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501. State at a Glance: Maryland | Agency for Healthcare Research and Quality
     www.ahrq.gov/policymakers/chipra/demoeval/demostates/md.html
     March 01, 2019 - one of the 10 grantees, Maryland is working with Georgia and Wyoming in an innovative multi-State learning … and its partner States implemented the project planning tool developed by CHCS as part of its Quality Learning … questions about the implementation and outcomes of their efforts including: How did the multi-State learning

502. State at a Glance: South Carolina | Agency for Healthcare Research and Quality
     www.ahrq.gov/policymakers/chipra/demoeval/demostates/sc.html
     March 01, 2019 - use health IT to automate quality reporting and feedback and improve care coordination; and (3) use a learning … The project will use a learning collaborative approach and will focus on the collection of quality measures … The State will use a learning collaborative model that involves semiannual meetings, technical assistance

503. Physician Champion Checklist | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/physician-checklist.html
     January 01, 2017 - Foster organizational learning and actively participate in the process of learning from defects.

504. Module 3: Systems Change: Understanding Your Workflow Processes To Prepare for System Change | Agency for Healthcare Research and Quality
     www.ahrq.gov/takeheart/training/module-3/index.html
     December 01, 2022 - Learning how to create a workflow process map, with a focus on automatic referral and care coordination … Learning Objectives Upon completion of this module, attendees should be able to: Understand the

505. Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams.html
     July 01, 2023 - Clinical Assistant Professor, Departments of Internal Medicine, Pediatrics, and Learning Health Sciences … Assistant Professor, Departments of Learning Health Sciences, Internal Medicine, Urology, and Information

506. Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety.html
     September 01, 2023 - Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error Learning … Organizational Safety Culture To Improve Diagnostic Safety Specific Barriers and Challenges to Reporting and Learning

507. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety1.html
     September 01, 2022 - Diagnostic Process Recognizing and Supporting Nurses in Diagnostic Safety Using Patient Cases for Learning … Informed by the literature and professional experience, we offer action-oriented steps and learning strategies

508. AHRQ NCEPCR: Building a New PBRN
     www.ahrq.gov/downloads/ncepcr/communities/pbrn/learning-series/building-newer-pbrn/index.html
     October 22, 2024 - AHRQ NCEPCR: Building a New PBRN

509. Executive Summary: Implementing PCOR To Increase Referral, Enrollment, and Retention in Cardiac Rehabilitation through Automatic Referral with Care Coordination (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/takeheart-executive-summary.pdf
     August 01, 2023 - To achieve these goals, TAKEheart included three primary components: Partner Hospitals, Learning Community … • The Learning Community was open to any facility or practitioner, and to other individuals interested … • The TAKEheart team operated PH-PAGs much like a community of practice or learning collaborative … Learning Community • In response to the pandemic, activating the Learning Community ahead of schedule … The TAKEheart team implemented an earlier-than-planned launch of Learning Community and focused its

510. The AHRQ Hospital Survey on Patient Safety Culture: A Tool to Plan and Evaluate Patient Safety Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Jones_29.pdf
     February 23, 2008 - errors are viewed as opportunities to improve the system.2 A voluntary reporting system that emphasizes learning … six CAHs to conduct RCAs within their organizations to further model this practice that supports a learning … Although we engaged and educated about numerous practices to support teamwork and a learning culture … However, a reporting culture must interact with just, flexible, and learning cultures. … Learning from failure in health care: Frequent opportunities, pervasive barriers.

511. State at a Glance: Massachusetts | Agency for Healthcare Research and Quality
     www.ahrq.gov/policymakers/chipra/demoeval/demostates/ma.html
     March 01, 2019 - How are CHIPRA demonstration States approaching practice-level quality measurement and what are they learning … Evaluation Highlight No. 13: How did CHIPRA quality demonstration States employ learning collaboratives … Provider-Based Model of Care In December 2013, Massachusetts completed the implementation of a 29-month-long Learning … The practices received financial support for participating in learning sessions and monthly action period

512. Improving Patient Safety in Long-Term Care Facilities: Training Modules (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/ltcinstructor.pdf
     June 01, 2012 - If the learning culture of your audience suggests they will have problems learning together, you can … Explain the goals of this exercise and relate them to the key learning objectives. … was taken in and appreciated, it can be hard to put the new learning into practice. … Explain the goals of this exercise and relate them to the key learning objectives. … put the new learning into practice.

513. Applying CUSP To Promote Safe Surgery (pdf file)
     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.

514. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Assemble the Team and Engage Leadership
     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. 

515. Spotlight on Massachusetts -- The National Evaluation of the CHIPRA Quality Demonstration Grant Program (pdf file)
     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

516. Spreading the Model to Partner States | Agency for Healthcare Research and Quality
     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

517. PowerPoint Presentation
     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,

518. Spreading the Model to Partner States | Agency for Healthcare Research and Quality
     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

519. 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/physician-checklist.docx
     January 01, 2017 - Foster organizational learning and actively participate in the process of learning from defects 17

520. CAUTI Sustainability: Embedding CAUTI Policies, Using Data to Monitor Proress and Hardwiring CUSP Principles | Agency for Healthcare Research and Quality
     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".