236 lines
51 KiB
HTML
236 lines
51 KiB
HTML
<!doctype html>
|
|
<!--[if lt IE 7]> <html class="no-js lt-ie9 lt-ie8 lt-ie7" lang="en"> <![endif]-->
|
|
<!--[if IE 7]> <html class="no-js lt-ie9 lt-ie8" lang="en"> <![endif]-->
|
|
<!--[if IE 8]> <html class="no-js lt-ie9" lang="en"> <![endif]-->
|
|
<!-- Consider adding a manifest.appcache: h5bp.com/d/Offline -->
|
|
<!--[if gt IE 8]><!--> <html class="no-js" lang="en"> <!--<![endif]-->
|
|
<head>
|
|
<meta charset="utf-8">
|
|
|
|
<meta name="perc_linkback" id="perc_linkback" content="FmZhZmxleAdmeAFjZ2x4BmZnYHgTZmFmYmY="/> <!-- Use the .htaccess and remove these lines to avoid edge case issues. More info: h5bp.com/i/378 -->
|
|
<meta http-equiv="X-UA-Compatible" content="IE=edge,chrome=1">
|
|
<title>Appendix C (continued) | AHRQ Archive</title>
|
|
<meta name="title" content="Appendix C (continued) | AHRQ Archive">
|
|
<meta name="description" content="Final Contract Report: Cost of Poor Quality or Waste in Integrated Delivery System Settings. The primary purpose of this IDSRN project was to collaboratively build a system that could be actively used to identify the costs of poor quality or waste in an effort to identify opportunities for improvement in hospital settings. The proposed identification strategy has been designed from a financial management perspective, recognizing that we are in the business of providing high-quality medical care.">
|
|
|
|
<!-- Mobile viewport optimized: h5bp.com/viewport -->
|
|
<meta name="viewport" content="width=device-width">
|
|
<!-- link rel="stylesheet" href="/css/style.css" -->
|
|
|
|
<!-- More ideas for your <head> here: h5bp.com/d/head-Tips -->
|
|
<!-- All JavaScript at the bottom, except this Modernizr build.
|
|
Modernizr enables HTML5 elements & feature detects for optimal performance.
|
|
Create your own custom Modernizr build: www.modernizr.com/ -->
|
|
<script src="/js/libs/modernizr-2.5.3.min.js"></script>
|
|
|
|
<!-- "metadata" -->
|
|
<meta name="keywords" content="Agency for Health Care Policy and Research, Agency for Healthcare Research and Quality, AHRQ, AHCPR, AIDS/HIV, ambulatory care, benchmark, child, cost, elderly, health cost, healthcare cost, hospital, long-term care, managed care, markets, mental health, methodology, minority health, nursing, nursing homes, outcome research, out-of-pocket spending, patient care, primary, primary care, research, rural, spending, study, Translating Research Into Practice, TRIP" />
|
|
<meta name="creator" content="Agency for Healthcare Research and Quality (AHRQ)">
|
|
<meta name="datecreated" content="September 2012">
|
|
<meta name="datereviewed" content="November 2014">
|
|
<meta name="language" content="en-us">
|
|
<!-- end="metadata" -->
|
|
<link rel="stylesheet" href="/css/archive.css">
|
|
<link rel="stylesheet" href="/css/ahrqstyleprint_arch.css" media="print">
|
|
<script>
|
|
(function(i,s,o,g,r,a,m){i['GoogleAnalyticsObject']=r;i[r]=i[r]||function(){
|
|
(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),
|
|
m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)
|
|
})(window,document,'script','//www.google-analytics.com/analytics.js','ga');
|
|
|
|
ga('create', 'UA-75759936-1', 'auto');
|
|
ga(' set', 'anonymizeIp', true);
|
|
|
|
ga('send', 'pageview');
|
|
|
|
</script></head>
|
|
<body><!-- Google Tag Manager -->
|
|
<noscript><iframe src="//www.googletagmanager.com/ns.html?id=GTM-W4DST4"
|
|
height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript>
|
|
<script>(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':
|
|
new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],
|
|
j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src=
|
|
'//www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);
|
|
})(window,document,'script','dataLayer','GTM-W4DST4');</script>
|
|
<!-- End Google Tag Manager -->
|
|
<!-- Prompt IE 6 users to install Chrome Frame. Remove this if you support IE 6.
|
|
chromium.org/developers/how-tos/chrome-frame-getting-started -->
|
|
<!--[if lt IE 7]><p class=chromeframe>Your browser is <em>ancient!</em> <a href="http://browsehappy.com/">Upgrade to a different browser</a> or <a href="http://www.google.com/chromeframe/?redirect=true">install Google Chrome Frame</a> to experience this site.</p><![endif]-->
|
|
|
|
<!-- Add your site or application content here -->
|
|
<noscript>Your browser doesn't support JavaScript. Please upgrade to a modern browser or enable JavaScript in your existing browser.</noscript>
|
|
<!-- Page Header v2.0 --><!--Begin Banner CodeS-->
|
|
<div id="ahrqbanner">
|
|
<div class="hhsportion" id="top" name="top">
|
|
<a class="skipnav" href="#h1">Skip Navigation</a>
|
|
<a title="Archive: U.S. Department of Health and Human Services" href="http://archive.hhs.gov/"><img border="0" alt="Archive: U.S. Department of Health and Human Services" src="/images/hhs_banner_arch.gif" width="376" height="49"></a>
|
|
<a class="hhsright" title="U.S. Department of Health and Human Services" href="http://www.hhs.gov/"><img alt="U.S. Department of Health and Human Services" src="/images/hhs_link_arch.gif" width="127" height="41"></a>
|
|
</div>
|
|
<div class="ahrqportion">
|
|
<a title="Archive: Agency for Healthcare Research Quality" href="/"><img border="0" alt="Archive: Agency for Healthcare Research Quality" src="/images/ahrq_banner_arch.jpg" width="566" height="69"></a>
|
|
<form id="banner_searchform" method="get" name="searchForm" action="https://search.ahrq.gov/search">
|
|
<label style="Z-INDEX: -1; POSITION: relative; FONT-SIZE: 0px; MARGIN-RIGHT: -65px" for="search">Search</label>
|
|
<input id="search" class="gotext" onfocus="this.value='';" value=" Search Archive" size="11" type="text" name="q" label="Search archive"/>
|
|
<input type="hidden" name="siteDomain" value="archive.ahrq.gov">
|
|
<input class="gobtn" onclick="javascript:document.searchForm.submit();" alt="Search" src="/images/topbn_GoButton.gif" type="image" name="Submit"/>
|
|
</form><a class="ahrqright" title="AHRQ Home—Live Site" href="http://www.ahrq.gov">www.ahrq.gov</a>
|
|
</div>
|
|
<div class="ahrqlinks">
|
|
<a href="https://www.ahrq.gov/">AHRQ Home—Live Site</a> | <a href="/">Archive Home</a> | <a href="/sitemap.htm">Site Map</a>
|
|
</div>
|
|
</div>
|
|
<div id="PrintBanner"><img alt="Archival print banner" src="/images/printbanner_arch.jpg"/></div><a id="h1" name="h1"></a><!-- End of Page header -->
|
|
<!-- Content Body -->
|
|
<div id="mainContent">
|
|
<!-- Main Content -->
|
|
<!-- Center Content section -->
|
|
<table border="0" cellpadding="0" cellspacing="0" width="100%">
|
|
<tbody><tr valign="top">
|
|
<td width="70%">
|
|
<!-- Center Content section -->
|
|
<table style="margin-left: 10px; margin-right: 10px; margin-top: 5px;" summary="This table gives the layout format of the bread crumb area and the center content area." border="0" cellpadding="0" cellspacing="0" width="100%">
|
|
<!--DWLayoutTable-->
|
|
<tbody><tr>
|
|
<td class="crumb_link"><div id="crumbContent">
|
|
</span></p>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
<tr>
|
|
<td>
|
|
<div id="centerContent">
|
|
<div class="headnote">
|
|
<p>This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: <a href="https://info.ahrq.gov/">https://info.ahrq.gov</a>. Let us know the nature of the problem, the Web address of what you want, and your contact information.</p>
|
|
<p>Please go to <a href="https://www.ahrq.gov/">www.ahrq.gov</a> for current information.</p>
|
|
</div>
|
|
<!-- T:ahrqPgPublication -->
|
|
<div role="main" id="page-container">
|
|
<div id="breadcrumb-container">
|
|
<div id="breadcrumbs" class="container_12">
|
|
<!-- T:SnBreadcrumbs -->
|
|
|
|
|
|
|
|
</div>
|
|
</div>
|
|
<div id="toolbar-container">
|
|
<div id="pub-toolbar" class="container_12">
|
|
<!-- T:ahrqSnPubNav -->
|
|
<div id="prev-next-buttons">
|
|
<a href="/research/findings/final-reports/costpqids/cpqidsappc.html" class="prev-button"><span>Previous Page</span></a>
|
|
<a href="/research/findings/final-reports/costpqids/cpqidsappd.html" class="next-button"><span>Next Page</span></a>
|
|
</div>
|
|
<div id="pub-utility-buttons">
|
|
<ul id="utility-groups">
|
|
<li class="utility content-button">
|
|
<a href="#" class=""><span>Table of Contents</span></a>
|
|
<div class="toc-dropdown">
|
|
<div class="arrow-up"></div>
|
|
<div class="toc-content">
|
|
</div>
|
|
</div>
|
|
</li>
|
|
<li class="utility download-button"><a href="#"><span>Download</span></a><div class="dl-dropdown"><div class="arrow-up"></div><div class="dl-content"><ul><li>
|
|
<span><a href="/research/findings/final-reports/costpqids/costpoorids.pdf">Cost of Poor Quality or Waste in Integrated Delivery System Settings: </a> [ <img src="/resources/file_logos/pdf.gif" alt="PDF file" title="PDF file" class="icon" /> - 504.63 KB]</span>
|
|
</li></ul></div></div></li> </ul>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div id="page-backdrop" class="container_12">
|
|
<div class="page">
|
|
<div id="left-col" class="alpha grid_3">
|
|
<nav id="left"><!-- T:SnleftNav -->
|
|
</nav> </div>
|
|
<!--<div id="content-col" class="grid_9">-->
|
|
<article class="grid_9">
|
|
<!-- Right Rail -->
|
|
<aside class="three-col">
|
|
<!-- T:ahrqSnPubCover -->
|
|
<div id="pub-nums">
|
|
<ul>
|
|
<li>Publication # 08-0096-EF</li> </ul>
|
|
</div>
|
|
|
|
</aside>
|
|
<!-- Center Rail -->
|
|
<h1>Appendix C (continued)</h1>
|
|
<h2>Cost of Poor Quality or Waste in Integrated Delivery System Settings</h2> <div id="basic-modal"><!-- start: Basic Modal -->
|
|
<a id="appc1" name="appc1"></a> <a id="Tab4" name="Tab4"></a><strong>Table 4. Summary of Error Risk and Description</strong> <table border="1" cellpadding="2" cellspacing="0" width="90%"><tbody><tr><th scope="col"><em>N</em></th><th scope="col">Risk</th><th scope="col">Description</th></tr><tr><td scope="row">8</td><td>Very low</td><td>Breakfast tray delivered to a fasting patient (removed before eaten), MD asked RN to obtain consent for bronchoscopy procedure (against hospital policy), electronic order entry errors (n=2) caught and corrected, Diazepam dose error (0.25 mg) on medication history form, Ofloxacin allergy listed in hospital information system was missing from MD and nursing history, premixed IV narcotics bag left at nurses' station, wrong preprinted name label attached to prescription slip (clerk caught and MD corrected error)</td></tr><tr><td scope="row">1</td><td>Low</td><td>Venipuncture repeated to correct a blood specimen labeling error</td></tr><tr><td scope="row">3</td><td>Moderate</td><td>RN copied 18 prescription drugs from patient history form to admission order form after MD wrote order to "continue previous meds," wrong medication strength found in electronic drug order file, pharmacist checking drug levels found Vancomycin dose not documented</td></tr><tr><td scope="row">4</td><td>High</td><td>Laboratory worker recapped a needle after processing a fluid specimen, technical worker assisted a patient out of bed despite postpacemaker insertion bedrest order, RN discovered wrong Total Parenteral Nutrition solution infusing,<a href="#star">*</a> MD found a worker administering oral contrast solution to a nauseated patient at high risk for aspiration despite cancelled order<a href="#star">*</a></td></tr></tbody></table><p><a id="star" name="star"> </a></p><p class="size2">*Worker-reported error.<br /><strong>Note:</strong> MD = medical doctor; RN = registered nurse; IV = intravenous.</p><p>Our intention is not to depict the observed workers as inattentive; in the majority of cases, quite the opposite was true. Most workers did not question the waste estimates during debriefing and welcomed the opportunity to assess their work process. Many workers offered illustrative examples of waste. An ICU physician in a teaching hospital estimated that at least half of the time he spends documenting is wasted by the need to locate information already recorded by others and by the repetition of day-to-day notes. A social worker indicated that delivering transportation vouchers and locating clothing wasted her time. A physical therapist expressed frustration over daily work interruptions related to the lack of designated physical therapy staff scheduling for the unit. A circulating nurse in a community hospital operating room described recurrent time wasted working around an inflexible, computerized, case cart system. A radiology technician, who spent 40% of the observation waiting for physician instructions, confirmed that waiting is a typical part of the daily work routine. The workers responded to problems by overcoming immediate obstacles and continuing work; management involvement was only observed once, when a phlebotomist mislabeled a blood specimen.</p><p>The following examples serve to illustrate typical responses to problems: When asked if the cramped workspace was distracting, a phlebotomist in an emergency department responded, "It's all part of the madness." A unit clerk, during a 1-hour morning observation, was interrupted 80 times while transcribing orders. A nurse opened an automated dispenser to retrieve a scheduled medication; even though the medication was available in the dispenser, it was missing from the electronic order file. The nurse sighed and then contacted a pharmacist to enter the order, delaying the medication administration by 10 minutes. During a routine review of drug-level results, a pharmacist discovered a Vancomycin dose missing from the electronic record. After briefly commenting on the fact that the drug levels indicated the dose was given, the pharmacist continued work without correcting the error. A physician, who found a worker erroneously administering oral contrast solution to a patient despite a cancelled written order, stopped the worker and had the clerk delete the order from the electronic record. When asked if he reported the problem or sought other remedies, he said, "I've tried it, and it doesn't do any good."</p><p>Time pressure was a prominent feature of the workflow, particularly of physician workflow. A physician in an urgent care clinic, who reported feeling fatigued because of limited sleep (related to clinical and academic demands) the previous night, was on the phone with his office receptionist and reviewing E-mail while four house staff waited for his time. An intensivist in a community hospital was conducting morning rounds with staff while writing orders and fielding interruptions. After finishing the discussion for each patient, the intensivist dictated a progress note on his mobile phone as other staff members waited. A conservative estimate of staff time spent waiting during the dictation was 42 minutes (not included in the waste estimates). During observation of two emergency department physicians, one did not hear his mobile phone ring, and the other hurried into an exam room and then suddenly stopped and remarked, "I forgot why I came in here." We could cite many other anecdotes that provide qualitative validation of our quantitative results.</p><h3>Discussion</h3><p>Our study suggests that the cost of waste for frontline health care worker activities is substantial. Given our data, the lowest cost of waste in caregiver activities for a single-day shift on one 46-bed medical unit (staffed with eight RNs, eight patient care technicians, two care managers, one social worker, one physical therapist, one pharmacist, one respiratory therapist, two clerks, and two hospitalists) is USD 2,309 (12 hours x 26 workers x 7.40 per hour); the annual cost for the same unit is USD 843,000 (USD 2,309 x 365). Because of our conservative assumptions, these estimates represent an underestimate. Tucker's estimates of the annual losses to operational failures (for nurses alone) in a 204-bed hospital with 75% occupancy range from a lower limit of USD 51,000 to a maximum of USD 27 million per year.<sup><a href="#ref11">11</a></sup></p><p>During the observations, workers spent less than half of their time engaged in operations. Nonoperational activities were almost evenly split between clarifying (20%), processing (19%), and motion (17%). The subgroup analyses suggested physicians and supervisory RNs spent more time and technicians spent less time than the overall average in clarification activities. Given the nature of their functions, these data are not surprising, and one might argue that time spent by more senior health care workers in clarification activities is important. We note that some of the clarification may be necessary aspects of training given the current methods used in academic teaching hospitals. Outside of training, one could argue that clarification activities indicate a lack of specified processes and a high tolerance for ambiguity,<sup><a href="#ref42">42</a>,<a href="#ref43">43</a></sup> resulting in greater waste of the most experienced workers in our system. It is easy to make the case that redundant documentation or paperwork is an unproductive use of workers' time. Despite the advanced information technology available at Intermountain, redundant documentation and paperwork were not infrequent. Other investigators who have included observation methods to evaluate information technology in clinical work reported unanticipated results that would not have been uncovered without the qualitative data.<sup><a href="#ref44">44</a></sup> It is self-evident that motion (i.e., traveling, locating, and waiting) is wasteful and should be minimized whenever possible.</p><h3>Limitations</h3><p>The main study limitations relate to sampling and the observation method. Although our sample was larger than most observational studies, we note that it was a small, nonrandom sample. A larger sample with more complete representation across job classes would strengthen the external validity of our research. Other factors that limit the external validity of our results include the short duration of observation and the limiting of observation periods to weekday mornings and afternoons. With the exception of the urgent care clinic physician, the endoscopy nurse, and the radiology technician, only inpatient hospital staff were observed. In addition, we were unable to evaluate time spent on problem resolution and differences in work activities related to worker roles, experiences, or time of day.</p><p>The observation method, which is inherently subjective, has several limitations. The data collection tool was newly developed, and although reliability appears good for capturing general frontline worker activities, formal validation would strengthen the results. The activity categories are explicitly defined but may not be useful for nonfrontline staff (e.g., management, leadership, ancillary support staff). Our analysis did not lend itself to a full description of shifts between activities or multitasking that was particularly apparent in physician and RN work. Finally, we did not test the reliability of the coding scheme for problems or error severity.</p><h3>Conclusions</h3><p>Despite the limitations, the data are consistent with other reports of persistent workplace and patient safety problems within our current health care system.<sup><a href="#ref11">11</a>,<a href="#ref45">45-47</a></sup> With the intent to guide quantitative study and generate hypotheses for future research, this study advances our understanding of the magnitude of the problem and the heterogeneity of the sample adds to the literature. Validation of the data with observed workers, our reliability assessment, explicit assumptions, and standardized data collection also lend credibility to the study. We noted a number of similarities between our study and another investigation with respect to daily operational problems, including problems' frequent occurrence and repetitive nature, as well as similar worker problem-solving behavior and a lack of management involvement.<sup><a href="#ref11">11</a></sup> Time pressure, a tolerance for ambiguity, and insufficient cross-departmental communication most likely contributed to the poor operational quality observed.<sup><a href="#ref11">11</a>,<a href="#ref36">36</a>,<a href="#ref42">42</a>,<a href="#ref48">48</a></sup> The participating institutions are nationally recognized for their excellence; therefore, our results are not explainable on the basis of selecting poor quality health systems.</p><p>Our results indicate that attention to operational quality is needed and could potentially improve patient safety. Results can be used to justify in-depth examination of targeted processes. In particular, results suggest the following recommendations for quality/safety initiatives:</p><ol><li>Minimize the need for clarification by explicitly specifying work processes and integrating problem-solving resources into the daily work flow.</li><li>Focus attention on nursing supervisors and care managers—those roles with the highest observed cost of waste for nonphysician staff.</li><li>Eliminate unnecessary documentation and paperwork.</li><li>Investigate and target unnecessary workflow disruptions.</li><li>Design facilities with attention to travel patterns and locate services where they are most accessible to users.</li></ol><p>Recent successful use of TPS (or "lean") principles in health care have shown promise as a global operational quality improvement intervention.<sup><a href="#ref42">42</a>,<a href="#ref43">43</a>,<a href="#ref47">47</a>,<a href="#ref49">49-55</a></sup> Successful application of TPS principles in other industries has created competitive, flexible organizations with the capacity to deliver operational excellence despite constant change.<sup><a href="#ref1">1</a>,<a href="#ref42">42</a>,<a href="#ref56">56-60</a></sup> The overarching goal of the TPS is the pursuit of ideal product or service delivery. In health care, ideal is defined as exactly what the patients need, when they need it, with immediate response to problems, without error or waste, in a physically, emotionally, and professionally safe environment<sup><a href="#ref61">61</a></sup> Four organizing principles guide the pursuit of ideal health care delivery:<sup><a href="#ref61">61</a></sup></p><ol><li>Work activities are highly specified as to content, sequence, timing, and outcome.</li><li>Pathways for all services are simple and direct.</li><li>Requests and customer-supplier connections are simple, direct, and unambiguous.</li><li>Improvements are made as close to the work as possible, by those most familiar with the work, guided by a coach trained in the use of the principles. All workers, at all levels, are taught to apply the principles and to maintain a relentless focus on solving operational process problems. The methods and tools employed to enact the principles are varied (e.g., standardized work, cross-trained workers, standardized problem solving using the A3 method),<sup><a href="#ref1">1</a>,<a href="#ref50">50-52</a>,<a href="#ref56">56</a>,<a href="#ref62">62-65</a></sup> but the emphasis on principles is critical.</li></ol><p>Health care leaders, policy makers, and health services researchers have been unsuccessfully seeking a cure for the escalating cost of health care. None of the change programs used so far (e.g., total quality management, continuous quality improvement, quality circles, work redesign, matrix structures, information technology, pay-for-performance) have been shown to successfully slow unsustainable growth in health care spending. This is not to imply that such efforts are of no value, but it is hard to argue that more of the same will produce different results.</p><p>Currently, it is too early to cite a model of health care TPS success,<sup><a href="#ref42">42</a></sup> but substantial evidence of successful transformation in manufacturing and other service industries should capture the attention of health care leadership.<sup><a href="#ref1">1</a>,<a href="#ref42">42</a>,<a href="#ref56">56-60</a></sup> There is no standard for implementing TPS principles, but there are key requirements for managing TPS-driven change.<sup><a href="#ref1">1</a>,<a href="#ref42">42</a>,<a href="#ref55">55</a>,<a href="#ref61">61</a>,<a href="#ref66">66</a>,<a href="#ref67">67</a></sup> First, view people as the organization's most important resource. It is hypothesized that developing frontline problem-solving capacity will lead to receding waste. Second, emphasize process over content. Third, recognize the limitation of across-the-board programmatic change; sustainable change is a learning process that spreads unit by unit or department to department. Fourth, discard the idea of a quick fix and persist for the long term. Fifth, prepare for management roles to change from that of solution giver/strategic planner to mentor/competency developer. Line managers will become problem-solving coaches. Middle managers will support line managers by participating on cross-functional teams, developing line-manager competencies, and communicating across departmental boundaries. Upper management will provide the vision, commitment, resources, and corporate structure to remove barriers to change. Finally, remember that if upper management does not "apply to themselves what they have been encouraging their general managers to do, the whole process can break down."<sup><a href="#ref66">66</a></sup> Frontline caregivers are responsible for the quality and safety of care delivery; increased attention to and support for the effectiveness of their activities is requisite for sustainable health system improvement.</p><h3>References</h3><p><a id="ref1" name="ref1"></a>1.Womack J, Jones D. Lean thinking: banish waste and create wealth in your corporation, revised and updated. New York: Simon and Schuster; 1996.<br /><br /> <a id="ref2" name="ref2"></a>2. Ohno T. The Toyota production system: beyond large scale manufacturing. New York: Productivity Press; 1988.<br /><br /> <a id="ref3" name="ref3"></a>3. Center for Medicare & Medicaid Services. National health care expenditures projections: 2004-2014. Center for Medicare & Medicaid Services; 2006.<br /><br /> <a id="ref4" name="ref4"></a>4. Sager A, Socolar D. Health care costs absorb one-quarter of economic growth, 2000�2005. Boston University School of Public Health; 2005.<br /><br /> <a id="ref5" name="ref5"></a>5. Reinhardt U, Hussey P, Anderson GF. U.S. health care spending in an international context. <em>Health Affairs (Millwood)</em> 2004;23(3):10-25.<br /><br /> <a id="ref6" name="ref6"></a>6. Hussey P, Anderson G, Osborn R, et al. How does the quality of care compare in five countries? <em>Health Affairs (Millwood)</em> 2004;23(3):89-99.<br /><br /> <a id="ref7" name="ref7"></a>7. Strunk B, Ginsburg P, Cookson J. Tracking health care costs: declining growth trend pauses in 2004. <em>Health Affairs</em>. Epub 2005 Jun 21.<br /><br /> <a id="ref8" name="ref8"></a>8. Whittington D, McLaughlin C. Finding time for patients: an exploration of nurses' time allocation in an acute psychiatric setting. <em>Journal of Psychiatric and Mental Health Nursing</em> 2000;7(3):259-68.<br /><br /> <a id="ref9" name="ref9"></a>9. Degerhammar M, Wade B. The introduction of a new system of care delivery into a surgical ward in Sweden. <em>International Journal of Nursing Studies</em> 1991;28(4):325-36.<br /><br /> <a id="ref10" name="ref10"></a>10. Potter P, Boxerman S, Wolf L, et al. Mapping the nursing process: a new approach for understanding the work of nursing. <em>Journal of Nursing Administration</em> 2004;34(2):101-9.<br /><br /> <a id="ref11" name="ref11"></a>11. Tucker A. The impact of operational failures on hospital nurses and their patients. <em>Journal of Operations Management</em> 2004;22:151-69.<br /><br /> <a id="ref12" name="ref12"></a>12. Biaggi P, Peter S, Ulich E. Stressors, emotional exhaustion and aversion to patients in residents and chief residents-what can be done? <em>Swiss Medical Weekly</em> 2003;133(23�24):339-46.<br /><br /> <a id="ref13" name="ref13"></a>13. Lurie N, Rank B, Parenti C, Woolley T, Snoke W. How do house officers spend their nights? A time study of internal medicine house staff on call. <em>New England Journal of Medicine</em> 1989;320(25):1673-7.<br /><br /> <a id="ref14" name="ref14"></a>14. Knickman JR, Lipkin M Jr, Finkler SA, Thompson WG, Kiel J. The potential for using non-physicians to compensate for the reduced availability of residents. <em>Academic Medicine: Journal of the Association of American Medical Colleges</em>.1992;67(7):429-38.<br /><br /> <a id="ref15" name="ref15"></a>15. Gillanders W, Heiman M. Time study comparisons of 3 intern programs. <em>Journal of Medical Education</em> 1971;46(2):142-9.<br /><br /> <a id="ref16" name="ref16"></a>16. Yoon R, Chapman R, Gourley DR, Murphy JE, Ward ES. Multidimensional work sampling to quantify a pharmacokinetics resident's duties. <em>American Journal of Hospital Pharmacy</em> 1990;47(8):1785-90.<br /><br /> <a id="ref17" name="ref17"></a>17. Hollingsworth JC, Chisholm CD, Giles BK, Cordell WH, Nelson DR. How do physicians and nurses spend their time in the emergency department? <em>Annals of Emergency Medicine</em> 1998;31(1):87-91.<br /><br /> <a id="ref18" name="ref18"></a>18. Ashton CM, Wray NP, Friedland JA, Zollo AJ, Scheurich JW. The association between residents' work-rounds styles and the process and outcome of medical care. <em>Journal of General Internal Medicine</em> 1994;9(4):208-12.<br /><br /> <a id="ref19" name="ref19"></a>19. Bartholomeyczik S, Hunstein D. Time distribution of selected care activities in home care in Germany. <em>Journal of Clinical Nursing</em> 2004;13(1):97-104.<br /><br /> <a id="ref20" name="ref20"></a>20. Burke TA, McKee JR, Wilson HC, et al. A comparison of time-and-motion and self-reporting methods of work measurement. <em>Journal of Nursing Administration</em> 2000;30(3):118-25.<br /><br /> <a id="ref21" name="ref21"></a>21. Caughey MR, Chang BL. Computerized data collection: example of a time-motion study. <em>Western Journal of Nursing Research</em> 1998;20(2):251-6.<br /><br /> <a id="ref22" name="ref22"></a>22. Dickson WM. Measuring pharmacist time use: a note on the use of fixed-interval work sampling. <em>American Journal of Hospital Pharmacy</em> 1978;35(10):1241-3.<br /><br /> <a id="ref23" name="ref23"></a>23. Finkler SA, Knickman JR, Hendrickson G, Lipkin MJr, Thompson WG. A comparison of work-sampling and time-and-motion techniques for studies in health services research. <em>Health Services Research</em> 1993;28(5):577-97.<br /><br /> <a id="ref24" name="ref24"></a>24. France DJ, Levin S, Hemphill R, et al. Emergency physicians' behaviors and workload in the presence of an electronic whiteboard. <em>International Journal Of Medical Informatics</em> 2005;74(10):827-37.<br /><br /> <a id="ref25" name="ref25"></a>25. Gagnon AJ, Waghorn K. Supportive care by maternity nurses: a work sampling study in an intrapartum unit. <em>Birth</em> 1996;23(1):1-6.<br /><br /> <a id="ref26" name="ref26"></a>26. Hall LM, O'Brien-Pallas L. Redesigning nursing work in long-term care environments. <em>Nursing Economics</em> 2000;18(2):79-87.<br /><br /> <a id="ref27" name="ref27"></a>27. Korst LM, Eusebio-Angeja AC, Chamorro T, Aydin CE, Gregory KD. Nursing documentation time during implementation of an electronic medical record. <em>Journal of Nursing Administration</em> 2003;33(1):24-30.<br /><br /> <a id="ref28" name="ref28"></a>28. Norman IJ, Redfern SJ, Oliver S, Tomalin DA. Evaluation of Kitson's therapeutic nursing function matrix in the assessment of quality of nursing care in hospital. <em>International Journal of Nursing Studies</em> 1994;31(4):337-48.<br /><br /> <a id="ref29" name="ref29"></a>29. Potter P, Wolf L, Boxerman S et al. Understanding the cognitive work of nursing in the acute care environment. <em>Journal of Nursing</em> Administration 2005;35(7-8):327-35.<br /><br /> <a id="ref30" name="ref30"></a>30. Rascati KL, Kimberlin CL, McCormick WC. Work measurement in pharmacy research. <em>American Journal of Hospital Pharmacy</em> 1986;43(10):2445-52.<br /><br /> <a id="ref31" name="ref31"></a>31. Segall LE, Kotzan JA. Comparison of two methods of observing work areas in a hospital pharmacy. <em>American Journal of Hospital Pharmacy</em> 1979;36(1):59-63.<br /><br /> <a id="ref32" name="ref32"></a>32. Stange KC, Zyzanski SJ, Jaen CR et al. Illuminating the 'black box'. A description of 4454 patient visits to 138 family physicians. The Journal of Family Practice 1998;46(5):377-89.<br /><br /> <a id="ref33" name="ref33"></a>33. Thomas LH. Comparing qualified nurse and auxiliary roles. <em>Nursing Times</em> 1993;89(38):45-8.<br /><br /> <a id="ref34" name="ref34"></a>34. Wikstrom AC, Satterlund Larsson U. Patient on display-a study of everyday practice in intensive care. <em>Journal of Advanced Nursing</em> 2003;43(4):376-83.<br /><br /> <a id="ref35" name="ref35"></a>35. Wirth P, Kahn L, Perkoff GT. Comparability of two methods of time and motion study used in a clinical setting: work sampling and continuous observation. <em>Medical Care</em> 1977;15(11):953-60.<br /><br /> <a id="ref36" name="ref36"></a>36. Tucker A, Edmondson A. Why hospitals don't learn from failures: organizational and psychological dynamics that inhibit system change. <em>California Management Review</em> 2003;45(2):55-72.<br /><br /> <a id="ref37" name="ref37"></a>37. Synergy Management Solutions Inc. Healthcare Salaries. WageAccess; 2005.<br /><br /> <a id="ref38" name="ref38"></a>38. The-Travel-Nurse.com. Medical and Public Health Social Worker Salaries; 2005.<br /><br /> <a id="ref39" name="ref39"></a>39. Guide Medical Student Resource. Salary Information for Physician Jobs; 2005.<br /><br /> <a id="ref40" name="ref40"></a>40. Guide Technician Salary. Phlebotomy Technicians; 2005.<br /><br /> <a id="ref41" name="ref41"></a>41. Fleiss J. Statistical methods for rates and proportions. New York: J Wiley & Sons, Inc.; 1981.<br /><br /> <a id="ref42" name="ref42"></a>42. Spear SJ. Fixing health care from the inside, today. <em>Harvard Business Review</em> 2005;83(9):78-91, 158.<br /><br /> <a id="ref43" name="ref43"></a>43. Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. <em>Annals of Internal Medicine</em> 2005;142(8):627-30.<br /><br /> <a id="ref44" name="ref44"></a>44. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. <em>Journal of the American Medical Association</em> 2005;293(10):1197-203.<br /><br /> <a id="ref45" name="ref45"></a>45. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.<br /><br /> <a id="ref46" name="ref46"></a>46. Institute of Medicine. Keeping patients safe: transforming the work environment of nurses. Washington, DC: National Academy of Sciences; 2003.<br /><br /> <a id="ref47" name="ref47"></a>47. Thompson DN, Wolf GA, Spear SJ. Driving improvement in patient care: lessons from Toyota. Journal of Nursing Administration 2003;33(11):585-95.<br /><br /> <a id="ref48" name="ref48"></a>48. Spear S. The essence of just-in-time: embedding diagnostic tests in work-systems to achieve operational excellence. <em>Production Planning and Control</em> 2002;13(8):754-7.<br /><br /> <a id="ref49" name="ref49"></a>49. Bahensky JA, Roe J, Bolton R. Lean sigma—will it work for healthcare? <em>Journal of Healthcare Information Management</em> 2005;19(1):39-44.<br /><br /> <a id="ref50" name="ref50"></a>50. Jimmerson C, Weber D, Sobek D. Reducing waste and errors: piloting lean principles at Intermountain Health Care. <em>JCAHO Journal of Quality Safety</em> 2005;31(5):249-57.<br /><br /> <a id="ref51" name="ref51"></a>51. Sobek D, Jimmerson C. A3 reports: tools for process improvement and organizational transformation; 2004.<br /><br /> <a id="ref52" name="ref52"></a>52. Sobek D. Applying the Toyota Production System to a hospital pharmacy; 2003.<br /><br /> <a id="ref53" name="ref53"></a>53. Stankovic AK. The laboratory is a key partner in assuring patient safety. <em>Clinics in Laboratory Medicine</em> 2004;24(4):1023-35.<br /><br /> <a id="ref54" name="ref54"></a>54. Sunyog M. Lean management and six-sigma yield big gains in hospital's immediate response laboratory. Quality improvement techniques save more than $400,000. <em>Clinical Leadership & Management Review: The Journal of CLMA</em> 2004;18(5):255-8.<br /><br /> <a id="ref55" name="ref55"></a>55. Womack J, Byrne A, Flume O, Kaplan G, Toussaint J. Going lean in health care. Cambridge: Institute for Healthcare Improvement; 2005.<br /><br /> <a id="ref56" name="ref56"></a>56. Sosbe T. DuPont: innovating with six sigma. 2005. Chief Learning Officer Media; 2004.<br /><br /> <a id="ref57" name="ref57"></a>57. Swank CK. The lean service machine. <em>Harvard Business Review</em> 2003;81(10):123-9, 138.<br /><br /> <a id="ref58" name="ref58"></a>58. Womack J, Jones D, Roos D. The machine that changed the world: the story of lean production. New York: Rawson Associates; 1990.<br /><br /> <a id="ref59" name="ref59"></a>59. Kenagy JW, Berwick DM, Shore MF. Service quality in health care. <em>Journal of the American Medical Association</em> 1999;281(7):661-5.<br /><br /> <a id="ref60" name="ref60"></a>60. WMEP. American Laser Products generates success with lean transformation. 2005. Wisconsin Manufacturing Extension Partnership; 2004.<br /><br /> <a id="ref61" name="ref61"></a>61. Spear S, Bowen HK. Decoding the DNA of the Toyota production system. <em>Harvard Business Review</em> 1999;96-106.<br /><br /> <a id="ref62" name="ref62"></a>62. Rother M, Shook J. Learning to see: value stream mapping to create value and eliminate muda. Brookline (MA): The Lean Enterprise Institute, 2003.<br /><br /> <a id="ref63" name="ref63"></a>63. Jimmerson C. reView: Realizing Value in Everyday Work; 2003.<br /><br /> <a id="ref64" name="ref64"></a>64. Sebesta R, Rohe D. Visual Control; 2005.<br /><br /> <a id="ref65" name="ref65"></a>65. Liker J. The Toyota way. New York: McGraw-Hill; 2004.<br /><br /> <a id="ref66" name="ref66"></a>66. Beer M, Eisenstat RA, Spector B. Why change programs don't produce change. <em>Harvard Business Review</em> 1990;68(6):158-66.<br /><br /> <a id="ref67" name="ref67"></a>67. Flinchbaugh J. Beyond lean. Lean Learning Center; 2005.</p><p><a id="TabA1" name="TabA1"> </a></p><h3>Appendix</h3><p><strong>Table A-1. Salary Table</strong></p><table border="1" cellpadding="2" cellspacing="0" width="70%"><tbody><tr><th colspan="2" scope="col">Average Salary</th><th scope="col">Average Fringe</th><th scope="col">Cost/Hour</th></tr><tr><th scope="col">Role</th><th align="center" scope="col">(USD)</th><th align="center" scope="col">(USD)</th><th align="center" scope="col">(USD)</th></tr><tr><td scope="row">RN bedside, non-ICU, ICU, emergency department, labor/delivery, PACU, operating room, outpatient</td><td align="center">27.14</td><td align="center">8.142</td><td align="center">35.282</td></tr><tr><td scope="row">RN house supervisor, care manager</td><td align="center">36.76</td><td align="center">11.028</td><td align="center">47.788</td></tr><tr><td scope="row">Pharmacist</td><td align="center">41.11</td><td align="center">12.333</td><td align="center">53.443</td></tr><tr><td scope="row">Physical therapist</td><td align="center">29.35</td><td align="center">8.805</td><td align="center">38.155</td></tr><tr><td scope="row">Respiratory therapist</td><td align="center">20.76</td><td align="center">6.228</td><td align="center">26.988</td></tr><tr><td scope="row">Clinical social worker</td><td align="center">19.10</td><td align="center">5.730</td><td align="center">24.830</td></tr><tr><td scope="row">Unit secretary/clerk</td><td align="center">13.99</td><td align="center">4.197</td><td align="center">18.187</td></tr><tr><td scope="row">Technical—pharmacy technician</td><td align="center">10.70</td><td align="center">3.210</td><td align="center">13.910</td></tr><tr><td scope="row">Technical—bedside patient care</td><td align="center">11.89</td><td align="center">3.567</td><td align="center">15.457</td></tr><tr><td scope="row">Technical—phlebotomist/specimen processor</td><td align="center">10.55</td><td align="center">3.165</td><td align="center">13.715</td></tr><tr><td scope="row">Technical—medical lab technician</td><td align="center">17.93</td><td align="center">5.379</td><td align="center">23.309</td></tr><tr><td scope="row">Technical—radiology technician</td><td align="center">23.81</td><td align="center">7.143</td><td align="center">30.953</td></tr><tr><td scope="row">Technical—central processing equipment tech</td><td align="center">10.46</td><td align="center">3.138</td><td align="center">13.598</td></tr><tr><td scope="row">Technical—cardiac catheterization lab tech</td><td align="center">17.93</td><td align="center">5.379</td><td align="center">23.309</td></tr><tr><td scope="row">Technical—surgical scrub</td><td align="center">15.36</td><td align="center">4.608</td><td align="center">19.968</td></tr><tr><td scope="row">MD, intensive medicine</td><td align="center">90.50</td><td align="center">0.000</td><td align="center">90.4962</td></tr><tr><td scope="row">MD, emergency department</td><td align="center">94.35</td><td align="center">0.000</td><td align="center">94.3487</td></tr><tr><td scope="row">MD, internal medicine</td><td align="center">70.98</td><td align="center">0.000</td><td align="center">70.9799</td></tr><tr><td scope="row">MD, hospitalist</td><td align="center">70.98</td><td align="center">0.000</td><td align="center">70.9799</td></tr></tbody></table><p class="size2"><strong>Note:</strong> RN = registered nurse; ICU = intensive care unit; PACU = post-anesthesia care unit; MD = medical doctor.</p><p><a id="TabA2" name="TabA2"> </a></p><p><strong>Table A-2. Activity Data: Percentage of Overall Observation Time (N=61): All Staff Groups and Hospitals Combined</strong></p><table border="1" cellpadding="2" cellspacing="0" width="70%"><tbody><tr><th scope="col">Waste Activity</th><th scope="col">Mean (5)</th><th scope="col">CI -95.000% (%)</th><th scope="col">CI +95.000% (%)</th><th scope="col">Minimum (%)</th><th scope="col">Maximum (%)</th><th scope="col">Range (%)</th><th scope="col">Std. Dev. (%)</th><th scope="col">Standard Error (%)</th></tr><tr><td scope="row">Operations</td><td align="center">40.75</td><td align="center">34.7</td><td align="center">46.8</td><td align="center">0.0</td><td align="center">97.5</td><td align="center">97.5</td><td align="center">23.7</td><td align="center">3.0</td></tr><tr><td scope="row">Defect</td><td align="center">1.76</td><td align="center">0.7</td><td align="center">2.8</td><td align="center">0.0</td><td align="center">21.3</td><td align="center">21.3</td><td align="center">4.3</td><td align="center">0.5</td></tr><tr><td scope="row">Error</td><td align="center">0.45</td><td align="center">-0.1</td><td align="center">1.0</td><td align="center">0.0</td><td align="center">15.0</td><td align="center">15.0</td><td align="center">2.2</td><td align="center">0.3</td></tr><tr><td scope="row">Clarifying</td><td align="center">19.64</td><td align="center">14.0</td><td align="center">25.3</td><td align="center">0.0</td><td align="center">89.5</td><td align="center">89.5</td><td align="center">22.0</td><td align="center">2.8</td></tr><tr><td scope="row">Documentation</td><td align="center">7.37</td><td align="center">5.1</td><td align="center">9.6</td><td align="center">0.0</td><td align="center">28.8</td><td align="center">28.8</td><td align="center">8.7</td><td align="center">1.1</td></tr><tr><td scope="row">Paperwork</td><td align="center">8.02</td><td align="center">4.8</td><td align="center">11.2</td><td align="center">0.0</td><td align="center">57.3</td><td align="center">57.3</td><td align="center">12.4</td><td align="center">1.6</td></tr><tr><td scope="row">Doc/PW</td><td align="center">15.39</td><td align="center">11.7</td><td align="center">19.1</td><td align="center">0.0</td><td align="center">57.3</td><td align="center">57.3</td><td align="center">14.3</td><td align="center">1.8</td></tr><tr><td scope="row">Preparation</td><td align="center">2.73</td><td align="center">1.5</td><td align="center">3.9</td><td align="center">0.0</td><td align="center">20.5</td><td align="center">20.5</td><td align="center">4.7</td><td align="center">0.6</td></tr><tr><td scope="row">Materials/stocking</td><td align="center">0.99</td><td align="center">0.2</td><td align="center">1.8</td><td align="center">0.0</td><td align="center">12.7</td><td align="center">12.7</td><td align="center">3.0</td><td align="center">0.4</td></tr><tr><td scope="row">Travel</td><td align="center">9.64</td><td align="center">7.3</td><td align="center">12.0</td><td align="center">0.0</td><td align="center">38.2</td><td align="center">38.2</td><td align="center">9.2</td><td align="center">1.2</td></tr><tr><td scope="row">Locating</td><td align="center">1.80</td><td align="center">1.2</td><td align="center">2.4</td><td align="center">0.0</td><td align="center">9.3</td><td align="center">9.3</td><td align="center">2.4</td><td align="center">0.3</td></tr><tr><td scope="row">Waiting</td><td align="center">5.79</td><td align="center">3.5</td><td align="center">8.1</td><td align="center">0.0</td><td align="center">39.6</td><td align="center">39.6</td><td align="center">8.9</td><td align="center">1.1</td></tr><tr><td scope="row">Other</td><td align="center">1.07</td><td align="center">0.5</td><td align="center">1.6</td><td align="center">0.0</td><td align="center">9.2</td><td align="center">9.2</td><td align="center">2.2</td><td align="center">0.3</td></tr><tr><td scope="row">Breaks</td><td align="center">0.6</td><td align="center">0.1</td><td align="center">1.0</td><td align="center">0.0</td><td align="center">8.3</td><td align="center">8.3</td><td align="center">1.8</td><td align="center">0.2</td></tr><tr><td scope="row">Total (no breaks)</td><td align="center">100.0</td><td align="center">100.0</td><td align="center">100.0</td><td align="center">100.0</td><td align="center">100.0</td><td align="center">0.0</td><td align="center">0.0</td><td align="center">0.0</td></tr></tbody></table><p class="size2"><strong>Note:</strong> Doc/PW = documentation and paperwork; CI = confidence interval.</p><p class="size2"><a href="/research/findings/final-reports/costpqids/cpqidsappd.html">Proceed to Appendix D</a></p> </div><!-- end: Basic Modal -->
|
|
<div class="current-as-of">Page last reviewed September 2008</div>
|
|
<div class="citation">
|
|
<span>Internet Citation: Appendix C (continued): Cost of Poor Quality or Waste in Integrated Delivery System Settings.
|
|
September 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/research/findings/final-reports/costpqids/cpqidsappc1.html</span>
|
|
<div class="citation-flag"></div>
|
|
</div>
|
|
</article>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<p> </p>
|
|
<div class="footnote">
|
|
<p> The information on this page is archived and provided for reference purposes only.</p>
|
|
</div>
|
|
<p> </p>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
</tbody>
|
|
</table>
|
|
</td>
|
|
</tr>
|
|
</tbody>
|
|
</table>
|
|
</div><!-- End of Content Body -->
|
|
<!-- Footer graphic 1.2-->
|
|
<table border="0" cellSpacing="0" cellPadding="0" width="100%">
|
|
<tbody>
|
|
<tr>
|
|
<td background="/images/bottom_ahrq_bkg.jpg" width="125">
|
|
<img alt="AHRQ" src="/images/bottom_ahrq_1.jpg" width="125">
|
|
</td>
|
|
<td background="/images/bottom_ahrq_bkg.jpg" width="100%">
|
|
<img alt="" src="/images/bottom_ahrq_bkg.jpg" width="10" height="34">
|
|
</td>
|
|
<td background="/images/bottom_ahrq_bkg.jpg" width="310">
|
|
<img alt="Advancing Excellence in Health Care" src="/images/bottom_ahrq_2.gif" width="310" height="34">
|
|
</td>
|
|
</tr>
|
|
</tbody>
|
|
</table>
|
|
<!-- Footer links section -->
|
|
<div id="banner_Footer2">
|
|
<p>
|
|
<a href="https://www.ahrq.gov/">AHRQ Home</a> |
|
|
<a class="footer_navlink" href="https://info.ahrq.gov/cgi-bin/ahrq.cfg/php/enduser/std_alp.php">Questions?</a> |
|
|
<a class="footer_navlink" href="https://www.ahrq.gov/contact/index.html">Contact AHRQ</a> |
|
|
<a class="footer_navlink" href="https://www.ahrq.gov/policy/electronic/accessibility/index.html">Accessibility</a> |
|
|
<a class="footer_navlink" href="https://www.ahrq.gov/policy/electronic/privacy/index.html">Privacy Policy</a> |
|
|
<a class="footer_navlink" href="https://www.ahrq.gov/news/foia.htm">Freedom of Information Act</a> |
|
|
<a class="footer_navlink" href="https://www.ahrq.gov/policy/electronic/disclaimers/index.html">Disclaimers</a> |
|
|
<a class="footer_navlink" href="http://www.hhs.gov/open/recordsandreports/plainwritingact/index.html">Plain Writing Act</a>
|
|
<br/>
|
|
<a class="footer_navlink" href="http://www.hhs.gov">U.S. Department of Health & Human Services</a> |
|
|
<a class="footer_navlink" href="http://www.whitehouse.gov">The White House</a> |
|
|
<a class="footer_navlink" href="http://www.usa.gov">USA.gov: The U.S. Government's Official Web Portal</a>
|
|
</p>
|
|
</div>
|
|
<div id="banner_Footeraddress">
|
|
<p>
|
|
Agency for Healthcare Research and Quality <img alt="" src="/images/bottom_dot.gif"> 5600 Fishers Lane Rockville, MD 20857 <img alt="" src="/images/bottom_dot.gif">
|
|
Telephone: (301) 427-1364
|
|
</p>
|
|
</div>
|
|
<!-- End of Footer links section -->
|
|
|
|
<!-- JavaScript at the bottom for fast page loading: http://developer.yahoo.com/performance/rules.html#js_bottom -->
|
|
<!-- Grab Google CDN's jQuery, with a protocol relative URL; fall back to local if offline -->
|
|
<script src="//ajax.googleapis.com/ajax/libs/jquery/1.7.2/jquery.min.js"></script>
|
|
<script>window.jQuery || document.write('<script src="js/libs/jquery-1.7.2.min.js"><\/script>')</script>
|
|
|
|
<!-- scripts concatenated and minified via build script -->
|
|
<script src="/js/plugins.js"></script>
|
|
<script src="/js/script.js"></script>
|
|
<script src="/scripts/javascript.js"></script>
|
|
<!-- end scripts -->
|
|
</body>
|
|
</html>
|