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www.ahrq.gov/news/newsroom/case-studies/201903.html
April 01, 2019 - Johns Hopkins Children’s Center Uses AHRQ-Funded I-PASS Tool to Boost Patient Safety
Search All Impact Case Studies
April 2019
Pediatric residents at Johns Hopkins Children’s Center in Baltimore, MD, changed the way they handed off patients between shift changes by closely adhering—sometimes by as much as …
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/stpra/stpra.pdf
March 01, 2012 - for infection control practices at ASCs be
modeled after the guidelines provided to hospitals and incorporated … As a result,
additional risk for infections may be inadvertently incorporated into the patient’s care … may lead to the adverse outcome
• Allows the uncertainty associated with error rate estimates to be incorporated … results of the data analyses for the California 2008 SASD are included in
Appendix B and are being incorporated … Therefore, the intervention should include opportunities for staff technique to be observed,
standards incorporated
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/facslides.html
September 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits
Facilitator Training Slide Presentation
Text version of slide presentation.
Slide 1: Overview of On-Time
AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department V…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining-slides.html
October 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training
Overview of On-Time
Text version of slide presentation.
Slide 1: Overview of On-Time
AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training
Overview of On-Time
Slide 2: On-Time Fall…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/facslides.html
December 01, 2017 - On-Time Pressure Ulcer Healing: Facilitator Training Slide Presentation
AHRQ’s Safety Program for Nursing Homes
Text version of slide presentation.
Slide 1: Overview of On-Time
AHRQ’s Safety Program for Nursing Homes:
On-Time Pressure Ulcer Healing Facilitator Training
Slide 2: On-Time Pressure Ulcer…
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/care-coordination-resource-guide.pdf
November 17, 2022 - Enhancing Care Coordination for CR Resource Guide
1
Enhancing Care Coordination for CR
Resource Guide
Care Coordination
1. International Council of Cardiovascular Prevention and Rehabilitation-CR Utilization
This online course is intended to train inpatient CR care coordinators/liaisons on how to encourage…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Raebel_53.pdf
May 07, 2008 - Factors documented to affect care processes and patient outcomes positively were incorporated
into the … In the KPCO Program,
these error-prone tasks are incorporated into a high-reliability model elsewhere … equivalent drug substitution for amitriptyline is authorized by the RDCs in the future, it
will be incorporated
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-impmenu.docx
June 02, 2025 - Agency for Healthcare Research and Quality Safety Program for Nursing Homes: On-Time Healing
AHRQ’s Safety Program for Nursing Homes: On-Time
Pressure Ulcer Healing
Menu of Implementation Strategies
The On-Time Menu of Process Improvement Strategies for using reports is a list of potential ways facility teams may choo…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-impmenu.pdf
June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time
Pressure Ulcer Healing
Menu of Implementation Strategies
The On-Time Menu of Process Improvement Strategies for using reports is a list of potential
ways facility teams may choose to integrate the pressure ulcer healing reports into clinical
practice. A menu of…
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www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/preface.html
March 01, 2016 - Similar strategies to improve ambulation and address over-prophylaxis have been incorporated, as has
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a4_pdi_casestudy.pdf
December 01, 2015 - The algorithm that the
team developed was incorporated into the hospital’s electronic medical record
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-pennsylvania-state-snapshot.pdf
January 01, 2018 - child-serving providers.1, 4 With
support from the CHIPRA quality demonstration, the health
systems—
• Incorporated
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/preface.html
March 01, 2016 - Similar strategies to improve ambulation and address over-prophylaxis have been incorporated, as has
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www.ahrq.gov/professionals/clinicians-providers/resources/rice/ceproj.html
October 01, 2014 - Policy Projects
Research Initiative in Clinical Economics
Clinical Economics Resource Links
Policy Projects
Evaluation of the Academy for Managed Care Pharmacy Format for Formulary Submissions
Deliberative Focus Groups: Citizen Input to Health Policy
Evaluation of the Academy for Man…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/factraining.html
September 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits
Facilitator Training
This version of the On-Time Facilitator Training Overview is for training Facilitators who have not had pressure ulcer prevention training. If they have had that training, this set of sli…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining.html
November 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention
Facilitator Training
This version of On-Time introduction is for training Facilitators who have not had pressure ulcer prevention training. If they have had that training, this set of slides can be omitted or may be used as a refresher.
Slide…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/module3_pu-bestpractices.docx
June 02, 2025 - Slide 13
Practice Insight
SAY: A large acute care hospital incorporated an annotated pocket pad image
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-11.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 6.11. Lean Tools for Horizon Hospital
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Case 2. Centr…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/031-hand-hygiene-monitoring.docx
October 01, 2024 - Direct Observation: Covert1-4
Incorporates unknown or undercover (“secret shopper”) observers to facilitate accurate data collection
Advantages
Disadvantages
· Minimizes the Hawthorne effect—the observer’s effect on the behavior being observed
· Identifies trends and barriers to adherence
· Includes possibility t…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/1_preventablehospitaledvisits-overview-ig.pdf
June 02, 2025 - Overview
Slide
AHRQ’s Safety Program for Nursing
Homes: On-Time Preventable Hospital
and Emergency Department Visits
Facilitator Training: Overview of
On-Time
This version of the On-Time Facilitator Training Overview is for
training Facilitators who have not had pressure ulcer prevention
training. If they h…