and respected worldwide as the premier resource for impartial, timely, and accurate medication safety information. http://www.ismp.org

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The Joint Commission on Accreditation of Healthcare Organization
www.jcaho.org

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Just Culture Community
The Just Culture Community is a community of individuals and organizations all working together to create open, fair, and just cultures that are supportive of improving organizational safety and performance.   Through this site, we share experiences, we learn together, and we help each other on this important journey.
http://www.justculture.org


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The Federation of State Physician Health Programs
The Federation of State Physician Health Programs, Inc. (FSPHP), is a nonprofit corporation whose purpose is to provide a forum for education and exchange of information among state programs, to develop common objectives and goals, to develop standards, to enhance awareness of issues related to physician health and impairment, to provide advocacy for physicians and their health issues at local, state, and national levels, and to assist state programs in their quest to protect the public. http://www.fsphp.org/

This is where physicians can find out what is available in their states.
www.fsphp.org

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The Leapfrog Group
The Leapfrog Group is a voluntary program aimed at mobilizing employer purchasing power to alert America’s health industry that big leaps in health care safety, quality and customer value will be recognized and rewarded. Among other initiatives, Leapfrog works with its employer members to encourage transparency and easy access to health care information as well as rewards for hospitals that have a proven record of high quality care.
www.leapfroggroup.org

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National Institute of Health (NIH)
NIH is the nation's medical research agency – making important medical discoveries that improve health and save lives.  The National Institutes of Health (NIH), a part of the U.S. Department of Health and Human Services, is the primary Federal agency for conducting and supporting medical research.
Helping to lead the way toward important medical discoveries that improve people’s health and save lives, NIH scientists investigate ways to prevent disease as well as the causes, treatments, and even cures for common and rare diseases.
www.health.nih.gov

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National Patient Safety Foundation (NPSF)
NPSF Mission is   to Improve the Safety of Patients through our efforts to: Identify and create a core body of knowledge; Identify pathways to apply the knowledge; Develop and enhance the culture of receptivity to patient safety; Raise public awareness and foster communications about patient safety; and Improve the status of the Foundation and its ability to meet its goals. www.npsf.org

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The National Quality Forum (NQF)
The National Quality Forum (NQF) is a not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. A shared sense of urgency about the impact of health care quality on patient outcomes, workforce productivity, and health care costs prompted leaders in the public and private sectors to create the NQF as a mechanism to bring about national change.

Established as a public-private partnership, the NQF has broad participation from all parts of the health care system, including national, state, regional, and local groups representing consumers, public and private purchasers, employers, health care professionals, provider organizations, health plans, accrediting bodies, labor unions, supporting industries, and organizations involved in health care research or quality improvement. Together, the organizational members of the NQF will work to promote a common approach to measuring health care quality and fostering system-wide capacity for quality improvement. www.qualityforum.org

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New Agreements in Healthcare
Our Vision: The transformation of American healthcare from “sickcare” to holistic wellness—One hospital, one caregiver, one patient, one leader/teacher at a time.Our Mission: To teach teachers, creating an extended community of kindred spirits who will live and teach the New Agreements in Healthcare in healthcare organizations throughout America.Our Promise: We will do our best to be the changes we want to see in healthcare and in the world. www.newagreementsleadership.com

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Partnership for Healthcare Excellence

The Massachusetts-based Partnership for Healthcare Excellence is the first statewide effort in the nation to focus specifically on patients – helping them to play a greater role in improving the quality of their health care.  The goals of the Partnership are to educate the public about variation in health care quality and to provide consumers with information and tools to improve the quality of their own care.  The Partnership seeks to motivate consumers to advocate for overall health system change that improve quality of care.  MITSS is a member of a broad coalition of organizations supporting the Partnership.  For information, visit www.partnershipforhealthcare.org.

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Partnership for Patient Safety
Partnership for Patient Safety is a patient-centered initiative to advance the reliability of healthcare systems worldwide. p4ps initiates focused partnerships and joint ventures with organizations and individuals that share our core values and objectives of achieving a healthcare system that is authentically patient-centered and systems based.
www.p4ps.org

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The Picker Institute
We are an independent, not for profit organization dedicated to the advancement of the principles of patient-centered care and the global patient-centered care movement.  The Picker Institute, Inc. sponsors research and education in the fields of patient- centered care, to support and cooperate with educational institutions, and other interested entities and persons. Picker Institute’ mission is to foster a broader understanding of the theoretical and practical implications of patient-centered care by approaching healthcare with a focus on the concerns of patients and other health care consumers.
Predicated on the understanding that the Picker Institute is a world leader focusing on the measurement of patient’s experience and that the Institute is recognized as an important source of information, advice and support; the Board of Directors of the Picker Institute, Inc. support the advancement of the science through a variety of Programs, Awards and related research, each of which focuses entirely on fostering the continued improvement in healthcare from the patient’s perspective.
www.pickerinstitute.org

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Planetree
Planetree is a non-profit membership organization working with hospitals and health centers to develop and implement patient-centered care in healing environments.  Planetree’s mission: Serving as a catalyst and partner in the development and implementation of models of health car that: cultivate healing of mind-body-spirit, are patient centered, value-based, holistic, and support the safety of patients through active involvement in their own care. www.planetree.org

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Risk Management Foundation
CRICO/RMF’s mission is to provide a superior medical malpractice insurance program to our members, and to assist them in delivering the safest health care in the world. To fulfill this mission, they: offer comprehensive, competitive coverage, provide expert legal and defense and customer service, protect providers’ assets and reputations, develop solutions to increase patient safety, and foster collaboration between local and national experts. www.rmf.harvard.edu

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TheKenneth B. Schwartz Center
The Center Mission is to support and advance compassionate health care in which caregivers, patients and their families relate to one another in a way that provides hope to the patient, support to caregivers and sustenance to the healing process. 
www.theschwartzcenter.org

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VA National Center for Patient Safety
The NCPS was established in 1999 to develop and nurture a culture of safety throughout the Veterans Health Administration. Our goal is the nationwide reduction and prevention of inadvertent harm to patients as a result of their care. Patient safety managers at 154 VA hospitals and patient safety officers at 21 VA regional headquarters participate in the program.
www.patientsafety.gov

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The World Health Organization (WHO)
The World Health Organization is the United Nations specialized agency for health. It was established on 7 April 1948. WHO's objective, as set out in its Constitution, is the attainment by all peoples of the highest possible level of health. Health is defined in WHO's Constitution as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
WHO is governed by 193 Member States through the World Health Assembly. The Health Assembly is composed of representatives from WHO's Member States. The main tasks of the World Health Assembly are to approve the WHO programme and the budget for the following biennium and to decide major policy questions.
www.who.org

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