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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/index.html
March 01, 2025 - Discharge Program Case Study: Penn Medicine Chester County Hospital Implements AHRQ Toolkit to Reduce … Readmissions Case Study: AHRQ's RED Toolkit Helps Lower Readmissions in Dignity Health Hospitals Case … Study: Memorial Hospital Uses AHRQ Resources to Cut Readmissions, Promote Patient Self-Management Case … Study: AHRQ's RED Toolkit Inspires Improved Patient Discharge at Nacogdoches Memorial Hospital Case … Degree of Patient Understanding Review What To Do if a Problem Arises Postdischarge Components
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/index.html
March 01, 2025 - Discharge Program Case Study: Penn Medicine Chester County Hospital Implements AHRQ Toolkit to Reduce … Readmissions Case Study: AHRQ's RED Toolkit Helps Lower Readmissions in Dignity Health Hospitals Case … Study: Memorial Hospital Uses AHRQ Resources to Cut Readmissions, Promote Patient Self-Management Case … Study: AHRQ's RED Toolkit Inspires Improved Patient Discharge at Nacogdoches Memorial Hospital Case … Degree of Patient Understanding Review What To Do if a Problem Arises Postdischarge Components
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www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod3.html
February 01, 2023 - study. … study. … I put a pad under her and instructed her on how to ring for the bedpan. … What might the manager do to mitigate this situation? … Janet: I do, too.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/reports-and-case-studies/ExecSummcaseplancustsvce-RAND7607.pdf
July 01, 2007 - 1
IMPROVING PERFORMANCE FOR
HEALTH PLAN CUSTOMER SERVICE
A Case Study … of a Successful CAHPS
Quality Improvement Intervention
Excerpt: The Case Study in Brief
For a copy … Farley
RAND Corporation
1
THE CASE STUDY IN BRIEF
Introduction
This report … How? … training procedures and
information systems to support the call center and
a culture of “How can we
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.html
October 01, 2014 - How Do We Implement Best Practices in Our Organization? … How do we implement best practices in our organization?
5. … How do we sustain the redesigned prevention practices?
7. … How do we pilot test the new practices? … , case study analysis, listserve discussion, and grand round talks.
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.html
October 01, 2014 - How Do We Implement Best Practices in Our Organization? … How do we implement best practices in our organization?
5. … How do we sustain the redesigned prevention practices?
7. … How do we pilot test the new practices? … , case study analysis, listserve discussion, and grand round talks.
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case2.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Case 2. … Studies
Introduction to the Case Studies
Case 1. … The case study methods, including the criteria for selection of the projects for analysis, were described … decreased by 57 percent (from 15,000 to about 8,000 cards) over the duration of this case study. … The focus of this case study report is on the qualitative data collected, and thus it addresses mostly
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www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/learn-from-defects.html
December 01, 2017 - Purpose of this Example Case Study: This example case study helps you understand the LFD process and … Then review this example case study about the LFD process and use of the tool. … The surgical safety team lead or a designee should review the example case study in preparation for the … How to use this tool: Review the example case study before you hold your first LFD meeting. … Then we had a discussion about how to do the scoring.
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www.ahrq.gov/sites/default/files/publications/files/clabsi-hpwpreport.pdf
May 01, 2015 - We used the case study format
to explore whether and how the implementation of HPWPs facilitates successful … to determine the most appropriate focus for our case study research; and
2. … Studies
For this task order we conducted indepth case studies of health care organizations and intensive … Case Study Process
The case studies included site visits between June 2011 and October 2012 to nine … First, to set the context for our results, we
provide a brief descriptive summary of the case study
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www.ahrq.gov/patient-safety/reports/liability/mincer.html
August 01, 2017 - Safety and Medical Liability
Implementing Shared Decision-Making: Barriers and Solutions—An Orthopedic Case … Study
Previous Page Next Page
Table of Contents
Advances in Patient Safety and Medical … Would the patient like to obtain a second medical opinion, talk to trusted others, or do additional research … Based on the patient’s expressed values and preferences, how would they like to move forward, including … Teach Back
The patient explains back to provider the decision that was made and how they got to that
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
May 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. … AHRQ Impact Case Studies
https://www.ahrq.gov/news/newsroom/case-
studies/index.html? … This subset of the Agency’s
Impact Case Studies specific to patient safety highlights these successes … AHRQ Impact Case Studies
2.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
December 01, 2017 - case study of a renal transplant patient.
24
Case Study: Renal Transplant
Who: A patient bleeding after … The patient was stabilized and the surgery to control the bleeding began.
25
Case Study: Renal Transplant … ASK:
What factors contributed to this event?
27
Case Study: Renal Transplant
What happened? … A handoff that worked in normal situations failed in an emergent one.
28
Case Study: Renal Transplant … Email blasts are not effective for teaching how to do a job better or to make sure patients are safer
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mgdod3.html
October 01, 2014 - to use the materials in the companion Student Workbook as a teaching session and also how to apply a … The second session describes how to do an assessment of fall risks for residents and how to respond to … Case Study
Mr. … What would they do differently next time? How did it feel to say____? How did it feel to hear____? … Plan: Identify a problem and design a change to address it.
Do: Implement a small change.
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www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-fac-notes.html
December 01, 2017 - How do we augment our work processes to include the emerging evidence? … Do we have those roles? Do you understand your assigned role? Do we have a plan of care? … Slide 19: How Do You Create a Mindful Process? … Slide 36: Case Study: Laparoscopic Surgery Trays
Say:
Debriefing also uncovered an inefficiency … Slide 37: Case Study: Laparoscopic Surgery Trays
Say:
Debriefing at the end of a case, the staff
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings_facnotes.docx
December 01, 2017 - How do we augment our work processes to include the emerging evidence? … Slide 18
How Do You Create a Mindful Process? … ASK:
How do you get everyone attending and participating in the briefing? … Slide 35
Case Study: Laparoscopic Surgery Trays
SAY:
Debriefing also uncovered an inefficiency related … Slide 36
Case Study: Laparoscopic Surgery Trays
SAY:
Debriefing at the end of a case, the staff questioned
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-k-debrief-audio-facnotes.docx
June 02, 2025 - Many places are already doing some form of a debrief, but just want to do it a little better or more … In this case we're going to designate an observer, and we're going to do it for 1 week to establish a … to use that observation log to actually determine if a case does a debrief or doesn't do the debrief … You want to set a goal that has a narrow timeframe specified because you know how it goes, if you don't … Remember we identified that cause of the lack of a trigger to do the debrief.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings.pptx
December 01, 2017 - ASK:
How do we take the evidence and turn it into something that care providers can use? … How do we augment our work processes to include the emerging evidence? … Do we have those roles? Do you understand your assigned role? Do we have a plan of care? … Do You Create a Mindful Process? … ASK:
How do you get everyone attending and participating in the briefing?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-k-study-elements.docx
June 02, 2025 - Describe what to measure and how to use the data.
· Identify the person who will collect the data.
· … Consider using the 3 A’s to decide what to
do next:
· Adopt – The goal was reached. … data to assess whether the intervention is working, but short enough to allow rapid evaluation.
· Do … Once again, consider using the 3 A’s to
decide what to do next:
· Adopt – The goal was reached. … Communication/
Reporting of Findings
Schedule a time to share all of the data collected, how it was
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-k-debrief-fac-notes.html
May 01, 2017 - Many places are already doing some form of a debrief, but just want to do it a little better or more … In this case we're going to designate an observer, and we're going to do it for 1 week to establish a … to use that observation log to actually determine if a case does a debrief or doesn't do the debrief … You want to set a goal that has a narrow timeframe specified because you know how it goes, if you don't … Remember we identified that cause of the lack of a trigger to do the debrief.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
December 01, 2017 - )
Appendix: Example Case Study
Problem statement: If a patient is harmed … Purpose of this Example Case Study: This example case study helps you understand the LFD process and … The surgical safety team lead or a designee should review the example case study in preparation for the … How to use this tool: Review the example case study before you hold your first LFD meeting. … Then we had a discussion about how to do the scoring.