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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/be-prepared_webinar_slides.pdf
January 01, 2015 - disclose.
2
Objectives
• Review the key threats to patient safety in
primary care settings and interventions … Key Project Deliverables
• Environmental Scan
• Four Case Studies of
Exemplar Practices
• Four Interventions … to
Improve Safety by PFE
• Final Guide
5
Key Threats & Promising Interventions
Threats … Medication management
• Diagnosis and treatment
• Fragmentation and
environment of care
Promising Interventions … care
• Structured communication
tools
6
Patient & Family Engagement in Primary Care
Four Interventions
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/104-what-are-4-es.pptx
April 01, 2025 - framework—Engage, Educate, Execute, Evaluate—and explain its significance in implementing effective interventions … Implement and prioritize interventions based on the 4 Es framework to address identified issues. … Review existing policies to ensure there are clear procedures that are consistent with the interventions … Engage: Prioritize Interventions11,12
Strength of Intervention Interventions
Strong Actions Forcing … 15
Case Example: Prioritizing Interventions
The team prioritizes interventions based on the Action Hierarchy
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www.ahrq.gov/practiceimprovement/delivery-initiative/alexander.html
December 01, 2020 - Assessing complex, multi-component interventions. … Slide 7
Modeling Intervention Context
Interventions can display different strengths, causal directions … Slide 10
Readiness for Change
Not all delivery systems/organizations are good candidates for interventions … Slide 11
Complex, Multi-Component Interventions
How the combined effects of multiple intervention
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/116-cusp-premortem-project-assessment.docx
January 01, 2007 - Having identified the reasons, the team brainstorms interventions that can be included in the intervention … For each of the three or four highest priority concerns, brainstorm interventions that can be carried … Insert reason
Insert ranking
Insert action steps
CUSP Premortem Results
Compile the list of specific interventions … below (not all the brainstormed interventions; just the ones the group selected).
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www.ahrq.gov/evidencenow/projects/heart-health/research-results/research/methods/measures.html
August 01, 2018 - Process Capability Questionnaires), burnout, practices’ readiness to implement quality improvement interventions … The cooperatives will use stepped wedge, cluster randomized, and factorial designs to evaluate their interventions … Interventions are randomized based on practice region and readiness
Northwest
Practices … expert consultation on the ACC/AHA heart risk calculator, or site visits to exemplar practices, both interventions
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www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamilyex2.html
July 01, 2018 - Hospital-based interventions and materials
What strategies and interventions have been identified … Who introduces these interventions in the hospital? … What outcomes are associated with these interventions?
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www.ahrq.gov/research/findings/evidence-based-reports/gapkaleidtp.html
April 01, 2018 - patient-centered medical home, QI strategies to address health disparities, effectiveness of medication adherence interventions … Results : The series collectively assessed the evidence across quality levers and various populations, interventions … reviews, including use of logic models, approaches to defining and searching for complex health care interventions … applying traditional systematic review methods to the multifaceted, context-dependent, systems-level interventions
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/saworksheet.html
December 01, 2017 - implementing the On-Time electronic reports into current workflow to help inform pressure ulcer wound interventions … Develops interventions specific to the risk factors to mitigate risk. … Check all that apply.
___ Nutritional interventions to meet the resident’s hydration, protein, calorie
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Leonhardt_35.pdf
March 15, 2008 - Interventions included education, personal medication lists, and
medication bags. … The
primary interventions focused on patient medication self-management tools. … Patient-directed interventions. … Provider interventions. … Interventions to
enhance patient adherence to medication prescriptions.
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www.ahrq.gov/news/newsroom/case-studies/cquips1303.html
April 01, 2013 - safety culture, track changes in patient safety over time, and evaluate the impact of patient safety interventions … safety culture, track changes in patient safety over time, and evaluate the impact of patient safety interventions … safety culture, track changes in patient safety over time, and evaluate the impact of patient safety interventions
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www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/followup.html
August 01, 2022 - is working with labor and delivery units at 50 participating hospitals to implement perinatal safety interventions … The interventions include safely managing labor-inducing medications and shoulder dystocia (when delivering … These and other interventions are bundled in evidence-based clinical tools and resources.
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide183.html
October 01, 2014 - Systems-Cost-Effectiveness of Tobacco Dependence Interventions
Treating Tobacco Use and Dependence
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-overview/slide37.html
October 01, 2014 - Systems Interventions: Clinician Training and Chart Reminders
Treating Tobacco Use and Dependence
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www.ahrq.gov/hai/cauti-tools/guides/sustainability-guide.html
October 01, 2015 - A Model for Sustaining and Spreading Safety Interventions
Next Page
Table of Contents … A Model for Sustaining and Spreading Safety Interventions
Appendix A. … attributed their success as much to a strong safety culture as to effective technical and clinical interventions … Staff Learn Both Technical and Adaptive Interventions
HAI prevention and other safety change initiatives … Active involvement of frontline workers and other end-users in safety interventions has multiple benefits
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb.html
December 01, 2017 - Assessment
Unsafe Behavior Worksheet
FMP Entry Log
Primary Care Provider Fax Report and Orders
Fall Interventions … Plan
Fall Interventions Monitor
Staff Materials
Pre and Posttests for Inservice #1, Why Falls … Primary Care Provider Handouts
Facts and Flow Chart
Suggestions for Further Assessment and/or Interventions
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/tap2.html
October 01, 2014 - Program Interventions
Oklahoma's care management program continued some of the interventions implemented … Implementing clinical interventions for year three (measures yet to be selected). … Program Interventions
Program interventions are mostly telephonic with community-based nurses paying … Program Interventions
Virginia's disease management interventions include:
Case management.
24 … Program Interventions
Washington's program with McKesson included member interventions such as assessment
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspxselfassessment.pdf
June 02, 2025 - are needed, and how they determine what those interventions are. … • Develop interventions specific to the risk factors to mitigate falls risk. … Are interventions for primary prevention* included in a falls prevention care plan? … Are interventions for secondary prevention* included in a falls prevention care plan? … Do falls prevention care plans include interventions addressing the following falls risk factors?
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/gap_analysis_tool.docx
November 01, 2019 - Unmarked questions ask about basic structure and commonly utilized interventions. … PA and PPRF are common and effective ASP interventions. … ☐ Yes
☐ No
How do you make AS interventions? … ☐ Yes
☐ No
☐ N/A
Other Interventions To Consider
➕Is there is a formal procedure for all clinicians … being conducted by the ASP to improve antibiotic use outside of core interventions.
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www.ahrq.gov/sites/default/files/publications/files/ccreroadmap.pdf
July 01, 2013 - Studies should include assessments of the feasibility and sustainability of interventions to
improve … The relevance and effectiveness of
particular interventions depend on each community’s unique needs, … Interventions should be flexibly tailored
when indicated to accommodate local circumstances. … Evaluating the public
health impact of health promotion interventions:
the RE-AIM framework. … Evaluating
primary care behavioral counseling interventions:
an evidence-based approach.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
December 01, 2017 - Slide 14
Prioritizing Interventions
SAY:
Prioritize interventions that will have the highest impact … Be realistic about the impact the interventions are likely to have. … Weak interventions are easier to bypass. … ASK:
Does your staff know about the interventions? … Prioritize the contributing factors and your interventions.