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  1. digital.ahrq.gov/sites/default/files/docs/page/2006Reiling_052411comp.pdf
    January 01, 2005 - Push • Standardize Work • Visual Control • Proven Technology • Culture of stopping to fix problems • … of Safety • Shared Values and Beliefs about Safety within the Organization • Always Anticipating … Precarious Events • Informed Employees and Medical Staff • Culture of Reporting • Learning Culture • … “JustCulture • Blame-Free Environment Recognizing Human Infallibility • Physician Team Work • Culture … Lean Principles Process Recommendations Creating a Culture of Safety 2005: Baseline Research Guiding
  2. Ahrqplenary6.05 (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/AHRQPlenary6.05.pdf
    November 01, 2004 - The pilots in the OR JCAHO gets real But will probably run out of gas –Awfully hard to regulate culture … big problem – There are some bad doctors and nurses, notwithstanding “no blame” paradigm – Now, not just … How to promote no blame culture for innocent slips or mistakes while holding persistent rule violators … Bates, JAMA, 1998 (& others) IT (everywhere but medicine) Nothing yet, but just wait Morey, HSR, 2002 … IT and safety culture)  Watch out for squeezed balloons  Expect unexpected consequences – Workarounds
  3. digital.ahrq.gov/sites/default/files/docs/publication/developmentmethodskeyinformantinterviewsreport.pdf
    July 10, 2012 - backgrounds. … While participants did not describe the process of understanding culture and translating these cultural … work as expected, does not help customers to meet their goals); and • Usefulness barriers (e.g., beliefbackgrounds. … While participants did not describe the process of understanding culture and translating these cultural
  4. digital.ahrq.gov/sites/default/files/docs/publication/r36hs018809-valdez-final-report-2012.pdf
    January 01, 2012 - background, health status, insurance status and IT use. … backgrounds approach health information communication with their social network. … Evidence supporting this category included the following quotes: “She and I just don't talk that often … benefit to the social network member because of her membership to the family (a social group): “Just … into the design process arise not only because of the time and challenges of translating cultural beliefs
  5. Title Page (pdf file)

    digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015270-hayden-final-report-2008.pdf
    January 01, 2008 - information in unfamiliar and perhaps more cumbersome ways, we believe that are also linked to a deeply held belief … Whether or not these changes are detrimental remains to be seen, but caregiver’s belief that they are … The disparity between the lack of change in beliefs that surround reporting of adverse events and near … correlated with both a deepening appreciation of the importance of good communication to safety and a belief … However, it is reasonable to consider that staff attitudes toward patient safety, and their beliefs
  6. digital.ahrq.gov/sites/default/files/docs/page/SuccessStory072012_Lapane.pdf
    June 16, 2021 - than  90  percent  of  patients  reported  the  length  of  DVD  segments  and  brochures  to  be  “just … effective  for  delivery  of  key  messages,  and  it  was  essential to  use  actors  from  different  cultures …   on  the  DVDs,  and  they  felt  that  length,  timing,  and   supporting  print  materials  were  just
  7. digital.ahrq.gov/sites/default/files/docs/citation/r18hs025131-jack-final-report-2022.pdf
    January 01, 2022 - Three CFIR constructs designed to elucidate staff perception of knowledge and beliefs about the implementation … Setting: Nine CFIR constructs and five novel codes to elucidate staff perception of knowledge and beliefs … Other facilitators included a culture where staff who went above and beyond their respective roles, … So really, just more everywhere. … So, it just kind of depends.
  8. digital.ahrq.gov/sites/default/files/docs/cds-slides-10192021.pdf
    October 19, 2021 - diagnosis • Perceived as a low-risk test for a disease with disastrous outcomes • Overuse of blood cultures … of the blood culture checklist Challenges to Using the Blood Culture Checklist 40 Critical Decision … ordered, 2 with fever but no blood culture ordered, 17 with no fever but blood culture ordered) ► … representations of each cause (analytical vs intuitive) ► Potential challenges ► Ordering blood cultures … trauma, oncology • Ease of incorporating new things ► Visualizations, ► New AI recommendations (just
  9. digital.ahrq.gov/sites/default/files/docs/citation/r21hs024767-yen-final-report-2019.pdf
    January 01, 2019 - & software computing infrastructure Content Patients Organizational Policies, Procedures & Cultures … competency with using technology and a major theme of “comfort” arose from the analysis, along with the belief … • “just tell me why, just give us a reason. … EMR Implementation Speed: Patient Safety Culture Paradox. … EMR Implementation Speed: Patient Safety Culture Paradox.
  10. digital.ahrq.gov/sites/default/files/docs/citation/r18hs022767-jean-jacques-final-report-2014.pdf
    January 01, 2014 - Therefore, we set out to determine what support CHCs will need not just to purchase or “turn on” CDS … , and quality improvement culture. … , and quality improvement culture. … The “holy grail” of Meaningful Use is not just to increase rates of CDS use but to actually improve … Clinical Decision Support: More Than Just "Alerts" Tipsheet. eHealth University.
  11. digital.ahrq.gov/sites/default/files/docs/HOW%20HEALTH%20IT%20CAN%20REDUCE%20UNNECESSARY%20REHOSPITALIZATION.pdf
    June 16, 2021 - But we also knew that if the easier we made the system for nurses to provide, the less culture of hospitals … Or “It was just like a nurse, actually better, because sometimes a nurse just gives you the paper and … This is what Terry has just been emphasizing, and I said I think it just needs to be underlined again … And we are trying to change a culture. This is not just a technical problem. … And we need to understand that changing that culture is going to be a real challenge for us.
  12. digital.ahrq.gov/sites/default/files/docs/publication/r18hs017167-kopal-final-report-2011.pdf
    January 01, 2011 - Facilitators of success included: leadership, organizational culture, provider engagement, rigorous … Sometimes you may just glance over, but when it's red it does stand out much more. … Especially when the blood pressure was just, say, 130 over 90, a lot of times we would have just ignored … I don’t think it’s just one or two things. … overall these things together plus just paying more attention to hypertension.
  13. digital.ahrq.gov/sites/default/files/docs/publication/r21hs020323-mollica-final-report-2014.pdf
    January 01, 2014 - Providers and patients from different cultural backgrounds may have different explanations of health … In addition, the doctor-patient relationship differs across cultures, which may cause misinterpretation … But it can be used as an effective tool in a PHC setting for building clinical capacity for the culture … I believe the VP willhelp me provide care to my traumatized patients from any cultural background … Clinical Information Systems for Primary Care: More Than Just an Electronic Medical Record.
  14. digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015284-reiling-final-report-2008.pdf
    January 01, 2008 - particular drug, device, test, treatment, or other clinical service. 3 Final Report Purpose Just … Joseph’s experience leads to the belief that whenever possible, “big bang” is the preferred approach … Just Culture is an essential ingredient. … Punishment of human error, based on a belief in “perfection” of performance, is too commonplace in health … Our belief is based on a growing amount of evidence.
  15. digital.ahrq.gov/sites/default/files/docs/phr-impact-chronic-disease-slides-012512.pdf
    January 25, 2012 - ” ■ “It was just the ability to go back and review certain items, and to be observant—any discrepancies … I don’t mean not having the capacity to do it but they just don’t have access to that technology and … guidelines on how fast a physician would get back to [patients] … it would be an opportunity for them to just … ■ Provider and patient attitudes—not just technical and financial considerations—impact individuals … about the PHR Other Provider Beliefs �about the PHR Other Beliefs Mentioned Only by Providers Summary
  16. digital.ahrq.gov/sites/default/files/docs/medication-management-elderly-transcript-081811.pdf
    June 16, 2021 - And we’ll just look at that again. … Again, just thinking about well what does this mean? … We used actors from different cultures rather than race-specific type educational materials. … This is just each packet would come with print materials. … Just help me get it done.”
  17. digital.ahrq.gov/sites/default/files/docs/patient-centered-care-transcript-033011.pdf
    June 16, 2021 - We use a lot of white space, and this is just the basic log-in screen. … I'll just pick up on that, because I think that's a really nice distinction. … TANG: The questioner also asked about privacy, and so I'll build on what someone just said. … CHRISCHILLES: I just wanted to mention, from the standpoint of just medications, we've been very slow … And maybe one just (ph) another question. This one is also for Dr. Chrischilles.
  18. digital.ahrq.gov/sites/default/files/docs/page/2006ClancyKeyesYoung_051211comp.pdf
    June 16, 2021 - in 4 practices have EHRs – but adoption alone not adequate measure  Importance of organizational culture …  Trust is key in developing a culture of quality.  Process  Demonstrating value at the user level … Key Insights  Culture—unequivocal leadership support and local champions are essential for change …  Patient-centered hospital design can support a culture of safety. …  Pursuing the principals and not just the tools of Lean. What Did We Learn?
  19. digital.ahrq.gov/sites/default/files/docs/medicaid/health-it-implementation.pdf
    December 01, 2005 - Change The hardest part about any HIT implementation process is the culture change. … with the stakeholders – Involve all people to some degree early on so people don’t feel they are just … Advancing Excellence in Health Care Culture and Workflow Change (Remember: Culture change = Advertising … +Support) Solution: Do not underestimate the training required in order to address culture change. … – Also make sure that you don’t just listen to a vendors’ demo but develop your own use cases and
  20. digital.ahrq.gov/sites/default/files/docs/publication/r18hs017281-lapane-final-report-2010.pdf
    January 01, 2010 - The length of the DVDs was "just right" (90+%), with 40% sharing the DVD and 48.4% watching the DVDs … A vast majority (95.4%) said that the lengths of the DVDs were just right. … They also 11 found the spacing of the DVD delivery to be just right (87.7%). … Ninety one percent said the amount of print materials they received were just right. … Medication Management Beliefs and Practices Of Low Income Older Adults From Diverse Racial/Ethnic Populations

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