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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.docx
January 01, 2010 - Identify which family or friends will provide care at home and include them in conversations. … Who: All clinical staff
Explain medicines to the patient and family (for example, print out a list every … Who: All clinical staff
Discuss the patient, family, and clinician goals and progress toward discharge … Who: All clinical staff
Involve the patient and family in care practices to improve confidence in caretaking … Who: All clinical staff
Strategy 1: Working with Patients & Families as Advisors
[Type text] [Type
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/putoolkit_module2_tools.docx
February 16, 2011 - When a change in condition occurs
Does your hospital’s policy state that a skin assessment … plan for patients who have been found to be at risk or who have a pressure ulcer. … AHRQ Pressure Ulcer Prevention Program
Module 2 Tools 13
Assessment of Pressure Ulcer Care Plan
Does … the care plan for pressure ulcers address all the areas below (as they apply)? … Decide what items of pressure ulcer prevention should be in your bundle
Clinical staff members
Within
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pcmh.ahrq.gov/sites/default/files/publications/files/postdisphone.pdf
February 14, 2013 - Using clinical judgment, use this conversation to determine if further
recommendations, teaching, or … If patient
has lost care plan, offer to send a new copy of AHCP by mail or email. … It
should be on the care plan on the appointments page. … Do you need me to mail or email
you another copy of your care plan? … If no, ask: Would you like me to email or mail a copy of your care plan to them?
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pcmh.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool5.html
March 01, 2013 - All RED patients should be called 2 to 3 days after discharge by a member of the clinical staff. … Understanding of how to manage any medical changes or whether he or she needs to seek medical care for … Advising the patient to go to urgent care or the emergency department. … When a patient has chosen not to take a medicine that is part of the discharge plan or insists on taking … When a patient is not following the treatment plan due to difficulty understanding the plan or an inability
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pcmh.ahrq.gov/teamstepps/rrs/rrs_slides/rrsslides.html
July 01, 2018 - You Care? … All five are standing on blocks, with the Activator and Responder penguins on a block labeled 'Clinical … plan
Activators may become Responders and assist in stabilizing the patient
Image: Responders … Background—What is the clinical background or context? … What is the plan? Are there contingency plans?
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
May 01, 2017 - · Care provider calls out concern for or diagnosis of shoulder dystocia, reducing error through an … anticipated and coordinated approach.
· Team members—
· Use callouts with fetal condition per National … · Cognitive aids such as checklists, algorithms, or protocols may improve clinical team response and … team members who arrive to support a rapid response, and
· when regrouping to discuss plan of care if … Use of transition communication techniques assures a shared mental model of plan of care and patient
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/medread-tools.pdf
July 28, 2016 - ” or other clinical readmission risk
Identify the “learner” or care plan partner to include in education … PLAN TEMPLATE
Patient Name
Patient MRN
DOB / Age / Gender
Care plan date
Date care plan created … or life-threatening condition]
• [Attempt to treat symptomatic pain without the use of narcotics] … PLAN EXAMPLE 2
This is an example of a “Complex Care Plan” (ED Care Plan) that is currently in use … Patient:
Age/Sex:
MRN#:
DOB:
[Acute or ED] Care Plan
Care Plan Date:
• [date plan was created
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4p_combo_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - paths, or
protocols for the full continuum of care for the prevention of pressure ulcers in children … of patient mobility.7
• Maintain head of bed at the lowest point consistent with patient’s medical condition … the individual’s tissue
tolerance, his/her level of activity and mobility, his/her general medical condition … , overall
treatment objectives, and assessments of the individual’s skin condition.7, 9
Toolkit … effectiveness of new processes, determine gaps, modify processes as needed, and
reimplement.11
• Develop a plan
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pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
August 01, 2022 - Patients want to hear from their care providers and/or the organization an explanation of what happened … Empathy—the ability to understand another person’s condition from their perspective. … This apology is a regretful acknowledgement of the event by the care provider and/or the organization … What would the cost of defending this claim be versus a well-thought-out compensation plan? … Clinical (medical/nursing and other caregiver staff).
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pcmh.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-reportaddendum.pdf
March 01, 2021 - Work
among clinical and nonclinical team members should include clearly delineated, explicit roles … • Print and review the care plan with the patient and family to ensure they understand it and
address … who interact with the patient; pay particular attention to changes to the care plan,
changes to medications … , and changes in the patient’s condition … if they are having any problems following their care plan.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrsslides.ppt
January 01, 2008 - All five are standing on blocks, with the Activator and Responder penguins on a block labeled 'Clinical … plan
Activators may become Responders and assist in stabilizing the patient
TEAMSTEPPS 05.2
Mod … Background―What is the clinical background
or context? … same location)
A handoff to a specialized team (cardiac team, code team, stroke team, etc)
A revised plan … She did not note any specific change in clinical status, though she agreed that the patient seemed lethargic
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.docx
April 01, 2011 - All clinical staff
Explain medicines to the patient and family and use teach back
All clinical staff … Discuss progress toward goals
All clinical staff
Involve the patient and family in care practices … needs after they leave the hospital.9 Hospital staff cannot plan discharge in isolation from the patient … concerns
Daily during hospital stay
Manage the patient’s condition
Assign a case manager or discharge … Plan the IDEAL Discharge Planning training for clinicians. Decide who will conduct the training.
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pcmh.ahrq.gov/page/coordinating-care-adults-complex-care-needs-patient-centered-medical-home-challenges-and
January 01, 2012 - and clinical guidelines for their care. … Develop and Update an Individualized Care Plan
A care plan tailored to the patient’s needs and based … roles should be included in the care plan. … In the past, CHP offered to pay PCPs $25 per month or $125 per care plan review for case management. … Some clinical or social support problems for complex-needs patients require so much advanced knowledge
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pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module4.pptx
March 07, 2019 - TeamSTEPPS for Office-Based Care Online Course. … Clinical status of the team’s patients — the current condition, diagnosis, plan, and status of each patient … Who attends — clinical or operations, or both? Who should attend? … It is a tool for maintaining shared understanding between team members regarding the plan of care.
9 … Excellent leaders partner with their patients and clinical and operational care team members to take
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4g_combo_psi10-postopmetaderangement-bestpractices.pdf
May 20, 2016 - of a number of conditions for which hospitals do not receive the higher payment for
cases when the condition … • Mandate that all personnel follow the safety protocols developed by the team and develop a
plan … Preadmission treatment plan with history of blood glucose
monitoring. … lity_measures/
Staff Required
• Physicians and other providers, nurses, pharmacists, dietitians, clinical … KDOQI Clinical Practice Guideline for Diabetes and CKD:
2012 update.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/shadowing.doc
August 08, 2012 - Follow your health care provider through his or her daily activities and again at the end of the day: … Why or why not? … (That is, did the outgoing care team debrief the oncoming care team regarding the patient’s condition … (That is, did the team leader quickly explain and direct the team regarding the plan of action?) … Now that you have shadowed a person in another profession, what will you do differently in your clinical
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pcmh.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
March 01, 2017 - If so, do these teams conduct Briefs to review any safety or care concerns? What does it look like? … B ackground—What is the clinical background?
A ssessment—What do I think the problem is? … The recommendations for additional labs and a revised plan of care was clearly communicated by the … to experience higher levels of satisfaction and also follow their care plan. … condition of the resident.
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pcmh.ahrq.gov/talkingquality/resources/comparative-reports/physicians.html
October 01, 2022 - Clinical quality measures are reported for asthma care, cancer screening, diabetes care, mental health … Subject: Primary and specialty care clinics
Developer: HealthPartners
Developer Type: Health plan … The cost ratings take into account the total cost of care for treating a whole person or specific conditions … , or both. … performance of over 200 medical groups who provide care to commercial HMO health plan members in California
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pcmh.ahrq.gov/teamstepps/simulation/traininggd.html
July 01, 2016 - Condition(s)—Specifies the conditions under which the behavior occurs. … Referring to Handout 3 (H-3), ask them to develop learning objectives for a simulation course that they plan … Allow about 10 minutes for participants to develop learning objectives for the skills on which they plan … All event sets consist of a trigger—the condition under which the event becomes fully activated or the … TeamSTEPPS tool or strategy.
Learning objective(s).
Clinical context.
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pcmh.ahrq.gov/hai/cusp/toolkit/shadowing.html
December 01, 2012 - Follow your health care provider through his or her daily activities and again at the end of the day: … Why or why not?
… (That is, did the outgoing care team debrief the oncoming care team regarding the patient's condition … ( That is, did the team leader quickly explain and direct the team regarding the plan of action?) … Now that you have shadowed a person in another profession, what will you do differently in your clinical