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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
December 01, 2017 - Problem solving breaks down into two types: first-order problem solving and second-order problem solving … First-order problem solving is where we fix an immediate problem. … SAY:
This is the growth process from reactive first-order problem solving to proactive second-order problem … First-order problem solving
Second-order problem solving
What Is a Defect? … first-order problem solving.
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www.ahrq.gov/teamstepps-program/curriculum/implement/activity/plan.html
February 01, 2024 - Improving a team process includes the following steps:
Identify a recurring problem or opportunity … Flowchart or map the process during which the targeted problem or opportunity for improvement occurs. … Define the problem, challenge, or opportunity for improvement. … Step 2: Define the Problem, Challenge, or Opportunity for Improvement
Objective
State the problem … Aims should align with your defined teamwork problem or opportunity for improvement.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-slides.pptx
June 01, 2021 - Identifying Targets
13
2
Problem Solving
14
1
First-order problem solving
Solves one problem in … one particular instance
Generally does not help prevent future harm from occurring
Second-order problem … Targets
14
Technical Problems
Technical solutions often require a checklist or protocol.
15
Problem … Start with a problem or potential harm that is easy to fix. … Use second-order problem solving to determine technical and adaptive solutions.
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psnet.ahrq.gov/issue/invited-article-managing-disruptive-physician-behavior-impact-staff-relationships-and-patient
February 03, 2010 - this area has investigated predictors of unprofessional actions and system-level solutions to the problem … September 24, 2010
Perspective
How to Identify and Manage Problem … April 22, 2011
Perspective
How to Identify and Manage Problem
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psnet.ahrq.gov/issue/creating-safer-health-care-system-finding-constraint
February 24, 2011 - These include agreement that a problem exists, agreement that a proposed solution actually solves the … problem, and identifying obstacles and how they can be overcome. … February 26, 2025
Development of "SWARM" as a model for high reliability, rapid problem
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA205-Materials_XIA.pdf
June 02, 2025 - V40.9 Unspecified mental or behavioral problem
10. V60.0 Lack of housing
11. … V61.20 Counseling for parent-child problem, unspecified
15. … F69 Unspecified mental or behavioral problem
10. Z59.0 Lack of housing
11. … Z71.89 Counseling for parent-child problem, unspecified
15.
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA204-Materials_XIA.pdf
June 02, 2025 - V40.9 Unspecified mental or behavioral problem
10. V60.0 Lack of housing
11. … V61.20 Counseling for parent-child problem, unspecified
15. … F69 Unspecified mental or behavioral problem
10. Z59.0 Lack of housing
11. … Z71.89 Counseling for parent-child problem, unspecified
15.
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psnet.ahrq.gov/issue/hospitals-installed-more-sinks-stop-infections-sinks-can-make-problem-worse
October 05, 2016 - The sinks can make the problem worse. … The sinks can make the problem worse. Branswell H. STAT. October 25, 2016. … The sinks can make the problem worse. Branswell H. STAT. October 25, 2016.
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psnet.ahrq.gov/issue/root-cause-analysis-core-problem-solving-and-corrective-action-second-edition
June 09, 2011 - Book/Report
Classic
Root Cause Analysis: The Core of Problem … Citation Text:
Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition … Cite
Citation
Citation Text:
Root Cause Analysis: The Core of Problem
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - to be solved at one point in time, rather than a recurring and evolving problem that is influenced by … representation
17
Practice iterative and dynamic problem representation (1)
Problem representation … The second way to conceive of problem representation is as an individual’s mental representation of a … problem representation in this case upon the patient’s first presentation could be:
A middle-aged … The importance of early problem representation during case presentations.
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psnet.ahrq.gov/issue/problem-engaging-hospital-doctors-promoting-safety-and-quality-clinical-care
August 18, 2017 - Review
The problem of engaging hospital doctors in promoting safety and quality in … The problem of engaging hospital doctors in promoting safety and quality in clinical care. … The problem of engaging hospital doctors in promoting safety and quality in clinical care.
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psnet.ahrq.gov/issue/human-factors-engineering-healthcare-systems-problem-human-error-and-accident-management
June 13, 2011 - Commentary
Human factors engineering in healthcare systems: the problem of human … Human factors engineering in healthcare systems: the problem of human error and accident management. … Human factors engineering in healthcare systems: the problem of human error and accident management.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manwsa.html
December 01, 2017 - If the resident is not comfortable in the wheelchair, describe the problem. _________________________ … _______________________________
* Anterior Superior Iliac Spine
Identify the resident's seating problem … Problem: Resident Slides Out of Chair
Reason: Posterior Pelvic Tilt
__ Contoured cushion with large … flexion
__ Contoured cushion with trough for femur(s)
__ Other ________________________________
Problem … Foot plate adjustment
__ Heel loops
__ Leg rests
__ Other ________________________________
Problem
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psnet.ahrq.gov/node/865884/psn-pdf
May 29, 2024 - to be solved
at one point in time, rather than a recurring and evolving problem that is influenced … to be solved.8,9,10 Problem representation is a key activity in most diagnostic reasoning
curricula … The second way to conceive of
problem representation is as an individual’s mental representation of … The importance of early problem representation during case
presentations. … Reasoning on rounds: summary statement or problem representation?
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-implementation-slides.pptx
June 02, 2025 - Is there a measurable problem? … List reasons defining your problem and goals is essential. … Define the problem, challenge, or opportunity for improvement. … 1.
2.
3.
29
Example: Problem Definition
Implementation
Problem:
Suboptimal communication among … Coach only to problem solve.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/postdisphone.pdf
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]? … 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? … What To Do If a Problem Arises
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www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part2-sbuse.html
May 01, 2018 - Same
No Change
People age 12 and over who needed treatment for illicit drug use or an alcohol problem … Substance Abuse Treatment
People age 12 and over who needed treatment for illicit drug use or an alcohol problem … noninstitutionalized population age 12 and over who needed treatment for illicit drug use or an alcohol problem … 2012, only 10.8% of people age 12 and over who needed treatment for illicit drug use or an alcohol problem
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-11-root-cause-analysis.pdf
December 27, 2021 - Ask the PF to facilitate identifying a problem with the class or course.
4. … Three categories of causes may underlie a
problem: human, physical, and organizational. … Work with practice members to identify the problem they want to solve or prevent.
2. … The practice may also want to include patients, depending on the nature of the problem. … Using five whys to review a simple problem.
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digital.ahrq.gov/principal-investigator/beebe-lora
January 01, 2023 - Beebe, Lora
Telephone Intervention-Problem Solving (TIPS) for schizophrenia … Telephone Intervention-Problem Solving (TIPS) for schizophrenia spectrum disorders: responses of stable … The long-term effects of cellular telephone-delivered telephone intervention problem solving (TIPS) for … Solving (TIPS)
The Long Term Effectiveness of Telephone Intervention Problem … The Long Term Effectiveness of Telephone Intervention Problem Solving (TIPS) - Final Report.
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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-study-elements.docx
June 02, 2025 - Improvement Study Framework
Element
Definition
Things To Keep in Mind
The Purpose
Define the problem … determination will come later after the data have been analyzed.
· Speculating about the cause of a problem … The Goal
Collect baseline data and set an improvement goal after the problem has been fully diagnosed … Cause of the Problem
If the goal was not met, discuss reasons why it was not met. … · Brainstorm with your team the possible causes of the problem.
· Select the cause(s) you have the