Results

Total Results: 1,248 records

Showing results for "just culture".
Users also searched for: just culture

441. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
     December 01, 2017 - Don’t just assume that an individual made one mistake. … lasting change, remember the human factors involved in the defect: the attitudes, the values, and the beliefs … Find what is hiding just below the surface, those protections that prevent the patient harm from getting … SAY: Think about the culture. … ASK: Was there something about the safety culture, the operating room culture, or the PACU culture that

442. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod2concl.html
     October 01, 2014 - Pitfalls Assuming that someone knows what is happening just because they have a higher position is … Assuming that someone from a different culture who speaks your language understands you may not be correct

443. Creating Safety in the Testing Process in Primary Care Offices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Elder_18.pdf
     February 19, 2008 - The most common resilience properties were top-level commitment and a learning culture applied to work … • Just culture: Reporting of issues, problems, events, and errors throughout the organization is … We found no examples of opacity, preparedness, or a just culture within any of these organizational … • Safety culture • Person • Tasks • Organization • Top level commitment • Learning culture … practices, future research will be necessary to tell if that is true of training programs in general or just

444. Preventing-Cauti-Icu-Setting-Facilitators-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-facilitators-guide.docx
     September 01, 2015 - We know that just because a patient is in the ICU, the patient may not require a urinary catheter. … In this way, you can see trends and beliefs related to catheter use. … Slide 12 Narration: In some instances, resistance to changing catheter use practices comes from the belief … Behavior-based beliefs are a challenge. … Slide 16 Narration: Many ICUs obtain cultures from multiple sites when a patient has a temperature spike

445. SOPS® Diagnostic Safety Supplemental Item Set for the SOPS Medical Office Survey (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/Final-DX-Safety-items-12-15-2022.docx
     January 01, 2022 - set should be added to the end of the SOPS Medical Office Survey, after Section G: Overall Ratings, just … Measures: A composite measure is a grouping of two or more survey items that assess the same area of culture … Development, pilot testing, and psychometric analysis of the AHRQ Surveys on Patient Safety Culture™

446. SOPS® Diagnostic Safety Supplemental Item Set for the SOPS Medical Office Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/Final-DX-Safety-items-2022-1215-ENGLISH-508.pdf
     January 01, 2022 - set should be added to the end of the SOPS Medical Office Survey, after Section G: Overall Ratings, just … Measures: A composite measure is a grouping of two or more survey items that assess the same area of culture … Development, pilot testing, and psychometric analysis of the AHRQ Surveys on Patient Safety Culture

447. Building on Innovation to Become a Champion | Agency for Healthcare Research and Quality
     www.ahrq.gov/evidencenow/projects/heart-health/about/stories/in-action/plymouth.html
     March 01, 2021 - “We had this room that we used for various purposes, and it just made sense that when a patient comes … Arenberg, “so the means to accomplish more is already part of the culture here.”

448. Mod4-System-Focused-Event-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
     April 01, 2016 - Just Culture When event investigation and analyses are conducted from a systems approach, with a focus … The fair and accountable culture is not a blame-free culture, as individuals must still be accountable … culture and systems thinking. … Just to remind everyone, this is our solutions meeting for [brief description of event]. … Discharging physician did not realize cultures were positive No handoff between nocturnist and next

449. AHRQ Webcast Introducing the New SOPS Hospital Survey 2.0 - Sorra (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/3-sorra-sops-hospital-survey-2-0-webcast.pdf
     July 20, 2020 - AHRQ Webcast Introducing the New SOPS Hospital Survey 2.0 - Sorra AHRQ Surveys on Patient Safety Culture … and the SOPS Surveys 14 What is Patient Safety Culture? … Shifting to a “Just Culture” framework to assess Response to Error; 4. … SOPS Surveys What is Patient Safety Culture? … What areas of patient safety culture does HSOPS 2.0 assess?

450. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/assess-psc-hsop-facguide.docx
     January 01, 2017 - ASK: What is safety culture? … Slide 3 Core Aspects of Safety Culture SAY: The culture of safety has six main components. … Slide 6 Why Safety Culture Matters ASK: Why does safety culture matter? … Slide 7 Measuring Safety Culture ASK: How is safety culture actually measured? … for Healthcare Research and Quality, or AHRQ, Safety Program for Mechanically Ventilated Patients is just

451. SOPS® Health Information Technology (IT) Supplemental Item Set for the SOPS Hospital Survey - Spanish (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/HIT-Patient-Safety-Items-2022-1215-SPANISH-508.pdf
     January 01, 2022 - with the core SOPS® Hospital Survey Version 2.0 to help hospitals assess the extent to which their culture … item set should be added to the end of the SOPS Hospital Survey 2.0, after Section F: Your Hospital, just … Measures: A composite measure is a grouping of two or more survey items that assess the same area of culture … Development, Pilot Testing, and Psychometric Analysis of the AHRQ Surveys on Patient Safety Culture

452. SOPS® Health Information Technology (IT) Supplemental Item Set for the SOPS Hospital Survey - Spanish (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/HIT-Patient-Safety-Item-Set-Spanish-12-15-22.docx
     December 01, 2022 - with the core SOPS® Hospital Survey Version 2.0 to help hospitals assess the extent to which their culture … item set should be added to the end of the SOPS Hospital Survey 2.0, after Section F: Your Hospital, just … Measures: A composite measure is a grouping of two or more survey items that assess the same area of culture … Development, Pilot Testing, and Psychometric Analysis of the AHRQ Surveys on Patient Safety Culture®

453. New Guideline Illuminates Path for Managing Genitourinary Syndrome of Menopause | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/965.html
     July 01, 2025 - Virginia Health System Improves Care With Surveys on Patient Safety Culture . … Virginia Health System Improves Care With Surveys on Patient Safety Culture  Riverside Health System, … based in Newport News, VA, has been using the  AHRQ Surveys on Patient Safety Culture ® (SOPS®) for … Safety culture survey responses in all categories also improved. … AHRQ in the Professional Literature Low resource, high impact: just-in-time training toolkit in response

454. 4. Discussion | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state4.html
     January 01, 2024 - In addition, we found gaps in the culture, workflow, and work system issues domain, where studies related … to how culture, behavior, and work system influence diagnostic safety were limited. … limitation was including search materials mostly since 2013 onward, so we missed certain key items published just

455. Working With and Supporting Practice Leaders (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-21-leadership.pdf
     September 01, 2015 - Foundational knowledge of organizational change • Cultural competency—knowledge of organizational cultures … Because adaptive challenges may involve staff values and deeply held beliefs and loyalties, they can … For example, avoid questions such as, “Why don’t you just change clinic hours?” … • Show genuine belief in the capacity of the other to grow and perform. … is not the right task for this person at this time, it is important to indicate that you still have belief

456. Slide 1
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-icu-051314.pptx
     February 07, 2014 - and CAUTI reduction Understand the CUSP framework for initiating culture change Apply culture change … change Apply culture change theory to urinary catheter culture Our goal is to assist healthcare … Organizational Culture 10 …the shared set of social values and beliefs, both explicit and implicit, that … values and beliefs, both explicit and implicit, that guides actions and decisions within the organization … Intubate Change the ventilator settings Order another test Human Nature Linda Lewis “Don’t just

457. PowerPoint Presentation: Learn From Defects Through Sensemaking
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
     December 01, 2017 - Don’t just assume that an individual made one mistake. … lasting change, remember the human factors involved in every defect, including the values, attitudes, and beliefs … lasting change, remember the human factors involved in the defect: the attitudes, the values, and the beliefs … Find what is hiding just below the surface, those protections that prevent the patient harm from getting … ASK: Was there something about the safety culture, the operating room culture, or the PACU culture that

458. CUSP Toolkit Spread Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/spread/notes.html
     December 01, 2012 - The other CUSP Toolkit modules focus on quality improvement projects at the unit level, where culture … "Spread Module" module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit introduces Just … Culture principles, which emphasize shared accountability and attitudes toward risk. … Organizational culture: Does the organizational culture embrace change? … Adoptable: The process is compatible with organization and unit values, attitudes, beliefs, and facilities

459. Case Example #7: Cherokee Health Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-7.html
     July 01, 2019 - “Cherokee tries to be the fabric of the local Appalachian culture.” –Dr. … I guess I just ignored everything, all the mental illness that's out there.” … Programmers use just-in-time data to create custom reports. … Interviewees said that the culture of care at Cherokee enables innovation. … This culture allows individuals to work on problems.

460. News Media and Health Care Providers at the Crossroads of Medical Adverse Events (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Whitten_85.pdf
     June 05, 2008 - • Instituting a culture of open discussion. … effective approach for understanding how people think and feel about an issue and for identifying lay beliefs … be better if adverse events data were employed within the circle of health care providers: “Let’s just … It is just reporting events; there is not a method of sharing of solutions so the State would be better … This is not just a hospital system issue, but an issue that involves local government officials and