Form #1 Form #1 Interest form

Form Approved

OMB No. 0935-0124

Exp. Date XX/XX/20XX

Phase II Interest Form

Public reporting burden for this collection of information is estimated to average 2 minutes per response, the estimated time required to complete the form. 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. Form Approved: OMB Number 0935-0124  Exp. Date xx/xx/20xx. 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 (0935-0124) AHRQ, 540 Gather Road, Room #5036, Rockville, MD 20850.

Overview

The Agency for Healthcare Research and Quality (AHRQ) is seeking an indication of interest from organizations willing to participate in Phase II of the AHRQ Quality Indicators Validation Pilot. The validation pilot is designed to gather evidence on the scientific acceptability of the AHRQ Patient Safety Indicators (PSI) in an effort to consolidate the evidence base of the AHRQ PSI, to improve guidance on the interpretation and use of AHRQ PSI data, and to evaluate potential refinements to the AHRQ PSI specifications.

Phase II of the Validation Pilot will focus primarily on these AHRQ Patient Safety Indicators:

• Foreign body left in during procedure

• Postoperative Hemorrhage or Hematoma

• Postoperative Respiratory Failure

• Postoperative Physiologic and Metabolic Derangement

• Postoperative Wound Dehiscence

Partner Organizations

As in Phase I, organizations participating in the validation pilot will be asked to 1) apply the AHRQ QI Windows software to an extract of hospital administrative (e.g., UB-04) data; 2) assist in the testing of protocols for case selection and data abstraction tools for additional data collection from medical records; 3) abstract data from medical records of selected patients based on the protocols and tools developed; 4) assist in the testing of a secure data collection application; and 5) report administrative and medical record data for pooled analyses.

The number of records and the amount of data collection required will depend on the interest and capability of the partner organization. Determination of the appropriate level of participation will be made by mutual agreement.

Study Timeline

The study timeline runs from X through Y.

Benefits for Partner Organizations

In addition to contributing to the development of the AHRQ PSI, participants will receive

• A certificate of appreciation from the Director of the Agency for Healthcare Research and Quality and recognition in the AHRQ e-newsletter and other AHRQ QI publications

• Training from experts on how to perform and use chart abstraction for quality improvement (including written guidelines, telephonic/e-mail consultation, and “over-reading” of selected records, upon request)

• Use of the data collection tools developed for the project to review potentially preventable complications and identify opportunities for quality improvement

• Comparative summary data aggregated from all pilot participants

• An invitation to one or more web-based conferences where the project investigators will discuss the validation results and implication of those results for quality improvement efforts and comparative reporting initiatives as well as indicator validation

Indicating Your Interest as a Partner Organization

At present, the AHRQ is seeking OMB approval to conduct Phase II of the validation pilot. It is anticipated that organizations selected to participate in the validation pilot must have the capacity to:

• apply the AHRQ QI software to a recent extract of acute inpatient administrative data; access medical chart data for identified cases from that extract

• provide qualified abstraction personnel (e.g., physicians, nurses, or health information professionals) to collect the data

• access coding personnel for clarifying questions that may arise, access an existing IRB and/or Privacy Board for review of and compliance with human subjects and HIPAA privacy and security requirements

• participate in training and complete data collection according to the timeline stated in this announcement

Organizations interested in participating in the Validation Pilot should complete the attached form to provide contact information and indicate acknowledgement of these requirements. Completed forms must be returned on or before COB on Z.

Submission of the indication of interest form does not commit the organization to participate or guarantee participation. However, only those organizations that submit the indication of interest form will be considered for participation.

For additional questions on the Validation Pilot, please contact Jennifer Cohen, Validation Pilot Coordinator, at (206) 528-3116 or [email protected]. For questions on the AHRQ Quality Indicators Project, contact Mamatha Pancholi, AHRQ Project Officer, at 301-427-1470 or [email protected].

Indication of Interest as a Partner Organization

Organization Contact Information

Contact Name:
Title/Position:
Department:
Organization:
City, State and Zip:
Contact Phone:
Contact Fax:
Contact E-mail:

Acknowledgement of Participation Requirements

My organization has the following required capacities for participation in this pilot project (check all that apply):

	Ability to apply the AHRQ QI Windows software to an extract of acute inpatient administrative data
	Access to medical chart data for identified cases from that extract
	Ability to provide qualified abstraction personnel (e.g., physicians, nurses, or health information professionals) to collect the data from medical records
	Access to coding personnel for clarifying questions that may arise
	Access to an existing IRB and/or Privacy Board for review of and compliance with human subjects and HIPAA privacy and security requirements
	Ability to participate in training and complete data collection according to the timeline stated in the attached announcement

Instructions for Submitting Completed Forms

Return the completed form via fax, e-mail or regular mail by COB on Z to:

AHRQ QI Validation Pilot

Attn: Jennifer Cohen, Pilot Coordinator

Battelle Memorial Institute

1100 Dexter Ave North, Suite 400

Seattle, WA 98109-3598

Fax: (614) 458-6743

E-mail: [email protected]

For additional information on the AHRQ QI, please visit the AHRQ QI web site at http://www.qualityindicators.ahrq.gov, contact the AHRQ QI Support Team via email at [email protected] or leave a voicemail at (888) 512 – 6090.