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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/nyp-webinar-servati-demo-project.pdf
June 02, 2025 - Implementing the New CAHPS® Protocol for Obtaining Patient Comments About Their Care
The NYP Patient Narrative
Demonstration Project
Tara Servati, M.P.H.
Patient Experience Specialist for the Ambulatory Care
Network, New York-Presbyterian
New York, NY
NYP Demonstration Project Overview
Overall Aim:
– Asses…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-survey-english.docx
June 02, 2025 - We look at staff actions and the way we do things to understand why mistakes happen in this pharmacy
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www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/pharmsops-composites.pdf
June 02, 2025 - We look at staff actions and the way we do things to understand why mistakes happen in this
pharmacy
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/coaching-fac-notes.html
October 01, 2020 - Can you help me understand why that didn’t happen? … If something harmful to the patient can be avoided, the coach should say something and not let it happen
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/assessing/takeheart-summary-presentation.pptx
April 26, 2023 - AHRQ Slide Template-Regular
TAKEheart:
AHRQ’s Initiative to Increase Patient Participation in Cardiac Rehabilitation
What We Planned, What Happened, and What We Learned
Michael Harrison and Dina Moss
April 26, 2023
(Edited 5-25-23)
Dina was COR and implementation lead; Michael was co-COR and evaluation/disseminati…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/4es-early-mobility-facguide.docx
January 01, 2017 - How can execute our plan and make this happen? … early mobility at our hospital, change the culture, and provide the necessary resources to make it happen … A defect is anything you do not want to happen again. Ask, “What happened and why did it happen?”
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-survey-english.pdf
June 02, 2025 - Staff are told about patient safety problems that
happen in this facility ......................... … We are good at changing processes to make sure
the same patient safety problems don’t happen again.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/learning-antibiotic-adverse-events-form.docx
November 01, 2019 - or situation involving the prescription or administration of antibiotics that you would not want to happen
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/coaching/coaching-facnotes.docx
May 01, 2017 - Can you help me understand why that didn’t happen? … If something harmful to the patient can be avoided, the coach should say something and not let it happen
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/012-ss-decolonization-strategies.pptx
April 01, 2025 - Why did it happen?
How to reduce the likelihood of this defect from happening again? … Inconsistent use of mupirocin nasal decolonization
Inconsistent screening of patients for MRSA
Why did it happen
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt2_transition_apx.pdf
September 01, 2019 - and Communication About Error 68% 65% 3% Major wording
change
We are informed about errors that happen … (C1)
We are informed about errors that happen in this
unit. … ------------------------------------- My supervisor/manager overlooks patient safety
problems that happen … (C1)
We are informed about errors
that happen in this unit. … (C3) 66% 66% 0% +/- 3%
[-3% to 3%]
No
change
When errors happen in this unit, we
discuss ways
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www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-narrative-items-cg-survey30-child.html
August 01, 2021 - Supplemental Items for the CAHPS Clinician & Group Child Survey 3.0/3.1: Narrative Comments
Population version: Child
Learn about the CAHPS Patient Narrative Item Sets .
Placing the items in the survey:
Insert these supplemental items before the "About Your Child and You" section of the survey.
Int…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/patient-narratives-webinar-quality.pdf
June 02, 2025 - The Power of Patient Stories for Improving the Patient Experience webcast - Nembhard
Using Narratives for Quality Improvement
Ingrid Nembhard, PhD, MS
Fishman Family President’s Distinguished
Associate Professor of Health Care Management
Disclosures
This work was funded by the Agency for Healthcare
Research a…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
December 01, 2017 - Slide 5
How Do These Errors Happen? … SAY:
Errors happen because people are fallible. … a powerful exercise in which teams evaluate their processes to identify gaps that allow mistakes to happen … :
Simply put, a defect is any clinical or operational event or situation that you would not want to happen
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www.ahrq.gov/ncepcr/tools/obesity-kit/obtoolkit5.html
March 01, 2014 - be translatable to any community resource and any practice willing to take the extra step to make it happen
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www.ahrq.gov/takeheart/assessing/index.html
August 01, 2023 - Assessing TAKEheart
Through our assessment of TAKEheart, we learned many lessons that will help guide future work in this area.
Our Evaluation Report Executive Summary describes the project activities, key findings, lessons learned, and recommendations for future similar efforts. Our Hybrid Cardiac Rehabilita…
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www.ahrq.gov/hai/tools/surgery/modules/implementation/audit-briefing-fac-notes.html
December 01, 2017 - with teammates, when people understand what that plan is, when they have a sense of what’s going to happen … Slide 7: Developing a Briefing Audit Tool
Ask:
How do you think briefings and debriefings should happen … Ask:
What is the worst thing that could happen, and what are we going to do about it if it did? … We know this is important, but it’s tough to make happen. … All of these steps happen before the case begins, or prior to incision.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_audit_briefing_facnotes.docx
December 01, 2017 - with teammates, when people understand what that plan is, when they have a sense of what’s going to happen … Slide 6
Developing a Briefing Audit Tool
ASK:
How do you think briefings and debriefings should happen … ASK:
What is the worst thing that could happen, and what are we going to do about it if it did? … We know this is important, but it’s tough to make happen. … All of these steps happen before the case begins, or prior to incision.
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www.ahrq.gov/sites/default/files/2024-12/moyer-report.pdf
January 01, 2024 - month but less than
1x/week
4
Frequent: Likely to occur immediately or
within a short period (may happen … times in 1 year)
Greater than 1x/year but less than
1x/month
3 Occasional: Probably will occur (may
happen … several times in 1 to 2 years)
Less than 2x/year
2 Uncommon: Possible to occur (may
happen sometime … in 2 to 5 years)
Once every 2 - 5 years
1 Remote: Unlikely to occur (may happen
sometime in 5 to
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/huddles/huddles-component-kit.docx
May 01, 2017 - In ambulatory surgery centers (ASCs), huddles can happen once per day with each unit (e.g., the operating … Level 3: Daily huddles happen when the supervisor is not present. … What can you do to make the huddle happen every day?