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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-webinar-slides.pdf
June 02, 2025 - 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 … care
• Structured communication
tools
6
Patient & Family Engagement in Primary Care
Four Interventions … Patient & Family Engagement in Primary Care
Four Interventions
What is the Warm Handoff Strategy?
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-overview/slide10.html
October 01, 2014 - Tobacco use interventions for individuals with low socio-economic status/limited formal education. … Tobacco use interventions for adolescent smokers. … Tobacco use interventions for pregnant smokers. … Providing cessation interventions as a health benefit. … Systems interventions, including provider training and the combination of training and systems interventions
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/111-cusp-program-sustainability.docx
October 01, 2024 - In essence, sustainability is achieved when the improved processes and interventions are embedded into … Slide 3
Keys to Sustainability
SAY:
It is vital to think about the sustainability of the interventions … The interventions must be designed in a way that does not overburden unit personnel with tasks that are … Some personnel may be resistant to change and may not understand the need for new interventions. … Continue to focus on the project’s interventions and monitor the team’s progress over time to ensure
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www.ahrq.gov/funding/policies/nofoguidance/index.html
January 01, 2025 - Design, implementation, dissemination and spread, and evaluation of interventions to improve patient … AHRQ does not fund comparisons of two known efficacy or effectiveness clinical interventions to determine … Research to develop, adapt, implement, and evaluate evidence-based interventions to eliminate disparities … interventions designed to improve access, quality, and outcomes by preventing and managing chronic disease … Mechanisms of sustainability of interventions developed and tested.
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www.ahrq.gov/sites/default/files/2024-02/schnipper2-report.pdf
January 01, 2024 - One site did not implement any interventions. … Interventions
The MARQUIS2 toolkit consisted of 17 interventions grouped into eight domains: taking … Patient-Level Interventions
Patient-level interventions included the following: BPMH in Emergency Department … System-level interventions by themselves, without patient-level interventions, did
not have a significant … Adoption and Implementation of System-Level Interventions by Site
Table 6.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/110-ss-lfd-sample.docx
April 01, 2025 - Identify two to five interventions that you will use. … Refer to the Strength of Interventions chart below for examples of strong and weak interventions and … Caylin (infection control specialist)
6 weeks
Strength of Interventions
Category
Examples of interventions … After the interventions have been put in place, complete the “Describe Defect” and “Interventions” sections … and have staff rate the interventions.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb5txt.html
December 01, 2017 - Step 5: Develop new individualized interventions. … Return to Document
Fall Interventions Plan (Text Description)
Resident: ____________________ … Revise interventions as needed and record below. Use one sheet for every 2 weeks.
… Are interventions effective: ___ Yes ___ No
Changes:
Comments:
Vision
Are interventions … effective: ___
Yes ___ No
Changes:
Comments:
Vision
Are interventions effective: _
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state-apa.html
January 01, 2024 - error + test results management
diagnostic safety/error + close the loop
diagnostic safety/error + interventions … diagnostic safety/error + interventions educational
diagnostic safety/error + interventions cognitive … diagnostic safety/error + interventions patient and family
diagnostic safety/error + interventions
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide194.html
October 01, 2014 - Evidence of effectiveness of tobacco dependence interventions in specific populations
Population … without counseling = 13.2 %; with counseling, abstinence rate = 17.7% [95% C.I. = 13.7%- 22.6%])
Interventions
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide20.html
October 01, 2014 - Effectiveness of cessation interventions for adolescent smokers. … Effectiveness of cessation interventions for pregnant smokers. … Effectiveness of cessation interventions for individuals with psychiatric illness and/or non-tobacco … Effectiveness of providing cessation interventions as a health benefit. … systems interventions.
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www.ahrq.gov/priority-populations/about/index.html
January 01, 2025 - researchers and others in the health services research field to conduct disparities research and assess interventions … to reduce disparities, improve data for measuring and tracking disparities, and identify and promote interventions … Developing the evidence for interventions to reduce disparities and facilitating the use of those interventions … The Northwestern Center of Excellence for Clinical Preventive Services work to develop and test interventions
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/002-cusp-learning-defects.pptx
October 01, 2024 - defects at a systems level
Focuses on identifying system factors that contribute to defects, planning interventions … :
Brainstorm with the entire team to identify interventions that address key contributing factors
Connect … with other CUSP teams who may be working on the same defect
Not all interventions are created equal … Examples of interventions, in order of decreasing strength of effectiveness, include the following: … Review audits and adjust interventions as needed.
May require thinking about defects again.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
April 01, 2025 - defects at a systems level
Focuses on identifying system factors that contribute to defects, planning interventions … :
Brainstorm with the entire team to identify interventions that address key contributing factors
Connect … with other CUSP teams who may be working on the same defect
Not all interventions are created equal … Examples of interventions, in order of decreasing strength of effectiveness, include the following: … Review audits and adjust interventions as needed.
May require thinking about defects again.
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www.ahrq.gov/patient-safety/reports/engage/next-steps.html
March 01, 2017 - Interventions
Environmental Scan Report
Over the coming months, we will continue to … with our project partners, AHRQ team, and Technical Expert Panel members to identify and prioritize interventions … vigilant in efforts to be informed of changes in policy and practice in the primary care domain to promote interventions
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/027-cusp-program-sustainability-fg.docx
April 01, 2025 - In essence, sustainability is achieved when the improved processes and interventions are embedded into … CUSP fosters a culture of patient safety by improving patient care through evidence-based interventions … The interventions must be designed in a way that does not overburden unit personnel with tasks that are … Some personnel may be resistant to change and may not understand the need for new interventions. … Continue to focus on the project’s interventions and monitor the team’s progress over time to ensure
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www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/contributions.html
August 01, 2022 - other materials, and many of these have the potential to spur or assist in the replication of PSML interventions … projects suggest positive (and in other cases, promising) outcomes associated with some facet of the interventions … projects would tie patient safety and malpractice liability together in basically similar ways in their interventions … These projects showed that the implementation of specific patient safety interventions (and/or the standardization … only to the impact of the PSML portfolio but also more broadly to the design and assessment of future interventions
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www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/lessons.html
August 01, 2022 - As a result, it is fundamentally unrealistic to implement new clinical or policy interventions for patient … intervene in the PSML environment, and it has a corresponding set of implications for the types of interventions … By contrast, an entirely different set of PSML interventions might be designed around reducing malpractice … These interventions, too, are intuitively reasonable, but they are also qualitatively different, and … For hospital systems and other health care entities that undertake PSML-style interventions in the future
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide197.html
October 01, 2014 - Evidence of effectiveness of tobacco dependence interventions in specific populations
Population … It should be noted that these studies typically included intensive psychosocial interventions for all
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/157-what-are-4-es.docx
October 01, 2024 - The Action Hierarchy is a useful model to prioritize interventions. … Strong Actions are interventions that do not rely on human memory and behavior. … with and reinforcing other interventions. … Slide 15
Case Example: Prioritizing Interventions
SAY:
The St. … First, they prioritize strong interventions with immediate impact.
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www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily2.html
July 01, 2018 - , reviewing the peer-reviewed and grey literature, and identifying and assessing relevant tools and interventions … patients, families, and health care professionals related to patient and family engagement; hospital interventions … The protocol focused on the following areas:
Patient, family, and health care professional interventions … to encourage engagement, along with barriers and facilitators to these interventions. … the conceptual framework: target audience perspectives, organizational context, and strategies and interventions