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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/assembling-cusp-team.pdf
April 01, 2022 - I
would like to ask each of you to describe how you view your role in preventing CLABSI and CAUTI. … How
does what you do impact our prevention efforts?”
“Thanks for being here today. … Case Studies, Tools, and Resources
The following materials reinforce material to improve how unit-based … Levels To Prevent Infections
in ICUs
o Audio interview with Anne Donovan – How To Increase Ownership … Studies, Tools, and Resources
References
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www.ahrq.gov/sites/default/files/wysiwyg/lhs/lhs_case_studies_denver_health.pdf
April 01, 2019 - Denver Health: How a Safety Net System Maximizes Its Value
Denver Health: How a Safety Net System … of case studies
to help health system chief executive officers (CEOs) and other C-suite leaders better … As this and other case studies show, becoming an
LHS is an iterative journey characterized by strong … wants to do better, right?” … wants to do better,
right?”
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www.ahrq.gov/pqmp/implementation-qi/toolkit/antipsychotic/qi-strategies.html
July 01, 2021 - Journal Article: How Long do Adolescents Wait for Psychiatry Appointments? … work to improve access and compliance ( Case Study 2 ). … Case Study 1: Pharmacy Edit
Plan A successfully implemented pharmacy “soft edits” to discourage inappropriate … Case Study 4: Pharmacy Edit
Plan A implemented pharmacy “soft edits” to discourage inappropriate prescribing … an antipsychotic medication ( Case Study 4 ).
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/McNeill.pdf
January 01, 2004 - Specific tactics may include case
studies, resource guides and workbooks, as well as targeted professional … specific how-to information, e.g., where to get the program
software, how to operate it, and what to … do and who to turn to if the program goes
astray from the expected course. … meaningful reports on the findings, and then
how to develop and implement change at a system level … do, hard to evaluate, and hard to prove.
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www.ahrq.gov/sites/default/files/2024-07/uhrig-report.pdf
January 01, 2024 - Health insurance plans and costs can
change
How do you use this guide? … METHODS
4.1 Phase 1: Case Studies
We conducted case studies at each employer site to gain a greater … RESULTS
5.1 Phase 1: Case Study Findings
5.1.1 HR Staff Interviews
Interviews with HR staff revealed … METHODS
4.1 Phase 1: Case Studies
4.2 Phase 2: Materials Design, Usability Testing, and Refinement … RESULTS
5.1 Phase 1: Case Study Findings
5.1.1 HR Staff Interviews
5.1.2 Employee/Retiree Focus Groups
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
June 01, 2021 - the System
2
View Potential Harms as Opportunities1
Reframe a problem or error as an opportunity to … What could you do to reduce the risk?
How do you know that risk was reduced? … Example – you create a new policy or procedure
Do staff know about policy or procedure? … Apply 4 moments
Identify a problem
Learn from the problem to improve the system
18
Changing the System … Use the Learning From Antibiotic-Associated Adverse Events form to develop a plan.
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www.ahrq.gov/ncepcr/reports/cost-guide/methodology-options.html
February 01, 2017 - enhancing the applicability of results beyond study settings
Drawbacks/Challenges:
Claims data do … Consider fixed or random effects models to address unobserved variation
Consider a difference-in-difference … transformation effort
Use a comparable control group to address attribution challenges; consider using … propensity score matching to identify a comparable control group
Micro-Costing (also known … If cost estimates are produced for multiple clinics, results can be stratified to show how costs vary
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-maintenance-notes.docx
April 01, 2022 - Slide 2
To start this discussion, let’s first consider a case study. Mrs. … Consider the case study at the beginning of this module and the unnecessarily frequent dressing changes … , as we saw in the case study. … Slide 13
So, how do you overcome the barriers to CVC maintenance? … Finally, begin to identify solutions by using a quality improvement cycle such as Plan-Do-Study-Act.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/088-or-traffic.pptx
April 01, 2025 - for MRSA Prevention | Surgical Services
OR Traffic
10
Case Example
How To Investigate Surgical Site … How to reduce the likelihood of this defect happening again?
How to know the risk is reduced? … 10 orthopedic cases and noted that the door openings ranged from 35 to 50 times/hour
There had been a … recommendations in this presentation are those of the authors, who are responsible for its content, and do … Adhering to a national surgical care bundle reduces the risk of surgical site infections.
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www.ahrq.gov/hai/cauti-tools/ena-slides/part1.html
October 01, 2020 - Practice Change
Part Two: Removing the Obstacles to Practice Change (continued)
Case Study
Conclusion … (select yes or no)
Slide 13
Do you currently have a well-functioning multidisciplinary ED team … Patient advocacy
What are the expressed needs of the patient and how do they balance with the needs … Slide 27
Do you have a protocol for assessing for indications to remove an indwelling catheter in … (select yes or no)
Slide 28
Do you have a protocol for assessing for indications to remove an indwelling
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/019-perioperative-infection-prevention-strategies-notes.docx
April 01, 2025 - , including the appropriate agents to use for skin prep prior to surgery and how they should be utilized … CHG and povidone-iodine do provide residual activity on the skin. … · How do we reduce the likelihood of this happening again?
· How do we know the risk is reduced? … Slide 33
Case Example: How To Reduce the Likelihood of This Defect Happening Again? … Slide 34
Case Example: How to Know the Risk is Reduced?
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/019-ss-periop-infection-prevention-fg.docx
April 01, 2025 - , including the appropriate agents to use for skin prep prior to surgery and how they should be utilized … CHG and povidone-iodine do provide residual activity on the skin. … · How do we reduce the likelihood of this happening again?
· How do we know the risk is reduced? … Slide 33
Case Example: How To Reduce the Likelihood of This Defect Happening Again? … Slide 34
Case Example: How to Know the Risk is Reduced?
-
www.ahrq.gov/cahps/surveys-guidance/helpful-resources/planning/Set-the-Stage-for-Conducting-the-Survey.html
December 01, 2019 - If they have multiple products/services, which do you want to know about? … How many individuals are eligible to be included in the sample frame for each organization/product? … Do you need to translate English questionnaires into other languages? … Do you need different reporting units for different audiences? … and to set appropriate parameters in your RFP for a vendor, who is likely to handle most of the work
-
www.ahrq.gov/nhguide/about/index.html
November 01, 2024 - use, and if so, how. … effective or do not work at all. … How Does the Guide Help Nursing Homes? … To make antimicrobial stewardship a priority, the Guide provides toolkits to help nursing homes— Establish … AHRQ’s Impact Case Studies highlight healthcare improvement through use of our toolkits.
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www.ahrq.gov/ncepcr/tools/obesity/obpcp-intro.html
May 01, 2014 - "; sometimes you have to be shown how to do it. "
Rural Community Focus Group Member
A Case Study … exercise, and returning to a healthier weight. … What Can Your Practice Do? … There is growing evidence that making a referral to community-based resources dedicated to the treatment … you have to be shown how to do it."
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
April 01, 2023 - Case studies
are included to document how transparency is practiced in each of the domains. … definition of Just Culture, presentations on Just Culture, a case
study, and videos.
5. … AHRQ Impact Case Studies
http://www.ahrq.gov/policymakers/case-studies/index.html? … This subset of the Agency’s
Impact Case Studies specific to patient safety highlights these successes … search_api_views_fulltext=%0bpatient+safety
http://www.ahrq.gov/policymakers/case-studies/index.html?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/urine-culturing/whento-order/urine-cultures.pptx
March 01, 2017 - .
2
How Can Ordering Urine Cultures
Lead To Resident Harms? … Looking at the choices offered, what would you do next? … As resident caregivers, we aren’t ever going to do “nothing.” … In communicating, we need to consider: 1) whom we are speaking with, and 2) how we are communicating … Let’s use the case study we discussed earlier in this presentation to practice using SBAR with Mrs.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/module3_pu-bestpractices_slides.pptx
June 02, 2025 - use
How to perform a comprehensive skin assessment
How to conduct a standardized assessment of pressure … Tool 3B
6
How To Do a Skin Assessment
Video Clip of Skin Assessment
7
Skin Assessment Frequency … Study – Mr. … How do you want the assessment to be conducted? … When do you plan to complete risk assessments?
-
www.ahrq.gov/ncepcr/research-transform-primary-care/transform/cost/exh1.html
October 01, 2015 - enhancing the applicability of results beyond study settings
Drawbacks/Challenges:
Claims data do … Consider fixed or random effects models to address unobserved variation
Consider a difference-in-difference … transformation effort
Use a comparable control group to address attribution challenges; consider using … propensity score matching to identify a comparable control group
Micro-Costing (also known … If cost estimates are produced for multiple clinics, results can be stratified to show how costs vary
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-facilitators-guide.pdf
February 04, 2022 - � Use and adapt cases:
� Use local examples and case studies as teaching tools to reflect on your team … Studies https://psnet.ahrq.gov/webmm-case-studies
PSNET Diagnostic Errors
Examples
https://psnet.ahrq.gov … gov.ahrq.teamstepps&hl=en
https://www.ncbi.nlm.nih.gov/books/NBK338598/
https://psnet.ahrq.gov/webmm-case-studies … Studies https://psnet.ahrq.gov/webmm-case-studies
PSNET Diagnostic Errors
Examples
https://psnet.ahrq.gov … gov.ahrq.teamstepps&hl=en
https://www.ncbi.nlm.nih.gov/books/NBK338598/
https://psnet.ahrq.gov/webmm-case-studies