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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/guide-appcusp.pdf
December 01, 2017 - ........................................................................................ 5
Step 4: Learning … —Safety Team Leader
Step 4: Learning From Defects Through Collective Sensemaking
Once defects are … We recommend learning from at
least one defect a quarter. … We went through the Learning From
Defects Through Sensemaking process at our next monthly meeting. … You will find a real-time identification of defects
and real-time system of learning.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/assemble/assemble-the-team.pptx
May 01, 2017 - Team
and Engage Leadership for Perinatal Safety
AHRQ Publication No. 17-0003-2-EF
May 2017
1
Learning … Pillars
Balanced Scorecard
American Organization of Nurse Executives Nurse Manager Leadership Partnership Learning … members feel that their environment supports the interpersonal risk involved in asking for help or learning … Invite input from all team members
Encourage team members to contribute
Promote active listening and learning … Managing the Risk of Learning: Psychological Safety in Work Teams. In West M, ed.
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-massachusetts-state-snapshot.pdf
January 01, 2018 - Through a
learning collaborative, the State educated the practices on
the medical home model and provided … Practices each received $1,150 per month to
support their work in the learning collaborative. … are CHIPRA demonstration States ap-
proaching practice-level quality measurement and what are they learning … • Evaluation Highlight No. 13: How did CHIPRA quality demonstration States
employ learning collaboratives … of core measures for families and providers, findings from the patient
experience survey, and the learning
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/final-impact/spread.html
October 01, 2015 - New Mexico did not seek to replicate its own structure in the partner States, but instead created a learning … Shared learning from the New Mexico program continues to build, and additional States, including Michigan … The creation of the learning community emerged as a result of in-person meetings among all four States … individual and group technical assistance from North Carolina faculty and experts and peer-to-peer learning … Maryland
Maryland built its program on the Maryland Learning Collaborative, which provided practice
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptx
August 24, 2015 - Creating a learning organization in which patient harm is reduced through ongoing learning from patient … Creating a learning organization is one of the most important outcomes in the CANDOR process. … Becoming a learning organization supports the goal of preventing similar harm to patients in the future … More information on supporting staff and creating a learning organization will be presented in the remaining … Resolution of an event presents an opportunity for organizational learning and sustainment of change,
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www.ahrq.gov/ncepcr/reports/grants-impact/spreading-model.html
February 01, 2017 - New Mexico did not seek to replicate its own structure in the partner States, but instead created a learning … Shared learning from the New Mexico program continues to build, and additional States, including Michigan … The creation of the learning community emerged as a result of in-person meetings among all four States … individual and group technical assistance from North Carolina faculty and experts and peer-to-peer learning … Maryland
Maryland built its program on the Maryland Learning Collaborative, which provided practice
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www.ahrq.gov/faqs/index.html?page=1
June 12, 2025 - Frequently Asked Questions
Check to find the answers to your questions about the Agency for Healthcare Research and Quality (AHRQ)
programs and activities. You can search by category or key words. You can also send us your questions or website
feedback here. We will respond to your requests based on the bes…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-moving-forward-hays-slides.pdf
October 01, 2017 - CAHPS® Moving Forward: Innovations in Tools and Research Webcast
Advancing the Science of Patient Experience
Assessment
Ron Hays, Ph.D.
University Of California – Los Angeles and RAND Health Program
www.ahrq.gov/cahps
CAHPS Family of Surveys
Facility Surveys
Hospital (HCAHPS)
In-Center Hemodialysis
Nursing Hom…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/data-tools-webcast-2022-sangria.pdf
January 01, 2022 - Useful Online Tools for CAHPS Survey Users - FISHER-SANGRIA
AHRQ Data Tools & CAHPS Data Reporting
Sylvia Fisher & Daniel Sangria
AHRQ & Westat
CAHPS User Network
Explore the AHRQ Data Tools
Medical Coverage and Expenditures
The Medical Expenditure Panel Survey (MEPS) helps researchers and the public exp lo…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/observation-comp-kit.html
June 01, 2017 - Standard Work Observation Component Kit
Contents
1. Why Standard Work Observation?
Connections to Other Components
2. Tips
3. Plan-Do-Study-Act Sequence: Observe Checklist Use Regularly
4. Example
Using the Observations
1. Why Standard Work Observation?
As you’ve adapted a surgi…
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www.ahrq.gov/news/newsletters/e-newsletter/948.html
March 01, 2025 - Use of Copper-Infused Surfaces Reduces Clostridioides difficile Spores
Issue Number
948
AHRQ News Now is a weekly newsletter that highlights agency research and program activities.
March 4, 2025
AHRQ Stats: Insurance Types Associated With Transportation Issues In 2021, 7.9 percent of adults on Medicare …
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www.ahrq.gov/sdoh/data-analytics.html
July 01, 2022 - SDOH Data and Analytics
Datasets and analytic tools that can power understanding of SDOH
Datasets | Analytic Tools
AHRQ Datasets
AHRQ has extensive data resources that can be used today by researchers to study the relationships between health, SDOH, and healthcare.
Social Determinants of Health Data…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/57-senior-executives-facilitator.docx
June 01, 2023 - AHRQ Safety Program for Improving
Surgical Care and Recovery
Facilitator Guide for Engaging Senior Executives Presentation Template
Slide Title and Commentary
Slide Number and Slide
Engaging the Senior Executive
Presentation Template
Title slide for the tool – delete this slide from the presentation to your seni…
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/2-overview-guide.docx
June 01, 2023 - Program Overview
This guide provides a high-level overview of the entire Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR) and toolkit.
In addition to this guide, consider reviewing the ISCR overview presentation and facilitator guide to learn about ISCR…
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/CG/health-literacy-cg-cahps-adult-spanish-2357-3b.pdf
June 02, 2025 - Supplemental Health Literacy Items for the CAHPS Clinician & Group Survey
12/1/2017 Page 1
Document No. 2357-3b
www.ahrq.gov/cahps
Supplemental Items for the CAHPS®
Clinician & Group Survey 3.0
Topic: Health Literacy
Population Version: Adult
Language: Spanish
Users of the CAHPS® Clinician & G…
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/adult-eng-cg40-3351a.pdf
October 30, 2020 - CAHPS Clinician & Group Adult Visit Survey 4.0 (beta)
CAHPS Clinician & Group Survey
Version: Adult Visit Survey 4.0 (beta)
Language: English
Notes
• Purpose of Visit Survey 4.0 (beta): This new version of the Clinician & Group Survey
asks patients about their experiences with care at their most recent visit…
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www.ahrq.gov/hai/tools/cauti-hospitals/toolkit-impl.html
October 01, 2020 - Implementation
Toolkit for Reducing CAUTI in Hospitals
The Implementation module of the Toolkit for Reducing CAUTI in Hospitals discusses the importance of a comprehensive, unit-based approach to safety and its impact on improving patient care. It takes users step by step through execution of clinical and cul…
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www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-public-health.html
May 01, 2024 - Investments in Primary Care Research for 2021 and 2022
Public Health and Community Integration
Previous Page Next Page
Table of Contents
Investments in Primary Care Research for 2021 and 2022
Acknowledgments and Authors
Message from the Acting Director of AHRQ's National Center for Excellence in…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/physician-checklist.docx
January 01, 2017 - Foster organizational learning and actively participate in the process of learning from defects
17
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www.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-slides.html
December 01, 2017 - Slide 2
Learning Objectives
Describe how to use data to change culture and sustain goals. … Slide 13
Lessons Learned = Sustaining the Gain
Treat a “CAUTI with respect – Learning from … Slide 22
The PDSA Cycle for Learning and Improvement
Image: The PDSA Cycle. … It is the result of preparation, hard work, and learning from failure.”
General Colin L. … One is titled "Mindfully Learning from Defects" and the other "Learning from Defects Fast Facts".