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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d1_pdi_improvementmethodsoverview.pptx
April 02, 2025 - AHRQ Quality Indicators
How to Improve Hospital Quality and Safety
Tool D.1 Slide ‹#›
Diagnose the problem … Step 1
Diagnose the Problem
Performance Improvement
Model
Source: Langley GJ, Nolan KM, Nolan TW … Step 1
Diagnose the Problem
Describe Improvement Initiative – Project Charter (Tool D.2)
Review and Select
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d1_combo_improvementmethodsoverview.pdf
April 02, 2025 - Diagnose the problem
2. Plan and implement best practices
3. Measure results and analyze
4. … Step 1
Diagnose the Problem
Performance
Improvement
Model
Source: Langley GJ, Nolan KM, Nolan TW … Step 1
Diagnose the Problem
• Describe Improvement Initiative – Project Charter (Tool D.2)
• Review and
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d1_pdi_improvementmethodsoverview.pdf
April 02, 2025 - Diagnose the problem
2. Plan and implement best practices
3. Measure results and analyze
4. … Step 1
Diagnose the Problem
Performance
Improvement
Model
Source: Langley GJ, Nolan KM, Nolan TW … Step 1
Diagnose the Problem
• Describe Improvement Initiative – Project Charter (Tool D.2)
• Review and
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digital.ahrq.gov/ahrq-funded-projects/information-needs-homecare-nurses-during-admission-and-care-planning
January 01, 2023 - with the problem list: Incongruence of patient problem information across the home care admission. … There's a problem with the problem list: Incongruence of patient problem information across the home … information across three phases of home care admission: there's a problem with the problem list. … Incongruence of patient problem information across three phases of home care admission: there's a problem … with the problem list.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams-6.html
July 01, 2023 - The patient and their family member or other support person inform the clinician about a health problem … with the patient/family/support person to develop a plan to diagnose and treat the patient’s health problem … The clinician recommends using an AI-based algorithm developed to evaluate the patient’s health problem … may provide updates about the patient's status after an intervention designed to address the health problem … autonomy should be preserved, AI will have variable levels of autonomy depending on the diagnostic problem
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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
December 01, 2017 - Use the Learning From Defects (LFD) tool to perform second-order problem-solving. … Slide 4: Problem-Solving Hierarchy
First-order problem solving
Recovers for one patient, but … Slide 5: Problem-Solving Goal
What is the long-term impact on patient safety culture? … Red arrow pointing down is captioned "First-order problem-solving addresses immediate need, but does … Green arrow pointing up is captioned "Second-order problem-solving addresses future needs and improves
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www.ahrq.gov/cahps/quality-improvement/improvement-guide/5-determining-focus/section5part2.html
January 01, 2020 - Various operational issues in the practice could contribute to this problem:
The physicians may not … Articulating the issue in writing helps you formalize the problem and describe it completely. … It also helps everyone on the improvement team focus on the same problem. … Step 2: Ask why the problem happens and write the answer down below the problem.
Why? … All patients who report a problem scheduling appointments.
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - in care, in the ways we learned from Toyota: see a problem and know that the problem you see is something … In the moment they have the problem, the problem gets swarmed. … make the problem go away. … the problem, and solve the problem are very robust. … problem recurrence.
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psnet.ahrq.gov/issue/reducing-unacceptable-missed-doses-pharmacy-assistant-supported-medicine-administration
June 07, 2023 - Recent interventions, such as barcode medication administration systems, may help mitigate this problem … While these findings suggest a possible robust solution to this common problem, major limitations to
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www.ahrq.gov/patient-safety/settings/hospital/match/chapter-2.html
July 01, 2022 - The charter will be a dynamic document that encompasses the following elements:
Problem statement … Problem Statement. … A problem statement is a concise description of the issues that need to be addressed by the team and … A good problem statement should consider the nature of the problem and how it impacts patient care. … The team should establish goals and objectives that directly relate to the above problem statement.
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cds.ahrq.gov/sites/default/files/cds/artifact/27811/Test-Cases.xlsx
October 28, 2021 - Rule Recommendations are mutually exclusive across rules (at most one given) Has Persistent Asthma on Problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem
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cds.ahrq.gov/sites/default/files/cds/artifact/27801/Test-Cases.xlsx
October 28, 2021 - Rule Recommendations are mutually exclusive across rules (at most one given) Has Persistent Asthma on Problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem
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cds.ahrq.gov/sites/default/files/cds/artifact/27796/Test-Cases.xlsx
October 28, 2021 - Rule Recommendations are mutually exclusive across rules (at most one given) Has Persistent Asthma on Problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem
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cds.ahrq.gov/sites/default/files/cds/artifact/27781/Test-Cases.xlsx
October 28, 2021 - Rule Recommendations are mutually exclusive across rules (at most one given) Has Persistent Asthma on Problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem
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cds.ahrq.gov/sites/default/files/cds/artifact/27806/Test-Cases.xlsx
October 28, 2021 - Rule Recommendations are mutually exclusive across rules (at most one given) Has Persistent Asthma on Problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem
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cds.ahrq.gov/sites/default/files/cds/artifact/27816/Test-Cases.xlsx
October 28, 2021 - Rule Recommendations are mutually exclusive across rules (at most one given) Has Persistent Asthma on Problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem
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cds.ahrq.gov/sites/default/files/cds/artifact/27771/Test-Cases.xlsx
October 28, 2021 - Rule Recommendations are mutually exclusive across rules (at most one given) Has Persistent Asthma on Problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem
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cds.ahrq.gov/sites/default/files/cds/artifact/27776/Test-Cases.xlsx
October 28, 2021 - Rule Recommendations are mutually exclusive across rules (at most one given) Has Persistent Asthma on Problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem … on SABA only 28 (adult) albuterol none none yes, 5 mo ago Mild persistent asthma active, confirmed problem
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/postdischarge-doc.html
March 01, 2025 - If new problem since discharge: Had the patient: ___ Contacted or seen clinician? … _____________________ 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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digital.ahrq.gov/sites/default/files/docs/citation/r01hs024945-lambert-final-report-2022.pdf
January 01, 2022 - based on alerts, and validated problem accuracy. … We hypothesize that indication alerts will double the
likelihood that a problem is placed on the problem … on their problem list.
3. … problem on the problem list. … Indication alerts to improve problem list documentation.