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301. TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety (pdf file)
     pcmh.ahrq.gov/downloads/pub/advances2/vol3/advances-king_1.pdf
     April 07, 2008 - Training and implementation have been provided as a whole-hospital approach, within specific specialty … Twenty- eight accounts (11 within the medical community) of the implementation of CRM training in hospitals … Carilion Clinic is planning to examine the relation between TeamSTEPPS and hospital-acquired infection … Given organizational demands associated with hospitals, it is crucial to find the appropriate interval … Director, Patient Safety Division, TRICARE Management Activity, Skyline 5, Suite 810, 5111 Leesburg Pike, Falls

302. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
     May 01, 2016 - six hospitals in the State; and created a resource Web site (http://www.macrmi.info). … Sioux Falls, SD; December 2011:16. Pichert JW, Hoffman WW, Danielson D, et al. … solutions for improving medication discrepancies in the hospital-to-home transition. … unit in one hospital. … developing projects piloting CARe in six hospitals in the State; and created a resource Web site (http

303. Patient and Family Engagement in the Surgical Environment Module: Facilitator Notes | Agency for Healthcare Research and Quality
     pcmh.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement-fac-notes.html
     May 01, 2017 - LTC Facilities Reducing CAUTI in Hospitals Reducing CLABSI Toolkit Safe Surgery Toolkit … Surgical Environment module is to augment the existing hospital setting Patient and Family Engagement … Slide 31: References American Hospital Association. … Chicago: American Hospital Association, Committee on Research; 2012. … Care Transitions from Hospital to Home: IDEAL Discharge Planning Training .

304. Statistical Process Control: Possible Uses to Monitor and Evaluate Patient-Centered Medical Home Models (pdf file)
     pcmh.ahrq.gov/sites/default/files/attachments/StatisticalProcess_032513comp.pdf
     March 01, 2013 - Statistical Process Control One issue in evaluating PCMH models is that reporting of changes in process … ▲ Eight or more values falling above or below the mean. … Such a display can be useful in engaging clinicians and staff in the intervention, a key element of … The use of run and control charts in the improvement of clinical practice. In: Carey R. … (John Hopkins University School of Medicine, Baltimore, MD and LifePoint Hospitals, Inc., Brentwood

305. TeamSTEPPS: Rapid Response Systems (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/instructor_slides/rrsinstructmod.pdf
     January 01, 2008 - People die unnecessarily every day in our hospitals. … SAY: Research suggests that after implementing a Rapid Response System, hospitals experience a decrease … , number of days in the hospital after an arrest, and inpatient deaths. … hospital: preliminary study. … S Safety Concerns—Critical lab values/reports, socio-economic factors, allergies, alerts (falls, isolation

306. AHRQ Safety Program for Perinatal Care: Experiences from the Frontline (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
     May 01, 2017 - , Winnie Palmer Hospital for Women & Babies, Carle Foundation Hospital, and WakeMed Health & Hospitals … • Private, not-for-profit health system in Raleigh, NC • Three hospitals Strategies: Shoulder dystocia … The hospitals have institutionalized the changes by codifying them in written policies and procedures … The corporate environment empowered hospitals to implement the Program in the way that worked best in … Winnie Palmer Hospital for Women & Babies Carle Foundation Hospital WakeMed Health & Hospitals System

307. AHRQ Safety Program for Perinatal Care: Experiences from the Frontline (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
     May 01, 2017 - , Winnie Palmer Hospital for Women & Babies, Carle Foundation Hospital, and WakeMed Health & Hospitals … • Private, not-for-profit health system in Raleigh, NC • Three hospitals Strategies: Shoulder … The hospitals have institutionalized the changes by codifying them in written policies and procedures … The corporate environment empowered hospitals to implement the Program in the way that worked best in … Winnie Palmer Hospital for Women & Babies Carle Foundation Hospital WakeMed Health & Hospitals System

308. The Medical Home: What Do We Know, What Do We Need to Know? A Review of the Earliest Evidence on the Effectiveness of the Patient-Centered Medical Home Model | PCMH Resource Center
     pcmh.ahrq.gov/page/medical-home-what-do-we-know-what-do-we-need-know-review-earliest-evidence-effectiveness-of-the-patient-centered-medical-home-model
     March 01, 2013 - Summary of evidence on hospital use Table 11. … began, and the evaluation controlled for baseline hospital use in the analyses. … Summary of evidence on hospital use View table 10 in new window Hospital Use. … In the case of hospital use, patients who are at high risk of immediate hospitalization, such as those … In the case of hospital use, four of the five evaluations providing rigorous evidence on different measures

309. Chsp-Accomplishments-Report-2021 (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/chsp/CHSP-accomplishments-report-2021.pdf
     January 01, 2021 - in the hospital survey guaranteed including the system owner in the system survey and a sample of … The Hospital Linkage Files link hospitals to health systems and include information on hospitals, including … Users of the hospital linkage file can identify hospitals within and outside of health systems. … Changes in Quality of Care After Hospital Mergers and Acquisitions. … Safety Net Hospitals in Health Systems: Variation in ACO Participation and Other Characteristics.

310. Final report: Realizing Improved Patient Care through Human-centered Design in the OR (pdf file)
     pcmh.ahrq.gov/sites/default/files/2024-01/joseph3-report.pdf
     January 01, 2024 - There are many new players and subspecialties involved in providing care in the operating room. … their tasks), environmental hazards (e.g., objects causing collision/bumping or the risk of slipping/falling … Infection Control and Hospital Epidemiology. 2018 April; 39(4):391-397. https://doi.org/10.1017/ice.2017.323 … /doi.org/10.1016/j.apergo.2018.03.011 https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology … influence-of-traffic-area-location-and-other-factors-on-operating-room-microbial-load/5B7991606B227B429D88E1744458D6B6 https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology

311. 2014-Women-Chartbook (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/2014-women-chartbook.pdf
     January 01, 2014 - ■ Patient Safety improved, led by a 17% reduction in rates of hospital-acquired conditions between … ■ Many Effective Treatment measures, including several measures of pneumonia care in hospitals publicly … Adverse drug events occur in 15% or more of older patients presenting to offices, hospitals, and extended … With the burden of suicide falling most heavily on adults of working age, the cost to the economy results … Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.

312. Prospects For Care Coord. Using Elect Data Sources 3-16-12 (pdf file)
     pcmh.ahrq.gov/sites/default/files/attachments/Prospects+for+Care+Coord.+Using+Elect+Data+Sources+3-16-12.pdf
     June 01, 2012 - new measures of care coordination Certified EHRs from providers and hospitals participating in the … Many of these alternative code sets were developed in-house and are used only in a single hospital or … For example, few HIEs today have participation from all providers or hospitals in a particular region … offers some guidance to sites on how to identify and export data, but the burden of data extraction falls … , and critical access hospitals may begin participating in Meaningful Use in 2011. 20 Table

313. Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions | PCMH Resource Center
     pcmh.ahrq.gov/page/coordinating-care-adults-complex-care-needs-patient-centered-medical-home-challenges-and
     January 01, 2012 - As a result, they are more vulnerable to fragmented care and “falling through the cracks.” … “They don’t assist on the transition [from the hospital back to] home. … coordinates care across all elements of the broader health care system, including specialty care, hospitals … The authors contend that to keep patients from falling through the cracks in a highly fragmented system … Other types of organizations that might fill this role may be found in the health system, such as hospitals

314. TeamSTEPPS 2.0 Module 9: Coaching Workshop
     pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule9.pptx
     April 10, 2006 - In this module, we'll discuss coaching in general, as well as how to include coaching in your implementation … This, in turn, results in improved team performance and safer patient care. … If the exercise falls before break, introduce the exercise and hand out the ASTD coaching self-assessment … The University of North Carolina Hospital used visuals to identify coaches and people prepared for coaching … At Franklin Memorial, our small community hospital, orientation of all new hires includes the full TeamSTEPPS

315. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
     April 27, 2022 - Center (MWHC), Washington, DC; ¶Michael Garron Hospital–Toronto East Health Network; #Institute of … of Health - National Institutes on Aging grant (4R33AG061882), and the Michael Garron Hospital Foundation … Communication: “In the past 5 years, have you left the hospital, the emergency department, or your provider … operationalize the NASEM definition and/or cite the re- port while using previous definitions, the work often falls … Malpractice claims related to diagnostic errors in the hospital.

316. Building Quality Improvement Capacity in Primary Care, No. 2 (pdf file)
     pcmh.ahrq.gov/sites/default/files/attachments/pcmhqi2.pdf
     April 01, 2013 - the United States in achieving the triple aim. … This leadership and team orientation in turn enables a practice to more fully engage in QI projects … , allows practices to fully understand where they are meeting patients’ needs and where they are falling … External Supports for Engaging in QI Work and Developing QI Capacity in Primary Care QI Support Description … In many cases, these strategies are used in combination.

317. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
     August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Issue … a hospital setting, and one way to think about a “team” in the context of the ED and diagnosis is to … Applied In- terdisciplinary Theory in Health Informatics. … Review: how do hospital organizational structure and processes affect quality of care? … teamwork’: using Goffman’s theory of impression man- agement to illuminate interprofessional practice on hospital

318. Sampling, Weighting, and Synthetization Methodologies (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/data/SyH-DR-Sampling-Weighting-Synthetization-Methodologies.pdf
     December 01, 2023 - Moreover, TRICARE and VA healthcare beneficiaries have access to hospital facilities that are available … only to them, and the treatments provided by these hospitals may be inconsistent with those provided … For each person, the number of IP and ED claims falling under each of the diagnosis groups was tabulated … The final weight in SyH-DR allows for weighted estimates of person-level characteristics and hospital … stay or returned to the hospital multiple times for the same procedure.

319. Guide To Implementing a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term Care (pdf file)
     pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/implementing-guide.pdf
     March 01, 2017 - in the LTC facility. … role is in supporting the changes to improve quality in the LTC facility. … Leadership and staff perceptions of resident harms such as CAUTIs or falls, AHRQ SAFETY PROGRAM FOR … substitute for care of the resident • Morbid obesity or immobility • Attempting to reduce the risk for falls … In-Service Education.

320. Case Studies of Leading Primary Care Practice Facilitation Programs—Program Snapshot: Vermont Blueprint's EQuIP Program (pdf file)
     pcmh.ahrq.gov/sites/default/files/attachments/Vermont_020413comp.pdf
     January 01, 2013 - In most cases, programs need to build their own by investing heavily in training. … In most instances, you’ll need to invest heavily in training. … These organizations usually are hospitals or, in some instances, Federally Qualified Health Centers … or physician hospital organizations. … The administrative entity for the CHTs is located in the health service area and is often a hospital