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ce.effectivehealthcare.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/slides.html
October 01, 2020 - four medical providers standing together
Slide 13: Potential Barriers to Sustainability
Lack of organizational … infrastructure and resources
Staff turnover
Organizational skepticism
Individual resistance to … change
Slide 14: Workable Solutions to Sustainability Barriers
Lack of organizational infrastructure … Staff turnover
– Embed newly developed processes into new staff orientation and organizational policies … – Fit within organizational mission.
– Ongoing evaluation and transparency of measures.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
July 01, 2023 - Latent conditions are sorted into two categories: technical failures and organizational failures. … In this model, 20 separate event cause types are given in four categories: technical, organizational, … As noted earlier, there are 20 codes that are divided into the categories of technical, organizational … OEX: Organizational, external.
OK: Organizational, knowledge transfer. … OM: Organizational, management.
HEX: Human, external.
HRV: Human, rule-based, verification.
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ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/identify/notes.html
December 01, 2012 - It looks at human failure, technical failure, and organizational failure. … Latent conditions are sorted into two categories: technical failures and organizational failures. … In this model, 20 separate event cause types are given in four categories: technical, organizational, … , external,
OK: Organizational, knowledge transfer,
OM: Organizational, management,
HEX: Human, … This is coded as OM—organizational, management.
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ce.effectivehealthcare.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module6/mod6-facguide.html
March 01, 2017 - An improvement that has become part of the organizational culture and has been maintained regardless … This can include financial resources such as funding and supplies, external organizational support, and … Failure to plan for and provide the necessary organizational infrastructure and resources can be a barrier … Organizational Skepticism and Resistance
Resistance may be present within the organization itself. … If the barrier is related to lack of resources, then the facility could plan for gaps in organizational
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-1.html
June 01, 2021 - Public health advocates such as The Leapfrog Group and Hospital Compare are working on ways to represent organizational … Coalitions and researchers dedicated to improving diagnosis have created resources to address common organizational … safety requires transformational leadership rooted in a growth mindset—a belief that individual and organizational
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ce.effectivehealthcare.ahrq.gov/patient-safety/news-events/summit-research-2020/questions.html
March 01, 2021 - Can we impact staff perception of organizational safety culture in long-term care through innovative … governance and priority-setting,
interventions that expand patient/family/resident engagement in organizational … Can patient safety be defined at an organizational level, and, if so, how can it best be measured and … to CMS by hospitals, what applicable measures could be assembled that could demonstrate/reflect an organizational … Strengthening Healthcare Infrastructure for Patient Safety
How does organizational design influence
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ce.effectivehealthcare.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-atlas3-1.html
October 01, 2013 - Domain
Organizational infrastructure (clinic/clinician)
Data source
Audit - An auditor may conduct … a review of relevant financial and organizational documents and gather information from clinic leaders … element
Potential Measure I
Item
Description
Title
Progress through the stages of organizational … Description
This measure assesses how well clinics/clinicians have been able to initiate and sustain organizational … the percentage of clinics or clinicians in a community that are able to initiate and sustain relevant organizational
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ce.effectivehealthcare.ahrq.gov/hai/cauti-tools/archived-webinars/leveraging-cultural-change-slides.html
December 01, 2017 - metrics
Local focused implementation – implementation at unit level
Frontline staff engagement
Organizational … Medical Director
Nurse Manager
Nurses
Intensivists
Others
Slide 14
Three Levels of Organizational … of Culture Assessment
Identify areas of culture in need of improvement:
Identify impairments in organizational … Slide 39
Summary and Next Steps
What is your organizational culture? … How can you utilize the components of the culture of safety model to assess and improve your organizational
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ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/scott-cawiezell-report.pdf
January 01, 2024 - Organizational factors, such as nursing leadership
and effective teamwork, appeared to be closely link … Elicit the organizational and individual barriers to safe medication practices within the
nursing home … Assess the nursing home climate and culture to determine organizational readiness to
embrace innovation … The research team had a great deal of
experience exploring nursing homes’ organizational capacity to … as nursing homes build their
organizational capacity to create and sustain improvement.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/training-tools-slideset.pptx
May 01, 2017 - beyond the life of the project1, or the institutionalization or routinization of programs into ongoing organizational … Planning Early
Sustainability | ‹#›
AHRQ Safety Program for Ambulatory Surgery
12
Lack of organizational … infrastructure and resources
Staff turnover
Organizational skepticism
Individual resistance to change … to Sustainability
Sustainability | ‹#›
AHRQ Safety Program for Ambulatory Surgery
13
Lack of organizational … Sustainability Examples: Organizational Structure
Sustainability | ‹#›
AHRQ Safety Program for Ambulatory
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apa.html
August 01, 2022 - Peer review process
Oversight/management of adverse or "harm" events
___
___
Organizational … plan
FMEAs or other proactive process
RCA policies/procedures/processes
___
___
Organizational … Structure
Organizational chart showing connections among safety, risk, quality, credentialing, ethics
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ce.effectivehealthcare.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/meenan.html
October 01, 2015 - Qualitative interviews with organizational leaders revealed that implementation occurred in two distinct … However, they soon realized that organizational system changes were required for sustained primary care … CareOregon cultivated engaged leadership with relatively scarce resources by convening a group of organizational … Communication: Clear and effective communication between organizational leadership and frontline staff
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ce.effectivehealthcare.ahrq.gov/health-literacy/improve/precautions/index.html
March 01, 2024 - It expanded the definition of health literacy to include organizational health literacy, an explicit … Organizational Health Literacy is the degree to which organizations equitably enable individuals to … Tool 2: Assess Organizational Health Literacy and Create a Health Literacy Improvement Plan will guide
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ce.effectivehealthcare.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module6/mod6-slides.html
March 01, 2017 - Slide 21: Potential Barriers to Sustainability
Lack of organizational infrastructure and resources … Organizational skepticism.
Individual resistance to change. … Staff turnover
Embed newly developed processes into new staff orientation and organizational policies … Slide 27: Key Concepts Review
Sustainability helps organizations embed processes into their organizational … Fit within organizational mission.
Ongoing evaluation and transparency of measures.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/modelchange.pdf
March 01, 2006 - feedback
indicated, however, new strategies and methodologies were necessary to provide the customized organizational … training and training evaluation are difficult to sustain
without the support and structure provided by organizational
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops101-3-gray-2018.pdf
January 01, 2018 - AHRQ Surveys on Patient Safety Culture
Surveys of providers and staff about the extent to
which the organizational … Assessed
Across SOPS Surveys
• Teamwork
• Communication Openness
• Communication About Error
• Organizational … Safety Supplemental
Items (Medical Office)
• Goals of the items
– To measure the extent to which the
organizational
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ce.effectivehealthcare.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 - The execution
and evaluation of organizational practices led to changes in respondents’ beliefs about … The primary aim of this project was to develop the organizational infrastructure for
voluntarily reporting … A commitment at the organizational level to detect and learn from errors.
3. … Managing the risks of organizational
accidents. Aldershot, UK: Ashgate; 1997.
17. … A typology of organizational cultures.
Qual Saf Health Care 2004; 13: 22-27.
28.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20160315/rick-evans-slides.pdf
March 15, 2016 - . – PFAC’s
Take the whole team into account
Links to organizational initiatives – e.g. –
access … Targets – organizational history, national
change reports
Structures and Initiatives for Improvement
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
August 01, 2022 - For the internal organizational resources, clinical, claims/finance, and legal personnel must be coordinated … to reestablish trust with the patient and/or family include an apology, compensation, and a show of organizational … Slide 11
Say:
A number of metrics can compare organizational performance both before and after … These metrics include organizational performance relative to adverse events, financial impact, as well … Resolution of an event presents an opportunity for organizational learning and sustainment of change,
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/leveraging-cultural-change-080814.pptx
January 01, 2013 - and metrics
Local focused implementation – implementation at unit level
Frontline staff engagement
Organizational … Understanding what position may have the greatest influence may help
13
Three Levels of Organizational … Culture
17
HSOPS Dimensions
Supervisor/manager expectations and actions promoting patient safety
Organizational … 38
38
Summary and Next Steps
39
What is your organizational culture? … How can you utilize the components of the culture of safety model to assess and improve your organizational