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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/ahcpsample.docx
September 01, 2012 - Question or Problem with this Packet? … Call your Discharge Educator: (555) 555-2222
Serious health problem? Call Dr. … mg gum
Gum
Chew
** Bring this Plan to ALL Appointments**
Oscar Sanchez
What is my main medical problem … :
Noncardiac Chest Pain
Noncardiac chest pain is pain that is not caused by a heart problem … My Medical Problem:
High Blood Pressure
High blood pressure is also called hypertension.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/overview/overview.pptx
May 01, 2017 - Healthcare Improvement (IHI) team studied 10 leading health care organizations that are addressing this problem … for frontline managers and staff
Key elements
Daily huddles
Use of visual boards at the front line
Problem-solving … jpeg
image3.jpeg
image5.tif
Daily Safety Huddle
• Standard agenda
• Data review
• Problem … tracking
Visual Management
• Outcomes over time
• Checklist compliance
• Problem log
Escalation
• … surgical checklist
• Infection control
procedures
Observation of
Safety Work:unit
lead & senior leader
Problem
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/ahcp-template-eng.html
March 01, 2025 - Hospital Care Plan for: [patient name] [Patient name] Discharge Date: [discharge date] Question or Problem … Call your Discharge Educator: (xxx) xxx-xxxx DE PHOTO HERE Serious health problem? … for ** Bring this Plan to ALL Appointments** [Insert Patient Name] What is my main medical problem
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/ahcp-template-eng.html
March 01, 2025 - Hospital Care Plan for: [patient name] [Patient name] Discharge Date: [discharge date] Question or Problem … Call your Discharge Educator: (xxx) xxx-xxxx DE PHOTO HERE Serious health problem? … for ** Bring this Plan to ALL Appointments** [Insert Patient Name] What is my main medical problem
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/ahcptemplen.docx
June 02, 2025 - Appointments**
After Hospital Care Plan for: [patient name]
Discharge Date: [discharge date]
Question or Problem … Call your Discharge Educator: (xxx) xxx-xxxx DE PHOTO HERE
Serious health problem? … ** Bring this Plan to ALL Appointments**
[Insert Patient Name]
What is my main medical problem
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/visual/visual-mgmt.pptx
May 01, 2017 - Keep the board free of clutter
Integrate the board with daily huddles
Start simple
Manage the problem … #1: Privacy and safety measures Problem #2: We already have a visual board, focused on patient flow … Problem #3: The board is not updated consistently
Solution #1: Cover the board when not in use
Solution … jpeg
image1.jpeg
image5.tif
Daily Safety Huddle
• Standard agenda
• Data review
• Problem … tracking
Visual Management
• Outcomes over time
• Checklist compliance
• Problem log
Escalation
•
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/echo/about/209_echo-reporting-measures.pdf
January 01, 2004 - MCO
only)
Getting clinician happy with
Delays in treatment while wait for plan
approval
Problem … materials or on the Internet
Helpfulness of customer service
Filling out paperwork
Big problem … Small problem
Not a problem
Perceived
improvement
Q31
Q32
Compare ability to deal with
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-k-blank-template.pptx
June 02, 2025 - Program for Ambulatory Surgery
Implementation Guide Appendix K – Quality Improvement Study Framework
1
Problem … Statement
problem statement here>
Quality Improvement Study Template | ‹#›
AHRQ Safety … Ambulatory Surgery
Implementation Guide Appendix K – Quality Improvement Study Framework
9
Cause of the Problem … problem>
Quality Improvement Study Template | ‹#›
AHRQ Safety
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-5-whys.pdf
June 02, 2025 - Create a problem statement, such as, “Patients have stopped attending our diabetes
self-management classes … Design a change or counter-measure to correct the problem. … Create a problem statement and write it at the "head" of the fish. This is the "effect."
2.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
December 01, 2017 - Problem statement: If a patient is harmed in the perioperative area, a typical first response is to … First-order problem solving focuses on the here and now, work-arounds, and “quick fixes.” … Purpose of this tool: This tool helps you with second-order problem solving. … Purpose of this tool:
This tool helps you with second
-
order problem solving. … Purpose of this tool: This tool helps you with second-order problem solving.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/postdiscalldoc.pdf
June 02, 2025 - If new problem since discharge:
Had the patient:
Contacted or seen clinician? … including side effects):
Medicine 1: ________________________________________________________________
Problem … _________________
Medicine 2: _________________________________________________________________
Problem … _________________
Medicine 3: _________________________________________________________________
Problem … Problems
Did patient/caregiver know what constituted an emergency and what to do if a nonemergent
problem
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www.ahrq.gov/evidencenow/projects/heart-health/about/stories/in-action/oklahoma.html
March 01, 2021 - Huge Gains for Small Oklahoma Practice
Busy solo primary care practitioner seeks a tenacious problem-solver
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management.html
June 01, 2017 - Word File , 261 KB; Text Version )
Example of PDSA Form ( Word File , 314 KB; Text Version )
Problem … Solving and Escalation
These resources help front line staff and leaders understand the problem-solving … and problem-escalation methods necessary to sustain improvements.
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www.ahrq.gov/nhguide/about/choosing-the-right-toolkit.html
October 01, 2016 - may be helpful to consider the following questions:
Has the nursing home identified a particular problem … If the nursing home has not identified a problem, it may want to start monitoring antimicrobial use with … This may help the antimicrobial stewardship team identify a problem on which to focus.
… expected to identify problems or opportunities for improvement, that represent high risk, high volume, or problem-prone
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-facilitator-guide.docx
June 01, 2021 - First-order problem solving involves solving one problem at a time by focusing on one particular instance … This type of problem solving generally does not help prevent future harm from occurring. … Solving an adaptive problem is complex. … An adaptive solution to this problem involves encouraging a culture of safety. … · Use second-order problem solving to determine technical and adaptive solutions.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
January 01, 2017 - Objectives
After this session, you will be able to—
Describe difference between first-order and second-order problem … defects in care more likely to occur
Use the Learning from Defects (LFD) tool to perform second-order problem … Hierarchy
First-Order
Problem Solving
Second-Order
Problem Solving
Recovers for one patient, but does … Learn From Defects ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
7
First-order problem … solving addresses immediate need, but does not improve patient safety culture
Second-order problem
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/overview/component-kit.docx
May 01, 2017 - .
· Well-Understood and Routinely Executed Problem-Solving and Escalation Methods. … (2) simple issues that have an obvious “just fix it” solution; (3) issues that are symptomatic of a problem … Problem Solving and Escalation
Well-understood problem solving methods (e.g., Model for Improvement; … Common understanding and execution of problem-solving methods ensures that huddles and visual management … tracking
Visual Management
• Outcomes over time
• Checklist compliance
• Problem log
Escalation
•
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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
December 01, 2017 - Slide 4: Problem-Solving Hierarchy
Say:
First-order problem solving resolves an issue for one patient … Instead of relying on first-order problem solving, practice second-order problem solving. … Slide 5: Problem-Solving Goal
Say:
First-order problem solving doesn’t encourage a positive patient … solving to second-order problem solving. … Does the hospital reward first-order problem-solving instead of second-order problem-solving?
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6-p.pdf
November 02, 2017 - The Problem
No matter how well you manage the customer service at your organization, problems are
inevitable … Fix the problem quickly and fairly.
4. Offer atonement.
5. Follow up.
6. … Involve the person in helping to solve the problem. … They include a process for tracking problems and
complaints to help identify the source of the problem … The Problem
6.P.2. The Intervention
6.P.3. Implementing This Intervention
6.P.4.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
June 01, 2021 - intervention is effective.
2
Changing the System
2
View Potential Harms as Opportunities1
Reframe a problem … or error as an opportunity to prevent the same problem from occurring again
System design
Can result … 17
Changing the System
17
Review
Consider system/active failures which may have led to the problem … Apply 4 moments
Identify a problem
Learn from the problem to improve the system
18
Changing the System