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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1c_combo_pdifactsheet.pdf
October 01, 2015 - 0340 2012
PDI 08 Perioperative Hemorrhage or Hematoma Rate 5.2
PDI 09 Postoperative Respiratory Failure
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/coaching/lepslcoaching.pdf
July 26, 2012 - Understanding
Performance Improvement
Setting Performance Goals
Rewarding Improvement
Dealing With Failure
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/coachslhandouts.pdf
July 25, 2012 - Understanding
Performance Improvement
Setting Performance Goals
Rewarding Improvement
Dealing With Failure
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pbrn.ahrq.gov/news/newsletters/e-newsletter/907.html
April 01, 2024 - New Research and Evidence From AHRQ
Rapid Evidence Product: Failure To Rescue – Rapid Response Systems
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/medread-tools.pdf
July 28, 2016 - 120 500 24% 5%
Sepsis 100 500 20% 4%
Psychosis 80 400 20% 3%
COPD 70 300 23% 3%
Renal Failure … 1%
Cellulitis w/o MCC 20 150 13% 1%
Total, Top 10 550
Total, All Readmissions 2550 22%
Heart Failure … 200 1300 15% 8%
COPD 30 300 10% 1%
Intracranial hemorrhage 25 50 50% 1%
Renal failure with CC 20 … with MCC 15 80 19% 1%
Psychosis 15 100 15% 1%
UTI 15 80 19% 1%
Sepsis 10 145 7% 0%
Respiratory failure … 25% 0%
Medicaid Cellulitis 10 100 10% 0%
COPD with MCC 5 30 17% 0%
Chest pain 5 35 14% 0%
Renal failure
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pbrn.ahrq.gov/news/newsletters/e-newsletter/873.html
July 01, 2023 - Failure to comply with the antibiotic timing and weight-adjusted dosing guidelines was associated with
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pbrn.ahrq.gov/teamstepps/events/webinars/dec-2016.html
July 01, 2018 - Failure.
Attention seeking.
Displaced anger.
Psychological/physiological causes.
Others.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b3a_combo_chartsforpresentations.xlsx
January 01, 2006 - Postoperative physiologic and metabolic derangements 1.59 0
PSI 11 Postoperative respiratory failure … (AMI) mortality 0 0 0.0611616 58.783 -100 0 0.104046408 IQI 15 Significantly Lower *
IQI 16 Heart failure … PDI 08 Perioperative Hemorrhage or Hematoma Rate 0.00248 0
PDI 09 Postoperative Respiratory Failure
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pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/ced-appendix2-comments.xlsx
October 12, 2022 - otherwise contraindicated for populations represented by Medicare, (e.g., seniors or patients in renal failure … reasonable timeframes for the CED requirements, substantial burden on participating stakeholders, and failure … reasonable timeframes for the CED requirements, substantial burden on participating stakeholders, and failure … otherwise contraindicated for populations represented by Medicare, (e.g., seniors or patients in renal failure
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pbrn.ahrq.gov/teamstepps/lep/coaching/lepslcoaching.html
December 01, 2012 - Situations
Performance Improvement
Setting Performance Goals
Rewarding Improvement
Dealing With Failure
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pbrn.ahrq.gov/teamstepps/instructor/fundamentals/module5/slsitmonitor.html
July 01, 2018 - Return to Contents
Slide 14: Conditions That Undermine Situation Awareness
Failure to—
Share
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1a_combo_iqifactsheet.pdf
October 01, 2015 - Mortality Rate 56.49 0730 2011
IQI 32 AMI Mortality Rate, without transfer cases 58.69
IQI 16 Heart Failure
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pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-miller.html
August 01, 2022 - “This discipline is always anticipating failure, looking for things to go wrong, and applying a systems
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pbrn.ahrq.gov/evidencenow/tools/keydrivers/implement-qi.html
November 01, 2018 - Sigma (focused on standardization), and several patient safety approaches (e.g., root cause analysis, failure
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pbrn.ahrq.gov/news/newsletters/e-newsletter/906.html
March 01, 2024 - Short-stay units vs routine admission from the emergency department in patients with acute heart failure
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pbrn.ahrq.gov/news/newsletters/e-newsletter/909.html
April 01, 2024 - AHRQ in the Professional Literature
Effects of the valsartan recall on heart failure patients: a nationwide
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule9.pptx
April 10, 2006 - expressing.
19
Performance Improvement
Setting Performance Goals
Rewarding Improvement
Dealing With Failure … - and long-term goals
Rewarding Improvement:
Provide positive reinforcement to others
Dealing With Failure … Don't wait until you see either perfection or failure on the task. … The third area is dealing with failure. … Patience can be a virtue or an enabler of more failure, so use it wisely.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
January 01, 2016 - used patient charts from only four conditions (acute myocardial infarction
[AMI], congestive heart failure … Iatrogenic Pneumothorax (PSI 6)
PSI Post-Op Hemorrhage or Hematoma (PSI 9)
PSI Post-Op Respiratory Failure … PSI 6) 10,674 0.36
PSI Post-Op Hemorrhage or Hematoma (PSI 9) 17,670 0.59
PSI Post-Op Respiratory Failure … Hemorrhage or
Hematoma (PSI 9)
17,670 0.59 16,154 0.54 16,154 0.54
PSI Post-Op
Respiratory Failure … charts from patients treated for four conditions:
acute myocardial infarction (AMI), congestive heart failure
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pbrn.ahrq.gov/news/newsletters/e-newsletter/875.html
August 01, 2023 - events and hospital performance on 30-day all-cause mortality and readmission for patients with heart failure
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pbrn.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.html
December 01, 2017 - Smith is an 82-year-old gentleman who was admitted to the hospital because of mild congestive heart failure … It would be so nice if people came in with little, you know, “hi, I have congestive heart failure,” sort … Measuring urine output in stable patients, for example, patients with congestive heart failure; assessing … The next slide is another case study and that would be congestive heart failure. … the protocols for tracking urine output, because that is important in patients with congestive heart failure