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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
March 15, 2016 - For example, missed cases could occur if an accidental
laceration is not clearly documented in the medical … Code all re-
intubations that occur after surgery and
extubation.
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talkingquality.ahrq.gov/teamstepps-program/curriculum/communication/tools/index.html
July 01, 2023 - Shift or staff changes: Transitions in care are the times when most communication breakdowns occur. … Where did miscommunication occur in this situation?
What are the possible outcomes?
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talkingquality.ahrq.gov/hai/tools/surgery/modules/implementation/audit-briefing-slides.html
December 01, 2017 - When did briefing occur?
Image: Logistics section of briefing form:
Who initiated briefing? … When did briefing occur?
Before patient entered.
Before induction.
Before incision.
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talkingquality.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
March 01, 2017 - For example, Kotter's Eight Steps of Change describes what happens to get change to occur. … transparency and open communication are necessary for true cooperation, coordination, and teamwork to occur
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talkingquality.ahrq.gov/teamstepps-program/curriculum/situation/teach/two-day.html
February 01, 2024 - Key points to make include:
That shared mental models are TEAM outcomes that occur when team members … continuously to retain shared mental models and that communication needed to sustain shared mental models can occur
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talkingquality.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
July 01, 2023 - patient harm are often caused by a provider overlooking messages alerting them to a test result or occur
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/facapplycusp.docx
September 04, 2012 - transparency and open communication are necessary for true cooperation, coordination, and teamwork to occur
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talkingquality.ahrq.gov/patient-safety/news-events/psaw-2022/index.html
July 01, 2022 - Thomas, M.D., M.P.H., " Understanding Where, Why, and How Diagnostic Errors Occur "
AHRQ PSNet Primer
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talkingquality.ahrq.gov/teamstepps-program/curriculum/communication/overview/index.html
June 01, 2023 - This step is particularly crucial for handoffs that occur electronically (e-handoffs).
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Education should occur upon hire,
annually, and when this protocol is added to job responsibilities.
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar04/formative_evaluation_webinar.pptx
July 15, 2013 - Advanced Methods in Delivery System Research – Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement Webinar #4: Formative Evaluation
Advanced Methods in Delivery System Research –
Planning, Executing, Analyzing, and
Reporting Research on
Delivery System Improvement
Webinar #4…
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module5-situation-monitoring.pptx
January 10, 2022 - problems that arise when understanding and expectations are out of sync.
6
Slide
Where do failures occur
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule2.pptx
February 09, 2006 - how to prepare to deliver this module
Module 2: Team Structure
‹#› of 25
Teamwork cannot occur … It is important to identify and recognize the structure of teams because teamwork cannot occur in the … Where did the breakdowns occur? … Now, where did the breakdowns occur between the components of this multi-team system?
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module4-presenters-notes.pdf
January 05, 2022 - When and where does clinic/site‐level quality improvement planning occur now?
2. Who attends? … They occur after an event or shift and are designed to improve teamwork skills.
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/igsitmonitor.pdf
February 12, 2014 - information must be communicated, a
leader must be clearly designated, and mutual support must
occur … Here are some examples of where failure can occur in the STEP
process:
• Status of the Patient: … It is important to establish the expectation that these team events
will occur and that all team members
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/strat3_tool_3_pres_video_508.pptx
July 23, 2010 - disclosed for:
Treatment
Health care operations
Payment
HIPAA acknowledges incidental disclosures may occur … Bedside Shift Report (Tool 3)
The HIPAA privacy rule recognizes that incidental disclosures might occur … Shift Report Training (Tool 3)
Addressing HIPAA concerns (continued 3)
Oral communications often must occur … Bedside Shift Report (Tool 3)
The HIPAA Privacy Rule recognizes that oral communications often must occur
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule6.pptx
February 09, 2006 - which information must be communicated, a leader must be clearly designated, and mutual support must occur … behavior)
Informational
Interpersonal
Module 6: Mutual Support
‹#› of 45
Because conflict can occur … in teams, it is important to know how to handle such situations when they occur. … Can we agree to follow such a procedure if this were to occur again?
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talkingquality.ahrq.gov/patient-safety/resources/learning-lab/improving-safety-diagnosis-long-desc.html
February 01, 2024 - Skip to main content
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talkingquality.ahrq.gov/teamstepps/instructor/fundamentals/module7/igsummary.html
March 01, 2014 - which information must be communicated, a leader must be clearly designated, and mutual support must occur
-
talkingquality.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6-p.pdf
November 02, 2017 - Recovery Programs
November 2017 6.P-4
The Axioms of Service Recovery
When problems with service do occur—and