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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/webinar-012220-fry.pdf
February 06, 2020 - Patient Satisfaction
Experience Satisfaction
• Whether something
happened, or how often it
happened
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
December 01, 2017 - First question, what happened? … What Happened? … What Happened? … What happened that had a good outcome? … SAY:
Armed with knowledge about what happened and why it happened, it’s time to build your interventions
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ce.effectivehealthcare.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/coaching-slides.html
May 01, 2017 - Displays genuine curiosity and interest in what happened. … Can you help me understand what happened?" … Can you help me understand what happened?" … I am curious, what do you think happened?" … What happened during the case?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
December 01, 2017 - The first question is, what happened? … Slide 9
What Happened?
ASK:
What happened?
SAY:
We recommend walking the process. … Slide 10
What Happened?
ASK:
Who was involved?
What were the actions? … What happened that actually may have helped ameliorate the situation? … SAY:
Armed with knowledge about what happened and why it happened, it’s time to build your interventions
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
August 21, 2015 - What happened exactly?
What are the implications for the patient’s health?
Why did it happen? … Module 5
12
The Disclosure Checklist includes:
What happened–identify the adverse event early in the … the adverse event occurred, but DO NOT guess or assume anything about what happened. … Tell the patient what should have happened. … This question is often a stand-in for “How could this have happened?”
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ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
December 01, 2017 - The first question is, what happened? … Slide 10: What Happened?
Ask:
What happened?
Say:
We recommend walking the process. … Slide 11: What Happened?
Ask:
Who was involved?
What were the actions? … What happened that actually may have helped ameliorate the situation? … Say:
Armed with knowledge about what happened and why it happened, it’s time to build your interventions
-
ce.effectivehealthcare.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 - Ideally, team members do this by reflecting on what has happened. … The question should express genuine curiosity about what happened. … · “I am curious, what do you think happened?”
· “How did that make you feel?” … Can you help me understand what happened?” … I’m curious, what do you think happened?”
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ce.effectivehealthcare.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/defects.html
March 01, 2017 - What happened? (brief description)
2. Why did it happen? … negative factors
What happened to cause the defect?
3. … Has it happened again?
With whom will we share our learning?
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ce.effectivehealthcare.ahrq.gov/takeheart/assessing/index.html
August 01, 2023 - Our PowerPoint Presentation explores what we planned from this project, what happened, and what we learned … Executive Summary
Hybrid Workgroup Evaluation
Presentation on TAKEheart: What We Planned, What Happened
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ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/silence.html
August 01, 2017 - However, what compounds the pain is when you are not told the truth about what has happened to your loved … There are four things patients and families want after medical harm has occurred: tell us what happened … are going to fix the problem, take responsibility, and apologize. 1 First, when we say "Tell us what happened … Second, we need to know that what happened to our loved one is not going to happen to anyone else. … No one should ever have to wait that long to find out answers about what happened to their loved one,
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
June 01, 2021 - Decision Making
11
Changing the System
11
Problems Are Opportunities To Improve
12
What happened … Learning From Antibiotic-Associated Adverse Events Form
Changing the System
12
What Happened? … Explain what happened.
Put yourself in the place of those involved.
Try to understand.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/administering-child-hcahps-narrative-items.pdf
November 01, 2023 - s hospital stay can be an intense
experience; please take as much time as you need to tell us what happened … Please explain what happened, how it happened, and how it felt.
H-PN2. … Please explain what happened, how it happened, and how
it felt.
H-PN3.
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ce.effectivehealthcare.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/coaching-fac-notes.html
October 01, 2020 - Ideally, team members do this by reflecting on what has happened. … The question should express genuine curiosity about what happened. … "I am curious, what do you think happened?"
"How did that make you feel?" … Can you help me understand what happened?" … I’m curious, what do you think happened?”
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
June 01, 2021 - (What happened?)
Step 2. … (What happened?)
2.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-webinar-jan-2017-schlesinger.pdf
January 01, 2017 - Please explain what happened, how it happened, and how it felt
to you.
4. … Please explain what happened, how it happened, and how it felt to you.
5.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
August 01, 2022 - Slide 11
Say:
The Disclosure Checklist includes:
What happened–identify the adverse … event early in the disclosure, explain what happened in a way that is easy to understand, explain what … is known about why the adverse event occurred, but DO NOT guess or assume anything about what happened … Tell the patient what should have happened. … This question is often a stand-in for "How could this have happened?"
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/penicillin-allergy.pdf
June 01, 2021 - _________________
o What year was it or how old was the resident when the reaction happened? … taking when he or she had the reaction:
What year was it or how old was the resident when the reaction happened
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-notes.docx
April 01, 2022 - It requires ground truth of what actually happened and not presumptions about what might have happened … Remember to ask these four basic questions when considering a defect:
· What happened? … guide through the initial investigation for a defects analysis where the primary goal is to learn what happened … If your team created a process map, fishbone chart, or a drawing to illustrate what happened, use it … to map out what happened and include the "why" under each defect.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/simulation/simslides-update-62819.ppt
January 30, 2006 - 05.2 Page *
Page *
Simulation
Outcomes tend to be more quantifiable and answer the question “What happened … Sometimes referred to as measures of performance (MOPs)
Explain how and why certain outcomes may have happened … 05.2 Page *
Page *
Simulation
Phase 3
Debriefing
Introduce the debrief process
Describe what happened … learned
TEAMSTEPPS 05.2
Mod 1 05.2 Page *
Page *
Simulation
Description Phase
Recap of what happened … 05.2
Mod 1 05.2 Page *
Page *
Simulation
Analysis Phase
A systematic investigation of why things happened
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20140603_QI/3_rachel_grob.pdf
June 25, 2014 - (past 12 months)
Positive experiences: 1 Question with
narrative guide (what happened, how did it … (past 12 months)
Positive experiences: 1 Question with narrative guide
(what happened, how did it happen