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psnet.ahrq.gov/node/50887/psn-pdf
February 12, 2020 - Lessons learned from a systems approach to engaging
patients and families in patient safety transformation … Lessons Learned from a Systems Approach to Engaging Patients
and Families in Patient Safety Transformation … https://psnet.ahrq.gov/issue/lessons-learned-systems-approach-engaging-patients-and-families-patient- … This article describes lessons learned during the six years after a large regional
health care system … https://psnet.ahrq.gov/issue/lessons-learned-systems-approach-engaging-patients-and-families-patient-safety-transformation
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight06.html
January 01, 2014 - For instance, they can draw on a wider pool of resources and expertise and apply lessons learned from … at least some activities with their partners through regular meetings in which they identify lessons learned … They intentionally delayed Idaho’s implementation so that it could leverage the lessons learned from … “It’s really useful to take the time to work with another State and hear its lessons learned. … Collaborating with these other States has saved us years and years of lessons learned.”
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/supln-slides.html
January 01, 2016 - Families in Society
Implementing Child Health Measures at the State and Practice-level: Lessons Learned … the CHIPRA Quality Demonstration Grants and the CMS Child Core Set
Evaluation Findings and Lessons Learned … Slide 24
Evaluation Findings and Lessons Learned from the CHIPRA Quality Demonstration Grant Program … Slide 55
Lessons Learned
Practice performance drives state performance
TA and QI tools needed … drives state performance on quality measures
Slide 57
Successes/Outcomes
Infusion of lessons learned
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight13.html
June 01, 2015 - This Highlight focuses on lessons learned from nine States—Alaska, Florida, Idaho, Maine, Massachusetts … Many practices learned how to conduct small tests of change, often using the Plan-Do-Study-Act (PDSA) … When several States (including Alaska, Massachusetts, and West Virginia) learned that practices appreciated … States learned that practice facilitation is most successful when facilitators undergo training in QI … Available at: http://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight01.html .
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-alaska-state-snapshot.pdf
January 01, 2018 - Quality Demonstration Grant Program
January 2018
This brief highlights the major strategies, lessons learned … Having learned from the State about
the goals and key components of care coordination,
all three practices … • Alaska applied the lessons learned from the CHIPRA quality
demonstration to other State programs … /demoeval/what-we-learned/highlight11.html
https://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned … /highlight11.html
https://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight13.html
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psnet.ahrq.gov/node/865807/psn-pdf
May 08, 2024 - Patients' perspectives on quality and patient safety
failures: lessons learned from an inquiry into … Patients’ perspectives on quality and patient safety failures: lessons
learned from an inquiry into … https://psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned … https://psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned-inquiry … https://psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned-inquiry
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psnet.ahrq.gov/node/865971/psn-pdf
May 29, 2024 - Lessons learned from a national hospital antibiotic
stewardship implementation project. … Lessons learned from a national hospital antibiotic stewardship
implementation project. … https://psnet.ahrq.gov/issue/lessons-learned-national-hospital-antibiotic-stewardship-implementation- … https://psnet.ahrq.gov/issue/lessons-learned-national-hospital-antibiotic-stewardship-implementation-project … https://psnet.ahrq.gov/issue/lessons-learned-national-hospital-antibiotic-stewardship-implementation-project
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-north-carolina-state-snapshot.pdf
January 01, 2018 - Quality Demonstration Grant Program
January 2018
This brief highlights the major strategies, lessons learned … /highlight03.pdf
https://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight10.html
https … /chipra/demoeval/what-we-learned/highlight11.html
http://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned … /highlight11.html
http://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight12.html
http … /chipra/demoeval/what-we-learned/highlight13.html
http://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned
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psnet.ahrq.gov/node/837000/psn-pdf
May 06, 2022 - Lessons Learned about Human Fallibility, System Design,
and Justice in the Aftermath of a Fatal Medication … https://psnet.ahrq.gov/issue/lessons-learned-about-human-fallibility-system-design-and-justice-aftermath … This webinar highlighted lessons learned in the aftermath of a fatal medication
error, and strategies … https://psnet.ahrq.gov/issue/lessons-learned-about-human-fallibility-system-design-and-justice-aftermath-fatal-medication … https://psnet.ahrq.gov/issue/lessons-learned-about-human-fallibility-system-design-and-justice-aftermath-fatal-medication
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psnet.ahrq.gov/node/74710/psn-pdf
January 26, 2022 - The evolution of the Anesthesia Patient Safety Movement
in America: lessons learned and considerations … The evolution of the Anesthesia Patient Safety Movement in America: lessons
learned and considerations … https://psnet.ahrq.gov/issue/evolution-anesthesia-patient-safety-movement-america-lessons-learned-and … https://psnet.ahrq.gov/issue/evolution-anesthesia-patient-safety-movement-america-lessons-learned-and-considerations … https://psnet.ahrq.gov/issue/evolution-anesthesia-patient-safety-movement-america-lessons-learned-and-considerations
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psnet.ahrq.gov/node/850913/psn-pdf
June 21, 2023 - Understanding ultrarare adverse events - lessons learned
from a twelve-year review of intraoperative … Understanding ultrarare adverse events - lessons learned from a
twelve-year review of intraoperative … https://psnet.ahrq.gov/issue/understanding-ultrarare-adverse-events-lessons-learned-twelve-year-review … https://psnet.ahrq.gov/issue/understanding-ultrarare-adverse-events-lessons-learned-twelve-year-review-intraoperative … https://psnet.ahrq.gov/issue/understanding-ultrarare-adverse-events-lessons-learned-twelve-year-review-intraoperative
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/amplify-impact-webinar.html
October 01, 2020 - The presentations featured highlights and a discussion of promising practices and key lessons learned
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psnet.ahrq.gov/node/837069/psn-pdf
January 01, 2024 - Usability of a human factors-based clinical decision
support in the emergency department: lessons learned … Usability of a human factors-based clinical decision support
in the emergency department: lessons learned … psnet.ahrq.gov/issue/usability-human-factors-based-clinical-decision-support-emergency-
department-lessons-learned … psnet.ahrq.gov/issue/usability-human-factors-based-clinical-decision-support-emergency-department-lessons-learned … psnet.ahrq.gov/issue/usability-human-factors-based-clinical-decision-support-emergency-department-lessons-learned
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psnet.ahrq.gov/node/853065/psn-pdf
August 30, 2023 - Exploring the impact of safety culture on incident
reporting: lessons learned from machine learning … Exploring the impact of safety culture on incident reporting: lessons
learned from machine learning … https://psnet.ahrq.gov/issue/exploring-impact-safety-culture-incident-reporting-lessons-learned-machine … https://psnet.ahrq.gov/issue/exploring-impact-safety-culture-incident-reporting-lessons-learned-machine-learning-analysis … https://psnet.ahrq.gov/issue/exploring-impact-safety-culture-incident-reporting-lessons-learned-machine-learning-analysis
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www.ahrq.gov/evidencenow/projects/state/how-to-guide/guide6.html
August 01, 2024 - This guide aims to help by sharing what has been learned across the Agency for Healthcare Research and … it as needed, apply it in their work, and then in turn share their own insights about what they have learned
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-oregon-state-snapshot.pdf
January 01, 2018 - Quality Demonstration Grant Program
January 2018
This brief highlights the major strategies, lessons learned … Alaska and West Virginia implemented similar
projects and met quarterly with Oregon to share lessons learned … https://www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight02 … .pdf
https://www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight02 … .pdf
https://www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight04
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psnet.ahrq.gov/node/72848/psn-pdf
March 17, 2021 - The development and piloting of the Ambulatory
Electronic Health Record Evaluation Tool: lessons
learned … The development and piloting of the Ambulatory Electronic Health
Record Evaluation Tool: lessons learned … psnet.ahrq.gov/issue/development-and-piloting-ambulatory-electronic-health-record-evaluation-tool-
lessons-learned … psnet.ahrq.gov/issue/development-and-piloting-ambulatory-electronic-health-record-evaluation-tool-lessons-learned … psnet.ahrq.gov/issue/development-and-piloting-ambulatory-electronic-health-record-evaluation-tool-lessons-learned
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/nashp-webinar-on-quality_measure-use.pdf
September 21, 2015 - Researcher, Agency for Healthcare
Research and Quality
• Overview of states’ strategies and lessons learned … jump in with questions or “raise
your hand”
4 4
Overview of States’ Strategies and
Lessons Learned … plans,
providers, public
9 9
Reporting Results to Stakeholders
• Lessons learned … ”
— North Carolina Practice Manager
14 14
Supporting Provider Improvement
• Lessons learned … Project Outcomes
Project Outcomes
Project Outcomes
Lessons Learned
Lessons Learned
Slide Number
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www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module_4-speaker-notes.docx
September 01, 2015 - In Module 1, you learned that hospital-acquired urinary tract infections impact almost 560,000 people … You also learned in Module 1 that very clear, evidence-based guidelines exist about catheter use. … In addition, you learned about the influence of unit culture on practice change and the importance of … You also learned about the power of teachable moments related to catheter use. … SLIDE 4
SAY:
In the first three modules, you learned a great deal about catheter use and its impact
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psnet.ahrq.gov/node/838249/psn-pdf
October 05, 2022 - Rooting an error review process in just culture: lessons
learned. … Rooting an error review process in just culture:
lessons learned. … https://psnet.ahrq.gov/issue/rooting-error-review-process-just-culture-lessons-learned
Shifting to a … Lessons learned highlight the importance
of who performs error follow-up, skills for navigating difficult … https://psnet.ahrq.gov/issue/rooting-error-review-process-just-culture-lessons-learned
https://psnet.ahrq.gov