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pcmh.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
December 01, 2017 - Step 1: Diagnose the Problem
Step 2: Plan and Implement Best Practices
Step 3: Measure Results and … performance improvement rationale, goals, barriers, and anticipated resources required
The Project Plan … of a number of conditions for which hospitals do not receive the higher payment for cases when the condition … responsibilities and set timeline
This figure includes the team responsibilities section of the implementation plan … Useful Tools
Improvement Methods (D.1)
Best Practices (D.4)
Gap Analysis (D.5)
Implementation Plan
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pcmh.ahrq.gov/sites/default/files/wysiwyg/evidencenow/cooperatives/evidencenow-executive-summary-southwest.pdf
November 01, 2017 - months of support
consisting of:
• A practice transformation support team: practice
facilitator, clinical … At baseline, a bit more than half reported their EHRs had
prompts for chronic condition monitoring or … Less than a third used standing orders for chronic condition
monitoring or prevention. … Publications:
• Health Extension and Clinical and Translational
Science: An Innovative Strategy for … the EvidenceNOW Southwest Trial to
Improve Cardiovascular Health [NAPCRG, 2017]
• Using Electronic Clinical
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pcmh.ahrq.gov/teamstepps-program/curriculum/situation/tools/step.html
June 01, 2023 - settings helping residents improve physical mobility, or for teams in other care settings. … Medications
Physical exam
Care plan
Psychosocial condition (e.g., patient's stress level, confusion … plan needs to be revised or when additional resources are needed. … that need to be completed
Continued appropriateness of the patient’s care plan
Goals are established … If something has changed, a huddle or followup briefing should be held to discuss how the plan needs
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pcmh.ahrq.gov/sites/default/files/attachments/pcpf-module-6-pf-process.pdf
September 01, 2015 - If the
improvement project involves implementation of new treatments or care processes, you may also … htm
4
Barlow goes on to say:
Efficacious self-management encompasses ability to monitor the condition … Regarding clinical care, remember techniques from shared decision making. … Often
the goal or plan does not seem related to the chronic illness from our point of
view, but to … Sometimes they have been overly ambitious with
the plan and chosen too much or too often.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-v2-resourcelist.pdf
April 01, 2023 - Supervisor, Manager, or Clinical Leader Support for Patient Safety
and Hospital Management Support … Supervisor, Manager, or Clinical Leader
Support for Patient Safety and Hospital Management Support for … Supervisor, Manager, or Clinical Leader Support for Patient
Safety and Hospital Management Support for … care partners to
use when planning care or during a stay in a hospital or skilled nursing facility. … Supervisor, Manager, or Clinical Leader Support for Patient Safety and Hospital Management Support for
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pcmh.ahrq.gov/patient-safety/resources/learning-lab/index.html
February 01, 2024 - workflow processes relevant to the patient's condition. … or errors, medication errors, and unexpected clinical deterioration. … Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders … , died within 90 days of hospitalization, or had complex clinical events). … To achieve this goal, investigators plan to redesign systems of clinical maternity care by defining postnatal
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/strat3_tool_3_pres_video_508.pptx
July 23, 2010 - what we want them to (it is a shared partnership where we listen to each other and decide on the best plan … We bring our clinical judgment to the table – it is important perspective as part of the health care … For example:
Coordinate services at nursing stations
Discuss a patient’s condition or treatment regimen … A physician may discuss a patient’s condition or treatment regimen in the patient’s semiprivate room. … Health care professionals may discuss a patient’s condition during training rounds in an academic or
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - Yes:
What was the condition on admission? … Other, including lack of communication/coordination between ICU and other
departments, patient condition … o Clinical anastomotic leakage should not exceed 5% (grade B). … greater) categories, which may be useful on a practical clinical level in
terms of decisionmaking. … Am J Crit
Care 2010 Mar;19(2):135-45.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/simulation/traininggd-update.pdf
February 01, 2011 - Condition(s)—Specifies the conditions under which the behavior occurs. … skills on which they plan to offer training. … All event sets consist of a
trigger—the condition under which the event becomes fully activated or the … ”
• “You shared the care plan with the team, but no one had a chance to speak
up or ask questions.” … TeamSTEPPS Tool or
Strategy
3. Learning
Objective(s)
4. Clinical Context
5.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
May 01, 2017 - a change in the plan of care. … it difficult for the patient’s care team
to create a safe plan of care. … Often, the patient’s birthing
plan and the clinical team’s plan of care contradicted each
other, as … Now physicians discuss this plan with patients and use it
to guide their care. … , charter, and project plan;
define the clinical components and resources; and create
benchmarking
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - a change in the plan of care. … it difficult for the patient’s care team
to create a safe plan of care. … Often, the patient’s birthing
plan and the clinical team’s plan of care contradicted each
other, as … Now physicians discuss this plan with patients and use it
to guide their care. … , charter, and project plan;
define the clinical components and resources; and create
benchmarking
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pcmh.ahrq.gov/prevention/resources/womens-health.html
July 01, 2018 - Clinical Guidelines and Recommendations
Clinicians and Providers
Curriculum Tools … iADAPT
Resources
Chronic Care
Research Initiative in Clinical Economics … Vision Rehabilitation: Care and Benefit Plan Models
Women's Health
Resources … Blastoma—cancers derived from immature precursor cells or embryonic tissue. … there are high levels of sugar in the blood, either because the body does not produce enough insulin or
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pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
August 01, 2022 - "You cannot change the human condition. But you can change the conditions in which humans work." … Collect all time-sensitive information from the electronic medical record (EMR) or other clinical information … For individuals who are involved in clinical care (e.g., nurses), speak with the supervisor to ensure … interviewee availability and clinical coverage. … Measurement plan for each solution ( Appendix G: Data Measurement Plan ).
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pcmh.ahrq.gov/sites/default/files/attachments/Information%20Technology%20to%20Support%20Transformation%20to%20Proactive%20Primary%20Care.pdf
July 01, 2010 - a primary care practice or group of practices (“practice-based”) to improve the
care and clinical outcomes … a primary care practice or group of practices (“practice-based”)
to improve the care and clinical outcomes … a primary
care practice or group of practices (“practice-based”) to improve the care and clinical outcomes … centers on the interaction between an individual patient and his or her clinician or
11
clinical … or disease management (e.g., based on clinical data, provider
preference, or insurance requirements
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pcmh.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/hmv-protocol.pdf
February 02, 2018 - Background and Objectives for the Systematic Review
Chronic respiratory failure is a common condition … units (ICUs), ventilator weaning units,
or long-term care hospitals. … If
meta-analysis is deemed appropriate, we plan to use the DerSimonian and Laird random
effect method … NSW
Agency for Clinical Innovation; 2012. … Meta-analysis in
clinical trials. Controlled clinical trials. 1986
Sep;7(3):177-88.
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pcmh.ahrq.gov/sites/default/files/attachments/pcpf-module-3-primary-care-landscape.pdf
September 01, 2015 - Supports evidence-based comparative
clinical effectiveness research. … Care management (or care coordination) fee. … Bundled payments can be viewed as a condition- or illness-specific capitation payment. … distinctions between these managed care plan types
have become less clear. … , create a comprehensive care
plan in collaboration with patients, enhance opportunities for patient-provider
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pcmh.ahrq.gov/page/early-evidence-patient-centered-medical-home-table-1
February 01, 2012 - practices to help manage care for Medicare Advantage members and collaborate with the clinical team. … Geisinger Health System ProvenHealth Navigator Geisinger Health Plan embedded a nurse case manager for … assess low-income seniors in the home, and develop and implement a care plan with a geriatrics interdisciplinary … specialist care manager (a nurse or psychologist) is embedded in the primary care practice to provide … with complex, chronic, terminal, or disabling diseases.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
November 01, 2012 - of a
number of conditions for which hospitals do not receive the higher payment for cases when
the condition … procedures that convert from laparoscopic to open, emergency
procedures).1
Educational Recommendation
• Plan … appropriate •
documentation, etc.2
Follow a standard for performance improvement such as PDSA (Plan-Do-Study-Act … follow the safety protocols developed by the team to prevent •
foreign body retention and develop a plan … /publications/bulletin/2009/2009%20november%20bulleti
n.ashx
Policies/Protocols
• Institute for Clinical
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/tpc-synthesis-report.pdf
July 22, 2015 - Additionally, two studies linked increased care coordination and
teamwork to improvements in clinical … Several of the studies linked improvements in clinical
measures to specific PCMH processes such as care … Practices also used plan-do-study-act (or plan-do-
check-act) cycles for quality improvement efforts. … (For
two of these eight grants, recognition or certification as a PCMH was a condition for inclusion … nonprofit
Medicaid
managed care
plan
17 Safety net
primary care
practices; mixed
type of
ownership
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pcmh.ahrq.gov/coronavirus/practice-improvement.html
July 01, 2022 - Telementoring, like Project ECHO, can bring scarce clinical expertise to rural or remote locations. … practices adapting to new models of care during COVID-19, such as improving complex processes of care … or increasing delivery of appropriate clinical preventive services. … and clinical informaticians in primary care and other ambulatory settings implement and adopt a clinical … (CUSP)
CUSP can help clinical teams make care safer by combining improved teamwork, clinical best practices