-
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-5-whys.pdf
June 02, 2025 - They can also be used to identify the factors contributing to exemplary
performance in order to replicate … 2
Fishbone Diagrams
Fishbone diagrams are another tool for helping a practice identify factors … existing category sets like this healthcare one: people,
materials, methods, measurement, environmental factors
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
December 01, 2017 - Seek out and record both types of factors. … Intervene to correct factors that contributed to the event. … Start by prioritizing the most important contributing factors. … In order to develop an action plan, you need to prioritize your list of factors. … Prioritize the contributing factors and your interventions.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspxspecs.pdf
February 01, 2018 - New Contributing Risk Factors
New contributing risk factors (NCRFs) are captured from multiple data … Summary of Fall Risk Factors Reports
3.2.1. … Contextual Factors Reports
3.3.1. … Below is a sample of the Contextual Fall Risk Factors Report. … Contextual Factors Reports
3.3.1. Report Description
3.3.2.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4g_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - $77,739 in additional charges.4
Recommended Practice Details of Recommended Practice
Assess risk factors … Develop a set of risk factors for postoperative respiratory
failure and screen all patients undergoing … Recommended Practice: Assess risk factors
• Determine which pediatric patients are at increased risk … adverse events postoperatively, as well as improve
allocation of resources after surgery.5
• Some risk factors … • Additional adult risk factors that are applicable to children are:
o Smoking.
o Obesity.
-
www.ahrq.gov/research/findings/final-reports/ssi/ssiapo.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … Final data sheet submitted by each site that included the list of potential SSI risk factors and other … Focus Group Risk Factors
Appendix Q. Surgeon Focus Group Content Analysis
Appendix R. … Probe on barriers and enabling factors.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - $77,739 in additional charges.4
Recommended Practice Details of Recommended Practice
Assess risk factors … Develop a set of risk factors for postoperative respiratory
failure and screen all patients undergoing … Recommended Practice: Assess risk factors
• Determine which pediatric patients are at increased risk … adverse events postoperatively, as well as improve
allocation of resources after surgery.5
• Some risk factors … • Additional adult risk factors that are applicable to children are:
o Smoking.
o Obesity.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
May 01, 2017 - Task factors
In addition to patient characteristics, task
factors can shape the delivery of care and … Team factors
Team factors may involve issues with
teamwork, communication, inadequate
supervision … While these
issues are the furthest removed from the
patient in the diagram, these factors
continually … Analyzing what happened and why it
happened helps the team understand the
contributing factors and … Being aware of
these factors will help units develop
environments that facilitate communication
and
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-1.html
March 01, 2022 - magnitude and importance of the problem, 3 , 4 an increasingly robust understanding has developed of the factors … that lead to diagnostic error, including system, cognitive, and contextual factors. 5 - 7
A promising … While individual, professional, contextual, patient, and health system factors make diagnostic error
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/surgical-complication-prevention/bim.docx
December 01, 2017 - Tools to identify factors that hinder guideline adherence, also called barriers, and approaches to mitigating … Based on these two factors, an action priority score is calculated, providing a ranked list of tasks. … Ask various staff members about the factors influencing compliance.
1. … They will also record the factors that encourage compliance; these are the facilitators. … Barrier Identification Table
GUIDELINE:
DATA COLLECTION MODE:
INVESTIGATOR:
UNIT:
FACTORS
-
www.ahrq.gov/sites/default/files/2024-09/kellogg-report.pdf
January 01, 2024 - Tracy Kim
Organization: MedStar Health
MedStar Institute for Innovation
National Center for Human Factors … the factors identified
in Specific Aim 1. … Are there factors about the ED environment that you think contribute to your stress level?
a. … Investigating Factors Related to Emergency Medicine
Physician Stress. … HFES 2019
International Symposium on Human Factors and Ergonomics in Health Care.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/module3_pu-bestpractices_slides.pptx
June 02, 2025 - perform a comprehensive skin assessment
How to conduct a standardized assessment of pressure injury risk factors … How to incorporate risk factors into care planning
Note: At various points during the module, we’ll … Scales
Only one part of risk assessment
Meant to be used in conjunction with a review of other risk factors … and clinical judgment
More factors to consider
Especially helpful in identifying patients at mild to … Best Practices
Need to be customized:
Each patient has a different set of pressure injury risk factors
-
www.ahrq.gov/talkingquality/plan/subject.html
December 01, 2022 - This page reviews the factors that should enter into your decision and suggests some strategies for dealing … Factors to Consider When Deciding Whose Quality to Report
To decide who to focus on, start by considering … the five factors below. … The feasibility of measuring and reporting quality depends on multiple factors, including political obstacles
-
www.ahrq.gov/research/findings/final-reports/ssi/ssiaph.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … Final data sheet submitted by each site that included the list of potential SSI risk factors and other … Focus Group Risk Factors
Appendix Q. Surgeon Focus Group Content Analysis
Appendix R.
-
www.ahrq.gov/research/findings/final-reports/ssi/ssi1.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … Final data sheet submitted by each site that included the list of potential SSI risk factors and other … Focus Group Risk Factors
Appendix Q. Surgeon Focus Group Content Analysis
Appendix R.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4h_combo_psi11-postoprespfailure-bestpractices.pdf
May 20, 2016 - Recommended Practice Details of Recommended Practice
Assess risk factors. … Develop a set of risk factors for postoperative respiratory
failure and screen all patients undergoing … Recommended Practice: Assess Risk Factors
• Determine which patients are at increased risk for postoperative … adverse events postoperatively, as well as improve allocation
of resources after surgery.3
• Risk factors … Best Processes/Systems of Care
Introduction: Essential First Steps
Recommended Practice: Assess Risk Factors
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
December 01, 2017 - Seek out and record both types of factors. … Intervene to correct factors that contributed to the event. … Start by prioritizing the most important contributing factors. … In order to develop an action plan, you need to prioritize your list of factors. … Prioritize the contributing factors and your interventions.
-
www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
December 01, 2017 - Seek out and record both types of factors. … Intervene to correct factors that contributed to the event. … Start by prioritizing the most important contributing factors. … In order to develop an action plan, you need to prioritize your list of factors. … Prioritize the contributing factors and your interventions.
-
www.ahrq.gov/evidencenow/projects/heart-health/about/cooperatives/nyc.html
March 01, 2021 - disease is the primary cause of death in the city, and prevalence of cardiovascular disease (CVD) risk factors … Use qualitative methods to assess factors that help and hinder practices in implementing change and achieving … ABCS-driven care
Three expert webinars on topics related to evidence-based management of CVD risk factors … practices [AcademyHealth, 2017]
Using Practice Facilitation in primary care settings to reduce risk factors … Population Health Summit, 2016]
Using Practice Facilitation in primary care settings to reduce risk factors
-
www.ahrq.gov/sites/default/files/publications/files/haify11.pdf
January 01, 2011 - To
accomplish these goals, the specific aims
are to—
• Define the incidence of and risk
factors for … goal of this project is to
focus on aligning and bundling work
system, environmental, and contextual
factors … Objectives
include—
• Performing an in-depth and
comprehensive review of the
literature that examines factors … The specific aims of this
project are to—
• Estimate the frequency of MRSA
transmission and risk factors … Risk Factors for Community-Onset
Healthcare-Acquired Urinary Tract
Infections
Funding Mechanism: Grant
-
www.ahrq.gov/npsd/data/spotlights.html
February 01, 2025 - Falls: Associated Factors and Clinical Outcomes (PDF, 4.6 MB) examines clinical outcomes and factors