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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?
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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
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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
-
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
-
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
-
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
-
psnet.ahrq.gov/issue/how-not-waste-crisis-qualitative-study-problem-definition-and-its-consequences-three
April 21, 2015 - Study
How not to waste a crisis: a qualitative study of problem definition and its … How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals … How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals
-
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
•
-
psnet.ahrq.gov/node/850930/psn-pdf
June 21, 2023 - Patient safety in emergency departments: a problem for
health care systems? … Patient safety in emergency departments: a problem for health
care systems? … https://psnet.ahrq.gov/issue/patient-safety-emergency-departments-problem-health-care-systems-
international-survey … https://psnet.ahrq.gov/issue/patient-safety-emergency-departments-problem-health-care-systems-international-survey … https://psnet.ahrq.gov/issue/patient-safety-emergency-departments-problem-health-care-systems-international-survey
-
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
-
psnet.ahrq.gov/node/50707/psn-pdf
December 04, 2019 - Spinal surgery complications: an unsolved problem-Is the
World Health Organization Safety Surgical Checklist … Spinal surgery complications: an unsolved problem-Is the
World Health Organization Safety Surgical Checklist … https://psnet.ahrq.gov/issue/spinal-surgery-complications-unsolved-problem-world-health-organization- … https://psnet.ahrq.gov/issue/spinal-surgery-complications-unsolved-problem-world-health-organization-safety-surgical … https://psnet.ahrq.gov/issue/spinal-surgery-complications-unsolved-problem-world-health-organization-safety-surgical
-
psnet.ahrq.gov/issue/insights-problem-alarm-fatigue-physiologic-monitor-devices-comprehensive-observational-study
July 17, 2013 - Study
Classic
Insights into the problem of alarm fatigue … Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational … Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational
-
psnet.ahrq.gov/issue/incident-reporting-system-does-not-detect-adverse-drug-events-problem-quality-improvement
February 10, 2011 - Classic
Incident reporting system does not detect adverse drug events: a problem … The incident reporting system does not detect adverse drug events: a problem for quality improvement. … The incident reporting system does not detect adverse drug events: a problem for quality improvement.
-
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
-
psnet.ahrq.gov/node/47629/psn-pdf
July 11, 2019 - How not to waste a crisis: a qualitative study of problem
definition and its consequences in three hospitals … How not to waste a crisis: a qualitative study of problem definition
and its consequences in three hospitals … https://psnet.ahrq.gov/issue/how-not-waste-crisis-qualitative-study-problem-definition-and-its-
consequences-three … https://psnet.ahrq.gov/issue/how-not-waste-crisis-qualitative-study-problem-definition-and-its-consequences-three … https://psnet.ahrq.gov/issue/how-not-waste-crisis-qualitative-study-problem-definition-and-its-consequences-three
-
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.
-
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.
-
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
-
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.