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www.ahrq.gov/ncepcr/tools/confid-report/three-strategies.html
February 01, 2016 - How easy is it for physicians to find out more information, such as details about individual patient … components and features of the report and how the report made them feel. … A decision to forgo testing before a report goes live could be a big mistake, as can be seen in the example … and “How has it influenced what you do in the treatment rooms? … How many physicians are coming to the Web site, what pages are they viewing, and how long are they staying
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfepc-fullguide-final508.pdf
April 01, 2018 - —Primary Care Physician
How Do We Implement Create a Safe Medicine List Together? … —Medical Assistant
How Do We Implement a Warm Handoff Plus? … Additional Resources
Case Studies
Four case studies of exemplar practices from across the country were … Each case study provides an overview of the program, implementation guidance, and contact
information … The full case studies and one-page summaries for patients and clinicians can be
retrieved from the Agency
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/spread/spreadnotes.docx
June 02, 2025 - spreading and how it affects the population it is spreading to. … Slide 9
SAY:
Improvement requires conducting small tests of change using a method such as a Plan-Do-Study-Act … Slide 11
DO:
Play the video.
ASK:
· How is the shadowing opportunity used on Kavita’s unit? … · How does Kavita use the 4 E’s with her team?
Slide 12
DO:
Play the video. … · Finding one person who is willing to do it all.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-ASC_Webcast_2021-Famolaro.pdf
January 01, 2021 - How to Use the AHRQ SOPS Ambulatory Surgery Center Survey to Improve Patient Safety - Famolaro
SOPS … not feel pressured to do tasks
they haven't been trained to do (B3)
53% We do not feel rushed when … CMS
Certification Number (CCN)
• Provide surgical/procedural services to patients that do
not require … hospitalization (except in unusual
circumstances)
• Do not share space with a hospital or hospital … support a facility's need to use a single check list that includes the safety checks
outlined in the
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/049-dec-implementation-slides.pptx
October 01, 2024 - If a dose is missed, resume decolonization according to original schedule.
Do not double up doses. … DO massage CHG firmly onto skin.
DO pay special attention to neck, joints, and skin folds. … Do a one-time check for Candida rashes, heat rashes, drug eruptions, vesicles, etc. … Execute: What do we need to do? How can we do it?
Evaluate: How do we know if we made a difference? … More resources on How To Integrate a CUSP Approach on the Toolkit website.
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-2-pf-as-a-resource.pdf
September 01, 2015 - A How-to Guide
(Knox, et al., 2011). … https://clinicalmicrosystem.org/programs
/team-coaching-program/
Case Studies: from the Agency for … Healthcare https://www.ahrq.gov/ncepcr/tools/case-
Research and Quality, these case studies profile … /
https://clinicalmicrosystem.org/programs/team-coaching-program/
https://www.ahrq.gov/ncepcr/tools/case-studies … /index.html
https://www.ahrq.gov/ncepcr/tools/case-studies/index.html
http://www.coachmedicalhome.org
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/015-ss-hand-hygiene-periop-fg.docx
April 01, 2025 - Slide 21
Case Study
SAY:
This next section of this presentation will delve into a case study involving … Slide 26
Case Example: How To Reduce Likelihood of This Defect from Happening Again? … SAY:
Now let’s talk about how to reduce the likelihood of this defect from happening again. … Slide 27
Case Example: How To Know the Risk Is Reduced? … SAY:
How to know when the risk is reduced?
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www.ahrq.gov/sites/default/files/publications/files/obesity-pcpresources.pdf
May 01, 2014 - Case Study: Ms. … Rural Community Focus Group Member
A Case Study: Ms. Smith
Ms. … you have to be shown how to do it.” … • How do we know when a patient is ready to do something about their weight? … Quick Start Guide
Contents
Introduction
A Case Study: Ms. Smith
What Can Your Practice Do?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Akins.pdf
January 01, 2003 - They have made an effort to align institutional operations
from top to bottom utilizing a variety of … present and in the future, shows that health care
administrators and professionals do not fully appreciate … health care administrators should do the following:
• Effectively communicate the priority of patient … CQI case study: reducing
medication errors. Jt Comm J Qual Improv 1995;21
(5):232–7.
37. … To err
is human: building a safer health system.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-removal.pptx
April 01, 2022 - hourly urine output is no longer needed to guide his care
Disclaimer: All case studies are hypothetical … Any similarity between a case study and actual patient or hospital experience is purely coincidental. … Grant’s risk of falling when getting up to urinate frequently
Disclaimer: All case studies are hypothetical … Any similarity between a case study and actual patient or hospital experience is purely coincidental. … How long is a transurethral catheter necessary in patients undergoing thoracotomy and receiving thoracic
-
www.ahrq.gov/sites/default/files/2024-01/rosen-report.pdf
January 01, 2024 - I X R • Systematic variability in how raters score a particular intensivist
(O:I) X R • Systematic … variability in how raters score specific observations
I X C • Variance due to intensivists performing … To further
investigate how this tool and measurement process could be improved, we conducted a
Decision … A systematic review of teamwork in the
intensive care unit: What do we know about teamwork, team tasks … A systematic review of behavioural marker
systems in healthcare: What do we know about their attributes
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops101-webcast-transcript-ad.pdf
June 01, 2020 - Gray, Slide 16
Here's another example from a case study featuring Yuma District Hospital and Clinics … Medical Office Survey Helps Colorado Hospital Provide Better Care:
https://www.ahrq.gov/news/newsroom/case-studies … /newsroom/case-studies/201709.html]
Then, my final example here is from St. … ,
including how you may still modify the background work areas or staff positions, as well as how to … If we
want to submit our survey results to the SOPS database for analysis, where or how do we upload
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_sr-execs.pptx
December 01, 2017 - 8
Case Study: Laparoscopic Surgery Trays
Laparoscopic gastrointestinal tray had 137 instruments including … new tray with 60 percent fewer instruments and reduced costs and saved time.
9
Case Study: Antibiotic … It can be difficult, and very few people are trained on how to do it. … Do not expect a decision immediately. … Use a title that states the how-to.
ASK:
Do you know how to access your HSOPS aggregate report?
-
www.ahrq.gov/sites/default/files/2024-07/madison-report.pdf
January 01, 2024 - Organizing for Higher Performance: Case Studies of Organized Delivery Systems. … -
Studies/2009/Jul/Organizing-for-Higher-Performance-Case-Studies-of-Organized-Delivery-Systems.aspx … https://www.commonwealthfund.org/publications/case-study/2009/jul/organizing-higher-performance-case-studies-organized-delivery … https://www.commonwealthfund.org/publications/case-study/2009/jul/organizing-higher-performance-case-studies-organized-delivery … marshfield-clinic-health-information-technology-paves-way
https://www.commonwealthfund.org/publications/case-study
-
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide1.html
October 01, 2017 - (covered in Section 4 and Training Module 4)
How do you measure pressure injury rates and pressure … This is how we do it here at our hospital.
This is sustainment. … How do you get leadership involved? … Are staff making the changes you said you were going to in your Action Plan? How do you know? … How do you know?
-
www.ahrq.gov/research/findings/final-reports/stpra/stpraapd.html
April 01, 2018 - A couple weeks to a week before. … on how to get to the ASC. … Nurses do not make call to cancel. … If they have a cough then tell them to not come, do not want small kids, people in waiting room, but … Staff are supposed to assume a patient could have MRSA or other infections, whether they do or not.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
April 01, 2025 - Another way to describe a defect is Anything that you do not want to happen again. … Frontline personnel are typically taught how to do their clinical job well. … This tool involves asking all staff to fill out a survey that asks the following: “Please describe how … As a team, identify how to measure success for each intervention. … are clinical or operational events that you do not want to happen again.
-
www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-3.html
July 01, 2019 - The risk scores are a barometer of a patient's medical complexity only and do not reflect utilization … MTM pharmacist teaches fellow Edina staff members, the MTM pharmacy residents, and pharmacy students how … who do not have a primary care provider and are encouraged to establish care at Edina. … also do this. … Consistent Care Model is Key: A Case Study of Integrated Medication Management at Fairview Health Services
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/breaking-down-barriers-transcript.docx
May 12, 2015 - nurse has to do rather than as a component of evidence-based practice. … How do we improve things like execution? Execution, then, has many components. … It's remained in with the licensed staff, because we realized how important and how many steps and how … to see how the nurses perform in doing a demonstration of insertion, again. … recent additions and changes, but then also work on some case studies with everyone on applying the
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
January 01, 2014 - As we saw in the “Do No Harm” Video, families reported how the silence they experienced after the adverse … way of getting answers to their questions.
7
What Do Patients Want? … Module 1
13
The response to medical injury involves more than just what to do and what we say to … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … If a Just Culture is so important to an organization’s culture, why do we still focus on blame?