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2061. Clinical Practice Improvement and Redesign: How Change in Workflow Can Be Supported by Clinical Decision Support (pdf file)
      digital.ahrq.gov/sites/default/files/docs/biblio/09-0054-EF-Updated_0.pdf
      June 01, 2009 - to mention advances in laboratory medicine technology for superior analysis of blood, urine, and cultures … The belief that CDS automation can improve health care delivery quality and safety is not new,70, 71 … Fit with culture can be measured with a variety of culture surveys. … experts may use explanations more to understand unexpected events or recommendations contrary to their beliefs … A recent study of anesthesia alarm design259 demonstrated that participants beliefs about which alarm

2062. Strategy 3: Bedside Shift Report (Tool 3) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_3_Pres_video_508.pdf
      June 02, 2025 - and how to get things done • Are strangers in this environment • Do n0t understand the system or culture … You’re not just a patient in the bed.” – “It makes you feel like you’re involved. … them to—it is simply too risky for them • Your job is to make it safe for them to be involved, not just

2063. AHRQ-Funded Patient Safety Project Highlights (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-pfe.pdf
      January 01, 2023 - Patient Advocacy Reporting System (PARS) promoted professional self-governance, fostered a fair and just … and knowledge needed to effectively incorporate patient and family engagement approaches into their cultures … implement an intervention process that promotes professional self- governance, fosters a fair and just … culture of safety and kindness, and reduces avoidable lawsuit risk. … It showed that physicians were not good judges of patients’ health beliefs.

2064. What Do We Know About Emergency Department Safety? | PSNet
      psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
      June 01, 2010 - PC: Just the way that people get set up for errors. … It never amounts to anything; she's just a frequent flyer." For me, those are red flags. … I make mistakes just like the next guy, but hopefully I'm making fewer because I see them coming. … One thing you can do is just take a time out and excuse yourself and say "I just have to attend to something … How did you get the culture to accept that? PC: It wasn't easy.

2065. CHII Costs (ppt file)
      digital.ahrq.gov/sites/default/files/docs/page/ADAMS_3_I.ppt
      January 01, 2013 - health improves immediately and she only misses one day of school Hannah’s mother returns to work after just … All rights reserved Multiple Systemic Problems Financial Poor Quality High Cost Culture Practice … Variations Social Factors Limited Access Unit Prices Administrative Costs Culture Structure Standards … Medical custom varies a great deal even among communities that are demographically and geographically … All rights reserved Structure – Too many masters results in no standards Culture – Impacts standards

2066. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
      January 01, 2021 - within each type of gauze material runs throughout the dressing, whereas on the right, the marker is just … training is provided by hospitals for nurses working on obstetric or gynecology units — Hospital culture … The organizational culture should encourage health care providers to communicate and collaborate with

2067. The CAHPS Ambulatory Care Improvement Guide: Are You Ready To Improve? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/3-are-you-ready/cahps-ambulatory-care-guide-section-3.pdf
      May 01, 2017 - Once they become part of the organization’s culture, these behaviors often play a large role in supporting … turnover rates in plan and medical group senior executives, the board can help sustain a corporate culture … www.ncbi.nlm.nih.gov/books/NBK99879/ “Creating loyalty means giving employees more for their labor than just … Here are just a few: • Exceptional job performance • Excellent team work • Outstanding customer … Orientation Orientation of new employees is the best place to begin the education about the culture

2068. Slide 1
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/cauti-sustainability.pptx
      December 01, 2015 - Joseph Mercy Hospital, Ann Arbor, MI Learning Objectives Describe how to use data to change culture … of safety Not having explicit intent to continue a program and resources Don’t just give “lip-service … 37 Building a Culture of Confidence How can we build and maintain a culture where success cycles are … of Confidence Building a culture of confidence is largely about amplifying successes and strengths to … ensure the ‘voices’ of possibility, optimism and self-belief drown out the ‘voices’ of self-doubt, negativity

2069. Mod5-Comm-Assessment (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
      April 01, 2016 - individual and systemic bases of patient harm ■ Genuine professional commitment to the principles of just … culture and the CANDOR process Most health care team members exhibit some of the skills and competencies … Think of their habits, their beliefs, their mannerisms, their relations to others, any characteristics … He says he just needs more time. What would you say to Ron? … I will be able to let you see her in just a few moments.”

2070. In Conversation with...Geri Amori, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
      December 01, 2010 - We didn't talk about those things—we just didn't have those tools in our quiver. … generation in that belief system. … Disclosure is also a skill for life, not a skill just for work. … I don't think it had anything to do with the places as much as the individual cultures of those hospitals … So families have an important role, but if I can be intimidated with what I know and my beliefs about

2071. Daily Goals During Interdisciplinary Rounds: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/cusp/daily-goals-rounds-fac-guide.html
      February 01, 2017 - They have a good team-oriented culture and share their beliefs, strategies, and methods for providing … Slide 15: Using Daily Goals Say: The Daily Goals process is not just a checklist but a means to

2072. Appendix V (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apv2b.html
      June 01, 2010 - Survey 4 4 3 5 16 Measure includes choices in several areas, not just … Survey 4 4 3 5 16 Measure includes choices in several areas, not just

2073. Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2024 User Database Report Part I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2024-medical-office-database-report-rev.pdf
      January 01, 2024 - Culture® e PATIENT SAFETY [This page intentionally left blank] Surveys on Patient Safety Culture … refers to the beliefs, values, and norms shared by staff throughout their organization that influence … Patient safety culture is the extent to which these beliefs, values, and norms support and promote patient … (Item F3*) 73% It is just by chance that we don't make more mistakes that affect our patients. … (Item F3*) 73% 26.50% 0% 33% 63% 80% 94% 100% 100% It is just by chance that we don’t make more mistakes

2074. Eliminating CLABSI, A National Patient Safety Imperative: Final Report (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/clabsifinal.pdf
      October 01, 2012 - The HSOPS is comprised of 10 dimensions assessing safely culture and 4 outcome variables. … worked to adapt, coordinate, and integrate other improvement techniques and tools such as TeamSTEPPS, Just … Culture, Lean, and Six Sigma programs with the CUSP efforts. … Some teams viewed On the CUSP: Stop BSI as just another quality ―flavor of the month,‖ or focused solely … It demonstrates how CUSP works with existing patient safety frameworks such as TeamSTEPPS, Just Culture

2075. From Public Testimony to Vehicle for Statewide Action: Experience of the Michigan State Commission on Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Valade_46.pdf
      May 05, 2008 - Build a safety culture • Continue to transform Michigan’s health care culture to one characterized … undergoing a cultural transformation, from blaming individuals to creating organized systems and cultures … Without a doubt, the Commission delivered just that. … This effort required a total investment of approximately $400,000, including just over $10,000 for transcription … Culture change is hard and requires a long-term commitment.

2076. Safe Medication Administration: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-slides.html
      July 01, 2023 - used on L&D units, but administration procedures vary greatly due to lack of standardization, local culture … Have "just in time" crucial conversations. … used on L&D units, but administration procedures vary greatly due to lack of standardization, local culture

2077. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867656/psn-pdf
      February 26, 2025 - Cross-cutting these are culture, values, and equity, which we believe need to be embedded in everything … We just do not know how to spread and scale it.” … And is it mature, or is it just starting? … You just must establish trust with the partners and have the willingness to share what is learned. … We will just ignore it. It will go away.”

2078. Final Progress Report: Engineering Safe Care Journeys for Vulnerable Older Adults (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/smith-werner-carayon-report.pdf
      January 01, 2025 - will also look at what happens to older patients over time (i.e., during their care journey), not just … I just had that document and just grabbed my phone… and made the call” [Pt-F] “I don’t remember … is pending, send a message to the SNF NP Pool and the Culture RN pool indicating pending culture … Notification to SNF NP of urine culture results – Culture RNs send results to SNF NP through EHR inbox … SNF NP following up with rad culture RN SNF NP SNF NPs will follow up with culture RNs regarding the

2079. Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
      April 20, 2004 - Use of the BCMA software ceased in November 2000, just 8 months after its implementation. … and helped to answer the question asked of any pharmacist: “If you knew that a critical patient had just … where the “two-challenge rule” is practiced— is essential to the growth of an institutional safety culture … : “Designing systems for safety requires specific, clear, and consistent efforts to develop a work culture … It is also necessary for organizational leadership to promote and endorse a culture of support during

2080. Final Progress Report: Clinical Decision Support Simulations for Medication Administration Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/moss-berner-report.pdf
      January 01, 2024 - It’s just…when I see red, I always think “stop,” and so I was just kinda like… ok, well maybe … Can’t they just do the whole MAR that way? Just to make sure everything is compatible?” … “There are days when I’m having a bad day and I’m in a hurry and I just …I mean, I’ll just type “ … and then…like if I had all my medicine and I just had the armband and scanned it and just scanned … to address issues related to medication technology implementation and compliance helped foster a culture