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www.talkingquality.ahrq.gov/cahps/about-cahps/patient-experience/index.html
September 01, 2023 - something that should happen in a healthcare setting (such as clear communication with a provider) actually happened … or how often it happened.
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
May 01, 2017 - When learning from defects, L&D unit teams
identify—
• What happened?
• Why did it happen? … Analyzing what happened and why it
happened helps the team understand the
contributing factors and … • What happened?
• Why did it happen?
• How will you reduce the risk of
recurrence?
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/elicitation/cahps-patient-narrative-elicitation-protocol-qa-03-01-2017.pdf
January 01, 2017 - Please explain what happened,
how it happened, and how it felt to you.
PN-4. … Please explain what happened,
how it happened, and how it felt to you.
PN-5.
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www.talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
July 01, 2023 - When learning from defects, L&D unit teams identify—
What happened?
Why did it happen? … Analyzing what happened and why it happened helps the team understand the contributing factors and processes … What happened?
Why did it happen?
How will you reduce the risk of recurrence?
-
www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
May 01, 2017 - Defects identification
CUSP asks L&D unit staff to work through a defect and ask—
What happened? … The recovery side is completed when the event is a near miss, that is, something that happened to stop … What happened?
Step 1. Reconstruct the timeline to understand what happened.
Step 2.
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/implementing-new-protocol-transcript.pdf
October 01, 2018 - Because before understanding what has actually happened to a patient we need to know what it is that … We probe, please explain what happened, how it happened and how it felt to you in order to get that complete … And again please
explain what happened, how it happened and how it felt to you. … Is this something that happened once or is this
something that happens to you often? … And how did what happened get brought about?
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-last10-patients-audit.pdf
May 18, 2021 - ago, care may not reflect current processes, and clinicians and staff may not be able
to recall what happened
-
www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/impact-ks-success-story.pdf
April 01, 2015 - “We were motivated by collaborations that had happened between the University of New Mexico and
New … cooperative extension folks at Kansas State to develop collaborations, which is
not something that had happened
-
www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
May 01, 2017 - Defects identification
CUSP asks L&D unit staff to work through a
defect and ask—
• What happened … The recovery side is
completed when the event is a near miss, that
is, something that happened to stop … What happened?
• Step 1. Reconstruct the timeline to
understand what happened.
• Step 2.
-
www.talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
August 01, 2022 - What happened during the handoff? … Was there anything that happened during the handoff that may have contributed to the event?
-
www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
May 01, 2017 - Providers communicate the facts of what happened and assure the patient and family that they will receive … A hospital committed to transparency offers an apology that the incident happened. … communicated to the patient and family:
An apology for any unreasonable care
An explanation of what happened
-
www.talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
July 01, 2023 - Defects identification
CUSP asks L&D unit staff to work through a defect and ask—
What happened? … The recovery side is completed when the event is a near miss, that is, something that happened to stop … What happened?
Step 1. Reconstruct the timeline to understand what happened.
Step 2.
-
www.talkingquality.ahrq.gov/ncepcr/research-transform-primary-care/transform/impactgrants/impact-ks-success-story.html
April 01, 2015 - “We were motivated by collaborations that had happened between the University of New Mexico and New Mexico … cooperative extension folks at Kansas State to develop collaborations, which is not something that had happened
-
www.talkingquality.ahrq.gov/hai/cusp/videos/index.html
September 01, 2019 - Identifying and Ranking Defects What Happened? Why Did It Happen?
-
www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
May 01, 2017 - Providers communicate
the facts of what happened and assure
the patient and family that they will
receive … A hospital committed to
transparency offers an apology that the
incident happened. … communicated to the patient and family:
• An apology for any unreasonable care
• An explanation of what happened
-
www.talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
July 01, 2023 - Providers communicate the facts of what happened and assure the patient and family that they will receive … A hospital committed to transparency offers an apology that the incident happened. … An explanation of what happened.
A meaningful discussion of projected outcomes.
-
www.talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
July 01, 2023 - The discovery event addresses what happened. … Arrows pointing downward lead from one question to the next:
Question 1: What happened?
-
www.talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
August 01, 2022 - To strengthen system accountability, we want to learn what happened, why it happened, what normally happens
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt-pdsa-form.docx
May 01, 2017 - Module 2: Example
AHRQ Safety Program for Ambulatory Surgery
Management Practices for Sustainability
Module 5: Visual Management
Sample “Plan-Do-Study-Act”[footnoteRef:1] Form [1: “Plan-Do-Study-Act” refers to a method for testing changes in clinical practice. In the “plan” step, lay out the specifications of your…
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/MO_Items-Composite_Measures.pdf
October 04, 2023 - SOPS Medical Office Items and Composite Measures
SOPS® Medical Office Survey Items and
Composite Measures
Version: 1.0
Language: English
Note
• For more information on getting started, selecting a sample, determining data collection
methods, establishing data collection procedures, conducting a Web-based sur…