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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemaking.pptx
January 01, 2006 - Form Failure Mode and Effects Analysis
Probabilistic Risk Assessment
Causal Tree Worksheet
2
3
Learning … From Defects and Sensemaking
17
Learning From Defects Overview
Health care providers are adept at … CUSP Tools To Learn From Defects
20
21
Learning From Defects:
Four Questions
1. … with others in your state collaborative (pending institutional approval)
30
Communicating the Learning … From Defects
Sensemaking and Learning from Defects share several common themes
The Learning from Defects
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-2.html
September 01, 2023 - News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning … Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error
Learning … safety to encourage transparent and open discussion of hazards and errors and to foster innovation and learning … that the team supports the individual, acknowledges and appreciates them for their contribution to learning … an organization; a safety culture fosters a shared commitment to identifying and mitigating risks, learning
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/research/grants-2019.html
March 01, 2024 - To create machine learning models that can be used to retrospectively identify patients in whom a diagnostic … An expert-guided machine-learning approach to estimate the incidence, risk and harms associated with … Application of a Machine Learning to Enhance e-Triggers to Detect and Learn from Diagnostic Safety Events … refine, test, and apply the Safer Dx Trigger Tools Framework to enable detection, measurement, and learning … To explore machine learning techniques that yield robust, accurate models to predict diagnostic errors
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
December 01, 2017 - The appendix has an example case study that helps you understand the learning from defects process and
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-idaho-state-snapshot.pdf
January 01, 2018 - Idaho modeled their approach to technical assistance
after Utah’s and included group in-person learning … They attended learning
collaborative sessions, implemented new care processes
(such as developing … • Spread the learning collaborative model to four
additional rural practices. … and running learning collaborative
sessions, training care coordinators, and offering QI
coaching … • IHAWCC planned to continue developing QI capacity and
offering learning collaboratives across the
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ce.effectivehealthcare.ahrq.gov/pcor/ahrq-pcor-trust-fund-training-projects/pcortf-tcdhs14004.html
June 01, 2018 - AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning … Trust Fund Investments At-A-Glance
AHRQ Training Projects Funded by PCOR Trust Fund
Learning … The advanced training component creates a national collaborative learning network on new and innovative
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/1-unc-webcast-intro.pdf
December 18, 2019 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture … at UNC Medical Center - Intro
Implementation of an Event Reporting and Learning
System Leads to Improvements
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module10/slmeasure.pptx
February 03, 2006 - 05.2
Mod 10 2.0 Page ‹#›
Measurement
How to Measure - Kirkpatrick
Level I – Reactions
Level II – Learning … Teamwork Attitudes Questionnaire (T-TAQ)
Learning Benchmarks
Team Performance Observation Tool
Teamwork … 05.2
Mod 10 2.0 Page ‹#›
Measurement
TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ)
Level II Learning … Communication
TeamSTEPPS Materials and Tools
TEAMSTEPPS 05.2
Mod 10 2.0 Page ‹#›
Measurement
Learning … Benchmarks
Level II Learning
Found in Tab F
A 23-item multiple-choice test
Uses:
To assess knowledge
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ce.effectivehealthcare.ahrq.gov/ncepcr/research-transform-primary-care/transform/final-impact/model.html
October 01, 2015 - A key focus of the IMPaCT funding in Pennsylvania was to develop two regional learning collaboratives … The collaboratives held four learning sessions to provide practical training to participating practices … North Carolina’s two types of learning collaboratives focused on health care professionals and leaders … North Carolina’s learning collaboratives included steps to identify region and practice priorities and … Two regional Pennsylvania AHEC directors were trained as learning collaborative practice facilitators
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module10/ts2-0ltc_module10_ig_msmt.pdf
October 18, 2017 - Measurement in
TeamSTEPPS
• A Model of Training
Evaluation
• Available Measures
(Reactions, Learning … Level II – Learning – Learning is defined at three levels: (1)
attitudes (feel), (2) knowledge (know … The Learning Benchmarks for Long-Term Care knowledge test
can be used for this purpose. … : TEAM PERFORMANCE OBSERVATION TOOL
LEARNING: TEAMSTEPPS TEAMWORK ATTITUDES QUESTIONNAIRE (T-TAQ)
LEARNING … : TEAMSTEPPS LEARNING BENCHMARKS
LEARNING: TEAM PERFORMANCE OBSERVATION TOOL
LEARNING: TEAMSTEPPS TEAMWORK
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ce.effectivehealthcare.ahrq.gov/teamstepps-program/welcome-guides/experienced-trainers.html
July 01, 2023 - It is guided by emerging research related to teams, team performance, communication, and adult learning … Active Learning Strategies: The use of passive learning methods (e.g., listening to lectures) is less … If you are reviewing materials on your own, take time to review all the learning options. … The use of active learning methods in the curriculum is designed to foster deeper engagement in the course … Resources for learning are drawn from multiple clinical settings and involve a variety of team members
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ce.effectivehealthcare.ahrq.gov/takeheart/training/care-coordination/index.html
April 01, 2023 - AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning … Community
TAKEheart Learning Community webinars, held between 2020–2022, featured discussions among … Learning Community webinars relating to the topics covered in the Enhancing Care Coordination training … Mary’s Hospital
This Learning Community webinar shares care coordination improvement successes, challenges … Brigham and Women's Hospital
Daniel Forman , MD, Cardiologist at UPMC Presbyterian and UPMC East
This Learning
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams-refs.html
July 01, 2023 - Deep learning to improve breast cancer detection on screening mammography. … Automated identification of diabetic retinopathy using deep learning. … Direct-to-consumer medical machine learning and artificial intelligence applications. … Active Learning Applied to Patient-Adaptive Heartbeat Classification. … Cardiac arrhythmia detection using deep learning: a review.
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ce.effectivehealthcare.ahrq.gov/research/findings/factsheets/errors-safety/simulproj15/index.html
August 01, 2018 - Optimizing learning conditions
Simulations have the advantage of creating conditions that optimize … the learning process. … Much of learning in the actual clinical environment occurs sporadically. … The creation of optimal conditions for learning refers to the purposeful manipulation and programming … Return to Contents
The Concept of Mastery Learning
Mastery learning is a rigorous and structured
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/pa-spread-impact.pptx
September 01, 2014 - Educated practices about
Patient Centered Medical Home
Chronic Care Model
Learning Collaborative … Model: Rapid Cycle Tests of Change
Source: Institute for Healthcare Improvement
Learning Sessions … The collaborative consisted of four quarterly Learning Sessions held in the evenings in each region. … The focus of each Learning Session was as follows:
Learning Session 1 Learning Session 2 Learning Session … Statewide Practice Facilitator Forum to foster networking and learning among all facilitators working
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ce.effectivehealthcare.ahrq.gov/pcor/at-a-glance/index.html
March 01, 2024 - Most recently, AHRQ and PCORI co-funded Learning Health System Embedded Scientist Training and Research … Grantees will create new models of learning health system infrastructure that will use evidence generated … AHRQ uses learning collaboratives among grantees to share valuable lessons, resources, curriculum, and … A learning culture requires careful analysis of the portfolio, from the mix of project types, targets … Becoming a learning portfolio will enhance the Agency's adaptability to change; increase capacity for
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ce.effectivehealthcare.ahrq.gov/practiceimprovement/initiatives.html
September 01, 2019 - AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning … Learning Health Systems
Becoming a learning health system is a journey characterized by strong leadership … effective use of data in the clinical setting, and a culture and workforce committed to continuous learning … providing training and tools to help healthcare delivery organizations of every size move towards becoming learning
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety5.html
September 01, 2022 - AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning … Diagnostic Process
Recognizing and Supporting Nurses in Diagnostic Safety
Using Patient Cases for Learning … diagnostic safety resources and integrating contemporary recommendations and efforts with available learning … obtained from the literature, online sources, and organizations’ data sources can be included in any learning … modality and can enhance learning, initiate discussion about diagnostic safety, and promote efforts
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-ref.html
September 01, 2023 - Psychological safety and learning behavior in work teams. Adm Sci Q 1999;44(2):350-383. … Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. … Creating a learning health system for improving diagnostic safety: pragmatic insights from U.S. health … Transitioning to peer learning: lessons learned. J Am Coll Radiol 2021 Mar;18(3 Pt B):499-506. … Practice inquiry: clinical uncertainty as a focus for small-group learning and practice improvement.
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ce.effectivehealthcare.ahrq.gov/patient-safety/diagnostic-error-grants/index.html
January 01, 2021 - To create machine learning models that can be used to retrospectively identify patients in whom a diagnostic … An expert-guided machine-learning approach to estimate the incidence, risk and harms associated with … Application of a Machine Learning to Enhance e-Triggers to Detect and Learn from Diagnostic Safety Events … refine, test, and apply the Safer Dx Trigger Tools Framework to enable detection, measurement, and learning … To explore machine learning techniques that yield robust, accurate models to predict diagnostic errors