-
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/tool.html
June 01, 2017 - General capacity to improve on more than one outcome or process
Partnership itself
Problem … Problem solving: If key elements are lacking, has a strategy been developed to address this issue? … Problem solving: If positive incentives are inadequate or disincentives are identified, have strategies …
Can pick and choose among offered activities
Other
Problem … Problem solving: If change goals are not aligned and integrated with the strategic goals, performance
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/improvement-facilitator-guide.pdf
November 01, 2019 - Another example of a technical problem would be
failure to administer needed antibiotics to septic … When considering possible technical solutions to a
problem, it is important to assess their ease of … First-order problem
solving involves solving one problem at a time. … Second-order problem solving uses both technical and
adaptive interventions. … change than first-
order problem solving.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-facguide.docx
January 01, 2017 - Slide 5
Problem-Solving Hierarchy
SAY:
First-order problem solving resolves an issue for one patient … ASK:
What method of problem solving should we employ? … SAY:
Instead of relying on first-order problem solving, practice second-order problem solving. … Slide 6
Problem-Solving Goal
SAY:
First-order problem solving addresses the immediate need but does … ASK:
How can you make sure that everyone is aware of the problem?
-
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-k-blank-temp.html
May 01, 2017 - Improvement Study Template
Ambulatory Surgery Center
Slide 2: Problem … Statement
problem statement here>
Slide 3: Improvement Team
Project Leader(s … Observed performance:
Current performance: Below Goal by X or Goal Achieved
Slide 10: Cause of the Problem … problem>
Slide 11: Corrective Actions/Interventions
Intervention
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/postdisphone.docx
June 02, 2025 - Using your own words, can you explain to me what your main problem or diagnosis is? … CALLER: Do you have any questions for me about your main problem [diagnosis]? … CALLER: Since you left the hospital, do you feel your main problem, [diagnosis], has improved, worsened … What To Do If a Problem Arises
CALLER: Before we hang up, I want to make sure that if a medical problem … CALLER: And what about if you [give example of urgent but not emergent problem] in the evening?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
February 01, 2004 - Problem types used for coding error reports
Problem Type Definition
Problematic
communication and … (Problem type: Decision)
Diagnostic “Patient with E.coli oh 157. … (Problem type: Other)
Equipment “Dictation was not completed due to a new technical problem not
encountered … (Problem type: Execution)
Problem Type
Categories Example error report
Problematic
communication … Problem types used for coding error reports
Table 3.
-
www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/postdischarge-phone.html
March 01, 2025 - Using your own words, can you explain to me what your main problem or diagnosis is? … CALLER: Do you have any questions for me about your main problem [diagnosis]? … CALLER: Since you left the hospital, do you feel your main problem, [diagnosis], has improved, worsened … What To Do If a Problem Arises CALLER: Before we hang up, I want to make sure that if a medical problem … CALLER: And what about if you [give example of urgent but not emergent problem] in the evening?
-
www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/postdischarge-phone.html
March 01, 2025 - Using your own words, can you explain to me what your main problem or diagnosis is? … CALLER: Do you have any questions for me about your main problem [diagnosis]? … CALLER: Since you left the hospital, do you feel your main problem, [diagnosis], has improved, worsened … What To Do If a Problem Arises CALLER: Before we hang up, I want to make sure that if a medical problem … CALLER: And what about if you [give example of urgent but not emergent problem] in the evening?
-
www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
February 01, 2017 - Use the Learning from Defects (LFD) tool to perform second-order problem solving. … Slide 6: Problem-Solving Hierarchy
First-Order Problem Solving
Recovers for one patient, but … Slide 7: Problem-Solving Goal
First-order problem solving addresses immediate need, but does not … Second-order problem solving addresses future needs and improves overall patient safety culture. … Image: Counterbalanced arrows illustrate first-order problem solving versus second-order problem solving
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/sustainability-tool.docx
May 01, 2017 - process or outcome
General capacity to improve on more than one outcome or process
Partnership itself
Problem … Problem solving: If key elements are lacking, has a strategy been developed to address this issue? … Problem solving: If positive incentives are inadequate or disincentives are identified, have strategies … Changing role throughout the project
Can pick and choose among offered activities
Other
Problem … Problem solving: If change goals are not aligned and integrated with the strategic goals, performance
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams-5.html
July 01, 2023 - member of dyadic diagnostic teams brings their unique perspective and skill set to address a diagnostic problem
-
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/visual-slides.html
June 01, 2017 - work by staff, the daily safety huddle, visual management, escalation, observation of safety work, problem … Keep the board free of clutter
Integrate the board with daily huddles
Start simple
Manage the problem … Slide 10: Testing and Implementation: Common Problems and Tips for Visual Management Boards
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
-
www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide108.html
October 01, 2014 - Common elements of practical counseling (problem-solving/skills training)
Practical counseling … (problem solving/ skills training) treatment component
Examples
Recognize danger situations … Develop coping skills —Identify and practice coping or problem-solving skills.
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/postdiscalldoc.docx
June 02, 2025 - If new problem since discharge:
Had the patient:
Contacted or seen clinician? … e.g., has not obtained, is not taking correctly, has concerns, including side effects):
Medicine 1:
Problem … patient/caregiver back
Called outpatient pharmacy and called patient/caregiver back
Other:
Medicine 2:
Problem … patient/caregiver back
Called outpatient pharmacy and called patient/caregiver back
Other:
Medicine 3:
Problem … Problems
Did patient/caregiver know what constituted an emergency and what to do if a nonemergent problem
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/team-roster.docx
April 01, 2022 - Physician
Champion
· Resourceful
· Problem solver
· Influencer
· Data driven
· Subject matter expert … List:
Bedside Nurses
· Resourceful
· Problem solver
· Inspire others to commit to project goals and … Infection Preventionist
· Subject matter expert
· Data driven
· Collaborative
· Problem solver
· Advocate … Nurse Educator
· Works across units
· Subject matter expert
· Problem solver
· Collaborative
· Meet … Performance Improvement Specialist
· Subject matter expert
· Data driven
· Problem solver
· Works across
-
www.ahrq.gov/teamstepps-program/curriculum/implement/pre-measure.html
May 01, 2023 - In discussing Slide 13, “Define a Measurable Goal or Problem You Plan To Address,” it’s important to … that TeamSTEPPS always should have a defined goal or be introduced in response to a clearly identified problem … Also explain that effective measurement requires clarity about the problem and what observable changes … It is being discussed as a pre-implementation topic because quantifying your problem at the beginning
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/ahcptemplen.pdf
June 02, 2025 - 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? … 5
** Bring this Plan to ALL Appointments**
[Insert Patient Name]
What is my main medical problem
-
www.ahrq.gov/es/questions/question-builder/online.html
June 09, 2025 - Create a list of questions that you can take with you whether you are getting a checkup, talking about a problem … To talk about a health problem
To get or change a medicine
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/data-analysis-webcast-advancing-methods-4.pdf
March 03, 2021 - Plan/ Solutions:
Results: Patient Experience score for FY ended above Max%
DO
(I
m
pr
ov
e)
Problem … •More people returned the survey, but this was a follow-up
question to having a problem. … •Because their problem was not resolved in a way they felt
we heard their concern. … •We did not verify that we understood and addressed the
problem we thought they had. … Why •Why did we not verify that they felt our actions rectified
their problem?
-
www.ahrq.gov/sites/default/files/2024-10/sirio2-report.pdf
January 01, 2024 - Feedback mechanisms exist from the Problem-Solving System such that, over
time, learning should enhance … NIs have been long recognized
as a critical problem affecting the quality of healthcare and a principal … voluntarily
by these hospitals to estimate the magnitude of the healthcare-associated infections
problem … Region-Wide Problem Solving
Initiatives to Eliminate Infections: PRHI facilitated implementation of … initiatives enabled PRHI to determine the impact of region-wide reporting, information
sharing, and problem