Medical errors and unsafe care harm and kill tens of thousands of Americans each year. The facts are alarming: approximately two million healthcare-associated infections occur annually in the United States, accounting for an estimated 90,000 deaths and more than $4.5 billion in hospital healthcare costs. Unplanned, often preventable, hospital admissions and readmissions cost Medicare and the private sector billions of dollars each year and take a significant toll on patients and families, who suffer from prolonged illness or pain, emotional distress, and loss of productivity.
As a result, the National Quality Strategy has made making care safer a national priority, focusing on three goals:
- Reduce preventable hospital admissions and readmissions.
- Reduce the incidence of adverse healthcare-associated conditions.
- Reduce harm from inappropriate or unnecessary care.
Related NQF Work
- Focus on HARM (Harmonizing Accountability in Reporting and Monitoring) 2024
NQF launched the “Focus on HARM” patient safety initiative in April 2024 to address the high rates of avoidable medical errors and preventable patient harms that continue despite decades of efforts to remediate these events. The initiative aims to improve patient safety and reduce avoidable harm by updating and harmonizing serious adverse event reporting and monitoring.
- Advancing Measurement of Diagnostic Excellence for Better Healthcare 2022
NQF will convene various multi-stakeholder groups, including an Advancing Measurement of Diagnostic Excellence Committee, Artificial Intelligence in Quality Measures Technical Expert Panel (TEP), and ad-hoc subcommittees to confront measurement challenges and recommend solutions.
- HIT Safety 2016
NQF initiated a project to develop a set of recommendations around the measurement of HIT-related safety issues. A multi-stakeholder committee (the HIT Safety Committee) was convened to provide input and direction on the development of a conceptual framework for analyzing measures of safety in health IT and to identify priority measurement areas with the greatest potential for both improving the safety of HIT and using HIT to improve patient safety.
- Patient Safety 2015
The Patient Safety project is entering its second phase. This project will evaluate measures related to patient safety that can be used for accountability and public reporting for all populations and in all settings of care.
- Patient Safety Measures 2015
NQF is seeking to endorse cross-cutting patient safety measures that span conditions, populations, and settings of care.
- Surgery 2014
The Surgery Project is now beginning its second phase. This project will include performance measures in the areas of general and specialty surgery that address surgical processes, including pre and post-surgical care, timing of prophylactic antibiotic, adverse surgical outcomes, and other related topics.
- Safe Practices 2010 Audit (2014)
Following NQF’s February 2014 report, NQF Safe Practices and Related Processes, a comprehensive audit of the 2010 Safe Practices for Better Healthcare was conducted. The audit assessed whether the 2010 Safe Practices report included reference to any commercial product or service, explicit or implicit and to assess the currency of the 2010 Safe Practices, in light of the four years that have passed since they were last updated. This final report includes the 34 safe practices that have undergone a three-part audit process consisting of review by internal NQF staff, review by an expert panel, and NQF member and public comment. The 2010 Safe Practices Audit Report was reviewed and approved for final ratification by the NQF Board Executive Committee on May 23, 2014.
- Critical Paths: Patient Safety 2012
This project assessed the readiness of electronic data and health IT systems to support data capture, normalization, and standardization to support patient safety reporting and evaluation across clinical information systems, with a specific focus on acute care infusion devices.
- Patient Safety: Complications Phase I Measures Project
2012
In June 2012, NQF endorsed 14 patient safety measures with a focus on complications, addressing a range of quality concerns, including medication safety, venous thromboembolism, surgical safety, and care coordination. Two additional measures – focused on venous thromboembolism prophylaxis and current medication documentation in medical records – were endorsed in August 2012 following additional review from the project’s steering committee.
- All-Cause Readmissions Measures Project 2012
In May 2012, NQF endorsed two measures that address all-cause unplanned readmissions in hospitals – an area of healthcare targeted for improvement given national imperatives to make healthcare safer, more affordable, and keep people healthy. Following an appeal in June, NQF upheld endorsement of both measures.
- Perinatal and Reproductive Health Measures Project 2012
In April 2012, NQF endorsed 14 quality measures on perinatal care. The measures address a wide range of care concerns, including childbirth, pregnancy and post-partum care, and newborn care. Several of the measures have the potential to dramatically affect the health and well-being of both mothers and newborns, including a measure focused on elective vaginal deliveries or cesarean sections before 39 weeks, as well as a measure focused on women receiving prophylactic antibiotics prior to a cesarean section.
- Patient Safety: Healthcare-Associated Infections Measures Project 2012
In January 20212, NQF endorsed four patient safety measures focused on healthcare-associated infections. During this project, two similar and competing surgical site infection measures from the Centers for Disease Control and Prevention and the American College of Surgeons were harmonized with NQF’s support.
- Surgery Measures Project 2012
In January 2012, NQF endorsed 24 quality measures on surgical care performed in hospitals and in outpatient facilities, including measures focused on complications in patients undergoing hip and knee replacements; prophylactic antibiotic use in surgical patients; and mortality rates for patients experiencing complications. In May 2012, nine additional measures were endorsed as part of this work, including a new measure evaluating patient experience of care following surgical procedures.
- Serious Reportable Events (SRE) Project 2011
Preventing adverse events in healthcare is central to NQF's patient safety efforts. To ensure that all patients are protected from injury while receiving care, NQF has developed and endorsed a set of Serious Reportable Events (SREs). This set is a compilation of serious, largely preventable, and harmful clinical events, designed to help the healthcare field assess, measure, and report performance in providing safe care.
- Safe Practices for Better Healthcare – 2010 Update
The Safe Practices for Better Healthcare – 2010 Update presents 34 practices that have been demonstrated to be effective in reducing the occurrence of adverse healthcare events. Additionally, the set can help healthcare providers assess the degree to which safe practices already have been implemented in their settings and the degree to which the practices provide tangible evidence of patient safety improvement and increased patient satisfaction and loyalty. With this update, healthcare organization leaders and governance boards are explicitly called on to be proactive by reviewing the safety of their organizations and continually improving the safety and thus the quality of care they provide. Safe Practice 22 updated in an ad hoc review and approved by the Board
- Safe Practices for Better Healthcare – 2009 Update
This project updated NQF’s Safe Practices for Better Healthcare and endorsed 34 Safe Practices. The Safe Practices were updated with current evidence and expanded implementation approaches. New practices were added including pediatric imaging, glycemic control, organ donation, catheter-associated urinary tract infection, and multi-drug resistant organisms
- NPP Readmissions and Maternity Action Teams
NPP formed two Action Teams comprised of nearly two-dozen stakeholders representing providers, purchasers, consumers, health plans, accreditation and certification bodies, and state, regional and local entities. Focused on improving maternity care and reducing hospital admissions and readmissions across multiple care settings, each group has developed plans of action that address the who, what, how and when of reducing hospital readmissions and harm.
