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psnet.ahrq.gov/perspective/conversation-maureen-bisognano
February 26, 2025 - Context + Mechanism = Outcome. … In other words, the culture and context matter, the leaders matter, and the mechanism is the change concept—it's … Hence, the theory was that if you understood your culture and you had a mechanism that you could try … For me quality improvement is about leaders understanding their local context, it's taking the mechanism … attention to that outcome so that you're watching every day or every week—in this particular ICU is this mechanism
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/vaesurveillance-slides.pptx
January 01, 2017 - Presentation: Program Overview
Ventilator-Associated Event Surveillance
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-41-EF
January 2017
VAE Surveillance ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Objectives
After this session, you will be able…
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digital.ahrq.gov/ahrq-funded-projects/robust-health-data-infrastructure
January 01, 2023 - Project Details -
Completed
Contract Number
13-717F-13
Funding Mechanism
-
digital.ahrq.gov/ahrq-funded-projects/data-individual-health
January 01, 2023 - Project Details -
Completed
Contract Number
14-721F-14
Funding Mechanism
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/intro-early-mobility-slides.pptx
January 01, 2017 - Presentation: Program Overview
Introduction and Evidence for Early Mobility:
A Protocol To Get Patients Out of Bed Faster
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-48-EF
January 2017
Evidence for Early Mobility ‹#›
AHRQ Safety Program for Mechanically Ventilated Patient…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/forming-cuspteam-slides.pptx
January 01, 2017 - Presentation: Program Overview
Forming a Comprehensive Unit-based
Safety Program Team
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No 16(17)-0018-28-EF
January 2017
Forming a CUSP Team ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Objectives
After this session,…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/sustainability/premortem-scorecard-slides.pptx
January 01, 2017 - Presentation: Tools for Sustainability: Premortem and Scorecard
Tools for Sustainability:
Premortem and Scorecard
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-39-EF
January 2017
Sustainability Tools ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Ob…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/monitoring-vae-slides.pptx
January 01, 2017 - Monitoring Ventilator-Associated Events Module 2
Monitoring Ventilator-Associated Events
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-26-EF
January 2017
Monitoring VAEs ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Objectives
After this sessio…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/measuredesc-ltvv-slides.pptx
January 01, 2017 - Presentation: Program Overview
Measure Descriptions for
Low Tidal Volume Ventilation
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-36-EF
January 2017
LTVV Measures ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Objectives
After this session, you wi…
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psnet.ahrq.gov/node/39790/psn-pdf
March 21, 2017 - important safety problems, there was little overlap in the types
of events identified with each reporting mechanism
-
psnet.ahrq.gov/node/38585/psn-pdf
April 30, 2014 - Incident reporting systems are a different mechanism to learn about
adverse events (AEs) and potentially
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND_0274_03-10-2008.pdf
January 01, 2008 - clinical effectiveness review
that evaluates expanded indications and includes health outcomes, harms, mechanism
-
psnet.ahrq.gov/node/45116/psn-pdf
February 15, 2017 - complications did not decrease, but postoperative mortality
improved, raising questions about what mechanism
-
psnet.ahrq.gov/node/43279/psn-pdf
October 20, 2014 - involved teamwork
training, standardizing care protocols, and establishing a robust quality assurance mechanism
-
psnet.ahrq.gov/node/38761/psn-pdf
July 15, 2009 - effect-bar-code-assisted-medication-administration-medication-administration-
errors-and
Bar coding technology is being rapidly adopted as a mechanism
-
psnet.ahrq.gov/node/45190/psn-pdf
February 15, 2017 - While the mechanism for this effect is unclear, it likely
varies for different disease processes.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/build-businesscase-slides.pptx
January 01, 2017 - Presentation: Program Overview
Build a Business Case for
Quality Improvement
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-38-EF
January 2017
Build a Business Case ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Objectives
After this session, you w…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-slides.pptx
January 01, 2017 - CMV_27_M3_CUSP_SSA_Premortem
Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-27-EF
January 2017
Overview of CUSP for MVP ‹#›
AHRQ Safety Program for Mechanically Ventilat…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/measuredesc-dailyearlymobility-slides.pptx
January 01, 2017 - Presentation: Program Overview
Measure Descriptions for Daily Early Mobility
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-49-EF
January 2017
Early Mobility Measures ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Objectives
After this session, you …
-
www.ahrq.gov/hai/tools/mvp/modules/technical/sat-sbt-protocol.html
January 01, 2017 - Coordinated Spontaneous Awakening and Breathing Trials Protocol
AHRQ Safety Program for Mechanically Ventilated Patients
Introduction
Reducing the number of days a patient is on mechanical ventilation has been shown to reduce the risk of ventilator-associated pneumonia. 1,2,3 Strategies for wea…